Mounting Evidence Against the Long Spine Board in EMS

Mounting Evidence
Against the Long Spine
Board in EMS
Ryan C. Jacobsen MD, EMT-P
Johnson County EMS System Medical Director
Assistant Professor of Emergency Medicine
Truman Medical Center/Children’s Mercy Hospitals and
Clinics
Disclosure
• This presentation was compiled from many gracious EMS
Medical Directors throughout the U.S. and I take little credit
for any of it….It is merely a synopsis/compilation of many
others hard work, for which I am very grateful.
Specific thanks to:
Charles (Chuck) Cady MD
Bryan Bledsoe MD
Keith Wesley MD
David Cone MD
Michael Millin MD
Steve Andrews MD
Kevin Sirmons MD
John Lyng MD
Objectives
• Understand current state of spinal care in EMS and associated
dogma.
• Understand the historical perspectives on prehospital spinal
care and immobilization in the U.S.
• Review of the evidence/literature surrounding prehospital
spinal immobilization.
• Benefits of reducing the use of the long spine board as an
immobilization device.
• Examples of various protocols being used throughout U.S. as
well as internationally.
• Barriers to the implementation of protocols reducing long
spine board use.
Divorce LSB from C-collars
• We’re NOT talking about cervical spine clearance. There would
be NO change in current c-spine clearance protocol.
• We’re NOT talking about limiting cervical collar use in the
field.
• This may actually increase the use of C-collars in the field!
• ****penetrating trauma
Scope
• Approximately 1 million spinal injuries in ED’s every year.
• 2-3% have actual spine injury (of those only handful unstable).
Dogma regarding Spinal
Immobilization
• Trauma=unstable spine injury=spinal cord injury=permanent
neurological deficit=bad.
• Any additional movement of the neck/back may cause an
injury that was not present immediately following the initial
trauma…or it may worsen an injury that was there prior to
any subsequent medical intervention.
• Further injury is avoided by immobilizing the spine.
• Immobilization of the spine is safe.
• Medicolegal issues prevent us from changing.
History
History
• Geisler et al. 1966
• Retrospective study of trauma patients with delayed paralysis.
• “failure to recognize the injury and protect the patient from the
consequences of his unstable spine.” …regarding an MVC patient with
skull fracture in 1955 who had delayed onset of paraplegia T4.
• “the importance of proper first-aid (by EMS providers in field) was
deduced from the fact that 29 patients [in their review] developed
further paralysis through faulty handling.”
Geisler WO, Wynne-Jones M, Jousse AT. Early management of patients with trauma to the spinal cord.
Med Serv J of Can. 1966;4:512-23.
The Dogma begins….
• Now the medical
community believes that
trauma patients should
be immobilized on rigid
devices to minimize the
risk of delayed paralysis
in the setting of occult
spinal column injury.
History Continued
• Farrington,1968
• Described the placement of a C-collar and a long or short backboard as
necessary to keep the head and neck from sagging during extrication.
• The backboard was designed to assist in minimizing spinal movement
during complex extrication maneuvers by freeing the hands of rescuers
from actively holding spinal precautions.
• The backboard was not initially envisioned to be a long-term device to
actually immobilize someone onto after they were extricated.
Farrington DJ. Extrication of Victims. Journal of Trauma. 1968;8(493-512)
The beginning of formal EMS
• 1971
• American Academy of
Orthopedic Surgeons
(AAOS)published first
guidelines for EMS.
Emergency Care and
Transportation of the Sick and
Injured.
• Advocated use of spinal
immobilization using a
backboard and C-collar for
trauma patients with signs
and symptoms of spinal
injury.
History Continued
• Bohlman, 1979.
• Linked delayed paraplegia, in 100 of 300 hospitalized cervical spine fracture
patients, with concern that these injuries were being “under-appreciated”.
• Blamed EMS=inevitable knee jerk response
• Began applying spinal immobilization, using backboards and C-collars, based
on mechanism of injury alone.
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Bohlman HH. Acute fractures and dislocations of the cervical spine. J Bone & Joint Surg. 1979;61A:1119-42.
Riggins RS, Kraus JF. The risk of neurologic damage with fractures of the vertebrae. J Trauma 1977;17:126-133.
