Simple KED Question... or not?

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EMSrush

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We had an interesting discussion at work today that I'd like some feedback on. It involves the immobilization process and the correct application of the KED on a seated adult patient. There are two basic sides to the coin:

1. Many EMS folks will maintain the head and neck in the position found (as reasonable and appropriate) and pad any spaces between the back of the head and the KED with the padding. The exact definition of "neutral in-line position" may vary, depending on the provider.

2. There are others who believe that KED padding should never be used to pad the void between the patient's head and the KED (unless Kyphosis or similar condition is present). The act of bringing the head into a "neutral in-line" position, if done correctly, will ensure that there is no gap between the KED and the back of the head. According to this side of the coin, the definition of "neutral in-line" is to apply traction and pull the head and shoulders back, until the ears are aligned with the shoulders.

Aside from movement required to maintain an airway, I'm not too comfortable with excessive manipulation of someone's head and posture when c-spine precautions are necessary. Also, depending on the patient's natural posture and position that they are found in, the amount of manipulation that must occur to achieve the goal can vary widely. Those who disagree will probably say that bringing the head to a neutral position does not qualify as excessive movement.

I haven't found too much on this with National Registry yet, but I'm still researching. In the meantime, I'm curious as to where other providers and agencies stand on this topic. Thanks!
 
Your answer would be simple. There is padding provided with the KED for a reason!
 
All depends on how the patient is. For practice some of us needed the pad in order to keep everything in line and some others didn't need the pad at all.
 
That was my first argument... but then they cried out in unison,

"The padding is for your knees when you check PMS!"

(Ok, well not really in unison, but you get the point...)
 
in 11 years, have used the KED exactly 2 times at an MVA. both times we padded the best we could

food for thought, with everyone saying how we over backboard people, does that same thought process go that there is no evidence to support that KEDs do any good?
 
KEDs are probably completely pointless if your only removing people from cars to a LSB with them. Unfortunately, they can't be used routinely without a LSB. I've use them in this role a fair amount (way more than using them to remove people from vehicles) when I had a patient that couldn't tollerate lying flat. This is completely anecdotal, but everyone of them to a person has fared very well using this method.
 
EMSrush said:
That was my first argument... but then they cried out in unison,

"The padding is for your knees when you check PMS!"

(Ok, well not really in unison, but you get the point...)
Click to expand...

Never heard that before.
 
usalsfyre said:
KEDs are probably completely pointless if your only removing people from cars to a LSB with them. Unfortunately, they can't be used routinely without a LSB. I've use them in this role a fair amount (way more than using them to remove people from vehicles) when I had a patient that couldn't tollerate lying flat. This is completely anecdotal, but everyone of them to a person has fared very well using this method.
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Yes, a KED is as close to full spinal immobilization as you can get. It is the most under used piece of equipment on a truck. Mainly because of lazy providers or people scared of them, from lack of using them. Any Pt that is not critical, should have one in place, before being moved. If you are worried about the spine, then it should be used. Unless a life threat is apparent, moving without one is wrong.

A KED is a national standard. When you are in court and the expert witness states that fact, you will be hung out to dry. I have testified for ambulance chasing scum, because they know they have a case there. When it is considered a standard and you choose not to use it. You better have a damn good reason for it and document it very well.

It takes all of 2 minutes to place one and makes moving the pt securely, much easier. If the Pt is truely having neck or back pain, it will help relieve the pain from movement.

People there is a reason why NREMT still tests on it's use.:rolleyes:
 
The KED does have it's uses... like extricating people vertically out of F1 Race cars. ;) They can also be used to stabilize a pelvis. While I still know how to apply one (and do it quickly) I view them mostly as extrication equipment.
 
reaper said:
Yes, a KED is as close to full spinal immobilization as you can get. It is the most under used piece of equipment on a truck. Mainly because of lazy providers or people scared of them, from lack of using them. Any Pt that is not critical, should have one in place, before being moved. If you are worried about the spine, then it should be used. Unless a life threat is apparent, moving without one is wrong.

A KED is a national standard. When you are in court and the expert witness states that fact, you will be hung out to dry. I have testified for ambulance chasing scum, because they know they have a case there. When it is considered a standard and you choose not to use it. You better have a damn good reason for it and document it very well.

