Mounting Evidence Against the Long Spine Board in EMS

Transcription

1 Mounting Evidence Against the Long Spine Board in EMS Ryan C. Jacobsen MD, EMT-P Johnson County EMS System Medical Director Assistant Professor of Emergency Medicine Truman Medical Center/Children s Mercy Hospitals and Clinics

2 Disclosure This presentation was compiled from many gracious EMS Medical Directors throughout the U.S. and I take little credit for any of it.it is merely a synopsis/compilation of many others hard work, for which I am very grateful. Specific thanks to: Charles (Chuck) Cady MD Bryan Bledsoe MD Keith Wesley MD David Cone MD Michael Millin MD Steve Andrews MD Kevin Sirmons MD John Lyng MD

3 Objectives Understand current state of spinal care in EMS and associated dogma. Understand the historical perspectives on prehospital spinal care and immobilization in the U.S. Review of the evidence/literature surrounding prehospital spinal immobilization. Benefits of reducing the use of the long spine board as an immobilization device. Examples of various protocols being used throughout U.S. as well as internationally. Barriers to the implementation of protocols reducing long spine board use.

4 Divorce LSB from C-collars We re NOT talking about cervical spine clearance. There would be NO change in current c-spine clearance protocol. We re NOT talking about limiting cervical collar use in the field. This may actually increase the use of C-collars in the field! ****penetrating trauma

5 Scope Approximately 1 million spinal injuries in ED s every year. 2-3% have actual spine injury (of those only handful unstable).

6 Dogma regarding Spinal Immobilization Trauma=unstable spine injury=spinal cord injury=permanent neurological deficit=bad. Any additional movement of the neck/back may cause an injury that was not present immediately following the initial trauma or it may worsen an injury that was there prior to any subsequent medical intervention. Further injury is avoided by immobilizing the spine. Immobilization of the spine is safe. Medicolegal issues prevent us from changing.

7 History

8 History Geisler et al Retrospective study of trauma patients with delayed paralysis. failure to recognize the injury and protect the patient from the consequences of his unstable spine. regarding an MVC patient with skull fracture in 1955 who had delayed onset of paraplegia T4. the importance of proper first-aid (by EMS providers in field) was deduced from the fact that 29 patients [in their review] developed further paralysis through faulty handling. Geisler WO, Wynne-Jones M, Jousse AT. Early management of patients with trauma to the spinal cord. Med Serv J of Can. 1966;4:

9 The Dogma begins. Now the medical community believes that trauma patients should be immobilized on rigid devices to minimize the risk of delayed paralysis in the setting of occult spinal column injury.

10 History Continued Farrington,1968 Described the placement of a C-collar and a long or short backboard as necessary to keep the head and neck from sagging during extrication. The backboard was designed to assist in minimizing spinal movement during complex extrication maneuvers by freeing the hands of rescuers from actively holding spinal precautions. The backboard was not initially envisioned to be a long-term device to actually immobilize someone onto after they were extricated. Farrington DJ. Extrication of Victims. Journal of Trauma. 1968;8( )

11 The beginning of formal EMS 1971 American Academy of Orthopedic Surgeons (AAOS)published first guidelines for EMS. Emergency Care and Transportation of the Sick and Injured. Advocated use of spinal immobilization using a backboard and C-collar for trauma patients with signs and symptoms of spinal injury.

12 History Continued Bohlman, Linked delayed paraplegia, in 100 of 300 hospitalized cervical spine fracture patients, with concern that these injuries were being under-appreciated. Blamed EMS=inevitable knee jerk response Began applying spinal immobilization, using backboards and C-collars, based on mechanism of injury alone. Bohlman HH. Acute fractures and dislocations of the cervical spine. J Bone & Joint Surg. 1979;61A: Riggins RS, Kraus JF. The risk of neurologic damage with fractures of the vertebrae. J Trauma 1977;17: Soderstrom CA, Brumback RJ. Early care of the patient with cervical spine injury. Orthopedic Clinics of North America 1986;17:3-13. Burney RE, Waggoner R, Maynard FM. Stabilization of spinal injury for early transfer. J Trauma 1989;29:

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14 Evidence NO randomized controlled studies ever done.

