4/19/2017. Prehospital Spinal Care: Then. Prehospital Spinal Care: Then. Prehospital Spinal Care: Then. Prehospital Spinal Care: Then. Why Immobilize?

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1 Management of Cervical Spine Injuries and Athletic Equipment Removal Gianluca Del Rossi, PhD, ATC Prehospital Spinal Care: Then While the exact origins of backboards in EMS are unclear, noted trauma surgeon J.D. Deke Farrington recommended their use in These recommendations made into EMT textbooks and thus became entrenched in the EMS culture. Prehospital Spinal Care: Then Prehospital Spinal Care: Then In the late 80s virtually all trauma patients were immobilized Why immobilize? Why Immobilize? Prehospital Spinal Care: Then Case reports of exacerbation of injuries from standard actions or procedures Harrop et al., 2001 Powell et al Amount of motion and forces required to create secondary neurologic injury unknown Manual stabilization Mechanical immobilization Cervical collars Various head stabilizing devices Tape/straps 1

2 Epidemiology Epidemiology Between 1 and 5 million patients receive spinal immobilization each year in the US (Stiell et al., 2001, Orledge and Pepe, 1998) 12,500 new cases of SCI annually in the US (NSCISC, 2014) 9% due to participation in sports and recreational activities Majority due to diving and swimming (Ghiselli, et al., 2003) ~ 7% of patients with spinal fractures but not complete SCI have an unstable spinal segment (Haut et al., 2010) Less than 0.4% of all severely traumatized patients had unstable c-spine fractures (Haut et al., 2010) Only 0.5% of patients who received prehospital spine immobilization had an unstable thoracolumbar spine injury (Clemency et al. 2016) A change is upon us A change is upon us In two separate Cochrane reviews of available research on prehospital spinal immobilization: Not a single randomized controlled trial that demonstrated evidence of benefit to the practice of spinal immobilization. (Kwan et al., 2001; Baez and Schiebel, 2006) Applying a cervical collar and spineboard to victims with potential cervical spine trauma may produce a number of deleterious side effects: Respiratory impairment (reduction in respiratory capacity) Tissue ischemia (pressure sores) Increased intracranial pressures Pain/discomfort Lerner et al, J Natl Assoc EMS Physicians Bauer et al, Ann Emerg Med Sheerin and de Frein, J Emerg Nurs Cordell et al, Ann Emerg Med Totten and Sugarman Prehosp Emerg Care, Chan et al Ann Emerg Med, Davies et al. Injury, Kolb et al., Amer J Emerg Med, Prehospital Spinal Care: Now Paradigm Shift The debate now is not whether EMTs can effectively determine which patients do not require immobilization in the field, it is whether they should immobilize at all. EMS Management of Patients with Potential Spinal Injury Approved by the ACEP Board of Directors January 2015 The use of the long spine board is not required to provide adequate spinal precautions and restriction 2

3 Change in Terminology Spinal immobilization vs. spinal motion restriction? In general, these are synonymous. Restrict motion of c-spine area Purpose: to prevent further harm True spinal immobilization is impossible. Spinal motion restriction is the preferred term and practice. Terminology Spinal motion restriction (SMR) Attempts to maintain the spine in anatomic alignment and minimizes gross movement, and does not require the use of specific adjuncts. Patient driven (subjective) When to Use SMR Appropriate patients to be immobilized with a spine board may include those with: High risk factors as mandated by NEXUS criteria or Canadian C-Spine rules Blunt trauma or high energy MOI Altered level of consciousness or any of the following Drug or alcohol intoxication Inability to communicate Distracting injury Mid-line spinal pain and/or tenderness Focal neurologic signs and /or symptoms Numbness and/or motor weakness Anatomic deformity of the spine NAEMSP. EMS Spinal Precautions and the Use of the Long Backboard. Prehosp Emerg Care.,2013 Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for: Patients who are found to be ambulatory at the scene Patients who must be transported for a protracted time, particularly prior to interfacility transfer Patients for whom a spine board is not otherwise indicated NAEMSP. EMS Spinal Precautions and the Use of the Long Backboard. Prehosp Emerg Care.,2013 Prehospital Spinal Care: Future Updated from 1998 document 9 recommendations Inter-Association Task Force: Publication:

4 Objective Review some recommendations from task force document Recommendation 3: The face mask should always be removed prior to transport regardless of airway status. When deemed necessary by onsite medical personnel, protective equipment may be removed prior to transport. Facemask Removal Facemask Removal Swartz et al (Spine J., 2014) reported that face mask removal resulted in less motion in all three planes of motion, required less completion time, and was easier to perform than helmet removal Combined tool approach CSD and cutting tool resulted in 100% success Average time: ± 15.37sec Copeland et al. Clin J Sport Med, 2007 On-field conditions throughout football season 98.6% (75/76) of removal attempts were successful with combined tool approach Average removal time 40.1 ± 15.1 seconds Gale et al. JAT, 2008 Equipment Removal Shoulder Pad Removal Rationale for allowing medical personnel to remove equipment prior to transport: Chest access is prioritized. Helmet removal may promote improved airway care. Equipment removal should be performed by those with the highest level of training and experience in removal techniques. It may be difficult to apply cervical collars correctly while protective equipment is in place. Various Techniques: 8 person lift Bi-valve pads Elevated torso technique Flat torso technique Levitation Log roll 4

