first spine boards now the c-collar?

[usalsfyre]

Speaking on MOI, I understand the spinal cord is one long piece, but it still doesn't make sense to me that someone who is shot in the chest needs a c-collar. I haven't been convinced that moving the head really moves the spinal cord in the chest/lumbar region much. The converse also goes for whiplash injuries. Those patients leave the hospital in a c-collar, walking. So I don't understand why someone who gets rear ended at 20 MPH, has neck pain but no back pain needs a board. Just collar them. I know that hasn't been proven with research but someone should get on it.

Your asking for some part of spinal immobilization to make sense. Good luck with that.

 

[JPINFV]

Speaking on MOI, I understand the spinal cord is one long piece, but it still doesn't make sense to me that someone who is shot in the chest needs a c-collar. I haven't been convinced that moving the head really moves the spinal cord in the chest/lumbar region much. The converse also goes for whiplash injuries. Those patients leave the hospital in a c-collar, walking. So I don't understand why someone who gets rear ended at 20 MPH, has neck pain but no back pain needs a board. Just collar them. I know that hasn't been proven with research but someone should get on it.

...because it's all connected. The spinal cord is a continuous chain of joints and the muscles that move those joints often span multiple joints. The reason why a patient who meets immobilization criteria (using standards such as NEXUS, not just a, "Whoa, look at that mechanism of injury") should be completely immobilized until imaging is the same reason why when immobilizing a bone anyplace else you immobilize the joints above and below the injury. You need to not only stabilize that segment, but also all of the surrounding joints that are controlled by muscles that are anchored on that bone.

 

[Akulahawk]

...because it's all connected. The spinal cord is a continuous chain of joints and the muscles that move those joints often span multiple joints. The reason why a patient who meets immobilization criteria (using standards such as NEXUS, not just a, "Whoa, look at that mechanism of injury") should be completely immobilized until imaging is the same reason why when immobilizing a bone anyplace else you immobilize the joints above and below the injury. You need to not only stabilize that segment, but also all of the surrounding joints that are controlled by muscles that are anchored on that bone.

Exactly. When "they" say "it's all connected" it's really meant. And the vertebral column is made up of many small bodies, the muscles and ligaments of which do span multiple bodies and joints. Here's an example. From a standing position, bend over as if to touch your toes. Look at the wall in front of you and then try to look at the ceiling by looking under your armpit. You should feel a light tug not only along the back of your neck, you should also feel a tug further down your back, possibly as far down as the small of your back. It's all connected.

 

[JPINFV]

Your asking for some part of spinal immobilization to make sense. Good luck with that.

Personally, I will accept that in a small fraction of patients spinal immobilization may be beneficial. However, how it is currently practiced in the US doesn't make any sense.

1. Too many patients are needlessly being immobilized. There are clinical evaluation tools available to cut down on the number of people being immobilized and they need to be used. Until that happens, any study not being significantly controlled to cut out the "20 mph MVA negative NEXUS criteria" (i.e. doesn't need to be x-rayed) patients, any research is meaningless. It would be like trying to validate the efficacy of naloxone by administering it to everyone who is altered without regard to the etiology of the altered mental state. Just like spinal immobilization isn't going to change the outcome of a patient who doesn't have a vertebral injury, naloxone isn't going to help a patient who is altered because of infection or hypoglycemia.

2. Better tools need to be implemented. The spine is curved for a reason. Strapping something that is naturally curved to something flat does not work on any level of thought. Just because the tools aren't designed properly doesn't mean that the underlying concepts are flawed.

 

[JPINFV]

Exactly. When "they" say "it's all connected" it's really meant. And the vertebral column is made up of many small bodies, the muscles and ligaments of which do span multiple bodies and joints. Here's an example. From a standing position, bend over as if to touch your toes. Look at the wall in front of you and then try to look at the ceiling by looking under your armpit. You should feel a light tug not only along the back of your neck, you should also feel a tug further down your back, possibly as far down as the small of your back. It's all connected.

This is why certain manual medicine techniques found in physical therapy and osteopathic manipulation looks weird from the outside. For example, manipulating the upper thoracic vertebral column (T1-T4) via muscle energy (for clarification, "manipulating" is more than 'cracking' joints) or articulatory techniques uses the head as the lever using the connecting joints and ligaments.

 

[hocomedic]

I personally think that a lot of these researchers don't have anything else to do excepts scrutinize everything and make them look bad because they have phd at the end of their name. my question is since c-spine collars are so "bad" what are they going to have us use next. i personally like them because they may be uncomfortable but at least they restrict some head movement.

 

[firetender]

There is now a company making the 'X COLLAR' which allows you to stabilize the head and spine in any position found. They say that it should be less compromise when holding c-spine.

http://www.xcollar.com

Having read the rest I think this might be a good time to re-post this. I think these guys are on to something. In observing the placement of the device, it appears you have much more control to work WITH the person where they are at...and at their level of comfort...much more easily and WITHOUT needing to manipulate. (If you must manipulate to align the head to fit into the device then the device is NOT appropriate; towels and duct tape will do fine!)

Its ability to adjust front and rear allows you to establish the exact angle you want to maintain manually and then incrementally adjust the front and rear to match. Even looking at the patient and seeing the primary immobilization force is on the chin and chest appears to provide stability without rigid implementation.

