Trauma Activation

[Ramathorn90]

This post is regarding whether or not to activate this patient into the trauma system or not.

Pt is a 22 y/o presenting with midline lumbar pain 3 days after being involved in a MVA. The Pt states he was the restrained front seat passenger of a vehicle that was traveling approximately 90mph before hopping over the center divide and losing control. It is uncertain as to what type of object the vehicle collided into and how much damage was actually caused to the vehicle. However, no airbag deployment was noted per the Pt, and the Pt states he signed AMA upon EMS arrival at time of MVA. The Pt reports he had no LOC, head pain, neck pain, numbness or tingling in all extremities at any time after the accident. He says he was ambulatory post MVA with no difficulty.The Pt mentioned that he went to visit his chiropractor the next day, and was immediately referred to an MD for further evaluation after the chiropractor noted deformity to his lumbar spine. The Pt then visits his local urgent care clinic and is immediately placed in c-spine precautions by the urgent care MD.

Upon arrival of my partner and I, we find a Pt in no obvious physical distress. Pt states his only complaint is his lumbar pain, which he describes is dead center on his back. We continue with C-spine and full spinal immobilization as noted that the Pt has not had an x-ray.

The question on this run, does this Pt warrant trauma activation criteria in spite of the incident being 3 days prior? Would you activate this Pt into your local trauma system?

 

[TransportJockey]

Probably not here... and for that matter they probably wouldn't have gotten boarded and collard either

 

[truetiger]

Nope, no trauma activation.

 

[Smash]

Probably not here... and for that matter they probably wouldn't have gotten boarded and collard either

I second this.

 

[exodus]

No trauma. And sure, why not c-spine. If the force was great enough to deform their back, it's possibly great enough to fx cervical isn't it?

 

[TransportJockey]

No trauma. And sure, why not c-spine. If the force was great enough to deform their back, it's possibly great enough to fx cervical isn't it?

The dude's been wandering around for three days. If he had an unstable C-spine fx, he'd have long displaced it and either died or had severe neuro deficit U/A of EMS

 

[ah2388]

I suppose the theory is that the pt has compromised the integrity of there spine to the point that if a cervical injury was present, it wouldve presented itself already.

In this specific instance, spinal immobilization is UNLIKELY to cause additional harm. Additionally, if this pt is being transported by ground to a facility that can repair the issue, it would not be uncommon in my experience for the receiving physicians in the ED to prefer the pt be packaged.

In this area, it would be unlikely but not unheard of for this pt to be met by a waiting trauma team at time of ED arrival.

 

[SanDiegoEmt7]

Normal vital signs, GCS 15, no neuro deficits. No activation

A stable patient with traumatic injury doesn't require the activation of a trauma team.

Edit: unless rapid deterioration is possible

I'd keep your guy in c-spine or atleast on the board just for CYA purposes, not that it would necessarily have any benefit (crazy world right)

 

[medicdan]

Ramathorn90, I'm not sure where you're from, but each state (county, municipality or hospital) has their own prehospital TTA protocol-- and it should be well communicated to EMS providers. A quick survey of other state's protocols identifies the following resources.

http://www.doh.wa.gov/hsqa/emstrauma/download/TraumaTeamAcviation.pdf
http://www.flightweb.com/archive/flightmed/2002/11/msg00028.html
http://www.nopacsurg.org/Abstracts/0619.pdf
http://mbemsc.org/files/provider_info_items/Region_IV_Trauma_Triage_POE_2011_Final.pdf (the protocols I operate under)

Your decision to activate the trauma team is going to be based on the patient's clinical presentation (you haven't provided enough information), regional protocols and your gut. My sense is that because this patient was previously seen at an urgent care (assumingly affiliated with the ED), they may have already called in a report (and alerted the trauma team, if necessary), this isn't like a regular 911 call.

 

[usalsfyre]

In this specific instance, spinal immobilization is UNLIKELY to cause additional harm.

And it provides what benefit, other than giving us the warm and fuzzies?

 

[usalsfyre]

To the OP, no trauma team for an apparently stable spinal issue three days in the making.