Soderstrom CA, Brumback RJ. Early care of the patient with cervical spine injury. Orthopedic Clinics of North America 1986;17:3-13.
Burney RE, Waggoner R, Maynard FM. Stabilization of spinal injury for early transfer. J Trauma 1989;29:1497-1499.
Evidence
NO randomized
controlled studies ever
done.
Evidence that Long Spine Boards
cause HARM
• Respiratory compromise (reduces FVC, FEV1 in healthy
patients strapped to a board)
• Effect on injured patients? Ptx, pulm contusions, rib fx etc..
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Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg
Med. 1988;17:915-8
Walsh M, Grant T, Mickey S. Lung function compromised by spinal immobilization. Correspondence. Ann Emerg Med.
1990;19:615-6
Evidence for HARM
• Pressure sores/tissue hypoxia
• Good evidence that even short time periods on
board cause tissue hypoxia on contact points as well
as pressure wounds……becomes worse with elderly
and severely injured folks who can’t readjust on
board (aka spinal cord injured patient!)
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Linares HA, Mawson AR, Suarez E, Biundo JJ. Association between pressure sores and immobilization in the immediate post-injury
period. Orthopedics. 1987;10:571-3.
Sheerin F, de Frein R. The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of
three surfaces. J Emerg Nurs. 2007;33:447-50.
Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board
immobilization. Ann Emerg Med. 1995;26:31-36.
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;14:419-24.
Evidence for HARM
• Increased pain
Healthy subjects placed on boards developed numerous complaints
when on boards for short times (headaches, back, neck pain,
dizziness, nausea)
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Barney RN, Cordell WH, Miller E. Pain associated with immobilization on rigid spine boards. Ann Emerg Med. 1989;18:918.
Lerner EB, Billittier AJ, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization of healthy
subjects. Prehosp Emerg Care. 1998;2:112-6
Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med.
1994;23:48-51
Evidence for HARM
• Increase in unnecessary radiologic imaging in ED (this is both
a cost and radiation risk issue)
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March J, Ausband S, Brown L. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care.
2002;6:421-4
Berrington de González A, Mahesh M, Kim K, Bhargavan M, Lewis R, Mettler F, Land C. Projected Cancer Risks From Computed
Tomographic Scans Performed in the United States in 2007. Arch Intern Med. 2009;169:2071-77.
Hall E, Brenner D. Cancer risks from diagnostic radiology. Br J Radiol. 2008 May;81:362-78.
Forley F, Pham J, Kirsch T. Use of advanced radiology during visits to US emergency departments for injury-related conditions, 19982007. JAMA. 2010;304:1465-71.
Evidence for Harm
• Hauswald et al. 1998.
• Compared neurologic outcomes of spinal injury patients in
New Mexico, where every EMS patient received full, spinal
immobilization, to those of spinal injury patients in Malaysia,
where none of the EMS patients received spinal
immobilization.
•
Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury.
Acad Emerg Med. 1998;5:214-19.
Malaysia vs New Mexico
Malaysia versus New Mexico
RESULTS
• The Odds Ratio for disability was higher for patients in the
United States (all with spinal immobilization) after adjustment
for the effect of all other independent variables (2.03; 95% CI
1.03-3.99; p = 0.04).
• The estimated probability of finding data as extreme as this
if immobilization has an overall beneficial effect is only 2%.
Thus, there is a 98% probability that immobilization is
harmful or of no value.
• They repeated analysis using only the subset of patients with
isolated cervical level deficits. They again failed to show a
protective effect of spinal immobilization (OR 1.52; 95% CI
0.64-3.62; p = 0.34).
Evidence for Harm
• Leonard et al. 2012
• Pediatric trauma patients (prospective cohort)
• spinal immobilization was associated with increased pain and
radiographic usage and increased admission to the hospital.
pain score (3 versus 2)
cervical radiography (56.6% versus 13.4%)
Admitted (41.6% versus 14.3%).
Leonard J, Mao J Jaffe D. Potential adverse effects of spinal immobilization in children. Prehosp Emerg Care 2012;16:513-518.
Penetrating trauma and Spine
Immobilization
• We should NOT be immobilizing penetrating trauma.
• Increases mortality and clear support from all parties involved
(AANS, ACS-COT, NAEMSP, NAEMT, ATLS/PHTLS etc..)
