LPA 8
(LANDELIJK PROTOCOL AMBULANCEZORG)
• ACHTERGROND UIT HET OOGPUNT LPA8
• WAT TE VERWACHTEN NA 1 JANUARI
• HOE TE HANDELEN HOSPITAAL
• DISCUSSIE
CASUS
• TRAUMACHIRURG, +/- 45 JAAR, FEESTJE
OUD&NIEUW
• BIJ INVOEGEN A9 AUTO VS AUTO
• BEKLEMD
• BZV ONDUIDELIJK
• ENKELE GLAZEN CHAMPAGNE
• BIJ AMBULANCE GOED AANSPREEKBAAR, ECHTER ZEER OPSTANDIG, WIL NIET OP EEN PLANK
• ‘HELP MIJ UIT DE AUTO, IK HEB VERDER NIKS’
1) INDICATIE WERVELKOLOM IMMOBILISATIE
2) GEEN INDICATIE WERVELKOLOM IMMOBILISATIE
NB: Hoog energetisch
trauma op zich is geen
indicatie om te
immobiliseren
•
?
NEXUS
(NATIONAL EMERGENCY X-RADIOGRAPHY UTILIZATION STUDY)
• GEEN DRUKPIJN CWK, EN
• GEEN TEKENEN
INTOXICATIE, EN
• GEEN VERLAAGD BEWUSTZIJN, EN
• GEEN FOCALE NEUROLOGISCHE
Test Sensitivity: 99.6%
Test Specificity: 12.9%
Negative Predictive
Value: 99.9%
VERSCHIJNSELEN, EN
• GEEN PIJNLIJK AFLEIDEND LETSEL
Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma:
methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg
Med. 1998 Oct;32(4):461-9.
CANADIAN C-SPINE
Test Sensitivity: 99.4-100%
Test Specificity: 42.5-45%
Negative Predictive Value: 100%
Canadian CT Head and C-Spine (CCC) Study
Group. Canadian C-Spine Rule study for alert and
stable trauma patients: I. Background and
rationale. CJEM. 2002 Mar;4(2):84-90.
N ENGL J MED. 2003 DEC 25;349(26):2510-8.
THE CANADIAN C-SPINE RULE VERSUS THE NEXUS LOW-RISK CRITERIA IN PATIENTS WITH
TRAUMA.
STIELL IG1, CLEMENT CM, MCKNIGHT RD, BRISON R, SCHULL MJ, ROWE BH,
WORTHINGTON JR, EISENHAUER MA, CASS D, GREENBERG G, MACPHAIL I, DREYER J, LEE
JS, BANDIERA G, REARDON M, HOLROYD B, LESIUK H, WELLS GA.
• FOR ALERT PATIENTS WITH TRAUMA WHO ARE IN STABLE CONDITION, THE CCR IS SUPERIOR TO
THE NLC WITH RESPECT TO SENSITIVITY AND SPECIFICITY FOR CERVICAL-SPINE INJURY, AND ITS
USE WOULD RESULT IN REDUCED RATES OF RADIOGRAPHY.
ENKELE ‘HOOGTEPUNTEN’
• ‘ALERTE PATIËNTEN DIE DRUKPIJN AANGEVEN CERVICAAL, KUNNEN MOGELIJK HET BESTE ZELF
UITSTAPPEN’
• ‘VERVOER BIJ VOORKEUR OP VACUUMMATRAS’
• ‘BEHOUD BIJ ALERTE PATIËNT VOORKEURSHOUDING; DUS OOK HALFZITTEND VERVOER’
• ‘WETENSCHAPPELIJKE MEERWAARDE VOLLEDIGE WERVELKOLOMMOBILISATIE IS NIET AANGETOOND’
• ‘NEUROLOGISCHE OUTCOME NIET VERBETERD’
• ‘NADELEN; ANGST/ONRUST, DECUBITUS, ASPIRATIE, RESP INSUFF’
• ‘ICP STIJGING DOOR COMPRESSIE VV JUGULARIS INTERNA’
• ‘BIJ GEBRUIK NEKSPALK REDUCTIE MONDOPENING 20-25%’
• ‘GEEN EVIDENCE DAT CERVICALE WK EXTRA GEIMMOBILISEERD WORDT DOOR HEADBLOCKS EN
KRAAG TEGELIJK’
• ‘AANLEGGEN SPALK BIJ KINDEREN DIENT ACHTERWEGE TE WORDEN GELATEN, ONVOLDOENDE
REKENING MET WISSELENDE ANATOMIE’
Evidence?
