# ride along scare



## emt brando (Feb 7, 2012)

so, when i went on my ride along for my emt class, we came across a patient that had a self inflicted gunshot wound to his head. he was laying on the floor in supine position and i inserted an opa as soon as we showed up. while i was ventilating the patient via bvm the medics were cutting off his clothing and taking his vitals. the backboard was placed next to the patient, and since i was at his head i was told to lead; at this point i asked the medic if we should secure spinal immobilization via a cervical collar and the response i got was, "we dont have time for c-spine, let's get him on the board". I see the reasoning behind this in the fact that he was bleeding out, however, i feel that there could have been some sort of spinal injury since the bullet most likely bounced around in the patient's head (there was a large amount of crepitus in the skull). IS THIS NORMAL PROTOCOL? I feel as if it wasnt...


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## JPINFV (Feb 7, 2012)

Generally spinal immobilization isn't needed for penetrating trauma. Additionally, if the bullet bounced around the brain pan than there's little need for spinal immobilization anyways.


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## Aidey (Feb 7, 2012)

What JP said. I have been directly told by my medical director to not backboard GSWs to the head.


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## bigbaldguy (Feb 7, 2012)

There will be times when taking the extra 3 mins or so to web someone down is 3 minutes too many. The sad thing is those times where time is so absolutely critical often overlap with the times C spine is also critical. Sometimes you have to make a call on getting a patient to the hospital alive or wrapped up and pretty.


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## Brandon O (Feb 7, 2012)

bigbaldguy said:


> There will be times when taking the extra 3 mins or so to web someone down is 3 minutes too many. The sad thing is those times where time is so absolutely critical often overlap with the times C spine is also critical. Sometimes you have to make a call on getting a patient to the hospital alive or wrapped up and pretty.



It's a pretty strong statement to say that C-spine is ever absolutely critical.


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## bigbaldguy (Feb 7, 2012)

Brandon Oto said:


> It's a pretty strong statement to say that C-spine is ever absolutely critical.



So not 100 percent sure what you're saying. C spine is never absolutely critical or you're saying I'm saying it is never absolutely critical?

I probably wasn't 100 percent clear in my original response so just to clarify.

Taking the time to strap up a patient on scene can mean a dead patient or a live patient that can't dance. Not in every instance not even in very many instances but there are the ones where there's not a damn thing you can do outside of a hospital for a patient and the best you can do is load em up and get them to the pros before they die on you. Getting them to the pros sometimes means you don't follow c spine because those 3 minutes can make a difference. That call just has to be made sometimes. Luckily as a lowly basic I'm not the one making it.


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## JPINFV (Feb 7, 2012)

The problem with discussing c-spine is everyone ultimately can play the trump card that there is no evidence that it does anything beneficial.


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## Maine iac (Feb 7, 2012)

The big bald guy just took my answer. haha.

One time we were transporting an ab pain pt and after we called our report left the radio on the hospital channel for a second too long... Another call that we saw on the computer was a GSW, and while we lingered on the hospital's channel the medic running that call called in his GSW to the head report.

Our pt heard the report and decided his ab pain wasnt much to be complaining about.


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## Mountain Res-Q (Feb 7, 2012)

JPINFV said:


> The problem with discussing c-spine is everyone ultimately can play the trump card that there is no evidence that it does anything beneficial.



Yuuppp...  All the reseach I have seen (unless someone has something new and amazing) indicates that for every case where spinal "immobilization" MIGHT... MIGHT... MIGHT have had some benifit, there are a far more cases where restraining the patient on a hard board for hours on end was medically unnecessary and caused more pain, suffering, and detriment.  I find any reason to forgo the backboard; IMHO it is an antiquated medical "treatment" that is overused by First Responders and Noobs that are taught "MOI, MOI, MOI, COOKBOOK" and feel like they are doing something useful by getting the spider straps tight enough (btw, I miss D Rings).  No amount of immobilization is going to treat the real reason why 911 was called in this case...


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## JPINFV (Feb 7, 2012)

Mountain Res-Q said:


> Yuuppp...










