EMS: Spinal ImmobilizationDaniel Kwan, MD

Objectives

Present a spinal immobilization patient case.

Review the current Fresno County spinal immobilization policy.

Review reasons for spinal immobilization.

Discuss the problems with spinal immobilization

Go over the new NAEMSP and ACSCT position statement.

Go over San Joaquin’s spinal immobilization policy.

Present new revision to CCEMS Policy.

Review the original case in light of new evidence.

EMS Case

53 yo F found laying next to her Ford Ranger truck. Pulled out in front of a Semi-truck traveling Southbound traveling at approx 55mph. Pt was self extricated, & assisted to the roadway.

Major passenger front-end damage to her truck noted w/ airbag deployment. Pt amnesic to the event. Pt noted lower abd pain, w/ abrasions/bruising to area of hip bones & across chest w/ mid-line lumbar pain, & poss LOC.

Pt GCS 15. Wanted to remove c collar because she needed to vomit.

Should we allow her to remove the collar?

Fresno County Policy Implement spinal immobilization

◦ Posterior midline spinal pain or tenderness with h/o or suspicion of trauma.

◦ H/o blunt trauma with a trauma score of <= 14

◦ Injuries distracting patient from distinguishing spinal pain (e.g., pelvic fracture, multi-system trauma, crush injury to hands or feet, long bone fracture proximal to the knee/elbow, or to the humerus/femur.

◦ Severe head or facial trauma.

◦ Numbness or weakness in any extremity after trauma.

◦ LOC 2/2 trauma

◦ AMS (including drugs, alcohol, and trauma) and : No history available; or

Found in setting of possible trauma (e.g. lying at the bottom of stairs or in street); or

Near drowning with a history of probability of driving injury.

Patients with need spinal immobilization are determined by above criteria and not mechanism of injury alone.

Reasons for Spinal

Immobilization Injured patients may have unstable

injury of the spine. Need to splint “joint

above and below”.

Prevent further injury to the spinal

cord as this can have high morbidity.

Determining pre-hospital spinal injury

can be difficult, so immobilize “just in

case”.

C Collars

Philadelphia

Soft

Miami J

Aspen

Backboards

Immobilize Everyone!

ATLS- Standard of care. Part of

ABCDE

ACS (Published new guideline in

2013)

Prehospital Trauma Life Support (Until

2011)

National Association of Emergency

Medical Technicians

Immobilize Everyone!

Missed C spine Injury in Trauma patients*

◦ 740 out of 32,117 trauma pts with CSI.

◦ Delayed or missed in 34 pts (4.6%)

◦ 10 of those 34 developed permanent sequelae.

◦ However, 31/34 missed 2/2 inadequate 3 view C spine XR

ER evaluation not adequate for spinal injury**

◦ Retrospective study from 1979

◦ Symptoms and physical exam findings not sufficient

◦ Immobilization of essentially all patients with potential

for spinal injury

*Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine

injuries. J Trauma. 1993;34(3):342-6.

** Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three

hundred hospitalized patients and review of the literature. J Bone Joint Surg Am.

1979;61(8):1119-42.

Good or bad?

Patients still should get spinal

immobilization because the benefits

outweigh the risk

… right?

There are three types of patients

◦ Stable spinal fracture

◦ Unstable spinal fracture with neurological

deficit

◦ Unstable spinal fracture without neurological

deficit

Do we help those in the 3rd category?

Injured Patients May Have

Unstable Injury of Spine • 1-5 million patients receive spinal immobilization per year in

the US.

• Rate of c spine fx is 2-5%– Unstable C spine fx is 1-2%.

– Among these, ½ showed neuro deficits upon arrival. (0.5-1%)

• Blunt trauma– C spine fx rate is 1.2-3.3%

– C spine injury is 0.4-0.7%

• Penetrating Trauma*

– 1.43% had spinal fractures

– 0.38% had unstable spine fractures • 74% had completed spinal injury prior to immobilization

• NNT: 1032; NNH 66

*Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm

than good?. J Trauma. 2010;68(1):115-20.

Further Movement Can Cause

Additional Injury Is the force enough?

◦ C spine fractures when >2,000-6,000

Newtons.

◦ L spine requires >4200 Newtons (even in

elderly).

◦ Hanging 4 kg head off the end of a stretcher-

40 Newtons

◦ Force after injury is diffused.

Malaysia vs New Mexico Study

Awake pts may protect their own spine if

they are awake.

Application of Spinal

Immobilization Prevents Motion

Correctly fitted collars allow over 30 degrees of flexion/extension. 16 degrees of lateral bending. Rotation about 27 degrees.

