Spinal Immobilization Question

RocketMedic

RocketMedic

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Question for y'all: If you have a patient with confirmed spinal abnormalities (ie, crepitus, tenderness, pain, deformity, new neuro deficit, etc) is putting them on a backboard a good idea or not? Why?

Personally, I think it's a bad idea to backboard these people, since you're going to be manipulating them fairly extensively to get them on a board from anything other than a supine or standing position. Immobilization in place in a position of comfort seems far more appropriate, but I don't know how to prove it.

(Yes, we are constrained by protocols, but this is intended as an intelligent discussion).
 
I think the biggest issue would be getting them from wherever they were to the stretcher. If you have a supine patient with severe back pain and neuro deficit, I would think having him stand up himself, even with a collar, would be more motion than a log roll. And picking him up by his arms and legs probably wouldn't do wonders either.

That being said, there was a new study that showed that the procedure for a patient in an MVA that caused the least movement of the spine was placing a c-collar on the patient and having them walk to the stretcher.

http://www.ncbi.nlm.nih.gov/pubmed/23079144

Once you get them on the stretcher though, I don't think a board is needed at all.
 
Very sketchy extract. Let me look at the original before I dump on it. ;)
 
I'm not getting the original. The questions I would be addressing:
1. HOW were these simulated? In a well-lit heated/cooled lab with an undamaged car the doors were removed from, or a rollover with all doors crushed and the two-door car lying on its side in the mud?
2. Was the subject conscious alert and oriented?
3. Who were the "rescuers", who judged whether they were competent and skilled or not?
4. Did they specify the type of equipment used?

This is the ominous passage to me: "It has been estimated that up to one-quarter of spinal cord injuries may be significantly worsened during extrication or early treatment after a motor vehicle accident".
1. "It has been estimated....": By whom and how?
2. " ...up to one-quarter..." How large a sale? How diverse a region?
3. "significantly worsened...": This presupposes a pre-knowldge of the injuries; ok in a lab study, but if "in vivo", impossible to know without diagnosing the pt before extrication. And what constitutes "significantly"?
4. "...extrication or early treatment..." : I get extrication, but what do they consider "early treatment"? Does it extend to unshipping onto the Emergency Department gurney?

"that...of spinal cord injuries may be...during...after a motor vehicle accident"...no issues at this time. Except definition of "accident".:cool:


PS: There are circumstances where the pt has to be moved by responders (namely, nearly all) and the inescapable result is some degree of injury. However, leaving them in the crushed car is not a viable alternative.

I think we can refine techniques and tools and ESPECIALLY training and rescue culture, but I really need to see this article to see how they had to slice and dice reality to make it fit.
Seriously. I killed my subscription to "Psych Today" when it became apparent that these "studies" were done by the authors using one of their psych classes at their school as the sample, period, then generalized to the whole word and maybe Mankind through the ages.
 
mycrofft said:
This is the ominous passage to me: "It has been estimated that up to one-quarter of spinal cord injuries may be significantly worsened during extrication or early treatment after a motor vehicle accident".
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The only study on god's green earth I'm aware of that suggests this -- and every time you see a remark like this it usually cites this study -- is Toscano 1988. It is... unconvincing.

Edit: yes, this is the paper cited, along with a consensus document which offers no additional primary evidence.
 
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mycrofft said:
I think we can refine techniques and tools and ESPECIALLY training and rescue culture, but I really need to see this article to see how they had to slice and dice reality to make it fit.
Seriously. I killed my subscription to "Psych Today" when it became apparent that these "studies" were done by the authors using one of their psych classes at their school as the sample, period, then generalized to the whole word and maybe Mankind through the ages.
Click to expand...

I was trying to get access through my college and I couldn't get it. But Mill Hill Ave Command, a blog by an EMTLifer (and EM physician) did a nice write-up on it: http://millhillavecommand.blogspot.com/2012/12/in-order-to-protect-c-spine-should-we.html

The psych literature tends to do that. :/


Regarding placing the patient in a position of comfort, that's what I'd prefer. Ideally, all we should do is use a collar and let them find a position of comfort. By protocol, neuro deficits and midline pain require me to board -- I have no latitude.
 
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mycrofft said:
"It has been estimated that up to one-quarter of spinal cord injuries may be significantly worsened during extrication or early treatment after a motor vehicle accident".
1. "It has been estimated....": By whom and how?
2. " ...up to one-quarter..." How large a sale? How diverse a region?
3. "significantly worsened...": This presupposes a pre-knowldge of the injuries; ok in a lab study, but if "in vivo", impossible to know without diagnosing the pt before extrication. And what constitutes "significantly"?
4. "...extrication or early treatment..." : I get extrication, but what do they consider "early treatment"? Does it extend to unshipping onto the Emergency Department gurney?
Click to expand...

I think this comes from commonly accepted theory based prior to modern knowledge of SCI. Which basically renders it moot.

Worsening of SCI post injury is largely due to inflammatory response, both a pseudocompartment sysndrome from paraspinal tissue which causes cord ischemia, and direct action of immune cells on the spinal cord.

