Selective Spine Immobilization Training Program

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Selective Spine Immobilization Training Program
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Reasons for New Guideline
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Purpose of EMS Selective Spinal Immobilization
Guideline

• Identify and immobilize 100 of patients at risk
  for unstable injuries
• Identify and NOT immobilize patients who have NO
  risk for cervical spine injury

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IMPORTANT Message

• Mechanism is going to be a crucial decision point
  in this process. This will rule some people out
  who previously were boarded and collared.
• Supine patients who meet the guidelines for Spine
  Immobilization will be boarded and collared as
  usual. Whereas, ambulatory patients who meet the
  protocol will only be collared.

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Cervical Spine Injuries-The Problem

• Between 2-4 of Blunt Trauma Patients sustain
  cervical spine injury
• Improvements in EMS systems and ATLS have
  resulted in increased awareness and practice of
  cervical immobilization

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Why not immobilize everybody?

• Immobilization is uncomfortable increased time
  immobilized increased pain, risk of aspiration,
  vulnerable position, etc...
• gt800,000 U.S. Patients receive cervical
  radiography each year
• Patient exposure to radiation
• gt97 of xrays are negative
• Cost exceeds 175,000,000 /year

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Incidence of SCI

• About 50 patients per million population.
• 12,000/year are treated while another 4,800 die
  prehospital.
• Male-to-female ratio is approximately 2.5-3.01
• About 80 of males with SCI are aged 18-25 years.

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Based on Science
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Most Common Causes of Adult SCI

• 45 - MVC
• 20 - Falls
• 15 - Sports
• 15 - Violence
• 5 - other

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Mechanism of Injury

• More than 50 of Spinal cord injuries are single
  vehicle crashes!

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Age Based Considerations

• 60 of all SCI in gt75 years population are caused
  by simple falls.
• Pediatric incidence varies between 1 11.
• 5 will occur in the age group of 0-16 years.
• Adolescents C5-C6 level most often injured
• Causes in Children
• 0-10 years falls and pedestrian vs auto
• gt10 years are same as adult

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National Emergency X-Radiography Utilization
StudyNEXUS

• Hypothesis
• Blunt trauma victims have virtually no risk of
  cervical spine injury if they meet all of the
  following criteria
• No neuro deficit,
• Normal Level of alertness
• No evidence of ETOH/Tox
• No posterior midline tenderness
• No other distracting painful injury

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NEXUS -Results

• 818 patients with fracture identified
• All except 8 were identified by clinical decision
  rule
• Sensitivity 99 (95 CI 98-99.6)

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8 Patients Not Identified By NEXUS Rules
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The Main Point

• You cant just decide to clear the spine
  without following a standard of care 100 of the
  time. No neck-pain is not an absolute
  clearance.
• Patients whose spinal cord injuries are missed
  are directly related to poor assessment, lack of
  recognition of SCI patterns and lack of knowledge
  about risk factors correlated to SCI.

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Spinal Injuries
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Kinematics (Mechanism)

• Process of evaluating the forces and motion
  involved when an accident occurs to determine
  what injuries may have resulted
• Based on fundamental principles of physics
  described in Newtons Law

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Kinematics of Blunt Spinal Injury

• Hyperextension
• Hyperflexion
• Compression
• Rotation
• Lateral Stress
• Distraction

• Axial Loading(diving)
• Blunt Trauma
• Motor Vehicle Collision
• Bicycle Fall
• Children Fall gt 3 feet
• Adult Fall from standing height

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Mechanism of Injury

• Physical manner and forces involved in producing
  injuries or potential injuries
• Valuable tool in determining if the a particular
  set of circumstances could have caused a spinal
  injury
• Mechanisms likely to produce spinal injuries
  occur in MVAs, falls, violence, and sports
  (including diving accidents)

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Cervical Spine Injuries

• C-spine very flexible
• Most frequently injured area of spine
• Most injuries at C-5/C-6 level

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Thoracic Spine Injuries

• T-spine less flexible
• Narrow spinal canal
• Cord injury occurs with minimal displacement
• Common mechanisms
• Any cord damage usually complete at this level
• Most T-spine injuries occur at T-9/T-10

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Lumbosacral Spine Injuries

• LS spine flexible nerve roots in roomy spinal
  canal
• May have bony injury w/o cord or nerve root
  damage
• Secondary injury still possible
• Neurological injury rare w/ isolated sacral
  injuries

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Spinal Column Injury

• Bony spinal injuries may or may not be associated
  with spinal cord injury
• These bony injuries include
• Compression fractures of the vertebrae
• Comminuted fractures of the vertebrae
• Subluxation (partial dislocation) of the
  vertebrae
• Other injuries may include
• Sprains- over-stretching or tearing of ligaments
• Strains- over-stretching or tearing of the muscles

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Spine Evaluation
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Identification of Mechanism of Injury

• Clearly Positive Mechanismspinal immobilization
  indicated
• Clearly Negative Mechanismspinal immobilization
  not indicated
• Uncertain MechanismMOI alone inconclusivefurther
  assessment required to determine if spinal
  immobilization necessary