Evidence for Harm in Penetrating
Trauma
• Cornwell EE, et al. 2001
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BACKGROUND:
Previous studies have suggested that patients transported by emergency medical services (EMS) following major trauma had a longer
injury-to-treatment interval and a higher mortality rate than their non-EMS-transported counterparts.
HYPOTHESIS:
There is little actual benefit of thoracolumbar immobilization for patients with torso gunshot wounds (GSW).
DESIGN:
Retrospective analysis of prospectively gathered data from the Maryland Institute for Emergency Medical Service Systems State Trauma
Registry from July 1, 1995, through June 30, 1998.
SETTINGS:
All designated trauma centers in Maryland.
PATIENTS:
All patients with torso GSW.
MAIN OUTCOME MEASURES:
(1) A patient was considered to have benefited from immobilization if he or she had less than complete neurologic deficits in the
presence of an unstable vertebral column, as shown by the need for operative stabilization of the vertebral column; (2) mortality.
RESULTS:
There were 1000 patients with torso GSW. Among them, 141 patients (14.1%) had vertebral column and/or spinal cord injuries. Two
patients (0.2%) (95% confidence interval, -0.077% to 0.48%) required operative vertebral column stabilization, while 6 others required
other spinal operations for decompression and/or foreign body removal. The presence of vertebral column injury was actually associated
with lower mortality (7.1% vs 14.8%, P<.02).
CONCLUSIONS:
This study suggests that thoracolumbar immobilization is almost never beneficial in patients with torso GSW, and that a higher
mortality rate existed among those GSW patients without vertebral column injury vs those with such injuries. The role of formal
thoracolumbar immobilization for patients with torso GSW should be reexamined.
Arch Surg. 2001 Mar;136(3):324-7.
Thoracolumbar immobilization for trauma patients with torso gunshot wounds: is it necessary?
Cornwell EE 3rd,
Evidence for Harm in Penetrating
Trauma
• Haut ER. 2010
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BACKGROUND:
Previous studies have suggested that prehospital spine immobilization provides minimal benefit to penetrating
trauma patients but takes valuable time, potentially delaying definitive trauma care. We hypothesized that
penetrating trauma patients who are spine immobilized before transport have higher mortality than
nonimmobilized patients.
METHODS:
We performed a retrospective analysis of penetrating trauma patients in the National Trauma Data Bank (version
6.2). Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients
with versus without prehospital spine immobilization, using patient demographics, mechanism (stab vs. gunshot),
physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was
performed based on Injury Severity Score category, mechanism, and blood pressure. We calculated a number
needed to treat and number needed to harm for spine immobilization.
RESULTS:
In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine immobilization. Overall
mortality was 8.1%. Unadjusted mortality was twice as high in spine-immobilized patients (14.7% vs. 7.2%, p <
0.001). The odds ratio of death for spine-immobilized patients was 2.06 (95% CI: 1.35-3.13) compared with
nonimmobilized patients. Subset analysis showed consistent trends in all populations. Only 30 (0.01%) patients
had incomplete spinal cord injury and underwent operative spine fixation. The number needed to treat with spine
immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine
immobilization to potentially contribute to one death was 66.
CONCLUSIONS:
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.
Evidence for Harm in Penetrating
Trauma
• Rhee P, et al. 2006
• 57,523 trauma patients
• Evaluated by:
• Blunt assault
• Stab wounds
• Gunshot wounds
Rhee P, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating
assault. J Trauma. 2006;61:1166-1170
Evidence for Harm in Penetrating
Trauma
• Rates for C-spine Fx:
• GSW (1.35%)
• Blunt Assault (0.41%)
• Stab Wound (0.12%).
• Rates of Spine Cord Inj:
• GSW (0.94%)
• Blunt Assault (0.14%)
• Stab Wound(0.11%)
• Rhee P, et al. Cervical spine injury is
highly dependent on the mechanism of
injury following blunt and penetrating
assault. J Trauma. 2006;61:1166-1170
• Surgical stabilization:
• GSW (26/158 [15.5%])
• Blunt Aslt(6/19 [31.6%])
• Stab Wnd (3/11 [27.8%])
• No patient with
penetrating SCI
regained significant
neurologic
recovery.
Author’s Conclusions
• Don’t get shot in the spinal cord……..