 

[daj72]

Nope, I would not activate the trauma team for this.

If neurologic fall out to the LE, I would immobilize, it there is no fall out, no board and collar.

 

[Akulahawk]

I would tend to agree... no trauma team activation. If given the ability to clear c-spine in the field, I'd see if the patient can be removed from spinal precautions. We don't collar and board all of our back pain patients, do we? I'd also want to get a look and feel for his L-Spine deformity. he's had any previous spinal "deformity" issues. I'd want to know if I'd want to know if he has any sensorimotor changes from normal, especially distal to the site of pain.

Given that he's 48-72 hours post event and essentially not so acute, I'd be thinking along the lines of a non-displaced Fx, burst Fx of the vertebral body that isn't impinging on the cord, muscular strain or ligament sprain as the cause of his discomfort. If the cord had been impinged in some way, it would likely have shown itself by now.

If I can get him out of spinal precautions, I'd transport him in a position of comfort, no trauma team activation, no oxygen, no monitor, probably no IV (saline lock maybe), and do repeat distal neuros with basic vitals every so often during the ride. If nothing changes from initial presentation, he'd be called in as a "c/o mid-back pain post MVA 3 days ago, (deformity described), no noted sensorimotor deficits... vitals (whatever they are), currently in a position of comfort, see ya in ??? minutes. Any questions?"

There really isn't much I'd do for this patient... based on what little info I have so far for him. I might call his chiro during transport to find out what was found or if the referral was knee-jerk and what this patient's back is normally like. That's if I decide to play Columbo.

Trauma team activation? Way overkill for this one at this point.

 

[Handsome Robb]

If I can get him out of spinal precautions, I'd transport him in a position of comfort, no trauma team activation, no oxygen, no monitor, probably no IV (saline lock maybe), and do repeat distal neuros with basic vitals every so often during the ride. If nothing changes from initial presentation, he'd be called in as a "c/o mid-back pain post MVA 3 days ago, (deformity described), no noted sensorimotor deficits... vitals (whatever they are), currently in a position of comfort, see ya in ??? minutes. Any questions?"

I'm going to second Akula and everyone else who has said his cervical spine is stable on this. He has been ambulatory for 3 days with no nuero deficits. If he was going to do damage to his spinal column he would have done it already.

I understand CYA but at this point I would not restrain the pt in full c-spine precautions. With the MD from the clinic already starting this though, I wouldn't argue with him and would transport the patient as packaged.

This patient does not warrant a trauma activation. I don't know exact numbers, but activating a trauma team can cost 10s of thousands of dollars. You are activating an entire trauma unit, a neurosurgeon along with a trauma surgeon and NPs, specialized nurses and techs(if applicable). It isn't something to be taken lightly.

This patient is complaining of LUMBAR back pain 3 days a after the initial injury. If he hasn't caused a debilitating injury by now, you aren't going to cause one unless you decide you need to wrestle him... C-spine immobilization infers cervical spine immobilization, which the patient has no complaint of cervical pain whatsoever. We had a case this year on the ski hill of a lumbar fracture that was actually irritated by our spinal immobilization to a hard spine board and the transport down the mountain while restrained to the LSB according to our QI/QA. I'm sure if there was more research/evidence of this, the practice of total spinal immobilization would be changed.

I understand that 'back pain' indicates c-spine precautions, but we are supposed to be clinicians. Be gentle with the patient. and position them in a position of comfort, O2 if indicated (which it seems like it is not) and transport him to the closest hospital with orthopedic capabilities.

Sorry for the long post. In summary, no trauma activation necessary and in my opinion no full spinal immobilization necessary

 

[clibb]

This post is regarding whether or not to activate this patient into the trauma system or not.