Could increase motion C1-C2 level. Paradoxical extension.

Approx 7.7 mm motion in axial plane and 2.9 mm in the cranial caudal direction in cadaver models.

During extrication, no movement reduction is added to C-collar by using a backboard.

Immobilization is a relatively

harmless measure, so apply as

“a precaution”.

Complications

◦ Back pain

◦ Respiratory Compromise

◦ ICP increase

◦ Increased aspiration

◦ Airway management difficulty

◦ Distracting an unstable fracture

◦ Delay in arriving to trauma center

◦ Cost

Back Pain

Small Prospective Study*

◦ 21 healthy volunteers

◦ Immobilized for 30 minute period.

◦ Results: occipital headache, sacral/lumbar

back pain, mandibular pain most

common.

◦ 55% subjects graded their symptoms as

moderate to severe.

◦ 29% developed symptoms 48 hours later

*Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal

immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48-51.

Respiratory Compromise

Backboard alone*

◦ 15 nonsmoking male volunteers

◦ Zee Extrication Device and Long Spinal board

◦ Sig differences in FVC and FEV1.

Backboard and cervical collar**

◦ 39 randomized crossover laboratory study

◦ Immobilized with philadelphia collar on hard wooden

backboard or Scandinavian vacuum mattress.

◦ 15% decrease in FEV1 on average. (worse at extremes of

age).

◦ Vacuum mattress more comfortable. *Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary

function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17(9):915-8.

**Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp

Emerg Care. 1999;3(4):347-52.

Increased ICP

Head injury occurs in 34% of trauma

patients

27% of trauma deaths

◦ More common than c spine injury

◦ AMS difficult to clear c spine.

Rise in ICP is 4.5 mm Hg on average. *

Mechanism

◦ Painful stimulus

◦ Disrupted Venous Flow***Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral

perfusion pressures. Anaesthesia. 2001;56(6):511-3.

**Stone MB, Tubridy CM, Curran R. The effect of rigid cervical collars on internal jugular vein

dimensions. Acad Emerg Med. 2010;17(1):100-2.

Increased Aspiration

Decreased ability to open mouth

Difficulty swallowing

Head Injury patients can vomit.

Houghton DJ, Curley JWA. Dysphagia caused by a hard cervical

collar. British Journal of Neurosurgery 1996;10(5):501–2.

Difficulty Managing Airway

Collar vs Manual Inline Stabilization (MILS)

◦ Manual inline stabilization (MILS) better than collar and board.

◦ 56% had 1 grades better and 10% had 2 grades better with MILS

MILS only **

◦ 200 Elective surgery patients

◦ Single blinded randomization to MILS vs not

◦ 50% had failure rate in 30 seconds with MILS vs 5.7% without.

*Heath KJ. The effect of laryngoscopy of different cervical spine immobilisation techniques. Anaesthesia.

1994;49(10):843-5.

** Thiboutot F, et al. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult

orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth.

2009;56(6):412-8.

Distracting Unstable Fracture

Ankylosing Spondylitis

◦ Extension of spine during

immobilization neuro deficits.

Malaysia (No collar) vs New Mexico

(routine collar)

◦ Increased frequency of neurological

deterioration

◦ More overall neuro disability.

Delayed Resuscitation

Prehospital care◦ Trauma pts may have better outcomes with

less.

◦ Severe trauma pts had better outcomes when transported with private vehicle.

◦ Canadian study- ALS programs worsened outcomes in those with severe TBI.

Penetrating trauma patients◦ Retrospective analysis of 45,284 patients

◦ OR 2.06 (1.35-3.13) of death in those immobilized

◦ NNT 1032, NNH 66

Cost

Backboards/C-collars

C-collars beget imaging to “clear the c

collar”.

Increased morbidity.

Prehospital Trauma Life

Support Recommendations (2011)◦ There are no data to support routine spinal

immobilization in patients with penetrating trauma to the neck or torso.

◦ There are no data to support the routine spinal immobilization in patients with isolated penetrating trauma to the cranium.

◦ Spinal immobilization should never be done at the expense of physical examination or correction of life-threatening conditions in patients with penetrating trauma.

◦ Spinal immobilization may be performed when a focal neurological deficit is noted although there is little evidence of benefit even in these cases.

National Association of EMS

Physicians and ACS on Trauma Position Statement on Backboards 2013

Utilization of backboards should be

judicious.