• Neurologic deficits from penetrating assault were
established and final at the time of presentation.
• Concern for protecting the neck should not hinder the
evaluation process or life saving procedures.
• Don’t waste time on scene “packaging”…..just go.
Evidence for Harm in Penetrating
Trauma
Vanderlan WB, et al. 2009
• NOLA retrospective chart
review:
• 847 charts
• 188 studied patients
• 35 (22.9%) died
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27 immobilized
8 not immobilized
GSW (94%)
Stab wound (6%)
Vanderlan WB, Tew BE, McSwain NE.
Increased risk of death with cervical spine
immobilization in penetrating cervical trauma.
Injury. 2009;40:880-883.
• C-spine immobilization
in this study was
associated with an
increased risk of death
(p = 0.016, odds ratio
2.77, 95% CI 1.18- 6.49).
Evidence for Harm in Penetrating
Trauma
Kaups KL, et al. 1998
• Fresno study.
• 215 patients with GSW to
head:
• DOA and c-spine injuries
excluded.
• Cervical spine clearance
was determined in 202
(93%).
Kaups KL, Davis JW. Patients with gunshot wounds to the
head do not require cervical spine immobilization and
evaluation. J Trauma. 1998;44:865-867.
• No patients had indirect
c-spine injury.
• 3 patients had direct cspine injury that was
readily apparent.
Author’s Conclusions
• More intubation attempts occurred in patients with cervical
collars:
• 49 attempts in 34 patients with c-collars
• 5 attempts in 4 patients without c-collars (p=0.008).
• Indirect spinal injury does not occur with GSWs to head.
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Kaups KL, Davis JW. Patients with gunshot wounds to the head do not require cervical spine
immobilization and evaluation. J Trauma. 1998;44:865-867.
GSWs rarely cause spine
injuries
• DuBose et al. 2009
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4204 patients with GSW’s to the head, neck, or
torso
327 (7.8%) had spinal column injuries
173/327 had spinal cord injuries
2 (0.6%) patients required surgery
None had unstable spinal injuries
DuBose et al: The role of routine spinal imaging and immobilization in asymptomatic patients after gunshot wounds. Injury
2009;40:860-863
American Academy of
Neurological Surgeons (AANS)
Position
• Theodore N et al. 2013. Neurosurgery
• “Spinal immobilization in patients with penetrating trauma is
not recommended because of increased mortality from
delayed resuscitation.”
PHTLS Position
• There are no data to support routine spine immobilization in
patients with penetrating trauma to the neck or torso.
• There are no data to support routine spinal mobilization in
patients with isolated penetrating trauma to the cranium.
• Spine immobilization should never be done at the expense of
accurate physical examination or identification and correction
of life-threatening conditions in patients with penetrating
trauma.
• Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. Prehospital
spine immobilization for penetrating trauma--review and recommendations from
the Prehospital Trauma Life Support Executive Committee. J Trauma.
2011;71:763-9; discussion 769-70.
Cochrane Review
• “Unwarranted spinal immobilization can expose patients to
the risks of iatrogenic pain, skin ulceration, aspiration and
respiratory compromise, which in turn can lead to multiple
radiographs, resulting in unnecessary radiation exposure,
longer hospital stay and increased costs. The potential risks of
aspiration and respiratory compromise are of concern because
death from asphyxiation is one of the major causes of
preventable death in trauma patients.”
• Kwan I, Bunn F, Roberts I. Spinal immobilization for trauma patients. Cochrane Database of
Systematic Reviews. 2009;1:1-15
U.S. Consortium of Metropolitan Medical Directors
Position Statement
aka: The Eagles
“Current best practices reflect that there are no randomized
controlled trials to evaluate the benefits of spinal
immobilization in out-of-hospital trauma patients. As a result,
current EMS protocols are based principally on historical
precedent, dogma and medico-legal concerns, and not on
scientific evidence. This situation is further complicated by the
reality that such studies will not likely be performed in the future,
primarily as a result of perceived legal and ethical concerns.
There is, however, a growing body of literature that points to
the potential deleterious effects of spinal immobilization,
whether or not this modality is applied in an appropriate
fashion.”