15 Evidence that Long Spine Boards cause HARM Respiratory compromise (reduces FVC, FEV1 in healthy patients strapped to a board) Effect on injured patients? Ptx, pulm contusions, rib fx etc.. Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17:915-8 Walsh M, Grant T, Mickey S. Lung function compromised by spinal immobilization. Correspondence. Ann Emerg Med. 1990;19:615-6

16 Evidence for HARM Pressure sores/tissue hypoxia Good evidence that even short time periods on board cause tissue hypoxia on contact points as well as pressure wounds becomes worse with elderly and severely injured folks who can t readjust on board (aka spinal cord injured patient!) Linares HA, Mawson AR, Suarez E, Biundo JJ. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics. 1987;10: Sheerin F, de Frein R. The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces. J Emerg Nurs. 2007;33: Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995;26: Berg G, Nyberg S, Harrison P, Baumchen J, Gurss E, Hennes E. Near-infrared spectroscopy measurement of sacral tissue oxygen saturation in healthy volunteers immobilized on rigid spine boards. Prehosp Emerg Care. 2010;14:

17 Evidence for HARM Increased pain Healthy subjects placed on boards developed numerous complaints when on boards for short times (headaches, back, neck pain, dizziness, nausea) Barney RN, Cordell WH, Miller E. Pain associated with immobilization on rigid spine boards. Ann Emerg Med. 1989;18:918. Lerner EB, Billittier AJ, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects. Prehosp Emerg Care. 1998;2:112-6 Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23:48-51

18 Evidence for HARM Increase in unnecessary radiologic imaging in ED (this is both a cost and radiation risk issue) March J, Ausband S, Brown L. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002;6:421-4 Berrington de González A, Mahesh M, Kim K, Bhargavan M, Lewis R, Mettler F, Land C. Projected Cancer Risks From Computed Tomographic Scans Performed in the United States in Arch Intern Med. 2009;169: Hall E, Brenner D. Cancer risks from diagnostic radiology. Br J Radiol May;81: Forley F, Pham J, Kirsch T. Use of advanced radiology during visits to US emergency departments for injury-related conditions, JAMA. 2010;304:

19 Evidence for Harm Hauswald et al Compared neurologic outcomes of spinal injury patients in New Mexico, where every EMS patient received full, spinal immobilization, to those of spinal injury patients in Malaysia, where none of the EMS patients received spinal immobilization. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998;5:

20 Malaysia vs New Mexico

21 Malaysia versus New Mexico

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23 RESULTS The Odds Ratio for disability was higher for patients in the United States (all with spinal immobilization) after adjustment for the effect of all other independent variables (2.03; 95% CI ; p = 0.04). The estimated probability of finding data as extreme as this if immobilization has an overall beneficial effect is only 2%. Thus, there is a 98% probability that immobilization is harmful or of no value. They repeated analysis using only the subset of patients with isolated cervical level deficits. They again failed to show a protective effect of spinal immobilization (OR 1.52; 95% CI ; p = 0.34).

24 Evidence for Harm Leonard et al Pediatric trauma patients (prospective cohort) spinal immobilization was associated with increased pain and radiographic usage and increased admission to the hospital. pain score (3 versus 2) cervical radiography (56.6% versus 13.4%) Admitted (41.6% versus 14.3%). Leonard J, Mao J Jaffe D. Potential adverse effects of spinal immobilization in children. Prehosp Emerg Care 2012;16:

25 Penetrating trauma and Spine Immobilization We should NOT be immobilizing penetrating trauma. Increases mortality and clear support from all parties involved (AANS, ACS-COT, NAEMSP, NAEMT, ATLS/PHTLS etc..)

26 Evidence for Harm in Penetrating Trauma Cornwell EE, et al BACKGROUND: Previous studies have suggested that patients transported by emergency medical services (EMS) following major trauma had a longer injury-to-treatment interval and a higher mortality rate than their non-ems-transported counterparts. HYPOTHESIS: There is little actual benefit of thoracolumbar immobilization for patients with torso gunshot wounds (GSW). DESIGN: Retrospective analysis of prospectively gathered data from the Maryland Institute for Emergency Medical Service Systems State Trauma Registry from July 1, 1995, through June 30, SETTINGS: All designated trauma centers in Maryland. PATIENTS: All patients with torso GSW. MAIN OUTCOME MEASURES: (1) A patient was considered to have benefited from immobilization if he or she had less than complete neurologic deficits in the presence of an unstable vertebral column, as shown by the need for operative stabilization of the vertebral column; (2) mortality. RESULTS: There were 1000 patients with torso GSW. Among them, 141 patients (14.1%) had vertebral column and/or spinal cord injuries. Two patients (0.2%) (95% confidence interval, % to 0.48%) required operative vertebral column stabilization, while 6 others required other spinal operations for decompression and/or foreign body removal. The presence of vertebral column injury was actually associated with lower mortality (7.1% vs 14.8%, P<.02). CONCLUSIONS: This study suggests that thoracolumbar immobilization is almost never beneficial in patients with torso GSW, and that a higher mortality rate existed among those GSW patients without vertebral column injury vs those with such injuries. The role of formal thoracolumbar immobilization for patients with torso GSW should be reexamined. Arch Surg Mar;136(3): Thoracolumbar immobilization for trauma patients with torso gunshot wounds: is it necessary? Cornwell EE 3rd,

