By: Kurt Bloomstrand, MD. EMS Medical Director

Transcription

1 By: Kurt Bloomstrand, MD EMS Medical Director

2 Review anatomy and physiology List the mechanisms of injury that cause a high index of suspicion for the possibility of spine injury Discuss historical perspectives and current literature regarding spinal motion restriction Discuss national guidelines regarding spinal motion restrictions Review Region 6 Spinal Motion Restriction Protocol Review SMR Techniques Test your knowledge

3 7 Cervical 12 Thoracic 5 Lumbar 5 Fused Sacral 4 Fused Coccygeal Lordotic Curves Kyphyotic Curves

4 Vertebral Column 33 Vertebrae Vertebrae = Body + Arch Vertebral Arch Pedicles Lamina Processes

5 Consists of 7 vertebrae separated by intervertebral discs Known as C1 (Superior Cervical Vertebrae) to C7 (Inferior Cervical Vertebrae) Top Cervical vertebrae (C1) is known as the Atlas This is the vertebrae connecting the head to the spine Second vertebrae (C2) is known as the Axis Supports the Atlas and allows the Atlas to pivot Cervical region allows for movement of the head and neck

6 Consists of 12 vertebrae separated by intervertebral discs Known as T1 (Superior Thoracic Vertebrae) to T12 (Inferior Thoracic Vertebrae Increase in size gradually from T1 to T12

7 Consists of 5 vertebrae separated by intervertebral discs Known as L1 (Superior Lumbar Vertebrae) to L5 (Inferior Lumbar Vertebrae) Largest vertebrae of the spinal column

8 5 fused Sacral Vertebrae & 4 fused Coccygeal Vertebrae Sacrum begins fusing around puberty and completely fused by the mid-30s Sacral region is the base of the spine and allows for articulation with the pelvis Coccygeal region (Coccyx) is below the Sacral region; serves a function as an attachment for various tendons, ligaments, and muscles Coccygeal region also allows for support for sitting

9 Ligaments Anterior/Posterior Longitudinal Vertebral Arch Ligaments Ligamentum Flavum Supraspinatous Ligament Interspinous Ligament Intertransverse Ligament Capsular Ligament Intervertebral Disks Nucleus Propulsus Annulus Fibrosus

10 Support structure for the human body Protects the spinal cord Provide structure for attachment of muscles, tendons, and ligament Flexibility and Mobility

11 Hyperextension excessive posterior movement of the head or neck Hyperflexion excessive anterior movement of the head or neck Compression weight of head or pelvis driven into stationary neck or torso Rotation excessive rotation of the torso or head and neck, moving one side of the spinal column against the next Lateral stress direct lateral force on spinal column, typically shearing one level of cord from another Distraction excessive stretching of column and cord

12 Mechanism of Injury

13

14 Clinical Suspicion IMMOBILIZE Any Trauma Above Clavicles IMMOBILIZE Not Sure IMMOBILIZE Fear of Punishment IMMOBILIZE Don t Feel Like Checking IMMOBILIZE

15 For the past 30 years, EMS providers were taught to have a very low threshold to apply spinal immobilization Most EMS textbooks emphasize mechanism of injury. Mechanism essentially started to trump the patient interview and physical exam

16 1966 National Academy of Sciences -Accidental Death and Disability: The Neglected Disease of Modern Society Quantified the magnitude of traffic-related death and disability Described the deficiencies in prehospital care in US More died in the US in MVCs each year during that time than during the entire Korean War 1966 The Highway Safety Act Required states to have a highway safety program, including emergency services Established the Emergency Medical Services program in the Department of Transportation

17 1966 study of 958 trauma patients with a spinal injury 29 patients (3%) had delayed onset of paraplegia The paralysis occurred in each case as a consequence of failure to recognize the injury to the spinal column and to protect the patient from the consequences of his unstable spine. Geisler WO, Wynne-Jones M, Jousse AT. Early management of patients with trauma to the spinal cord. Med Serv J Can. 1966;4:

18 Spinal immobilization, like most EMS procedures, was adopted with little scientific basis

19 1968 study showed that a cervical collar and a long or short backboard 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. Farrington DJ. Extrication of victims. J Trauma. 1968;8:

20 AND SO IT BEGAN!!!

21 Spinal immobilization a key feature of early Emergency Medical Technician training

22

23 1989 study of 90 trauma victims showed improvement or resolution of Cervical and Lumbar spine pain when patients were removed from the backboard Barney RN, Cordell WH, Miller E. Pain associated with immobilization on rigid spine boards. Ann Emerg Med. 1989;18: study caused 100% of 21 healthy volunteers to report pain within 30 minutes of being strapped to a backboard Chan D, Goldberg R, Tascone A, et al. The effect of spinal immobilisation on healthy volunteers. Ann Emerg Med. 1994;23:48 51.