The Eagles
• Taking it one step further….(they apparently don’t like c-collars
that much either)
• “We might therefore consider discontinuing the use of the
cervical collar in alert, cooperative trauma patients, even with
a suspected C-spine fracture, unless consciousness deteriorates
or if the application of a collar might provide the patient with
a degree more comfort. It is certainly also time for EMS
systems to remove collars from their protocols for the
management of patients with penetrating trauma.”
Evidence for Benefit
• ???
We have assumption
that LSB’s actually
immobilize the spine…..
3 points of contact for LSB
• Occiput
• T-spine
• Sacrum
We painted a student….
Then carefully laid them on a
LSB
Then lifted the student off…
T-spine
occiput
sacrum
HOW WELL DO BOARDS IMMOBILIZE?
Spine boards as immobilization
devices
• Mazolewski et al. 1994
• Study of different strapping techniques demonstrated that
healthy, cooperative volunteers are still able to move when
strapped to a backboard.
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Mazolewski P, Manix T. The effectiveness of strapping techniques in spinal immobilization. Ann Emerg Med. 1994;23:1290-5
Spine boards as immobilization
device
• Silbergleit R et al. 1991
• During transport, once on a backboard, patients still subject to
significant head to toe and side to side forces.
• (remember boards are slippery and we fix their head to
them and allow body to move)
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Silbergleit R, Dedrick DK, Pape J, Burney RE. Forces acting during air and ground transport on patients stabilized by standard
immobilization techniques. Ann Emerg Med 1991;20:875-877.
Spine boards as immobilization
devices
• Peery et al. 2007
• A prospective observational study showed 70% of study
patients had at least one backboard strap with 4 or more cm
of slack, and 12% of study patients had 4 or more backboard
straps with 4 or more cm of slack.
•
Peery CA, Brice J, White WD. Prehospital spinal immobilization and the backboard quality assessment study.
Prehosp Emerg Care. 2007;11:293-7.
Combative Patients
• We pin them down, onto a board, while they squirm and are held
down at head. Likely increasing energy/forces transmitted to spine.
Uncooperative Patient
Combative patients
• We claim that we are forcefully pinning their head down and
forcing them supine on a hard board in order toe “protect
their spine” from themselves as they violently squirm under
the straps.
• This technique likely increases forces/energy transmitted to
the spine.
• Allowing them to have collar on and get into position of
comfort likely less energy to spine.
Forced Immobilization….worse
than no immobilization?
• Hauswald M. 2012
• Tightening the straps may restrict movement but not the
forces generated by the patient on the spine in resistance to
restraining efforts. Attempting to enforce immobilization of
the uncooperative patient may result in
more
force transmission to the spine than
before the struggle commenced
•
Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. 2012;00:1–4.
Spine board as immobilization
device
• The clinical significance of strap tightness and patient
movement while “immobilized” has not been established, but
such movement cannot qualify as immobilization, the very
purpose for which backboards continue to be used during
transport.
Spine Boards as Immobilization
Devices
• If patients are still able to move despite being strapped to a
backboard, spinal immobilization is more a function of their
cooperation than the due to the ability of the backboard and
straps to assure spinal immobilization.
Limitations of Studies on Long
Spine Boards
• Studies on the effectiveness of backboards as an
immobilization device have only included cooperative
patients, healthy volunteers, and cadaver models; no study
has been done evaluating patient resistance and its effect on
the spine.
What about Scoop Stretchers
• Del Rossi et al. 2010
• Scoop Stretchers and the
“lift and slide” technique
were able to restrict
motion of the spine as well
as the log-roll technique
with long board.
•
Del Rossi et al. Are Scoop Stretchers Suitable for
use on spine-injured patients? American Journal
of Emergency Medicine 2010.
What Extrication Technique Causes
Least Spine Movement?
• Shafer et al. 2009. West J Emerg Med. 2009 May; 10(2): 74–78.
• Cervical Spine Motion During Extrication. A Pilot Study
• They used motion capture video to look at motion of spine
during different techniques of extrication from car.
Extrication techniques and Spine
Motion
4 Different Techniques were compared
1.
2.
3.
The patient was allowed to exit the vehicle on their own and lie on a
backboard.
The patient was allowed to exit the vehicle on their own with a C-Collar
in place and lie on a backboard.
The patient was extricated head first via standard technique by two
paramedics with a C-Collar alone. (Standard technique involves turning the
driver so that the legs are in the passenger’s seat, allowing the driver to lie
back and raising the right hip so a long board can be placed under the hip. A
second paramedic who enters the front seat passenger’s door helps slide the
patient up on to the board.)
