# GSW/Stabbing Immobilization



## bnn987 (May 27, 2012)

You arrive to find a victim with either a gunshot wound or a GSW that is alert and oriented with a GCS of 15. Bleeding is controlled and there is no airway compromise or breathing difficulty. Do you immobilize the patient due to MOI?


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## Aidey (May 27, 2012)

Hell no.



> The number needed to treat with spine immobilization to potentially  benefit one patient was 1,032. The number needed to harm with spine  immobilization to potentially contribute to one death was 66.


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## STXmedic (May 27, 2012)

Aidey said:


> Hell no.



This.

ESPECIALLY if there aren't any signs of spinal compromise.


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## usalsfyre (May 27, 2012)

Penetrating injuries aren't a "high" mechanism as far as the spine's concerned. Gonna have to go with the above.


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## phideux (May 27, 2012)

Are they shot in the spine?????


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## rwik123 (May 27, 2012)

As stated above.

Glad we could do your homework for you.


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## TatuICU (May 27, 2012)

bnn987 said:


> You arrive to find a victim with either a gunshot wound or a GSW that is alert and oriented with a GCS of 15. Bleeding is controlled and there is no airway compromise or breathing difficulty. Do you immobilize the patient due to MOI?



POC homie, POC


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## Mad Russian (May 27, 2012)

If someone has an isolated GSW or Stab Wound to an extremity no but I have seen plenty of GSW's that have pinballed around and the patients were more grievously wounded than previous thought due to location of enty wound. For example I had a patient with an entry wound to his left hip the fragment tracked through his pelvis and was lodged next to the patient's spine.


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## Aidey (May 27, 2012)

The plural of anecdote is not data. Read the study I posted.


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## hoop762 (May 27, 2012)

If there is an entrance wound with no exit wound, then yes, I would immobilize. Had a pt last year shot once in there left shoulder with no exit wound and the bullet fractured his T10. 

Sent from my Incredible 2 using Tapatalk


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## NomadicMedic (May 27, 2012)

The question was:



bnn987 said:


> Do you immobilize the patient due to MOI?



The answer is a resounding *no*.


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## AnthonyM83 (May 27, 2012)

Aidey said:


> The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.



"Potentially contribute"? I would need better data on the types/severity of the 66 cases of "harm".


As for the original question: no provided they don't have neuro defecits (motor/sensory). GSW is definitely a high mechanism. It's just that neurological injuries tend to at the time of event...not down the line from turning the wrong way like with blunt trauma. So says PHTLS.

Local policy requires us to immobilize, though (unless patient is hypotensive).


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## abckidsmom (May 27, 2012)

Mad Russian said:


> If someone has an isolated GSW or Stab Wound to an extremity no but I have seen plenty of GSW's that have pinballed around and the patients were more grievously wounded than previous thought due to location of enty wound. For example I had a patient with an entry wound to his left hip the fragment tracked through his pelvis and was lodged *next to* the patient's spine.



Beside.

And I bet his wasn't moving much with that pelvis.  Ideally, you'd use the scoop to get him onto the stretcher and just transport.  I would make sure he laid as close to flat as possible, though.


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## Aidey (May 27, 2012)

AnthonyM83 said:


> "Potentially contribute"? I would need better data on the types/severity of the 66 cases of "harm".
> 
> 
> As for the original question: no provided they don't have neuro defecits (motor/sensory). GSW is definitely a high mechanism. It's just that neurological injuries tend to at the time of event...not down the line from turning the wrong way like with blunt trauma. So says PHTLS.
> ...




I believe the full text of the article is available online. Read the abstract I posted and if you still have questions search for the full text.


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## sir.shocksalot (May 27, 2012)

Aidey said:


> The plural of anecdote is not data. Read the study I posted.


HA! I like that.

As many have said, DO NOT BACKBOARD PENETRATING TRAUMA. Read the study that was posted.