Pt is a 22 y/o presenting with midline lumbar pain 3 days after being involved in a MVA. The Pt states he was the restrained front seat passenger of a vehicle that was traveling approximately 90mph before hopping over the center divide and losing control. It is uncertain as to what type of object the vehicle collided into and how much damage was actually caused to the vehicle. However, no airbag deployment was noted per the Pt, and the Pt states he signed AMA upon EMS arrival at time of MVA. The Pt reports he had no LOC, head pain, neck pain, numbness or tingling in all extremities at any time after the accident. He says he was ambulatory post MVA with no difficulty.The Pt mentioned that he went to visit his chiropractor the next day, and was immediately referred to an MD for further evaluation after the chiropractor noted deformity to his lumbar spine. The Pt then visits his local urgent care clinic and is immediately placed in c-spine precautions by the urgent care MD.

Upon arrival of my partner and I, we find a Pt in no obvious physical distress. Pt states his only complaint is his lumbar pain, which he describes is dead center on his back. We continue with C-spine and full spinal immobilization as noted that the Pt has not had an x-ray.

The question on this run, does this Pt warrant trauma activation criteria in spite of the incident being 3 days prior? Would you activate this Pt into your local trauma system?

No this should not be a trauma team activation. Just taken to the ER and tell them what the MD found earlier.

 

[mycrofft]

Trauma team=no. Where did all this C spine issue come from?

Trauma team is for acute presentation of severe injury. Even a new EMT-B should see this is not the case here. There was no complaint to the chiropractor of cervical pain or referred pain. No mention is made of a cervical spine xray at the "doc in a box". I think the freestandoing emergency clinic covered themselves and the pt by going for the immobilization and ambulance route.

Not to say a cervical injury has not occured, though. There are many people walking around with cervical injury, some of them extremely painful and which could benefit from surgery and could be further exacerbated should their car ride to the hospital be interrupted by another collision, hitting a tree or pothole, etc. The rule-out is radiographic, not just because they are walking around.

And as for pain right over the center of his back, does that mean limited to right over the spinous processes, or affecting a region in the middle of the back? Pain centered right on the spine is not common in a genmuine spinal injury; not impossible, especially with spinous process fractures, but uncommon, and fx of the spinous process while sitting in a car seat with restraints is rare.

And...90 mph??

 

[Aidey]

Just from being put on a back board during training I would say that if anything, it causes MORE displacement of the lumbar region. I am not a big person, and lying with my legs flat causes excessive lordosis. Why would I want to do that to someone complaining of lumbar pain?

 

[usalsfyre]

Not to say a cervical injury has not occured, though. There are many people walking around with cervical injury, some of them extremely painful and which could benefit from surgery and could be further exacerbated should their car ride to the hospital be interrupted by another collision, hitting a tree or pothole, etc. The rule-out is radiographic, not just because they are walking around.

Again, show me the proof "immobilization" helps in this situation, especially with the crap gear used by most EMS agencies.

Not trying to be an ***, but we've got to do better than dogma and guesses.

 

[mycrofft]

I am against indiscriminate spineboarding.

What is the current practice for transporting someone if you are suspicious of a cervical injury? (Me, I'd go for a KED and careful handling, at least). Of course, straightening and fixing the back of the head to a board can also injure a damaged spine; as for me, my airway would shut. Gotta practice medicine, not recite it.

If there is a valid professional suspicion (not knee-jerk protocols or "just cause I can" enthusiasm) of a cervical injury, is it ethical or legal not to address it for transport (which is what field splints of all sorts are, packaging for transport)? Should we be revisiting field halo traction as we did in the Eighties? Or what? Or should a blanket caution be made to "minnimize cervical movement enroute" and left to practitioners how best to do it? Valid non-sarcastic questions.

In this instance, the clinic was covering itself and the pt, unless there is missing data, such as dermatome manifestations linked to the C spine, xrays, etc. Trauma team not needed.

 

[ah2388]

And it provides what benefit, other than giving us the warm and fuzzies?

I didn't advocate for any benefit, but I'd generally prefer to avoid confrontations on scene with a physician who has packaged the pt. If this pt's comfort is not going to be effected, and it presents no other complications, id prefer to keep the environment peaceful and calm instead of fighting a battle which could make the environment hostile.
With that being said, if the pt presents as being uncomfortable and fails to tolerate his current situation, I would have no trouble removing the equipment, as it is likely to be unnecessary.

If the situation was different, in that we were called to this pt's home...it would be rare that this pt gets packaged.