4.
The patient was extricated head first via standard technique by the two
paramedics with a C-Collar and a KED.
Author Conclusions?
• “Ultimately, we documented the least movement of the
cervical spine in subjects who had a cervical collar applied and
were allowed to simply get out of the car and lie down on a
stretcher.”
Extrication techniques on Spine
Movement
Emerg Med J. 2013 Jun 28.
Dixon M, O'Halloran J, Cummins NM.
.
METHODS:
A crew of two paramedics and four fire-fighter first responders extricated a
simulated patient from a prepared motor vehicle using nine different extrication
techniques. The patient was marked with biomechanical sensors and relative
movement between the sensors was captured via high speed infrared motion
analysis cameras. A 3D mathematical model was developed from the recorded
movement.
RESULTS:
Control measurements were taken from the patient during self-extrication and
movement was recorded of 4.194° left of midline (LOM) to 2.408° right of
midline (ROM) resulting in a total movement of 6.602°. The least deviation
recorded during equipment aided extrication was movement of 3.365° LOM and
8.352° ROM resulting in a total movement of 11.717°. The most deviation
recorded during equipment aided extrication was movement of 1.588° LOM and
24.498° ROM resulting in a total movement of 26.086°.
CONCLUSIONS:
Conventional extrication techniques record up to four times more cervical
spine movement during extrication than controlled self-extrication. This proof
of concept study demonstrates the need for further evaluation of current
rescue techniques and the requirement to investigate the clinical and
operational significance of such movement.
Ambulance Cots are essentially
Padded Long Spine Boards
• Once the patient is secured to the ambulance cot, the
backboard becomes redundant, as the standard transport cot
provides a flat surface to which the patient can be secured.
• Like the hospital bed, the ambulance cot and straps can
provide spinal protection reducing spinal flexion, rotation, and
lateral motion.
• In addition, the cot mattress can conform to the anatomic
shape of the spine and the non-slick surface minimizes patient
movement on the cot.
• Transport on a mattress is largely without the downside risks
of the backboard.
Our EMS Cot
We re-painted our student….and
laid him on our cot mattress
Comparison of points of contact showed likely increased points
of contact and more comfortable than LSB
Using Logic as an
argument to reduce
LSB use in the field
We’ve all met these
elderly/kyphotic patients
• Risk>>>>benefit
Faulty Assumptions
The time that the patient hits the ED door
DOES NOT mean that their evaluation and/or care
begins at that point in time.
Patients who arrive immobilized may stay that
way for significant periods of time until they are
seen and removed from the board by someone
authorized to do so.
Should I go to the hospital?
• We’ve always
instinctively known
that these patients
don’t need a Long
Spine Board.
• Minor falls
• Ambulatory patients
• Minor MVC’s
• What does the ED do
with walk-ins?
New Thoughts
• Hauswald: A Re-conceptualisation of Acute Spinal Care
• Injury caused by ENERGY (MVC, Fall, GSW), not motion.
• Energy at time of injury great
• Energy during EMS care/extrication is minimal
• Motion at uninjured segments different than injured segments
and force may not equate to visible motion.
• Longboard: low friction surface, energy to anchor points
(head/neck)…isn’t that worse?
Questioning long held beliefs that
movement by field providers causes
harm
• Hauswald. 2012
• The spine requires little energy to move within its normal ROM, and offers little
resistance to motion within this range.
• Since the spinal components fail at similar force, spinal injuries are either minor, with
no threat to the spinal cord, or are catastrophic, with multiple, irreversible failures
that may irreparably damage the spinal cord so severely that they will be unaffected
by prehospital emergency spinal care.
•
If the force experienced to create the unstable fracture was not enough to injure
the cord at that time, then forces experienced during patient movement by EMS are
unlikely to injure the cord.
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If the force results in injury but not gross instability, additional forces applied by
prudent rescuers during extrication and transport will be spread throughout the spine
(as long as not outside normal ROM).
• Most spinal injuries are “stable” in the short term and those that are truly “unstable”
and offer no resistance to motion are irrevocably damaged at the time of the event.