EMERG MED J. 2013;30(1067-9) PRE-HOSPITAL
SPINAL IMMOBILISATION: AN INITIAL CONSENSUS
STATEMENT. CONNOR ET AL.
• BESCHREVEN
CONSENSUS
Emerg Med J. 2012 Feb;29(2):104-7
Value of a rigid collar in addition to head blocks: a
proof of principle study.
Holla M.
• 10 vrijwilligers
• Digitale meting nekkraag vs headblocks
• Maximale mondopening
• Geen extra immobillisatie
• Mondopening significant verminderd bij nekkraag
Emerg Med J. 2013 Dec; 30(12):1065-6
Minimal patient handling: a faculty of prehospital care
consensus statement
Moss R, Porter K (UK)
• Beschreven consensus
Journal of neurotrauma. March 2014;31:531-540.
Prehospital Use of cervical collars in trauma patients: a
critical review.
Terje Sundstrom et al.
INTRODUCTIE
• AL 30 JR ONGEWIJZIGD BELEID, 50-60 LANDEN
• KRAGEN TER PREVENTIE SECUNDAIR LETSEL
• COCHRANE 2007: RCT MISSEN, ONBEKENDE
EFFECTEN OP MORTALITEIT/NEUROLOGISCHE
SCHADE
• LITERATURE SEARCH; 50 ARTIKELEN + EXPERT OPINION
DOEL
•
EVIDENCE VOOR IMMOBILISATIE IS MOGELIJK ZWAK, IS ER EVIDENCE VOOR ADVERSE EFFECTS?
ENKELE CIJFERS…
• 2-4% TRAUMAPATIENTEN
MET
CWK
LETSEL, WAARVAN
• DELAYED OF MISSED DIAGNOSE 1.3%
• INCIDENTIE WERVELFRACTUREN 12:100000
• FALL OF MOTOR VEHICLE ACCIDENT
20% SCI
EN VERDER…
• MEDICOLEGAAL
• VOELT VERSTANDIG
• SYMBOOL HOGE KWALITEIT ZORG
• RELATIEF MAKKELIJK EENDUIDIG PROTOCOL
EFFECTIEF?
• 3-25% SCI IS SECUNDAIR
-MOEILIJK TESTEN
NEUROLOGISCHE UITVAL IN PREHOSPITALE SETTING
-EXTRAPOLATIE BEVINDINGEN
ZKH NAAR PREHOSPITAAL
-GEDATEERD
THEODORE ET AL. 2013 NEUROSURGERY
BELL ET AL. 2009 SPINE J.
SUNDHEIM ET AL. 2006 ANN. EMERG. MED.
• BETERE IMMOBILISATIE KRAAG + PLANK EN HEADBLOCKS
JUIST/ONJUIST
• BETERE IMMOBILISATIE BIJ KRAAG VS GEEN KRAAG
JUIST/ONJUIST
• KRAAG/VACUUM VS KRAAG/PLANK
?
Emerg Med J. 2012 Feb;29(2):104-7
Value of a rigid collar in addition to head blocks: a
proof of principle study.
Holla M.
• 10 vrijwilligers
• Digitale meting nekkraag vs headblocks
• Maximale mondopening
• Geen extra immobillisatie
• Mondopening significant verminderd bij nekkraag
CONRAD ET AL. MOTION IN THE UNSTABLE
CERVICAL SPINE DURING HOPSITAL BED
TRANSFERS. J. TRAUMA 2010: 69;432-436
•
METHODS:
•
CERVICAL SPINE INSTABILITY WAS CREATED AT C5-C6 IN CADAVERS.
•
MANUAL TRANSFER PERFORMED BY SIX TRAINED INDIVIDUALS AND A TRANSFER MADE BY TWO PEOPLE USING THE
LATERAL TRANSFER DEVICE.
•
BOTH TECHNIQUES WERE TESTED UNDER FOUR COLLAR CONDITIONS.
•
CERVICAL SPINE MOTION WAS MEASURED USING AN ELECTROMAGNETIC MOTION ANALYSIS DEVICE WITH SENSORS
FIXED TO THE ANTERIOR BODIES OF C5 AND C6.
•
RESULTS:
•
NO SIGNIFICANT DIFFERENCES WERE OBSERVED
•
(FLEXION, [P = 0.325]; AXIAL ROTATION [P = 0.590]; LATERAL BENDING [P = 0.112]).
