STOP THE MADDNESS! 4/19/2012. Mechanism of Injury A historical review of bad advice and dangerous dogma
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1 OBJECTIVES Discuss the inherent inaccuracy of using mechanism of injury as the primary indicator leading to spinal immobilization. STOP THE MADDNESS! Jim Morrissey, EMT-P Alameda County EMS PHCC FBI Tactical Paramedic 1 Discuss the harmful sequelae of spinal immobilization. Discuss a sub-set of trauma patients who should NOT be immobilized. Discuss appropriate spine injury assessment and clearance algorithms. Look at an ideal protocol. Look at tools that are less harmful if immobilization is warranted. One of the most common treatments done every day in EMS, whether the patient needs it or not. there might have been a mechanism of injury. Mechanism of Injury A historical review of bad advice and dangerous dogma If the MOI suggests it, suspect a spinal injury and treat your patient accordingly (2009 EMT text) Fall of 2-3 times the patient height Diving injuries Injury above the clavicle Motor vehicle accidents with damage to the vehicle Any accident involving motion Any violent accident 4 1
2 The following are indicators of spinal trauma Damage to the vehicle EMT text book The following are indicators that the spine may have been injured. These patients should be immobilized: FALL Climber falls 1,000 feet down Highlands mountain and lives Falls from a tricycle or bicycle From PHTLS text A Climber who survived a 1,000ft tumble down a mountain yesterday joked that he d had worse injuries shaving. Adam Potter, 36, bounced off three rocky outcrops as he fell down a nearly-vertical cliff in the Scottish Highlands. Rescuers ignored him because when they spotted him he was standing on his feet, reading a map. He said: I just slipped. Speed built up really fast and every time I tried to slow myself I went over a cliff edge, then I would land on a sloppier bit and try to lose speed and then go over another cliff and 7 so on. 2
3 Is going OTB a MOI for spine injury? REALLY? 9 10 Injury above the clavicle AAOS text 12 3
4 unstable spine should be assumed with seizure activity WTF? Any skier who collides with another skier From OEC text, by Warren Bowman et al.. 4
5 Spine damage must be assumed when the mechanism of injury involves motion So Why Do We Immobilize? In theory: to prevent secondary cord injury Further manipulation makes any potential lesions larger and more severe Manipulation of unstable fractures may cause a cord lesion. In reality: Tradition Dogma Fear of litigation ER shite 19 There is no evidence immobilization helps.at all YOU HAVE HEARD IT ALL: It s how we were taught Better Safe, then sorry You never know??? we don t diagnose in the field I am just following protocols it is just precautionary I don t want to get yelled at When in doubt QUIT BEING IN DOUBT!!! 20 5
6 General rule: As danger, threat level and urgency increase, there should be an inversely proportional attention paid to immobilizing potential spine injuries. J Trauma Jan;68(1):115-20; discussion Spine immobilization in penetrating trauma: more harm than good? Immobilization is "a tradition that started decades ago," says Dr. Demetriades, who directs the Division of Acute Care Surgery at USC. "There was never any scientific evidence that it works." First responders would have to immobilize the spines of 1,032 patients before potentially benefiting one person, the study s authors wrote. But it only took 66 patients to potentially contribute to one death. 22 Injured woman drowns under rescue boat while strapped to a backboard - Boston Globe 8/24/06 23 Yates's friends said they don't know why she needed to be strapped in. Why would you take a 64-year-old lady that's got a little bump on the head and a sprained ankle and strap her into a situation where if there was an accident, she couldn't get out. She didn't want to go in the ambulance. She didn't want to be rescued, 24 6
