Spinal Immobilization

1. Spinal Immobilization • Erin Burnham, MD - erinburner@gmail.com

2. To Cspine or not to Cspine? • That is the Question!

3. Framework for Discussion • Who should be immobilized? • How should they be immobilized? • How can we Assure Quality?

4. Who should be immobilized?

5. Goal • Clearing C-spine in the field?

6. Case: 78 yo male • An 78 yo male brought in Code-3 by EMS after cardiac arrest. Dispatched for “possible heart attack”. • Hx: Had been fishing that morning with son with no complaints. Stood up from recliner chair and collapsed onto ground.

7. Case: 78 yo male • Paramedics found patient apneic, pulseless • EKG showed V-fib • Patient was successfully defibrillated in field with ROSC.

8. Case: 78 yo male • Pt arrives in ED in NSR, intubated with no spontaneous respiratory effort. • He is placed in C-collar in ED because noted to have contusion on forehead.

9. Case: 78 yo male • CT scan of head is normal • CT scan of C-spine revealed type II odontoid fracture with displacement • EKG and labs unremarkable

10. Case: 78 yo male • Family elects to have patient extubated, and he expires in ED • Would pre-hospital immobilization have effected outcome? • Medico-legal liability?

11. Case: 49 yo male • Motorcycle vs Deer • Speed estimated at 45 mph. • Patient can’t remember exactly what caused accident, but EMT’s find dead deer nearby. • Was wearing full leathers/helmet • He was not intoxicated

12. Case: 49 yo male • Only c/o L. Shoulder pain • Patient arrives not in spinal immobilization • Placed in c-collar in ED • L. Scapula fracture, 2 rib fractures and small L. PTX identified

13. Case: 49 yo male • CT head and C-spine obtained • CT head is normal • C-5 transverse process fracture identified

14. Case: 49 yo male • Fracture is stable and doesn’t effect his outcome • He is transferred to a trauma center • Uneventful recovery • Out windsurfing a few weeks ago

15. Goal • Clearing C-spine in the field? • Provide clear, simple and safe guidelines for prehospital spinal immobilization.

16. Why should we immobilize patients?

17. Why immobilize? • 253,000 people in US living with spinal cord injuries • 12,000 new cases each year • In US, cost of MVC related SCI estimated $34.8 billion per year • 5 million patients in the US receive spinal immobilization each year • Spinal Cord Injury Information Network (www.spinalcord.uab.edu)

18. Epidemiology • 77.8% males • Average age of injury is increasing: • 28.7 yo in 1970’s • 39.5 yo in 2005 • Spinal Cord Injury Information Network (www.spinalcord.uab.edu)

19. Epidemiology • MVC - 42% • Falls - 27% • Violence - 15% • Sports - 7.4% • Spinal Cord Injury Information Network (www.spinalcord.uab.edu)

20. Why immobilize? Why immobilize? • AANS 2001 Guidelines for Pre-Hospital Cervical Spinal Immobilization following trauma: • “There is insufficient evidence to support treatment standards” • “There is insufficient evidence to support treatment guidelines.” • American Association of Neurological Surgeons, 2001

21. Why immobilize? Why immobilize? • “It is estimated that 3 to 25% of spinal cord injuries occur after the initial traumatic insult”: • During extrication • During transit • American Association of Neurological Surgeons, 2001

22. Why immobilize? Why immobilize? • Over the last 30 years there has been a dramatic improvement in the neurologic status of spinal cord injured patients arriving in the emergency department. • 1970’s - 55% complete neurologic lesions • 1980’s - 49% • American Association of Neurological Surgeons, 2001

23. Why immobilize? Why immobilize? • “This has been attributed to the development of Emergency Medical Services initiated in 1971, and the pre-hospital care (including spinal immobilization) rendered by EMS personnel. • What about NHTSA? • American Association of Neurological Surgeons, 2001

24. 1999 NAEMSP Position Paper INDICATIONS FOR PREHOSPITAL SPINAL IMMOBILIZATION Robert M. Domeier, MD, for the National Association of EMS Physicians Standards and Clinical Practice Committee • http://www.naemsp.org/pdf/spinal.pdf

25. 1999 NAEMSP Position Paper • “There have been no reported cases of spinal cord injury developing during appropriate normal patient handling of trauma patients who did not have a cord injury incurred at the time of the trauma.” • http://www.naemsp.org/pdf/spinal.pdf

26. 1999 NAEMSP Position Paper • “Although early emergency medical literature identified mis-handling of patients as a common cause of iatrogenic injury, these instances have not been identified anywhere in the peer-reviewed literature and probably represent anecdote rather than science.” • http://www.naemsp.org/pdf/spinal.pdf

27. 1999 NAEMSP Position Paper • Spine immobilization is indicated with a significant mechanism of injury and at least one of following criteria: • Altered mental status • Evidence of intoxication • A distracting painful injury (e.g. Long-bone extremity fracture) • Neurologic deficit • Spinal pain or tenderness

