C-Spine Stabilization research

[spenac]

Here we are implementing a protocol where medics transfer the patient to the ER gurney and immediately remove them from the backboard, leaving them in the c-collar laying flat on the bed before being seen by the physician. It is not c-spine clearance (in fact, most of these patients will ultimately undergo c-spine imaging), but goes far to improve their comfort. This also takes some of the pressure off (ha ha) us to interrupt our resuscitation of someone to take someone else off the backboard. This has met unanimous approval from the regional physicians advisory board as well as EMS providers who have been consulted. This does not apply to patients with neuro deficits or who cannot follow instructions, who must be seen immediately on arrival by the physician anyway.

'zilla

Doc can you provide some references I could submit to my medical directors. The services I work for are rural and have long transport times. We have progressive protocols except when it comes to back boarding. We have to backboard any accident, even if somebody just rolled off a low bed and has no pain. I have seen many patients no pain on scene have severe pain by time we get to hospital. After removal from board pain quickly diminished. I feel we are doing more harm than good but I need science behind it to have any hope of making a change.

[Dustdevil]

I've been on this soapbox before: we adhere strongly in EMS to a doctrine of spinal immobilization without evidence to support it. Most EMS providers I've run into don't seem to understand that standard treatment of spinal fractures, including c-spine fractures, is laying flat on the bed (with c-collar if it's a c-spine) until a brace is obtained, halo is applied, or fusion is performed. Long backboards have no role in spinal fracture treatment. I believe that securing the patient well to the gurney during transport with straps and no board will provide equivalent spinal immobilization to a LBB with a whole lot more comfort. The LBB should be reserved for getting the patient out of the car/house/grinder and to the gurney, particularly with long transport times.

Bingo. This is a point that is inadequately covered by a FAILing EMS education system. It's another one of those protocol monkey procedures that we just do without having a complete understanding of the rationale and physiology surrounding it. We're taught to put people on these things, but we are taught neither why to do it, when to take them off, or when not to do it at all. Instead, we're stuck in with everybody making incorrect ASSumptions.

As Zilla points our, the reason we put people on a hard board is to get them safely from point A (the position they are found in) to point B (the stretcher). They can be perfectly immobilised on the stretcher without a board. The board serves no therapeutic function. It is only a means of transport. If your school FAILS to teach that, then your school sucks.

[Doczilla]

Search the following Pubmed ID numbers:

12385610 Probably the strongest study to support this. Shows that immobilization creates false-positive findings for vertebral tenderness, and recommends immediate removal from LSB upon arrival at the ER.

8273958 Showed 100% of healthy volunteers had pain after immobilization for 30 minutes, half of which rated it as moderate to severe. 29% developed additional pain complaints over next 48 hours.

1877767 Immobilized healthy children and showed that their respiratory status was impaired by the immobilization as measured in FVC.

11446541 Showed that the LSB creates higher subjective pain scores that vacuum mattress splints.

15748015 A review of available literature on spinal immob.

10534038 Shows LSB restricts breathing in healthy adults

16023909 Shows that high and potentially ischemic pressures were created by immobilization, with the highest on the LSB.

7793717 Compared LSB with and without an interposed air mattress. LSB causes more pain. Also noted high tissue pressures with LSB.

7584752 Showed that adding closed cell padding to LSB caused less pain and didn't affect immobilization efficacy.

10488515 I don't know if this study refutes my assertion or not. It shows that if not strapped to a spine board, patients who want to move their neck will move it more.

16418091 study comparing the scoop stretcher with LSB. Shows that immobilization is better with scoop and comfort is improved as well. This helps us start thinking outside the box with spinal immob. Take it for what it's worth: it was sponsored by the manufacturer.

A couple of notes:

Our protocol for removal from the LSB upon ER arrival is universal for all EMS squads transporting to this particular hospital. After initial phase-in, it will be adopted at all hospitals. It is not in protocols because it does not need to be. The medics aren't clearing c-spines, and in fact are providing standard of care that the patient would receive if the physician were at the bedside.

Upon arrival, medics are triaged to a room, where they give report to the receiving nurse. As long as the patient a) can follow directions and has no neuro deficits, they are unbuckled from the board and log rolled off in essentially the same manner that the board was applied. They are left to lie flat awaiting physician evaluation.

I have never met a patient that wasn't grateful to get off the board. With this removal protocol, it happens much sooner. Again, we are still meeting the standard of care as it has been for years.

