# C-Spine rearing its ugly head



## thegreypilgrim (Jun 22, 2012)

Here in wonderful SoCal we are in love with c-spine. It's like our main form of treatment in EMS. Even though we have a spinal clearance protocol in pretty much every county, it's just one of those things that hasn't quite entered the realm of cultural acceptance. Oddly, and perhaps ironically, in my experience this is actually more on the hospital's end of things. Most providers I've responded with try to find ways to implement the spinal clearance protocol, often only to be chided about doing so by hospitals. Yesterday, I kind of got my first taste of that.

Anyway, I give you the following rather routine scenario and tell me what you think:

HPI: 83 year old female presenting to urgent care facility status post unwitnessed fall at home. Patient is amnestic to event and cannot definitively help you rule out syncope vs. mechanical fall. Currently patient is alert and oriented complaining only of tenderness to right temporal skull. Family is bedside and states that the fall took place about 2 and a half hours ago.
Vitals: BP 144/98, P 112, RR 18, SpO2 98% RA, BGL 263 mg/dL. 
General: Well developed, appears comfortable. Seated in wheel chair.
HEENT: Approximately 2" laceration to right temporal skull which has not been closed. No other trauma. Pupils PERRLA. No dysarthria. Equal facial symmetry.
Neck: Trachea midline. No JVD. No tenderness on palpation. No vertebral step-offs. 
Chest: Denies chest pain. No accessory muscle use. Clear and equal to auscultation bilaterally.
Abdomen: Denies tenderness. No rigidity, distention, or guarding.
Extremities: No edema, clubbing, or trauma noted. Equal grips/pushes. Positive circulation and sensory-motor function x 4. 
Skin: Warm and dry.

PMHx: Diabetes, Atrial Fibrillation, HTN
Allergies: Penicillin, Morphine
Medications: Diltiazem, Coumadin, Diovan, Glyburide.



ECG looks something like this except a bit slower:









So, do you c-spine this patient or not? In case anyone asks, the urgent care has not performed any radiographic imaging, labwork, or provided any other interventions other than requesting your code 2 (no lights and sirens) response.


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## Medic Tim (Jun 22, 2012)

I would not be boarding this pt.


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## Veneficus (Jun 22, 2012)

I would also not board this patient.

Though with the coumadin, she certainly would get a ct.


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## Epi-do (Jun 22, 2012)

Nope, I wouldn't board.


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## thegreypilgrim (Jun 22, 2012)

Shame on all three of you!

As soon as care was transferred in the ED the resident ordered her to be placed in a c-collar.

I hope you learned your lesson.


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## Medic Tim (Jun 22, 2012)

thegreypilgrim said:


> shame on all three of you!
> 
> As soon as care was transferred in the ed the resident ordered her to be placed in a c-collar.
> 
> I hope you learned your lesson.



lol


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## Handsome Robb (Jun 22, 2012)

thegreypilgrim said:


> Shame on all three of you!
> 
> As soon as care was transferred in the ED the resident ordered her to be placed in a c-collar.
> 
> I hope you learned your lesson.



Really? That's ridiculous. Why why why!? Did you get reprimanded?

I wouldn't have boarded her either. Amnestic to the event doesn't prove LOC. it's not uncommon that people won't remember what happened to them. Not saying she didn't syncope but I don't see spinal motion restriction indicated at all by this case.


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## Aidey (Jun 22, 2012)

Why did the urgent care call?


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## thegreypilgrim (Jun 22, 2012)

NVRob said:


> Really? That's ridiculous. Why why why!? Did you get reprimanded?


 Not really. They asked me why I didn't do it, and after I answered proceeded to do it anyway. Pretty standard fair.



> I wouldn't have boarded her either. Amnestic to the event doesn't prove LOC. it's not uncommon that people won't remember what happened to them. Not saying she didn't syncope but I don't see spinal motion restriction indicated at all by this case.


 Agreed. Problem is everyone around here interprets that part of NEXUS rather conservatively.


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## thegreypilgrim (Jun 22, 2012)

Aidey said:


> Why did the urgent care call?


 No CT capabilities on site. Couldn't really manage the patient there either.


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## adamjh3 (Jun 22, 2012)

I agree with you about the hospitals. I was told by an MICN that if you bring someone in as a trauma resource they must be c-spined, regardless of assessment findings. I smiled and nodded to get him to stop talking so I could walk away.


