1. EMS Spinal Immobilization Paul Spellman, MD EMS Physician

2. The History at some point someone thought it would be a good idea - Dr. Farrington - Trauma Surgeon in 1968 Backboarding enters DOT EMT curriculum in 1984 but it was widely used prior to entering the curriculum if we immobilize a long bone fracture, then we should do the same with the spine

3. The Problem this idea wasn’t founded on any research!!!!! just because something seems like a good idea, doesn’t mean that it actually is a good idea

4. Evidence Based Medicine there’s risks and benefits to any medical treatment Benefits should be: effective spinal immobilization improved patient outcomes new research suggests that for many/most patients the risks outweigh the benefits

5. Downside of Backboarding increased back pain confusing to ER staff - pain from injury vs board increased testing increased cost increased radiation exposure increased length of stay difficulty with airway management respiratory compromise risk for aspiration mechanical pressure sores increased patient anxiety and aggitation

6. The Reality - Blunt Trauma 1998 Study by Hauswald compared University of New Mexico to University of Malaysia (5yr retrospective study comparing outcomes) neurological deterioration was less prevalent in patients in Malaysia that were not backboarded 1999 Perry, et al found that spinal immobilization techniques were ineffective at limiting spinal motion during simulated vehicle motion (ie – patient transport)

7. Interesting Statistics 1-5 Million patients placed in spinal immobilization per year 1-5 Million patients placed in spinal immobilization per year 1-3% of severely traumatized patients with cervical fracture 1-3% of severely traumatized patients with cervical fracture.4-.7% have unstable cervical fracture.4-.7% have unstable cervical fracture 50-70% of patients with unstable cervical fracture have a completed spinal cord injury 50-70% of patients with unstable cervical fracture have a completed spinal cord injury

8. The Reality - Penetrating Trauma Journal of Trauma 2006 article studied assault victims in Las Angeles 57,532 assault victims 0.41% had cervical fracture GSW’s had 1.35%, Stabbing had 0.11%

9. Precautionary Immobilization It’s estimated that at least five million patients are immobilized in the prehospital environment in the U.S. each year. Most have no complaints of neck or back pain or other evidence of spine injury EMS personnel were not traditionally given protocols or authority to determine the need for spinal immobilization this was based on false belief that immobilization was always the safest option !!!!!!!!!

10. Paradigm Shift Some prehospital care providers will admit that they often immobilize patients without evidence of spine injury because they want to avoid being questioned on arrival at the emergency department This dynamic can (and must) change with education and outreach

11. Conclusion the number of cases where backboarding served its intended purpose is dwarfed by the number of cases where it served no purpose other than to delay transport and increase costs of emergency care

12. New Philosophy Spinal immobilization can cause potential harm to the patient and may in some cases delay or impede life saving care Spinal immobilization can cause potential harm to the patient and may in some cases delay or impede life saving care It should not be preformed without the proper justification It should not be preformed without the proper justification Consider risks of immobilization vs risks of not immobilizing Consider risks of immobilization vs risks of not immobilizing You must also consider the time involved in immobilization and delay of patient transport. You must also consider the time involved in immobilization and delay of patient transport.

13. New Definition of Spinal Immobilization Spinal immobilization will consist of an appropriately sized cervical collar and securing the patient adequately to the stretcher Spinal immobilization will consist of an appropriately sized cervical collar and securing the patient adequately to the stretcher

14. Adjuncts for Immobilization These are other tools to be used to assist in moving a patient who is unable or unwilling to move due to pain or injury These are other tools to be used to assist in moving a patient who is unable or unwilling to move due to pain or injury

15. Considerations If secondary devices are used to assist with patient transport and immobilization the method selected should: If secondary devices are used to assist with patient transport and immobilization the method selected should: Minimize gross movement of the spine Minimize gross movement of the spine Minimize patient discomfort Minimize patient discomfort Allow for adequate airway protection Allow for adequate airway protection

16. Purpose of a Backboard Extrication Device Extrication Device Firm Surface for chest compressions Firm Surface for chest compressions

17. Patient Self-Extrication May be allowed if the patient is alert and cooperative May be allowed if the patient is alert and cooperative Patient should be able to assist in limiting gross movement of the spine Patient should be able to assist in limiting gross movement of the spine Apply collar and ask patient to limit bending and rotation of the spine Apply collar and ask patient to limit bending and rotation of the spine Assist patient out of vehicle/circumstance to a waiting stretcher placed as close as possible to the patient Assist patient out of vehicle/circumstance to a waiting stretcher placed as close as possible to the patient

18. Self Extrication Continued This option should be reserved for situations where mechanism of injury is less likely to produce spinal injury This option should be reserved for situations where mechanism of injury is less likely to produce spinal injury Any patient stating they are in too much pain to self extricate should be extricated in traditional fashion by EMS providers Any patient stating they are in too much pain to self extricate should be extricated in traditional fashion by EMS providers

19. Patient Monitoring Any patient who undergoes spinal immobilization should have frequent reassessments of their airway and neurologic status Any patient who undergoes spinal immobilization should have frequent reassessments of their airway and neurologic status

