# To collar or not to collar.



## Melclin (Apr 29, 2012)

The age old debate in EMS. 

Consider the following three jobs I've been to in the past 2 weeks:

1. A modern SUV involved in a single car role at 110km/h with significant cabin intrusion on drivers side. Driver GCS 6, cushings triad, RSI'd flown to level 1. Pt, usually healthy 27YOF, was rear passenger side occupant, wearing a seatbelt, self extricated, ambulating after accident. Reports being uninjured, pain free, doesn't look sick, nil evident injuries, strong radial pulse, warm hands. A quick GCS and bare bones neuro exam/nexus criteria assessment = GCS 15, but reduced sensation reported in L leg, otherwise NAD. Stood her up, sat her on the board, collared her, moved to the truck for further exam. All NAD except HR of between 100 and 130, apparently rising with waves of anxiety about the condition of the driver. Now not complaining of altered sensation in L left leg and more thorough neuro exam is spotless. I elected to keep her immobilised based on mechanism, the original question of altered sensation and some system specific technicalities that aren't relevant to my question. 

2. Mid 90's hatch back, rolled down ~2m ditch onto roof after sliding off gravel road at approx 40km/h. Nil cabin intrusion. Pt 19YOF, self extricated, ambulating normally at the scene. O/E: GCS 15, neuro exam NAD, NEXUS all negative, nil complaints other than small lacerations on hands, which I cleaned and dressed. Borderline tachy reduced to 80 with some calming influences. Sent pt home with someone to observe her, gave her minor head injury advice just in case. 

3. 60YOF cyclist travelling approx 30km/h, was clipped by another cyclist travelling the opposite direction. Pt pushed sideways onto grass, landing on L arm and shoulder, is unsure about 2ndry head strike. Pt is collared and sitting on the side of the road on our arrival (first crew on scene is treating her more seriously injured cycling partner, but had briefly assessed and collared our pt). Pt is GCS 15, neg NEXUS criteria, nil neuro deficits. Stood pt up & boarded her, moved to truck for further exam. C/O Pain in R scapula around the area of an older injury, pain radiating up R side of neck and into occiput, with generalised minor headache. Nil trauma evident anywhere. Rest of exam NAD. Pt has nil medical hx and is on no medications. I elected to remove the collar and board. Pt complained approx 1 hour after initial exam of aching around C-2, not changing with palpation and radiation of pain in scapula to thoracic vertebrae, again not changing with palpation. I didn’t change my treatment plan.

Considering these cases in retrospect, there does seem to be a little inconsistency in my decision making and I was wondering what you all thought of these decisions. I’m not at all interested in “I wud board them all coz protocol says” or “Just follow your protocols”. That’s fine if you have to do that, but I’m more interested in what you thought I should have done with each of these pts individually outside of guideline/protocol specific discussion and if you think there is some inconsistency in the way I’ve applied spinal precaution overall.

I will give you all some outcome info after I’ve heard a few people pipe up.


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## Veneficus (Apr 29, 2012)

I see no problems with any of this.

In your first case, the 2nd patient could be reasonably assumed to be distracted, perhaps not by an injury, but by the event and condition of other driver.

A collar for an unreliable patient seems in order.

2nd case: You suspected no spinal injury and so you didn't treat it. there were probably some observations you didn't type up that also led you to believe there was no spinal injury.

To steal your phrase: "no worries mate"

3rd case: not sure if a board or collar would help here. Initially reading, I was thinking about muscle injury, particularly the sternocleidomastoid, however, a secondary injury attributable to compartment syndrome is not an unexpected finding on re-exam.

Her age would cause me concern, and while I may opt to put her in a collar, I would not fix her to a board. 

If her arm was outstretched or assumed upon impact that could again reasonably transmit force into the spine, but it would have to be a significant impact, and I would again be more suspect of soft tissue injury than an actual body fracture.

But I really don't see the "OMG! OH NO!" moment here. 

Even if they did find a fracture on CT, what did they do about it?"


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## Aidey (Apr 29, 2012)

Pretty much what Vene said. I also was thinking that in the first case the issue could be transient not resolved, which is enough reason to continue to be suspicious. 

In the third case it sounds like the next pain that developed was more along the lateral aspect of the neck, did I read that right?


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## Melclin (Apr 29, 2012)

Veneficus said:


> I see no problems with any of this.
> 
> In your first case, the 2nd patient could be reasonably assumed to be distracted, perhaps not by an injury, but by the event and condition of other driver.
> 
> ...