•
NOR WERE THERE SIGNIFICANT DIFFERENCES AMONG THE THREE COLLARS USED (FLEXION [P = 0.462]; AXIAL
ROTATION [P = 0.434]; LATERAL BENDING [P = 0.250]).
•
FOR ALL TRANSFERS, USING NO COLLAR RESULTED IN MORE MOTION THAN USING A COLLAR; BUT WAS NOT
STATISTICALLY SIGNIFICANT.
ON3
LUSCOMBE ET AL. COMPARISON OF A LONG SPINAL
BOARD AND VACUUM SPLINTS FOR CERVICAL SPINE
IMMOBILIZATION. ANN. EMERG. MED. 1992:21(11851188)
•
METHODS:
•
NINE VOLUNTEERS
•
AN OPERATING DEPARTMENT TABLE WAS USED
AND ADDITIONALLY 45 DEGREES LATERALLY.
•
MOVEMENTS OF THE HEAD, STERNUM, AND PUBIC SYMPHYSIS (PELVIS) FROM A FIXED POSITION WERE
•
THE COMFORT LEVEL DURING THE PROCEDURE
AND 10=WORST PAIN IMAGINABLE.
•
RESULTS:
•
THE MEAN BODY MOVEMENTS IN THE HEAD UP POSITION (23.3 V 6.66 MM), HEAD DOWN (40.89 V 8.33MM), AND LATERAL TILT
(18.33 V 4.26MM) WERE SIGNIFICANTLY GREATER ON THE BACKBOARD THAN ON THE VACUUM MATTRESS (P<0.01 FOR ALL PLANES
OF MOVEMENT).
•
USING THE NRS THE VACUUM MATTRESS (MEAN SCORE=1.88) WAS
(MEAN SCORE=5.22) (P<0.01).
•
CONCLUSIONS:
•
IN THE MEASURED
WEARING STANDARDISED CLOTHING AND RIGID NECK COLLARS WERE SECURED ON TO A BACKBOARD AND
VACUUM MATTRESS
TO TILT THE VOLUNTEERS FROM
WAS ASSESSED USING A
45 DEGREES HEAD UP TO 45 DEGREES HEAD DOWN,
THEN RECORDED.
10 POINT NUMERICAL RATING SCALE (NRS) WHERE 1=NO PAIN
SIGNIFICANTLY MORE COMFORTABLE THAN THE BACKBOARD
PLANES THE VACUUM MATTRESS PROVIDES SIGNIFICANTLY SUPERIOR STABILITY AND COMFORT THAN A BACKBOARD.
ADVERSE EFFECTS
• TOEGENOMEN FREQUENTIE NEUROLOGISCHE SCHADE.
•
PTN MET ANKYLOSING SPONDYLITIS. 5% PTN MET WERVELFRACTUUR HAD AS
• 4.5 MMHG ICP STIJGING DOOR COMPRESSIE VV
JUGULARIS
•
GECOMPROMISEERDE MONDOPENING
•
ASPIRATIE
• DECUBITUS
• DISCOMFORT, PIJN, STRESS
• TOENAME BEELDVORMING
•
BIJ PENETREREND LETSEL; VERHOOGDE MORTALITEIT EN MORBIDITEIT
NEUROLOGISCHE SCHADE
HAUSWALD ET AL. OUT OF HOSPITAL SPINAL
IMMOBILIZATION: ITS EFFECT ON NEUROLOGIC
INJURY. ACAD EMERG MED 1998:5(214-219)
•
METHODS:
•
A 5-YEAR RETROSPECTIVE CHART REVIEW AT 2 UNIVERSITY HOSPITALS.
•
NONE OF THE 120 PATIENTS SEEN AT THE UNIVERSITY OF MALAYA HAD SPINAL IMMOBILIZATION DURING TRANSPORT
•
ALL
•
NEUROLOGIC INJURIES WERE ASSIGNED TO 2 CATEGORIES, DISABLING OR NOT DISABLING,
•
RESULTS:
•
THERE WAS LESS NEUROLOGIC DISABILITY IN THE UNIMMOBILIZED MALAYSIAN PATIENTS (OR 2.03; 95% CI 1.03-3.99;
P = 0.04).
•
RESULTS WERE SIMILAR WHEN THE ANALYSIS WAS LIMITED TO PATIENTS WITH CERVICAL INJURIES (OR 1.52; 95% CI
0.64-3.62; P = 0.34).
