MVA and spinal immobolization

[chri1017]

I'm a new EMT and my region has a very poorly written selective spinal immobilization protocol. I was wondering where do most people draw the line when it comes to back boarding a patient following an MVA. Who would you and who wouldn't you board?

 

[MSDeltaFlt]

I would suggest using the search function. There was a recent thread that continued for several pages on this very subject.

 

[Handsome Robb]

Look up NEXUS and the Canadian C-Spine Rule.

 

[Christopher]

I'm a new EMT and my region has a very poorly written selective spinal immobilization protocol. I was wondering where do most people draw the line when it comes to back boarding a patient following an MVA. Who would you and who wouldn't you board?

Call it Spinal Motion Restriction and you'll have an easier time not placing a patient on a rigid spine damaging device.

Selective SMR protocols exist to help you to identify Low Risk patients. Pay attention to your exact criteria, but they're usually likely something like NSAID (from NEXUS):

(N)eurological deficit?
(S)pinal tenderness along midline?
(A)ltered level of consciousness?
(I)ntoxicated?
(D)istracting injury?

If all of these are "No", then your patient is at a very low risk for a spinal injury to be found via imaging. Practically this means you can overtriage for who needs SMR using these criteria.

I would say if you incorporate "NSAID" with the following you'll be pretty good:

(1) Ambulatory patients without complaints get no board/c-collar
(2) Patients who can self extricate get no board/c-collar
(3) Patients without complaint who remain in a vehicle get no board/c-collar
(4) Patients with physical exam findings consistent with the mechanism of injury get board/c-collar
(5) Patients with physical exam findings inconsistent with the mechanism of injury get a detailed examination prior to board/c-collar

... and the most important one of them all ...

(6) Patients with Ankylosing Spondylitis (AS) or severe kyphosis complicated by OI are NEVER candidates for SMR via traditional means. You can kill these patients with rigid devices. Really any patient with non-standard anatomy should only have spinal motion restriction with padding alone.

Look up NEXUS and the Canadian C-Spine Rule.

These will tell you who is likely to get an imaging study in the ED, rather than who needs spinal motion restriction.

We can certainly use them as a surrogate measure though, but it doesn't tell you who needs SMR (my system uses a modified CCR).

 

[Uclabruin103]

Look at your local protocol because it will vary. In my county an EMT can only look at mechanism, while only medics can use a protocol to clear c-spine.

 

[Sharps]

If we arrive and the occupants involved in the MVA are out of the vehicle walking around, we always ask if they have any head, neck, or back pain. If they say no, we will assess the patient ('s) vital signs, treat any wounds .etc. If the patient answers yes to any of these, there being collared, boarded etc. If the occupants are still in the vehicle, its the same scenario. If they reply yes to any of the questions above, we will most likely used a C collar and KED to extricate them from the vehicle. When on MVA's ask if the patient was wearing there seat belt. Note if there is any steering wheel deformity or spidering of the windshield in the event the patient's head struck the windshield at the time of impact.

 

[Sharps]

To more specifically answer your question, patients such as these need to be C collared and boarded:

-Head injury and or pain
-back pain
-neck pain
-people with altered LOC ( reason behind this is, say the patient a head on collision and they don't remember what happened. This can sometimes be the result of a head injury such as striking the steering wheel, windshield, losing consciousness .etc. Not all the time will this be the case. It could of just happened so fast the patient doesn't recall anything, But universal precaution in a case like this is a must to protect the patient just in case. )
-people who were ejected from a vehicle
-serious vehicle damage

 

[Christopher]

If we arrive and the occupants involved in the MVA are out of the vehicle walking around, we always ask if they have any head, neck, or back pain. If they say no, we will assess the patient ('s) vital signs, treat any wounds .etc. If the patient answers yes to any of these, there being collared, boarded etc.

From Scene mobility status as a predictor of injury severity and mortality due to vehicular crashes:

"Those who self-exited and exited with assistance experienced a mortality of 0.02%."

"MVC occupants who "self-exited" or "exited with assistance" experienced a very low injury severity and mortality. Further efforts are needed to decrease the overtriaging of these patients."