27 Evidence for Harm in Penetrating Trauma Haut ER BACKGROUND: Previous studies have suggested that prehospital spine immobilization provides minimal benefit to penetrating trauma patients but takes valuable time, potentially delaying definitive trauma care. We hypothesized that penetrating trauma patients who are spine immobilized before transport have higher mortality than nonimmobilized patients. METHODS: We performed a retrospective analysis of penetrating trauma patients in the National Trauma Data Bank (version 6.2). Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital spine immobilization, using patient demographics, mechanism (stab vs. gunshot), physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on Injury Severity Score category, mechanism, and blood pressure. We calculated a number needed to treat and number needed to harm for spine immobilization. RESULTS: In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine immobilization. Overall mortality was 8.1%. Unadjusted mortality was twice as high in spine-immobilized patients (14.7% vs. 7.2%, p < 0.001). The odds ratio of death for spine-immobilized patients was 2.06 (95% CI: ) compared with nonimmobilized patients. Subset analysis showed consistent trends in all populations. Only 30 (0.01%) patients had incomplete spinal cord injury and underwent operative spine fixation. The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66. CONCLUSIONS: Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010;68:115-20; discussion

28 Evidence for Harm in Penetrating Trauma Rhee P, et al ,523 trauma patients Evaluated by: Blunt assault Stab wounds Gunshot wounds Rhee P, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma. 2006;61:

29 Evidence for Harm in Penetrating Trauma Rates for C-spine Fx: GSW (1.35%) Blunt Assault (0.41%) Stab Wound (0.12%). Rates of Spine Cord Inj: GSW (0.94%) Blunt Assault (0.14%) Stab Wound(0.11%) Rhee P, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma. 2006;61: Surgical stabilization: GSW (26/158 [15.5%]) Blunt Aslt(6/19 [31.6%]) Stab Wnd (3/11 [27.8%]) No patient with penetrating SCI regained significant neurologic recovery.

30 Author s Conclusions Don t get shot in the spinal cord.. Neurologic deficits from penetrating assault were established and final at the time of presentation. Concern for protecting the neck should not hinder the evaluation process or life saving procedures. Don t waste time on scene packaging..just go.

31 Evidence for Harm in Penetrating Trauma Vanderlan WB, et al NOLA retrospective chart review: 847 charts 188 studied patients 35 (22.9%) died 27 immobilized 8 not immobilized GSW (94%) Stab wound (6%) C-spine immobilization in this study was associated with an increased risk of death (p = 0.016, odds ratio 2.77, 95% CI ). Vanderlan WB, Tew BE, McSwain NE. Increased risk of death with cervical spine immobilization in penetrating cervical trauma. Injury. 2009;40:

32 Evidence for Harm in Penetrating Trauma Kaups KL, et al Fresno study. 215 patients with GSW to head: DOA and c-spine injuries excluded. Cervical spine clearance was determined in 202 (93%). No patients had indirect c-spine injury. 3 patients had direct c- spine injury that was readily apparent. Kaups KL, Davis JW. Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. J Trauma. 1998;44:

33 Author s Conclusions More intubation attempts occurred in patients with cervical collars: 49 attempts in 34 patients with c-collars 5 attempts in 4 patients without c-collars (p=0.008). Indirect spinal injury does not occur with GSWs to head. Kaups KL, Davis JW. Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. J Trauma. 1998;44:

34 GSWs rarely cause spine injuries DuBose et al patients with GSW s to the head, neck, or torso 327 (7.8%) had spinal column injuries 173/327 had spinal cord injuries 2 (0.6%) patients required surgery None had unstable spinal injuries DuBose et al: The role of routine spinal imaging and immobilization in asymptomatic patients after gunshot wounds. Injury 2009;40:

35 American Academy of Neurological Surgeons (AANS) Position Theodore N et al Neurosurgery Spinal immobilization in patients with penetrating trauma is not recommended because of increased mortality from delayed resuscitation.

