To Backboard or Not To Backboard? Selective Spinal Immobilization
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1 To Backboard or Not To Backboard? Selective Spinal Immobilization Will Smith, MD, EMT-P Medical Director Grand Teton National Park and Jackson Hole Fire/EMS, Jackson, WY
2
3 Objectives Discuss current standard of care and protocols regarding spine injuries. Review research on spine injuries and evaluation/treatment standards. How to implement spine assessment protocols into your system.
4 Spinal Immobilization Spine Stabilization (In Line Traction) Spinal Motion Restriction Spinal Clearance Protocols Selective Spinal Immobilization Focused Spine Assessment Terminology
5
6 s Spinal Immobilization EMS standards developed Consensus and Common Sense Thought to be best practice Now changing? MAST Pants, Massive IVF in trauma
7 Who needs to be immobilized?
8 Even if they walked away from this?
9 Do we immobilize for: Spinal Immobilization Mechanism of Injury? Symptoms and/or Physical findings?
10 Little research Spinal Immobilization Never been shown to improve outcomes
11 Malaysian /New Mexico Study Hauswald, Acad Emerg Med yr retrospective chart review of 2 university hospitals Less neurologic disability in unimmobilized Malaysian patients Disproves many theories that previously justified widespread spine immobilization
12 Malaysian /New Mexico Study C-spine fractures = >2,000-6,000 N L-spine fractures = >4,200 N Head off the end of stretcher = 40 N
13 Spinal Immobilization BUT - Standard of Care (in U.S.) One of the most common EMS procedures Millions of patients immobilized each year Not necessarily in other parts of the world
14 Most Current EMS Protocols Apply spinal immobilization to all patients with potential for spine injury based on mechanism of injury If in doubt - IMMOBILIZE!
15 picture
16 The Research No RCT to asses spinal immobilization on trauma patient mortality, neurologic injury, spinal stability, or adverse effects sustained Kwan, Cochrane Database 2001/2007 #2803
17 NEXUS The Research Hoffman, et. al. - NEJM, July 2000 Canadian C-Spine Rule Stiell, et. al. - JAMA, Oct 2001
18 Moves to a standard of clinical spine clearance in emergency departments NEXUS Decreased imaging in 12.6 % (4,309 pts) N=34,069 patients
19 NEXUS All 5 criteria met = No Xray 1. No midline cervical tenderness 2. No focal neurological defect 3. Normal alertness 4. No intoxication 5. No painful distracting injury
20 Canadian C-Spine Rule Provides another clinical spine clearance pathway Slightly different protocol - more if/then Age listed as a factor (>65) Mechanism still plays a role Range of motion of neck final test
21
22 Wilderness EMS Taking this to the field Rural EMS Urban EMS
23 Extended Transport 2 hours to days Risks of Spinal Immobilization Decubitus ulcers, pt. discomfort Airway concerns - vomit, blood, etc. Extrication problems, rescuer risks Wilderness EMS **Risk vs. Benefit of Spinal Immobilization
24 Wilderness EMS
25 Focused Spine Assessment Wilderness EMS Accepted protocol for Wilderness First Responders (WFR) WMA, NOLS/WMI, SOLO
26 Rural EMS Prolonged Transport 15 minutes to 1-2 hours Pt. uncomfortable No provider risk
27 Rural EMS Several Devices to Increase Comfort
28 Urban EMS Rapid Transport Less than 15 minutes Present to emergency departments Spine clearing protocols NEXUS, Canadian C-Spine Rule Xrays or CTs Little risk to patients or EMS providers
29 Flight EMS Patient s cleared in referral ED s by CT and board certified EM physicians placed back on boards for transfer to trauma centers.
30 Why change what we re doing? Patient Comfort Airway Compromise Vomit, Blood, Position Breathing Compromise Skin Compromise Patient/Provider safety in technical settings
31 Maine Michigan California National Park Service Some places have Malaysia (by default)
32 Selective Spinal Immobilization Protocol Implementation Review Research References are a start Do your own search as well! Medical Director / Medical Control Support Critical for success
33 Selective Spinal Immobilization Protocol Implementation Review Established Protocols State of Maine National Park Service Others
34 State of Maine
35 National Park Service NPS EMS Field Manual, Version 02/05, Procedure 1150
36 Wilderness Medical Associates
37 Selective Spinal Immobilization Protocol Implementation Develop Protocol that works for your system Age >65 get collar? Backboard? Peds excluded?
38 Selective Spinal Immobilization Protocol Implementation Good QA/QI program Education of EMS Providers Ongoing Review of Decisions and Outcomes
39 Summary Not everyone with blunt trauma needs spinal immobilization in the ED or in the field Selective spinal immobilization can and should be done by prehospital providers
40 Questions? Questions??? Lecture Notes: Copy of lecture notes
To Backboard or Not To Backboard, That is the Question? Selective Spinal Immobilization
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Objective 1 Review Research on spine injuries and evaluation standards.
To Backboard or Not To Backboard? Spinal Clearance Protocols Will Smith, MD, NREMT-P Medical Director, Jackson Hole Fire/EMS, Grand Teton National Park Wilderness and Emergency Medicine Consulting (WEMC),
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