Naturally this takes time to progress, so I would think that it would of course "look like but isn't" worsening of the injury from manipulation post incident to an observer.

I also think the key word here is "immobilization." In EMS that usually is synonymous with a long board, but could also include standard matresses, self splinting, and full body vacuum devices.

If we think of a board (without all the headblocks and crap) as an extrication device, it could reasonably be concluded it does restrict spinal motion, whether or not that has any effect on the outcome is debatable, with signs pointing towards no.
 
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Veneficus said:
I think this comes from commonly accepted theory based prior to modern knowledge of SCI. Which basically renders it moot.

Worsening of SCI post injury is largely due to inflammatory response, both a pseudocompartment sysndrome from paraspinal tissue which causes cord ischemia, and direct action of immune cells on the spinal cord.

Naturally this takes time to progress, so I would think that it would of course "look like but isn't" worsening of the injury from manipulation post incident to an observer.

I also think the key word here is "immobilization." In EMS that usually is synonymous with a long board, but could also include standard matresses, self splinting, and full body vacuum devices.

If we think of a board (without all the headblocks and crap) as an extrication device, it could reasonably be concluded it does restrict spinal motion, whether or not that has any effect on the outcome is debatable, with signs pointing towards no.
Click to expand...

So movement of the potentially injured spine during extrication is moot? I can see that from the standpoint that a conscientious and fortunate extrication will not make things worse after/versus the insult from a horrendous accident. I can see that unstructured extrication ("I cut off the roof, dude, walk to me!", or dragging pts out by one extremity) could potentially exacerbate injuries.

The "all or nothing", "good or bad" thing irks me I guess. Like throwing out all my claw hammers when I buy a cordless screwdriver.

Consider these:
1. The extrication ritual acts to moderate the actions of PEMS and extrication people as much as it does to "stabilize a spine"??

2. Maybe the emphases for extrication should be speed and smoothness rather than just "use this collar and that headblock and this strap and that KED and you are doing ok"? Like my CPR students, they are getting two inches down and a hundred a minute, but they're lunging like rodeo horses, hands are not letting the chest rise...meeting the basic criteria, but their style can make a real difference.

3. Consider which approach to use and use it wisely and properly and gently.

You know, at a couple points the use of cervical collars was going to be thrown out because they offered totally inadequate support. The advent of field use for the "Philly Collar" then more "stiff neck" type collars brought them back from extinction. Moderate and graduate, don't don't bombasticate. (:huh: huh?)
 
Perhaps a better study would not observe just how much motion an extricated patient goes through (And I forgot the study brief was so tiny, forgive me), but how spinal motion, if any, effects outcome in a SCI patient.

I have no idea how such a study would be performed, but it should at least give us an idea if we should look at current extrication techniques as something to be improved, or something to be thrown out and started from scratch. After all, worrying about small to moderate cervical spine movement in a patient is useless if that motion causes no further damage.

It's also 1AM and I'm a little delirious, so there's that too.
 
I would agree with position of comfort but how are you going to get them to the gurney without manipulating them?
 
Anonymous said:
I would agree with position of comfort but how are you going to get them to the gurney without manipulating them?
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Ever heard of or seen a scoop stretcher? We're required to carry one on every ambulance, I just assumed it was a pretty standard piece of equipment. I use our scoop all the time. I'd venture to say on a daily basis, sometimes multiple times a day. They work wonders and require very little if any manipulation of the patient. Works wonders for getting grandma or grandpa off the floor after they fell and buggered their femur or hip.

People always use spine boards to carry patients if you can't get the gurney to them even if they don't require spinal motion restriction, I generally use the scoop, never understood why most use an LSB. Scoops are contoured so they're generally more comfortable for the patient AND since the patient sits down inside the scoop and they generally have a bar at the bottom you can rest their feet on the patient is more secure than laying on a perfectly flat board. A couple of the spider strap velcro, don't even have to use them all, and the aren't going anywhere while you carry them down or up the stairs and out to the gurney. Then just unclip it and pop it out for transport and use the gurney sheet to move them at the hospital.

MVA is a little more difficult. People hate it but personally, if I had a patient with confirmed spinal abnormalities and/or neuro deficits/complaints with no other immediate life threats you can be damn sure I'll be the guy that takes the time to use a KED and do it right. Something you use often? Definitely not, but in a situation like one described in this thread I'd definitely be inclined to use it to extricate a seated patient from a vehicle.
 
Robb said:
Ever heard of or seen a scoop stretcher? We're required to carry one on every ambulance, I just assumed it was a pretty standard piece of equipment. I use our scoop all the time. I'd venture to say on a daily basis, sometimes multiple times a day. They work wonders and require very little if any manipulation of the patient. Works wonders for getting grandma or grandpa off the floor after they fell and buggered their femur or hip.

People always use spine boards to carry patients if you can't get the gurney to them even if they don't require spinal motion restriction, I generally use the scoop, never understood why most use an LSB. Scoops are contoured so they're generally more comfortable for the patient AND since the patient sits down inside the scoop and they generally have a bar at the bottom you can rest their feet on the patient is more secure than laying on a perfectly flat board. A couple of the spider strap velcro, don't even have to use them all, and the aren't going anywhere while you carry them down or up the stairs and out to the gurney. Then just unclip it and pop it out for transport and use the gurney sheet to move them at the hospital.

