insanity of immobilization? an extrication device becomes a splint

8/11/2019 Insanity of Immobilization? An Extrication Device Becomes a Splint

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Insanity of

Immobilization?: AExtrication Device

Becomes a Splint

J Brent Myers MD MPHDirector | Medical Director

Wake County Dept of EMS

Raleigh, NC, USA


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The Plan

How did we get here?

What does the evidence say?

What should we do now?

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The pessimist complains about the wind;

The optimist expects it to change;

The realist adjusts his sails.

- William Arthur Ward


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J of Trauma, 2010; 68:115-121


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What Does This Tell Us?

Retrospective Review of National

Trauma Database

Limitations include only 4.3% of over

45,000 penetrating trauma patients had

spinal immobilization

Regression was performed to control

for other variables

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Overall mortality was 8.1%, with 14.7%

mortality in the immobilized group and

7.2% in the non-immobilized group

Odds of death 2.06 for immobilized vs.

non-immobilized

Only 0.01% (30 total patients out of

over 45,000) had incomplete spinal

injury and underwent surgery

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A Few Numbers

Number needed to treat to provide

benefit: 1,032

Number needed to treat to confer harm:

66

Thus, immobilization of the spine in

penetrating trauma harms 15 patients

for every one it potentially helps

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J of Trauma 1989; 29:1497-99


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Retrospective review of 61 patients

transferred for spinal injury

70% cervical spine injuries

18% thoracic spine injuries

12% lumbar spine injuries

Method of transfer

40% ground

55% rotor wing

5% fixed wing9


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No particular method of immobilization

was proscribed

95% had some type of long board

Various mechanisms of towel rolls, rigid

collars, etc. were utilized

4 patients had cervical traction

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The exact method of immobilization

had no demonstrated associated with

outcome:

No patient had ascending neuro deficit

16 of 39 patients with partial deficits had

improvements prior to hospital discharge

10 of 22 patients with complete deficitshad improvements prior to hospital

discharge

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Annals of EM 1994; 23: 48-51


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What Did They Do?

21 healthy volunteers with no history of

back disease were placed on a

backboard for 30 minutes

100% of these volunteers developed

symptoms

55% said they were moderate to severe

29% developed additional symptoms over

subsequent 48 hours

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What Symptoms Did They

Develop?

During the observation period:

Occipital headache 76%

Sacral pain 9%

Lumbar pain 7%

Mandible pain 7%

Most common delayed symptom was

headache (12%)

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J of Trauma 1983;23: 461-65


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What Did We Learn?

Tape and sandbags are the only way to

truly immobilize the c-spine

Hard collar, soft collar, and

Philadelphia collars all allow too much

movement

If we we really want to immobilize, this

is it

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PEC 2010;14:419-24


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What Did We Learn?

73 healthy volunteers were placed on

the spine board

After 30 minutes, they were removed

and tissue oxygenation was measured

There was clear evidence of

hypoperfusion of the sacral area during

the 30 minutes

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Bauer D and Kowaloski R, Annals of EM1988;17:915-918


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What Did We Learn?

15 healthy male volunteers age 23 to 28

were placed on long spine board or

KED

Forced vital capacity (FVC), Forced

Expiratory Capacity in 1 Second

(FEC1), Forced Midexpiratory Flow

(FEF), and FEC1:FVC ratio weremeasured

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What Did We Learn?

In both the LSB and KED situation, all

parameters except the FEC1:FVC ratio

were adversely affected

The clinical implications of apparent

restrictive disease in these healthy

volunteers as it relates to injured

trauma patients is not known

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This study . . . poses a question that

challenges another sacred cow of EMStraining and practice. Specifically it asks

whether out-of-hospital spinal

immobilization truly has a positive effect on

neurologic outcome. This question, which

was perhaps unimaginable a few years ago,

addresses a subject that hits hard at the

core of EMS


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Academic EM 1998;5(3):203-4


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PEC 2013;17:392-93


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Who Needs Full Deal?

Blunt Trauma and Altered LOC

Spinal pain or tenderness

Spinal DeformityNeurologic complaint

High energy mechanism and

distraction/intoxication/inability tocommunicate

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Who Does NOT Need Full

Deal?

Cleared blunt trauma patients may not

need full immobilization:

GCS 15/no intoxication/no distration

No pain

No deficits

Patient with penetrating trauma without

neuro deficits should NOT receiveimmobilization

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insanity of immobilization? an extrication device becomes a splint

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