Transcript Spinal Immobilization Harmful or Helpful?

Spinal Immobilization
Harmful or Helpful?
Jason Hoffman
EMT-P, CC EMT-P
Objectives:
 Discuss the problem of using mechanism of injury (MOI) as
the primary indicator for spinal immobilization.
 Discuss the harmful outcomes of spinal immobilization.
 Discuss a sub-set of trauma patients who should NOT be
immobilized.
 Discuss appropriate spine injury assessment as. Look at an
“ideal” protocol.
One of the most common “treatments” done by EMS everyday, whether the
patient needs it or not.
“This is just precautionary.”
“Better safe then sorry.”
“We don’t diagnose in the field.”
“I am just following protocols.”
“When in doubt…”
Mechanism of Injury (MOI)
 MOI Video
NYS EMT-B Protocol
 Suspected Spinal Injuries (Not Meeting Major Trauma Criteria)
 This protocol is for awake and stable adult and pediatric
patients NOT meeting the Major Trauma Criteria (Protocol T –
6).
 Spine injury should be suspected if blunt mechanism of injury
is present and should be treated if one or more of the following
criteria is present:
NYS EMT-B Protocol (con’t)
IMMOBILIZATION CRITERIA

1. Altered Mental Status for any reason, including possible intoxication from alcohol or drugs (GCS
<15 or AVPU other than A).
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2. Complaint of neck and/or spine pain or tenderness.

3. Weakness, tingling, or numbness of the trunk or extremities at any time since the injury.

4. Deformity of the spine not present prior to this incident.
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5. Distracting injury or circumstances (i.e. anything producing an unreliable physical exam or
history).

High risk mechanisms of injury associated with unstable spinal injuries include, but are not limited
to:
• Axial load (i.e. diving injury, spearing tackle)
• High speed motorized vehicle crashes or rollover • Falls greater than standing height

IF THERE IS ANY DOUBT, SUSPECT THAT A SPINE INJURY IS PRESENT!
Mechanism of Injury (MOI)
Mechanism of Injury (MOI)
 A CLIMBER fell 1,000ft
from the top of a
mountain – and walked
away. Adam Potter, 35,
quickly became the
subject of a helicopter
rescue mission – but
when they found him he
was standing up,
reading a map.
Why do we Immobilize?
 In theory– “to prevent
secondary cord injuries.”
 Further manipulation
makes any spinal injury
potential worse or more
severe.
 Manipulation of unstable
fractures may cause a
cord injury.
 IN REALITY:




Tradtion
Dogma
Fear of Litigation
ER criticism
 There is no evidence
immobilization
helps……at all!
Journal of Trauma. 2010 Jan; 68;
discussion 120-1.
 Name of Article– Spine Immobilization in penetrating
trauma: more harm then good?
 Immobilization is “a tradition that started decades ago” said
Dr. Demetriades. “There was never any scientific evidence
that it works.”
 The author reports first responders would have to
immobilize 1,032 patients before potentially benefiting one
person. While it only took immobilizing 66 patients before
potentially contributing to a death.
Boston Globe
Injured woman drowns while strapped to a
backboard.
 Virginia Yates, 64, of
Rockingham, Vt., was
stepping on a dock when
she slipped Tuesday, injured
her head.
 “She didn't want to go in
the ambulance. She didn't
want to be rescued”
 ``Why would you take a 64year-old lady that's got a
little bump on the head and
a strained ankle and strap
her into a situation where if
there was an accident, she
couldn't get out?"
Potentially harmful side effects of
Spinal Immobilization.
 Pain
 Increased pain which leads
to patient needing
sometimes unnecessary XRays/CT.
 Anxiety
 Cause we need our
patients to be more
anxious.
 Aspiration
 Lying supine, your risk of
aspiration increases.
 Head injury patients tend
to vomit.
 Increased ICP
 Respiratory Compromise
 15-20% reduction in
respiratory capacity.
 Skin ulcers
 Heels, buttocks, shoulders.
 Time delay
 On scene, in ER.
Patient Assessment
What’s wrong?
What’s not wrong?
What’s wrong?
What’s not wrong?
-Clear Mental Status
-Clear of New Symptoms
-Clear Physical Exam
A “CLEAR” Spine Assessment
means that there is no spine injury
and no need for spinal
immobilization.
“Clear Mental Status”
 Reliable patient
 No significant distracting
injury.
 Not intoxicated.
 Cooperative.
“Clear of New Symptoms”
 No new complaint of
significant neck or back
pain.
 No new complaint of
distal numbness or
weakness.
 Any positive findings
during this exam means
you should treat for a
spinal injury.
“Clear Physical Exam”
 Distal motor and sensory
exam is intact.
 Finger or wrist
abduction/extension
against resistance.
 Dorsiflexion or
Plantarflexion of foot or
big toe.
 No tingling or numbness
 Intact sensory perception
Ok…. So all this talk about not immobilizing.
Who SHOULD we immobilize?
 MOI for a spinal injury is
present AND…
 Pt is unconscious/not
alert.
 Patient has significant
neck/back pain with
tenderness.
 Neuro-defecits.
 Significant multi-system
trauma.
 BAD TRAUMA!
Wake County EMS
North Carolina
 Protocols are written orders from our
Medical Director that tell our
personnel what they can do to treat
patients. The Medical Director of the
Wake County EMS System has
entrusted our Advanced Life Support
personnel with progressive, standing
order-based protocols.
 The Wake County EMS System has
some of the most aggressive
protocols in the U.S.
 Our protocols are reviewed and
revised on an annual basis and must be
approved by the Wake County Peer
Review Committee and the North
Carolina Office of EMS prior to
implementation.
What a Spinal Immobilization
Protocol should look like…
 Wake County Protocol 83
Other More Effective Spinal
Immobilization Equipment
 Vacuum Mattresses
 Highly effective
 More comfortable
 Keeps patients
immobilized, warm, and
comfortable.
 Weight is more evenly
distributed.
 Many Studies published
as to the benefits in using
vacuum mattresses as
opposed to LBB.
Vacuum Mattress
Summary
 MOI is a very poor predictor of spinal injury.
 A proper Physical Assessment can rule out most spinal
injuries.
 Most EMS protocols call for unnecessary spinal
immobilization.
 Spinal Immobilization has harmful consequences.
 A different approach along with different tools will have
more beneficial results for patients in need of spinal
immobilization.