I don't really have a problem with the 2nd job. It was more that they were quite similar so I was asking myself if I really needed to be collaring the first chick. 

Then I've gone back to the original NEXUS & CCS studies for a refresher and just came out of it with more questions. Both rollover and speed are listed equally under high risk mechanisms in CCS that deserve radiography. I still feel the second chick was fine, but I'm a bit confused about what CCS is telling me. Then I got a bit worried about my cyclist, because any cycle collision is listed as a high risk mechanism and directed for mandatory imaging in CCS which weakened my position in any hypothetical argument over immobilising her. I feel like some of their mechanisms need a little more explaining. 

Which then got me to wondering how you reconcile the presence of a high risk criteria, which both of these chicks had, in ADDITION to the obvious presence of a number of low risk criteria that push you in the direction of clearing. The articles seem to offer little guidance, but it being 0630 here now, I'm less than capable of a decent interpretation. I think it may lay in the inclusion criteria for entry to the algorithm.

We aren't supposed to clear people older than 55 and she had a reasonable mechanism. So this one is kinda chalked down in the expectable bending of the guidelines column. As such, I wanna be able to justify it solidly with an evidence based argument.




Aidey said:


> Pretty much what Vene said. I also was thinking that in the first case the issue could be transient not resolved, which is enough reason to continue to be suspicious.
> 
> In the third case it sounds like the next pain that developed was more along the lateral aspect of the neck, did I read that right?



3rd case: Yeah it seemed that way initially but as time went on and we talked more and I re-examined her twice more over the course of an hour, the story changed a little to be more central and more cervical. She was quite sure her condition wasn't changing, she was just describing it differently, so I started to worry that maybe she had always had that pain. While it wasn't boney tenderness on palpation, it was central neck pain, in a 60yo, with a decent mechanism...who'd I'd just cleared. You see what I'm saying.


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## Veneficus (Apr 29, 2012)

Melclin said:


> Which then got me to wondering how you reconcile the presence of a high risk criteria, which both of these chicks had, in ADDITION to the obvious presence of a number of low risk criteria that push you in the direction of clearing. The articles seem to offer little guidance, but it being 0630 here now, I'm less than capable of a decent interpretation. I think it may lay in the inclusion criteria for entry to the algorithm.




In my mind, high risk doesn't mean injury, it just increases the likelyhood.

Which then starts the argument how rapidly occult injury can manifest clinically or if/how secondary injury can be made worse or prevented.

Just because somebody needs scanned, and just because a fx shows up on a scan, doesn't mean that will alter the treatment.

That is the big hold up I think in EMS in general. motion restriction compared to immobilization.

As I mentioned before, I think that in the past, EMS got a lot of undue blame for secondary injury which was not its doing.




Melclin said:


> So this one is kinda chalked down in the expectable bending of the guidelines column. As such, I wanna be able to justify it solidly with an evidence based argument.



Wouldn't we all 

But I think I would argue general state of health and fitness if I had to.


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## Brandon O (Apr 29, 2012)

AFAIK rollovers are no longer associated with increased M&M so long as restraints are used.


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## Akulahawk (Apr 29, 2012)

Patient #3 sounds more like a Brachial Plexus or nerve root injury vs cervical fx to me...


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## Melclin (Apr 30, 2012)

Brandon Oto said:


> AFAIK rollovers are no longer associated with increased M&M so long as restraints are used.



AFAIK rollovers?


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## Melclin (May 1, 2012)

Also, has anyone else considered what happens now that plain films are not the standard (as they were in the NEXUS and CCS studies) for diagnosing an injury? 

There are places around here that have moved to MRI and I know CT is basically a standard of care in many cases. How do clinical clearance criteria fare against these new standards?


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## Veneficus (May 1, 2012)

Melclin said:


> Also, has anyone else considered what happens now that plain films are not the standard (as they were in the NEXUS and CCS studies) for diagnosing an injury?
> 
> There are places around here that have moved to MRI and I know CT is basically a standard of care in many cases. How do clinical clearance criteria fare against these new standards?



A few years ago I went to a trauma conference where this was discussed.

Without some type of deficit, MRI is to this day considered money wasting overkill. 

With deficit, it is often the diagnostic of choice.

CT is its own animal, and I don't think it is beneficial to try to compare the utility of the two. 