MVA is a little more difficult. People hate it but personally, if I had a patient with confirmed spinal abnormalities and/or neuro deficits/complaints with no other immediate life threats you can be damn sure I'll be the guy that takes the time to use a KED and do it right. Something you use often? Definitely not, but in a situation like one described in this thread I'd definitely be inclined to use it to extricate a seated patient from a vehicle.
Click to expand...

Yes I am familiar with it but no we don't carry those which is why it didn't cross my mind. closest thing we have is a flat break away stretcher but patients still have to be placed on it.
 
Anonymous said:
Yes I am familiar with it but no we don't carry those which is why it didn't cross my mind. closest thing we have is a flat break away stretcher but patients still have to be placed on it.
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Gotcha.

That's unfortunate you don't carry them.

Probably one of the most used pieces of equipment on my ambulance along with the stair chair. Rather than trying to navigate the gurney all the way to that back bedroom just wheel 'em on out. I've been known to use office chairs when there's one available rather than walking out to the rig to grab the stair chair :D
 
mycrofft said:
Re the 1980's article:

http://www.ncbi.nlm.nih.gov/pubmed?...before admission to a spinal cord injury unit

The extract says nothing about extrication methods exacerbating or causing spinal insult.
Click to expand...

The full article is available online for free: http://www.nature.com/sc/journal/v26/n3/abs/sc198823a.html

His claim is that a massive number of these patients suffered secondary (i.e. after the initial event but before definitive care) neurological deterioration, often severe, as a direct result of failure on the part of EMS to adequately recognize the injuries and stabilize them accordingly.

He bases this on interviews with the involved parties and reviews of the documentation from prehospital care all the way through discharge. Via personal correspondence (I tracked him down and followed up), he claims these were obvious causal links -- the proverbial "turned his head and collapsed" legends we've all heard.

But there's very little to go on here, and such results radically contradict not only all other literature but the anecdotal experience of, well, everybody. (I have been unable to find a single such sasquatch story that can be substantiated, and yes, I've looked.) Toscano directs the interested reader to review the full text of his medical school thesis, upon which the Paraplegia paper is based, but which exists only as a hardcopy in the University of Melbourne library. I would like to examine it, but they refuse to circulate it, so I think the only avenue is to come up with $70 and they'll scan it.

But I'm poor, so I am accepting donations toward this noble cause. Yes, seriously.
 
Brandon Oto said:
But I'm poor, so I am accepting donations toward this noble cause. Yes, seriously.
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You want donations for a thesis that old and an outlier to everything else currently available on the subject?

Sorry, I like you, but not a chance.
 
Veneficus said:
You want donations for a thesis that old and an outlier to everything else currently available on the subject?

Sorry, I like you, but not a chance.
Click to expand...

Well, just seems proper to make a good-faith effort at disproving your own beliefs. This is the only evidence so far to contradict my claim that there's never been a patient described in the history of modern medicine who suffered neurological deterioration from an unstable spinal injury during the prehospital phase. (Doesn't mean it's never happened, but it's never been published, even as a lonely case report; nor even described anecdotally in reliable circumstances)
 
Brandon Oto said:
Well, just seems proper to make a good-faith effort at disproving your own beliefs. This is the only evidence so far to contradict my claim that there's never been a patient described in the history of modern medicine who suffered neurological deterioration from an unstable spinal injury during the prehospital phase. (Doesn't mean it's never happened, but it's never been published, even as a lonely case report; nor even described anecdotally in reliable circumstances)
Click to expand...

An outlier for $70 is a waste of money.

Even if it was true in one case, it is would never meet preponderance of evidence, and even if you or I saw it personally, it would be so rare that we would either:

a: never be able to reliably correlate the cause

b: it would not merit consideration or money spent on it.

We do not write protocols or spend millions of dollars for single patient presentations.
 
Brandon Oto said:
He bases this on interviews with the involved parties and reviews of the documentation from prehospital care all the way through discharge. Via personal correspondence (I tracked him down and followed up), he claims these were obvious causal links -- the proverbial "turned his head and collapsed" legends we've all heard.
Click to expand...

Just to follow up on this, the closest thing to such a story in the literature (beyond the aforementioned paper) is in Harrop 2001:

The third patient had an incomplete central cord injury (C4 ASIA D) after a fall. In the emergency department, the patient was extremely agitated and would not remain recumbent while immobilized in a rigid cervical collar. The injury quickly ascended to a C4 complete CSCI with the patient's self- manipulation of his neck.
Click to expand...

Of course, this still doesn't qualify for my purposes, because it happened at the hospital (i.e. not in the prehospital phase), and the patient was actually wearing a collar already. Still, at least it's close. Yet that's the type of event that's purported to be widespread, and it was the only such report (in fact the only secondary neurological deterioration within 1 hour of the initial injury) in this 1904-person study.
 
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