Spinal Immobilisation

[Melclin]

Question 1: Has anybody ever come across the idea that LOC precludes a patient from being clinically cleared? Its in our clearance guidelines and I've never been able to figure out why. I mostly ignore it but given that I do, I'd like to understand it better. Nobody has ever been able to provide me with a good reason.

The only two things I can think of:
1. If they've had an LOC, then they're not reliable to be examined, which seems absurd.
2. If the blow to the head was sufficient to cause LOC, then it was sufficient to cause spinal injury - Also absurd. My understanding is that even in the most severe of head injuries, the presence of the injury alone doesn't predict spinal injury.

Question 2: Hx of vertebral disease is also included in the clearance criteria. I am aware that this may increase the likelihood on injury, but does it increase the likelihood of occult injury. Why can't they just be examined like the rest of us and if they have evidence of injury, then they cannot be cleared. Is it simply because pt like this are often excluded for clearance criteria research and we there for have little data to guide us on the topic so we can't clear them?

 

[Handsome Robb]

Question 1: Has anybody ever come across the idea that LOC precludes a patient from being clinically cleared? Its in our clearance guidelines and I've never been able to figure out why. I mostly ignore it but given that I do, I'd like to understand it better. Nobody has ever been able to provide me with a good reason.

The only two things I can think of:
1. If they've had an LOC, then they're not reliable to be examined, which seems absurd.
2. If the blow to the head was sufficient to cause LOC, then it was sufficient to cause spinal injury - Also absurd. My understanding is that even in the most severe of head injuries, the presence of the injury alone doesn't predict spinal injury.

Question 2: Hx of vertebral disease is also included in the clearance criteria. I am aware that this may increase the likelihood on injury, but does it increase the likelihood of occult injury. Why can't they just be examined like the rest of us and if they have evidence of injury, then they cannot be cleared. Is it simply because pt like this are often excluded for clearance criteria research and we there for have little data to guide us on the topic so we can't clear them?

1) I've had plenty of medics tell me that LOC eliminates them from eligibility to be cleared in the field for the same reasons you listed above but I'm with you, it's a ridiculous statement and (yes I've thrown it around a lot lately don't shoot me) by my protocol it does not eliminate my ability to clear their spine in the field. FWIW we use NEXUS plus active ROM from the Canadian C-Spine Rule, age <12 and language barriers limiting proper assessment added in for our field clearance protocol.

ALOC is a disqualifier, LOC but now A&Ox3 with a GCS of 15 is not. There's no reason, that I've found or read for that matter, that a patient who was knocked unconscious but is now oriented appropriately cannot have their spine cleared prehospitally.

2) I can't provide any studies so this is all my own thoughts from what I've been taught and researched on my own but I'd be much more cautious clearing a patient with a Hx of vertebral disease, especially a degenerative one, in the field. I'm not sure if it's true and have no evidence to support it but I'd assume that these patients are predisposed to an acute spinal injury. ( I know, assumptions make an *** out of U and ME! ) With that said, you bring up a good point. Why can't they be cleared with traditional methods?

You've caught my attention with this thread, I'm interested to see what the brains of this operation have to say about this.

A few anecdotal experiences: I know physicians here, in my few experiences with this, have always gone straight to radiography for these patients. If they walk into the ER or come in by EMS without spinal motion restriction in place the ERs here seem to usually place a c-collar if they have a traumatic MOI and neck pain (or simply off of "severe" MOI itself) and wait for radiology before calling their C-spine clear.

When I was in a ski accident after my previous neck injury the Ski Patrollers, EMS crew and ER staff was much more cautious with my after they found out about my previous spinal injury. Wanted to fly me for a "smoother ride", which I refused, rather than riding down the curvy mountain road in the back of a box. I definitely ended up on a backboard and in a CT scanner, although I did have neck pain with ROM and numbness in my hands (it happens from time to time even without me getting in a car accident anyways. Either from sleeping/sitting awkwardly or from being an idiot and going to wild on my sled, skis at the gym, things of that nature.)

 

[Brandon O]

Question 1: Has anybody ever come across the idea that LOC precludes a patient from being clinically cleared? Its in our clearance guidelines and I've never been able to figure out why. I mostly ignore it but given that I do, I'd like to understand it better. Nobody has ever been able to provide me with a good reason.

LOC has been shown to be weakly predictive of C-spine injury in Jacobs 1986. P=.382. So... basically no.