5 Shoulder Pad Removal Shoulder Pad Removal Traditional Flat Torso Pad Removal Horodyski et al., Spine, 2009 Methods of removal Levitation Tilt Log roll Levitation caused more anterior displacement, shear and moment when compared to the other two methods Dahl et al, J Applied Biomechanics (2009) Elevated Torso Removal Cervical Collars Why now? Recommendation 5: If equipment is removed or the athlete is not wearing protective equipment, a properly fitted rigid cervical stabilization device should be applied to any athlete suspected of a severe cervical spine injury prior to transport. Manual in-line stabilization should be maintained until stabilization on a full-body SMR device has been achieved. Often cannot correctly apply cervical collars when the athlete is wearing equipment NATA Position Statement (2009) Cervical Collars Concerns Application of Cervical Collars Do they work?? Impact to spine (motion) Time of application Delay in beginning critical life saving procedures Effect of application Collars can be placed and removed with manual in-line stabilization and (potentially) minimal risk Prasarn et al., Trauma Acute Care Surg,

6 Effectiveness of Cervical Collars Effectiveness of Cervical Collars Cervical collars do not effectively reduce motion in an unstable cervical spine Horodyski et al. J Emerg Med, 2011 Miller CP et al. Spine, 2010 Bearden et al. J Neurosurgery, 2007 Del Rossi et al. The Spine Journal, 2004 Application of a cervical collar caused increased separation at the injury site C1-C2 level Ben-Galim et al. J Trauma, 2010 Biomechanics of cervical restriction with collars Rigid collars create pivot points that contribute to intervertebral motion Lador et al. J Trauma, 2011 Why bother to use a collar? Patient Transfer - Supine Position Some motion restriction is better than none!! Options Log roll (traditional) vs. lift-and-slide (or straddle lift or 6+) vs mechanical device (scoop stretcher) Influencing factors Patient size Personnel Number Relative strength Level of training (team) Availability of equipment Patient Transfer - Supine Patient Patient Transfer - Supine Patient Log roll vs lift-and-slide (Del Rossi et al., JAT, 2003) Training study 48 healthy subjects (8 teams) Log roll vs lift-and-slide (Del Rossi et al., JAT, 2003) Flexion- Extension Axial rotation Lateral flexion 6

7 Patient Transfer - Supine Patient Patient Transfer - Supine Position Cadaveric study Log roll vs lift-and-slide vs 6+ person lift (Del Rossi et al., JAT, 2008) Inter-Association Task Force for the Appropriate Care of the Spine-injured Athlete recommendation (2001) Log roll vs lift-and-slide vs 6+ person lift (Del Rossi et al., JAT, 2008) Patient Transfer - Supine Position Patient Transfer - Supine Position Mechanical Transfer Devices Log roll vs scoop stretcher (SS) (Krell et al., Prehosp Emerg Care, 2006) 31 healthy subjects Electromagnetic sensors Forehead, C3 (surface), T12 (surface) Results 6-8 degrees greater motion in sagittal, lateral and axial planes during LR compared to SS Mechanical Transfer Devices Angular Motion (degrees) Log roll vs LS vs scoop stretcher (Del Rossi et al., AJEM, 2010) Cadaveric study Destabilized C5-C6 Flexion - Extension Axial Rotation Lateral Flexion Linear Translation (cm) Medial - Lateral Translation Distraction - Compression Anterior - Posterior Displacement 0 LR LS Technique SCOOP 0 LR Technique LS SCOOP Supine Patient - Summary Supine Patient Planning Ahead LS and 6+ generate less motion than LR Scoop stretcher As safe as LS Consider LS, 6+ and scoop stretcher as alternative to LR (supine patient) 8+ for large patients Using the 6+ (now termed the multiperson lift) still recommended Horodyski et al. (2015) Six SMR strategies 2 person lift to gurney Log roll onto spine board, lift to gurney, log roll off to gurney Scoop stretcher, lift onto gurney, scoop stretcher off onto gurney 8 person lift to gurney, secure to gurney 7

8 Supine Patient Planning Ahead Patient Transfer - Prone Position Six immobilization techniques 8 person lift onto spine board, lift board to gurney, 8 person lift off board onto gurney 8 person lift, strap to spine board, lift and secure to gurney Options Log roll (pull) vs. log roll (push) Spinal Motion Restriction Spinal Motion Restriction Spinal motion restriction using a vacuum mattress is also possible Vacuum mattress vs. spine board (Hamilton and Pons, J. Emerg Med, 1996). 26 subjects Active motion following immobilization Spinal Motion Restriction Changes on the Horizon Vacuum mattress vs. spine board (Luscombe and Williams, Emerg Med J, 2003). 9 subjects (vague methodology) Motion with longitudinal and lateral tilts. EMS use alternative SMR and transfer devices Scoop stretchers CombiCarriers Vacuum mattress In Europe, the standard is scoop stretcher onto vacuum mattress. Spine boards if used, strictly for extrication, not transport 8

9 Recommendation 6: Spine-injured athletes should be secured to a SMR device prior to transportation and transported on the SMR device. every effort should be made to minimize the time an athlete is on the long spine board. The ED medical team is encouraged to assess the athlete on arrival to the ED with transfer to an appropriate hospital bed as soon as safely possible. Spine Board Mortuary Thank you!! 9