Spinal Immobilization

Erin Burnham, MD [email protected]

To C

spine

or not to C

spine

?

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?

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.

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: 49 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

Goal

• Clearing C-spine in the field?

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

)

Epidemiology

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

)

• • 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

• • • “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

• • 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% ✤ American Association of Neurological Surgeons, 2001

• • “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

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

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

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

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

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

Why shouldn’t we immobilize everyone?

Adverse Effects of Spinal Immobilization

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

Kwan, et al 2004

Effects of Prehospital Spinal Immobilization: A Systematic Review of Randomized Trials on Healthy Subjects Irene Kwan, MSc;1 Frances Bunn, MSc2 ✤ 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 ✤ http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

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/kwan.pdf

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

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

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. 2009;54:663-671

Vaillancourt, et al 2009

Vaillancourt, et al 2009

• • 1,949 patients • Paramedics classification showed: 100% sensitivity • 37.7% specificity ✤ Ann Emerg Med. 2009;54:663-671

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. 2009;54:663-671

Vaillancourt, et al 2009

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

✤ Ann Emerg Med. 2009;54:663-671

Vaillancourt, et al 2009

• • 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

• “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

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/kwan.pdf

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

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

Quality Assurance

1999 NAEMSP Position Paper

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

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.”

Goal

• Clearing C-spine in the field?

• 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, Int J Emerg Med 2009; 2:13-17

Myers et al, 2009

• • When immobilization was indicated Caregivers were 77.6% compliant ✤ Myers, et al, Int J Emerg Med 2009; 2:13-17

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

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 mecha nism with the potential for causing spinal injury and meets ANY of the following clinical cri teria: 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 distr ess, etc.).

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.

PROCEDURE :

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

Jackson County Protocol

No Criteria

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 Evidence of intoxication Distracting injury, such as significant 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 or active ROM of neck rotation limited to < 45º If any answer is “yes”, then spinal immobilization indicated.

Yes

Case: 78 yo male

• • • ★ ★ • • • • ✴

Age < 10 years or > 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 < 45 °

Case: 49 yo male

• ★ • • • ★ • ★ • ★ Age < 10 years or > 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 < 45 °

Jackson County Protocol

No Criteria

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 Evidence of intoxication Distracting injury, such as significant 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 or active ROM of neck rotation limited to < 45º If any answer is “yes”, then spinal immobilization indicated.

Yes

Discussion

Discussion

• Who should be immobilized?

• How should they be immobilized?

• How can we Assure Quality?