# Trauma Activation



## Ramathorn90 (Jul 10, 2011)

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?


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## TransportJockey (Jul 10, 2011)

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


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## truetiger (Jul 10, 2011)

Nope, no trauma activation.


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## Smash (Jul 10, 2011)

TransportJockey said:


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



I second this.


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## exodus (Jul 10, 2011)

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?


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## TransportJockey (Jul 10, 2011)

exodus said:


> 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


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## ah2388 (Jul 10, 2011)

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.


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## SanDiegoEmt7 (Jul 11, 2011)

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)


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## medicdan (Jul 11, 2011)

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.


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## usalsfyre (Jul 11, 2011)

ah2388 said:


> 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?


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## usalsfyre (Jul 11, 2011)

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


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## daj72 (Jul 11, 2011)

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.


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## Akulahawk (Jul 11, 2011)

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.


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## Handsome Robb (Jul 11, 2011)

Akulahawk said:


> 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


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## clibb (Jul 11, 2011)

Ramathorn90 said:


> 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.
> 
> ...



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


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## mycrofft (Jul 11, 2011)

*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??


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## Aidey (Jul 11, 2011)

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?


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## usalsfyre (Jul 11, 2011)

mycrofft said:


> 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.


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## mycrofft (Jul 11, 2011)

*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.


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## ah2388 (Jul 11, 2011)

usalsfyre said:


> 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.


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## abckidsmom (Jul 11, 2011)

No TTA.


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## lightsandsirens5 (Jul 11, 2011)

SanDiegoEmt7 said:


> 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)***



Understatement of the day right there. 

Unfortunately it is very true. 



Sent from a small, handheld electronic device that somehow manages to consume vast amounts of my time. Also know as a smart phone.


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## Trevor (Jul 11, 2011)

In my system, we would only activate the trauma team IF he had some type of neurologic sign or symptoms... 

In my system we have a pretty liberal spinal clearance protocol... (Based on NEXUS and the Canadian C Spine Rule Study).
I HATE backboarding people, however i do it (and probably more then most of my co-workers) because its the *Standard of Care *(in my system and assuming they meet some criteria for it)... 

*Look up this study...*Out-of-hospital Spinal Immobilization: Its Effect on Neurologic Injury
Mark Hauswald, MD, Gracie Ong, MBBS, Dan Tandberg, MD, Zaliha Omal; MBBS
1998.


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## usalsfyre (Jul 11, 2011)

So I somehow missed the FACILITY boarded the patient and not the crew. My apologies, I doubt I would have removed them either.

I HATE conventional long boards. With the fire of 1000 suns. Probably because there's zero evidence they do any good, but plenty of evidence of harm. There's nothing "patient centered" about keeping them. If spinal motion restriction is a valid concept (and I have my doubts about that in the conscious patient with acute injury) then you can't convince me we can't do better.


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## Trevor (Jul 11, 2011)

usalsfyre said:


> So I somehow missed the FACILITY boarded the patient and not the crew. My apologies, I doubt I would have removed them either.
> 
> I HATE conventional long boards. With the fire of 1000 suns. Probably because there's zero evidence they do any good, but plenty of evidence of harm. There's nothing "patient centered" about keeping them. If spinal motion restriction is a valid concept (and I have my doubts about that in the conscious patient with acute injury) then you can't convince me we can't do better.



agreed....


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## Ramathorn90 (Jul 11, 2011)

Thanks for all of the feedback guys.

I ended up continuing C-spine precautions on the notion that the Pt was already on a back board with a c-collar and a terribly MacGyvered version of a head bed. I felt uneasy removing him from spinal precautions based on the report given by the Dr and the Pt being a terrible historian. I also took the Pt to the hospital of his choice, without activating the trauma team. My reasoning being that he had been neurologically asymptomatic since the event. And aside from midline lumbar pain, has not had any issues otherwise. However, my concern as to whether or not it should have been a trauma was raised when I had 2 nurses give me baffled looks as to why I brought the Pt to their hospital.

Unfortunately, in my system, we are required to activate traumas per MOI as well. Therefore, any MVA >40mph would be a trauma activation. This has been quite a nuisance for many cases as the belted driver who reports she was driving 40mph but has minimal damage and no complaints greater than an ache would be given the "minor" trauma tag at our local trauma center.


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## mycrofft (Jul 12, 2011)

*Ramathorn90, you've been most patient.*

Thanks for sharing.


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## ah2388 (Jul 13, 2011)

usalsfyre said:


> So I somehow missed the FACILITY boarded the patient and not the crew. My apologies, I doubt I would have removed them either.
> 
> I HATE conventional long boards. With the fire of 1000 suns. Probably because there's zero evidence they do any good, but plenty of evidence of harm. There's nothing "patient centered" about keeping them. If spinal motion restriction is a valid concept (and I have my doubts about that in the conscious patient with acute injury) then you can't convince me we can't do better.




To the first paragraph...Hey now

as for the second, agree 100%


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## DrParasite (Jul 13, 2011)

Ramathorn90 said:


> Unfortunately, in my system, we are required to activate traumas per MOI as well. Therefore, any MVA >40mph would be a trauma activation.


while that maaaaaay be the policy, it isn't absolute.  after all, while the crash was at 90mph, it was 3 days ago.  

for example, if I was involved in an MVA in 1998 where I hit the wall divider at 120 mph, and it messed up my knee, and today I'm calling you because my knee is still hurting, would you make me a trauma because of the mechanism?

If the doc puts the patient on a board and collar, unless I have a really good reason, 99% of the time I'm not going to remove it.  not that I think they do much, but if someone (MD, FFs, sports trainers, etc) boards someone, it's just easier to leave them on it.



Ramathorn90 said:


> I had 2 nurses give me baffled looks as to why I brought the Pt to their hospital.


because the signs said emergency entrance, and you figured sick and injured people should go there, instead of to the bus stop, the local shelter, Wall Street, the state capital, or McDonalds?


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## Melclin (Jul 13, 2011)

*Are you serious?*

Have I missed something here? I would get laughed out of the trauma centre if I took this person there and if the case got reviewed, my team manager or CSO would be having words with me. 

I wouldn't immobilise this person and to be honest, I'm not even sure he really needs to go to hospital. Maybe I don't get the "urgent care" thing, but isn't this something they could handle and refer to hospital if it was something needing surgical intervention? They don't have xray at the urgent care? This MD sounds like a f**k knuckle to me.


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## CAOX3 (Jul 13, 2011)

No board, no trauma alert, no trauma center and he should probably take himself to the hospital to avoid a whopping bill that is going to be determined by his insurance company to be absolutely un warranted transport.


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## tom.watkins (Jul 17, 2011)

If the pt or doc are adamant that they go by ambulance, I'd say a KED just for CYA and pt "comfort". C-spine, pshhh.... We dont need no stinken' c-spine. A definite no-go on the trauma alert, though. Let's save it for when we need it. We have a hospital where I work that is now triaging our reports and determining what to do themselves instead of just listening to us. Guess there were too many wolf cries.... <_<


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