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## AnthonyM83 (Jun 22, 2012)

TheGreyPilgrim, the way you respond to that is, "I cleared the patient per cspine protocol". That basically forces them to refer to the protocol, which the residents might not even be aware of. Don't try to explain the specifics, just say you used the protocol (that your medical director wants you to follow).

I don't know what your specific protocol states, but the head laceration could be considered a distracting injury by whoever tries to judge you. I will say I'd be cautious with an 83 y/o...


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## thegreypilgrim (Jun 22, 2012)

adamjh3 said:


> I agree with you about the hospitals. I was told by an MICN that if you bring someone in as a trauma resource they must be c-spined, regardless of assessment findings. I smiled and nodded to get him to stop talking so I could walk away.


 Yeah I don't get it man. This is like a universal Southern California thing to have hospitals be kind of unofficially at odds with random EMS protocols - even the rare progressive ones. I suppose that isn't all that unusual, but the near universal rejection of EMS c-spine clearance by hospitals around here is something I cannot wrap my mind around.


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## mycrofft (Jun 22, 2012)

If C spine is working how can it rear its ugly head?
Sorry couldn't resist.


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## thegreypilgrim (Jun 22, 2012)

AnthonyM83 said:


> TheGreyPilgrim, the way you respond to that is, "I cleared the patient per cspine protocol". That basically forces them to refer to the protocol, which the residents might not even be aware of. Don't try to explain the specifics, just say you used the protocol (that your medical director wants you to follow).


 They ought to know what NEXUS/CCR is. It's basically a standard of practice now, but I'm sure you know the fact that it's in the protocol doesn't mean much around here. I'm not in LA anymore, but the whole even-though-it's-in-the-protocols-I-don't-think-you-should-have-done-it thing still happens even out here.



> I don't know what your specific protocol states, but the head laceration could be considered a distracting injury by whoever tries to judge you. I will say I'd be cautious with an 83 y/o...


 I hate c-spining the elderly. I feel like I'm causing them more problems by doing it, and by all available evidence that appears to be the case.


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## DesertMedic66 (Jun 23, 2012)

I'm on a BLS unit right now. Most of our falls are elderly people in SNFs. If its a fall that the patient possibly hit their head then honestly I don't have a choice but to C-spine. The supervisors want it, our protocol person at work wants it, and the doctors/nurses at the hospitals want it. 

We do have spinal clearence protocols on BLS and ALS units. Everytime I have followed that protocol I get "talked to". 

So I go C-spine on most SNF falls. Why? Because I'm an EMT who has a job where there are a million EMTs who have in applications. I work at an at will state meaning I can be fired for nothing really. So I'm not going to give my employer something to fire me over because I need a paycheck.


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## Melclin (Jun 23, 2012)

I'm ganna throw a spanner in the works. 

I'd probably collar her. 

She's over 65 with what sounds like a decent whack to the head. I'd think she was ganna get a collar per CCR.

Maybe I'm picturing the wrong thing. But she doesn't sound that reliable to me when we're talking about NEXUS. NEXUS required pristine mental status. Doesn't really sound too pristine to me. 

That said I can totally see how actually sitting in front of this pt might change things. Has she been ambulating with no deficits since? Maybe her mental status is perfect. Maybe the lac makes you think she graze a lamp shade on the way down rather than collecting a solid metal bench or something. You know...all that actually seeing the pt type stuff. 

I've had similar pts and not collared. Perfect mental status, perfect neuro, nil tenderness and ambulating since. Even then I explained that there was a risk and said I wanted to, and then allowed her to refuse.


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## Maine iac (Jun 23, 2012)

Per my protocols, anybody that has been ambulatory after an event and has no neck/back pain or altered mental status does not require a collar or board (although I can use one if I feel it is warrented).

So since it sounds like none of these things fit in this pt- I would not board or collar this PT.

(obviously i am not there to see the pt for myself- so this is my opinion based on the information at hand.)


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## thegreypilgrim (Jun 23, 2012)

Melclin said:


> I'm ganna throw a spanner in the works.
> 
> I'd probably collar her.
> 
> ...


 Ah, you're killing me Melcin!

I'll grant you she's probably not pristine in terms of mental status, but for 83 it's hard to do better I imagine. She was completely alert and oriented to time/place/person/event. She understood what was happening, why she was in urgent care, remembered events prior to fall. Just couldn't say how she fell.

Neuro exam is perfect. No nausea/vomiting. No paresthesias. Nothing of concern.

