Spinal Motion
Restriction
Modernizing Our Management of Injured Patients
A Valley Medical Directors Collaboration
Objectives
•
Historical perspective
•
Understand injury based on biomechanical
principles
•
Review current evidence
•
Learn spinal motion restriction concept
Historical Perspective
•
Clinical Suspicion = IMMOBILIZE
•
Any Trauma Above Clavicles = IMMOBILIZE
•
Not Sure = IMMOBILIZE
•
Fear of Punishment = IMMOBILIZE
•
Don’t Feel Like Checking = IMMOBILIZE
Historical Perspective
•
How bad is it?
•
> 50% of trauma patients with no complaint of
back/neck pain get full spinal immobilization
•
13% get immobilized without being asked
about pain
The Facts
•
1-5 million EMS patients per year with suspected
c-spine injury
•
2% have a fracture
•
1% develop neuro deficits
Why Do We Do It?
•
To avoid further patient injury caused by us
during movement and transport
•
Focus is on stopping gross visible spinal
movement
•
Patient packaging stops movement
•
No movement = spine, cord, and patient are
safer, right???
Evidence Is Weak
•
Large meta-analysis on spinal immobilization
•
“Effect on mortality, neurologic injury, spinal
stability… uncertain.”
•
“possibility that immobilization may increase
mortality and morbidity cannot be excluded”
Evidence is Weak
What Really Matters?
•
Visible movement is only one threat
•
What about…
• Pulmonary function compromise
• Risk of aspiration/airway compromise
• Increased intracranial pressure
• Delays in transport
• Concealment of other injuries
• Soft tissue ischemia/necrosis
• Cost of unnecessary diagnostics
Column and Cord
•
Movement
•
Significant amount of force needed to break
bone and tear ligament
•
Subsequent movement by EMS is less than
force required to cause damage
Column and Cord
•
Movement
•
Normal range of motion = non-destructive distortion
•
Movement within normal range requires almost no
energy
•
Resistance to movement within normal range is
essentially zero
•
No such thing as “less than zero”
Column and Cord
•
Movement
•
Viscoelastic tissues of spine stiffen and spasm
post-injury
•
Swelling increases preload on intact ligaments
•
Locked facets and bone-on-bone impingements
functionally immobilize spine
•
Normal patients “self-splint” to avoid pain
Column and Cord
•
Post Injury Deterioration
•
Tissue hypoxia (local/global)
•
Direct contusion
•
Biochemical cascade, cell death
Column and Cord
•
Post Injury Deterioration
•
Mitigated by getting to definitive care FAST
•
EMS focus should be reducing delays
•
Patient packing with full SI is a potential delay
Summary
•
We immobilize way too many patients
•
Most injured patients will be mechanically stable
•
Totally unstable patients probably have maximum
damage at time of impact
•
All immobilized patients can be potentially
harmed
Spinal Immobilization
•
SI is a method of transport, not a therapy
•
SI is a misnomer
•
Just say “no” to the standing takedown
•
“Spinal Motion Restriction”
•
Reducing of gross movement
•
Prevention of duplicating damaging mechanism
Just To Be “Safe”
•
SI harms patients
•
Cannot justify an intervention known to do harm
just for small possibility of benefit
•
Simple risk/benefit decision
How Does SI Hurt?
•
Cervical collars
•
Proven to increase ICP
•
Produce axial distracting force
•
Transfer force to ends
•
Obscure neck injuries
•
Make airway management more difficult
How Does SI Hurt?
•
Rigid long back boards
•
Cause iatrogenic pain
•
Cause 15-20% reduction in respiratory capacity
•
Causes delays in transport
•
Possible risk o pressure ulcers
Backboards
• Still reasonable for…
• Blunt trauma with ALOC
• Spine pain/tenderness and neuro complaint
• Anatomic deformity of spine
• High-energy mechanism with ALOC,
distracting injury, inability to communicate
How Does SI Hurt?
•
Penetrating trauma victims
•
NNT = 1,032
•
NNH = 66
How Does SI Hurt?
•
“Time Zero” Myth
•
Patient evaluation and treatment does not
begin at the exact time of arrival to the ED
Now What?
•
Allow EMS to selectively immobilize
•
Allow EMS to use the least amount of package
needed for safe transport
•
Monitor outcomes
Empowering EMS
•
Several studies show EMS capable of deciding
•
Tools derived from NEXUS and CCR
Spinal Motion Restriction
SMR - Blunt
Adult
SMR - Penetrating
Adult
SMR - Blunt
Peds
SMR - Penetrating
Peds
Backboards
• Still reasonable for…
• Blunt trauma with ALOC
• Spine pain/tenderness and neuro complaint
• Anatomic deformity of spine
• High-energy mechanism with ALOC,
distracting injury, inability to communicate
What About the Equipment?
•
Scoop stretchers same or superior than log roll
and lift-and-slide techniques
•
Kendrick devices, short boards?
•
Self-extrication with collar may be better, but
ONLY for normal, reliable patients
What About the Equipment?
What About the Equipment?
•
“Backboards are like spatulas; at some point that
burger has to be put on a bun…”
•
Backboards are an extrication tool, not a medical
treatment.
Backboards
• Still reasonable for…
• Blunt trauma with ALOC
• Spine pain/tenderness and neuro complaint
• Anatomic deformity of spine
• High-energy mechanism with ALOC,
distracting injury, inability to communicate
Spinal Immobilization Algorithm:
Blunt Trauma
Altered level of consciousness (GCS less than 15)
No
Yes
IMMOBILIZE
Rapid transport
Spinal pain or tenderness?
or
Neurological deficit or complaint?
or
Anatomic deformity of spine?
Yes
No
IMMOBILIZE
Concerning
mechanism of injury?
Rapid transport
(Cont’d)
Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc.
69
Spinal Immobilization Algorithm:
Blunt Trauma (Cont’d)
Concerning Mechanism of Injury
Yes
No
Presence of:
Evidence of alcohol/drugs
or
Distracting injury
or
Inability to communicate
IMMOBILIZATION NOT
INDICATED
Transport
Yes
No
IMMOBILIZE
IMMOBILIZATION NOT
INDICATED
Rapid transport
Transport
Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc.
71
ED Transfer of Care
•
Helpful to discuss with ED why you decided to
package or not package patient
•
Share your information and decision-making
•
Patient packaging no longer a contextual clue to
guide radiography needs
•
ED providers will have to independently reexamine and decide if radiography indicated
Interfacility Transfers
•
Medical directors need to reconsider protocols
•
How is first hospital “clearing?”
•
Crews should independently examine patients
•
Implications of GCS < 15?
•
Collar reasonable, but rigid long board???
•
Other ways to “puts handles on a patient”
SMR Video
Thank You!
•
Valley Medical Directors
•
Jim Morrissey, Alameda County EMS
•
Jerry Schirmer, Laura McElhatten, Mark Jones, Mesa
Fire/Medical EMS Division, Charlie Foster, Amy Gaber
•
MFMD 204-A, CFD E286-C and R286-C
•
SWA SW208
•
SFD E601-A, P608
Spinal Motion
Restriction
Modernizing Our Management of Injured Patients
A Valley Medical Directors Collaboration