Questioning Long Held Beliefs
• Spinal column itself is very strong, requiring up to 2000-6000 Newtons to fracture the
cervical spine. (approx 500-1500 pounds of force!)
• A 4kg head hanging off of the bed only generates about 40N of force!
•
Spinal motion during extrication by careful rescuers creates forces at most on the
order of magnitude created by gravity, and are spread throughout the spinal column
unless the column itself – cord included – had lost all structural integrity at that level.
Thus, motions induced by rescuers do not achieve the forces needed to threaten
spinal column integrity.
• High friction, comfortably firm surface (aka the cot or bed) is the ideal surface.
• Traditional low friction, hard/slipper surfaces that are uncomfortable (ie: can cause
tissue hypoxia) are bad.
•
Maiman D, Sances A, Myklebust J, Larson S, Houterman C, Chilbert M, El-Ghatit A. Compression injuries of the cervical spine: a
biomechanical analysis. Neurosurgery 1983;13:254–60.
Evidence for Benefit of Long Spine
Board
• ????
Potential Benefits to NOT using
LSB?
• Reduce amount of on-scene personnel.
• Reduce amount of patients lifted from ground on LSB who are
already ambulatory.
• Reduce amount of awkward positions providers place
themselves in to extricate otherwise well patients from
vehicles.
• Reduce scene times by eliminating time spent immobilizing to
board. (cot straps are quick!...LSB strapping is NOT quick)
Increases Ability for
Providers to Expose
Patients While Enroute
to Hospital?
Virtually Impossible to Gain Access to
patient when strapped to Long Spine
Board
• If you do unstrap
enroute you’ll only have
head secured as fixed
point (that’s bad!)
Benefits to reducing LSB use
• Decreased awkward extrication of stable patients who could
self-extricate
• Less resources/manpower needed (two folks and a cot for
most minor MVC’s with neck pain).
• Less scene time when using cot straps and not securing head.
• More exposure/access to patient enroute.
• More comfort for patient.
• Saves patient from ED doc who leaves on board in hospital.
• Decrease radiological studies.
• Decreases cost.
• Decrease in resistance to placing a c-collar in elderly or
borderline patient when not mandated to use LSB.
We’re not alone in
our efforts to
minimize LSB use
Agencies/EMS Systems Minimizing LSB use
North Memorial Ambulance & Aircare
Minneapolis, MN
HealthEast Medical Transportation
St. Paul, MN
Xenia Fire Department
Xenia, OH
Rio Rancho Fire Department
New Mexico
Albuquerque-Bernalillo County Medical Control Board
New Mexico
Bernalillo County Fire Department
New Mexico
SERTAC (Southeast Regional Trauma Advisory Council in WI)
State of Connecticut (Department of Health)
State of Maryland
CentraCare Health
Monticello, MN
Kenosha Fire Department
Kenosha, WI
MedicWest Ambulance
Nevada
Norwalk Hospital
Connecticut
Eagle County Ambulance District
Colorado
Milwaukee EMS
WI
• Outside of US
• Queensland Ambulance Service,
Trauma clinical practice procedures:
Use of an extrication board. 2012;
http://www.ambulance.qld.gov.au/m
edical/pdf/09_cpp_trauma_030912.p
df
Example Protocol Wording in
Wisconsin
• SERTAC (Southeast Regional Trauma Advisory Committee)
• Spinal immobilization consists of keeping the head, neck and spine
inline. The neck can be immobilized with a well fitted cervical collar,
head blocks, blanket rolls or other immobilization techniques.
Patients who are already walking or standing should be laid directly
on the ambulance stretcher and secured to the stretcher with
seatbelts. Back boards and scoop stretchers are designed and
should only be used to extricate patients.
• Once extricated, patients should be taken off the back board or
scoop stretcher and be placed directly on the ambulance stretcher.
• Patients with penetrating traumatic injuries should only be
immobilized if a focal neurologic deficit is noted on physical
examination (although there is little evidence of benefit even in
these cases)
Example Protocol Wording
• Yale/New Haven Sponsor Hospital EMS System
• “Effective immediately, long backboards will no longer be utilized
for spinal immobilization of ambulatory patients. Patient who are
ambulatory at the scene, but who require cervical immobilization
based on our selective spinal immobilization protocol, will be
placed in the position of comfort, limiting movement of the neck
during the process. This change in procedure is the first step
toward eventually using long boards only when needed to
facilitate extrication, and not during transport.”