She ambulates with assistance even in normal circumstances. Family were the ones who brought her there to begin with, meaning she had to get up and walk back in the house, out to the car, sit in the car upright on the bouncy road, get out the car, and get herself back in her wheelchair all without spinal restriction.


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## Anonymous (Jun 23, 2012)

Had almost the exact same scenario the other day. Protocol in this county states that because the patient was over 55 they should be c-spined. 

In your case my answer to the hospital staff would be the patient would not tolerate it.


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## Anonymous (Jun 23, 2012)

These are our clearance protocols:

http://www.ochealthinfo.com/docs/me...elines/10 Procedures/ALS Procedures/PR-85.pdf


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## Melclin (Jun 23, 2012)

thegreypilgrim said:


> Ah, you're killing me Melcin!
> 
> I'll grant you she's probably not pristine in terms of mental status, but for 83 it's hard to do better I imagine. She was completely alert and oriented to time/place/person/event. She understood what was happening, why she was in urgent care, remembered events prior to fall. Just couldn't say how she fell.
> 
> ...



Ambulates extensively afterwards with no new deficits are words that really change things in my mind. I love to see how many pts with no pain, no deficit and ambulating since turn out to have unstable vertebral/ligamentous injury. I bet its not that many. As I say I've had similar pts a not collared and I think its a judgement call so I'm not busting your balls. Its a shame your system doesn't necessarily see it as such. 

I share your hatred of c-spining oldies. You can always make arguments about anatomical oddities or the possibility of orthopnea preventing it. As I say I've sat with similar pts and said, look we probably should be putting a collar on your neck, but I believe you're very low risk (explanation of risk and intervention) and let them know they can refuse. I never had anyone chose a collar.

Honestly our hospital hate it when we collar unnecessarily because it puts the burden of clearance on them and they need to find an x-ray bed as well. But if you have to, you have too. 

Do you use general, lumbar and occipital padding? It works wonders for comfort. I'll email you a bit of lit search doc on its affects on pressure distribution and discomfort if you like. It does ad some extra movement and complexity depending on what equipment you're using and probably not the best thing for the major trauma pt but I think its good for those oldies you have trouble clearing based solely on age and reliability.


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## daughteroftheking (Jun 24, 2012)

I had a similar call....
Elderly female at a local assisted living facility who fell outside. She went outside to see the ducks, and fell when she tried to sit down. The staff then assisted her back into the facility before calling us. Patient denied any spinal tenderness, and no crepitus was noted. She did have a 3cm lump on the left posterior aspect of her head, but the injury was isolated and she denied pain anywhere else. 
Patient was alert and oriented and was able to recount the accident with detail. Vitals were  within normal limits, and she didn't want to go to the hospital but the nursing staff insisted. 
Needless to say, we did not backboard this patient. She was elderly, but full-body immobilization did not seem indicated


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## Tigger (Jun 24, 2012)

It may also be worth noting that the US connotation of c-spine restriction is backboard, collar, block, tape, and straps. In other parts of the world (New Zealand, and possibly Australia), c-spine means a collar, and that's about it. I did three calls on my ride for 9 year olds with ruby related head injuries. We put a collar on them, scooped them onto the cot, took the scoop off, and told them to lie still. A folded towel was placed under the head to maintain neutral alignment as well. That was it. 

Maybe we need to get away from the all or nothing mentality?


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## JakeEMTP (Jun 25, 2012)

daughteroftheking said:


> I had a similar call....
> Elderly female at a local assisted living facility who fell outside. She went outside to see the ducks, and fell when she tried to sit down. The staff then assisted her back into the facility before calling us. Patient denied any spinal tenderness, and no crepitus was noted. She did have* a 3cm lump on the left posterior aspect of her head, *but the injury was isolated and she denied pain anywhere else.
> Patient was alert and oriented and was able to recount the accident with detail. Vitals were  within normal limits, and she didn't want to go to the hospital but *the nursing staff insisted. *Needless to say, we did not backboard this patient. She was elderly, but full-body immobilization did not seem indicated



You did not mention what medications the patient was on. Aspirin or Anticoagulants would be a cause of concern for the elderly.  The same goes for Diovan as a choice for the patient in the orginal post since the choice to use it may have had something to do with osteoporsis.