Question 2: Hx of vertebral disease is also included in the clearance criteria. I am aware that this may increase the likelihood on injury, but does it increase the likelihood of occult injury. Why can't they just be examined like the rest of us and if they have evidence of injury, then they cannot be cleared. Is it simply because pt like this are often excluded for clearance criteria research and we there for have little data to guide us on the topic so we can't clear them?

Vertebral artery injury is a known (uncommon but real) complication of C-spine injury, and in some cases there's a delayed presentation (days). Couple of papers that show this. I don't know of anything addressing clinical detectability of these patients, but I would expect these aren't very obvious.

Buzz if you want, I can send the papers over.

 

[mycrofft]

Key phrase "In the field" (read that "In the hands of those bloody technicians"). And, altered consciousness can alter reporting of pain or disability no matter where you are.

When WILL those mobile CT and MRI machines arrive? We ordered them from Amazon weeks ago....

I think the issue's eminence is still another fossil/echo from why EMT's in the US at least were created; the motor vehicle on the roads of/in the 1960's precipitated spinal injuries and responding people were often not trained to care for that, neither in extrication nor consideration of the likely injuries during loading and transport.

Modern vehicles are much much safer, and the majority of response are not to car crashes, but since the essence of being an EMT was the spine board sequence, it was preserved and actually expanded. Like bedmaking (don't laugh!) for nursing students, or the old intricately coordinated shift of compressors and inflaters during CPR when it was 60/min.

 

[Veneficus]

Question 1: Has anybody ever come across the idea that LOC precludes a patient from being clinically cleared? Its in our clearance guidelines and I've never been able to figure out why. I mostly ignore it but given that I do, I'd like to understand it better. Nobody has ever been able to provide me with a good reason.

The only two things I can think of:
1. If they've had an LOC, then they're not reliable to be examined, which seems absurd.
2. If the blow to the head was sufficient to cause LOC, then it was sufficient to cause spinal injury - Also absurd. My understanding is that even in the most severe of head injuries, the presence of the injury alone doesn't predict spinal injury.

Question 2: Hx of vertebral disease is also included in the clearance criteria. I am aware that this may increase the likelihood on injury, but does it increase the likelihood of occult injury. Why can't they just be examined like the rest of us and if they have evidence of injury, then they cannot be cleared. Is it simply because pt like this are often excluded for clearance criteria research and we there for have little data to guide us on the topic so we can't clear them?

What really makes this question is the follow on, if there is injury, occult or otherwise, is it a treatable injury with some intervention other than rest and watchful waiting?

 

[Brandon O]

What really makes this question is the follow on, if there is injury, occult or otherwise, is it a treatable injury with some intervention other than rest and watchful waiting?

Actually, I disagree. Even among those patients who do receive surgical or other intervention, that still doesn't necessarily mean they should have been immobilized prehospitally. The questions are different (is the spine stable until hospital arrival vs is the spine stable for discharge), and that's not to say that all these surgeries are necessary (i.e. beneficial) either.

 

[mycrofft]

There's immobilization, and there's immobilization.
Being strapped, wrapped and belted (which may be of use if you're being extricated) or being gently handled and smoothly transported with due regard.

Spine boards were for extrication (they are unpadded long hard SPLINTS) and became the hallmark of PEMS. One more good tool which is over prescribed like Valium used to be.

 

[Melclin]

LOC has been shown to be weakly predictive of C-spine injury in Jacobs 1986. P=.382. So... basically no.
....
Buzz if you want, I can send the papers over.

That would be great. I'm getting so pissed off about this. I spoke to the ex-top clinical manager in the state today. He was of the opinion that the LOC issue came not from our service but from the people running the state trauma system. This simultaneously gives it both more and less weight. It was created by trauma experts but also by people with a reasonably poor understanding of the average paramedic's ability so there may have been and element of ambulance driver haters contributing to this.

The deeper I dig, the more interested in this topic I become. I'm actually thinking of making a evidence based submission to the committee that reviews our guidelines periodically. The mentioned resources and more so, your consultation would be very welcome.

I think the issue's eminence is still another fossil/echo from why EMT's in the US at least were created; the motor vehicle on the roads of/in the 1960's precipitated spinal injuries and responding people were often not trained to care for that, neither in extrication nor consideration of the likely injuries during loading and transport.

What is interesting though, is that we don't have that hx and we introduced spinal immobilisation relatively recently compared to our antipodean counterparts.

While my opinion of the intervention itself is low, I've always had a great deal of admiration for American EMS teams who can immobilise pts in under 136 milliseconds before loading. Maybe not on this topic and not in regards to the majority of pts, but we would do well to learn from American drilling type training in some instances. Arrests, major trauma etc.

