Selective c-spine - would you c-spine this patient

[Epi-do]

Just looking for some feedback on this one. So we are all using the same rules, here's my protocol for "clearing" c-spine.

Out-of-Hospital Spinal “Clearing”

A. Full spinal immobilization is to be provided to patients with any evidence of spinal injury and considered for patients meeting trauma alert criteria or with a suggestive mechanism of injury.

B. The examination must be completed by the paramedic.

ALS

1. Patients who have no clinical evidence of spine injury may have out-of-hospital spinal immobilization deferred if they meet all of the following requirements:

a. Able to understand and participate fully in the Out-of-hospital examination for spinal injury. The patient must:

1. be awake, alert, and oriented;
2. not be clinically under the influence of drugs or alcohol; and
3. Understand the paramedic well enough to comprehend the instructions and questions (age 5 or greater).

b. No neck pain;

c. No tenderness on palpation of the posterior midline elements of the neck;

d. No peripheral neurological deficits at the time of examination or at any time since the injury; and

e. No significant distracting (painful) injury.

2. Full spinal immobilization is always appropriate if the ALS provider has concerns regarding possible injury to the spine, even if the patient meets the criteria listed above.

3. Spinal immobilization devices may not be removed. If spinal immobilization has already been initiated (other than manual in-line immobilization), it is to be completed and the patient transferred to definitive care for further evaluation.

4. Patients may be transported by BLS personnel following paramedic clearance of the cervical spine.

5. Appropriate documentation of the above listed examination must be made by the paramedic on the patient medical record regarding the out-of-hospital spinal clearance.

Now that we all have the same set of rules, here's the scenario:

You are dispatched to an MVC, along with the engine at your station. When you arrive onscene there is a single vehicle pulled to the side of the road, just past an intersection. There is no visible damage to the car. Airbags did not deploy and the only occupant is the driver, a teenage boy, who is still wearing his seat belt.

The driver appears to be dazed, but acknowledges you as you approach the car. He is slow to answer your questions at first, but he is able to tell you his name, where he is (street names of intersection), where he was going, and what happened.

The patient states the car in front of him stopped to make a left turn, so he stopped behind them. The vehicle behind him did not stop in time and bumped him, causing him to hit his head on the steering wheel. His only complaint is head pain.

Upon palpation of his neck, along the back of his spine, he has no complaints of pain. He tells you his name is Josh (verified by ID), he was on his way to school, and that it is Thursday morning. There is no evidence that he is under the influence of anything. He is exhibiting no obvious neuro deficits and is able to move all extremities without difficulty. He still appears slightly dazed but is answering questions more quickly. There are no visually obvious injuries and the patient again denies anything but head pain. At some point, the patient was clear-headed enough to either contact his mother or have a bystander do it for him, and she arrives before you have the patient out of the car.

So, do you board this patient? I will tell "the rest of the story" after there have been some replies.

 

[johnrsemt]

if you can figure out why he is dazed: if due to hitting head or drinking or doing drugs, then Yes I would do c-spine; if it is due to having an accident and being confused that he got hit even though he did everything right: then no, I would NOT do c-spine.

keep me informed

 

[DigitalSoCal]

I would c-spine him. The fact that he hit his head on the steering wheel after a rear impact suggests a pretty significant force because the initial reaction would be to be pressed backward into the seat. To then be whipped forward and into the steering wheel would take a good amount of decelerative (is that a word?) force.

 

[GoldenBeaR6]

Affirmative on the c-spine

 

[akflightmedic]

Ummm, was he really in a car accident???

Only one vehicle yet he was hit hard enough from behind to whip forward and strike the steering wheel? Why no damage on the vehicle if he was hit this hard?

Where is the other car? Why no air bag deployment? The seat belt allowed him to hit his head on the forward momentum?
No obvious injury (contusion) to his head??? He would also have clavicle or chest pain from a hit hard enough to make him stress the seat belt and strike the wheel.

No I would not cspine him cause I think there is more to this story than a MVC...

 

[JPINFV]

Fits NEXUS criteria for selective spinal immbolization. He's alert, orientated, and awake. He might be slow, but that's a global neurological symptom which isn't indictative of a spinal column injury. How often do you see foot ball players go off the field dazed after a hit in full c-spine restriction?

 

[Epi-do]

Ummm, was he really in a car accident???

Only one vehicle yet he was hit hard enough from behind to whip forward and strike the steering wheel? Why no damage on the vehicle if he was hit this hard?

I wondered the same thing. Apparently, the vehicle that struck him was also slowing to a stop, just didn't stop soon enough. The impact was described as a "bump."

Where is the other car? The second vehicle left the scene without stopping.
Why no air bag deployment? Not sure. My guess is the impact wasn't significant enough to deploy the airbags.
The seat belt allowed him to hit his head on the forward momentum? Again, no answer. It's possible he put it on after the accident, but before PD arrived to avoid a ticket.

No obvious injury (contusion) to his head??? Correct, he had no visable injuries.
He would also have clavicle or chest pain from a hit hard enough to make him stress the seat belt and strike the wheel. I agree. He denied this.

No I would not cspine him cause I think there is more to this story than a MVC...

Sorry I can't provide better answers to your questions, but those are all I have.

 

[akflightmedic]

Did he have an exam that day, parental troubles, girlfriend troubles...were there any witnesses besides him?

