EMS Field Cervical Spine Assessment Protocol

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EMS Field CervicalSpine Assessment Protocol

• VVEMS
• Todd Lang, MD
• EMS Medical Director

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Why do this?

• Current practice it totally variable
• Clear, reproducible local standard
• Easy tool to measure compliance
• Formal training in cspine evaluation
• Can modify in future to incorporate new data

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Objectives

• Discuss Risk Benefit of C Spine Immobilization
• Identify ways to safely lower use of C Spine
  Immobilization
• Review structure and function of the nervous
  system

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Objectives

• Identify situations in which full immobilization
  is indicated
• Identify situations in which full spinal
  immobilization is not indicated
• Review VVEMS spinal assessment protocol
• Maintain appropriate level of suspicion for this
  dangerous but rare condition

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Terminology
We use the words Spinal Assessment to indicate
that we are evaluating the spine for risk of
injury. We are not Clearing it or
guaranteeing that there are no injuries. We are
using medical evidence to formulate a policy to
balance the risks and benefits of immobilization
for the bulk of our patients.
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Who can use this protocol?

• Only those EMS providers who have successfully
  completed the training for the VVEMS Spinal
  Assessment.
• This be the didactic portion
• Then, pass the test
• Then use it!

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What is NEXUS?

• National Emergency X-radiography Utilization
  Study
• Prospective study with 34,069 patients
• Evaluated decision rule to identify patients with
  cervical injury by clinical exam who did not need
  radiography

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How do we decide in the ED?

• Two main studies
• NEXUS
• Canadian C-Spine Rule

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NEXUS

• Out of 34,069 patients, the decision rule
  identified 810 of 818 patients with injury
• 2 of blunt trauma patients had cervical injury
• Two patients classified as unlikely to have
  injury actually had a cervical injury.
• One of the two one missed patients required
  surgery.

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NEXUS

• Did not include MOI
• Did include altered LOC/intoxication, Midline
  tenderness, distracting injury, neuro exam,
• Up to age 60

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Stable, GCS 15 pts. A dangerous mechanism is
considered to be a fall from an elevation of gt3
feet or 5 stairs an axial load to the head
(e.g., diving) a motor vehicle collision at high
speed (gt100 km per hour) or with rollover or
ejection a collision involving a motorized
recreational vehicle or a bicycle collision. A
simple rear-end motor vehicle collision excludes
being pushed into oncoming traffic, being hit by
a bus or a large truck, a rollover, and being hit
by a high-speed vehicle.
Canadian C Spine Rule
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Does C-Spine Immobiliztion Work?

• No one really knows.

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Hauswald Study

• Compared Malaysian patients to New Mexico
  patients.
• Worse outcomes from New Mexico spinal cord
  injuries more likely to have disability
• Not definitive, but very provocative
• No evidence to the contrary, either, yet

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Benefits of Immobilization

• Standard of Care
• May prevent injury worsening
• Thought to prevent liability
• Not so convincing, are they?

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Harms of C-spine Immobilzation

• Pain
• Anxiety
• More radiographs and CT scans
• Money
• Pressure sores
• Harder to manage airway
• Change in lung function

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Why immobilize anyone?

• Unstable cervical injury is rare.
• Any protocol needs to
• emphasize safety (sensitivity) over efficiency
  (specificity)
• balance the small benefit of avoiding spinal
  immobilization in the many patients without
  injury against the possibly catastrophic harm
  associated with failing to immobilize the rare
  patient with significant spinal injury

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The Skull

• Made up of bones that form immovable joints
• Know the helmet bones of the skull
• Frontal, parietal, temporal, and occipital
• Important in describing injury location
• Mandible
• the lower jaw bone
• Maxilla
• the upper jaw bone

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Skull

• Temporal bone (Basilar) skull fractures often
  diagnosed by exam
• Raccoon eyes
• Battles sign
• The middle meningeal artery runs within the
  temporal and parietal bones
• Fractures associated with epidural bleeding

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Skull Exam

• Lumps, dents, wounds describe by location and
  size and structures seen
• Ears blood or not, TM normal or not
• GCS dont say in out. Use a number.
• Pupils/CN exam
• Jaw function, voice, airway

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CSF (cerebrospinal fluid) bathes brain and spinal
cord

• Patient with closed head injury who has a runny
  nose is leaking CSF (basilar skull fracture)
• Can also come out of ears

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The Spine

• Cervical (7)
• Thoracic (12)
• Lumbar (5)
• Sacral 5 (1 fused)
• Coccyx 4(1 fused)

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The Vertebrae

• The spinal cord rests between the bony processes
  and body of the vertebrae.
• The spine of the vertebra is superficial and can
  be palpated when performing a physical exam.

