1. Selective Spinal Immobilization Matt Dunn, DO Dept. of Emergency Medicine Albany Medical Center

2. Objectives  Understand the background of spinal immobilization.  Understand the rationale for developing a selective spinal immobilization protocol.  Review the data on the selective spinal immobilization.  Cases and application of protocol

3. The Problem  Between 2-4% of blunt trauma patients sustain cervical spine injury  Early trauma education suggested mechanism of injury as a sole reason for treatment of presumed spinal injury  EMS education resulted in increased practice of cervical immobilization

4. Kinematics of Blunt Spinal Injury  Hyperextension  Hyperflexion  Compression  Rotation  Lateral Stress  Distraction  Axial Loading(diving)  Blunt Trauma  Motor Vehicle Collision  Bicycle Fall  Children: Fall > 3 feet  Adult: Fall from standing height

5. Immobilization - The Concept  Prevent neurologically intact, unstable injuries from deteriorating  Prevent progression of neurologic deficits as a result of unstable injury movement

6. Why not immobilize everybody?  99.5-96% of EMS trauma patients do not have a spine injury  EMS provider confusion/education  Immobilization causes patient pain and anxiety…possibly injury  Patient refusal for immobilization

7. Why not board and collar everybody?  Time consuming for EMS/ED  Unnecessary transports  Immobilization is uncomfortable  Time immobilized = Increased pain Potential trauma Risk of aspiration Vulnerable position

8. Cervical Spine Evaluation EMS vs. ED Perspectives  EMS –Who is at risk for cervical injury such that injury might be exacerbated with EMS movement / transport?  ED –Who is at risk for cervical injury such that radiographic studies need to be done to elucidate question of injury?

9. What’s all the fuss  Why is this such a big deal? –Time –Money –Health issues

10. Why not film/immobilize everybody?  >1,000,000 U.S. Patients receive cervical radiography each year  >97% of exams are negative  Cost exceeds $175,000,000 each year  Patient exposure to radiation –~3000 cases of thyroid cancer/yr  Immobilization causes pain and anxiety  Slows time to disposition

11. Cervical Spine Evaluation EMS vs. ED Perspectives  EMS –Who is at risk for cervical injury such that injury might be exacerbated with EMS movement / transport?  ED –Who is at risk for cervical injury such that radiographic studies need to be done to elucidate question of injury?

12. Can we recognize who may have injuries? Yes! National Emergency X- Radiography Utilization Study NEXUS!

13. Hypothesis: Blunt trauma vicitms have virtually no risk of cervical spine injury if they meet all of the following criteria:  No Neurologic deficit  No posterior midline tenderness  No evidence of ETOH/Tox  No other distracting painful injury

14. NEXUS Criteria  No Neurologic deficit  No posterior midline tenderness  No evidence of ETOH/Tox  No other distracting painful injury

15. NEXUS Definition: Altered Neurologic function  GCS 14 or less –disoriented to person,place,time,events  Inability to remember 3 objects at 5 min.  Any focal deficit –Numbness, tingling, weakness  Delayed/inappropriate response to external stimuli

16. NEXUS Criteria  No posterior midline tenderness –Specific to midline spinal tenderness  Not considered positive if there is tenderness on the sides of the neck

17. NEXUS Definition: Intoxication Patients should be considered intoxicated if they have 1) History of recent intoxication or ingestion 1) History of recent intoxication or ingestion 2) Evidence of intoxication on exam 2) Evidence of intoxication on exam

18. What is a significant distracting injury?  Ill-defined in the literature:  “Distracting Painful Injuries associated with Cervical Spinal Injuries in Blunt Trauma”* suggests: 1)Any long bone fracture 2) Visceral injury necessitating surgical consult * Ullrich, et al. AEM 2001;8:25-29.