Did he have a description of the other vehicle?

I do not buy the story...

 

[rescuepoppy]

Our area does not yet have protocol for clearing C-Spine, but is moving in that direction. In the case that we did I will probably be a little more on the cautious side than some others might be. Due to the fact that with my fractures of c-3, and c-4 last year I had no pain or point tenderness until several hours after the accident. I would probably c-spine this patient because of the knowledge that you can have a completely shattered vertebrae without pain or deficits.

 

[cm4short]

I would C-spine this patient, but, I don't feel this patient requires spinal immobilization. My reasons for c-spine are because this patient has suffered trauma above the clavicles; which requires c-spine application according to our protocols. This could possibly be written off though due to the non specificity of our protocols, as there is no visible head trauma. But, due to legal reasons, you'd most likely get ripped apart in a lawsuit.

Now, I do not feel this person requires c-spine immobilization. C-spine refers to cervical spinal immobilization. This involves c1-c7. Immobilization of the cervical spine without associating injuries is just another example of repetitive ignorance, our lack of knowledge and medical decision.

 

[Epi-do]

I really wish I could give you more info. The officer onscene wanted the patient boarded. I told him that I wasn't going to do it because he didn't need it done. Per protocol, I was able to determine it wasn't needed. The officer insisted, I said some things I shouldn't have said and the patient was boarded. I ended up not going in on the ambulance, and another medic was put on the truck with my partner.

 

[JPINFV]

The officer insisted, I said some things I shouldn't have said and the patient was boarded.

Was it something along the lines of "Where did you go to medic school?"

 

[Sasha]

Was it something along the lines of "Where did you go to medic school?"

Her officer is an EMT!!

 

[johnrsemt]

I have been known to get in trouble with officers and supervisors for this very thing (and anyone that knows me , will have problems believing that I know).

I have always stated that I have no problems working for Supervisors or officers that are NOT medics, as long as they don't try to tell me what to do with patient care at the scene with the patients. When they start telling me how to do my job, I start having problems. this is a prime case.

Epi was perfectly justified in NOT cspining this patient, it is in her protocols as a MEDIC; but not in the officer's protocols as a BASIC. so he thought he was right; but he shouldn't have argued with the medic. BUT at the same time she shouldn't have argued with the officer on something that didn't and wouldn't cause patient harm.

No Win situation for Epi

 

[emtfarva]

I would have used C-Spine precautions... I would have let the Doc take the responsibility to clear him. Just by the fact that he was slightly altered, I would think head bleed. (I tend to think the worse case). Did you take VS? I am wondering what they were. I would guess that you might have gotten a CBG? We can't clear C-Spine, but I would still have taken the precaution.

 

[JPINFV]

Just by the fact that he was slightly altered, I would think head bleed. (I tend to think the worse case).

What would c-spine do for a head bleed? You don't splint every arm with a fresh bruise on it, right?

 

[emtfarva]

What would c-spine do for a head bleed? You don't splint every arm with a fresh bruise on it, right?

Nope, but every head bleed that we have taken to Boston required a C-collar and a board, not by our choice, it was required by ER Doc. I would have just because he had head pain. Thats the way I roll. I have boarded and collared for less.

 

[emtfarva]

I have been burnt before. My partner and I have not boarded someone that fell from standing and ended up having a C-2 fracture. He had no pain, or couldn't tell us he had pain due to the fact he didn't speak english. Now, if we think that there might be spine damage, we c-spine.

 

[Epi-do]

So, here's the rest of the story. After the patient was boarded and put in the truck, he was transported BLS to the ER.

The crew asked additional questions about the incident, and while the general story was consistent, the details would change. The kid didn't have a single mark on his face, not even a red mark to show any sort of impact. He was wearing glasses and there were no marks from them, either. They were completely undamaged.

During the transport, he would act completely normal and then be a bit slow to answer questions again, although he was still answering them correctly.

The medic that transported said he believes whatever was going on with the kid (if anything) had nothing to do with the accident. He said he couldn't help but wonder if there was something else going on that the kid wouldn't/didn't tell us, or that he was trying to get out of something. His other thought was that there was something like an anuerism that was causing the symptoms. He also believed the patient should not have been boarded.

Also, the part you have all been waiting for - the board & collar came off pretty much immediately after getting to the ER.

 

[emtfarva]

So, here's the rest of the story. After the patient was boarded and put in the truck, he was transported BLS to the ER.

The crew asked additional questions about the incident, and while the general story was consistent, the details would change. The kid didn't have a single mark on his face, not even a red mark to show any sort of impact. He was wearing glasses and there were no marks from them, either. They were completely undamaged.

During the transport, he would act completely normal and then be a bit slow to answer questions again, although he was still answering them correctly.

The medic that transported said he believes whatever was going on with the kid (if anything) had nothing to do with the accident. He said he couldn't help but wonder if there was something else going on that the kid wouldn't/didn't tell us, or that he was trying to get out of something. His other thought was that there was something like an anuerism that was causing the symptoms. He also believed the patient should not have been boarded.

Also, the part you have all been waiting for - the board & collar came off pretty much immediately after getting to the ER.

Epi, I was thinking that, but i would let the Doctor take the hit if there was something major wrong with him. And plus from what he said about the MVC, I would have boarded and collared him just on MOI alone... Like I said I have boarded for less. And yes, all those Pt's have had C-Spine removed right away.