It takes all of 2 minutes to place one and makes moving the pt securely, much easier. If the Pt is truely having neck or back pain, it will help relieve the pain from movement.

People there is a reason why NREMT still tests on it's use.:rolleyes:
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"National standard" and "effective in any way whatsoever " are two completely different things. MAST and Isuprel were national standards at on point too.

I think a pretty convincing case can be built, based on evidence, that routine immobilization of any sort is not called for vs an expert witness spouting dogma out of a text book written at a 7th grade level.
 
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A close friend of mine who is a Medical Director for several large departments in Florida had a discussion with me a few months back and he asked a question which made me stop and seriously think.

There is no clear answer to this question and I can see a lot of rationale in it...I would like to hear your views.

When a patient presents with a fracture and is already holding it in the position of comfort, we as providers do not attempt to manipulate it as long as all distal PMS is intact. We will do our best to keep it in same position and provide additional pain relief measures if possible.

If the above is true....then why do we insist on manipulating a person who has neck or back pain into what we deem a better position? They are already in their position of comfort and for this example let us say there is no distal neuro compromise....why do we force them out of that position into a "better" one?
 
regarding KEDs

What makes the KED a national standard is not the device itself.

It is the desire for spinal restriction on a seated patient.

It is a device meant to improve upon the short spine board. It is not the only device to do so. From my experience there are actually better devices.

The idea of spinal motion restriction in stable patients is a matter of debate. I think it is important to recall the conditions and circumstances in which these devices gained notoriety.

It was on cars made of steel with very little safety features and laws in place.

The very nature of the materials tranferred the force of the impacts directly to the occupants. Coupled with the lack of restraining systems, in my early days before seatbelt laws and the cultural shift towards wearing them, it was not unheard of to find seated patients with spinalcord injuries in vehicles.

Having said that, in a majority of the cases they also had other grevious injuries as well. Whether or not immobilization of any type at that point made a difference is a matter of debate. But the modern medical knowledge along with some emerging studies, cited in this forum for ages, are pointing towards "no."

Every now and again, humans being rather ingenious creatures, will manage to create a situation where there is a assumed potential benefit from spinal motion restriction in a seated position. (The most common I am aware of is amuzement park rides, particualrly roller-coasters, log rides, etc.)

Seated spinal motion restricition is a tool. Like every other tool in the box it is not meant for all patients or all circumstances.

It is a tool designed to help with a medical condition which must be assessed by sound clinical judgement using today's knowledge and techniques.

It is also worthy to note that seated spinal restriction is meant for stable patients, instability being a contraindication to use. As well, all of the devices are meant to restrict movement, it really is not very likely complete immobilization can even be obtained.

Given that we know today that occlusion and ischemia are responsible for significant amount of cord injury, I think that the use of restriction devices needs to be seriously re-evaluated as they will reduce the the size of the compartment surrounding the spine.

For the same reasons we don't use circumferential plaster splinting in the initital management of orthopedic injuries of the extremities, what possesses us to do exactly the opposite when a spine injury is detected or suspected and think we are actually helping?

As for the OP, officially when splinting anything, especially the spine, padding of void space is indicated. Otherwise, you are allowing movement.

The first question that really has to be addressed is not technique, but if the treatment actually makes a difference. In medicine there are also multiple ways to accomplish the same ends. There is no 1 right way.
 
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I appreciate the responses. I guess I was looking for specific feedback on the purposeful manipulation of the head in order to achieve a "neutral in-line position" and what actually defines neutral in-line position. Also, how much manipulation are you willing to do in order to achieve your goal?

Maybe I didn't phrase the question well- I was tired when I wrote it. :P
 
akflightmedic said:
If the above is true....then why do we insist on manipulating a person who has neck or back pain into what we deem a better position? They are already in their position of comfort and for this example let us say there is no distal neuro compromise....why do we force them out of that position into a "better" one?
Click to expand...

I think that's kind of where I'm going with this. Add to that the possible damage that we can cause by manipulating into a "better" position and we can create some serious complications.
 
Veneficus said:
As for the OP, officially when splinting anything, especially the spine, padding of void space is indicated. Otherwise, you are allowing movement.