•
CONCLUSION:
•
OUT-OF-HOSPITAL IMMOBILIZATION HAS LITTLE OR NO EFFECT ON NEUROLOGIC OUTCOME IN PATIENTS WITH BLUNT
SPINAL INJURIES.
334 PATIENTS SEEN AT THE UNIVERSITY OF NEW MEXICO DID.
MAAR…
• EXCLUSIE OVERLEDEN PTN (ONGEVAL OF TIJDENS TRANSPORT)
• GEEN TRAUMA SEVERITY SCORES
• HETEROGENITEIT SPINAL INJURY
• NIVEAU ZORG?
• ALLEEN INCLUSIE BIJ BEWEZEN LETSEL
ICP
GRAIG ET AL. 1991 INTENSIVE CARE MED
DAVIES ET AL. 1996 INJURY
HUNT ET AL. 2001 ANESTHESIA
KOLB ET AL. 1999 AM J EMERG
MOBBS ET AL. 2002 ANZ J SURG
STONE ET AL. 2010 ACAD EMERG MED
• GRAIG: 2X CASE REPORT IC, BIJ KRAAG ICP STIJGING
• DAVIES: N=19, IC, GEMIDDELDE STIJGING 4.5 MMHG, LANGDURIG KRAAG
• HUNT: N=30, IC, GEMIDDELDE STIJGING 4.6 MMHG, >15 MMHG STERKER
• KOLB: N=20, CEREBROSPINAL FLUID PRESSURE (CSFP) 24.8MM H2O STIJGING
• MOBBS: N=10, GEMIDDELDE STIJGING 4.4 MMHG, KRAAG BIJ TRAUMA
• STONE: N=42 VRIJWILLIGERS, DOORSNEDE VV JUG MET ECHO, SIGN TOENAME
PRESSURE ULCURS
POWERS ET AL. THE INCIDENCE OF SKIN BREAKDOWN
ASSOCIATED WITH USE OF CERVICAL COLLARS. J
TRAUMA NURS 2006:13(198-200)
• 484 PATIENTS
• PATIENTS HAD THE CERVICAL COLLAR IN PLACE FOR AN AVERAGE OF 10.3 DAYS, WITH
SD OF 11.4 DAYS.
• SKIN BREAKDOWN WAS NOTED IN 33 (6.8%) PATIENTS
AN
WALKER ET AL. PRESSURE ULCURS IN CERVICAL
SPINE IMMOBILISATION: A RETROSPECTIVE
ANALYSIS. J WOUND CARE 2012;21(323-326)
• N=90, RETROSPECTIEF
• GAAT OM LANGDURIG GEÏMMOBILISEERDE PTN (PERMANENTE
KRAAG, HALO)
PIJN, STRESS, ONRUST
MARCH ET AL. CHANGES IN PHYSICAL EXAMINATION CAUSED BY
USE OF SPINAL IMMOBILIZATION. PREHOSP EMERG MED 2002;6(421424)
• METHODS:
• THIS WAS A SINGLE-BLINDED, PROSPECTIVE STUDY AT A TERTIARY CARE UNIVERSITY TEACHING HOSPITAL.
• TWENTY HEALTHY VOLUNTEERS WITHOUT PREVIOUS BACK PAIN OR INJURIES, WERE FULLY IMMOBILIZED FOR ONE
HOUR, WITH A CERVICAL COLLAR AND STRAPPED TO A LONG WOODEN BACKBOARD.
• MIDLINE PALPATION OF VERTEBRAE TO ILLICIT PAIN WAS PERFORMED AT 10-MINUTE INTERVALS.
• PARTICIPANTS WERE ASKED TO RATE NECK AND BACK PAIN ON A SCALE FROM 1 TO 10 (1 FOR NO PAIN, AND
10 FOR UNBEARABLE PAIN), TO SEE WHETHER SUBJECTIVE PAIN FROM IMMOBILIZATION CORRELATED WITH
TENDERNESS TO PALPATION.
• RESULTS:
• THREE PATIENTS HAD POINT TENDERNESS OF CERVICAL VERTEBRAE WITHIN 40 MINUTES. FIVE PATIENTS DEVELOPED
POINT TENDERNESS OF VERTEBRAE BY 60 MINUTES. EIGHTEEN OF 20 PARTICIPANTS COMPLAINED OF INCREASING
DISCOMFORT OVER TIME.
• THE MEDIAN INITIAL PAIN SCALE WAS 1 (RANGE 1-1), IN CONTRAST TO 4 (RANGE 1-9) AT 60 MINUTES, P <
0.05.
