Back Boarding

Sasha

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After the I'm Confused thread, I did a little bit of searching for articles on backboarding, and here's two articles I found interesting

Previously I was in the "What could it hurt?" camp. According to this article, it can hurt quite a bit!

The act of immobilizing a cervical spine is not a completely benign process. It taxes the patient financially and physically. Spinal immobilization is estimated to cost $15 or more per patient, leading to more than $75 million a year in extra medical expenses.2

According to current ATLS teaching, a cervical spine is not immobilized properly unless the patient is placed in a semi-rigid collar, then strapped and taped to a rigid backboard.3This can be an uncomfortable and traumatic procedure in itself. It has long been known that long-term exposure to a c-collar and backboard can lead to decubitus ulcers and pain.

In a study of 21 healthy individuals placed in full spinal immobilization, all were found to have immediate pain, with six patients complaining of delayed symptoms from the immobilization 48 hours later.4 There also is the possibility of further damage to a spinal injury from manipulating it into a cervical collar.
The researchers found less disability (even in the patients with fractures) in the nonimmobilized patients than the immobilized patients.5The study has limitations, but it certainly supports further investigation into the value of cervical immobilization in all trauma patients.
The article also refrences another study which uses five criteria to rule out the need for immoblization

The five criteria are no focal neurologic deficits, no intoxication, alert and oriented times three, no distracting injury, and no midline cervical vertebral tenderness.
And the results:
By using these criteria on 34,069 patients, 810 of 818 cervical spine injuries were identified and filmed appropriately. Of the eight missed injuries, only two were considered clinically significant. In addition, 240 of the total fractures were deemed clinically insignificant, occurring in either the spinous or transverse processes and having no risk of neurologic injury. Of the 34,069 patients enrolled in this study, it was estimated that by using these five criteria, 4,309 patients did not need to be evaluated with x-rays
And here's a study that there may be less benefit to backboarding than EMT texts lead you to believe.

A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did.
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34). CONCLUSION: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.
And looking at it from a personal, non sciencey side... I, like many others, was backboarded (although only for a short time) in EMT school by practicing classmates. In the short time I was backboarded I found myself squirming around in the C-Collar, headblocks and straps trying to get comfortable and I was completely okay and cognizant of what was going on. I couldn't imagine having to in those for any length of time. Would you not think that a person is less likely to try and move laying down on a slightly more comfortable stretcher for a nice ride to the hospital, or immoblized in an uncomfortable, unanatomically correct position? Look at your spine, then look at a spine board. We have some natural spinal curvatures! We're not flat, and we aren't meant to be.
 
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Mountain Res-Q

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For those that haven't read my profile, I am also an EMT Supervisor at a 60 acre snow park. We specialize in snow tubing. Speeds reach the 20-30. You have no seat belt. You have no breaks. You have no helmet. You have no control. We see our fair share of wipe-outs. Based on the MOI of most crashes you would almost wnat to backboard everyone. Our policy is that when we witness a crash we walk (not run) to the scene. The 90 seconds it takes to get there (versus 60 running on ice and snow) gives us time to evaluate the patients reactions. Often they bounce right up and are laughing their butts off. We still ask if they want to be evaluated to CYA, but we are nt going to force them onto a backboard because the MOI was there. 50,000 customers see our mountain a year and we only backboard a half dozen at most (actually none this year). One of my duies is to train teh newbies (usually fresh out of EMT or FR and only with us for a season), and they are so inundated with "backboard, BackBoard, BACKBOARD," from class, that they don't understand that not everyone needs a backboard, any more than not every fracture needs traction. There is a time a place for them, and you had better be sure that you use one when needed. If we place a non-spinal muscle strain on a backboard, just because "they have some pain an were in a high speed crash", we are not getting them off until ALS Medics show up in 45-60 minutes. On the other hand, I bette not see a 60-year-old woman who is in so much pain that she can;t stand up be told by one of my people that it is probably a strain, take a few minutes, and we will try to walk it off." The point is that backboards have there place, like everything else, and shouldn't be slapped on every trauma patient just to CYA.
 
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NEMed2

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There has been "talk" for some time about giving EMT-B's in CT the ability to clear c-spine in certain circumstances. I'm not going to hold my breath on that one, I'm still waiting for the new EMT-I criteria to be made effective.