Spinal immobilization or limitation of movement should have a choice of methods to fit the patient and not necessary mean a hard board. You still have to take into consideration the patient has sustained a fall or some injury that could still be aggravated by sudden or awkward movements. Climbing into an ambulance or moving from stretcher to stretcher are examples of such movements.


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## daughteroftheking (Jun 25, 2012)

I believe she was prescribed aspirin...no osteoporosis though. Thanks for bringing that up, as that should always be factored into the decision.


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## Handsome Robb (Jun 25, 2012)

Anticoagulants aren't really a factor in my decision as to c-spine someone or not but I will definitely be pushing much much harder to go to the hospital for a CT.


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## OIFXGunner (Jun 27, 2012)

Current PHTLS guidelines advocate taking spinal precautions in the presence of a distracting injury... would you consider her temporal pain to be potentially distracting?


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## Melclin (Jun 28, 2012)

OIFXGunner said:


> Current PHTLS guidelines advocate taking spinal precautions in the presence of a distracting injury... would you consider her temporal pain to be potentially distracting?



Its not really in the same ball park as the injuries the NEXUS investigators considered distracting. 



> (a) a long bone fracture; (b) a visceral injury
> requiring surgical consultation; (c) a large laceration, degloving injury, or
> crush injury; (d) large burns; or (e) any other injury producing acute functional impairment.


 
but note that..



> Physicians may also classify any injury as distracting
> if it is thought to have the potential to impair the patient’s ability to
> appreciate other injuries.



I've had a few pts that for what ever reason just refuse to focus on my exam because they're worried concerned about their very minor injuries. If they also happened to be ?spinal pts I can see circumstances popping up where they couldn't be considered reliable. 

I also once had a young bloke who had been involved in an MVA in which his mother had also died. Not surprisingly he wasn't really able to focus on my exam. I suppose you could consider that a psychological distracting injury.


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## OIFXGunner (Jun 28, 2012)

I guess it's hard to say without actually laying eyes on the patient.


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## Veneficus (Jun 28, 2012)

*If I could just inquire...*

disregarding the question on whether or not to c-spine for a minute...


What next?

People with actual spinal injuries do not just go to the hospital spend a few days and come out right as the rain. 

What is the course of an 83 y/o with a spinal cord injury?

Do the elderly have less of a chance of secondary injury from blunt force because of reduced inflammatory ability?

I would just like to put forth that while a protocol says you must do something and you are in a postion that must comply, that doesn't mean when you do something it is the right treatment or even beneficial.

Somebody will now accuse me of being arrogant in the next statement.

Most levels of healthcare providers are taught concepts as right and wrong.

But there are actually very few cases of that in real life. 

EMS providers, and I admit my guilt in the past as well, often think that what they do is so obviously right, anyone who doesn't do the same must be stupid or wrong.

I could probably type yet another rant on the foolishness of thinking backboards actually help prevent secondary spinal injury and likely cause it, but instead, I will just finish my lunch and allow it to be pondered on an individual level.


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## Melclin (Jun 28, 2012)

Is a good read on the topic.

The lit review on blunt trauma immobilisation in conscious pts on page 10&11 seems a pretty good summary of the topic. 

http://secure.collemergencymed.ac.uk/code/document.asp?ID=5718




Vene: I'm not sure I understand your point here. The validity of spinal immobilisation is not in questions here. Its about the application of the standard. 

Immobilisation is, for better or worse, a standard of care. Its not even an EMS-ism. We can argue about the literature and how it should inform the standard until the cows come home. Changing standards is another argument. How the standard is applied is whats in questions here.


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## Veneficus (Jun 28, 2012)

Melclin said:


> Is a good read on the topic.
> 
> The lit review on blunt trauma immobilisation in conscious pts on page 10&11 seems a pretty good summary of the topic.
> 
> ...



I was trying to cover both the standard and its application. 

There is a question of distracting injury and whether this pt needs to be immobilized. 

I think a "distracting injury" must be a clinical decision. Not a list of potentially distracting injuries. Simply too much variation in patients.

Some question arose about applying the standard to this patient as a proper or improper treatment. 

My question is, with her likely sequele if there was an actual spinal cord injury in a 8 decade patient, would applying the board if you determined she met a predefined criteria or not applying the board if you decided she didn't meet the criteria make any difference at all?

There is also the question about whether the treatment would help or harm. 

The topics are inseperable. The idea of the standard is based on flawed logic. 

So the question is really in this case is really "do I make a clinical decision or just follow the flow chart?"