The first question that really has to be addressed is not technique, but if the treatment actually makes a difference. In medicine there are also multiple ways to accomplish the same ends. There is no 1 right way.
Click to expand...

I agree with you. What some of my co-workers were saying, is that if you bring the head to a neutral in-line position "correctly", you will NEVER need to use the padding, because the back of the head will make contact with the KED on its own. I've never heard of this before.
 
EMSrush said:
I agree with you. What some of my co-workers were saying, is that if you bring the head to a neutral in-line position "correctly", you will NEVER need to use the padding, because the back of the head will make contact with the KED on its own. I've never heard of this before.
Click to expand...

That is strange they would say that. When the head is neutral there is almost always a space between the head and the KED board which requires padding.

On the topic of KED's... they do double as decent pediatric backboards.
 
EMSrush said:
I agree with you. What some of my co-workers were saying, is that if you bring the head to a neutral in-line position "correctly", you will NEVER need to use the padding, because the back of the head will make contact with the KED on its own. I've never heard of this before.
Click to expand...

This is what we Basics are taught (except for obvious anatomical variations) as of 2011
 
EMSrush said:
I appreciate the responses. I guess I was looking for specific feedback on the purposeful manipulation of the head in order to achieve a "neutral in-line position" and what actually defines neutral in-line position. Also, how much manipulation are you willing to do in order to achieve your goal?

Maybe I didn't phrase the question well- I was tired when I wrote it. :P
Click to expand...

I had this exact conversation with a group of 2 or 3 dozen skill and lecture instructors for an EMT program a few weeks ago. Many of the instructors were trained elsewhere, and had slightly different initial training, and we were working to standardize our curriculum, and testing for the class practical exam (comparing it to how we taught it). There were several state examiners in attendance, and each had a different take. Where we were looking for consistency, we found zero standards, and complete ambiguity in protocols, even the device instruction manual.

I turned, like a good product of academia, to PubMed, and found the below articles/discussions:
Wilderness Environ Med. 2008 Summer;19(2):108-10.
The use of extrication devices in crevasse accidents: official statement of the International Commission for Mountain Emergency Medicine and the Terrestrial Rescue Commission of the International Commission for Alpine Rescue intended for physicians, paramedics, and mountain rescuers.
Winterberger E, Jacomet H, Zafren K, Ruffinen GZ, Jelk B; International Commission for Mountain Emergency Medicine; Terrestrial Rescue Commission of the International Commission for Alpine Rescue.
Source
International Commission for Mountain Emergency Medicine, Medical Commission of Alpine Rescue Switzerland. eveline.winterberger@rega.ch
Abstract
Injured patients in crevasses who are suspected of having sustained spinal injuries should ideally be extricated after being immobilized in a horizontal position on a stretcher and having a cervical collar applied. Sometimes, however, horizontal stabilization is not possible, because the crevasse is too narrow, and the patient needs to be stabilized in a vertical position. In such cases an extrication device can be a useful adjunct. The Kendrick Extrication Device stabilizes the position of the body and maintains firm support of the head, neck, and torso. Therefore, the International Commission for Mountain Emergency Medicine supports the use of this device in narrow crevasses, if horizontal evacuation is not possible.

PMID: 18513106 [PubMed - indexed for MEDLINE]
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Reading the full article, it provides no data for our question, it simply supports the use of a KED for seated/vertical trapped patients in a crevice, and stability of the KED to raise the patient out.

Ann Emerg Med. 1989 Sep;18(9):943-6.
A practical radiographic comparison of short board technique and Kendrick Extrication Device.
Howell JM, Burrow R, Dumontier C, Hillyard A.
Source
Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas.
Abstract
Cervical spine immobilization is necessary during the prehospital care of most trauma patients. Earlier studies performed in controlled, indoor settings suggested short board technique (SBT) was the standard against which other methods of cervical stabilization should be measured. Our study approximated the prehospital setting by comparing the use of tape, SBT, and Philadelphia collar (PC) with tape, the Kendrick Extrication Device (KED), and PC after immobilization in and extrication from a compact car. Seven men were immobilized with KED and SBT in addition to PCs and tape. These subjects were extricated and then taken by ambulance stretcher across a 50-yd length of concrete to the radiology suite. Flexion, extension, lateral bending, and rotation were measured. KED-PC (16 degrees +/- 8 degrees) was statistically superior to SBT-PC (41 degrees +/- 5 degrees) in limiting rotation (P less than .001). KED-PC and SBT-PC were similar in their abilities to limit extension (8 degrees +/- 4 degrees vs 6 degrees +/- 5 degrees), flexion (4 degrees +/- 2 degrees vs 4 degrees +/- 4 degrees), and lateral bending (13 degrees +/- 5 degrees vs 17 degrees +/- 6 degrees). In an approximation of the prehospital setting, tape, a PC, and either KED or SBT substantially limit extension, flexion, and lateral bending of the normal cervical spine. KED-PC is more beneficial in rotation.

