# Which services require spinal immobilization for penetrating trauma?



## BEorP (Jul 30, 2012)

I am just wondering if anyone works somewhere where your protocols require you to routinely backboard and immobilize patients who have sustained penetrating trauma (e.g. shot or stabbed). 

I asked this on another forum and it sort of transitioned into a discussion about whether it is appropriate for penetrating trauma patients to be immobilized. I'm not too interested in having that discussion, but am just hoping to know if there is anywhere that it is specifically required or even just done as routine practice without it being formally required.

Thanks!


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## DesertMedic66 (Jul 30, 2012)

Not here unless we have reason to suspect the injury has compromised the spinal column.


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## shfd739 (Jul 30, 2012)

Ours is only if neuro deficits/complaints or it's above the clavicle.


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## BEorP (Jul 30, 2012)

Thank you both.

shfd739, would a gunshot wound to the head necessitate immobilization for you then?


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## DPM (Jul 30, 2012)

My county can be found here.

Backboard isn't mandated, it depends on the PT. GCS>12 / unstable might be likely, but I can see situations where you woudn't have to do it.


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## DesertMedic66 (Jul 30, 2012)

DPM said:


> My county can be found here.
> 
> Backboard isn't mandated, it depends on the PT. GCS>12 / unstable might be likely, but I can see situations where you woudn't have to do it.



That actually seems like a good protocol for backboarding. I think in my county we have maybe 4 lines of text about backboarding and that's all.


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## shfd739 (Jul 30, 2012)

BEorP said:


> Thank you both.
> 
> shfd739, would a gunshot wound to the head necessitate immobilization for you then?



Yes. But like others I can see where we could not do it and be okay.


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## BEorP (Jul 30, 2012)

shfd739 said:


> Yes. But like others I can see where we could not do it and be okay.



That's good if they will give you appropriate room for judgement. It is still interesting to hear what the letter of your protocols would require, which is exactly what I was hoping to hear about in this thread. Thanks for sharing.


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## sir.shocksalot (Jul 30, 2012)

Not required here. I have never boarded a penetrating trauma, and I believe PHTLS recommends not immobilizing penetrating trauma even in the setting of deficits. I hope most agencies don't require boarding, but EMS and current medical literature aren't always in sync.


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## BEorP (Jul 30, 2012)

sir.shocksalot said:


> Not required here. I have never boarded a penetrating trauma, and I believe PHTLS recommends not immobilizing penetrating trauma even in the setting of deficits. I hope most agencies don't require boarding, but EMS and current medical literature aren't always in sync.



I agree... the literature is clear on this one. I hope that this won't prevent people in agencies that have not yet caught up from commenting though. I'm quite curious about agencies where they are still a bit behind, but I wouldn't hold that against the EMTs and paramedics themselves who are simply at the mercy of their agency's protocols.


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## med51fl (Jul 30, 2012)

My department still requires immobilization for all penetrating trauma to head / neck / torso or gsw to extremities without an exit (c-collar and LBB).  The local trauma helicopter requires all patients being transported (trauma or medical) to be on a backboard.  There are those of us who would like to use a more updated approach in determining the need, but the wrath of the Q&A / Protocol Board is an ever present issue.


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## BEorP (Jul 30, 2012)

Thanks, med51fl. That's exactly the type of blanket protocol that I was wondering about.


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## Bullets (Jul 30, 2012)

sir.shocksalot said:


> Not required here. I have never boarded a penetrating trauma, and I believe PHTLS recommends not immobilizing penetrating trauma even in the setting of deficits. I hope most agencies don't require boarding, but EMS and current medical literature aren't always in sync.



From PHTLS book

"SMR should be CONSIDERED when the patient displays such fidnings as numbness, tingling, and loss of motor or sensory function or actual LOC. However, if the patient with penetrating injury have no neurological complaints, seconday mechanism of injury, or findings, the spine does not need to be immobilized (although the backboard may still be used for lifting and transport purposes


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## AMF (Jul 31, 2012)

In Maine we have rule-outs which work pretty well but they throw around the term "significant" (with reference to mechanism of injury) which literature doesn't really support.  The modified CN exam works pretty well though, and it's definitely saved us from a lot of grief.


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## NYMedic828 (Jul 31, 2012)

Can anyone provide some literature on why it's harmful?

I don't do it and it's not required but I have worked with partners who do and I'd like to read up to have a good defense as to not doing it.