7 The Malayan/ New Mexico comparative spine study ACADEMIC EMERGENCY MEDICINE MAR 1998 VOL 5/NO 3 Five year retrospective chart review at two university teaching hospitals. University of Malaya and the University of New Mexico 354 patients seen with SCI None of the 120 Malayan patients were immobilized All of the 334 New Mexico patients were immobilized Neurological disability was less for the Malayan subjects! (11% vs. 21%) Conclusion: immobilization has little or no effect on neurologic outcome! 25 Harmful Sequelae of Spinal Immobilization Pain / Anxiety- pain on spine leading to X-ray Increased intracranial pressure Cervical collar- distraction, masking injuries Risk of aspiration- Potential for airway compromise, head injured patients often vomit Respiratory Decompensation % reduction in respiratory capacity On Scene delay, ED delay, OR delay Time, money, equipment Decubitus ulcers: Occiput Sacrum Heels Prehospital Spinal Immobilization Does Not Appear to Be Beneficial and May Complicate Care Following Gunshot Injury to the Torso The Journal of TRAUMA Injury, Infection, and Critical Care Volume 67, Number 4, October 2009 damage to the cord after penetrating trauma is not related to manipulation of the spine but rather the direct damage done by the projectile. on the basis of our analysis, PHSI seems to be of little or no benefit to those with GSW to the torso it seems clear that patients sustaining GSW to the torso are more likely to require some form of emergent intervention that may be affected by the process of PHSI. The potential to delay definitive surgical treatment, the potential to complicate airway management, and the overall lack of neurologic improvement after gunshot injury to the spinal cord suggest that PHSI in this patient population may by unjustified. 28 7
8 An ideal protocol for penetrating trauma victims The Reliability of Prehospital Clinical Evaluation for Potential Spinal Injury Is Not Affected By the Mechanism of Injury Prehosp Emerg Care, 1999 Victims of penetrating trauma (e.g. stabbings, gunshot wounds) to the head, neck and/or torso should not be spinal immobilized (cervical collar, backboard) unless there is a significant secondary mechanism of injury (e.g. after getting shot, fell down a flight of stairs) or have an obvious neurologic deficit to the extremities. Conclusion: MOI does not affect the ability of clinical criteria to predict spinal injury in this population What s Wrong Patient Assessment System (PAS) What s Not Wrong Spine Injury Assessment Positive or uncertain mechanism: Clear mental status Spine is clear Clear of new symptoms Clear physical exam A clear spine assessment means that there is no spine injury and no need for spine stabilization. When these things are present, the physical exam is MORE accurate than the x-ray at ruling out a cervical fracture! NOTE: be extra careful with the elderly pt. as the ability to perceive pain/tenderness may be blunted. 8
9 Spine Injury Assessment Clear mental status: Reliable patient No distracting injury or ASR Not intoxicated Wants to cooperate Can cooperate Spine Injury Assessment Clear of new symptoms: No complaint of new neck or back pain No complaint of new distal numbness or weakness Any positive findings during the exam, such as tenderness or the inability to move the extremities equally, means that you should treat for spine injury. 10 * Spine Injury Assessment Distal motor and sensory exam: Motor exam for the upper extremities: Finger abduction or OR Finger or wrist extension against resistance Sensory exam for the upper extremities: Intact sensory perception (No tingling or numbness) Differentiation between pain/sharp and light/dull stimulation on back of hand and wrist 9
10 11 * Spine Injury Assessment Distal motor and sensory exam: Motor exam for the lower extremities: Dorsiflexion of foot or big toe and Plantar flexion of foot or big toe. Sensory exam for the lower extremities: Intact sensory perception (No tingling or numbness) Distinction between pain/sharp and light/dull stimulation on top of foot or lateral aspect of lower leg or ankle Well OK then Who SHOULD we provide spinal motion restriction?? MOI for SPINE injury Spine injuries (column and/or cord) typically present with. PAIN TENDERNESS in awake pt. Other findings that should lead you towards immobilization. Neuro deficits- limbs Significant multi-system trauma Altered Mental Status Significant Distracting Injuries Summary MOI is a poor predictor of spine injury, and the physical exam criteria is sufficient in ruling out the vast majority of spine injuries. Most EMS protocols require unnecessary immobilization. We will do our best to stop the non-sense here in Alameda County then the world. Immobilization itself has harmful consequences and should not be done on many patients. Spine immobilization in the tactical or potentially hostile environment is problematic. 39 Patient protection/ stabilization is better done with a different approach and different tools than we are currently using today. 10
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