19. What is a significant distracting injury? #2 3) Large laceration, degloving or crush 4) Large burns 5) any injury producing acute functional impairment  Ultimately up to clinician. –Use to increase sensitivity

20. NEXUS  21 Centers enrolled 34,069 Blunt trauma victims who underwent cervical spine radiography.

21. NEXUS -Results  818 patients with fracture identified  All except 8 were identified by clinical decision rule  Sensitivity 99% (95% CI 98-99.6%)

22. 8 Patients NotIdentified By NEXUS Rules

23. NEXUS- ER Doc Results  Application of NEXUS criteria would reduce imaging by 12.6% in emergency departments.  Average emergency physician could expect to miss a fracture every 125 years of practice.

24. NEXUS  Performed in hospital setting  Can this be applied to the pre- hospital setting?  With less training, will an EMT/Paramedic miss a fracture? –Protocol is straightforward.

25. Good medical care requires good clinical judgment; this can not be defined or legislated, but must be employed. Remember, FIRST DO NO HARM!

26. Purpose a Selective Spinal Immobilization Protocol  Identify and immobilize 100% of patients at risk for unstable injuries  Identify and NOT immobilize patients who have NO risk for cervical spine injury…

27. Burton JH, Dunn MG, Harmon NR, Hermanson TA, Bradshaw JR. A Statewide, Prehospital Emergency Medical Service Selective Patient Spine Immobilization Protocol. Journal of Trauma: Injury, Infection, and Critical Care, 2006;61:161-166.

28. Maine EMS Spine Assessment & Selective Immobilization Protocol 1994-2001 Mechanism of Injury PositiveUncertainNegative Positive NegativeSpine Inj Spine Pain/Tenderness YesNo PositiveMotor/Sensory Exam Spine InjNormal

29. Maine EMS Spine Assessment Protocol 1994-2001 NoYes PositiveExam Spine InjReliable? No Motor/Sensory Exam Normal PositiveNegativeSpine Inj Calm, Sober, Alert Acute Stress Rxn, Brain Inj Intox, Alt MS, Distracting Inj Yes

31. Stable Spine Injuries UNStable Spine Injuries

32. Not Clinically Significant SpineInjuries ClinicallySignificantSpineInjuries

33. Maine EMS 2002 Question of spine injury? Yes No Unreliable? Immobilize Don’t (Intox/Alt LOC)Immobilize Distracting Inj? Abnormal sensory motor? Spine Pain/Tenderness? Yes No Yes No

34. Study Objective To evaluate the outcomes associated with a statewide, emergency medical services (EMS) protocol for selective spinal immobilization in the trauma patient.

35. Study Design: 1 Year Maine EMS EMS Encounters Run Reports Spine Fractures 35 Maine Hospitals Acute EMS Spine Fractures Date of Birth EMS Run # Date of Run

36. EMS Run Report Demographic and Clinical Data  Age, gender...  Chief complaint categorization: Medical vs Trauma  Subcategorization of chief complaint  Drug/Procedure interventions  Immobilization interventions: cervical collar, long board, KED  Vital signs, GCS  Narrative

37. Maine Hospital Database Demographic and Clinical Data  Age, gender...  Injury and admission source categorization  Diagnosis Coding: ICD-9  Spine injury interventions: CPT “Unstable” Definition

38. Focused Clinical Data Review for All Spine Fracture Patients  Demographics  Injury categorization: Medical vs Trauma  Immobilization interventions: cervical collar, long board, KED  Diagnosis and Procedure coding  Narrative

39. Study Design: 1 Year Maine EMS 207,545 EMS Encounters (31,884 Trauma) 846 Spine Fractures 35 Maine Hospitals 158 Acute Spine Fractures Date of Birth EMS Run # Date of Run (0.50%) 17 unstable (11%)

40. Fractures by Spine Location

41. Immobilization Decision in All Trauma Patients 31,885 Trauma Evaluations

42. 158 EMS spine fractures 23 Stable fxs 1 Unstable Immobilization Decision in Spine Fracture Trauma Patients

43. Missed Fracture Patient Outcomes 1 Unstable Injury: 86 yof - fall off couch one week before 911 call T6/7 subluxation Treated with operative fusion

44. Nonimmobilized Fractures by Spine Location

45. 24 Non-Immobilized Spine Fracture Trauma Patients AGEAGE

46. Conclusions  The use of this statewide, EMS spine assessment protocol resulted in a decision not to immobilize greater than half of all trauma patients assessed.  The incidence of spine fractures in EMS-assessed trauma patients in this rural state was 0.50%

47. Conclusions  Approximately 15% of patients with a documented spine fracture do not appear to have been immobilized with the use of this EMS spine assessment protocol.  The use of this statewide, EMS spine assessment protocol resulted in one non- immobilized, unstable spine fracture patient in approximately 32,000 trauma encounters.

