Heidi Lako-Adamson, MD, NRP, FAEMS FM Ambulance and Sanford EMS Education Medical Director

Heidi Lako-Adamson, MD, NRP, FAEMS FM Ambulance and Sanford EMS Education Medical Director

Spinal cord injury statistics. Definition of spinal motion restriction. Difference between spinal motion restriction and spinal immobilization. Understand the criteria to rule out spine injury. When a backboard may be appropriate. When and who should be removing athletic equipment.

Cervical Region Thoracic Region Thoracolumbar Region Lumbosacral Region

Cervical Region Thoracic Region Thoracolumbar Region Lumbosacral Region 55% 15% 15% 15%

Vehicular: 38% Falls: 30% Violence: 14% Sports/Recreation: 9% Medical/Surgical: 5% Other: 4%

12,500 new SCI s occur each year 240,000-337,000 people currently living with SCI in the US 55% of injuries result in quadrapalegia

Accounts for 558 spinal cord injuries Diving: 3.44% Winter Sports: 0.83% Football: 0.28% Wrestling: 0.25% Baseball/Softball: 0.07% Field Sports: 0.07% Basketball/Volleyball: 0.06% Track and Field: 0.01%

Approximately 10% of Patients with a Cervical Spine Fracture have a Second, Noncontiguous Vertebral Column Fracture.

Maintenance of attention to minimizing spine flexion, extension, and rotation of the entire spine Appropriately fitted c-collar Vacuum mattress Ambulance Cot Spine Board? Minimize position changes Slider board

Acutely altered level of consciousness Neck or back pain Focal neurologic signs and/or symptoms Anatomic deformity of the spine Distracting injury

Nexus Criteria Canadian C-spine Rules

National Emergency X-ray Utilization Study Prospective assessment of 27,389 x-rayed trauma patients with 659 (2.4%) cervical injuries Only 15 of 659 cervical fractures were missed by the low risk criteria None had neurologic sequela

No posterior midline cervical tenderness Not intoxicated Normal mentation No neurologic deficit No painful distracting injuries **This alone could decrease spinal immobilization of trauma patients by 37% without missing any neurologically significant injury

Adds: Age as a factor Mechanism Movement

High Risk Sixty Five Fast Drive Sense Deprive Image if Alive Low Risk Slow Wreck Slow Neck Sitting Down Walking Around C-spine Fine Range the Spine

Blunt trauma and altered level of consciousness Spinal pain or tenderness Neurologic complaints Anatomic deformity of the spine High energy mechanism of injury Drug or alcohol intoxication Inability to communicate Distracting injury Age >65

Standard practice since 1960s Belief that delayed onset of paraplegia was caused by failure to recognize and protect the patient s spine 1965 Retrospective study of 958 spinal cord injury patients in Toronto 29 Pts (3%) had evidence of delayed paralysis Author concluded that he suspected a larger number undoubtedly suffered the same fate. Anecdotal???

1966: Use of the long backboard to move a victim from a vehicle with a minimum of additional trauma and such movement was to occur with due regard to maximum gentleness."

1.Pain 2. Unnecessary Radiological Testing 3. Respiratory Compromise 4. Pressure Sores

Especially at pressure points head and sacrum Lower back and Cervical Spine New pain not present prior to application Difficult for receiving facility to distinguish between injury or side effect 1993: 100% of healthy volunteers reported pain within 30min of being strapped to a backboard

Receiving Physicians unable to identify whether or not pain was from trauma or backboard Leads to increase: X-rays CT scans Chance for radiation injury Cost to patients and insurance

Straps across chest if tight enough to restrict spinal motion will restrict chest excursion and vital capacity 15% Respiratory Restriction

Occipital and Sacral Contact pressures are significantly above the pressure at which tissue necrosis can occur 1995 study 80 minutes on the backboard >32mmHg causes capillary collapse Sacrum 149mmHg Occiput 59mmHg Heels 51mmHg Near Infrared Spectroscopy Significant tissue hypoxia in sacral tissue within 30min or less of being on the backboard in healthy patients If hypotensive pressure sores can occur within 20-30min

New Mexico

**NAEMSP Position Paper and Resource Document

Sample of 50 low acuity backboarded subjects at a level 1 ED: 30% had at least 1 point where a strap or tape did not secure the head 70% had 1 strap with >4cm slack A well secured head and mobile body creates the greatest movement around the neck area Backboards do not necessarily make patients lie still!

Yes and No (NAEMSP says absolute no) Extrication Tools Pt should be rolled or levitated off the board as soon as safe Minimum of 3 people Time

Spinal motion restriction should be used instead of spinal immobilization Spine board should only be utilized for extrication Patient removed from spine board as soon as possible

ED Physicians? ED Nurses? Pre-hospital personnel? Athletic Trainers?

NATA 2015 Equipment should be removed prior to transport When appropriate, protective equipment may be removed prior to transports Rescuers should be able to recognize when it is not appropriate to remove equipment Preparation is essential

1. Preparation 2. Time Out 3. Proper Assessment and Management 4. Protective Athletic Equipment should be removed prior to transport to ED 5. Equipment removal should be performed by at least three rescuers trained in the procedure

6. Medical team should be skilled in the particular equipment for the sport they are covering 7. C-collar and Manual Stabilization of Cervical Spine 8. Spine injured athletes should be transported using a rigid immobilization device 9. Minimize spinal motion when transporting from the field to the transporting vehicle 10. Transportation plan prior to event starting

11. Transport patient to a hospital that can deliver immediate, definitive care 12. Prevention of spine injuries is priority 13. Medical team should have strong working knowledge of current research as well as national and local regulations. 14. It is essential that future research continue to investigate the efficacy of devices used to provide spinal motion restriction.

Athletic training and EMS must work as a team Nexus and/or Canadian C-spine rules to eliminate some immobilization all together Remove equipment C-collar Scoop Stretcher for extrication Remove patient from board as soon as feasible

Rule out low risk patients Remove equipment C-collar Spinal Motion Restriction Scoop Stretcher Off board ASAP

Thank You

ATLS Emergency Trauma Care: Current Topics and Conversies Volume 1 Volume 2 Trauma.org Washtinaw Livingston EMS Backboard Criteria CDC ACEP and NAEMSP Trauma and EMS Update NAEMSP Position Statement on Spinal Motion Restriction Emergency Medicine Monthly Tintinelli s Emergency Medicine 7 th Edition National Spinal Cord Injury Statistical Center FM Ambulance Service Protocols