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## Handsome Robb (Jun 28, 2012)

Veneficus said:


> I think a "distracting injury" must be a clinical decision. Not a list of potentially distracting injuries. Simply too much variation in patients.



Agreed 100%

Some people whine about the smallest things and you can argue they are distracted whereas some can have a wicked "distracting" injury by definition but be totally reliable during the assessment.


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## Melclin (Jun 28, 2012)

Veneficus said:


> I think a "distracting injury" must be a clinical decision. Not a list of potentially distracting injuries. Simply too much variation in patients.



Agreed. I'm sure my post on the NEXUS criteria for distracting injury reflects thats.



> My question is, with her likely sequele if there was an actual spinal cord injury in a 8 decade patient, would applying the board if you determined she met a predefined criteria or not applying the board if you decided she didn't meet the criteria make any difference at all?



An interesting question. Not one that ever gets asked here in discussions about immobilisation. I don't know why. We ask it in regards to other interventions: choppers, intubation aggressive use of pressors/inotropes. 

Are there any sites/texts/articles that you would recommend on the topic?



> There is also the question about whether the treatment would help or harm.
> 
> The topics are inseperable. The idea of the standard is based on flawed logic.
> 
> So the question is really in this case is really "do I make a clinical decision or just follow the flow chart?"



I don't agree. The whole point of those flow charts is to create a decision aid that improves on clinical judgement. No decision tool is without the need for sound and informed clinical judgement it just improves and informs those decisions. 

Additionally, not everyone can be experts on all topics. Guidelines are fantastically helpful in offering a summary of the literature seen through the eyes of expert opinion, when you don't, yourself have time, to become similarly well read. Sure its a good idea to scratch the surface a little and do more than just read the conclusions, but realistically we cannot all be experts in everything. Acknowledging that is not to avoid making your own clinical judgements. I'd rather make my own judgement informed by a combination of guidelines and relatively light reading, than I would rely solely on my own understanding of a limited selection of the literature on a given topic.


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## Veneficus (Jun 28, 2012)

Melclin said:


> Are there any sites/texts/articles that you would recommend on the topic?.



Not really, just the experiences of neurologists and neuro surgeons.



Melclin said:


> I don't agree. The whole point of those flow charts is to create a decision aid that improves on clinical judgement. No decision tool is without the need for sound and informed clinical judgement it just improves and informs those decisions. .



I agree that is what they are for.

I don't think that is how they are routinely used.



Melclin said:


> Additionally, not everyone can be experts on all topics. Guidelines are fantastically helpful in offering a summary of the literature seen through the eyes of expert opinion, when you don't, yourself have time, to become similarly well read. Sure its a good idea to scratch the surface a little and do more than just read the conclusions, but realistically we cannot all be experts in everything. Acknowledging that is not to avoid making your own clinical judgements. I'd rather make my own judgement informed by a combination of guidelines and relatively light reading, than I would rely solely on my own understanding of a limited selection of the literature on a given topic.



again I agree this is how it should be, but not how it plays out practically.


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## AnthonyM83 (Jun 29, 2012)

Veneficus said:


> So the question is really in this case is really "do I make a clinical decision or just follow the flow chart?"



I think a more applicable question is do I have the knowledge and information to make a proper clinical decision here.

Not directed at anyone specifically, but a lot of people seem to get off on not immobilizing, almost in an attempt to seem the most educated or a subconscious "screw you" to all the times they did have to immobilize or to other providers for not being 'up to date'.

Yet it keeps happening that people keep making poor decisions and we keep finding fractures that were not immobilized. Many of these aren't too concerning, because they were so minor...but some have not been.


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## Veneficus (Jun 29, 2012)

AnthonyM83 said:


> I think a more applicable question is do I have the knowledge and information to make a proper clinical decision here.
> 
> Not directed at anyone specifically, but a lot of people seem to get off on not immobilizing, almost in an attempt to seem the most educated or a subconscious "screw you" to all the times they did have to immobilize or to other providers for not being 'up to date'.
> 
> Yet it keeps happening that people keep making poor decisions and we keep finding fractures that were not immobilized. Many of these aren't too concerning, because they were so minor...but some have not been.



Just my opinion, but I think a strong push against immobilizing every patient needs to be implemented to get over the immbolize everyone mentality.

Some people are always going to slip through the cracks in any medical procedure.

It sucks when it is you, but if you have case reports of people whose clinical course was changed by not being immobilized, I would like to take a look if I could?


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