Selective Spinal
Assessment
When to Immobilize and When
Not to Immobilize
Program Goals
All patients who are injured will be properly assessed and treated for
spinal injuries in accordance with the Spinal Assessment protocol
•Describe under what circumstances the Spine Protocol can be used
•Describe the core components of the assessment
•Differentiate between:
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–
–
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Reliable and unreliable patients
Distracting and non-distracting injury
Normal versus abnormal neurological evaluation
Complaints of spine pain/tenderness vs. no spine pain/tenderness
•Evaluate injured patients in accordance with spinal assessment
protocol and determine if immobilization is warranted
•Describe the importance of proper QA/QI in spinal immobilization
History of Spinal Immobilization
• Topic of great attention over past decade
• Impact on individuals and society
• Pre-Hospital care of spine injury still debated
– Two dominant theories on pre-hospital
immobilization
• Consequences of pre-hospital immobilization
Immobilization Theory 1
• Initial trauma to the spine is the cause of
cord injury with additional care and
treatment representing minimal risk of
further injury – ensuring that major axial or
rotational loading is minimized.
– This theory argues that pre-hospital
immobilization of the spine is not needed
because of the relative insignificance of postinjury movement forces compared to initial
injury.
Immobilization Theory 2
• Energy from the initial traumatic incident is
of significant force and that any additional
movements of the spine can result in injury
exacerbation with secondary cord injury.
– Supporters of this theory have argued and
promoted immobilization as essential to prehospital secondary injury prevention
– This is a theory of immobilization based on
mechanism
NEXUS Study Group
• What is NEXUS?
– Multi-center investigation enrolled 34,069 patients
with 818 identified cervical spine fractures
– Evaluated a 5-step clinical decision rule for cervical
spine assessment
1). Midline posterior cervical spine tenderness
2). Focal neurologic deficit
3). Altered mental status/altered level of alertness
4). Acute intoxication
5). Presence of painful, distracting injury
What did NEXUS find?
• The clinical decision rule successfully identified nearly
100% of all significant cervical spine injuries
• a “missed injury” frequency of approximately 1 in 4000
patients
• application of the algorithm would have resulted in ~ 13%
fewer radiographic studies at the participating centers
• Patients with significant cervical spine injuries present
with physical assessment findings independent of the
historical mechanism of injury
How does NEXUS apply to EMS?
• NEXUS clinical decision rule can be generalized to
apply to the vast majority of prehospital populations
• Exclusions - special groups of patients with injury
risk factors beyond those discovered in the typical
patient population- EXAMPLE- the elderly!
EMS Providers – Extension of
the ED
• EMS providers are a vital part of the delivery of emergency care
– Have the tools of assessment, treatment, technology, and
participate in the QA/QI process
• EMS professionals are considered an extension of the care provided
in the ED
– As an extension, they should be expected to provide care
consistent with the standards practiced by their counterparts in
the ED
• New/Revised Spinal Assessment Protocol
– Attempts to align pre-hospital practice with ED practice and
consistent with NEXUS
– “First, do no harm.” – providers are expected to use the new
protocol to the patients’ benefit in choosing who needs prehospital immobilization
Why Does Massachusetts Need a
Spinal Assessment Protocol?
• Risks to the immobilized patient
• Use of available resources
• Consistent with best practices
Spinal Assessment
Using a modified NEXUS clinical
decision method in the prehospital
setting
Prehospital Clinical Decision on
Immobilization Asks 4 Questions
• Is the patient RELIABLE?
• Are DISTRACTING INJURIES present?
• Does the patient have MOTOR or
SENSORY DEFICITS?
• Does the patient have SPINE
PAIN/TENDERNESS?
Notice mechanism is NOT a factor in the
decision.
Mechanism of Injury
• Does NOT necessitate c-spine
immobilization
• Mechanism of injury serves only as a
key to alert EMS providers to the need
for a thorough spinal assessment
•Mechanism of injury should not be the sole
indicator for determining spinal
immobilization in trauma patients.