36 PHTLS Position There are no data to support routine spine immobilization in patients with penetrating trauma to the neck or torso. There are no data to support routine spinal mobilization in patients with isolated penetrating trauma to the cranium. Spine immobilization should never be done at the expense of accurate physical examination or identification and correction of life-threatening conditions in patients with penetrating trauma. Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011;71:763-9; discussion

37 Cochrane Review Unwarranted spinal immobilization can expose patients to the risks of iatrogenic pain, skin ulceration, aspiration and respiratory compromise, which in turn can lead to multiple radiographs, resulting in unnecessary radiation exposure, longer hospital stay and increased costs. The potential risks of aspiration and respiratory compromise are of concern because death from asphyxiation is one of the major causes of preventable death in trauma patients. Kwan I, Bunn F, Roberts I. Spinal immobilization for trauma patients. Cochrane Database of Systematic Reviews. 2009;1:1-15

38 U.S. Consortium of Metropolitan Medical Directors Position Statement aka: The Eagles Current best practices reflect that there are no randomized controlled trials to evaluate the benefits of spinal immobilization in out-of-hospital trauma patients. As a result, current EMS protocols are based principally on historical precedent, dogma and medico-legal concerns, and not on scientific evidence. This situation is further complicated by the reality that such studies will not likely be performed in the future, primarily as a result of perceived legal and ethical concerns. There is, however, a growing body of literature that points to the potential deleterious effects of spinal immobilization, whether or not this modality is applied in an appropriate fashion.

39 The Eagles Taking it one step further.(they apparently don t like c-collars that much either) We might therefore consider discontinuing the use of the cervical collar in alert, cooperative trauma patients, even with a suspected C-spine fracture, unless consciousness deteriorates or if the application of a collar might provide the patient with a degree more comfort. It is certainly also time for EMS systems to remove collars from their protocols for the management of patients with penetrating trauma.

40 Evidence for Benefit???

41 We have assumption that LSB s actually immobilize the spine..

42 3 points of contact for LSB Occiput T-spine Sacrum

43 We painted a student.

44 Then carefully laid them on a LSB

45 Then lifted the student off T-spine occiput sacrum

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47 HOW WELL DO BOARDS IMMOBILIZE?

48 Spine boards as immobilization devices Mazolewski et al Study of different strapping techniques demonstrated that healthy, cooperative volunteers are still able to move when strapped to a backboard. Mazolewski P, Manix T. The effectiveness of strapping techniques in spinal immobilization. Ann Emerg Med. 1994;23:1290-5

49 Spine boards as immobilization device Silbergleit R et al During transport, once on a backboard, patients still subject to significant head to toe and side to side forces. (remember boards are slippery and we fix their head to them and allow body to move) Silbergleit R, Dedrick DK, Pape J, Burney RE. Forces acting during air and ground transport on patients stabilized by standard immobilization techniques. Ann Emerg Med 1991;20:

50 Spine boards as immobilization devices Peery et al A prospective observational study showed 70% of study patients had at least one backboard strap with 4 or more cm of slack, and 12% of study patients had 4 or more backboard straps with 4 or more cm of slack. Peery CA, Brice J, White WD. Prehospital spinal immobilization and the backboard quality assessment study. Prehosp Emerg Care. 2007;11:293-7.

51 Combative Patients We pin them down, onto a board, while they squirm and are held down at head. Likely increasing energy/forces transmitted to spine.

52 Uncooperative Patient

53 Combative patients We claim that we are forcefully pinning their head down and forcing them supine on a hard board in order toe protect their spine from themselves as they violently squirm under the straps. This technique likely increases forces/energy transmitted to the spine. Allowing them to have collar on and get into position of comfort likely less energy to spine.

54 Forced Immobilization.worse than no immobilization? Hauswald M Tightening the straps may restrict movement but not the forces generated by the patient on the spine in resistance to restraining efforts. Attempting to enforce immobilization of the uncooperative patient may result in more force transmission to the spine than before the struggle commenced Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. 2012;00:1 4.

55 Spine board as immobilization device The clinical significance of strap tightness and patient movement while immobilized has not been established, but such movement cannot qualify as immobilization, the very purpose for which backboards continue to be used during transport.