48. Limitations  Large sample size is dependent on database methodology and data inherent within the database.  Database linkage methodology  Decision not to immobilize does not mean the decision rule/protocol was negative…EMS providers may be selectively choosing not to immobilize certain patients.  Education and practice disparities across large state with 6 EMS regions (one set of state protocols).

49. Maine EMS 2002 Question of spine injury? Yes No Unreliable? Immobilize Don’t (Intox/Alt LOC)Immobilize Distracting Inj? Abnormal sensory motor? Spine Pain/Tenderness? Yes No Yes No

50. Maine EMS 2004: QA Sensitivity for fractures: 84.8% Negative Predictive Value: 99.9% Sensitivity for unstable fracture: 94.1% Negative Predictive Value for unstable: 99.9%

51. EMS older patient spine conundrum –Nexus: Be Selective on Everyone –Canadian: Don’t apply to pts > 65 yoa

52. Maine EMS 2004: QA -Outcomes followup study: 31,885 encounters -QA Study: 2220 QA sheets in the state 9 fractures (0.45%)

53. Maine EMS 2004: QA

56. Multicenter Prospctive Validation of Prehsp Clin Spinal Clearance Criteria J Trauma 2002;53:744-750

58. Multicenter Prospctv Validation of Prehsp Clin Spinal Clearance Criteria J Trauma 2002;53:744-750 2 unstable injuries: 71 yom fall, c1/2 odontoid fx Treated with halo and pain rx 47 yom head on MVC, T6/7 sublx Treated with operative fusion

59. 12 Cases  Use the checklist  Immobilize ?  Not immobilize ?  Rationale  30 Seconds for each case

60. The Checklist

61. Case #1 22 Y/0 Female Bicycle Crash  Asking repeated questions  Facial abrasions  Obvious wrist fracture

62. Case #2 Two Car Crash  Ambulatory  Alert  No spine pain  No obvious injuries  Pale  Anxious  P-130

63. Case # 3 Male Baseball Player  Fell on head during play  Alert  Denies any injuries/pain  Obvious scalp contusion  Vitals normal  Exam normal

64. Case # 4 Bar Fight  In fight  Large contusion  Denies pain  Exam normal  ETOH smell

65. Case # 5 2 Car MVC  Minor 2 Car MVC  Knee contusion  Exam normal  No pain  Vitals normal  Wants to go home

66. Case # 6 Motorcycle MVC  Keeps asking “how is my bike ? ”  Road rash  Vitals normal  Exam normal  Denies pain

67. Case # 7 High Impact MVC  Lone 48 Y/0 Driver  Airbag deployment  Chest pain, sweaty  Denies spine pain  Exam normal  Vitals –BP 130/90 –P 130 –R 18

68. Case # 8 Roll Over  Wearing seat belt  No apparent injuries  Denies pain  Alert, No ETOH  Exam normal

69. Case # 9 4 Y/0 Child Falls on Playground  No loss of consciousness  Contused head  Screaming crying  Won’t let you touch them  No apparent pain  Exam seems normal

70. Case # 10 Jogger Struck By Bicycle  Spun around  Obvious patella dislocation  Contused head  Denies spinal pain  Alert, sober

71. Case # 11 Fell Off Bike  Bike racer  Road rash  Denies spinal pain  Exam normal  Alert, sober  Vitals normal  Slightly tachycardic

72. Case # 12 Fall Down Ladder  Alert, Sober  Denies spinal pain  Exam normal  Small scalp laceration  Vitals normal

73. OK, let’s review the results!