BY ROMMIE L. DUCKWORTH
What would you do if you had a driver involved in a motor vehicle accident who had potentially injured his arm but yet hadn’t actually injured his arm? Would you splint that arm anyway? If the arm were injured, would you think that the best way to splint it would be to straighten it out as much as you could and strap it to a flat piece of plastic? If you did and your patient told you that it hurt much more in the splint and in this position, would you tell him, “I know. I’m sorry, but that’s just the way we do things around here”? Of course you wouldn’t!
Any discussion of current practices in spinal immobilization is challenging because it involves three separate but related issues:
- Spinal immobilization is the only common emergency medical services (EMS) practice where mechanism of injury overrides clinical assessment.
- Commonly used spinal immobilization tools and techniques (such as the long spine board and “log roll” move) have not demonstrated benefit to patients and have been shown to cause harm.
- Despite the overwhelming science directing responders toward better assessment and treatment options for spinal injuries, many EMS personnel find themselves challenged to change such long-embedded practices.
|(1) Three alternatives to the log roll. (Photo by author.)
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A BETTER UNDERSTANDING
Understanding how a normally working spinal column functions and what happens during injury does not have to be complicated, but the information given to responders should be more in depth than what has been provided to most responders. Although the spine itself is a flexible structure composed of 26 cervical, thoracic, lumbar, and sacral/coccygeal vertebrae, we don’t usually splint individual vertebrae or sections. Picture the entire spinal column as a single long bone with a joint at either end; the joint at the top is the cervical spine, and the joint at the bottom is the hips. Thinking this way can help providers better understand how spinal injuries affect patients and how best to stabilize an injured spinal column.
Although the spinal column provides structure to the body, it is also a channel for the spinal cord. Except for the first cervical vertebrae (C1), pairs of nerves leave the spinal column at each vertebrae, branching off from the spinal cord to carry impulses to and from individual parts of the body. An individual area of the body served primarily by a single spinal nerve is called a dermatome. Dermatomes generally refer to sensation, but it is important to remember that there are descending motor nerves and ascending sensory nerves in the spinal cord. These nerve paths both bring nerve impulses to the brain (afferent/sensory nerves) or carry them from the brain (efferent/motor nerves). Nerves branching off from higher vertebrae generally serve the upper parts of the body, whereas nerves branching off from the lower vertebrae typically serve the lower part of the body.
Good patient assessment requires providers to understand that nerves in the spinal cord run together in bundles called spinal tracts, much like individual telephone lines are grouped inside a telephone cable. These tracts run in right and left pairs and are identified according to their location in the spinal cord as well as by the nerve functions they perform.
The largest portion of the spinal cord is the anterior portion, which contains two separate tracts. The corticospinal tracts control motor function on the same side of the body, and the spinothalamic tracts carry sensation of light touch, temperature, and pin-prick pain from the opposite side of the body.
The posterior columns of the spinal cord carry sensation of light touch like the anterior spinothalamic tract, but the posterior columns also carry sensations of fine touch, body position, and movement.
Because nerves of different tracts can carry the same sensations, it is critical to fully assess motor and sensation for patients highly suspected of having spinal injuries.
Spinal injuries should not be thought of in terms of simply “injured or uninjured,” “all or nothing.” It is important to understand the differences between primary and secondary as well as complete and incomplete spinal injuries.
Primary spinal injuries describe damage to the spinal cord occurring at the moment of impact. Other than prevention, there is nothing emergency responders can do to eliminate primary injuries; they are typically over before the 911 call is made.
Secondary spinal injuries occur after the initial impact. They are injuries that responders will look to manage or prevent.
The secondary spinal injury providers tend to think of first is a mechanical injury where nerves of the spinal cord may be cut or crushed by boney structures of the spine or bone fragments.
