Introduction. Objectives C-Spine: Where Are We Now? NAEMSP Medical Director Course 1/9/2013

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1 NAEMSP Medical Director Course 1/9/2013 Objectives C-Spine: Where Are We Now? Robert M. Domeier, MD EMS Medical Director Washtenaw/Livingston Medical Control Authority Department of Emergency Medicine Saint Joseph Mercy Hospital, Ann Arbor, Michigan Spinal Injury Treatment Understand the historical perspective of spine immobilization Discuss the evolution of prehospital treatment Describe a current EMS spine injury assessment protocol Discuss new innovations in hospital treatment Discuss innovations in EMS treatment Discuss the future for NAEMSP Introduction Spinal Injury Treatment Historical perspective ED spine clearance algorithms Evolution of prehospital treatment W/L study results Current EMS spine injury assessment protocol Traumatic Arrest ACS/NAEMSP position paper non-resuscitation criteria Local data 1

2 Spinal Cord Injured / Spinal Fractures million MVA injuries/year (NHTSA) Spine fracture occurs in 3% of trauma patients 14% of spinal fractures have a cord injury ,000 Spinal cord injuries/yr 1971 AAOS book said... Signs of spinal injury Pain Tenderness Unconscious Lacerations Deformity NO mention of mechanism Painful movement (Simple ROM test recommended) Studies that Changed it all Bohlman, cervical spine injuries 100 had initial injury missed in the ED Head injury Alcohol Multiple trauma 2

3 Reports of Missed Injury Numerous reports of deterioration in neurologic function after injury Origin of this data is vague Prehospital Treatment Even after years of research, no formula has been devised to predict who has the unstable fracture or cord injury that will be aggravated by improper packaging. The only safe course of action is constant suspicion of spinal injury combined with proper patient handling and packaging. BTLS 1988 X-Ray everyone on a backboard ED Response 3

4 ED Clinical Clearance Prospective studies of X-rayed trauma patients (2.6%) cervical fractures in 4170 patients Ross, et al, 1992 Hoffman, et al, 1992 Kreipke, et al, 1989 Roberge, et al, 1988 Neifeld, et al, 1987 Jergens, et al, 1977 ED Clinical Clearance All fractures identified by clinical criteria Altered mental status Neurologic deficit Neck pain or tenderness Evidence of intoxication Severely painful distracting injury ED Clinical Clearance - NEXUS Prospective assessment of 27,389 X-rayed trauma patients with 659 (2.4%) cervical injuries Low risk criteria no posterior midline cervical tenderness not intoxicated normal level of alertness no focal neurologic deficit no painful distracting injury Mower

$ED Clinical Clearance Only 15 of 659 cervical fractures were missed by the low risk criteria None had neurologic sequelae Mower 1999 ED Clinical Clearance Canadian C-spine Rule$ 0%) clinically important cervical injuries Protocol not followed in 10% of patients Sensitivity between 95.3 and 99.4% Specificity between 40.4 and 50.

0%) clinically important cervical injuries Protocol not followed in 10% of patients Sensitivity between 95.3 and 99.4% Specificity between 40.4 and 50.

5 ED Clinical Clearance Only 15 of 659 cervical fractures were missed by the low risk criteria None had neurologic sequelae Mower 1999 ED Clinical Clearance Canadian C-spine Rule Validation study of prospectively derived Canadian C-Spine Rule 8283 alert (GCS 15) trauma patients with 169 (2.0%) clinically important cervical injuries Protocol not followed in 10% of patients Sensitivity between 95.3 and 99.4% Specificity between 40.4 and 50.7% Stiell 2003 Radiography Mandated Age > 64 Dangerous mechanism Fall from elevation > or = 3 feet/5 stairs Axial load to head, e.g. diving MVC high speed (100km/hr), rollover, ejection Motorized recreational vehicles Bicycle collision Paresthesias in extremities 5