20. Documentation Careful documentation should be done detailing the rationale for the selected method of spinal immobilization or the decision to not use spinal immobilization Careful documentation should be done detailing the rationale for the selected method of spinal immobilization or the decision to not use spinal immobilization This documentation will include a detailed physical exam of the patient’s vertebral column, a detailed neurologic exam, an assessment of the patient’s mental status and competency, as well as the presence or absence of distracting injuries This documentation will include a detailed physical exam of the patient’s vertebral column, a detailed neurologic exam, an assessment of the patient’s mental status and competency, as well as the presence or absence of distracting injuries

21. Who Needs Spinal Immobilization? If the answer to either of these questions is ‘yes’, the patient should undergo spinal immobilization. If the answer to both of these questions is ‘no’, the patient may be transported in a position of comfort. If the answer to either of these questions is ‘yes’, the patient should undergo spinal immobilization. If the answer to both of these questions is ‘no’, the patient may be transported in a position of comfort. 1 – Is the patient or their exam unreliable? 1 – Is the patient or their exam unreliable? 2 – Does the patient have an abnormal spine or neurologic exam? 2 – Does the patient have an abnormal spine or neurologic exam?

22. Reliable Exam patient must be mentally competent with no signs of altered mental status or intoxication patient must be mentally competent with no signs of altered mental status or intoxication must not have a distracting injury causing pain that would mask spinal tenderness must not have a distracting injury causing pain that would mask spinal tenderness the patient must have no language barriers preventing clear communication with the EMS crew the patient must have no language barriers preventing clear communication with the EMS crew The patient must not have dementia The patient must not have dementia The patient must not be someone less than 5 years old or greater than 65 years old who has a significant mechanism of injury. The threshold for significant mechanism of injury is much lower in the elderly. The patient must not be someone less than 5 years old or greater than 65 years old who has a significant mechanism of injury. The threshold for significant mechanism of injury is much lower in the elderly.

23. Abnormal Spine or Neuro Exam pain to palpation of the vertebral column. pain to palpation of the vertebral column. any pain in the vertebral column with range of motion movement. any pain in the vertebral column with range of motion movement. Do not assess range of motion if the patient has tenderness of the vertebral column or already meets the criteria for spinal immobilization. Do not assess range of motion if the patient has tenderness of the vertebral column or already meets the criteria for spinal immobilization. deformities of the spinal column. deformities of the spinal column. motor or sensory deficits. motor or sensory deficits. tingling in the extremities, even in the presence of intact sensation. tingling in the extremities, even in the presence of intact sensation.

24. Drowning Victims should not undergo spinal immobilization unless there is a clear history of trauma discovered in the history or exam should not undergo spinal immobilization unless there is a clear history of trauma discovered in the history or exam Spinal immobilization (especially if done in the water) may delay life saving resuscitative efforts such as quality chest compressions Spinal immobilization (especially if done in the water) may delay life saving resuscitative efforts such as quality chest compressions

25. Penetrating Trauma immobilization for victims of penetrating trauma may delay life saving surgical intervention immobilization for victims of penetrating trauma may delay life saving surgical intervention

26. When to Immobilize Penetrating Trauma Obvious neurologic deficit in the extremities Obvious neurologic deficit in the extremities Significant secondary blunt mechanism of injury (ex: fall down the stairs after sustaining a gunshot wound) Significant secondary blunt mechanism of injury (ex: fall down the stairs after sustaining a gunshot wound) Priapism Priapism Neurogenic shock Neurogenic shock Anatomic deformity to the spine secondary to the injury Anatomic deformity to the spine secondary to the injury

27. Ambulatory Patients Patients who are ambulatory at the scene and who meet the criteria for spinal immobilization may be assisted to a nearby stretcher and immobilized Patients who are ambulatory at the scene and who meet the criteria for spinal immobilization may be assisted to a nearby stretcher and immobilized Ambulatory patients should not be placed on a backboard Ambulatory patients should not be placed on a backboard cervical collar should be applied and they can be secured adequately to the stretcher cervical collar should be applied and they can be secured adequately to the stretcher

28. Infant Car Seats Infants restrained in a rear facing car seat may be extricated and immobilized in the car seat Infants restrained in a rear facing car seat may be extricated and immobilized in the car seat They may remain there if they are secure and their condition allows They may remain there if they are secure and their condition allows

29. Combative Patients Combative patients should be immobilized in a way that does not provoke increased spinal movement or combativeness Combative patients should be immobilized in a way that does not provoke increased spinal movement or combativeness These cases should be carefully documented These cases should be carefully documented

30. New KY State Protocol

31. Selective Spine Immobilization

32. In Conclusion This change has been a long time coming This change has been a long time coming State Protocol can be used by agencies currently using the state protocols, others will have to submit protocol for approval State Protocol can be used by agencies currently using the state protocols, others will have to submit protocol for approval Local Medical Directors all seem to be supportive Local Medical Directors all seem to be supportive We will establish a new local standard of care We will establish a new local standard of care ??????’s ??????’s