• CONCLUSION:
• STANDARD IMMOBILIZATION CAUSES A FALSE-POSITIVE EXAM FOR MIDLINE VERTEBRAL TENDERNESS.
LEONARD ET AL. POTENTIAL ADVERSE EFFECTS OF SPINAL
IMMOBILIZATION IN CHILDREN. PREHOSP EMERG CARE
2012;16(4):513-518
• METHODS:
• A PROSPECTIVE COHORT STUDY OF CHILDREN PRESENTING TO THE EMERGENCY DEPARTMENT (ED) FOR EVALUATION
FOLLOWING TRAUMA OVER A 13-MONTH PERIOD.
• SPINAL IMMOBILIZATION PRIOR TO PHYSICIAN EVALUATION OR IF THEY MET THE AMERICAN COLLEGE OF SURGEONS
(ACS) GUIDELINES FOR SPINAL IMMOBILIZATION BUT WERE NOT IMMOBILIZED.
• SELF-REPORTED PAIN, USE OF RADIOGRAPHY TO EVALUATE THE CERVICAL SPINE, ED LENGTH OF STAY, AND ED
DISPOSITION.
• RESULTS:
• 137 SPINE-IMMOBILIZED CHILDREN AND 112 NOT IMMOBILIZED
• THERE WERE DIFFERENCES BETWEEN THE TWO STUDY GROUPS, WHICH INCLUDED AGE, MECHANISM OF INJURY
• COMPARABLE PEDIATRIC TRAUMA SCORES (PTSS) AND GLASGOW COMA SCALE SCORES (GCSS).
• IMMOBILIZED CHILDREN HAD A HIGHER MEDIAN PAIN SCORE (3 VERSUS 2)
• CERVICAL RADIOGRAPHY (56.6% VERSUS 13.4%)
• ADMITTED TO THE HOSPITAL (41.6% VERSUS 14.3%)
• THE COMPARISON GROUPS HAD SIMILAR LENGTHS OF STAY IN THE ED.
CONCLUSIE
• EVIDENCE = ZWAK, MET NAME GEBASEERD
• STEEDS
OP DE HISTORISCHE BEÏNVLOEDING
MEER ONDERZOEK WIJST OP NEGATIEVE EFFECTEN
• STOP ROUTINEMATIG
AANBRENGEN KRAAG
• WERVELPLANK, BLOCKS EN STRAPS
• EXTRACTIE MET BEHULP
• POGEN TOT VERVOER
KRAAG
MINDER RIGIDE VACUUMMATRAS
Prehospital Emergency Care. 2014 Apr/June: 18(2);306-314
EMS spinal precautions and the use of the long backboard resource document to the
position statement of the national association of EMS physicians and the american
college of surgeons committee on trauma
Chelsea C White et al.
• Overeenkomstig
• Cultuuromslag
• Spinal immobilisatie naar spinal voorzorgsmaatregelen
ADVERSE EFFECTS
• TOEGENOMEN FREQUENTIE NEUROLOGISCHE SCHADE.
•
PTN MET ANKYLOSING SPONDYLITIS. 5% PTN MET WERVELFRACTUUR HAD AS
• 4.5 MMHG ICP STIJGING DOOR COMPRESSIE VV
JUGULARIS > KLINISCH RELEVANT?, IC SETTTING
•
GECOMPROMISEERDE MONDOPENING
•
ASPIRATIE
• DECUBITUS > KLINISCHE RELEVANT?, PROBLEEM
BEHANDELING
• DISCOMFORT, PIJN, STRESS > FOUTPOSITIEF ONDERZOEK
• TOENAME BEELDVORMING > BIJ KINDEREN, JA
•
BIJ PENETREREND LETSEL; VERHOOGDE MORTALITEIT EN MORBIDITEIT
TERUG NAAR LPA8…EIGEN MENING
• EVIDENCE VOOR ZWAK
• EVIDENCE TEGEN
ZWAK
• NIET ALLE ‘HOOGTEPUNTEN’
• STREVEN
TERUG TE VINDEN IN LITERATUUR
NA KORTDURENDE IMMOBILISATIE
• VACUUMMATRAS
VERDEDIGBAAR
• TOENAME DISCUTABELE
SITUATIES AANGEBODEN TRAUMAPATIENTEN (DENK AAN DE
TRAUMACHIRURG CASUS)
• LOGISTIEKE PROBLEMEN
TE VERWACHTEN?
Discussie