Another type of secondary spinal injury occurs when the rapid swelling of tissue either slows or stops blood supply to part of the spinal cord or puts direct pressure on the cord itself. This is sometimes known as “spinal shock”; just like mechanical damage to the spinal cord, it can result in loss of function distal (further down) to the site of the spinal cord injury.
Another aspect of spinal cord injury is neurogenic shock. Neurogenic (or spinal) shock occurs when nerve pathways that control the autonomic nervous system are affected, causing blood vessels to lose muscle tone, typically resulting in low blood pressure, low heart rate, and hypothermia.
Although the swelling that causes spinal shock results in issues that EMS will have to deal with, the good news is many of these issues will resolve within hours to days as the swelling reduces and nerve function returns.
Rescuers generally picture all spinal injuries as complete injuries, where the spinal cord is completely severed with loss of all function distal to the site of injury resulting in quadriplegia or paraplegia. Although this does happen, patients may also sustain incomplete spinal injuries when damage occurs to individual or parts of spinal tracts.
Incomplete injuries may result in syndromes where the patient has weakness or loss of function in part of an extremity but yet retains motor, sensation, or other function because other spinal tracts remain intact. If not careful, a provider may be fooled into thinking a patient is okay because there is still some neurological function in an extremity (“Can you squeeze my hands?”) when further assessment would actually reveal an incomplete spinal injury.
Generally recognized as the first textbook for EMS, the American Academy of Orthopedic Surgeons (AAOS) “orange book,” published in 1971, originally recommended that responders use a patient’s symptoms and a physical exam to identify potential spinal injury and the need for immobilization.1 Over the years, textbooks have gradually moved mechanism of injury to become the primary determinant of whether a responder should immobilize a patient, the idea is that “there’s no way to know in the field.”2,3
Ironically, in the same 40 years, assessment of spinal injuries in the emergency department has moved in a much different direction.4-6Although emergency department physicians have long had X-rays as a diagnostic tool, they are not always available in a timely manner, forcing doctors to search for clinical hands-on assessment criteria to direct immediate treatment for spinal trauma.7 Additionally, clinical assessment criteria reduce costs of equipment, supplies, and needless radiological studies (X-ray, CT, MRI) as well as unnecessary exposure to radiation.8
In the late 1990s, the National Emergency X-ray Utilization Study (NEXUS) looked at 34,069 patients and found that five basic clinical criteria could allow physicians to screen victims of blunt trauma and identify those who did not need X-rays or further spinal immobilization with 99 percent sensitivity and 12.9 percent specificity.9-10 These criteria follow the mnemonic NSAID:
- Neurological deficit
- Spinal tenderness
- Altered mental status
- Distracting injury
If a patient were found to have any of these criteria, he would require spinal immobilization until evaluation by X-ray.
The NEXUS criteria were quickly followed by the slightly more accurate (100 percent sensitivity, 42.5 percent specificity in 8,924 patients) Canadian C-spine rule, which uses only three questions, albeit slightly more complex ones:
- Is there any high-risk factor present that mandates radiography (i.e., age > 65 years, dangerous mechanism, or paresthesias in extremities)?
- Is there any low-risk factor present that allows safe assessment of range of motion (i.e., simple rear-end motor vehicle collision, sitting position in Emergency Department (ED), ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness)?
- Is the patient able to actively rotate the neck 45° to the left and to the right?
Again, if a patient were to meet any of these criteria, he would require spinal immobilization until evaluated by X-ray. (4)11-12
These studies worked well in the ED setting and, more importantly, also worked for EMTs and paramedics in the field.13-18 In 1994, Maine Regional Medical Director Dr. Peter Goth instituted the Maine protocol; it was one of the first of many EMS systems to base its spinal stabilization decisions primarily on patient assessment and clinical criteria.19 In the 20 years hence, countless fire departments and EMS agencies including, Ridgefield, Connecticut; Ann Arbor, Michigan; Alameda, California; Austin, Texas; and others have used validated clinical assessment criteria to reduce unnecessary immobilization and focus efforts on patients who truly require spinal stabilization. (14)20
Risk vs. Benefit
After using validated clinical assessment criteria to identify a patient who is likely to have a spine injury, the next step is to choose the best spinal stabilization tools and techniques based on an educated risk/benefit assessment.