Let me edit to add: There are no comparison studies on efficacy of immobilization with the ambulance stretcher to support my assertion that the stretcher immobilizes the patient just as well as LSB. I'll take this on the chin if someone wants to refute it. The ambulance stretcher mattress is a thin foam pad on a rigid backing, which contours to the patient's shape, providing some lateral support as well as the vertical support provided by the flat rigid stretcher backing. Properly secured with straps to the cot, I believe that in a compliant patient this will result in adequate immobilization. Vomiting will require the patient to be log-rolled again, which means unbuckling them from the stretcher to do so. Drunken raving lunatics may benefit from continued immobilization on the LSB. I also believe this would make an excellent study for those looking for a research project.

Now when it comes to selective immobilization of the c-spine (c-spine clearance), there are several good studies which support the practice with very few "missed injuries" and no adverse events that I'm aware of. Another topic.

'zilla

[spenac]

Thank you Doc. That will give me information to research and refer to in trying to improve our patient care.

[akroeze]

This practice would likely also lead to an increased usage of a scoop for spinal care as opposed to a LSB which is better for the patient as well.

[Scaramedic]

I have heard (not actually done yet though) that if you inflate a BP cuff in the small of the back it can provide some relief

Been doing that for years, never had a BP cuff not returned. I always carry an extra Large adult just for that reason. Pump it up, clamp it with hemostats (which I carry in my kit, not on my person) and remove the sphyg. Of course it helps if you carry the kits with the screw off sphygs. :wink:

Also having been on a backboard I cannot stress enough just how uncomfortable they are. I swear you can feel every bump on the road and they become outright painful damn quick.

[Dustdevil]

Also having been on a backboard I cannot stress enough just how uncomfortable they are. I swear you can feel every bump on the road and they become outright painful damn quick.

Seriously. After the first few minutes on that thing, you find yourself wondering how this could possibly be "helping" you. The answer is, it is not.

[northernmedic]

Regarding this study http://www.ncbi.nlm.nih.gov/pubmed/16418091 which Doczilla referenced: I was referred to this study last year by the director of the spinal unit at the hospital where I normally transport to. His opinion is that the scoop is superior to the LSB in every respect and that is all that they use for transferring and moving spinal patients in the largest spinal cord trauma unit in Western Canada. Granted this study was a small sample size and sponsored by Ferno but I have used the scoop many, many times with great success.

Our normal policy at the above hospital is that every patient in taken off the LSB/scoop on arrival in emergency and left with a C-Collar on a transaver and care is transferred to the bedside nurse. The emergency staff specifically request pts be removed from spinal equipment on arrival to prevent pressure sores and aid in more rapid assessment.

[CBEMT]

Here we are implementing a protocol where medics transfer the patient to the ER gurney and immediately remove them from the backboard, leaving them in the c-collar laying flat on the bed before being seen by the physician. It is not c-spine clearance (in fact, most of these patients will ultimately undergo c-spine imaging), but goes far to improve their comfort.

There's no protocol and it's not standard practice, but there are several Ambulance Triage nurses at our trauma center who do exactly that.

Anyone who stays on a board comes off it as soon as they are seen by a doctor. Most of the nurses are pretty good about doing a "Hi Doctor, would you mind taking a minute and take a look at the patient that was just brought in so they can come off the board?" It also goes without saying that any boarded patient who goes to a trauma room loses the board within seconds.

It makes me laugh every time I see a backboard advertised as "100% x-ray translucent," because I've never once seen a patient go to any imaging device while still on a board. Collar, sure. Board, never.

The only part that annoys me is when Triage starts popping the buckles on board straps and farking around with the blocks and straps if the patient is staying on the board. If you've decided the patient has to stay immobilized until seen by a doctor, then KEEP them immobilized. I mean, duh?

This practice would likely also lead to an increased usage of a scoop for spinal care as opposed to a LSB which is better for the patient as well.

Part of a complete trauma assessment is visualization and palpation of the back- something I've never seen in any patient who was "scooped" from position found to the stretcher.

[Doczilla]

It makes me laugh every time I see a backboard advertised as "100% x-ray translucent," because I've never once seen a patient go to any imaging device while still on a board. Collar, sure. Board, never.

This may be more geared for the (category 1 or 2) trauma patients. Here, the patient is on the board for the primary and most of the secondary survey. Initial chest xray and pelvis xray are shot in the trauma bay within the first few minutes, and if the patient is on the board during that time, it greatly simplifies placing the xray cassettes to shoot the xray. When we roll to check the back, the patient is taken off the board.

I agree with CBEMT on the scoop issue. It may discourage the provider from log-rolling and doing a complete assessment. (I still think it should be used, just the point about assessing the back should be emphasized in training.) We see a similar issue with infants immobilized in place in car seats. Their back is rarely assessed, as evidenced by the broken glass they are laying on.

'zilla