My 2 centavos

 

[Sandog]

Here is a good read on this subject.
http://static.spineuniverse.com/pdf/traumaguide/1.pdf

 

[mycrofft]

I'd comment but "five is still four". Oh, what the crock.

Blanket orders for spinal immobilization date back to lowest common denominator/fastest dissemination days starting up EMS. Long board (and we used to be required to additionally use a short board as well for extrications or whenever you rotated the patient, remember?) can be made and operated by anyone with a saw, a pencil, 3/4 to 1 inch plywood and access to screws, screwdriver, and automobile seatbelts. Sandpaper, varnish and auto paste wax optional but so much better.

"Blanket orders" for anything are for ignoramuses, rookies, and people intent on busting other people's chops. Teach people the range of meaures and when to use them and let the art catch up to the science.
OK, back to my corner.

 

[zmedic]

Look, if "everything is connected" then why do patients with known neck fractures walk out of the hospital and live their lives in a neck brace, but no back brace? Why aren't they on bed rest? Because bending their back isn't hurting their neck. Similarly people who fracture a lumbar vertebra are sent out of the hospital with no C-collar, because they don't have a neck injury.

I know in the field we often aren't sure what is hurt so we immobilize the whole thing. But if patient's who have known fractures are not living life on a spine board with a c-collar on, you have to ask if we really have to immobilize everything if there is a mechanism that makes a fracture of only a part of the spinal column likely.

As far as the researchers who are out to show "everything is bad," it's more like we recognize that the treatments we do often aren't benign, and that there has been little evidence that they help. Therefore one should be critically examining everything we do.

 

[jrm818]

I don't have it in front of me now, but I believe either NEXUS or a related studies (or maybe a CT vs xray study) reported a very high incidence of second fractures once a single fracture was identified, and that many of the second fractures were occult and at different levels of the spine. If I'm remembering properly (and, of course, "I think I read in some study somewhere" is pretty poor evidence), would that perhaps give some support to the idea that, in truly high risk patients, total immobilization may be prudent until more definitive examination is possible (probably CT, maybe MR)?

 

[usalsfyre]

I personally think that a lot of these researchers don't have anything else to do excepts scrutinize everything and make them look bad because they have phd at the end of their name. my question is since c-spine collars are so "bad" what are they going to have us use next. i personally like them because they may be uncomfortable but at least they restrict some head movement.

So somehow having PhD at the end of your name is bad now? This is one more example of field providers somehow thinking the medicine they practice is different from medicine in any other setting. The fact of the matter is c-collars as currently available suck. If you can't get them on without manipulating the neck, then they're useless. "What they need to give us next" is something that works, not a useless piece of plastic that clings to the old days.

 

[phildo]

Back in the 80's in Port Arthur, Texas, we had 2 piece extrication collars that were the best I've used before or since. You put the front on first, then ran the velcro strap behind the head. Then you put the back part on. It was taller than the front by quite a bit. and it rendered the wearer incapable of turning their head. I tried it, couldn't do it. We had cardboard headbeds that taped to the board, then had a velcro strap for the forehead, and a piece of tape for the chin. You could carry 20 in your trauma bag and still have room for plenty of other stuff. Can't remember the brand of the collar. dang.

 

[phildo]

Necloc!!thats it!!

 

[JPINFV]

Look, if "everything is connected" then why do patients with known neck fractures walk out of the hospital and live their lives in a neck brace, but no back brace? Why aren't they on bed rest? Because bending their back isn't hurting their neck. Similarly people who fracture a lumbar vertebra are sent out of the hospital with no C-collar, because they don't have a neck injury.

...because they've been imaged and know what's broken, what's not broken, and where those are. Not every fracture is an unstable fracture. Not every fracture needs a ton of immobilization, but some do. Unlike clinical criteria for immobilization such as NEXUS, if you do immobilize, you need to immobilize everything pending imaging.

 

[enjoynz]

Bring back the sand bags...or maybe a bean or wheat bag is a softer option!

Enjoynz

 

[Aidey]

...because they've been imaged and know what's broken, what's not broken, and where those are. Not every fracture is an unstable fracture. Not every fracture needs a ton of immobilization, but some do. Unlike clinical criteria for immobilization such as NEXUS, if you do immobilize, you need to immobilize everything pending imaging.

If you need to immobilize everything pending imaging how come so many patients in the ER get taken off the board with the c-collar left on almost as soon as we put them on the bed?

 

[Veneficus]

...because they've been imaged and know what's broken, what's not broken, and where those are. Not every fracture is an unstable fracture. Not every fracture needs a ton of immobilization, but some do. Unlike clinical criteria for immobilization such as NEXUS, if you do immobilize, you need to immobilize everything pending imaging.

For legal reasons or medical ones do you think?

 

[JPINFV]

If you need to immobilize everything pending imaging how come so many patients in the ER get taken off the board with the c-collar left on almost as soon as we put them on the bed?

1. Hospitals generally don't bounce around.

2. There are better options than backboards, such as firm mattresses that don't bounce around.

3. Too many patients are being needlessly immobilized by EMS systems that still go after having any mechanism instead of basing it off of a physical exam.

 

[JPINFV]

For legal reasons or medical ones do you think?

I'd argue both for the reasons I put forth earlier. I won't necessarily say that the concept of spinal immobilization is useless, just useless to the majority in the current patient population that it is applied to.