docUpdates in EMS-Backboards
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Updates in EMS-Backboards
Roberto C. Portela, MD, FACEP Pitt County Medical Director EMS Fellowship Associate Director Clinical Assistant Professor East Carolina University 1. 2. 3. 4. It is based in hard evidence Immobilization to prevent spinal cord injury Minimize movement while extricating patients There is no harm to patient Well…not really Oops!!! Delayed onset paraplegia due to failure to recognize injury and protect patient from the consequences of his unstable spine ¡ Hours to days Discussed ¡ only 2 patients Observational study, patient interview “This man would surely have been protected from the paraplegic condition had the spinal instability been recognized and precautions taken.” “The importance of proper first-aid was deduced from the fact that 29 patients developed further paralysis through faulty handling.” J Trauma. 1965 Nov;5(6):703-8. The removal of injured personnel from wrecked vehicles. Kossuth LC Death in a Ditch. 1967. Farrington JD J Trauma. 1968 Jul;8(4):493-512. Extrication of victims-surgical principles. Farrington JD J.D. Farrington “Carefully splint the injured spine, avoiding abnormal or excessive motion. Be sure that the injured person is properly splinted and transported on a long backboard or special stretcher without bending or twisting the spine in any direction.” American Academy of Orthopedic Surgeons (AAOS)published first guidelines for EMS. Advocated use of spinal immobilization using a backboard and C-collar for trauma patients with signs and symptoms of spinal injury. Spinal immobilization for trauma patients “We did not find any randomized controlled trials that met the inclusion criteria. The effect of spinal immobilization on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilization, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilization may increase mortality and morbidity cannot be excluded. Large prospective studies are needed to validate the decision criteria for spinal immobilization in trauma patients with high risk of spinal injury. Randomized controlled trials in trauma patients are required to establish the relative effectiveness of alternative strategies for spinal immobilization.” At least five million immobilized per year About 2% of injuries presenting to the ED Approx. 54 cases of SCI per million population (17,000 per yr) Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. 2013 Sep;30(9):720-3. doi: 10.1136/emermed-2012-201847. Spinal Cord Injury Statistics. Birmingham, AL: National Spinal Cord Injury Association Resource Center; 2016. 33,922 patients enrolled, 21 centers Cervical spine injury was present in 818 (2.40%) Lowery DW, Wald MM, Browne BJ, Tigges S, Hoffman JR, Mower WR; NEXUS Group. Epidemiology of cervical spine injury victims. Ann Emerg Med. 2001 Assigned to either LSB or stretcher mattress only C-collar, foam head blocks Driven on a closed course at a low speed The stretcher mattress significantly reduced lateral movement during transport. Wampler DA, Pineda C, Polk J, Kidd E, Leboeuf D, Flores M, Shown M, Kharod C, Stewart RM, Cooley C. The long spine board does not reduce lateral motion during transport-a randomized healthy volunteer crossover trial. Am J Emerg Med. 2016 Apr;34(4):717-21. “None of the three immobilization techniques was successful in eliminating head motion or neck rotation.” “Movement of the trunk contributed substantially to the lateral bending that occurred across the neck” Perry SD, McLellan B, McIlroy WE, Maki BE, Schwartz M, Fernie GR. The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976). 1999;24:1839- 1844. Video motion capture used to quantify the ROM of the head relative to the torso Four different extrication techniques Significant decrease in movement for all motions when the driver exited the vehicle unassisted with C-collar Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS. Cervical spine motion during extrication. J Emerg Med. 2013 Jan;44(1):122-7. 21 healthy volunteers without back disease Placed in standard backboard for a 30-minutes 100% developed pain in: ¡ Occipital, sacral, lumbar, and mandibular pain 55% graded their symptoms as moderate to severe Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994 Jan;23(1):48-51. 15 healthy, nonsmoking male volunteers Immobilize in backboard and KED Tested four pulmonary function parameters Significant difference between prestrapping and poststrapping values for: ¡ ¡ ¡ Forced Vital Capacity Forced Expiratory Volume in 1 sec. Forced Mid-Expiratory Flow Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med. 1988 Sep;17(9):915-8. 73 healthy volunteers in backboard Baseline and 30 min. peripheral tissue oxygen saturation measurements in sacral area Pressure ulcer formation may begin prior to admission with immobilization backboard Berg G, Nyberg S, Harrison P, Baumchen J, Gurss E, Hennes E. Near-infrared spectroscopy measurement of sacral tissue oxygen saturation in healthy volunteers immobilized on rigid spine boards. Prehosp Emerg Care. 2010 OctDec;14(4):419-24. Retrospective analysis of penetrating trauma patients in the National Trauma Data Bank Compared patients with vs. without prehospital spine immobilization Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010;68:115-20; discussion 120-1 American College of Emergency Physicians National Association of EMS Physicians Prehospital Trauma Life Support Current practices lack scientific support Evolving evidence suggest harm True spinal immobilization is impossible Airway, hemorrhage and other time-critical interventions should not be hindered Backboards should not be use as precautionary measures Not to be used in penetrating trauma w/o evidence of spinal injury Joint statement with ACS (COT) Benefit of the backboard is largely unproven Can induce pain, agitation, respiratory compromise and pressure sores Do no immobilize penetrating trauma w/o evidence of spinal injury Mechanism of injury should no be the sole factor to undergo spinal immobilization “Because many pts do not have spinal injury, a selective approach is… appropriate” “Patients with penetrating trauma need not undergo spinal immobilization” Spinal motion restriction Sustain injury with a mechanism having the potential for causing spinal injury And at least one of the following: 1. 2. 3. 4. 5. AMS Evidence of intoxication Distracting painful-injury Neurological deficit Spinal pain or tenderness 5-year ¡ ¡ retrospective, 2 university hospitals 120 patients seen at University of Malaya 334 patients seen at University of New Mexico All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998 Mar;5(3):214-9. Less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04) Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998 Mar;5(3):214-9. The long spine boards are NOT considered standard of care I most cases of potential spinal injury The backboard is an excellent extrication device No immobilization for penetrating trauma Use spinal motion restriction when indicated Use NEXUS or Canadian C-spine rules Problems…. First, we need to stabilize the spine Harm Benefit [email protected] [email protected]