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Spinal Cord

• Part of the central nervous system (CNS)
• Nerves leaving each vertebra have a specific
  function.
• Bathed in cerebrospinal fluid (CSF).
• Protected by bony vertebrae.

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Cervical nervesC3,4,5 keeps the diaphragm
alive!

• C1
• C2 neck rotation and sensation
• C3 spontaneous breathing
• C4 spontaneous breathing
• C5 diaphragm, shrugging shoulders
• C6 flexion of elbow
• C7 extension of elbow

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Cases Requiring Full Immobilization
Patients meeting any of the following criteria
must be fully immobilized.

1. Higher Risk or unknown mechanism of injury
2. Altered LOC (GCSlt15, or changed)
3. Presence of other distracting painful injury
4. Subjective spine pain
5. Subjective neurological deficit
6. Objective neurological deficit
7. Objective midline spine tenderness
8. Any pain with unassisted neck motion

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MOI with some risk

• Fall
• MVA
• High energy injury
• Even minor MOI in right (wrong!) patient

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Higher Risk MOI

• Violent impact to the head, neck, torso, or
  pelvis.
• Sudden acceleration, deceleration, or lateral
  bending forces to the neck or torso.
• Falls from greater than 3 feet. Elderly patients
  (gt65) falling out of bed or from standing height.
• Ejection or fall from motorized or human powered
  transportation device.
• Axial load (diving).
• Unwitnessed loss of consciousness/syncope with
  head trauma

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Mechanism of Injury

• A relatively weak tool, but one which is easy and
  free.
• One which has been used more in the past than in
  the present and future
• No really good data to tell us what MOI can give
  you a spinal injury?
• We will use this as a part of our first revision
  of spinal immobilization protocol

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Altered Level of Alertness

• Clearance of the cervical spine requires that the
  patient be calm, cooperative, clinically sober,
  and alert.
• Includes patients that are poor historians.
• Children and toddlers
• Some elderly are they altered from usual?
• Generally, GCS must be 15 to clear spine

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Reliable Physical Exam

• Language
• GCS/Capacity/reproducibility
• Hearing
• Ability to sense pain

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LOC/Intox

• What about 2 beers?
• Chronic drunks?
• Chronic narcotics?
• Other drugs like meth?
• Just anxious?
• No clear answer from literature
• Probably more to lose than to gain in this group
  by not immobilizing

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Distracting Injury

• Of variable use
• Some injuries are more distracting than others
• Not part of Canadian C-S rule
• Is part of NEXUS, but was left up to the
  attending physician to define it
• Part of EMS criteria for now
• Less used in ED assessment now

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Presence of Distracting Injury

• Any injury that produces pain that impairs the
  patients ability to appreciate other injuries
• Head injury
• Long bone fractures
• Large lacerations
• Abdominal or pelvic pain
• Large burns
• Medical conditions cardiac pain or difficulty
  breathing
• This is an equivocal and poorly defined concept
• Will remain a part of our EMS algorithm.

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Subjective Neurological Deficit

• Patient complains of numbness, tingling, pins and
  needles, shooting arm pain, etc.
• Patient complains of decreased strength or
  decreased ability to move limbs
• Any patient who describes transient numbness and
  tingling should be fully immobilized even if
  symptoms have resolved

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Subjective Spine Pain

• Patient complains of cervical or thoracic spine
  pain.
• Do you have any neck or back pain?
• If yes, immobilize.

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Objective Neurological Deficit

• Patient cannot move an extremity
• Patients extremities are flaccid
• (Patient has abnormal motor reflexes)
• Generally grips, push pull, flex/extend feet,
  intact gross sensory in all 4.

