C-Spine?: A review of the literature surrounding prehospital immobilization

1. C-Spine?: A review of the literature surrounding prehospital immobilization Justin Hunter, B.A.S., NRP, FP-C Tulsa Life Flight EMSStat, OSU/OKC, OCCC www.EMSSuccess.org

2. Objectives Quick review over what our standard definition of spinal immobilization is. Review of why spinal immobilization is usually indicated and what EMS’ standard of care is. Review of studies that have taken place over the past 15 years that look at several key factors such as Are we properly immobilizing patients? Does the act of fully immobilizing the trauma patient have an effect on overall patient outcome? Is EMS being advocates for their patients? • Discuss how we might be able to make changes in the future.

3. What is spinal immobilization?? Complete spinal immobilization includes the immobilization of the patient using a long board with straps, stiff cervical collar, and head immobilization device (head blocks or towel rolls) secured to the board and the patient's head. Complete spinal immobilization may be applied to the supine patient, the standing patient or to the seated patient (utilizing the KED).

4. Why is spinal immobilization performed?? …to return the spine to its natural anatomic in-line position.1

5. When is spinal immobilization indicated?? Now THAT is a loaded question….. From an actual protocol… Any victim with obvious neuro deficit, such as paralysis, weakness, or paresthesia. Any victim of trauma who complains of pain or discomfort in the head, neck, back, or chest. Any victim of trauma who is unconscious. Any victim of trauma who may have injury to the spine but in whom evaluation is difficult. Any unconscious patient who may have been subjected to trauma. Any water related injury, involving the head, neck, chest, or back. Any trauma victim with facial or head injuries. Any trauma victim subjected to significant deceleration forces. When in doubt,,,,,,IMMOBILIZE!

6. Out-of-hospital Spinal Immobilization: Its Effect onNeurologic Injury2Mark Hauswald, MD, Gracie Ong, MBBS, Dan Tandberg, MD, Zaliha Omal; MBBS 1998 Objective: To examine the effect of emergency immobilization on neurologic outcome of patients who have blunt traumatic spinal injuries. Methods: A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did. The 2 hospitals were comparable in physician training and clinical resources. Neurologic injuries were assigned to 2 categories, disabling or not disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as explanatory variables. Results: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a ~ 2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p= 0.34).

7. Out-of-hospital Spinal Immobilization: Its Effect onNeurologic InjuryMark Hauswald, MD, Gracie Ong, MBBS, Dan Tandberg, MD, Zaliha Omal; MBBS Conclusion: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.

8. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital settingMarc D. Muhr1, David L. Seabrook3 and Lynn K. Wittwer1,2† Vancouver, WA. 1999 OBJECTIVE: To determine whether paramedics can safely useaspinalclearance algorithm to reduce unnecessary spinal immobilization (SI) in the out-of-hospital setting. METHODS: Paramedics were instructed in the use of aspinalclearance algorithm that prompted assessment of the trauma patient's 1) level of consciousness, 2) drug and/or alcohol use, 3) loss of consciousness during the event, 4) presence of spinal pain/tenderness, 5) presence of neurologic deficit, 6) concomitant serious injury, or 7) presence of pain with range of motion. The algorithm indicated that if any of the above were present, the patient should receive full SI, and if all of the above were negative, then SI could be withheld. Paramedics completed a tracking form that included the above and followed the patient to the emergency department (ED). Data were then gathered to determine the presence of spinal fracture, neurologic deficit, or a combination of the two. To compare the trends for SI, a retrospective medical incident report (MIR) review was conducted from the previous year. MIRs were selected based on the same criteria as those used for study inclusion.

9. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting3Marc D. Muhr1, David L. Seabrook3 and Lynn K. Wittwer1,2† RESULTS: Two hundred eighty-one patients were included in the study, with 65% (n = 183) of them receiving SI. Two hundred ninety-three MIRs were included in the retrospective sample, with SI being provided 95% (n = 288) of the time. Comparison of these samples shows a 33% reduction in utilization of SI (95% confidence interval: 27.2%- 38.8%). CONCLUSION: An out-of-hospital spinalclearance algorithm administered by paramedics can reduce SI by one-third. Any application of aspinalclearance algorithm should be accompanied by rigorous medical supervision.

11. Patients with Gunshot Wounds to the Head Do Not Require Cervical Spine Immobilization and Evaluation4Kaups, Krista L. MD; Davis, James W. MD 1998 Objective: The purpose of this study was to determine the incidence of indirect spinal column injury in patients sustaining gunshot wounds to the head. Methods: A retrospective review of patient records and autopsy reports was conducted of patients admitted with gunshot wounds to the head between July of 1990 and September of 1995 were included. Those with gunshot wounds to the neck and those who were dead on arrival were excluded. Results: A total of 215 patients were included in the study. Cervical spine clearance in 202 patients (93%) was determined either clinically, radiographically, or by review of postmortem results. No patients sustained indirect (blast or fall-related) spinal column injury. Three patients had direct spinal injury from bullet passage that were apparent from bullet trajectory. More intubation attempts occurred in patients with cervical spine immobilization (49 attempts in 34 patients with immobilization versus five attempts in four patients without cervical spine immobilization, p = 0.008).

12. Patients with Gunshot Wounds to the Head Do Not Require Cervical Spine Immobilization and Evaluation4Kaups, Krista L. MD; Davis, James W. MD Conclusions: Indirect spinal injury does not occur in patients with gunshot wounds to the head. Airway management was compromised by cervical spine immobilization. Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.

13. Prehospital Spinal Immobilization Does Not Appear to Be Beneficial and May Complicate Care Following Gunshot Injury to the Torso5Brown, Joshua B. BA; Bankey, Paul E. MD, PhD; Sangosanya, Ayodele T. MD; Cheng, Julius D. MD; Stassen, Nicole A. MD; Gestring, Mark L. MD 2009 University of Rochester Medical Center, Rochester, NY Background: Prehospital spinal immobilization (PHSI) is routinely applied to patients sustaining torso gunshot wounds (GSW). Our objective was to evaluate the potential benefit of PHSI after torso GSW versus the potential to interfere with other critical aspects of care. Methods: A retrospective analysis of all patients with torso GSW in the Strong Memorial Hospital (SMH) trauma registry during a 41-month period and all patients with GSW in the National Trauma Data Bank (NTDB) during a 60-month period was conducted. PHSI was considered potentially beneficial in patients with spine fractures requiring surgical stabilization in the absence of spinal cord injury (SCI).

14. Prehospital Spinal Immobilization Does Not Appear to Be Beneficial and May Complicate Care Following Gunshot Injury to the Torso5Brown, Joshua B. BA; Bankey, Paul E. MD, PhD; Sangosanya, Ayodele T. MD; Cheng, Julius D. MD; Stassen, Nicole A. MD; Gestring, Mark L. MD Results: Three hundred fifty-seven subjects from SMH and 75,210 from NTDB were included. A total of 9.2% of SMH subjects and 4.3% of NTDB subjects had spine injury, with 51.5% of SMH subjects and 32.3% of NTDB subjects having SCI. No SMH subject had an unstable spine fracture requiring surgical stabilization without complete neurologic injury. No subjects with SCI improved or worsened, and none developed a new deficit. Twenty-six NTDB subjects (0.03%) had spine fractures requiring stabilization in the absence of SCI. Emergent intubation was required in 40.6% of SMH subjects and 33.8% of NTDB subjects. Emergent surgical intervention was required in 54.5% of SMH subjects and 43% of NTDB subjects. Conclusions: Our data suggest that the benefit of PHSI in patients with torso GSW remains unproven, despite a potential to interfere with emergent care in this patient population. Large prospective studies are needed to clarify the role of PHSI after torso GSW.