Just think about it logically, if a bullet bounced around in a victims thoracic or abdominal cavity is your chief concern really spinal immobilization? How about any of the well fed organs residing in those cavities? Any of the massive vessels? The pump itself? Also, If the bullet severed the spinal cord then the damage is done, restricting their movement will not undo the spinal injury.

Critical trauma patients need surgeons, any action taken to increase the time it takes for the victim to get to a trauma surgeon worsens their outcome. So why spend 2 minutes back boarding someone if it doesn't change anything for the better? I think the last PHTLS book even says not to back board penetrating trauma.

Edit: another thought: Military deals largely with GSWs, do you see backboards as a regular part of a military medic's equipment?

I won't bring up the general effectiveness (or lack thereof) of backboards...


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## Brandon O (May 27, 2012)

AnthonyM83 said:


> "Potentially contribute"? I would need better data on the types/severity of the 66 cases of "harm".



http://www.ncbi.nlm.nih.gov/pubmed/20065766



> So says PHTLS.



PHTLS agrees that: "Because of the very low risk of an unstable spinal injury and because the other injuries created by the penetrating trauma often require a higher priority in management, patients with penetrating trauma need not undergo spinal immobilization." Seventh Edition, p. 256


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## Aidey (May 27, 2012)

That is the same study I posted.

Here, are three more studies if the first one wasn't convincing enough.


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## EpiEMS (May 27, 2012)

Data says no. Common sense says no.

Heck no.


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## Handsome Robb (May 28, 2012)

Nope. No spinal motion restriction without neurological signs and symptoms. 

We aren't required to spinal these patients by protocol either, thankfully. 

Protocol says "Consider spinal motion restriction if indicated"


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## mycrofft (May 28, 2012)

Long spine boards carry airway risks (enforced supine position) which can lead to pharmaceutic paralysis for an airway, etc etc. Just what you want in addition to a GSW.

TIme is part of the risk-benefit ratio. And don't treat based solely on MOI, treat based upon exam and complaint.


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## Tigger (May 28, 2012)

NVRob said:


> Nope. No spinal motion restriction without neurological signs and symptoms.
> 
> We aren't required to spinal these patients by protocol either, thankfully.
> 
> Protocol says "Consider spinal motion restriction if indicated"



I want to know how many people have protocols like yours and mine (which covers all of Massachusetts), yet still say "protocols require us to spinal." It seems to me that there are many out there (not specifically you AnthonyM83!) that through lack of education, fear the worst and spinal everyone and therefore can only hope to justify their actions with their protocols. Just because it's mentioned in the protocols, does not not mean you have to do it, unless it specifically says you must. Most treatments are to be given *when indicated.*



abckidsmom said:


> Beside.
> 
> And I bet his wasn't moving much with that pelvis.  Ideally, you'd use the scoop to get him onto the stretcher and just transport.  I would make sure he laid as close to flat as possible, though.



It seems to me that having someone properly strapped to a scoop, along with proper stretcher seatbelts, would sufficiently prevent the patient from moving in such a way to cause the bullet to move within the body no matter where it lies..


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## Brandon O (May 28, 2012)

Tigger said:


> I want to know how many people have protocols like yours and mine (which covers all of Massachusetts), yet still say "protocols require us to spinal."



It's not what it says; it's how your medical director, CQI people, and basically your "boss" interprets it. And in Mass. it's broadly interpreted to mean "board everyone on the list."


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## Pavehawk (May 28, 2012)

Brandon Oto said:


> It's not what it says; it's how your medical director, CQI people, and basically your "boss" interprets it. And in Mass. it's broadly interpreted to mean "board everyone on the list."



What he said!! 

All the science in the world will not trump the system. Until the system changes or until you are an MD calling the shots it is going to fall back on protocol and standard of care.

Once there are enough legal decisions validating the medical literature, for the most part spinal immobilization will be done "even when not needed" because the fear of litigation is too strong.


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## NYMedic828 (May 28, 2012)

NYC requires us to immobilize any penetrating trauma to the thorax.

It sucks.