6 Assessable Conditions Simple rear end MVC (see note) Sitting position in ED Ambulatory at any time Delayed onset of neck pain Absence of midline c-spine tenderness If not one of these radiographs required ED Clinical Clearance Asymptomatic fractures Case reports of missed bony or ligamentous injuries None with neurologic injury as a result of these missed injuries SJMH ED Practice Clinical Clearance Radiographs used to clear the spine in 13,357 trauma patients % get cervical X-rays/65% of BB pts 24% get thoracic X-rays/36% of BB pts 26% get lumbar X-rays/39% of BB pts 6

7 Benefits of immobilization? Prevent movement of spine What is the best method How much movement is too much? Reduce catastrophic secondary SCI? Risks to Immobilization? Uncomfortable Delays transport Aspiration/airway Un-necessary x-rays Potential movement on a well immobilized head of the body Immobilization Complications Back and head pain Ausband, et al 1996 Cordell, et al, 1996, 1995 Chan, et al 1994 Delbridge, et al, 1993 Altered clinical exam March, et al, 2002 Unnecessary X-rays 7

8 Immobilization Complications Reduced pulmonary function FVC, FEV1, FEF 25-75% Bauer, et al 1988 Schafermeyer, et al 1991 Pulmonary compromise case Walsh, et al, 1990 Immobilization Complications Neurologic deficits caused by immobilization of elderly patients Podolsky, et al, 1983 Slagel, et al, 1985 Pressure related complications Pressure sores Infection Multicenter Prospective Validation of Prehospital Clinical Spinal Clearance Criteria Domeier et al. Journal of Trauma 2002;53: Prospectively assessed clinical findings in spine immobilized patients Patients transported by 23 ambulance services to 17 Michigan hospitals Outcomes for each patient determined Spinal fracture Neurologic deficit Spine fracture management 8

9 Results 8975 complete cases 291 patients with spinal injuries 108 cervical fractures 83 thoracic fractures 100 lumbar fractures Captured Results Missed Positive Pred Val ( ) Sensitivity Specificity Negative Pred Val 95.2% ( ) 35.0% ( ) 99.5% ( ) Study Conclusion Absence of: altered mental status neurologic deficit evidence of intoxication spinal pain or tenderness suspected long-bone extremity fracture has a high sensitivity for detecting significant spinal injury. 9

10 Prehospital Clinical Findings 38% of patients had none of the criteria present and could have had spine immobilization omitted Protocol Implementation Southeastern Michigan protocol for immobilization based on spinal injury assessment implemented October 1997 Washtenaw/Livingston Wayne Oakland Prehospital personnel trained to perform spinal injury assessment Immobilization based on result Protocol Performance Assessment Domeier, Frederiksen, Welch. Ann Emerg Med 2005;46: year assessment of the southeastern Michigan spine injury assessment protocol 13,357 patients All patients with a spine injury assessment documented 10

Methods Data entered in documentation table as yes, no or cannot assess Yes or cannot assess on table treated as positive findings Methods All trauma run sheets collected from ambulance service

11 Methods Data entered in documentation table as yes, no or cannot assess Yes or cannot assess on table treated as positive findings Methods All trauma run sheets collected from ambulance service Outcomes determined Spine/Spinal Cord Injuries 415 Spine Injuries 128 Cervical / 34 (26.6%) SCI 125 Thoracic / 13 (10.4%) SCI 162 Lumbar / 4 (2.5%) SCI Spine Fractures and Cord Injuries Spine Injuries Cord Injuries Cervical Thoracic Lumbar Spinal Level 11

12 EMS Trauma Patient Ages Missed Spine Injuries Results Study Patients by Age N=13, Age Missed Spine Injuries C1 C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 Spine Level Using the protocol 382 of 415 spinal injuries were immobilized Only two of the 33 patients with injuries not immobilized required more than pain management or conservative treatment with bracing or a collar No patients without immobilization had a spinal cord injury as an outcome Protocol Performance Sensitivity Specificity Entire Population 92.0% ( %) 39.7% ( %) 12