Harm That We Risk
A battery of field and laboratory studies from all over the world makes the risks of spinal immobilization very clear. Prehospital spinal immobilization often interferes with priority patient assessment and can complicate and delay life-saving care. (7)21-24 Traditional methods of spinal immobilization can result in back pain, (24)25-29 pressure sores, (26)30 airway difficulties, (2)31 respiratory compromise,32-34 and neurological deterioration.35 In addition, cervical collars can cause separation of the cervical vertebrae36 and increased intracranial pressure.37-43
Benefits to the Patient
On the other hand, evidence supporting the benefits of current spinal immobilization tools and techniques is nowhere near as strong. (27)44-45
In September 2011, the Executive Committee of Prehospital Trauma Life Support (PHTLS) issued the following statements (22):
- There are no data to support routine spinal immobilization in patients with penetrating trauma to the neck or torso.
- There are no data to support the routine spinal immobilization in patients with isolated penetrating trauma to the cranium.
- Spinal immobilization should never be done at the expense of physical examination or correction of life-threatening conditions in patients with penetrating trauma.
- Spinal immobilization may be performed when a focal neurological deficit is noted, although there is little evidence of benefit even in these cases.
Even though this may be a vast departure from previous practice, many providers were surprised that the recommendations did not go further considering the large amount of evidence that immobilizing victims of penetrating trauma does more harm than good.46-49
If spinal immobilization does more harm than good for penetrating trauma, what is the benefit for victims of blunt trauma? This was the question Dr. Mark Hauswald asked in his landmark 1998 study comparing patients with spinal cord injuries treated with routine spinal immobilization at a University of New Mexico hospital vs. those treated without routine immobilization in a comparable hospital at the University of Malaya.50 Although this retrospective study had its limitations, the results showing better neurological outcome in patients who had never touched a backboard called into question the mindset that virtually all victims of blunt trauma should receive routine spinal immobilization.51
SPINAL IMMOBILIZATION TOOLS
Although many spinal stabilization tools are available to EMS providers, it appears that those used most often may be the least helpful.52
Even when properly applied with appropriate straps and padding, long spine boards often create enough pain that patients adjust themselves for comfort, causing the very movement that rescuers intended to prevent. (28-29) For patients forced to wait for long periods before being “cleared” off long spine boards, pressure sores may develop, especially in geriatric and obese patients. (28-29, 52)53 Thinking of them as giant “people spatulas,” long spine boards can still be used effectively to move patients and may be the best option for immediate patient extrication. If no better spinal immobilization options are available, long spine boards should be applied with padding or inflatable cushioning on the board; proper strapping of the torso, hips, and lower extremities (to manage the spine as a long bone with joints above and below); as well as padding in voids behind and to the sides of the patient. (28-30)54-55
Full-body vacuum-style splints have proven more comfortable and ergonomic than standard long spine boards and have been used as the primary device choice for spinal stabilization outside of the United States for many years. (26,52)56-59
Although time consuming to apply, the Kendrick Extrication Device (KED) is a tool that works well to immobilize and transfer patients found in the seated position, typically without a significant amount of discomfort. 60,61
While intended to help stabilize one of the two “joints” of the spinal column, cervical collars can cause anxiety, discomfort, increased intracranial pressure, and separation of cervical vertibrae. (36-37, 39-41)62 Few alternatives to the traditional Aspen-style collar currently exist; however, new devices like the X-collar claim to provide improved cervical stabilization.63 Tools such as the X-collar may not be perfect, but they demonstrate the inventive thinking needed for EMS to improve the equipment we use to treat victims of spinal injury.