24 2002 study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness May lead to inadvertent imaging, radiation exposure, cost and prolonged ED stays March J, Ausband S, Brown L. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002;6:421 4.

25 A 1995 study at Methodist Hospital of Indiana measured the interface (contact) pressures over bony prominences of 20 patients on wooden backboards over 80 minutes Interface pressure > 32 mm Hg causes capillaries collapse, resulting in ischemia and pressure ulceration. This study measured mean interface pressures as high as 149 mm Hg at the sacrum, 59 mm Hg at occiput, and 51 mm Hg at heels Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissueinterface pressures during spine-board immobilization. Ann Emerg Med. 1995;26:31 6.

26 1988 study at Beaumont Hospital of healthy, back boarded males concluded that backboard straps significantly decrease pulmonary function Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17:915 8.

27 Straps tightened across the torso have a restrictive effect Lowers forced vital capacity (13.97%) Lowers forced expiratory volume over 1 second (14.16%) Lowers forced mid-expiratory flow (18.70%) Injuries to the chest wall and lungs further interfere with respiratory mechanics Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999,3:

28 2000 Prospective, observational study Regional adult level one trauma center Public, urban, tertiary care facility 102 subjects Total backboard time (±45.87) minutes Total ED backboard time (±44.88) minutes Mean transport time 15.8 (±11.4) minutes Lerner EB, Moscati R. Duration of patient immobilization in the ED. Am J Emerg Med. 2000;18:28-30.

29 2010 Retrospective analysis of 45,284 penetrating trauma patients in the National Trauma Data Bank Highlights Twice as likely to die if immobilized No benefit for any specific population group SI was independently associated with significantly decreased survival GSW with hypotension - 3x increased risk of death with SI Stab wounds - no statistical impact of SI on mortality Haut E, Kalish B, Efron D, Haider A, Stevens K, Kieninger A, Cornwell E, Chang D. Spine immobilization in penetrating trauma: more harm than good? J Trauma Jan;68(1):115 20; discussion

30 A collar may increase intracranial pressure by 5.3 mmhg (51.6 ± 60.6%) Obstruction of venous drainage edema Persistent painful stimulus from collar pressure points Venous congestion by collars exacerbate global brain injuries Observed after attempted suicide by hanging 25% of patients with spinal injury have at least a mild TBI Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial pressure after head injury. ANZ J Surg 2002; 72:

31 Pain Increased pain which leads to patient needing sometimes unnecessary X- Rays/CT. Anxiety Cause we need our patients to be more anxious. Aspiration Lying supine, your risk of aspiration increases. Head injury patients tend to vomit. Increased ICP Respiratory Compromise 15-20% reduction in respiratory capacity. Obesity CHF Skin ulcers Heels, buttocks, shoulders. Time delay On scene, in ER.

32

33 Hint: It s not a backboard!

34 Dixon, O'Halloran, & Cummins, 2013

35

36 34,069 total patients 818 (2.4%) radiographed confirmed cervical spine injuries 8 patients were missed by the decision rule Sensitivity 99% (95% CI %)

37

38 July 2013

39

40 EMS Management of Patients with Potential Spinal Injury Spinal motion restriction should be considered for patients with plausible blunt mechanism of injury and any of the following: Altered level of consciousness or clinical intoxication Mid-line spinal pain and/or tenderness Focal neurologic signs and /or symptoms (e.g., numbness and/or motor weakness) Anatomic deformity of the spine Distracting injury

41 Backboards should not be used as a therapeutic intervention or as a precautionary measure either inside or outside the hospital or for inter-facility transfers. Spinal immobilization should not be used for patients with penetrating trauma without evidence of spinal injury.

