To Backboardor Not To Backboard?

Selective Spinal Immobilization

Will Smith, MD, EMT-PMedical Director

Grand Teton National Park andJackson Hole Fire/EMS, Jackson, WY

www.wildmedconsulting.com

ObjectivesDiscuss current standard of care and

protocols regarding spine injuries.Review research on spine injuries and

evaluation/treatment standards.How to implement spine assessment

protocols into your system.

TerminologySpinal ImmobilizationSpine Stabilization(In Line Traction)Spinal Motion RestrictionSpinal Clearance ProtocolsSelective Spinal ImmobilizationFocused Spine Assessment

Spinal Immobilization1960-70’s

EMS standards developedConsensus and Common Sense

Thought to be best practiceNow changing?

MAST Pants, Massive IVF in trauma

Who needs to be immobilized?

Even if they walked away from this?

Spinal ImmobilizationDo we immobilize for:

Mechanism of Injury?

Symptoms and/or Physical findings?

Spinal ImmobilizationLittle research

Never been shown to improve outcomes

Malaysian /New Mexico StudyHauswald, Acad Emerg Med 1998

5 yr retrospective chart review of 2university hospitals

Less neurologic disability inunimmobilized Malaysian patients

Disproves many theories that previouslyjustified widespread spine immobilization

Malaysian /New Mexico StudyC-spine fractures = >2,000-6,000 NL-spine fractures = >4,200 N

Head off the end of stretcher = 40 N

Spinal ImmobilizationBUT - Standard of Care (in U.S.)

One of the most common EMS proceduresMillions of patients immobilized each yearNot necessarily in other parts of the world

Most Current EMS ProtocolsApply spinal immobilization to all

patients with potential for spine injurybased on mechanism of injury

If in doubt - IMMOBILIZE!

picture

The ResearchNo RCT to asses spinal immobilization

on trauma patient mortality, neurologicinjury, spinal stability, or adverse effectssustainedKwan, Cochrane Database 2001/2007 #2803

The ResearchNEXUS

Hoffman, et. al. - NEJM, July 2000

Canadian C-Spine RuleStiell, et. al. - JAMA, Oct 2001

NEXUSMoves to a standard of clinical spine

clearance in emergency departmentsDecreased imaging in 12.6 % (4,309 pts)

N=34,069 patients

NEXUS All 5 criteria met = No Xray

1. No midline cervical tenderness2. No focal neurological defect3. Normal alertness4. No intoxication5. No painful distracting injury

Canadian C-Spine RuleProvides another clinical spine clearance

pathwaySlightly different protocol - more if/then

Age listed as a factor (>65)Mechanism still plays a roleRange of motion of neck final test

www.caep.ca

Taking this to the field…Wilderness EMS

Rural EMS

Urban EMS

Wilderness EMS Extended Transport

2 hours to days Risks of Spinal Immobilization

Decubitus ulcers, pt. discomfortAirway concerns - vomit, blood, etc.Extrication problems, rescuer risks

**Risk vs. Benefit of SpinalImmobilization

Wilderness EMS

Wilderness EMSFocused Spine AssessmentAccepted protocol for Wilderness First

Responders (WFR)WMA, NOLS/WMI, SOLO

Rural EMSProlonged Transport

15 minutes to 1-2 hours

Pt. uncomfortableNo provider risk

Rural EMSSeveral Devices to Increase Comfort

Urban EMSRapid Transport

Less than 15 minutesPresent to emergency departments

Spine clearing protocolsNEXUS, Canadian C-Spine Rule

Xrays or CTs

Little risk to patients or EMS providers

Flight EMSPatient’s cleared in referral ED’s by CT

and board certified EM physicians placedback on boards for transfer to traumacenters.

Why change what we’re doing?Patient ComfortAirway Compromise

Vomit, Blood, PositionBreathing CompromiseSkin CompromisePatient/Provider safety in technical

settings

Some places have…MaineMichiganCaliforniaNational Park Service

Malaysia (by default)

Selective Spinal ImmobilizationProtocol Implementation

Review ResearchReferences are a startDo your own search as well!

Medical Director / Medical ControlSupportCritical for success

Selective Spinal ImmobilizationProtocol Implementation

Review Established ProtocolsState of MaineNational Park ServiceOthers

State of Maine

www.maine.gov/dps/ems

National Park Service

NPS EMS Field Manual, Version 02/05, Procedure 1150

Wilderness Medical Associates

www.wildmed.com

Selective Spinal ImmobilizationProtocol Implementation

Develop Protocol that works for yoursystemAge >65 get collar? Backboard?Peds excluded?

Selective Spinal ImmobilizationProtocol Implementation

Good QA/QI programEducation of EMS ProvidersOngoing Review of Decisions and

Outcomes

SummaryNot everyone with blunt trauma needs

spinal immobilization in the ED or in thefield

Selective spinal immobilization can andshould be done by prehospital providers

Questions???

Copy of lecture noteswww.wildmedconsulting.com

Questions?

Lecture Notes: www.wildmedconsulting.com