Cervical Immobilization Devices
Although many commercial and “homegrown” versions of cervical immobilization devices (CIDs) exist, research suggests that few, if any, of them achieve their goal of helping to restrict motion and support the potentially injured cervical spine, even when used properly. (44) A potential hazard occurs when providers focus too much time on the application of a CID (or any spinal immobilization equipment) in situations where addressing other life threats should take priority.
Scoop stretchers, breakaway backboards, and similar devices highlight the connection between spinal immobilization devices and the techniques employed to use them. Scoop stretchers and related devices are intended to transfer patients from the locations in which they are found, allowing providers to avoid using patient transfer techniques that may wind up causing the very movements and resulting damage they are intended to prevent.64-65
Best and Worst Spinal Immobilization Techniques
It can be easy to label particular immobilization devices as “good” or “bad,” but in many cases, it is not the devices themselves but the way in which they are used that benefit or harm patients. Regardless of what equipment is used to stabilize a patient’s spinal column, rescuers must figure out the best way to move the patient onto the equipment or apply the equipment to the patient.
One of the most common methods used to transfer patients to spinal mobilization devices is the log-roll technique. One study suggests that the “push” log-roll technique may be more effective than the “pull” technique; however, a great deal of research has shown that any log roll causes significant unwanted motion when transferring patients to or from a long spine board (photo 1).66-69,70
The lift-and-slide technique consists of one rescuer maintaining inline stabilization of the patient’s head while coordinating other rescuers. Up to three rescuers on either side of the patient simultaneously lift the patient’s upper torso, pelvis, and lower extremities while another rescuer slides the stretcher, vacu-splint, or other device under the patient, who is then lowered onto the device. (67-69)
Considering the extreme unlikelihood that an ambulatory victim of blunt trauma would have sustained a spinal injury significant enough to require immobilization coupled with the significant spinal movement that rescuers cause using a standing takedown technique, many agencies now recommend strongly against using the standing takedown under any circumstances.71
Several preliminary but very intriguing studies now suggest that some victims of motor vehicle crashes for whom spinal immobilization might be indicated may be better off extricating themselves rather than having rescuers attempt to immobilize and remove them.72-74 Although this may seem counterintuitive at first, any emergency care provider must ask, “Am I applying more force to the patient’s potentially injured spine by trying to move him out of the car than he would apply by stabilizing himself and moving gently over to my stretcher?”
ADVANCED LIFE SUPPORT PROCEDURES
In the near future, prehospital treatment of spinal injuries may include more than simple immobilization and transport. Here’s what may change, why it should, and how your department can do it.
Several advanced-level therapies are being evaluated including the administration of steroids (methylprednisolone) and therapeutic hypothermia. As of yet, none have been clinically demonstrated to improve patient outcome.75
MAKING THE CHANGE
A large number of emergency responders are ready, willing, and able to make changes to their spinal immobilization practices, but they are unsure of how to go about it. The first step is to approach stakeholders and decision makers for your agency, including chiefs, administrators, and medical directors, and present them with questions, concerns, and answers about current practices in spinal immobilization.76
Some decision makers may be hesitant to change current practice for fear that EMS providers may be operating outside of their scope of (comfortable) practice, deviating from a standard of care, or straying from major recommendations.
Scope of Practice
Although exact scope of practice and standard of care for emergency responders differ from state to state, some underlying concepts apply universally. Because of the rapidly evolving nature of health care, most agencies that issue licenses and certifications for EMS providers write scope of practice documents in such a way as to leave them open for continual advances in health care. For this reason, in the United States, the national EMS scope of practice model only mentions maintaining skills in “manual stabilization of suspected cervical spine injuries.”77 Statutory changes are sometimes required to allow for advances in spinal immobilization practices, but this is not the case in most regions of the country.