What really makes this question is the follow on, if there is injury, occult or otherwise, is it a treatable injury with some intervention other than rest and watchful waiting?

Very interesting...wanna fund my RCT?

Actually, I disagree. Even among those patients who do receive surgical or other intervention, that still doesn't necessarily mean they should have been immobilized prehospitally. The questions are different (is the spine stable until hospital arrival vs is the spine stable for discharge), and that's not to say that all these surgeries are necessary (i.e. beneficial) either.

Woah woah, once paradigm shift at a time.

There's immobilization, and there's immobilization.
Being strapped, wrapped and belted (which may be of use if you're being extricated) or being gently handled and smoothly transported with due regard.

Spine boards were for extrication (they are unpadded long hard SPLINTS) and became the hallmark of PEMS. One more good tool which is over prescribed like Valium used to be.

I agree. We recognise the board as an extrication device but unfortunately, our inability to properly secure a pt to the stretcher while moving is limited without the board. Again its a money issue.

I love the vacuum matresses though. Very big fan. If immobilisation has to happen, the vac mat is vary much my preference.

 

[Handsome Robb]

Key phrase "In the field" (read that "In the hands of those bloody technicians"). And, altered consciousness can alter reporting of pain or disability no matter where you are.

I may have misread the OP but I was under the impression we were talking about patients who had a loss of consciousness but are now awake, alert and oriented.

I agree, ALOC greatly reduces the reliability of what the patient is reporting to you, thus why it's a disqualifier for both NEXUS and CCSR.

Melclin, I'm assuming that the vacmats work well since you're fond of them. Have you ever run into a situation where they didn't work? I know our air-splints are useless once they get a pin-hole in them.

Unfortunately I've never had the opportunity to use one for spinal immobilization. I do routinely use the large air splint we carry to immobilize suspected pelvic and proximal femur injuries with great results, they work like a charm.

 

[Veneficus]

Actually, I disagree. Even among those patients who do receive surgical or other intervention, that still doesn't necessarily mean they should have been immobilized prehospitally. The questions are different (is the spine stable until hospital arrival vs is the spine stable for discharge), and that's not to say that all these surgeries are necessary (i.e. beneficial) either.

I just saw this today, but I thought I should respond to it because I think you misunderstood what I was trying to say.

I ackowledge that surgical correctin of a spindal injury is desperation. In the rare circumstance it is indicated, it is not really useful as curative as it is more or less palliative.

At this point in history, we do not have a reliable method to aid in CNS injury.

However, you are arguing your own point, not mine. The purpose of immobiliztation is to prevent secondary injury.

We know that secondary injury is largely caused by inflammatory and immune responses. If you have figured out a way immobilization in any environment particularly on a longboard, helps with that I would ask you to share it so we can figure out how to nominate you for a Nobel prize.

In the hospital and post extrication phase in a fair amount of places, the long spine board is removed ad "immobilization" becomes spinal motion restriction. Rusty as my Engish may be, there is still a difference there. No movement vs. some movement.

The only way you could get no movement in a hospital is to basically keep these people in a coma for an extended period of time. While there are definately benefits to this in some instances, ICUs are not full of people in induced comas for spinal injury treatment.

Your argument here seems to be that people heal enough in the hospital over time and thus are less injured when they are discharged compared to when they are admitted. But it ignores the actual problem which is secondary spinal injury is not a product of excessive movement and happens over time.

The development and the use of prehospital immobilization with the LSB was put into place when we didn't know that.

Which is probably why you cannot find a case study showing the sudden decompinsation of somebody of somebody walking around with an unstable spine injury.

I would encourage you to think of the spine and cord as 2 seperate structures and consider the anatomy of both, along with the pathophys of secondary injury. In doing so, I think you will find that rigid immobilization will actually worsen the problem.

While the LSB is useful as an extrication tool, I am of the mind prehospital immobilization, should be no different than in hospital immobilization, and I would argue that if it wasn't true, then we would be wrenching every kyphotic elderly person onto a LSB, not what is currently done which is motion restriction the same as in the hospital.

I would extend your self-challenge to find a case study where one of these geriatric patients suffered a secondary cord injury from this current treatment and furhter challenge you that if we don't do it to decompensated older people, why do we think it helps in otherwise healthy young people?

Is the "C" shape of their spine fundamentally less suseptable to injury than the "S" shape of a healthy person? Because it seem to me the inverse would be true, that this population should suffer more frequent and more severe secondary injury than the Healthier group.