56 Spine Boards as Immobilization Devices If patients are still able to move despite being strapped to a backboard, spinal immobilization is more a function of their cooperation than the due to the ability of the backboard and straps to assure spinal immobilization.

57 Limitations of Studies on Long Spine Boards Studies on the effectiveness of backboards as an immobilization device have only included cooperative patients, healthy volunteers, and cadaver models; no study has been done evaluating patient resistance and its effect on the spine.

58 What about Scoop Stretchers Del Rossi et al Scoop Stretchers and the lift and slide technique were able to restrict motion of the spine as well as the log-roll technique with long board. Del Rossi et al. Are Scoop Stretchers Suitable for use on spine-injured patients? American Journal of Emergency Medicine 2010.

59 What Extrication Technique Causes Least Spine Movement? Shafer et al West J Emerg Med May; 10(2): Cervical Spine Motion During Extrication. A Pilot Study They used motion capture video to look at motion of spine during different techniques of extrication from car.

60 Extrication techniques and Spine Motion 4 Different Techniques were compared 1. The patient was allowed to exit the vehicle on their own and lie on a backboard. 2. The patient was allowed to exit the vehicle on their own with a C-Collar in place and lie on a backboard. 3. The patient was extricated head first via standard technique by two paramedics with a C-Collar alone. (Standard technique involves turning the driver so that the legs are in the passenger s seat, allowing the driver to lie back and raising the right hip so a long board can be placed under the hip. A second paramedic who enters the front seat passenger s door helps slide the patient up on to the board.) 4. The patient was extricated head first via standard technique by the two paramedics with a C-Collar and a KED.

61 Author Conclusions? Ultimately, we documented the least movement of the cervical spine in subjects who had a cervical collar applied and were allowed to simply get out of the car and lie down on a stretcher.

62 Extrication techniques on Spine Movement Emerg Med J Jun 28. Dixon M, O'Halloran J, Cummins NM.. METHODS: A crew of two paramedics and four fire-fighter first responders extricated a simulated patient from a prepared motor vehicle using nine different extrication techniques. The patient was marked with biomechanical sensors and relative movement between the sensors was captured via high speed infrared motion analysis cameras. A 3D mathematical model was developed from the recorded movement. RESULTS: Control measurements were taken from the patient during self-extrication and movement was recorded of left of midline (LOM) to right of midline (ROM) resulting in a total movement of The least deviation recorded during equipment aided extrication was movement of LOM and ROM resulting in a total movement of The most deviation recorded during equipment aided extrication was movement of LOM and ROM resulting in a total movement of CONCLUSIONS: Conventional extrication techniques record up to four times more cervical spine movement during extrication than controlled self-extrication. This proof of concept study demonstrates the need for further evaluation of current rescue techniques and the requirement to investigate the clinical and operational significance of such movement.

63 Ambulance Cots are essentially Padded Long Spine Boards Once the patient is secured to the ambulance cot, the backboard becomes redundant, as the standard transport cot provides a flat surface to which the patient can be secured. Like the hospital bed, the ambulance cot and straps can provide spinal protection reducing spinal flexion, rotation, and lateral motion. In addition, the cot mattress can conform to the anatomic shape of the spine and the non-slick surface minimizes patient movement on the cot. Transport on a mattress is largely without the downside risks of the backboard.

64 Our EMS Cot

65 We re-painted our student.and laid him on our cot mattress

66 Comparison of points of contact showed likely increased points of contact and more comfortable than LSB

67 Using Logic as an argument to reduce LSB use in the field

68 We ve all met these elderly/kyphotic patients Risk>>>>benefit

69 Faulty Assumptions The time that the patient hits the ED door DOES NOT mean that their evaluation and/or care begins at that point in time. Patients who arrive immobilized may stay that way for significant periods of time until they are seen and removed from the board by someone authorized to do so.

70 Should I go to the hospital? We ve always instinctively known that these patients don t need a Long Spine Board. Minor falls Ambulatory patients Minor MVC s What does the ED do with walk-ins?

71 New Thoughts Hauswald: A Re-conceptualisation of Acute Spinal Care Injury caused by ENERGY (MVC, Fall, GSW), not motion. Energy at time of injury great Energy during EMS care/extrication is minimal Motion at uninjured segments different than injured segments and force may not equate to visible motion. Longboard: low friction surface, energy to anchor points (head/neck) isn t that worse?