Standard of Care
There is often a misunderstanding that “common practice” is the same thing as “standard of care.” In fact, standard of care as determined in a court of law is not typically based on “common practice.” Rather, courts determine standard of care as effectively “doing the best thing for the patient” by reviewing current research, practice guidelines, recommendations, and expert testimony.78 Thus, although some recommended updates may not yet be common practice in a particular region, they are certainly supported by current research, practice guidelines, recommendations, and expert testimony.
When it comes to changing current practices in spinal stabilization where the research does not speak for itself, leading emergency care organizations are loud and clear including the PHTLS Executive Committee, the National Association of EMS Physicians, the American College of Surgeons Committee on Trauma, the Faculty of Pre-hospital Care, the Royal College of Surgeons of Edinburgh, and the U.S. Metropolitan Municipalities EMS Medical Directors Consortium: The “Eagles” Coalition. Virtually all agree on five primary recommendations:
- More quality research is needed on EMS care for spinal injuries.
- Better tools and techniques are needed for EMS care for spinal injuries.
- In the meantime, selective spinal immobilization is a tested and validated method of minimizing the number of patients placed at risk of harm from current immobilization practices with little to no discernable benefits.
- Although spinal injuries remain an important consideration in prehospital trauma care, they should not delay or interfere with other higher-priority assessments and interventions.
- In some cases, long spine boards may be appropriate to facilitate patient movement, but even when used properly, they remain a poor choice for spinal stabilization.
CHANGING SPINAL IMMOBILIZATION PRACTICES
Although questions remain in 2014, changes in spinal immobilization have been progressing for 20 years. Emergency service providers risk the health and well-being of their patients if they do not do the following:
- Determine the need for spinal immobilization using clinical criteria.
- Stabilize patients who require immobilization using best practices in spinal immobilization tools and techniques.
- Change long-embedded and outdated immobilization habits with up-to-date protocols that better serve responders; emergency service agencies; and, most importantly, our patients.79
The next time you wonder what you’ll do on an upcoming trauma call, think about why “better safe than sorry” may be doing “more harm than good.” Consider who may have sustained a spinal injury, when spinal stabilization is indicated, how you should stabilize your patient, and be proud that your agency is where it is done correctly.
Note: The complete list of references is posted at http://bit.ly/1tsV2uv.
1. American Academy of Orthopaedic Surgeons. Emergency Care and Transportation of the Sick and Injured. (American Academy of Orthopaedic Surgeons, 1971).
14. Domeier, R. M., Evans, R. W. & Swor, R. A. “The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury.” Prehospital … (1999).
15. Stroh, G. & Braude, D. “Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization.” Annals of Emergency Medicine 37, 7–7 (2001).
22. Stuke, L. E. et al. “Prehospital spine immobilization for penetrating trauma—review and recommendations from the Prehospital Trauma Life Support Executive Committee.” The Journal of Trauma: Injury, Infection, and Critical Care 71, 763–770 (2011).
27. Kwan, I. & Bunn, F. “Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects.” Prehospital and Disaster Medicine 20, 47–53 (2005).
46. Haut, E. R. et al. “Spine immobilization in penetrating trauma: more harm than good?” The Journal of Trauma: Injury, Infection, and Critical Care 68, 115–111 (2010).
50. Hauswald, M., Ong, G., Tandberg, D. & Omar, Z. “Out-of-Hospital Spinal Immobilization: Its Effect on Neurologic Injury.” Academic Emergency Medicine 5, 214–219 (1998).
71. Connor, D., Greaves, I., Porter, K., Bloch, M.consensus group, Faculty of Pre-Hospital Care. “Pre-hospital spinal immobilisation: an initial consensus statement.” Emergency Medicine Journal 30, 1067–1069 (2013).
ROMMIE L. DUCKWORTH, LP, is a career fire lieutenant and EMS coordinator for the Ridgefield (CT) Fire Department. He has more than 20 years of experience working in career and volunteer fire agencies, public and private emergency services, and hospital-based healthcare systems. He is a frequent speaker at national conferences and a regular contributor to research programs, magazines, textbooks, and news media on fire and emergency service topics.
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