28. 1999 NAEMSP Position Paper • Caveats: • Language or communication barriers • Extremes of age • Difficult to assess intoxication in field • Variable interpretation of spinal pain or tenderness • http://www.naemsp.org/pdf/spinal.pdf

29. Why shouldn’t we immobilize everyone?

30. Adverse Effects of Spinal Immobilization • Time • Compliance • Nausea/aspiration • Pain/unhappiness • Increased MD workup bias • Ulcers • Impaired ventilation • Increased ICP

31. Kwan, et al 2004 Effects of Prehospital Spinal Immobilization: A Systematic Review of Randomized Trials on Healthy Subjects Irene Kwan, MSc;1 Frances Bunn, MSc2 • http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

32. Kwan, et al 2004 • 2004 Cochrane Review • Systematic review of 17/4453 randomized controlled trials comparing types of spinal immobilization devices • http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

33. Kwan, et al 2004 • Adverse effects of spinal immobilization included: • Significant increase in respiratory effort • Skin ischemia • Pain/discomfort • http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

34. ATLS 2008 • Several studies have shown correlation between the length of time on a rigid spine board and the development of pressure ulcers. • “A paralyzed patient who is allowed to lie on a hard board for more than 2 hours is at high risk for serious decubitus ulcers.” • 2008 ATLS Course Manual, 8th edition

35. Increased ICP • Cervical collars have been associated with elevations of intracranial pressure (ICP) • Prospective study of 20 patients • Rigid Philadelphia collar • Significant (p = .001) increase in ICP from 176.8 to 201.5 mm H20 • Kolb, et al, Ann Emerg Med. 1999; 17:135-137

36. NEXUS National Emergency X-Radiography Utilization Study • Prospective, multi-hospital • Cervical spine clearance if no • Intoxication • Distracting injury • Neuro deficit • Midline spine tenderness • 34,069 at risk for cervical fracture from blunt • 818 (2.4%) cervical spine injuries • Missed 8 (99% sensitive, 12% specific) • Good confidence intervals (98-99.6%) • Only 2 injuries deemed clinically significant • Hoffman, et al, NEJM, July 13, 2000, Vol. 343, No. 2; p. 94 - 99

37. Pediatric Cervical Spines • 3065 (9%) of NEXUS patients were <18 years • 0.98% cervical spine injury • No SCIWORA • Decision rule 100% sensitive • Confidence intervals 87-100% • Viccellio, et al, Pediatrics, Aug 2001, Vol. 108, No. 2

38. Vaillancourt, et al 2009 • The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics • Ann Emerg Med. 2009;54:663-671

39. Vaillancourt, et al 2009 • Prospective cohort study • Alert and stable trauma patients • Advanced and basic care paramedics interpreted rule • All were then immobilized and evaluated in ED • Ann Emerg Med. 2009;54:663-671

40. Vaillancourt, et al 2009

41. Vaillancourt, et al 2009 • 1,949 patients • Paramedics classification showed: • 100% sensitivity • 37.7% specificity • Ann Emerg Med. 2009;54:663-671

42. Vaillancourt, et al 2009 • Paramedics conservatively misinterpreted the rule in 320 (16.4%) • Paramedics were comfortable applying the rule in 1,594 (81.7%) • Ann Emerg Med. 2009;54:663-671

43. Vaillancourt, et al 2009 • Application of the criteria could have reduced 731 (37.7%) out-of-hospital immobilizations. • Ann Emerg Med. 2009;54:663-671

44. Vaillancourt, et al 2009 • Conclusion: • Paramedics can apply the Canadian C-spine rule reliably without missing any important cervical spine injuries. • Ann Emerg Med. 2009;54:663-671

45. Methods of Immobilization

46. ATLS 2008 • “Cervical spine injury requires continuous immobilization of the entire patient with a semirigid cervical collar, head immobilization, backboard, tape, and straps before and during transfer to a definitive-care facility.” • 2008 ATLS Course Manual, 8th edition

47. Kwan, et al 2004 • The following methods were efficacious in restricting movement: • Collars • Spine boards • Vacuum splints • Abdominal/torso strapping • http://pdm.medicine.wisc.edu/Volume_20/issue_1/kwan.pdf

48. Neutral Postion • The “neutral position” is poorly defined: • “The anatomic position of the head and torso that one assumes when standing and looking ahead” • 12° of cervical spine extension on lateral radiograph • American Association of Neurological Surgeons, 2001

49. Neutral Postion • “McSwain et al determined that more than 80% of adults require 1.3 cm to 5.1 cm of padding to achieve neutral positioning.” • This appears to be a reference to PHTLS text • American Association of Neurological Surgeons, 2001

50. Quality Assurance