J Trauma. 2011 Sep;71(3):737-41.

 

[Brandon O]

6) Patients with Ankylosing Spondylitis (AS) or severe kyphosis complicated by OI are NEVER candidates for SMR via traditional means. You can kill these patients with rigid devices. Really any patient with non-standard anatomy should only have spinal motion restriction with padding alone.

This is a quite strong claim. Although certainly patients with AS and similar disorders are extraordinarily high-risk for significant spinal injury (particularly for the otherwise-rare phenomenon of neurological deterioration), it doesn't really seem clear how they should best be managed. There are reports of AS patients who worsened upon attempts at stabilization, but also plenty who worsened in its absence. I don't know of any attempts to qualitatively compare management strategies, even in a retrospective way.

It does seem like AS patients whose baseline spinal curvature is not neutral (i.e. significantly kyphotic) probably do not benefit from attempts to force them into neutral alignment. But that's a matter of anatomical shape, not so much the tissue pathology that's otherwise instrumental in making so many of these spines crack.

 

[medic109]

The Canadian and NEXSUS protocols are long established and proven, Maine adopted a number of years ago w/o any catastrophe, Boston EMS under Peter Moyer MD modified for EMS and 1st Responders 10 years + ago w/o issues. Massachusetts is slowly incorporating slowly for a formal protocol and a powerpoint presentation (adopted from Maine) google Mass OEMS

 

[Brandon O]

Boston EMS under Peter Moyer MD modified for EMS and 1st Responders 10 years + ago w/o issues

Actually I believe they stopped using it after some perceived "misses." But the state is inching back that way, as you say.

 

[Christopher]

This is a quite strong claim. Although certainly patients with AS and similar disorders are extraordinarily high-risk for significant spinal injury (particularly for the otherwise-rare phenomenon of neurological deterioration), it doesn't really seem clear how they should best be managed. There are reports of AS patients who worsened upon attempts at stabilization, but also plenty who worsened in its absence. I don't know of any attempts to qualitatively compare management strategies, even in a retrospective way.

It does seem like AS patients whose baseline spinal curvature is not neutral (i.e. significantly kyphotic) probably do not benefit from attempts to force them into neutral alignment. But that's a matter of anatomical shape, not so much the tissue pathology that's otherwise instrumental in making so many of these spines crack.

A number of case reports from the early 90's onward detail deaths after the application of rigid c-collars to AS patients (and some kypthotic OI/type II odontoid fx pts).

Basically, if you do not immobilize them in their pre-injury "neutral", you're highly likely to cause harm, death being a non-trivial possibility.

 

[Brandon O]

A number of case reports from the early 90's onward detail deaths after the application of rigid c-collars to AS patients (and some kypthotic OI/type II odontoid fx pts).

Sure... but there are also plenty of reports of these folks coming unwound without immobilization. The reliable take-away is that they're very high-risk, but what to do about that isn't really clear. There's probably a decent review article if anyone wants to collect the published case reports on both sides and pool them into a loose case-control format.

 

[Christopher]

Sure... but there are also plenty of reports of these folks coming unwound without immobilization. The reliable take-away is that they're very high-risk, but what to do about that isn't really clear. There's probably a decent review article if anyone wants to collect the published case reports on both sides and pool them into a loose case-control format.

The mixed reports indicate simply that inappropriate immobilization is bad. Whether that be too much or not enough, morbidity/mortality are increased when the anatomical alignment for that patient are not used. If an adult adjustable c-collar barely fits a majority of the physiologically common anatomy...

 

[Brandon O]

The mixed reports indicate simply that inappropriate immobilization is bad. Whether that be too much or not enough, morbidity/mortality are increased when the anatomical alignment for that patient are not used. If an adult adjustable c-collar barely fits a majority of the physiologically common anatomy...

On physiological grounds, I agree. But we should be good little troopers and acknowledge that there's no evidence demonstrating this conclusion.

Not that that's a departure from the norm when it comes to prehospital spinal care.