◦ Appropriate patients for immobilization

Blunt trauma and AMS

Spinal Pain or Tenderness

Neurologic Complaint

Anatomic deformity of the spine

High energy mechanism of injury or any of the

following

Drug or ETOH intoxication

Inability to communicate

Distracting injury

National Association of EMS

Physicians and ACS on Trauma Backboard Immobilization not

necessary◦ Normal level of consciousness (GCS 15)

◦ No spine tenderness or anatomic abnormality

◦ No neurologic findings of complaints

◦ No distracting injury

◦ No intoxication

Penetrating trauma to the head, neck, and torso and no evidence of spinal injury should not be immobilized on a backboard

National Association of EMS

Physicians and ACS on Trauma Spinal precautions can be maintained

by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and maybe most appropriate for:◦ Pts who are ambulatory at scene

◦ Pts who must be transported for protracted time, particularly prior to interfacility transfer

◦ Pts for whom backboard is not otherwise indicated

San Joaquin County Policy

Apply C spine immobilization in blunt force trauma pts◦ Posterior midline cervical tenderness or pain

◦ Distal numbness, tingling, weakness, paresthesia

◦ Paralysis

◦ Neck guarding or restricted ROM

◦ GCS motor score 5

◦ Unconscious pt except GLF

Do not apply c spine immobilization◦ Penetrating Trauma

◦ Unconscious adult GLF

◦ Cardiac arrest

Backboards may be used for extrication or movement at scene, but not for transport to the hospital.

CCEMS Policy RevisionsSpinal Immobilization

No Neck Pain

or Tenderness

Neck Pain or

Tenderness

Neuro Signs

or Symptom

Altered

Mental Status

AmbulatoryPosition of

Comfort

Gurney

Position of

Comfort

with/without

Support

FullPosition of

Comfort

Non-

ambulatory

Position of

Comfort

Gurney

supine

Position of

Comfort with

extrication

support

Full Full

Severe

Multisystem

Trauma

Full Full Full Full

Back to the case…

Pt is GCS 15 and ambulatory (self-

extricated)

Back pain, abd pain but no neck pain.

No neurological symptoms

Per our new policy, this could be a

person that could be transported

without cervical collar or backboard.

Summary

True unstable spinal injuries are rare.

Ambulatory patients may protect their own spine.

C collars do not fully immobilize neck movement.

Spinal immobilization is not without complications.

New guidelines do not recommend routine backboard usage. ◦ Use NEXUS and Canadian C spine as guides

Other systems are changing their policies to have more judicious usage of spinal immobilization.

CCEMS is revising the current policy as well

References1. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed

cervical spine injuries. J Trauma. 1993;34(3):342-6.

2. Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am. 1979;61(8):1119-42.

3. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good?. J Trauma. 2010;68(1):115-20.

4. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214-9.

5. Bandiera G, Stiell IG, Wells GA, Clement C, De Maio V, Vandemheen KL, Greenberg GH, Lesiuk H, Brison R, Cass D, Dreyer J, Eisenhauer MA, Macphail I, McKnight RD, Morrison L, Reardon M, Schull M, Worthington J, on behalf of the Canadian C-Spine and CT Head Study Group The Canadian C-spine rule performs better than unstructured physician judgment. Ann EmergMed. 2003;42:395–40.

6. James CY, Riemann BL, Munkasy BA, Joyner AB: Comparison of Cervical Spine Motion During Application Among 4 Rigid Immobilization Collars. J AthlTrain 2004, 39(2):138-145.

7. Hughes SJ. How effective is the Newport/Aspen collar? A prospective radiographic evaluation in healthy adult volunteers. J Trauma. 1998;45(2):374-8.

8. Chin KR, Auerbach JD, Adams SB, Sodl JF, Riew KD. Mastication causing segmental spinal motion in common cervical orthoses. Spine. 2006;31(4):430-4.

References1. Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim

RS. Cervical spine motion during extrication. J Emerg Med. 2013;44(1):122-7.

2. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48-51.

3. Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17(9):915-8.

4. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. PrehospEmerg Care. 1999;3(4):347-52.

5. Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia. 2001;56(6):511-3.

6. Stone MB, Tubridy CM, Curran R. The effect of rigid cervical collars on internal jugular vein dimensions. Acad Emerg Med. 2010;17(1):100-2.

7. Thumbikat P, Hariharan RP, Ravichandran G, Mcclelland MR, Mathew KM. Spinal cord injury in patients with ankylosing spondylitis: a 10-year review. Spine. 2007;32(26):2989-95.

8. Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008;178(9):1141-52.

9. EMS spinal precautions and the use of the long backboard. Prehosp EmergCare. 2013;17(3):392-3.

Thanks!