Selective Spinal Assessment

When to Immobilize and When Not to Immobilize

Program GoalsAll patients who are injured will be properly assessed and treated for

spinal injuries in accordance with the Spinal Assessment protocol

•Describe under what circumstances the Spine Protocol can be used•Describe the core components of the assessment•Differentiate between:

– Reliable and unreliable patients– Distracting and non-distracting injury– Normal versus abnormal neurological evaluation– Complaints of spine pain/tenderness vs. no spine pain/tenderness

•Evaluate injured patients in accordance with spinal assessment protocol and determine if immobilization is warranted•Describe the importance of proper QA/QI in spinal immobilization

History of Spinal Immobilization

• Topic of great attention over past decade• Impact on individuals and society• Pre-Hospital care of spine injury still debated

– Two dominant theories on pre-hospital immobilization

• Consequences of pre-hospital immobilization

Immobilization Theory 1

• Initial trauma to the spine is the cause of cord injury with additional care and treatment representing minimal risk of further injury – ensuring that major axial or rotational loading is minimized. – This theory argues that pre-hospital

immobilization of the spine is not needed because of the relative insignificance of post-injury movement forces compared to initial injury.

Immobilization Theory 2

• Energy from the initial traumatic incident is of significant force and that any additional movements of the spine can result in injury exacerbation with secondary cord injury.– Supporters of this theory have argued and

promoted immobilization as essential to pre-hospital secondary injury prevention

– This is a theory of immobilization based on mechanism

NEXUS Study Group

• What is NEXUS? – Multi-center investigation enrolled 34,069 patients

with 818 identified cervical spine fractures– Evaluated a 5-step clinical decision rule for cervical

spine assessment1). Midline posterior cervical spine tenderness2). Focal neurologic deficit3). Altered mental status/altered level of alertness4). Acute intoxication5). Presence of painful, distracting injury

What did NEXUS find?

• The clinical decision rule successfully identified nearly 100% of all significant cervical spine injuries

• a “missed injury” frequency of approximately 1 in 4000 patients

• application of the algorithm would have resulted in ~ 13% fewer radiographic studies at the participating centers

• Patients with significant cervical spine injuries present with physical assessment findings independent of the historical mechanism of injury

How does NEXUS apply to EMS?

• NEXUS clinical decision rule can be generalized to apply to the vast majority of prehospital populations

• Exclusions - special groups of patients with injury risk factors beyond those discovered in the typical patient population- EXAMPLE- the elderly!

EMS Providers – Extension of the ED

• EMS providers are a vital part of the delivery of emergency care– Have the tools of assessment, treatment, technology, and

participate in the QA/QI process• EMS professionals are considered an extension of the care

provided in the ED– As an extension, they should be expected to provide care

consistent with the standards practiced by their counterparts in the ED

• New/Revised Spinal Assessment Protocol– Attempts to align pre-hospital practice with ED practice and

consistent with NEXUS– “First, do no harm.” – providers are expected to use the new

protocol to the patients’ benefit in choosing who needs pre-hospital immobilization

Why Does Massachusetts Need a Spinal Assessment Protocol?

• Risks to the immobilized patient

• Use of available resources

• Consistent with best practices

Spinal Assessment

Using a modified NEXUS clinical decision method in the prehospital

setting

Prehospital Clinical Decision on Immobilization Asks 4 Questions• Is the patient RELIABLE? • Are DISTRACTING INJURIES present? • Does the patient have MOTOR or

SENSORY DEFICITS? • Does the patient have SPINE

PAIN/TENDERNESS?

Notice mechanism is NOT a factor in the decision.

Mechanism of Injury

• Does NOT necessitate c-spine immobilization

• Mechanism of injury serves only as a key to alert EMS providers to the need for a thorough spinal assessment

•Mechanism of injury should not be the sole indicator for determining spinal immobilization in trauma patients.

•NEXUS demonstrated that patients with significant cervical spine injuries present with physical assessment findings independent of the historical mechanism of injury

Concerning Mechanisms

• Axial load (e.g. diving into a body of water)• Blunt trauma (particularly to the head or neck)• Motor vehicle collision or bicycle accident (MVC

– e.g. automobile, snowmobile, motorcycle, all terrain vehicle, etc.)

• Falls from a height greater than 3 feet• Falls from a standing height represent a risk to

adult patients, particularly elderly patients, or those with pre-existing spine injuries.

• Electric shock

Risk Factors

• Additional considerations in the decision to immobilize or not

• Age: Infant to age 8 or over 65 years

• Preexisting spinal injury

• Preexisting condition altering bone density

The Age Risk Factor

• The NEXUS study showed a missed injury rate of only 1:4000, however …

• The rate of missed injury was much higher in the infant to 8 years and the over 65 age groups because of– Patient reliability– Physical exam compliance – Physiologic differences

Patient Reliability

• Is the patient reliable or unreliable?• Is the patient intoxicated, do they have an altered mental status, are

they having an acute stress reaction, or some other response that makes the provider question their alertness?

• Clearance of the spine requires the patient to be calm, cooperative, sober, and alert

• Unreliable– If the patient is deemed to be unreliable based on the

assessment - Immobilize

• Reliable• If the patient is deemed reliable, proceed to next step in spinal

assessment process

Distracting Injury• Does the patient have a distracting injury?

– Distracting injury includes any injury that produces clinically apparent pain that might distract the patient from the pain of a spine injury. Such pain would include medical as well as traumatic etiologies of pain.

• If Distracting injury is present, immobilize • If no distracting injury, proceed to next step in

spinal assessment process• What about atraumatic pain? • Non-significant traumatic injuries?

Abnormal Sensory/Motor Exam

• What is the Sensory/Motor Exam?– Commonly accepted assessment means to determine motor or

sensory deficits from spine injury.– Evaluates peripheral sensation, motor function and

proprioception • What is abnormal?

– Paresthesias or loss of sensation in extremities– Weakness or paralysis of extremities– Loss of proprioception– Loss of urethral or rectal sphincter control

• If there is abnormal sensory response/deficit or abnormal/deficit motor response present, immobilize

• If there are no abnormal sensory or motor deficits proceed to next step in spinal assessment process

Spine Pain or Tenderness• Examine the spine

– The assessment should include, but is not limited to, palpation of the posterior, midline spine, and cervical spine

• Spine Pain/Tenderness found?• If assessment finds the patient experiencing any

pain or tenderness along the spine, immobilize• If no spine pain/tenderness is found do not immobilize

the patient. Transport to the most appropriate hospital

Frequent Questions

• What if we are unsure about the patient at any point during the assessment of the spine?– Proceed to spinal immobilization– The first rule is “ do no harm”. If the provider is unsure

about the patient, the assessment, disagreement between providers, etc. always err on the side of caution

• Will there be a QA/QI process?

QA/QI Process

• Quality Assurance form– Services must complete whenever a patient is

assessed utilizing the Spinal Assessment Protocol

– Submit to local ambulance service QA/QI coordinator/medical director

– Submit an electronic copy to the Regional EMS Council for compilation

Acknowledgements

Joanne LebrunRegional CoordinatorTri-County EMS300 Main St.Lewiston, ME 04240

Jay BradshawDirectorMaine Emergency Medical ServicesDepartment of Public Safety45 Commerce Drive Suite 1 152 State House StationAugusta, ME 04333-0152

Maine Emergency Medical Services Spine protocol materialsState of New Hampshire Advanced Spinal Assessment Protocol

Questions??