•NEXUS demonstrated that patients
with significant cervical spine
injuries present with physical
assessment findings independent of
the historical mechanism of injury
Concerning Mechanisms
• Axial load (e.g. diving into a body of water)
• Blunt trauma (particularly to the head or neck)
• Motor vehicle collision or bicycle accident (MVC
– e.g. automobile, snowmobile, motorcycle, all
terrain vehicle, etc.)
• Falls from a height greater than 3 feet
• Falls from a standing height represent a risk to
adult patients, particularly elderly patients, or
those with pre-existing spine injuries.
• Electric shock
Risk Factors
• Additional considerations in the decision to
immobilize or not
• Age: Infant to age 8 or over 65 years
• Preexisting spinal injury
• Preexisting condition altering bone density
The Age Risk Factor
• The NEXUS study showed a missed injury
rate of only 1:4000, however …
• The rate of missed injury was much higher
in the infant to 8 years and the over 65
age groups because of
– Patient reliability
– Physical exam compliance
– Physiologic differences
Patient Reliability
• Is the patient reliable or unreliable?
• Is the patient intoxicated, do they have an altered mental status, are
they having an acute stress reaction, or some other response that
makes the provider question their alertness?
• Clearance of the spine requires the patient to be calm, cooperative,
sober, and alert
• Unreliable
– If the patient is deemed to be unreliable based on the
assessment - Immobilize
• Reliable
•
If the patient is deemed reliable, proceed to next step in spinal
assessment process
Distracting Injury
• Does the patient have a distracting injury?
– Distracting injury includes any injury that produces
clinically apparent pain that might distract the patient
from the pain of a spine injury. Such pain would
include medical as well as traumatic etiologies of
pain.
• If Distracting injury is present, immobilize
• If no distracting injury, proceed to next step in
spinal assessment process
• What about atraumatic pain?
• Non-significant traumatic injuries?
Abnormal Sensory/Motor
Exam
• What is the Sensory/Motor Exam?
– Commonly accepted assessment means to determine motor or
sensory deficits from spine injury.
– Evaluates peripheral sensation, motor function and
proprioception
• What is abnormal?
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–
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Paresthesias or loss of sensation in extremities
Weakness or paralysis of extremities
Loss of proprioception
Loss of urethral or rectal sphincter control
• If there is abnormal sensory response/deficit or
abnormal/deficit motor response present, immobilize
• If there are no abnormal sensory or motor deficits
proceed to next step in spinal assessment process
Spine Pain or Tenderness
• Examine the spine
– The assessment should include, but is not limited to,
palpation of the posterior, midline spine, and cervical spine
• Spine Pain/Tenderness found?
• If assessment finds the patient experiencing any
pain or tenderness along the spine, immobilize
• If no spine pain/tenderness is found do not immobilize
the patient. Transport to the most appropriate hospital
Frequent Questions
• What if we are unsure about the patient at
any point during the assessment of the
spine?
– Proceed to spinal immobilization
– The first rule is “ do no harm”. If the provider is unsure
about the patient, the assessment, disagreement between
providers, etc. always err on the side of caution
• Will there be a QA/QI process?
QA/QI Process
• Quality Assurance form
– Services must complete whenever a patient is
assessed utilizing the Spinal Assessment
Protocol
– Submit to local ambulance service QA/QI
coordinator/medical director
– Submit an electronic copy to the Regional
EMS Council for compilation
Acknowledgements
Joanne Lebrun
Regional Coordinator
Tri-County EMS
300 Main St.
Lewiston, ME 04240
Jay Bradshaw
Director
Maine Emergency Medical Services
Department of Public Safety
45 Commerce Drive Suite 1
152 State House Station
Augusta, ME 04333-0152
Maine Emergency Medical Services Spine protocol materials
State of New Hampshire Advanced Spinal Assessment Protocol
Questions??