Spinal Immobilization Question

[EpiEMS]

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.

Plus, as we all know, immobilization is dependent on patient compliance (or sedation, I suppose).

 

[Brandon O]

Plus, as we all know, immobilization is dependent on patient compliance (or sedation, I suppose).

Well, yes. Since in some systems this person would've been mandated to be immobilized in the usual fashion (and sedation is not always possible), I suppose it demonstrates that even when you play the game it may not make a difference. But I do wish they gave more details about the exact chain of events.

 

[EpiEMS]

Well, yes. Since in some systems this person would've been mandated to be immobilized in the usual fashion (and sedation is not always possible), I suppose it demonstrates that even when you play the game it may not make a difference. But I do wish they gave more details about the exact chain of events.

Yup, more detail would be good. I'm surprised they didn't bother to use some sort of sedation, I guess. If I were trying to manage this in a BLS setting, there's not much to be done if they don't want to be immobilized...

 

[Brandon O]

Yup, more detail would be good. I'm surprised they didn't bother to use some sort of sedation, I guess. If I were trying to manage this in a BLS setting, there's not much to be done if they don't want to be immobilized...

Well, imagine how many times a similar situation (uncooperative and mobile patient in C-spine) plays out. Wouldn't want to snow all of them.

Although in fairness, this guy already had a clinically-apparent spinal cord injury, so it was hopefully clear that he was high-risk.

 

[EpiEMS]

Well, imagine how many times a similar situation (uncooperative and mobile patient in C-spine) plays out. Wouldn't want to snow all of them.

Although in fairness, this guy already had a clinically-apparent spinal cord injury, so it was hopefully clear that he was high-risk.

In the first case, if they're moving around, I'd imagine that their spinal injury can't be THAT severe -- at least, assuming that if it hurts to move, we tend not to move?

 

[Brandon O]

In the first case, if they're moving around, I'd imagine that their spinal injury can't be THAT severe -- at least, assuming that if it hurts to move, we tend not to move?

Well, he was initially ASIA D at C4, which is the least significant classification -- "Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more." He might've only had some parasthesias or weakness.

And you'd certainly think that people wouldn't move if it hurt... that's the reason why turning your head is part of the Canadian C-spine rule. It's safe because we assume competent people won't turn their head if there's an unstable fracture; they'll feel their spine literally separating and stop. But I presume that the patient in question was in some manner altered.

 

[Handsome Robb]

And you'd certainly think that people wouldn't move if it hurt... that's the reason why turning your head is part of the Canadian C-spine rule. It's safe because we assume competent people won't turn their head if there's an unstable fracture; they'll feel their spine literally separating and stop. But I presume that the patient in question was in some manner altered.

Which is a reason ALOC or gross intoxication is generally an automatic failure criteria for c-spine clearance without radiography. Even then though, some people are dumb even without booze or drugs onboard. Although if I'm not mistaken, intoxication isn't included or a disqualifier for the CCSR. It just says "Alert (GCS 15), stable trauma patients".

I know that if you're using NEXUS, which is what we use here (plus no pain with active ROM like CCSR includes), "evidence of intoxication" is a disqualifier. There's a good thread on here about intoxicated vs. not intoxicated so I wont get into that in this one. "Painful distracting injury" is one that always brings up discussion as well. What is a painful distracting injury? Pretty sure there was a thread on that one as well, or maybe it was just a discussion within a thread.

The thing that really confuses me is how the U.S. is one of the last countries to routinely utilize long spine boards for spinal motion restriction rather than a properly sized cervical collar and a scoop or allowing the patient to be placed, or place themselves, in their position of comfort.

 

[EpiEMS]

Scoop stretchers, a collar, and POC makes sense. Come to think of it, I've never actually used the scoop except in training. May have to make it a mission to use it!

 

[KellyBracket]

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?

....

I know that the discussion has revolved around the prehospital treatment, but sometimes there is an incomplete understanding of what happens (or ought to happen) in the ED and hospital.

In the scenario described by the OP, regardless of whether a board was used by EMS or not, the patient with spinal injury and neuro deficits should come off the board ASAP once they hit the ED. They will stay in a collar and be rolled/moved gently, and in-line, but they need to get off the hard surface before they end up with a life-threatening skin ulcer. And this isn't my wacky opinion, it's ATLS.

(Here I usually would have mentioned my review In order to protect the c-spine, should we stop helping?, but EpiEMS already did!)

 

[ExpatMedic0]

Really Interesting information Kelly. Is that your personal blog?

 

[Handsome Robb]

Scoop stretchers, a collar, and POC makes sense. Come to think of it, I've never actually used the scoop except in training. May have to make it a mission to use it!

They work wonders. Like I said, I use either my scoop or combicarrier nearly every shift for something.

With that said, most agencies will not allow them for use for spinal motion restriction. We started carrying a CombiCarrierII on each of our ambulances and they are approved for spinal motion restriction but someone brought up a good point that the metal hinges on both ends of the board render any imaging done with them in place useless as far as radiology goes.

Like Kelly said, they should be coming off the board immediately in the ER anyways but that doesn't always happen, often for ease of movement. In the trauma bay they usually come off quickly but if they go to a room they often will stay on the board for a while until a physician can come and assess them.

 

[KellyBracket]

Well, not too personal!

It's not an official outlet for my hospital or local medical control, but I try to keep it local - good cases, new policies. But I also use it it to talk about stuff beyond local protocols and policies. Gotta look forward in EMS!*

*As with backboards...

 

[Christopher]

They work wonders. Like I said, I use either my scoop or combicarrier nearly every shift for something.

With that said, most agencies will not allow them for use for spinal motion restriction. We started carrying a CombiCarrierII on each of our ambulances and they are approved for spinal motion restriction but someone brought up a good point that the metal hinges on both ends of the board render any imaging done with them in place useless as far as radiology goes.

Never seen that before, but I will probably have these on our truck by the end of next week. Talk about useful and probably far more comfortable than a normal backboard.

Plus that half-back FastSplint they have would likely provide actual immobilization and comfort...hmmm.

 

[ExpatMedic0]

Over here in Copenhagen there using some kind of full body vacuum splint. I would be curious to compare that device vs the other methods of immobilization.