PMID: 2764327 [PubMed - indexed for MEDLINE]
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In a controled situation, the researchers compared the effectiveness of a KED + Philadelphia Collar to Short Board + Philadelphia Collar (remember, this is 1989), and found them to be essentially identical, the distinction being in rotation, where the KED was superior. These were, of course, perfect conditions, and theoretically correct technique. I couldn't get full access to the article (on request through ILL), but when I do, I'll share their methods (if listed).

Ann Emerg Med. 1987 Oct;16(10):1127-31.
A radiographic comparison of prehospital cervical immobilization methods.
Graziano AF, Scheidel EA, Cline JR, Baer LJ.
Source
Department of Emergency Medicine, Butterworth Hospital, Grand Rapids, Michigan.
Abstract
Three methods of prehospital cervical immobilization were studied radiographically and compared to the short board technique (SBT). The methods were California Stif-Neck Immobilizing Collar (CSC), Kendrick Extrication Device (KED), and Extrication Plus-One (XP-One). Forty-five volunteers were immobilized in the short board (SB) and one of the test devices studied. Cervical movement in the sagittal and frontal planes was measured radiographically. Movement in the horizontal plane was measured directly. Two-tailed, paired t test analysis was performed comparing test devices to the SBT. The SBT proved to be significantly better (P less than .05) in the following comparisons: the CSC in extension and lateral bending; the KED in lateral bending; and the XP-One in extension. We confirm the SBT as the standard of comparison against which newer prehospital devices can be compared objectively. Of the three devices compared against the SBT, the factory-fabricated short board devices (KED and XP-One) provided the greatest degree of immobilization, in addition to logistical advantages over the SBT.

PMID: 3662158 [PubMed - indexed for MEDLINE]
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Lastly, this study from 1987, also examined the Short Board, compared to KED, XP-1, and StiffNeck Collar (I presume the predecessor to the current Laerdal collar, but does anyone else know?). The Short board was found to be the best of the group-- and statistically significant in certain circumstances, KED and XP-1 in others. I am also waiting on ILL access to the full text.

So, short story: No data proving even base effectiveness of the KED. No academic discussion of cervical spinal manipulation. Brown, maybe this should be your next published study?
 
reaper said:
Yes, a KED is as close to full spinal immobilization as you can get. It is the most under used piece of equipment on a truck. Mainly because of lazy providers or people scared of them, from lack of using them. Any Pt that is not critical, should have one in place, before being moved. If you are worried about the spine, then it should be used. Unless a life threat is apparent, moving without one is wrong.

A KED is a national standard. When you are in court and the expert witness states that fact, you will be hung out to dry. I have testified for ambulance chasing scum, because they know they have a case there. When it is considered a standard and you choose not to use it. You better have a damn good reason for it and document it very well.

It takes all of 2 minutes to place one and makes moving the pt securely, much easier. If the Pt is truely having neck or back pain, it will help relieve the pain from movement.

People there is a reason why NREMT still tests on it's use.:rolleyes:
Click to expand...

Considering how infrequently it is used, it would be hard define it as a "standard of care". For something to be a standard of care, would not it have to be frequently employed for a given condition. In 8 years I've applied the KED once for an individual who couldn't tolerate a LSB. I've only seen it applied one other time. I know of few medics and EMTs that have used it more than once. Its most frequent use seems to be for off-label purposes - pelvic fractures, immobilization of pediatric patients, etc. It is in no way a standard of care. The book does not determine the standard of care, the sum of the end-users does. To state it as a standard of care in my area (and many many others) would be to tell a lie.
 
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