selective spine immobilization training program. reasons for new guideline

Selective Spine Immobilization Training Program

REASONS FOR NEW GUIDELINE

PURPOSE OF EMS SELECTIVE SPINAL

IMMOBILIZATION GUIDELINE

Identify and immobilize 100% of patients at risk for unstable injuries

Identify and NOT immobilize patients who have NO risk for cervical spine injury…

IMPORTANT MESSAGE

• Mechanism is going to be a crucial decision point in this process. This will rule some people out who previously were boarded and collared.• Supine patients who meet the guidelines for

Spine Immobilization will be boarded and collared as usual. Whereas, ambulatory patients who meet the protocol will only be collared.

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CERVICAL SPINE INJURIES-THE PROBLEM

Between 2-4% of Blunt Trauma Patients sustain cervical spine injury

Improvements in EMS systems and ATLS have resulted in increased awareness and practice of cervical immobilization

WHY NOT IMMOBILIZE EVERYBODY?

Immobilization is uncomfortable: increased time immobilized = increased pain, risk of aspiration, vulnerable position, etc...

>800,000 U.S. Patients receive cervical radiography each year

Patient exposure to radiation >97% of xrays are negativeCost exceeds $175,000,000 /year

INCIDENCE OF SCI

About 50 patients per million population. 12,000/year are treated while another 4,800 die

prehospital. Male-to-female ratio is approximately 2.5-3.0:1About 80% of males with SCI are aged 18-25

years.

BASED ON SCIENCE

MOST COMMON CAUSES OF ADULT SCI

45% - MVC20% - Falls15% - Sports15% - Violence5% - other

MORE THAN 50% OF SPINAL CORD INJURIES ARE SINGLE VEHICLE CRASHES!

MECHANISM OF INJURY

AGE BASED CONSIDERATIONS

60% of all SCI in >75 years population are caused by simple falls.

Pediatric incidence varies between 1 – 11%.• 5% will occur in the age group of 0-16 years.• Adolescents: C5-C6 level most often injured

Causes in Children• 0-10 years: falls and pedestrian vs auto• >10 years are same as adult

NATIONAL EMERGENCY X-RADIOGRAPHY UTILIZATION STUDY

NEXUS

Hypothesis:Blunt trauma victims have virtually no

risk of cervical spine injury if they meet all of the following criteria:

No neuro deficit, Normal Level of alertness No evidence of ETOH/Tox No posterior midline tenderness No other distracting painful injury

NEXUS -RESULTS

818 patients with fracture identifiedAll except 8 were identified by clinical decision

ruleSensitivity 99% (95% CI 98-99.6%)

8 Patients8 PatientsNot Not IdentifiedIdentifiedBy NEXUSBy NEXUSRulesRules

THE MAIN POINT:

• You can’t just decide to “clear” the spine without following a standard of care 100% of the time. No “neck-pain” is not an absolute clearance.

• Patients whose spinal cord injuries are missed are directly related to poor assessment, lack of recognition of SCI patterns and lack of knowledge about risk factors correlated to SCI.

SPINAL INJURIES

KINEMATICS (MECHANISM)

Process of evaluating the forces and motion involved when an accident occurs to determine what injuries may have resulted

Based on fundamental principles of physics described in Newton’s Law

KINEMATICS OF BLUNT SPINAL INJURY

HyperextensionHyperflexionCompressionRotationLateral StressDistraction

Axial Loading(diving)Blunt TraumaMotor Vehicle CollisionBicycle FallChildren: Fall > 3 feetAdult: Fall from

standing height

MECHANISM OF INJURY

Physical manner and forces involved in producing injuries or potential injuries

Valuable tool in determining if the a particular set of circumstances could have caused a spinal injury

Mechanisms likely to produce spinal injuries occur in MVAs, falls, violence, and sports (including diving accidents)

CERVICAL SPINE INJURIES

C-spine very flexibleMost frequently injured area of spineMost injuries at C-5/C-6 level

THORACIC SPINE INJURIES

T-spine less flexibleNarrow spinal canalCord injury occurs with minimal displacementCommon mechanismsAny cord damage usually complete at this levelMost T-spine injuries occur at T-9/T-10

LUMBOSACRAL SPINE INJURIES

LS spine flexible nerve roots in roomy spinal canalMay have bony injury w/o cord or nerve root

damageSecondary injury still possibleNeurological injury rare w/ isolated sacral injuries

SPINAL COLUMN INJURY

Bony spinal injuries may or may not be associated with spinal cord injury

These bony injuries include:• Compression fractures of the vertebrae• Comminuted fractures of the vertebrae• Subluxation (partial dislocation) of the vertebrae

Other injuries may include:• Sprains- over-stretching or tearing of ligaments• Strains- over-stretching or tearing of the

muscles

SPINE EVALUATION

IDENTIFICATION OF MECHANISM OF INJURY

• Clearly Positive Mechanismspinal immobilization indicated

• Clearly Negative Mechanismspinal immobilization not indicated

• Uncertain MechanismMOI alone inconclusivefurther assessment required to determine if spinal immobilization necessary

