spinal immobilization erin burnham, md - [email protected]@gmail.com

Spinal ImmobilizationErin Burnham, MD - [email protected]

To Cspine or not to Cspine?That is the Question!

Framework for Discussion

• Who should be immobilized?

• How should they be immobilized?

• How can we Assure Quality?

Who should be immobilized?

Goal

• Clearing C-spine in the field?

• An 78 yo male brought in Code-3 by EMS after cardiac arrest. Dispatched for “possible heart attack”.

• Hx: Had been fishing that morning with son with no complaints. Stood up from recliner chair and collapsed onto ground.

Case: 78 yo male

• Paramedics found patient apneic, pulseless

• EKG showed V-fib

• Patient was successfully defibrillated in field with ROSC.

Case: 78 yo male

• Pt arrives in ED in NSR, intubated with no spontaneous respiratory effort.

• He is placed in C-collar in ED because noted to have contusion on forehead.

Case: 78 yo male

• CT scan of head is normal

• CT scan of C-spine revealed type II odontoid fracture with displacement

• EKG and labs unremarkable

Case: 78 yo male

• Family elects to have patient extubated, and he expires in ED

• Would pre-hospital immobilization have effected outcome?

• Medico-legal liability?

Case: 78 yo male

• Motorcycle vs Deer

• Speed estimated at 45 mph.

• Patient can’t remember exactly what caused accident, but EMT’s find dead deer nearby.

• Was wearing full leathers/helmet

• He was not intoxicated

Case: 49 yo male

• Only c/o L. Shoulder pain

• Patient arrives not in spinal immobilization

• Placed in c-collar in ED

• L. Scapula fracture, 2 rib fractures and small L. PTX identified

Case: 49 yo male

• CT head and C-spine obtained

• CT head is normal

• C-5 transverse process fracture identified

Case: 49 yo male

• Fracture is stable and doesn’t effect his outcome

• He is transferred to a trauma center

• Uneventful recovery

• Out windsurfing a few weeks ago

Case: 49 yo male

Goal


• Provide clear, simple and safe guidelines for prehospital spinal immobilization.

Why should we immobilize patients?

Why immobilize?• 253,000 people in US living with

spinal cord injuries

• 12,000 new cases each year

• In US, cost of MVC related SCI estimated $34.8 billion per year

• 5 million patients in the US receive spinal immobilization each year

✤ Spinal Cord Injury Information Network (www.spinalcord.uab.edu)

Epidemiology• 77.8% males

• Average age of injury is increasing:

• 28.7 yo in 1970’s

• 39.5 yo in 2005


Epidemiology

• MVC - 42%

• Falls - 27%

• Violence - 15%

• Sports - 7.4%


Why immobilize?

• AANS 2001 Guidelines for Pre-Hospital Cervical Spinal Immobilization following trauma:

• “There is insufficient evidence to support treatment standards”

• “There is insufficient evidence to support treatment guidelines.”

✤ American Association of Neurological Surgeons, 2001

Why immobilize?

Why immobilize?

• “It is estimated that 3 to 25% of spinal cord injuries occur after the initial traumatic insult”:

• During extrication

• During transit


Why immobilize?

Why immobilize?• Over the last 30 years there has been

a dramatic improvement in the neurologic status of spinal cord injured patients arriving in the emergency department.

• 1970’s - 55% complete neurologic lesions

• 1980’s - 49%


Why immobilize?

Why immobilize?

• “This has been attributed to the development of Emergency Medical Services initiated in 1971, and the pre-hospital care (including spinal immobilization) rendered by EMS personnel.

• What about NHTSA?


Why immobilize?

INDICATIONS FOR PREHOSPITAL SPINAL IMMOBILIZATIONRobert M. Domeier, MD, for the National Association of EMS Physicians Standards and Clinical Practice Committee

1999 NAEMSP Position Paper

✤ http://www.naemsp.org/pdf/spinal.pdf


• “There have been no reported cases of spinal cord injury developing during appropriate normal patient handling of trauma patients who did not have a cord injury incurred at the time of the trauma.”



• “Although early emergency medical literature identified mis-handling of patients as a common cause of iatrogenic injury, these instances have not been identified anywhere in the peer-reviewed literature and probably represent anecdote rather than science.”



• Spine immobilization is indicated with a significant mechanism of injury and at least one of following criteria:

• Altered mental status

• Evidence of intoxication

• A distracting painful injury (e.g. Long-bone extremity fracture)

• Neurologic deficit

• Spinal pain or tenderness


• Caveats:

• Language or communication barriers

• Extremes of age

• Difficult to assess intoxication in field

• Variable interpretation of spinal pain or tenderness


Why shouldn’t we immobilize everyone?