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## sir.shocksalot (Jul 31, 2012)

NYMedic828 said:


> Can anyone provide some literature on why it's harmful?


http://traumatoday.com/prehospital-spine-immobilization-for-penetrating-trauma.html

This is kinda what you are looking for. Basically the extended scene times futzing around with a backboard that has no evidence it does anything increases mortality for penetrating trauma patients.

And to the person who quoted PHTLS, I actually reread the book and yes, you're right, that quote is in the 2007(?) edition. Is that quote from the newest edition? If so how new is it? The link above refers to a PHTLS committee from 2011 that says there is little evidence of benefit in the setting of neuro deficits. So I'm not sure if PHTLS is still recommending it or not.


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## Medic Tim (Jul 31, 2012)

We do not have a blanket policy to board all penetrating trauma.


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## Epi-do (Jul 31, 2012)

Our last protocol update stated that we no longer have to board penetrating trauma.  Our medical director told us that part of the reasoning behind it is that the damage is already done with a penetrating wound, so there is little to no benefit to the patient.  (Now if only they would come around to similar thinking when it comes to spinal immobilization in general.)


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## BEorP (Jul 31, 2012)

NYMedic828 said:


> Can anyone provide some literature on why it's harmful?
> 
> I don't do it and it's not required but I have worked with partners who do and I'd like to read up to have a good defense as to not doing it.



Certainly! This is probably one of the best papers (my emphasis added).

BACKGROUND:
Previous studies have suggested that prehospital spine immobilization provides minimal benefit to penetrating trauma patients but takes valuable time, potentially delaying definitive trauma care. We hypothesized that penetrating trauma patients who are spine immobilized before transport have higher mortality than nonimmobilized patients.
METHODS:
We performed a retrospective analysis of penetrating trauma patients in the National Trauma Data Bank (version 6.2). Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital spine immobilization, using patient demographics, mechanism (stab vs. gunshot), physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on Injury Severity Score category, mechanism, and blood pressure. We calculated a number needed to treat and number needed to harm for spine immobilization.
RESULTS:
In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine immobilization. Overall mortality was 8.1%. *Unadjusted mortality was twice as high in spine-immobilized patients (14.7% vs. 7.2%, p < 0.001). The odds ratio of death for spine-immobilized patients was 2.06 (95% CI: 1.35-3.13) compared with nonimmobilized patients.* Subset analysis showed consistent trends in all populations. Only 30 (0.01%) patients had incomplete spinal cord injury and underwent operative spine fixation. 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.
CONCLUSIONS:
Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma.


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## Handsome Robb (Jul 31, 2012)

NYMedic828 said:


> Can anyone provide some literature on why it's harmful?
> 
> I don't do it and it's not required but I have worked with partners who do and I'd like to read up to have a good defense as to not doing it.



Where's aidey when you need her? She's got some good pubmed references to studies on exactly what you're asking about. I'm just too lazy after 9 hours of mind numbing boredom in my academy today to search for them.

We don't have to immobilize penetrating trauma to the torso if we can rule out a spinal injury. It's still mandatory if they don't meet our spinal clearance criteria. I'm not sure about head/neck, it's a grey area in our protocols. Good thing we are doing protocol review for the rest of the week...


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## Bullets (Aug 1, 2012)

sir.shocksalot said:


> http://traumatoday.com/prehospital-spine-immobilization-for-penetrating-trauma.html
> 
> This is kinda what you are looking for. Basically the extended scene times futzing around with a backboard that has no evidence it does anything increases mortality for penetrating trauma patients.
> 
> And to the person who quoted PHTLS, I actually reread the book and yes, you're right, that quote is in the 2007(?) edition. Is that quote from the newest edition? If so how new is it? The link above refers to a PHTLS committee from 2011 that says there is little evidence of benefit in the setting of neuro deficits. So I'm not sure if PHTLS is still recommending it or not.



That is actually copied directly from our protocols but it is based off PHTLSs most recent edition


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## LearningByMistakes (Aug 1, 2012)

Bullets, sorry to inform you BUT that is NOT what the MOST recent edition says. See below.

PHTLS 7th Edition
Page 256

Numerous studies have shown that unstable spinal injuries rarely occur from penetrating  trauma to the head, neck, or torso and that penetrating injuries are not indications for spinal immobilization. (The book has not in bold lettering).


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