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Objective Spine Tenderness

• Patient has tenderness upon palpation of the
  cervical or thoracic spine.
• You must palpate each cervical and thoracic
  vertebra
• Continue down spine
• Apply an axial load to top of head

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Practice exam!

• Demo up front 2 people
• Same every time you do it
• You wont forget a step that way.
• Stop at first positive sign and immobilize.
• Dont do ROM if they have pain, n/t, or other
  sign!

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Other Exam Abnormality

• Your physical exam reveals
• Swelling
• Bruising or redness
• Abrasions
• Deformity

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Abnormal Motor or Sensory

• This has room for error and was source of error
  in the studies of C-S
• Pain down arm/leg, numb/tingle, even transient sx
• Bony Tenderness (midline, on the spine)
• Pain with ROM

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Beware the Stinger

• Transient shooting pain down the arm
• Common in football
• This is a subjective neuro sign and is grounds
  for concern and immobilization
• You cant get this without injury to a nerve

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Pain with Unassisted Neck Motion

• If ALL of the previous criteria have been
  satisfied, the final step is to ask the patient
  to move their neck without your assistance.
• If the patient has any subjective pain, they need
  to be fully immobilized.
• Look to the left and right. Now touch your chin
  to your chest. Now look back over your head.

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Bottom Line

• Can they reliably, reproducibly, and convincingly
  understand you, cooperate, and pay attention for
  the exam and have a MOI that should not have
  broken their neck?
• If not, immobilize.

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Guiding Principles

• The VVEMS Spinal Assessment Protocol is designed
  to allow EMS providers to assess and transport
  those few blunt trauma patients for whom
  significant injury is unlikely without full
  immobilization.
• Once one criterion for immobilization is
  positive, immobilize and transport the patient.

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Guiding Principles

• Patients who satisfy all of the criteria in the
  Protocol and who request EMS transport may be
  transported without full spinal immobilization.
• All Protocol criteria must be carefully evaluated
  and documented for all patients transported
  without full spinal immobilization.

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VVEMS C-Spine Assessment Tool
Higher risk MOI?
Yes
No
Yes
Altered level of alertness?
No
Yes
Distracting injury?
Full Spinal Immobilization
No
Yes
Objective or subjective neurological deficit?
Yes
No
Neck pain or tenderness?
Yes
No
Pain with unassisted neck motion?
No
Transport without full spinal immobilization
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Sample Documentation

• MVC low speed
• GCS15, clear speech
• No numb/tingle/pain down arms, moves all 4
• No sig injuries
• No spine tenderness
• Normal ROM w/o pain
• Immob not indicated

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Maine 2002 C-spine
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(No Transcript)
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Guiding Principles

• EMS providers should involve online medical
  direction for any difficult cases, including
  patients who meet criteria for spinal
  immobilization, request EMS transport, and refuse
  immobilization.
• If a patient requests transport with full
  immobilization, EMS providers should comply with
  their wishes independent of significant injury
  risk.

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Guiding Principles

• The default management of any blunt trauma
  patient in the field is full immobilization.
• EMS providers must use full c-spine
  immobilization for cases that are vague.
• Let us err on the side of caution because a
  single bad outcome will cause endless suffering

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Conclusion

• Always use full immobilization for patients with
  an unknown or significant MOI.
• Elderly patients are more prone to orthopedic
  injuries and may not present with obvious signs
  and symptoms of injury.
• Contact online Medical Direction for questions in
  the field.

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Conclusion

• A patient with blunt trauma should be fully
  immobilized unless ALL criteria of the VVEMS
  Spinal Assessment Protocol are met.

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Dont fall asleep at the wheel just because spine
injuries are rare! Assess each patient
carefully!
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Sources

• Maine 2002 Spinal Assessment Protocolhttp//www.m
  aine.gov/dps/ems/docs/assessment20book.pdf
• Hauswald M, et al. Out-of-hospital spinal
  immobilization its effect on neurologic injury
  http//www.aemj.org/cgi/content/abstract/5/3/214
• EAST Practice Management Guidelines for
  Identifying Cervical Spine Injuries Following
  Trauma http//www.east.org/tpg/chap3.pdf
• Canadian C-Spine rule
• NEXUS paper

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Questions?