16. Respiratory effects of spinal immobillzatlon6 Vicken Y. Totten1† and David B. Sugarman21999 Department of Emergency Medicine Providence, RI Objective. To evaluate the effect of whole-body spinal immobilization on respiration. Methods. This was a randomized, crossover laboratory study with 39 human volunteer subjects (20 males; 19 females) ranging in age from 7 to 85 years. Respiratory function was measured three times: at baseline (seated or lying), immobilized with a Philadelphia collar on a hard wooden backboard, and on a Scandinavian vacuum mattress with a vacuum collar. The comfort levels of each of the two methods were assessed on a forced Likert scale.

17. Respiratory effects of spinal immobillzatlon6Vicken Y. Totten1† and David B. Sugarman2 Results. Both immobilization methods restricted respiration, 15% on the average. The effects were similar under the two immobilization conditions, although the FEV, was lower on the vacuum mattress. Respiratory restriction was more pronounced at the extremes of age. The vacuum mattress was significantly more comfortable. Conclusion. This study confirmed the previously reported respiratory restriction caused by spinal immobilization. Vacuum mattresses are more comfortable than wooden backboards.

18. A Statewide, Prehospital Emergency Medical Service Selective Patient Spine Immobilization Protocol7 Burton, John H. MD; Dunn, Matthew G. DO; Harmon, Nathan R. DO; Hermanson, Tari A. MD; Bradshaw, Jay R. EMT-PPublished 2006 Background: To evaluate the practices and outcomes associated with a statewide, emergency medical services (EMS) protocol for trauma patient spine assessment and selective patient immobilization. Methods: An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter data. Prehospital patient data were linked to a statewide hospital database that included all patients treated for spine fracture during the 12-month period following the spine assessment protocol implementation. Incidence of spine fractures among EMS-assessed trauma patients and the correlation between EMS spine immobilization decisions and the presence of spine fractures-stable and unstable-were the primary investigational outcomes.

19. A Statewide, Prehospital Emergency Medical Service Selective Patient Spine Immobilization Protocol7Burton, John H. MD; Dunn, Matthew G. DO; Harmon, Nathan R. DO; Hermanson, Tari A. MD; Bradshaw, Jay R. EMT-P Results: There were 207,545 EMS encounters during the study period, including 31,885 transports to an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%) patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154 acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization interventions. This nonimmobilized group included 19 stable spine fractures and one unstable thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was 87.0% (95% confidence interval [CI], 81.7-92.3) with a negative predictive value of 99.9% (95% CI, 99.8-100). Conclusions: The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected a decision not to immobilize greater than half of all EMS- assessed trauma patients.

20. Spine Immobilization in Penetrating Trauma: More Harm Than Good8Haut, Elliott R. MD; Kalish, Brian T. BA, EMT-B; Efron, David T. MD; Haider, Adil H. MD, MPH; Stevens, Kent A. MD, MPH; Kieninger, Alicia N. MD; Cornwell, Edward E. III MD; Chang, David C. MBA, MPH, PhD 2010 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.

21. Spine Immobilization in Penetrating Trauma: More Harm Than Good8Haut, Elliott R. MD; Kalish, Brian T. BA, EMT-B; Efron, David T. MD; Haider, Adil H. MD, MPH; Stevens, Kent A. MD, MPH; Kieninger, Alicia N. MD; Cornwell, Edward E. III MD; Chang, David C. MBA, MPH, PhD 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.

22. Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma9Richard A. Connell, Colin A. Graham, Philip T. MunroPublished 2003 from the UK Introduction: Previous work suggests that patients with isolated penetrating trauma rarely require spinal immobilisation. This study aimed to identify the incidence of mechanically unstable, or potentially mechanically unstable, spinal column injuries in penetrating trauma patients. The study also aimed to identify the incidence of spinal cord injury as a result of penetrating trauma in Scotland. Design: Retrospective analysis of prospectively collected data from the Scottish Trauma Audit Group (STAG). Methods: Study patients were identified from the period 1992–1999. Patients coded for both penetrating trauma and spinal column or spinal cord injury were included. Case records, theatre notes and post mortem information were also examined.

23. Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma9Richard A. Connell, Colin A. Graham, Philip T. Munro Results: 34,903 patients were available for study. Twenty-seven patients were coded as having had penetrating trauma and concurrent spinal injury. 15 were excluded as they also had a major blunt mechanism of injury or had no actual injury to the spinal cord or column. In the remaining 12 patients, four cervical, one combined cervical and thoracic and seven thoracic spinal cord injuries were identified. 11 were male and 11 were assaulted. One assault was due to a gunshot wound; 10 resulted from sharp weapons. Four complete cord transections and nine partial cord lesions were identified. All 12 patients with spinal cord injury associated with isolated penetrating trauma either had obvious clinical evidence of a spinal cord injury on initial assessment or were in traumatic cardiac arrest. All had spinal immobilisation. Conclusion: Fully conscious patients (GCS=15) with isolated penetrating trauma and no neurological deficit do not require spinal immobilisation.

24. What are physicians saying? Melissa Costello, M.D., FACEP President of American College of Emergency Physicians Regarding a question about LSB use of IFT… “The cot being slightly softer is better to actually “immobilize” the spine. We don’t place casts without padding and we don’t admit known spine fractures on boards. The LSB is an EXTRICATION device ONLY. It is NOT a splint for the spine. Collars only for transfers…and that is probably debatable also…(cont)

25. What are physicians saying? Melissa Costello, M.D., FACEP Chairof American College of Emergency Physicians Regarding a question about LSB use of IFT… “The American College of Surgeons Committee on Trauma has a policy statement coming out this summer against a lot of traditional field/IFT LSB use. It will be excellent ammunition to use against obstinate out-of- date surgeons. I, speaking only for myself, regard putting patients BACK on a LSB as a significant deviation from the standard of care if not outright negligence.”

26. What are physicians saying? The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma believe that: Long backboards are commonly used to attempt to provide rigid spinal immobilization among emergency medical services (EMS) trauma patients. However, the benefit of long backboards is largely unproven. The long backboard can induce pain, patient agitation, and respiratory compromise. Further, the backboard can decreased tissue perfusion at pressure points, leading to the development of pressure ulcers.

27. What are physicians saying? Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks. Patients with penetrating trauma to the head, neck, or torso and no evidence of spinal injury should not be immobilized on a backboard.

28. What are physicians saying? Bryan Bledsoe, DO, FACEP, FAAEM Professor and Director of EMS Fellowship Dept of Emergency Medicine University of Nevada School of Medicine Again, in response to IFT use: “I work in a Level 1 trauma center and we get patients off the boards ASAP. With higher risk patients we go to the scanner and check their backs as they are moved off the board into the scanner. Even if we find an unstable fracture they still go onto a soft bed. I don’t think there is any role for backboards in EMS—especially IFTs.”

29. Who has made a change? EMSStat in Norman, OK is just one of many nationwide…. These patients may require immobilization with a cervical collar: High risk or suspicious injury (high speed MVC, axial loading injury, multi-system trauma) Signs or symptoms of shock Focal neurological deficits such as paralysis, weakness or numbness Intoxication or altered mental status Loss of consciousness due to trauma Age >65 Presence of any tenderness of the neck or spine (touch or movement) Severe head of facial trauma Distracting injury Patients without any of the above findings may be transported without a cervical collar.

30. EMSStat protocol cont… Selectively immobilize (with a cervical collar) only those patients at high risk for spinal injury as above or with clinical indications of spinal injury. Use the long spine board to minimize movement of the patient when moving them from the point of injury to the stretcher. Once the patient is moved to the stretcher, using log roll or lift-and-slide technique, lay the patient flat on the stretcher and leave the c-collar in place. Elevate the back of the stretcher as needed for patient comfort.