UNCERTAIN MECHANISMASSESSMENT BY CLINICAL CRITERIA

Pain/Tenderness ExamNeurological Exam• Motor Function• Sensory Function

Reliable vs. Unreliable Patient Exams

EXAMPLES OF POSITIVE MECHANISM

Penetrating trauma to head, chest, abdomen, pelvis

Axial loading injury Rollover with signs of impact Multiple system injuries Compressed roof of vehicle Falls greater than 20 feet

EXAMPLES OF POSITIVE MECHANISM

Death of occupant in same car Struck by vehicle traveling more than 30 mph Severe vehicle deformity, intrusion of car >12

inches Ejection from vehicle

PAIN/TENDERNESS EXAM

Spine PainSpine Tenderness

NEUROLOGICAL EXAM

Motor FunctionSensory FunctionReliable vs. Unreliable Patient Exams

MOTOR FUNCTION

Upper Extremities• Abduction/Adduction• Finger/Hand extension

Lower Extremities• Plantar Flexion• Great Toe Dorsiflexion

SENSORY FUNCTION

Test sensation at two levelsMust include testing for sensation to pain and

light touch at the lateral and medial aspects of each upper extremity and each lower extremity

SENSORY FUNCTION

Abnormal Sensation- Numbness, weakness, paraesthesia, or ridiculer pain

Pain Sensation- Test ability to distinguish pain from light touch in both upper and lower extremities

EXAMPLES OF ABNORMAL NEURO FINDINGS

Paresthesia distal to injury, unilateral or bilateral Unilateral weakness, motor or sensory findings in

limbs Altered level of consciousness or affect Any abnormality to pan, temperature or position

sense.

RELIABLE VS. UNRELIABLE PATIENT EXAMS

INDICATIONS FOR PATIENT EXAM RELIABILITY*NO **YESAcute Stress Reaction (ASR) CalmAgitated, Combative CooperativeIntoxication/Drug Use Sober/No Drug UseAbnormal Mental Status -- Alert & Oriented (Note: be particularly careful assessing mental status in head-injured patients)Distracting Injuries – (painful long bone fractures, significant soft tissue injuries, etc.)Communication Problems -- Language Barrier, mental handicap, etc.

CRITERIA FOR HIGH RISK/ UNRELIABLE PATIENTS

GCS ≤ 12Pediatric ≤ 12, ≥ Elderly 65Alcohol, drug, any mind altering substance use.

Other painful injuries.Down Syndrome.Acute stress reaction or severe anxiety.

ShockHistory of serious spine problems.

SPINAL IMMOBILIZATION DECISION ALGORITHM

RULE 1

“Use algorithm for stable patients with negative or questionable mechanism of injury.”

SPINAL IMMOBILIZATION DECISION ALGORITHM

RULE 2“Any unstable patient or potentially

unstable patient with positive mechanism of injury, are to be rapidly extricated and immobilized per regional guidelines and PHTLS recommendations without compromising short scene times.”

SPINAL IMMOBILIZATION DECISION ALGORITHM

RULE 3“Immobilization can be safely deferred

when there is a negative mechanism of injury. When the mechanism is questionable or uncertain, clinical criteria are to be used to determine immobilization of the stable patient.”

“OTHER PAINFUL INJURIES.”DISTRACTING INJURIES

• These patients have been correlated with missed fractures/ injuries due to the masking effects of sympathetic nervous system stimulation.

POSITIVE OR QUESTIONABLE MECHANISM OF INJURY

POSITIVE: “Positive mechanism” is determined following the State of Connecticut Trauma Protocols and Regulations. (Example: Fall of 25 feet)• S.I. indicated

QUESTIONABLE: “Questionable mechanism” exists where the mechanism of injury is unclear regarding impact and forces involved. (Examples: Minor MVC with minimal vehicle damage; simple fall of less than 5 feet) • S.I. POSSIBLY not indicated, continue with assessment

to determine S.I. need.

POSITIVE OR QUESTIONABLE MECHANISM OF INJURY

NEGATIVE: “Negative mechanism” exists when no reasonable possibility of spinal injury is present. (Example: Knee/ankle injury while running with no fall, GSW to arm/leg) • S.I. not indicated

NOTE: These are only baseline principles. All factors, including patient vital signs and symptoms, should be evaluated prior to final determination of need for S.I.

TAKE HOME MESSAGE

• Long backboards may not need to be utilized for spinal immobilization of patients who have been ambulatory after the mechanism of injury before EMS has arrived.

• Ambulatory patients who require spinal immobilization can be placed in an appropriately sized collar and secured on the ambulance stretcher in the position of comfort while limiting the movement of the neck during the process.

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• Mechanism is going to be a crucial decision point in this process. This will rule some people out who previously were boarded and collared.

• Supine patients who meet the guidelines for Spine Immobilization will be boarded and collared as usual. Whereas, ambulatory patients who meet the protocol will only be collared.

