Selective Spine
Immobilization
Training Program
REASONS FOR NEW
GUIDELINE
PURPOSE OF
EMS SELECTIVE SPINAL
IMMOBILIZATION GUIDELINE
Identify and immobilize 100% of patients at
risk for unstable injuries
Identify and NOT immobilize patients who
have NO risk for cervical spine injury…
IMPORTANT MESSAGE
• Mechanism is going to be a crucial decision point in
this process. This will rule some people out who
previously were boarded and collared.
• Supine patients who meet the guidelines for Spine
Immobilization will be boarded and collared as
usual. Whereas, ambulatory patients who meet the
protocol will only be collared.
4/13/2015
4
CERVICAL SPINE INJURIESTHE PROBLEM
Between 2-4% of Blunt Trauma Patients sustain
cervical spine injury
Improvements in EMS systems and ATLS have
resulted in increased awareness and practice of
cervical immobilization
WHY NOT IMMOBILIZE
EVERYBODY?
Immobilization is uncomfortable: increased
time immobilized = increased pain, risk of
aspiration, vulnerable position, etc...
>800,000 U.S. Patients receive cervical
radiography each year
Patient exposure to radiation
>97% of xrays are negative
Cost exceeds $175,000,000 /year
INCIDENCE OF SCI
About 50 patients per million population.
12,000/year are treated while another 4,800 die
prehospital.
Male-to-female ratio is approximately 2.5-3.0:1
About 80% of males with SCI are aged 18-25 years.
BASED ON SCIENCE
MOST COMMON CAUSES OF
ADULT SCI
45% - MVC
20% - Falls
15% - Sports
15% - Violence
5% - other
MECHANISM OF INJURY
MORE THAN 50% OF SPINAL CORD INJURIES
ARE SINGLE VEHICLE CRASHES!
AGE BASED CONSIDERATIONS
60% of all SCI in >75 years population are
caused by simple falls.
Pediatric incidence varies between 1 – 11%.
• 5% will occur in the age group of 0-16 years.
• Adolescents: C5-C6 level most often injured
Causes in Children
• 0-10 years: falls and pedestrian vs auto
• >10 years are same as adult
NATIONAL EMERGENCY X-RADIOGRAPHY
UTILIZATION STUDY
NEXUS
Hypothesis:
Blunt trauma victims have virtually no
risk of cervical spine injury if they
meet all of the following criteria:
 No neuro deficit,
 Normal Level of alertness
 No evidence of ETOH/Tox
 No posterior midline tenderness
 No other distracting painful injury
NEXUS -RESULTS
818 patients with fracture identified
All except 8 were identified by clinical decision rule
Sensitivity 99% (95% CI 98-99.6%)
8 Patients
Not
Identified
By NEXUS
Rules
THE MAIN POINT:
• You can’t just decide to “clear” the spine without
following a standard of care 100% of the time. No
“neck-pain” is not an absolute clearance.
• Patients whose spinal cord injuries are missed are
directly related to poor assessment, lack of
recognition of SCI patterns and lack of knowledge
about risk factors correlated to SCI.
SPINAL INJURIES
KINEMATICS (MECHANISM)
Process of evaluating the forces and motion
involved when an accident occurs to determine
what injuries may have resulted
Based on fundamental principles of physics
described in Newton’s Law
KINEMATICS OF BLUNT SPINAL INJURY
Hyperextension
Hyperflexion
Compression
Rotation
Lateral Stress
Distraction
Axial Loading(diving)
Blunt Trauma
Motor Vehicle Collision
Bicycle Fall
Children: Fall > 3 feet
Adult: Fall from
standing height
MECHANISM OF INJURY
Physical manner and forces involved in
producing injuries or potential injuries
Valuable tool in determining if the a
particular set of circumstances could have
caused a spinal injury
Mechanisms likely to produce spinal injuries
occur in MVAs, falls, violence, and sports
(including diving accidents)
CERVICAL SPINE INJURIES
C-spine very flexible
Most frequently injured area of spine
Most injuries at C-5/C-6 level
THORACIC SPINE INJURIES
T-spine less flexible
Narrow spinal canal
Cord injury occurs with minimal displacement
Common mechanisms
Any cord damage usually complete at this level
Most T-spine injuries occur at T-9/T-10
LUMBOSACRAL SPINE INJURIES
LS spine flexible nerve roots in roomy spinal canal
May have bony injury w/o cord or nerve root
damage