I agree that not everyone needs to be boarded. Putting 90 yo granny on a backboard can cause significantly more damage than allowing her to sit comfortably. But, for now I don't have the ability to clear c-spine and unless the pt is capable & refuses that care, it's required by my medical control.
 

medic417

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Sorry basics should not have selective spinal immobilization protocols until the education requirement increases drastically. Basics and sadly many Paramedics do not get enough A&P to have any clue as to what is going on.
 

NEMed2

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Sorry basics should not have selective spinal immobilization protocols until the education requirement increases drastically. Basics and sadly many Paramedics do not get enough A&P to have any clue as to what is going on.
Agreed. It makes me cringe to know Basics aren't requried to take CEs.
 

JPINFV

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^
To be fair, a lot of EMT-B level CMEs are so watered down or generalized that they are next to useless anyways.
 

Mountain Res-Q

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Agreed. It makes me cringe to know Basics aren't requried to take CEs.
By CE's I take it you are refering to Continuing Education Credits. They don;t have to in your neck of the woods? And out here in Calif, I've deen putting out good money every year. I need to move to your state.

We all know Backboarding is overdone in general. If beefing up training is what is needed, fine. But too amny EMT's and Fr I know adhear so closely to following Step 1, Step. 2, Step 3" that they don't think for themselves. If all it takes to run EMS is the ability to follow an instruction manual, then what good ar BLS level providers. There should be criterial for backboarding, but not an overkill of everyhting gets a backboard, it is medically speaking irresponsible, and so may the training standards for certain levels of EMS in certain areas.
 

MSDeltaFlt

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After the I'm Confused thread, I did a little bit of searching for articles on backboarding, and here's two articles I found interesting

Previously I was in the "What could it hurt?" camp. According to this article, it can hurt quite a bit!





The article also refrences another study which uses five criteria to rule out the need for immoblization



And the results:


And here's a study that there may be less benefit to backboarding than EMT texts lead you to believe.





And looking at it from a personal, non sciencey side... I, like many others, was backboarded (although only for a short time) in EMT school by practicing classmates. In the short time I was backboarded I found myself squirming around in the C-Collar, headblocks and straps trying to get comfortable and I was completely okay and cognizant of what was going on. I couldn't imagine having to in those for any length of time. Would you not think that a person is less likely to try and move laying down on a slightly more comfortable stretcher for a nice ride to the hospital, or immoblized in an uncomfortable, unanatomically correct position? Look at your spine, then look at a spine board. We have some natural spinal curvatures! We're not flat, and we aren't meant to be.
There are those that need backboarding, and there are those that may not. The key is assessment as you have referenced. I don't mean a quick glance over. I mean a detailed hands on assessment.

Ask yourself these questions. Is his/her neck/back broken? If yes, board them. If not sure, follow protocols. Assess and make a decision if allowed to do so.

As far as MOI goes, it all refers to how much of a change in velocity and how many different changes in velocity your pt receives. There are very few true mechanisms of injury. A fall 3X pt's height and rollover MVC with ejection are two for sure. As always you need to put your hands on your pt and assess them.

One more thing. I've said this multiple times I know. I aplologize. It's just that this is one of my quirks. But noone has their cervical spine truely immobilized until they have a halo placed on their skull. Everything else is only restrictive.

Good article, Sasha.
 

lightsandsirens5

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........or immoblized in an uncomfortable, unanatomically correct position? Look at your spine, then look at a spine board. We have some natural spinal curvatures! We're not flat, and we aren't meant to be.
Sasha! There is a wonderful oppurtunity!

1) Invent a new ridgid adjustable backboard the is shaped like a spine.
2) Patent it.
3) Sell patent or rights to manufacture to Ferno. (Or somone)
4) Retire and live happily ever after.

;)
 

LucidResq

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This discussion brings to mind the use of full body vacuum splints for immobilization. Does anyone use them? A few other SAR teams out here are in love with them. We have one, but it's a piece of junk and I refuse to use it. I'd like to try out a newer one that works correctly, however.

Here's a study on their use.

In conclusion, the vacuum splint is an effective and more comfortable alternative to the backboard for cervical spine immobilization.
A few other studies I've seen generally agree.
 

EMT007

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There has been "talk" for some time about giving EMT-B's in CT the ability to clear c-spine in certain circumstances. I'm not going to hold my breath on that one, I'm still waiting for the new EMT-I criteria to be made effective.
Sorry basics should not have selective spinal immobilization protocols until the education requirement increases drastically. Basics and sadly many Paramedics do not get enough A&P to have any clue as to what is going on.
Well thats the beautiful thing about the NEXUS criteria. You don't really need to know much A&P to use them, and they have been shown to be 99.8% sensitive for spinal cord injury. Studies have shown that EMT-B's trained to use the criteria are just as accurate with proper clearance as paramedics.