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## Tigger (May 28, 2012)

Brandon Oto said:


> It's not what it says; it's how your medical director, CQI people, and basically your "boss" interprets it. And in Mass. it's broadly interpreted to mean "board everyone on the list."



I still maintain that much of it is done in fear of the CQI and at times the medical director though I do not have an especially active medical director at work. I've had discussions with our Quality Assurance director about these sorts of things, his point is just to be able to justify your actions. However it would seem that many are afraid to justify their actions or *more likely* in a predominantly IFT setting it is common to "over-treat" patients when the opportunity presents itself to, er, do EMT type things.


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## Brandon O (May 28, 2012)

Tigger said:


> I've had discussions with our Quality Assurance director about these sorts of things, his point is just to be able to justify your actions.



Those discussions are smart to have before the event, although frankly, if it's not obtained in writing, it may end up having "never happened."


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## Akulahawk (May 28, 2012)

Penetrating trauma, absent any signs of spinal compromise, will not have any spinal restriction applied by me unless I absolutely have to do so... as in my protocols leave me no wiggle room. I may have to place the patient in some kind of movement restriction if I have to intubate, to decrease the chance of extubation, but... that's not specific to penetrating trauma of a high speed or low speed variety.


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## DrParasite (May 28, 2012)

Pavehawk said:


> All the science in the world will not trump the system. Until the system changes or until you are an MD calling the shots it is going to fall back on protocol and standard of care.
> 
> Once there are enough legal decisions validating the medical literature, for the most part spinal immobilization will be done "even when not needed" because the fear of litigation is too strong.


BINGO!!! I can quote studies, I can show data, but as long as protocols say to board them, despite evidence to the contrary I still need to board them.  And if i don't, than the question of "well, when the lawsuit comes, and your intervention isn't up to the standard of care, and now the person is paralyzed, what will you do?"  the fact that the patient was paralyzed before we got on scene is completely irrelevant....

That all being said, I think almost every penetrating trauma I've seen has been on a board.  more often than not, they get carried from wherever they get picked up on a board, onto the cot, and transported to the trauma center.  it's used as a carrying device, not an immobilization device.


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## Tigger (May 29, 2012)

Brandon Oto said:


> Those discussions are smart to have before the event, although frankly, if it's not obtained in writing, it may end up having "never happened."



Very true. While I trust that my bosses will generally look after their staff, I do not trust that they will choose defending me over being involved in any sort of potential law suit. Even with these conversations, there is no way to talk about every potential situation, so even if it were in writing, such discussions are unlikely to any actual incident by either side.


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## mycrofft (May 29, 2012)

If you follow protocol and board them and they die of positional asphyxia, you're in trouble but not for failing protocol.

If you don't follow protocol and they don't die for whatever reason, especially not due to iatrogenic ones related to long spine boards, then you are in trouble maybe for not following protocol but the pt is alive, maybe because you used judgement.

A good documented PCR with the indications for what you do will be your saving grace if there are any.


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## Brandon O (May 29, 2012)

DrParasite said:


> the fact that the patient was paralyzed before we got on scene is completely irrelevant....



Well, generally a claim of negligence requires actual harm to be inflicted, so if you can demonstrate that you caused none you may be okay. Of course, you don't get a judge and jury when it comes to your employer or certifying agency.


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## Christopher (May 29, 2012)

If by 2012 you're still performing spinal immobilization based on MOI alone just tear up your certification...you're not treating patients you're just pushing a button on a machine.

Using MOI with no other indications is no different than using information provided by a 3rd party caller to 911 as a reason to board and collar somebody.

MOI without any signs of deficit is nothing more than hearsay.


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## Tigger (May 29, 2012)

Christopher said:


> If by 2012 you're still performing spinal immobilization based on MOI alone just tear up your certification...you're not treating patients you're just pushing a button on a machine.
> 
> Using MOI with no other indications is no different than using information provided by a 3rd party caller to 911 as a reason to board and collar somebody.
> 
> MOI without any signs of deficit is nothing more than hearsay.



Testify brother oh testify!

If only the absentee medical directors of the world could be made aware of this.


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