Secondary injury still possible
Neurological injury rare w/ isolated sacral injuries
SPINAL COLUMN INJURY
Bony spinal injuries may or may not be
associated with spinal cord injury
These bony injuries include:
• Compression fractures of the vertebrae
• Comminuted fractures of the vertebrae
• Subluxation (partial dislocation) of the vertebrae
Other injuries may include:
• Sprains- over-stretching or tearing of ligaments
• Strains- over-stretching or tearing of the muscles
SPINE EVALUATION
IDENTIFICATION OF MECHANISM OF
INJURY
• Clearly Positive Mechanism
spinal immobilization indicated
• Clearly Negative Mechanism
spinal immobilization not indicated
• Uncertain Mechanism
MOI alone inconclusive
further assessment required to determine if spinal
immobilization necessary
UNCERTAIN MECHANISM
ASSESSMENT BY CLINICAL CRITERIA
Pain/Tenderness Exam
Neurological Exam
• Motor Function
• Sensory Function
Reliable vs. Unreliable Patient Exams
EXAMPLES OF POSITIVE
MECHANISM
 Penetrating trauma to head, chest, abdomen,
pelvis
 Axial loading injury
 Rollover with signs of impact
 Multiple system injuries
 Compressed roof of vehicle
 Falls greater than 20 feet
EXAMPLES OF POSITIVE
MECHANISM
 Death of occupant in same car
 Struck by vehicle traveling more than 30 mph
 Severe vehicle deformity, intrusion of car >12 inches
 Ejection from vehicle
PAIN/TENDERNESS EXAM
Spine Pain
Spine Tenderness
NEUROLOGICAL EXAM
Motor Function
Sensory Function
Reliable vs. Unreliable Patient Exams
MOTOR FUNCTION
Upper Extremities
• Abduction/Adduction
• Finger/Hand extension
Lower Extremities
• Plantar Flexion
• Great Toe Dorsiflexion
SENSORY FUNCTION
Test sensation at two levels
Must include testing for sensation to pain and light
touch at the lateral and medial aspects of each
upper extremity and each lower extremity
SENSORY FUNCTION
Abnormal Sensation- Numbness, weakness,
paraesthesia, or ridiculer pain
Pain Sensation- Test ability to distinguish pain from
light touch in both upper and lower extremities
EXAMPLES OF ABNORMAL NEURO
FINDINGS
 Paresthesia distal to injury, unilateral or bilateral
 Unilateral weakness, motor or sensory findings in
limbs
 Altered level of consciousness or affect
 Any abnormality to pan, temperature or position
sense.
RELIABLE VS. UNRELIABLE PATIENT
EXAMS
INDICATIONS FOR PATIENT EXAM RELIABILITY
*NO
**YES
Acute Stress Reaction (ASR)
Calm
Agitated, Combative
Cooperative
Intoxication/Drug Use
Sober/No Drug Use
Abnormal Mental Status -Alert & Oriented
(Note: be particularly careful
assessing mental status in
head-injured patients)
Distracting Injuries – (painful long
bone fractures, significant soft
tissue injuries, etc.)
Communication Problems -- Language Barrier, mental handicap, etc.
CRITERIA FOR HIGH RISK/
UNRELIABLE PATIENTS
GCS ≤ 12
Pediatric ≤ 12, ≥ Elderly 65
Alcohol, drug, any mind altering substance
use.
Other painful injuries.
Down Syndrome.
Acute stress reaction or severe anxiety.
Shock
History of serious spine problems.
SPINAL IMMOBILIZATION
DECISION ALGORITHM
RULE 1
“Use algorithm for stable patients with negative
or questionable mechanism of injury.”
SPINAL IMMOBILIZATION
DECISION ALGORITHM
RULE 2
“Any unstable patient or potentially unstable
patient with positive mechanism of injury, are to be
rapidly extricated and immobilized per regional
guidelines and PHTLS recommendations without
compromising short scene times.”
SPINAL IMMOBILIZATION
DECISION ALGORITHM
RULE 3
“Immobilization can be safely deferred when
there is a negative mechanism of injury. When the
mechanism is questionable or uncertain, clinical
criteria are to be used to determine immobilization
of the stable patient.”
“OTHER PAINFUL INJURIES.”
DISTRACTING INJURIES
• These patients have been correlated with
missed fractures/ injuries due to the
masking effects of sympathetic nervous
system stimulation.
POSITIVE OR QUESTIONABLE
MECHANISM OF INJURY
POSITIVE: “Positive mechanism” is determined
following the State of Connecticut Trauma
Protocols and Regulations. (Example: Fall of 25
feet)