Adverse Effects of Spinal Immobilization

• Time

• Compliance

• Nausea/aspiration

• Pain/unhappiness

• Increased MD workup bias

• Ulcers

• Impaired ventilation

• Increased ICP

Effects of Prehospital Spinal Immobilization: A Systematic Review of Randomized Trialson Healthy SubjectsIrene Kwan, MSc;1 Frances Bunn, MSc2

Kwan, et al 2004

✤ http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

Kwan, et al 2004

• 2004 Cochrane Review

• Systematic review of 17/4453 randomized controlled trials comparing types of spinal immobilization devices


Kwan, et al 2004

• Adverse effects of spinal immobilization included:

• Significant increase in respiratory effort

• Skin ischemia

• Pain/discomfort


ATLS 2008

✤ 2008 ATLS Course Manual, 8th edition

• Several studies have shown correlation between the length of time on a rigid spine board and the development of pressure ulcers.

• “A paralyzed patient who is allowed to lie on a hard board for more than 2 hours is at high risk for serious decubitus ulcers.”

Increased ICP

• Cervical collars have been associated with elevations of intracranial pressure (ICP)

• Prospective study of 20 patients

• Rigid Philadelphia collar

• Significant (p = .001) increase in ICP from 176.8 to 201.5 mm H20

✤ Kolb, et al, Ann Emerg Med. 1999; 17:135-137

NEXUS National Emergency X-Radiography Utilization

Study

• Prospective, multi-hospital

• Cervical spine clearance if no

• Intoxication

• Distracting injury

• Neuro deficit

• Midline spine tenderness

• 34,069 at risk for cervical fracture from blunt

• 818 (2.4%) cervical spine injuries

• Missed 8 (99% sensitive, 12% specific)

• Good confidence intervals (98-99.6%)

• Only 2 injuries deemed clinically significant

✤ Hoffman, et al, NEJM, July 13, 2000, Vol. 343, No. 2; p. 94 - 99

Pediatric Cervical Spines

• 3065 (9%) of NEXUS patients were <18 years

• 0.98% cervical spine injury

• No SCIWORA

• Decision rule 100% sensitive

• Confidence intervals 87-100%

✤ Viccellio, et al, Pediatrics, Aug 2001, Vol. 108, No. 2

Vaillancourt, et al 2009

• The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics

✤ Ann Emerg Med. 2009;54:663-671


• Prospective cohort study

• Alert and stable trauma patients

• Advanced and basic care paramedics interpreted rule

• All were then immobilized and evaluated in ED

✤ Ann Emerg Med. 2009;54:663-671


• 1,949 patients

• Paramedics classification showed:

• 100% sensitivity

• 37.7% specificity

✤ Ann Emerg Med. 2009;54:663-671


• Paramedics conservatively misinterpreted the rule in 320 (16.4%)

• Paramedics were comfortable applying the rule in 1,594 (81.7%)

✤ Ann Emerg Med. 2009;54:663-671


• Application of the criteria could have reduced 731 (37.7%) out-of-hospital immobilizations.

✤ Ann Emerg Med. 2009;54:663-671


• Conclusion:

• Paramedics can apply the Canadian C-spine rule reliably without missing any important cervical spine injuries.

✤ Ann Emerg Med. 2009;54:663-671

Methods of Immobilization

ATLS 2008

✤ 2008 ATLS Course Manual, 8th edition

• “Cervical spine injury requires continuous immobilization of the entire patient with a semirigid cervical collar, head immobilization, backboard, tape, and straps before and during transfer to a definitive-care facility.”

Kwan, et al 2004

• The following methods were efficacious in restricting movement:

• Collars

• Spine boards

• Vacuum splints

• Abdominal/torso strapping


Neutral Postion

• The “neutral position” is poorly defined:

• “The anatomic position of the head and torso that one assumes when standing and looking ahead”

• 12° of cervical spine extension on lateral radiograph


Neutral Postion

• “McSwain et al determined that more than 80% of adults require 1.3 cm to 5.1 cm of padding to achieve neutral positioning.”

• This appears to be a reference to PHTLS text


Quality Assurance


• “Currently, spinal immobilization is often performed based only on the mechanism of injury without consideration of the patient’s symptoms and physical findings.”


• “EMS systems adopting procedures for clearance from prehospital spinal immobilization must develop mechanisms for education and quality improvement to ensure safe and appropriate use of clearance protocols.”

Goal


• Provide clear, simple and safe guidelines for prehospital spinal immobilization.