And selective spinal immobilization protocols are already in use by basics all over the country (I did a lot of research about this, as I proposed to get this protocol approved for my BLS agency).

Here are the references, if you're interested...

__________________

Domeier, et al: Prospective Performance Assessment of an Out-of-Hospital Protocol for Selective Spine Immobilization Using Clinical Spine Clearance Criteria. Ann Emerg Med. 2005; 46: 123-131

Domeier, et al: The reliability of pre-hospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehosp Emerg Care. 1999; 3: 332-337

Dunn, et al: Are emergency medical technician-basics able to use a selective immobilization of the cervical spine protocol?: a preliminary report. Prehosp Emerg Care. 2004; 8(2): 207-211

Sahni, Menegazzi, Mosesso: Paramedic evaluation of clinical indicators of cervical spinal injury. Prehosp Emerg Care. 1997; 1: 16-8

Hoffman, et al: Validation of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000; 343: 94-99

Stroh, Braude: Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med. 2001; 37: 609-615.
 
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Veneficus

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This discussion brings to mind the use of full body vacuum splints for immobilization. Does anyone use them? A few other SAR teams out here are in love with them. We have one, but it's a piece of junk and I refuse to use it. I'd like to try out a newer one that works correctly, however.

Here's a study on their use.



A few other studies I've seen generally agree.
You use them here, pt is extricated with the board, then transferred to the splint before transport. They seem to be a better alternative used this way, but I haven't seen an actual spinal injury pt with cord compromise on one yet. Just a lot of transverse and spinous process fx. (which doesn't require a board either)
 

Scout

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L&S that wouldt work becuase you would have trouble rolling and sliding the board in and out.

As for the vacume splints They are great its like a snug roll of silk in comparison to a slab of plastic. But they are massive and take up loads of room.

I did see a concept thing a while back, it was a sheet of foam that was vacume sealed in a bag the lenth of a board, you opened it somehow and then it inflated about an inch or so and relieved the pressure like a spunge. Duno why it did't make it further.
 

Sasha

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4) Retire and live happily ever after.
That sounds like way too much work.

My future plans still include marrying rich and widowing early.



Just kidding! :p
 

Sasha

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More Vacuum Splint Reading.

http://cat.inist.fr/?aModele=afficheN&cpsidt=3180275
The vacuum splint was judged to be significantly more comfortable on a 10-point scale than the rigid backboard after subjects had been lying on each device for 30 minutes (P <.001). It was also taster to apply : 131.6 ± 24.3 seconds versus 154.6 ± 22.2 seconds (P <.001). Various measures of immobilization were similar for the two devices. The vacuum splint provided better immobilization of the torso and less slippage on a gradual lateral tilt. The rigid backboard with head blocks was slightly better at immobilizing the head.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1323441
We found that the Cervical Vacuum Immobilizer limited cervical spine range of motion in forward flexion, extension, and lateral flexion. The Cervical Vacuum Immobilizer can be easily placed on an injured, fully equipped football player and serves to limit cervical spine range of motion while the athlete is immobilized and transported. Future research should determine how the Cervical Vacuum Immobilizer limits range of motion with the athlete immobilized to the spine board.
 

LucidResq

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One of the concerns that has been raised with vacuum splints, especially in the SAR setting, is that if it gets torn somehow, you can kiss any immobilization goodbye.
 

Scout

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One of the concerns that has been raised with vacuum splints, especially in the SAR setting, is that if it gets torn somehow, you can kiss any immobilization goodbye.

get your suction unit on to it and give it a suck on a low setting.

not quiet but it did work,

edit, and duck tape!!!!!
 

Mountain Res-Q

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get your suction unit on to it and give it a suck on a low setting.

not quiet but it did work,

edit, and duck tape!!!!!
Agreed Lucid, DUCK TAPE is the greatest thing in the wilderness setting.

You can role in you hands and use it for rappeling rope.
You can use it to patch up the hole in your Swiftwater Raft that has been there for 2 years.
You can fastened the tread back together on your snowmobile when it breaks.
AND you can use it to tape your victims mouth shut when you start the short haul. :unsure:

It's great. How do you think NASA reattches those heat panels that keep falling off?
 

Veneficus

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One of the concerns that has been raised with vacuum splints, especially in the SAR setting, is that if it gets torn somehow, you can kiss any immobilization goodbye.
vacuum in a stokes basket is a wonderful thing.
 
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