Spinal Immobilization

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Spinal Immobilization

• Erin Burnham, MD - erinburner_at_gmail.com

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To Cspine or not to Cspine?

• That is the Question!

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Framework for Discussion

• Who should be immobilized?
• How should they be immobilized?
• How can we Assure Quality?

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Who should be immobilized?
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Goal

• Clearing C-spine in the field?

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Case 78 yo male

• 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.

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Case 78 yo male

• Paramedics found patient apneic, pulseless
• EKG showed V-fib
• Patient was successfully defibrillated in field
  with ROSC.

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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.

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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

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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?

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Case 49 yo male

• Motorcycle vs Deer
• Speed estimated at 45 mph.
• Patient cant remember exactly what caused
  accident, but EMTs find dead deer nearby.
• Was wearing full leathers/helmet
• He was not intoxicated

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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

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Case 49 yo male

• CT head and C-spine obtained
• CT head is normal
• C-5 transverse process fracture identified

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Case 49 yo male

• Fracture is stable and doesnt effect his outcome
• He is transferred to a trauma center
• Uneventful recovery
• Out windsurfing a few weeks ago

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Goal

• Clearing C-spine in the field?
• Provide clear, simple and safe guidelines for
  prehospital spinal immobilization.

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Why should we immobilize patients?
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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)

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Epidemiology

• 77.8 males
• Average age of injury is increasing
• 28.7 yo in 1970s
• 39.5 yo in 2005
• Spinal Cord Injury Information Network
  (www.spinalcord.uab.edu)

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Epidemiology

• MVC - 42
• Falls - 27
• Violence - 15
• Sports - 7.4
• Spinal Cord Injury Information Network
  (www.spinalcord.uab.edu)

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Why immobilize?
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

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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
• American Association of Neurological Surgeons,
  2001

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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.
• 1970s - 55 complete neurologic lesions
• 1980s - 49
• American Association of Neurological Surgeons,
  2001

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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?
• American Association of Neurological Surgeons,
  2001

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1999 NAEMSP Position Paper
INDICATIONS FOR PREHOSPITAL SPINAL
IMMOBILIZATION Robert M. Domeier, MD, for the
National Association of EMS Physicians Standards
and Clinical Practice Committee

• http//www.naemsp.org/pdf/spinal.pdf

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1999 NAEMSP Position Paper

• 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.

• http//www.naemsp.org/pdf/spinal.pdf

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1999 NAEMSP Position Paper

• 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.

• http//www.naemsp.org/pdf/spinal.pdf

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1999 NAEMSP Position Paper

• 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

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1999 NAEMSP Position Paper

• Caveats
• Language or communication barriers
• Extremes of age
• Difficult to assess intoxication in field
• Variable interpretation of spinal pain or
  tenderness

• http//www.naemsp.org/pdf/spinal.pdf

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Why shouldnt we immobilize everyone?
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Adverse Effects of Spinal Immobilization

• Time
• Compliance
• Nausea/aspiration
• Pain/unhappiness
• Increased MD workup bias
• Ulcers
• Impaired ventilation
• Increased ICP

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Kwan, et al 2004
Effects of Prehospital Spinal Immobilization A
Systematic Review of Randomized Trials on Healthy
Subjects Irene Kwan, MSc1 Frances Bunn, MSc2

• http//pdm.medicine.wisc.edu/Volume_20/issue_1/kwa
  n.pdf

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Kwan, et al 2004

• 2004 Cochrane Review
• Systematic review of 17/4453 randomized
  controlled trials comparing types of spinal
  immobilization devices

• http//pdm.medicine.wisc.edu/Volume_20/issue_1/kwa
  n.pdf

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Kwan, et al 2004

• Adverse effects of spinal immobilization
  included
• Significant increase in respiratory effort
• Skin ischemia
• Pain/discomfort

• http//pdm.medicine.wisc.edu/Volume_20/issue_1/kwa
  n.pdf

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ATLS 2008

• 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.