31. EMSStat protocol cont… Do not transport a patient to the hospital on a backboard unless it is necessary for patient safety. Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor.  Patients may remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew.

32. EMSStat protocol cont… A multi system blunt trauma patient, such as from a high velocity crash or significant fall, who is unable to follow commands due to combativeness, intoxication, or decreased mental status, should remain on the backboard for their safety until handoff to the ED.   Never immobilize a patient with penetrating trauma such as a gunshot wound or stab wound. Even with neurologic deficits caused by transection of the spinal cord, the damage is done; additional movement will not worsen an already catastrophic injury.  Emphasis should be on airway and breathing management, treatment of shock, and rapid transport to an appropriate trauma center.

33. EMSStat protocol cont… If manual cervical stabilization is hampering effort to intubate the patient, the neck should be moved to allow securing the airway.  An unsecured airway is a far greater danger to the patient than a spinal fracture. Eliminate the "standing take-down" for backboarding patients who are ambulatory after an injury.  Place a collar and allow the patient to sit on the cot, than lie flat.  Patients who are ambulatory and able to follow commands do a better job of preventing movement of an injured spine than rescuers do. Remove cervical collars on conscious patients that tolerate them poorly due to anxiety or shortness of breath.

34. EMSStat protocol cont… The new protocol will: reduce pain and suffering reduce complications decrease on scene times reduce injuries to crews who are attempting to carry immobilized patients reduce unnecessary imaging costs and radiation exposure

35. Where do we go from here??? Obviously, more studies need to take place and on a larger scale. Studies should focus on EMS in America as we still have the most conservative protocols relating to immobilization. Studies should be prospective We need to move away from the “cookbook” mentality. Education needs to focus more on competency in both skills and decision making as opposed to simply completing the allotted amount of hours. Finally, we need to always remember that we are advocates for our patients. We make the decisions that effects their lives….

36. Questions???

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38. References ACEP. (2013). Critical Care Medicine section of the American College of Emergency Physicians. Retrieved from http://www.acep.org/criticalcaresection/ Aehlert, B. (2010). Paramedic Practice Today: Above and Beyond. Volume 2. St. Louis, MO:Mosby JEMS Elsvier. Brown, J.B., et al. (2009). Prehospital Spinal Immobilization Does Not Appear to Be Beneficial and May Complicate Care Following Gunshot Injury to the Torso. Journal of Trauma-Injury Infection & Critical Care. 67(4): 774-778. Burton, J., Dunn, M., Harmon, N., Hermanson, T., & Bradshaw, J. (2006). A statewide, prehospital emergency medical service selective patient spine immobilization protocol. Journal Of Trauma, 61(1): 161-167. Hauswald, M., Tandberg, D. (2008). Out-of-hospital Spinal Immobilization: Its Effect on Neurologic Injury. Journal of Academic Emergency Medicine. 5(3): 214-219. Retrieved from Backboard... Haut, E., Kalish, B., Efron, D., Haider, A., Stevens, K., Kieninger, A., & ... Chang, D. (2010). Spine immobilization in penetrating trauma: more harm than good?. Journal Of Trauma, 68(1): 115-121. Kaups, K.L., Davis, J.W. (1998). Patients with Gunshot Wounds to the Head Do Not Require Cervical Spine Immobilization and Evaluation. Journal of Trauma-Injury Infection & Critical Care. 44(5): 865-867. Muhr, M., Seabrook, D., & Wittwer, L. (1999). Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehospital Emergency Care, 3(1): 1-6. NAEMSP. (2013) EMS Spinal Precautions and the Use of the Long Backboard. Prehospital Emergency Care. 17(3): 392- 393. Richard A., C., Colin A., G., & Philip T., M. (n.d). Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?. Injury, 34: 912-914. Totten, V. Y., & Sugarman, D. B. (1999). Respiratory effects of spinal immobilization. Prehospital Emergency Care, 3(4): 347.