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Uncertain MechanismAssessment by Clinical
Criteria

• Pain/Tenderness Exam
• Neurological Exam
• Motor Function
• Sensory Function
• Reliable vs. Unreliable Patient Exams

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Examples of Positive Mechanism

• Penetrating trauma to head, chest, abdomen,
  pelvis
• Axial loading injury
• Rollover with signs of impact
• Multiple system injuries
• Compressed roof of vehicle
• Falls greater than 20 feet

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Examples of Positive Mechanism

• Death of occupant in same car
• Struck by vehicle traveling more than 30 mph
• Severe vehicle deformity, intrusion of car gt12
  inches
• Ejection from vehicle

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Pain/Tenderness Exam

• Spine Pain
• Spine Tenderness

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Neurological Exam

• Motor Function
• Sensory Function
• Reliable vs. Unreliable Patient Exams

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Motor Function

• Upper Extremities
• Abduction/Adduction
• Finger/Hand extension
• Lower Extremities
• Plantar Flexion
• Great Toe Dorsiflexion

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Sensory Function

• Test sensation at two levels
• Must include testing for sensation to pain and
  light touch at the lateral and medial aspects of
  each upper extremity and each lower extremity

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Sensory Function

• Abnormal Sensation- Numbness, weakness,
  paraesthesia, or ridiculer pain
• Pain Sensation- Test ability to distinguish pain
  from light touch in both upper and lower
  extremities

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Examples of Abnormal Neuro Findings

• Paresthesia distal to injury, unilateral or
  bilateral
• Unilateral weakness, motor or sensory findings
  in limbs
• Altered level of consciousness or affect
• Any abnormality to pan, temperature or position
  sense.

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Reliable vs. Unreliable Patient Exams
INDICATIONS FOR PATIENT EXAM RELIABILITY NO
YES Acute Stress Reaction (ASR)
Calm Agitated, Combative
Cooperative Intoxication/Drug Use
Sober/No Drug Use Abnormal Mental Status
-- Alert Oriented (Note be particularly
careful assessing mental status in
head-injured patients) Distracting Injuries
(painful long bone fractures, significant soft
tissue injuries, etc.) Communication Problems --
Language Barrier, mental handicap, etc.
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Criteria for High Risk/ Unreliable Patients

• GCS 12
• Pediatric 12, Elderly 65
• Alcohol, drug, any mind altering substance use.
• Other painful injuries.
• Down Syndrome.
• Acute stress reaction or severe anxiety.
• Shock
• History of serious spine problems.

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Spinal Immobilization Decision Algorithm

• RULE 1
• Use algorithm for stable patients with
  negative or questionable mechanism of injury.

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Spinal Immobilization Decision Algorithm

• RULE 2
• Any unstable patient or potentially unstable
  patient with positive mechanism of injury, are to
  be rapidly extricated and immobilized per
  regional guidelines and PHTLS recommendations
  without compromising short scene times.

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Spinal Immobilization Decision Algorithm

• RULE 3
• Immobilization can be safely deferred when
  there is a negative mechanism of injury. When the
  mechanism is questionable or uncertain, clinical
  criteria are to be used to determine
  immobilization of the stable patient.

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Other painful injuries.Distracting Injuries

• These patients have been correlated with missed
  fractures/ injuries due to the masking effects of
  sympathetic nervous system stimulation.

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Positive or questionable mechanism of injury

• POSITIVE Positive mechanism is determined
  following the State of Connecticut Trauma
  Protocols and Regulations. (Example Fall of 25
  feet)
• S.I. indicated
• QUESTIONABLE Questionable mechanism exists
  where the mechanism of injury is unclear
  regarding impact and forces involved. (Examples
  Minor MVC with minimal vehicle damage simple
  fall of less than 5 feet)
• S.I. POSSIBLY not indicated, continue with
  assessment to determine S.I. need.

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Positive or questionable mechanism of injury

• NEGATIVE Negative mechanism exists when no
  reasonable possibility of spinal injury is
  present. (Example Knee/ankle injury while
  running with no fall, GSW to arm/leg)
• S.I. not indicated
• NOTE These are only baseline principles. All
  factors, including patient vital signs and
  symptoms, should be evaluated prior to final
  determination of need for S.I.

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Take Home Message

• Long backboards may not need to be utilized for
  spinal immobilization of patients who have been
  ambulatory after the mechanism of injury before
  EMS has arrived.
• Ambulatory patients who require spinal
  immobilization can be placed in an appropriately
  sized collar and secured on the ambulance
  stretcher in the position of comfort while
  limiting the movement of the neck during the
  process.

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• Mechanism is going to be a crucial decision point
  in this process. This will rule some people out
  who previously were boarded and collared.
• Supine patients who meet the guidelines for Spine
  Immobilization will be boarded and collared as
  usual. Whereas, ambulatory patients who meet the
  protocol will only be collared.

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Case Studies
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Case Study One

• Dispatch
• 68 y/o female c/o weakness to arms, unable to get
  out of car. Car parked in shopping mall parking
  lot.
• Arrival
• Pt sitting in drivers seat of car, GCS 15, no
  distress
• Pt states she drove car over concrete parking
  divider, really jerking my head when she drove
  over 6 inch divider.