So. Much. Hate.


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## Veneficus (Feb 7, 2012)

*let us look at some logic?*

If you have penetrating injury to the spine, the physical structure is destroyed. 

Immobilization is not going to undestroy or less destroy the structure of the spine.

Additionally in temporary cavitation, the spinal arteries may be destroyed, which means the neural tissue is suffering from ischemic injury. (not helped by a backboard)

Furthermore, blood is generally toxic to neural tissue, so when there is crossover in inappropriate places, there is neural damage. That is not going to be helped by immobilization.

In a GSW to the head, if the spine is severed, that would actually be the medula or high c-spine, (1st verabrae or maybe 2nd.) In any those are associated with vegatative function. (like breathing)

You will probably notice that without much effort. 

Those vegatative functions are not coming back, so that is going to be a done deal. Even if you could "save" that person, they are going to be a vent dependant quadraplegic that will have a party thrown in their honor if they can ever move their lips on their own.

About the only bright side in that scenario is that the is a burr hole ready made to reduce ICP.

If you step out of the trauma scenario for a second, what you have is basically a hemorrhagic stroke (bleeding into the brain.) Have a look see at the term liquefactive necrosis and find a picture in the brain.

Moreover you have active bleeding from one of the most vascular organs in the body without the benefit of a closed skull to help tamponade the bleeding while the body tries it's best to get more blood there.

So in light of this discussion, what would you say is the purpose of spinal precautions?

In a person bleeding from a GSW to the brain, or even near the brain if the bullet by miracle just circumnavigated the skull, why would you be worried more about "paralysis" than getting this person to somebody who stands a chance at helping?

Just being the devil's advocate, pretending that spinal immobilization actually might help for a minute, wouldn't preservation of life take precedent over limb?


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## WTEngel (Feb 7, 2012)

Veneficus said:


> About the only bright side in that scenario is that the is a burr hole ready made to reduce ICP.



As usual Vene, making lemons from lemonade... err, however the saying goes!


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## systemet (Feb 7, 2012)

J Trauma. 2000 Nov;49(5):860-3.
C-spine injury associated with gunshot wounds to the head: retrospective study and literature review.
Lanoix R, Gupta R, Leak L, Pierre J.
Source

Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, New York 10451, USA. richlanoix@aol.com
Abstract
OBJECTIVE:

To determine the incidence of C-spine injury (CSI) associated with gunshot wounds (GSWs) to the head.
METHODS:

A retrospective chart review including patients with GSWs to the head and excluding those with penetrating facial/neck trauma was performed. Cervical clearance was by clinical/radiologic criteria in survivors, and autopsy in nonsurvivors. A MEDLINE literature search was performed and relevant articles reviewed.
RESULTS:

One hundred seventy-four charts were available for review; 90 had C-spine radiographs (complete series [49], lateral [33], and computed tomographic scan [8]). Of 84 with no radiographs, 29 were clinically cleared, and 55 died (32 cleared at autopsy). Twenty-three died without evaluation. None of the remaining 151 (87%) had CSI. Literature search yielded only three relevant articles. Combining the data from these articles yielded 534 patients, and CSI was excluded in 507 (95%).
CONCLUSION:

C-spine immobilization and diagnostic radiography are probably not necessary in patients with isolated GSWs to the head and may complicate and delay emergency airway management.

PMID:
    11086776
    [PubMed - indexed for MEDLINE]


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## Veneficus (Feb 7, 2012)

WTEngel said:


> As usual Vene, making lemons from lemonade... err, however the saying goes!



See, I am here for you  guys.


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## themooingdawg (Feb 11, 2012)

those are always judgement calls unless theres a stiff protocol in place; but in this situation, c spine probably really won't matter considering this pt has a penetrating wound to the head, so really, any damage to any nerves has already been done. c-spining him at this point instead of just throwing him onto the backboard and transporting would prob not be the wisest decision at the time


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## Bosco578 (Feb 11, 2012)

Spray foam. Squirt,expand,immobilize........:beerchug:


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