•
S.I. indicated
QUESTIONABLE: “Questionable mechanism” exists
where the mechanism of injury is unclear
regarding impact and forces involved. (Examples:
Minor MVC with minimal vehicle damage; simple
fall of less than 5 feet)

•
S.I. POSSIBLY not indicated, continue with assessment to
determine S.I. need.
POSITIVE OR QUESTIONABLE
MECHANISM OF INJURY
NEGATIVE: “Negative mechanism” exists
when no reasonable possibility of spinal
injury is present. (Example: Knee/ankle injury
while running with no fall, GSW to arm/leg)
• S.I. not indicated
NOTE: These are only baseline principles. All
factors, including patient vital signs and
symptoms, should be evaluated prior to final
determination of need for S.I.
TAKE HOME MESSAGE
•
•
Long backboards may not need to be
utilized for spinal immobilization of
patients who have been ambulatory
after the mechanism of injury before
EMS has arrived.
Ambulatory patients who require
spinal immobilization can be placed in
an appropriately sized collar and
secured on the ambulance stretcher
in the position of comfort while limiting
the movement of the neck during the
process.
• Mechanism is going to be a crucial decision point in this
process. This will rule some people out who previously
were boarded and collared.
• Supine patients who meet the guidelines for Spine
Immobilization will be boarded and collared as usual.
Whereas, ambulatory patients who meet the protocol will
only be collared.
4/13/2015
46
Case Studies
Case Study One
Dispatch
–68 y/o female c/o weakness to arms, unable
to get out of car. Car parked in shopping mall
parking lot.
Arrival
–Pt sitting in drivers seat of car, GCS 15, no
distress
–Pt states she drove car over concrete parking
divider, “really jerking my head” when she
drove over 6 inch divider.
Case Study One (cont)
 Initial assessment: ABC’s normal, c-spine control initiated
 Stable or unstable?
 Evaluate MOI
 Secondary Assessment
– VS normal
– No pain on palpation of spine
– No deformity palpable
– Lower extremities= normal motor or sensory exam
– Upper extremities= Good sensation to light touch and
sharp touch; but, weak motor function
Case Study One (cont)
Risk/Reliability: Hx of osteoporosis
Treatment: Full immobilization
Reassessment: VS normal, further decrease in
motor function of upper extremities, No sensory
changes, lower extremities without changes,
patient c/o dull pain to neck
Case Study One (cont)
Diagnosis: Central Cord Syndrome
Discussion
–Hyperextension mechanism
–Swelling of central cord
–Most common type of cord injury
–Loss of motor and sensory function below
level of cord injury with greater loss in arms
than legs
Case Study Two
 Description of case: A 53 year old
male was involved in a moderatespeed MVA. He was driver of car that
rear-ended another car. Both cars
have serious fender damage. The hood
of your patients car is pushed in and
bent. the windshield is intact. He
states he was wearing his seat belt.
He complains of some shoulder
soreness. He is sitting in his car when
you arrive.
Case Study Two (cont)