Case Studies

Case Study One

Dispatch– 68 y/o female c/o weakness to arms, unable to get

out of car. Car parked in shopping mall parking lot.

Arrival– Pt sitting in drivers seat of car, GCS 15, no distress– Pt states she drove car over concrete parking

divider, “really jerking my head” when she drove over 6 inch divider.

Case Study One (cont)

Initial assessment: ABC’s normal, c-spine control initiatedStable or unstable?Evaluate MOI

Secondary Assessment– VS normal– No pain on palpation of spine– No deformity palpable– Lower extremities= normal motor or sensory exam– Upper extremities= Good sensation to light touch and

sharp touch; but, weak motor function

Case Study One (cont)

Risk/Reliability: Hx of osteoporosisTreatment: Full immobilizationReassessment: VS normal, further decrease in

motor function of upper extremities, No sensory changes, lower extremities without changes, patient c/o dull pain to neck

Case Study One (cont)

Diagnosis: Central Cord SyndromeDiscussion

– Hyperextension mechanism– Swelling of central cord– Most common type of cord injury– Loss of motor and sensory function below

level of cord injury with greater loss in arms than legs

Case Study Two

Description of case: A 53 year old male was involved in a moderate-speed MVA. He was driver of car that rear-ended another car. Both cars have serious fender damage. The hood of your patients car is pushed in and bent. the windshield is intact. He states he was wearing his seat belt. He complains of some shoulder soreness. He is sitting in his car when you arrive.

Case Study Two (cont)

Initial Assessment: ABCs are normal. Cervical spine stabilization is manually obtained because of the appearance of the cars.

Decide Stability of patient: Stable Evaluate MOI: Questionable.

Secondary Assessment - Neurological and Sensory Exam: Vital signs are normal. Pt. denies pain on palpation of spine. you feel no deformity. Neurosensory exam is normal. Pt is able to perform range-of-motion without pain or limitation. Motor examination is normal.

Risk / Reliability Assessment: Pt. has no risk factors.

Case Study Two (cont)

Treatment: Transport for evaluation of shoulder discomfort.

Reassessment: Unchanged. Diagnosis: No indications for spinal

immobilization

Case Study Two (cont)

Discussion: Clinical clearance or inclusion using the algorithm is a systematic approach as noted above. This patient has no indications for spinal immobilization. Be sure to document your exam and treat his shoulder. Transport to the ED is still indicated.

Case Study Three

Description of case: You are called to the home of a 32 year old woman who is complaining of left wrist pain. She is embarrassed that she had to call 911, but she can’t stand the pain in her wrist and can’t drive herself to the ER. She states that she injured her wrist about 6 hours earlier after she fell out of a moving car. She reports her friends said that she was initially unconscious for several minutes. She admits to drinking a few beers prior to the accident.

Case Study Three (cont)

Initial Assessment: ABCs are normal. No manual stabilization initially maintained. Pt. denied any neck/back complaints.

Decide Stability of patient: Stable. Evaluate MOI: Significant.

Secondary Assessment - Neurological and Sensory Exam: Vital signs are stable. Palpation of cervical spine reveals mild tenderness. Manual cervical spine stabilization is obtained. Neurological exam reveals intact sensation to light touch and pain. proprioception is normal. Patient moves all extremities. You note multiple abrasions over forehead, scalp and left arm and leg. Patient has a Babinski reflex on the left and her DTR were decreased on left.

Case Study Three (cont)

Risk / Reliability Assessment: Loss of consciousness, alcohol use, associated injuries.

Treatment: Full spinal immobilization. Splint wrist fracture.

Reassessment: Unchanged Diagnosis: Subluxation of C-4 on C-5

with fracture of pedicle and arch of C-4

Case Study Three (cont)

Discussion: This patient required surgery (cervical diskectomy, decompression and fusion with insertion of iliac crest bone dowel) and immobilization with Gardner-Wells tongs. This patient has risk factors as well as mild tenderness on palpation. She also has a distracting injury. There was a significant MOI with several minute loss of consciousness

Case Study Four

Description of case: 5 year old male fell out of tree approximately 10 feet. Landed on hard ground. Parents report patient was unconscious for a few minutes. Child is now alert, oriented and is very quiet and still.

Case Study Four (cont)

Initial Assessment: Airway, breathing and circulation are normal.

Decide Stability of patient: Stable. Evaluate MOI: Significant.

Secondary Assessment - Neurological and Sensory Exam: Vital signs are normal. Secondary exam reveals shoulder pain and burning in both legs. Patient refuses to participate in exam any further or describe any other sensations.

Risk / Reliability Assessment: Patient is at high risk for spinal cord injury/fracture due to age.

Case Study Four (cont)

Treatment: Full immobilization Reassessment: Unchanged. Diagnosis: Spinal cord injury Discussion: This patient suffered a fractured

clavicle and a spinal cord injury.

QUESTIONS

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