Queensland Ambulance
Queensland Ambulance
Protocol Wording
• If Spinal Immobilization is indicated, an appropriately sized cervical
collar should be placed.
• Patients who are already ambulatory or standing should NOT be placed
on a long spine board, but rather be laid directly on the ambulance cot
and secured to the cot with seatbelts in a position of comfort.
• Back boards and scoop stretchers are designed for extrication and
patient movement and should not be used for spinal immobilization.
• There is no role for the KED board in EMS.
• Once extricated, patients should be taken off the back board or scoop
stretcher and be placed directly on the ambulance stretcher.
• Patients with penetrating traumatic injuries (including head, neck and
torso) should only be immobilized if a focal neurologic deficit is noted on
physical examination.
• Decisional patient’s have the right to refuse any aspect of spinal
immobilization.
Queensland
• Notice they do NOT allow transport on a LSB!
Parting Thoughts
• Despite the long-standing history and culture of spinal
immobilization with a backboard and cervical collar, using the
best evidence available, many abroad and in the US believe
the risk-benefit analysis shows that the proven harm is much
worse than the theoretical, but unproven, benefit of the
backboard.
People don’t like to change…
Note the conclusion in this article!
If Spine Boards were a
Medication?
• If a medication had the same risk/benefit as the LSB, use of
the drug would be stopped immediately by the FDA.
Barriers to Implementation
• Overcoming Dogma/Institutional Culture/Long Standing Traditions
• Buy-In from Hospital/Helicopter Agencies/Critical Care Transport
Agencies
• Physicians
• Nursing
• Flight Crews
•
•
•
•
•
•
Buy-in from EMS Providers
Risk Management/Liability Issues
Ensuring proper documentation/QA
EMS Provider educational roll-out
Equipment Issues (differences between agencies, budgetary issues)
Logistics (actual procedures to be performed in field, ensuring they are
quick/safe/effective)
• Appropriate wording of Protocol to ensure common
understanding/intent by field providers
• Overcoming differences with State/National Curriculums and Standards
Johnson County EMS Proposed
Language (see bolded print)
•
•
•
•
•
Spinal Immobilization:
Indications
Blunt trauma patients that meet Step 1, 2 or 3 (See appendix B) or experience axial load; fall of >3 feet; rollover,
ATV, cycle or pedestrian/vehicle accidents will be immobilized.
Patients with penetrating traumatic injuries should NOT be immobilized unless a focal neurologic deficit is
noted on physical examination.
Spinal immobilization is indicated in trauma patients who sustain a mechanism of injury sufficient to cause a neck
or back injury and who display at least one of the following criteria. Use caution for occult fracture in age >65 or
<4 years old or history of osteoporosis, bone or vertebral disease.
•
•
•
•
•
•
•
•
•
•
Unreliable physical exam, such as GCS < 15, inability to fully cooperate, evidence of intoxication or acute stress reaction
Pain, deformity or tenderness to the neck or back
A distracting painful injury
Neurologic deficit
Pain produced on unassisted rotation of the head 45 degrees in each direction
Techniques
Stabilize head and neck in neutral position unless movement causes pain, deformity, or resistance. If so,
immobilize the head and neck in the position found.
If the patient is ambulatory, place an appropriately sized cervical collar and position the patient directly on the
ambulance cot in the position of comfort, limiting movement of the spine during the process.
Patients that are stable, alert and without neurological deficits may be allowed to self-extricate to the
ambulance cot after placement of a cervical collar. Limit movement of the spine during the process.
If a Long Spine Board or Scoop Stretcher are used for extrication or patient movement, the patient should be
taken off the long spine board or scoop stretcher and placed directly on the ambulance cot using an appropriate
technique that minimizes movement of the spine.
Issues to deal with…..
• What to do with multiple boarded patients when we’d
typically put one on the bench seat in full package?
• Vomiting patient that is not on board.
• Gravid patient not on board (how to roll them off their IVC).
• Football players with helmets on.
• Swimming pools already packaged by lifeguards on arrival of
EMS.
Pregnant patients, vomiters ?
Seemed like a good idea at the
time………but
Spine Boards as Modern Art?
• Maybe their best use?
Best Picture EVER