Initial Assessment: ABCs are normal. Cervical spine
stabilization is manually obtained because of the appearance
of the cars.
Decide Stability of patient: Stable
Evaluate MOI: Questionable.
Secondary Assessment - Neurological and Sensory
Exam: Vital signs are normal. Pt. denies pain on palpation
of spine. you feel no deformity. Neurosensory exam is
normal. Pt is able to perform range-of-motion without pain
or limitation. Motor examination is normal.
Risk / Reliability Assessment: Pt. has no risk factors.
Case Study Two (cont)



Treatment: Transport for evaluation of
shoulder discomfort.
Reassessment: Unchanged.
Diagnosis: No indications for spinal
immobilization
Case Study Two (cont)
Discussion: Clinical clearance or inclusion
using the algorithm is a systematic approach as
noted above. This patient has no indications for
spinal immobilization. Be sure to document
your exam and treat his shoulder. Transport to
the ED is still indicated.
Case Study Three

Description of case: You are called to the
home of a 32 year old woman who is
complaining of left wrist pain. She is
embarrassed that she had to call 911, but she
can’t stand the pain in her wrist and can’t
drive herself to the ER. She states that she
injured her wrist about 6 hours earlier after
she fell out of a moving car. She reports her
friends said that she was initially unconscious
for several minutes. She admits to drinking a
few beers prior to the accident.
Case Study Three (cont)




Initial Assessment: ABCs are normal. No manual
stabilization initially maintained. Pt. denied any neck/back
complaints.
Decide Stability of patient: Stable.
Evaluate MOI: Significant.
Secondary Assessment - Neurological and Sensory
Exam: Vital signs are stable. Palpation of cervical spine
reveals mild tenderness. Manual cervical spine stabilization
is obtained. Neurological exam reveals intact sensation to
light touch and pain. proprioception is normal. Patient
moves all extremities. You note multiple abrasions over
forehead, scalp and left arm and leg. Patient has a Babinski
reflex on the left and her DTR were decreased on left.
Case Study Three (cont)
 Risk / Reliability Assessment: Loss
of consciousness, alcohol use,
associated injuries.
 Treatment: Full spinal immobilization.
Splint wrist fracture.
 Reassessment: Unchanged
 Diagnosis: Subluxation of C-4 on C-5
with fracture of pedicle and arch of C-4
Case Study Three (cont)
Discussion: This patient required surgery
(cervical diskectomy, decompression and fusion
with insertion of iliac crest bone dowel) and
immobilization with Gardner-Wells tongs. This
patient has risk factors as well as mild
tenderness on palpation. She also has a
distracting injury. There was a significant MOI
with several minute loss of consciousness
Case Study Four

Description of case: 5 year old male fell
out of tree approximately 10 feet. Landed on
hard ground. Parents report patient was
unconscious for a few minutes. Child is now
alert, oriented and is very quiet and still.
Case Study Four (cont)





Initial Assessment: Airway, breathing and
circulation are normal.
Decide Stability of patient: Stable.
Evaluate MOI: Significant.
Secondary Assessment - Neurological and
Sensory Exam: Vital signs are normal. Secondary
exam reveals shoulder pain and burning in both legs.
Patient refuses to participate in exam any further or
describe any other sensations.
Risk / Reliability Assessment: Patient is at high
risk for spinal cord injury/fracture due to age.
Case Study Four (cont)




Treatment: Full immobilization
Reassessment: Unchanged.
Diagnosis: Spinal cord injury
Discussion: This patient suffered a fractured
clavicle and a spinal cord injury.
QUESTIONS
?