Selective Spinal Immobilization
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1 Selective Spinal Immobilization
2 Objectives Understand the background of spinal immobilization. Understand the rationale for developing a current selective spinal immobilization protocol. Review the data on the selective spinal immobilization. Cases and application of protocol
3 The Problem Between 2-4% of blunt trauma patients sustain cervical spine injury Early trauma education suggested mechanism of injury as a sole reason for treatment of PRESUMED spinal injury EMS education resulted in increased practice of cervical immobilization
4 Immobilization - The Concept Prevent neurologically intact, unstable injuries from deteriorating Prevent progression of neurologic deficits as a result of unstable injury movement
5 Why not immobilize everybody? % of EMS trauma patients do not have a spine injury EMS provider confusion/education Immobilization causes patient pain and anxiety possibly injury Patient refusal for immobilization
6 Why not board and collar everybody? Time consuming for EMS/ED Unnecessary transports Immobilization is uncomfortable Time immobilized = Increased pain Potential trauma Risk of aspiration Vulnerable position
7 What s all the fuss? Why is this such a big deal? Time Money Health issues
8 Why not immobilize everybody? >1,000,000 U.S. Patients receive cervical radiography each year >97% of exams are negative Cost exceeds $175,000,000 each year Patient exposure to radiation ~3000 cases of thyroid cancer/yr Immobilization causes pain and anxiety Slows time to disposition
9 Cervical Spine Evaluation EMS vs. ED Perspectives EMS Who is at risk for cervical injury such that injury might be exacerbated with EMS movement / transport? ED Who is at risk for cervical injury such that radiographic studies need to be done to elucidate question of injury?
10 Can we recognize who may have injuries? Yes! National Emergency X- Radiography Utilization Study NEXUS!
11 National Emergency X- Radiography Utilization Study Hypothesis: Blunt trauma victims have virtually no risk of cervical spine injury if they meet all of the following criteria: No Neurologic deficit No posterior midline tenderness No Altered Level of Consciousness No evidence of ETOH/Tox No other distracting painful injury
12 NSAID mnemonic Neurologic deficit Spinal Tenderness, posterior midline Altered Mental Status or LOC Intoxicated Distracting painful injuries
13 NEXUS Definition: Altered Neurologic function GCS 14 or less disoriented to person,place,time,events Inability to remember 3 objects at 5 min. Any focal deficit Numbness, tingling, weakness Delayed/inappropriate response to external stimuli
14 NEXUS Criteria No posterior midline tenderness Specific to midline cervical spinal tenderness Not considered positive if there is tenderness on the sides of the neck
15 NEXUS Definition: Intoxication Patients should be considered intoxicated if they have: 1) History of recent intoxication or ingestion 2) Evidence of intoxication on exam
16 What is a significant distracting injury? Ill-defined in the literature: Distracting Painful Injuries associated with Cervical Spinal Injuries in Blunt Trauma * suggests: 1)Any long bone fracture 2) Visceral injury necessitating surgical consult * Ullrich, et al. AEM 2001;8:25-29.
17 What is a significant distracting injury? #2 3) Large laceration, degloving or crush 4) Large burns 5) any injury producing acute functional impairment Ultimately up to clinician. Use to increase sensitivity
18 NEXUS Study 21 Centers enrolled 34,069 Blunt trauma victims who underwent cervical spine radiography.
19 NEXUS -Results 818 patients with fracture were identified 8 were not identified by Nexus criteria 810 were identified by clinical decision rules (Nexus criteria) Sensitivity 99% (95% CI %)
20 8 Patients Not Identified By NEXUS Rules
21 NEXUS Performed in hospital setting Can this be applied to the pre-hospital setting? With less training, will an EMT/Paramedic miss a fracture? Protocol is straight-forward.
22 Purpose of Selective Spinal Immobilization Protocol Identify and immobilize 100% of patients at risk for unstable injuries Identify and NOT immobilize patients who have NO/low risk for cervical spine injury
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27 Stable Spine Injuries UNStable Spine Injuries
28 NON- Clinically Significant Spine Injuries Clinically Signficant Spine Injuries
29 EMS older patient spine conundrum Nexus: Be Selective on Everyone Canadian: Doesn t apply to 12 pt 65
30 12 Cases Use the checklist Immobilize? Not immobilize? Rationale 30 Seconds for each case
31 The Checklist
32 Case #1 22 y/o Female Bicycle Crash Asking repeated questions Facial abrasions Obvious wrist fracture
33 Ambulatory Alert No spine pain No obvious injuries Pale Anxious P-130 Case #2 Two Car Crash
34 Case # 3 Male Baseball Player Fell on head during play Alert Denies any injuries/pain Obvious scalp contusion Vitals normal Exam normal
35 In fight Large contusion Denies pain Exam normal ETOH smell Case # 4 Bar Fight
36 Minor 2 Car MVC Knee contusion Exam normal No pain Vitals normal Wants to go home Case # 5 2 Car MVC
37 Keeps asking how is my bike? Road rash Vitals normal Exam normal Denies pain Case # 6 Motorcycle MVC
38 Case # 7 High Impact MVC 48 y/o Restrained Driver Airbag deployment Chest pain, sweaty Denies spine pain Exam normal Vitals BP 130/90 P 130 R 18
39 Wearing seat belt No apparent injuries Denies pain Alert, No ETOH Exam normal Case # 8 Roll Over
40 Case # 9 Jogger Struck By Bicycle Spun around Obvious patella dislocation Contused head Denies spinal pain Alert, sober
41 Case # 10 Fell Off Bike Bike racer Road rash Denies spinal pain Exam normal Alert, sober Vitals normal Slightly tachycardic
42 Case # 11 Fall Down Ladder Alert, Sober Denies spinal pain Exam normal Small scalp laceration Vitals normal
43 OK, let s review the results! 1. No posterior neck pain or tenderness. 2. No intoxication. 3. No altered level of alertness. 4. No focal neurologic deficit. 5. No painful distracting injuries.
44
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