Quality Assurance

• Protocol should be:

• Clear

• Simple

• Safe

Quality Assurance

• System should ensure:

• Efficacy

• Compliance

Myers et al, 2009

• Retrospective study

• 2 gold standards:

• Radiographic findings

• Physician clearance without x-ray

✤ Myers, et al, Int J Emerg Med 2009; 2:13-17

Myers et al, 2009• Guideline allows exclusion of spinal

immobilization if:

• No pain, stiffness, soreness or tenderness in the neck or back

• No alteration in LOC

• No intoxication

• No other painful or distracting condition

• No signs or symptoms of shock✤ Myers, et al, Int J Emerg Med 2009; 2:13-17

Myers et al, 2009

• Included 942 patients

• 384 did not meet criteria for clearance

• 36 (9.4%) had fractures

• 558 patients met criteria for clearance

• 7 (1.3%) had fractures


Myers et al, 2009

• When immobilization was indicated

• Caregivers were 77.6% compliant


Myers et al, 2009

Myers et al, 2009

• The median age of the fractures that were immobilized was 48 years

• The median age of the 7 fractures not immobilized was 82 years

• An age extreme criteria may enhance this guideline


Protocols for Immobilization

Columbia Gorge Protocol• SPINAL STABILIZATION

• Trauma patients with the following injuries or signs/symptoms should be treated with full spinal immobilization.

• Head or facial injury

• Decreased level of consciousness

• Head, neck or back pain, consider spinal stabilization.

• Any patient meeting the trauma system criteria

• The level of treatment given other patients will be left to the discretion of the senior EMT. The mechanism of injury should be considered in this decision. This protocol is not intended to discourage the use of full spinal immobilization on any patient.

• Consider padding the upper half of the board for patient comfort if time and circumstances permit.

Multnomah County Protocol

• Selective Spinal Immobilization

• Immobilize using a long spine board if the patient has a mechanism with the potential for causing spinal injury and meets ANY of the following clinical criteria:

• A. Altered mental status.

• B. Evidence of intoxication.

• C. Distracting pain/injury (extremity fracture, drowning, etc.).

• D. Neurologic deficit (numbness, tingling or paralysis)

• E. Spinal pain or tenderness.

• F. Distracting situation (communication barrier, emotional distress, etc.).

State of Jefferson Protocol

SPINAL IMMOBILIZATIONFirst Responder, EMT-B, EMT-I, EMT-P

INDICATIONS:

Patients with a risk of cervical, thoracic, or lumbar spine injury based on mechanism of injury and findings of spinal pain, tenderness or neurologic abnormality.

PROCEDURE:

For actual or suspected penetrating trauma of the spine,then spinal immobilization indicatedFor blunt trauma with mechanism for spinal cord injury, thenspinal immobilization if any of the following are answered “yes”:

Jackson County ProtocolCriteria Yes No

Age < 10 years or > 65 years

Altered mental statusor loss of consciousness

Significant mechanism of injury, such ashigh speed motor vehicle crashaxial loadingrollover motor vehicle crashfall from greater than standing height

Evidence of intoxication

Distracting injury, such assignificant fracture or laceration

Neurological deficit

Midline spine pain (subjective)

Midline spine tenderness (objective)

EMT suspects spinal cord injury based on mechanism, history or exam findings.

Pain with active neck rotation oractive ROM of neck rotation limited to < 45º

If any answer is “yes”, then spinal immobilization indicated.

★ Age < 10 years or > 65 years

★ Altered mental status or loss of consciousness


• Significant mechanism of injury, such as high speed motor vehicle crash, axial loading, rollover motor vehicle crash, fall from greater than standing height

• Distracting injury, such as significant fracture or laceration


• Midline spine pain


✴ EMT suspects spinal cord injury based on mechanism, history or exam findings

• Pain with active neck rotation or active ROM of neck rotation < 45°

Case: 78 yo male

• Age < 10 years or > 65 years

★ Altered mental status or loss of consciousness


★ Significant mechanism of injury, such as high speed motor vehicle crash, axial loading, rollover motor vehicle crash, fall from greater than standing height

★ Distracting injury, such as significant fracture or laceration


• Midline spine pain


• EMT suspects spinal cord injury based on mechanism, history or exam findings

★ Pain with active neck rotation or active ROM of neck rotation < 45°

Case: 49 yo male

Jackson County ProtocolCriteria Yes No

Age < 10 years or > 65 years

Altered mental statusor loss of consciousness

Significant mechanism of injury, such ashigh speed motor vehicle crashaxial loadingrollover motor vehicle crashfall from greater than standing height

Evidence of intoxication

Distracting injury, such assignificant fracture or laceration

Neurological deficit

Midline spine pain (subjective)

Midline spine tenderness (objective)

EMT suspects spinal cord injury based on mechanism, history or exam findings.

Pain with active neck rotation oractive ROM of neck rotation limited to < 45º

If any answer is “yes”, then spinal immobilization indicated.

Discussion

Discussion

• Who should be immobilized?

• How should they be immobilized?

• How can we Assure Quality?

spinal immobilization erin burnham, md - [email protected]@gmail.com

Documents

yo male slide

c spine

spinal cord injuries

intoxicated case

goal clearing cspine

normal ct scan of c

labs unremarkable case

ct head