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Case Study One (cont)

• Initial assessment ABCs normal, c-spine control
  initiated
• Stable or unstable?
• Evaluate MOI
• Secondary Assessment
• VS normal
• No pain on palpation of spine
• No deformity palpable
• Lower extremities normal motor or sensory exam
• Upper extremities Good sensation to light touch
  and sharp touch but, weak motor function

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Case Study One (cont)

• Risk/Reliability Hx of osteoporosis
• Treatment Full immobilization
• Reassessment VS normal, further decrease in
  motor function of upper extremities, No sensory
  changes, lower extremities without changes,
  patient c/o dull pain to neck

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Case Study One (cont)

• Diagnosis Central Cord Syndrome
• Discussion
• Hyperextension mechanism
• Swelling of central cord
• Most common type of cord injury
• Loss of motor and sensory function below level of
  cord injury with greater loss in arms than legs

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Case Study Two

• Description of case A 53 year old male was
  involved in a moderate-speed MVA. He was driver
  of car that rear-ended another car. Both cars
  have serious fender damage. The hood of your
  patients car is pushed in and bent. the
  windshield is intact. He states he was wearing
  his seat belt. He complains of some shoulder
  soreness. He is sitting in his car when you
  arrive.

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Case Study Two (cont)

• Initial Assessment ABCs are normal. Cervical
  spine stabilization is manually obtained because
  of the appearance of the cars.
• Decide Stability of patient Stable
• Evaluate MOI Questionable.
• Secondary Assessment - Neurological and Sensory
  Exam Vital signs are normal. Pt. denies pain
  on palpation of spine. you feel no deformity.
  Neurosensory exam is normal. Pt is able to
  perform range-of-motion without pain or
  limitation. Motor examination is normal.
• Risk / Reliability Assessment Pt. has no risk
  factors.

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Case Study Two (cont)

• Treatment Transport for evaluation of shoulder
  discomfort.
• Reassessment Unchanged.
• Diagnosis No indications for spinal
  immobilization

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Case Study Two (cont)

• Discussion Clinical clearance or inclusion
  using the algorithm is a systematic approach as
  noted above. This patient has no indications for
  spinal immobilization. Be sure to document your
  exam and treat his shoulder. Transport to the ED
  is still indicated.

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Case Study Three

• Description of case You are called to the home
  of a 32 year old woman who is complaining of left
  wrist pain. She is embarrassed that she had to
  call 911, but she cant stand the pain in her
  wrist and cant drive herself to the ER. She
  states that she injured her wrist about 6 hours
  earlier after she fell out of a moving car. She
  reports her friends said that she was initially
  unconscious for several minutes. She admits to
  drinking a few beers prior to the accident.

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Case Study Three (cont)

• Initial Assessment ABCs are normal. No manual
  stabilization initially maintained. Pt. denied
  any neck/back complaints.
• Decide Stability of patient Stable.
• Evaluate MOI Significant.
• Secondary Assessment - Neurological and Sensory
  Exam Vital signs are stable. Palpation of
  cervical spine reveals mild tenderness. Manual
  cervical spine stabilization is obtained.
  Neurological exam reveals intact sensation to
  light touch and pain. proprioception is normal.
  Patient moves all extremities. You note multiple
  abrasions over forehead, scalp and left arm and
  leg. Patient has a Babinski reflex on the left
  and her DTR were decreased on left.

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Case Study Three (cont)

• Risk / Reliability Assessment Loss of
  consciousness, alcohol use, associated injuries.
• Treatment Full spinal immobilization. Splint
  wrist fracture.
• Reassessment Unchanged
• Diagnosis Subluxation of C-4 on C-5 with
  fracture of pedicle and arch of C-4

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Case Study Three (cont)

• Discussion This patient required surgery
  (cervical diskectomy, decompression and fusion
  with insertion of iliac crest bone dowel) and
  immobilization with Gardner-Wells tongs. This
  patient has risk factors as well as mild
  tenderness on palpation. She also has a
  distracting injury. There was a significant MOI
  with several minute loss of consciousness

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Case Study Four

• Description of case 5 year old male fell out of
  tree approximately 10 feet. Landed on hard
  ground. Parents report patient was unconscious
  for a few minutes. Child is now alert, oriented
  and is very quiet and still.

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Case Study Four (cont)

• Initial Assessment Airway, breathing and
  circulation are normal.
• Decide Stability of patient Stable.
• Evaluate MOI Significant.
• Secondary Assessment - Neurological and Sensory
  Exam Vital signs are normal. Secondary exam
  reveals shoulder pain and burning in both legs.
  Patient refuses to participate in exam any
  further or describe any other sensations.
• Risk / Reliability Assessment Patient is at
  high risk for spinal cord injury/fracture due to
  age.

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Case Study Four (cont)

• Treatment Full immobilization
• Reassessment Unchanged.
• Diagnosis Spinal cord injury
• Discussion This patient suffered a fractured
  clavicle and a spinal cord injury.

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Questions

• ?