72 Questioning long held beliefs that movement by field providers causes harm Hauswald The spine requires little energy to move within its normal ROM, and offers little resistance to motion within this range. Since the spinal components fail at similar force, spinal injuries are either minor, with no threat to the spinal cord, or are catastrophic, with multiple, irreversible failures that may irreparably damage the spinal cord so severely that they will be unaffected by prehospital emergency spinal care. If the force experienced to create the unstable fracture was not enough to injure the cord at that time, then forces experienced during patient movement by EMS are unlikely to injure the cord. If the force results in injury but not gross instability, additional forces applied by prudent rescuers during extrication and transport will be spread throughout the spine (as long as not outside normal ROM). Most spinal injuries are stable in the short term and those that are truly unstable and offer no resistance to motion are irrevocably damaged at the time of the event.

73 Questioning Long Held Beliefs Spinal column itself is very strong, requiring up to Newtons to fracture the cervical spine. (approx pounds of force!) A 4kg head hanging off of the bed only generates about 40N of force! Spinal motion during extrication by careful rescuers creates forces at most on the order of magnitude created by gravity, and are spread throughout the spinal column unless the column itself cord included had lost all structural integrity at that level. Thus, motions induced by rescuers do not achieve the forces needed to threaten spinal column integrity. High friction, comfortably firm surface (aka the cot or bed) is the ideal surface. Traditional low friction, hard/slipper surfaces that are uncomfortable (ie: can cause tissue hypoxia) are bad. Maiman D, Sances A, Myklebust J, Larson S, Houterman C, Chilbert M, El-Ghatit A. Compression injuries of the cervical spine: a biomechanical analysis. Neurosurgery 1983;13:

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76 Evidence for Benefit of Long Spine Board????

77 Potential Benefits to NOT using LSB? Reduce amount of on-scene personnel. Reduce amount of patients lifted from ground on LSB who are already ambulatory. Reduce amount of awkward positions providers place themselves in to extricate otherwise well patients from vehicles. Reduce scene times by eliminating time spent immobilizing to board. (cot straps are quick!...lsb strapping is NOT quick)

78 Increases Ability for Providers to Expose Patients While Enroute to Hospital?

79 Virtually Impossible to Gain Access to patient when strapped to Long Spine Board If you do unstrap enroute you ll only have head secured as fixed point (that s bad!)

80 Benefits to reducing LSB use Decreased awkward extrication of stable patients who could self-extricate Less resources/manpower needed (two folks and a cot for most minor MVC s with neck pain). Less scene time when using cot straps and not securing head. More exposure/access to patient enroute. More comfort for patient. Saves patient from ED doc who leaves on board in hospital. Decrease radiological studies. Decreases cost. Decrease in resistance to placing a c-collar in elderly or borderline patient when not mandated to use LSB.

81 We re not alone in our efforts to minimize LSB use

82 Agencies/EMS Systems Minimizing LSB use North Memorial Ambulance & Aircare Minneapolis, MN HealthEast Medical Transportation St. Paul, MN Xenia Fire Department Xenia, OH Rio Rancho Fire Department New Mexico Albuquerque-Bernalillo County Medical Control Board New Mexico Bernalillo County Fire Department New Mexico SERTAC (Southeast Regional Trauma Advisory Council in WI) State of Connecticut (Department of Health) State of Maryland CentraCare Health Monticello, MN Kenosha Fire Department Kenosha, WI MedicWest Ambulance Nevada Norwalk Hospital Connecticut Eagle County Ambulance District Colorado Milwaukee EMS WI Outside of US Queensland Ambulance Service, Trauma clinical practice procedures: Use of an extrication board. 2012; edical/pdf/09_cpp_trauma_ p df

83 Example Protocol Wording in Wisconsin SERTAC (Southeast Regional Trauma Advisory Committee) Spinal immobilization consists of keeping the head, neck and spine inline. The neck can be immobilized with a well fitted cervical collar, head blocks, blanket rolls or other immobilization techniques. Patients who are already walking or standing should be laid directly on the ambulance stretcher and secured to the stretcher with seatbelts. Back boards and scoop stretchers are designed and should only be used to extricate patients. Once extricated, patients should be taken off the back board or scoop stretcher and be placed directly on the ambulance stretcher. Patients with penetrating traumatic injuries should only be immobilized if a focal neurologic deficit is noted on physical examination (although there is little evidence of benefit even in these cases)

84 Example Protocol Wording Yale/New Haven Sponsor Hospital EMS System Effective immediately, long backboards will no longer be utilized for spinal immobilization of ambulatory patients. Patient who are ambulatory at the scene, but who require cervical immobilization based on our selective spinal immobilization protocol, will be placed in the position of comfort, limiting movement of the neck during the process. This change in procedure is the first step toward eventually using long boards only when needed to facilitate extrication, and not during transport.