Because not "immobilizing" the elderly population prehospital the same way we do the younger generation, you have created a control group to which compare non-LSB secondary injury (in a much more vulnerable group due to aging and underlying pathology) to compare to LSB immobilized people in a healthier group.

Now somebody may claim that the mechanisms are different, and while certainly true, the elderly are still much more prone to injuries from lesser mechanism (fall from standing) than the younger are from greater mechanism (like a car accident)

Not only is nobody looking at this data, it is being outright ignored.

Now back to our regularly scheduled argument...

That would be great. I'm getting so pissed off about this. I spoke to the ex-top clinical manager in the state today. He was of the opinion that the LOC issue came not from our service but from the people running the state trauma system. This simultaneously gives it both more and less weight. It was created by trauma experts but also by people with a reasonably poor understanding of the average paramedic's ability so there may have been and element of ambulance driver haters contributing to this.

The most problem is not this, the most important is what material was used to adopt this?

Was it pre inflammatory mechanism of significant secondary injury or post? In the post inflammatory world, early hypothermia has been successful for improved outcome.

The deeper I dig, the more interested in this topic I become. I'm actually thinking of making a evidence based submission to the committee that reviews our guidelines periodically. The mentioned resources and more so, your consultation would be very welcome.

Better him than me, I am really tired of this topic.

While my opinion of the intervention itself is low, I've always had a great deal of admiration for American EMS teams who can immobilise pts in under 136 milliseconds before loading. Maybe not on this topic and not in regards to the majority of pts, but we would do well to learn from American drilling type training in some instances. Arrests, major trauma etc..

That is interesting becase I see this as the biggest problem.

Very interesting...wanna fund my RCT?

I just told you where to get study material above. Sorry, no money for you.

I agree. We recognise the board as an extrication device but unfortunately, our inability to properly secure a pt to the stretcher while moving is limited without the board. Again its a money issue.

I love the vacuum matresses though. Very big fan. If immobilisation has to happen, the vac mat is vary much my preference.

See my above statement on motion restriction in the geriatric population. It is not a money issue, if you have a c-collar, a soft matress, and something to pad voids with, then you have absolutely everything you need.

Here is food for though:

When you are taking a long car or plane trip, do you find more comfort for your neck resting your head on a soft pillow or a wooden block?

Why doesn't Skymall sell wooden blocks?

 

[Brandon O]

Your argument here seems to be that people heal enough in the hospital over time and thus are less injured when they are discharged compared to when they are admitted. But it ignores the actual problem which is secondary spinal injury is not a product of excessive movement and happens over time.

Oh, no. My point is that when the spine doc asks, "Is this C-spine fracture stable/insignificant enough to let this patient go with no treatment?" that's not the same question as when we ask, "Does that same patient need to be immobilized prior to hospital arrival?" even if we somehow knew the type and severity of injury at that time. Just like asking if a HTN patient needs antihypertensives from his PCP is distinct from asking if he needs them promptly from EMS.

So if we use the criteria of whether that patient ultimately received definitive stabilization to determine whether we (EMS) should have done our board-and-collar thing, we'll get an over-sensitive result. Which is what we've done.

Is the "C" shape of their [geriatric] spine fundamentally less suseptable to injury than the "S" shape of a healthy person? Because it seem to me the inverse would be true, that this population should suffer more frequent and more severe secondary injury than the Healthier group.

I know that I've been told older and kyphotic patients are higher risk for spinal injury, although to be honest I haven't seen the latter reflected in the literature.

 

[Veneficus]

Oh, no. My point is that when the spine doc asks, "Is this C-spine fracture stable/insignificant enough to let this patient go with no treatment?" that's not the same question as when we ask, "Does that same patient need to be immobilized prior to hospital arrival?" even if we somehow knew the type and severity of injury at that time. Just like asking if a HTN patient needs antihypertensives from his PCP is distinct from asking if he needs them promptly from EMS.

So if we use the criteria of whether that patient ultimately received definitive stabilization to determine whether we (EMS) should have done our board-and-collar thing, we'll get an over-sensitive result. Which is what we've done.

If EMS treatment actually worked I would agree.

But it doesn't.

I know that I've been told older and kyphotic patients are higher risk for spinal injury, although to be honest I haven't seen the latter reflected in the literature.

Because they seperate bony injury from CNS injury. (like they should)

It also takes into account pathological fractures, not just traumatic ones.