• 2008 ATLS Course Manual, 8th edition

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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 17135-137

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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

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Pediatric Cervical Spines

• 3065 (9) of NEXUS patients were lt18 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

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Vaillancourt, et al 2009

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

• Ann Emerg Med. 200954663-671

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Vaillancourt, et al 2009

• 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. 200954663-671

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Vaillancourt, et al 2009
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Vaillancourt, et al 2009

• 1,949 patients
• Paramedics classification showed
• 100 sensitivity
• 37.7 specificity

• Ann Emerg Med. 200954663-671

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Vaillancourt, et al 2009

• Paramedics conservatively misinterpreted the rule
  in 320 (16.4)
• Paramedics were comfortable applying the rule in
  1,594 (81.7)

• Ann Emerg Med. 200954663-671

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Vaillancourt, et al 2009

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

• Ann Emerg Med. 200954663-671

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Vaillancourt, et al 2009

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

• Ann Emerg Med. 200954663-671

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Methods of Immobilization
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ATLS 2008

• 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.

• 2008 ATLS Course Manual, 8th edition

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Kwan, et al 2004

• The following methods were efficacious in
  restricting movement
• Collars
• Spine boards
• Vacuum splints
• Abdominal/torso strapping

• http//pdm.medicine.wisc.edu/Volume_20/issue_1/kwa
  n.pdf

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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

• American Association of Neurological Surgeons,
  2001

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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

• American Association of Neurological Surgeons,
  2001

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Quality Assurance
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1999 NAEMSP Position Paper

• Currently, spinal immobilization is often
  performed based only on the mechanism of injury
  without consideration of the patients symptoms
  and physical findings.

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1999 NAEMSP Position Paper

• 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.

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Goal

• Clearing C-spine in the field?
• Provide clear, simple and safe guidelines for
  prehospital spinal immobilization.

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Quality Assurance

• Protocol should be
• Clear
• Simple
• Safe

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Quality Assurance

• System should ensure
• Efficacy
• Compliance

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Myers et al, 2009

• Retrospective study
• 2 gold standards
• Radiographic findings
• Physician clearance without x-ray

• Myers, et al, Int J Emerg Med 2009 213-17

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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 213-17

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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, Int J Emerg Med 2009 213-17

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Myers et al, 2009

• When immobilization was indicated
• Caregivers were 77.6 compliant

• Myers, et al, Int J Emerg Med 2009 213-17

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Myers et al, 2009
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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

• Myers, et al, Int J Emerg Med 2009 213-17

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Protocols for Immobilization
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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.

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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.).

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State of Jefferson Protocol
SPINAL IMMOBILIZATION First 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. PROCED
URE For actual or suspected penetrating trauma
of the spine,then spinal immobilization
indicated For blunt trauma with mechanism for
spinal cord injury, thenspinal immobilization if
any of the following are answered yes
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Jackson County Protocol
Criteria Yes No
Age lt 10 years or gt 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 lt 45º
If any answer is yes, then spinal
immobilization indicated.
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Case 78 yo male

• Age lt 10 years or gt 65 years
• Altered mental status or loss of consciousness
• Evidence of intoxication
• 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
• Neurologic deficit
• Midline spine pain
• Midline spine tenderness
• EMT suspects spinal cord injury based on
  mechanism, history or exam findings
• Pain with active neck rotation or active ROM of
  neck rotation lt 45

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Case 49 yo male

• Age lt 10 years or gt 65 years
• Altered mental status or loss of consciousness
• Evidence of intoxication
• 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
• Neurologic deficit
• Midline spine pain
• Midline spine tenderness
• EMT suspects spinal cord injury based on
  mechanism, history or exam findings
• Pain with active neck rotation or active ROM of
  neck rotation lt 45

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Jackson County Protocol
Criteria Yes No
Age lt 10 years or gt 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 lt 45º
If any answer is yes, then spinal
immobilization indicated.
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Discussion
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Discussion

• Who should be immobilized?
• How should they be immobilized?
• How can we Assure Quality?