85 Queensland Ambulance

86 Queensland Ambulance

87 Protocol Wording If Spinal Immobilization is indicated, an appropriately sized cervical collar should be placed. Patients who are already ambulatory or standing should NOT be placed on a long spine board, but rather be laid directly on the ambulance cot and secured to the cot with seatbelts in a position of comfort. Back boards and scoop stretchers are designed for extrication and patient movement and should not be used for spinal immobilization. There is no role for the KED board in EMS. Once extricated, patients should be taken off the back board or scoop stretcher and be placed directly on the ambulance stretcher. Patients with penetrating traumatic injuries (including head, neck and torso) should only be immobilized if a focal neurologic deficit is noted on physical examination. Decisional patient s have the right to refuse any aspect of spinal immobilization.

88 Queensland Notice they do NOT allow transport on a LSB!

89 Parting Thoughts Despite the long-standing history and culture of spinal immobilization with a backboard and cervical collar, using the best evidence available, many abroad and in the US believe the risk-benefit analysis shows that the proven harm is much worse than the theoretical, but unproven, benefit of the backboard.

90 People don t like to change Note the conclusion in this article!

91 If Spine Boards were a Medication? If a medication had the same risk/benefit as the LSB, use of the drug would be stopped immediately by the FDA.

92 Barriers to Implementation Overcoming Dogma/Institutional Culture/Long Standing Traditions Buy-In from Hospital/Helicopter Agencies/Critical Care Transport Agencies Physicians Nursing Flight Crews Buy-in from EMS Providers Risk Management/Liability Issues Ensuring proper documentation/qa EMS Provider educational roll-out Equipment Issues (differences between agencies, budgetary issues) Logistics (actual procedures to be performed in field, ensuring they are quick/safe/effective) Appropriate wording of Protocol to ensure common understanding/intent by field providers Overcoming differences with State/National Curriculums and Standards

93 Johnson County EMS Proposed Language (see bolded print) Spinal Immobilization: Indications Blunt trauma patients that meet Step 1, 2 or 3 (See appendix B) or experience axial load; fall of >3 feet; rollover, ATV, cycle or pedestrian/vehicle accidents will be immobilized. Patients with penetrating traumatic injuries should NOT be immobilized unless a focal neurologic deficit is noted on physical examination. Spinal immobilization is indicated in trauma patients who sustain a mechanism of injury sufficient to cause a neck or back injury and who display at least one of the following criteria. Use caution for occult fracture in age >65 or <4 years old or history of osteoporosis, bone or vertebral disease. Unreliable physical exam, such as GCS < 15, inability to fully cooperate, evidence of intoxication or acute stress reaction Pain, deformity or tenderness to the neck or back A distracting painful injury Neurologic deficit Pain produced on unassisted rotation of the head 45 degrees in each direction Techniques Stabilize head and neck in neutral position unless movement causes pain, deformity, or resistance. If so, immobilize the head and neck in the position found. If the patient is ambulatory, place an appropriately sized cervical collar and position the patient directly on the ambulance cot in the position of comfort, limiting movement of the spine during the process. Patients that are stable, alert and without neurological deficits may be allowed to self-extricate to the ambulance cot after placement of a cervical collar. Limit movement of the spine during the process. If a Long Spine Board or Scoop Stretcher are used for extrication or patient movement, the patient should be taken off the long spine board or scoop stretcher and placed directly on the ambulance cot using an appropriate technique that minimizes movement of the spine.

94 Issues to deal with.. What to do with multiple boarded patients when we d typically put one on the bench seat in full package? Vomiting patient that is not on board. Gravid patient not on board (how to roll them off their IVC). Football players with helmets on. Swimming pools already packaged by lifeguards on arrival of EMS.

95 Pregnant patients, vomiters?

96 Seemed like a good idea at the time but

97 Spine Boards as Modern Art? Maybe their best use?

98 Best Picture EVER

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