42 Spinal Motion Restriction (SMR) is not indicated in every trauma patient The long spine board and other rigid devices are primarily extrication devices designed to move a patient to a transport stretcher Patients should be removed from the long spine board as soon as it is safe and practical to do so SMR onto a long board is not indicated in penetrating wounds of the torso, head or neck unless there is clinical evidence of a spinal injury.

43

44

45 Spinal Immobilization Misnomer Impossible to achieve Spinal Motion Restriction Maintain spine in anatomic alignment Minimize gross movement

46 Notes 1. Penetrating trauma patients DO NOT require transport on a long spine board. 2. Patients who are ambulatory on EMS arrival generally DO NOT require full spinal motion restriction on a long spine board UNLESS any criteria in section (A) is present. 3. Patients outside these guidelines will be treated by the judgment of the prehospital provider on scene, with the assistance of online medical control if needed.

47 1. Ejection from motor vehicle 2. Separation from motorcycle/atv 3. Vehicle rollover 4. Prolonged extrication 5. Pedestrian struck by vehicle at speed > 20 mph 6. Falls > 3x patient s height 7. Suspected dive into shallow water 8. Hanging 9. Signs of spinal cord injury from a blunt mechanism 10.GCS < Depressed or open skull fracture

48 FULL SPINAL MOTION RESTRICTION (C-collar, CIDs and backboard) A. High Risk Spinal Injury criteria AND any of the following: 1. Unconscious during exam 2. Altered mental status 3. Intoxication 4. Language barrier 5. Neurologic deficit present or reported 6. Any thoracic or lumbar spine deformity or midline tenderness on palpation or with movement.

49 CERVICAL-COLLAR ONLY B. Blunt Trauma Patients with ANY of the following: 1. Presence of cervical deformity or midline tenderness on palpation or movement 2. Age > Distracting injury present 4. High Risk Spinal Injury Criteria 5. Prehospital Provider s discretion

50 Additional long spine board indications include: 1. Lower extremity fractures- to support splinted limb(s) 2. CPR- to enhance compressions

51 Its acceptable to use a long spine board for extrication purposes. Patients who do not meet any of the criteria in section (A) should be logrolled off of the long board onto the cot and be seat belted for transport.

52 Pregnancy: Third trimester pregnant patients who need to be immobilized on a long spine board should have the board tilted ~25 degrees into the left lateral recumbent position.

53 CHILDREN Secure children in their car seats If car seat is unavailable or child was unsecured in a MVA, the child should be fully immobilized so long as doing so does not cause the child to struggle and compromise the SMR effort

54

55 GCS = 15, A & O x 4 Wrist/hand extension strength normal bilaterally Foot plantarflex and dorsiflex strength normal bilaterally Sensory intact x 4, no parasthesias reported

56 2 Hand Technique Domeier, MD (2014)

57 2 Arm Squeeze Technique Domeier, MD (2014)

58 Start with normal cervical stabilization with manual techniques and collar. Domeier, MD (2014)

59 Domeier, MD (2014) If the patient is comfortable with self extrication, assist the patient with the process as needed.

60 Assist the patient as needed to exit the crash setting. The patient s effort and collar are used for cervical stabilization. Addition manual stabilization is not needed. Domeier, MD (2014)

61 Domeier, MD (2014) Move the patient to the ambulance cot.

62 Domeier, MD (2014) Place the patient in a position of comfort on the ambulance cot.

63 Domeier, MD (2014)

64 Domeier, MD (2014)

65 Domeier, MD (2014)

66 Domeier, MD (2014) If time & patient condition permit remove the patient from the extrication device. Remove any straps used for patient movement to the ambulance.

67 Use a two or more person log roll technique to remove the backboard. Domeier, MD (2014)

68 Answer the following questions as a group. If doing this CE individually, please your answers to: shelley.peelman@presencehealth.org Use September 2016 CE in subject box. You will receive an confirmation. Print this confirmation for your records, and document the CE in your PREMSS CE record book.

69 Apply the Spinal Motion Restriction protocol to the following patients. Determine what category of SMR each patient needs, if any.

70

71

72

73

74

75

76

77

78

79 EMS spinal immobilization processes cannot make normal spines more safe and they cannot undo permanent spinal injury, but the argument can be made that all packaged patients have the potential to be harmed.

80