13 Missed Cervical Injuries From Prospective Studies Age Sex Mechanism Injury Management 58 F Fall - Standing/Sitting/Supine C1 Ring, C2 Odontoid Halo 86 F Fall - Standing/Sitting/Supine C1 Ring, C2 Odontoid Halo 71 M Fall - unspecified C1, 2 Odontoid Fracture (Fx) Halo, Pain Control 80 F Fall - Standing C 2/3 Subluxation, 3-4 mm Philadelphia Collar 87 M MVC Frontal C3-5 Spinous Process, Philadelphia Collar 91 F Fall - Standing/Sitting/Supine C2 Lateral Mass Collar C6 Laminar, C7 Compression 16 F MVC Head-on C6 A nterior Body Fracture Stiff neck Collar 45 F MVC Frontal C6-7 Facet Fx (CTO) Brace 59 M Motorcycle C3 Body Collar Between the two studies, three significant cervical injuries C1,2 were missed Falls with head strike mechanisms, 2 of 3 over 65, third 58 y/o wheelchair pt Our Spine Injury Assessment Protocol Prevent spinal movement by in-line manual stabilization. Assure adequate management of ABC's Any unstable patient or patient with inadequate ABC's should be treated as a positive spine injury Assessment Protocol Assess for the presence of Clinical Criteria. Presence of any of the clinical criteria should be treated as a positive spine injury. Altered Mental Status Evidence of Intoxication Extremity Fracture Motor and/or Sensory Deficit Spine Pain and/or Tenderness 13

14 Result of Injury Assessment Spine Immobilization and Neurologic Injury Neurologic Injuries Any of the criteria positive Full spine immobilization All of the criteria negative Spine immobilization may be withheld Transport still indicated which is to be done on a stretcher Soft immobilization In patient s age 65 or greater place a collar Out-of-hospital spinal immobilization: its effect of neurologic injury. Hauswald M, et al. Acad Emerg Med 1998 Retrospective Review - blunt spinal injuries University of Malaya University of New Mexico Cord Total Injury Cervical 34 (30%) 113 Immob (US) Unimmob 10 (25%) 40 (Malaysia) Thoracic 22 (21%) 107 Immob (US) Unimmob 2 (6%) 33 (Malaysia) Lumbar 14 (12%) 113 Immob (US) Unimmob (Malaysia) 1 (2%) 47 MI - Spinal Cord Injury Rate Cervical (26.6%) Thoracic (10.4%) Lumbar (2.5%) 14

15 Characteristics of Patients with Spinal Cord Injuries Breakdown of Cord Injuries Cord Injuries Domeier, Swor, Frederiksen (2003 NAEMSP Abstract) 22,329 Total patients 710 (3.2%) Spinal injuries 103 (14.5%, 0.4% of total) Spinal Cord Injuries Spinal Cord Injuries by Level SCIWORA Partial Complete 52 of 103 (50%) Complete Cord Lesions 38 of 103 (0.2% of total patients) Partial Cord Injury 0 C1 C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 13 of 103 (13%) Spinal Cord Injury without Radiographic Abnormality (SCIWORA) 15

16 EMS Findings in Spinal Cord Injury Complete (52 Patients) Neurologic deficit evident Altered mental status preventing evaluation of neurologic function Partial (38 Patients) 19 (50%) identified by altered mental status or neurologic deficit 6 with distractions (Intoxication, Extremity Fracture) 13 with pain in the area of injury Changes in ED Practice Many trauma centers removing patients from spine immobilization on presentation to the ED Concerns for pressure injuries and recognition of lack of benefit Australian Back Board Used for Extrication Patients often removed from board after use for extrication Patients not left on Board at Hospital 16

17 Australian Spine Immobilization Position Paper In considering spine immobilisation the Medical Committee of the Convention of Ambulance Authorities believes that: Apart from the use in extrication, the use of long spinal boards for transport does not prevent secondary spinal injury. Conclusion There is no proven benefit of rigid spine immobilization as practiced in the U.S. The future may include backboards as an extrication devise only 17

To Backboard or Not To Backboard, That is the Question? Selective Spinal Immobilization

To Backboard or Not To Backboard, That is the Question? Selective Spinal Immobilization Will Smith, MD, NREMT-P Medical Director, Jackson Hole Fire/EMS, Grand Teton National Park Emergency Medicine, St.