The speaker(a critical care surgeon whose resume I could not hope to replicate) at the conference demonstrated that while at the time, x-ray missed about 30% of all spinal fractures. It was also pointed out by the same, that while these injuries were "missed," the increase in identifying injury with CT did not change the treatment plan in any of the patients studied.

The use of CT for the diagnosis and treatment planning of other injuries in trauma however more than makes up for its lack of value in spinal recons.

There is also the legal aspect of identification and conservative treatment of a vertebral injury vs. not knowing it was there.

So in a round about way, clinical clearance may not detect an existing injury, but this unknown injury may be subclinical, and even if known, would be unlikely to change treatment anyway.  

The issue is not quite as dramatic as "we shot an x-ray and we didn't find an injury and the patient was later a quad."

In fact, it didn't even miss injuries that caused chronic pain or sensation alteration.


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## Melclin (May 1, 2012)

Veneficus said:


> A few years ago I went to a trauma conference where this was discussed.
> 
> Without some type of deficit, MRI is to this day considered money wasting overkill.
> 
> ...



Interesting. I love this idea of the "clinically important" injury. The PECARN head CT study talked a lot about it and really liked that focus. Who cares if there is a line on screen, does it change anything?

I can feel a literature deep dive coming on.


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## Brandon O (May 1, 2012)

Melclin said:


> AFAIK rollovers?



As far as I know 

EMcrit did a recent post on imaging protocols for spinal clearance.


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## Melclin (May 1, 2012)

Brandon Oto said:


> As far as I know
> 
> EMcrit did a recent post on imaging protocols for spinal clearance.



No I mean what is a _AFAIK_ rollover?


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## Brandon O (May 1, 2012)

As far as I know, rollovers are no longer associated with increased M&M


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## mycrofft (May 1, 2012)

"AFAIK" = "As Far As I Know".

And we Yanks need to be reminded the cyclists were probably each on their LEFT side of the path so their RIGHT sides contacted and the mech of injury on ground contact would be a possible lateral (left) hyper-adduction of the head and neck, with stretching on the right side and compression on the left, unless there was torsion during the fall or other forces altering the direction of force to the head-neck.

Cyclist sounds like a cervical compression or stretch.

Case #1: I'd ask about distribution of the leg paresthesia and test for weakness if it made time-sense (while guarding against iatrogenic spinal injury..."Does THIS hurt!?"). If your experienced spider sense says to immobilize or not, I'd trust it, but caution or direct about followup the next day if it worsens despite home remedies and RICE.

Case#2: I presume she was driving and had no appreciable anterior torso injury or pain (suggesting force of antero-posterior movement versus steering column), just the owies you described. Little you describe suggests an actual need for spinal immobilization, but wouldn't it have been nice to be able to go back and see her once again an hour or two later, check the ocular fundii and reflexes and look once again for delayed signs of closed head injury or cervical strain? (Maybe silly note: you CAN have closed head injury without cervical injury, couldn't the possible nausea of progressing intracranial issues be a bad combination with immobilization of a spine that could be just fine?


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## mycrofft (May 1, 2012)

PPS: was that a six or four cylinder AFAIK?


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## Melclin (May 6, 2012)

Brandon Oto said:


> As far as I know, rollovers are no longer associated with increased M&M



Ohh I should know that. I'm a nerd who also has the internets. Isn't my face red :rofl:


To ALL: Cheers for the input. I've recent had two more jobs that have further made me question some of the aspects of this conversation. I'll might post them for interest's sake if I get time over the next few days. As always, you've been very helpful.


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## OzAmbo (May 7, 2012)

Awww melclin..... sill thinking about this eh!


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## Melclin (May 17, 2012)

So the outcomes...

None of the pts turned out to have injuries warranting spinal precautions. (Although thats not doesn't mean some shouldn't have been immobilised).

The cyclist was the only pt to cause the docs in any discomfort by not having immobilised her but after a short chat they also decided not to image. 

I took the cases to our clinical QA/QI type person for his opinion. He agreed with with my decisions in all cases but with the following caveat (Something that I'd already noted myself and made a practice change in a subsequent job MVA). He disagreed with my having stood pt one (110km/hr accident with neuro deficit on first exam but self extraction and ambulation after accident), saying that right or wrong, I made the decision to immobilise and that once you make that decision you do it properly. You don't half immobilise them. You either do or you don't feel that their is a possibility of injury. If you do then they need the works just like you might do for a pt with a more obvious injury.


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