April 23, 2016
1) Understand best practices of spinal immobilization 2) Updated indications for use of backboard and C- collar 3) Open the conversation with your local medical director Disclaimer: This discussion and the opinions by the panel members is not intended to supersede local protocols. Talk with your medical director.
1) Dr Gee SPH 2) Dr Gildea CMC 3) Ron Brunell City Fire 4) Blaine Cowan Rural Fire 5) Don Leatham Life Flight Network 6) Brian Vibbert Clinton Fire 7) Jeff Welch MESI
Montana BOME: MT Prehospital Treatment Protocols Criteria for spinal precautions (only 1 needs to be present to require spinal precautions) Mechanism consistent with potential for spinal injury (ie. Significant falls (greater than 20ft), or MVC with significant MOI, or direct trauma to head, neck, or back) Neck/back pain or tenderness Abnormal neuro exam or complaint of sxs (ie. Sensory/motor abnormalities or hx of LOC with current injury, or altered mental status) Multi-system trauma (potential for distracting injury) Revision 1.5 March 2015
Montana BOME: MT Prehospital Treatment Protocols Omission criteria (all of the following must be met to allow for selectively not following spinal precautions) Normal neurological exam in cooperative pt (fully alert and oriented pt and normal sensory/motor exam) Normal VS Absence of intoxicants Absence of neck/back pain or tenderness Absence of distracting injuries No communication barriers (due to language, intellect, intoxication, emotional condition, etc) Revision 1.5 March 2015
Montana BOME: MT Prehospital Treatment Protocols Patients with penetrating trauma to head, neck, torso and no evidence of SCI should not be immobilized on a backboard Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for 1) pts who are found to be ambulatory at the scene, 2) pt who must be transported for a protracted time, particularly prior to IFT, or 3) pts for whom a backboard is not otherwise indicated (p. 42) Revision 1.5 March 2015
Montana BOME: MT Prehospital Treatment Protocols General Considerations Manual Immobilization Cervical Collar Backboard Rapid Extrication vs KED/Short Board http://b.bsd.dli.mt.gov/license/bsd_boards/med_boar d/pdf/emt_protocols.pdf
Event: 25 yo M MVC at highway speeds roll over ETOH smell and beer cans all over ground EMS Patient walking on scene. Questionable as to whether ejected or self extricated. Significant bleeding from scalp. Patient is agitated and combative, does not remember events of accident. P 110, BP 145/90, Sat 95%, RA, RR 24, GCS 14 Pt denies neck pain, denies cervical pain with palpation, pressure dressing placed on scalp with continued bleeding. Denies numbness or tingling in extremities, equal strength in all extremities. Patient becomes more agitated and uncooperative.
What further examination should be conducted on scene? Do you think a C-Collar necessary? Do you think a back board necessary? What does an abnormal spine feel like? What if you were only 10 min from the hospital? Or 60 min?
Arrived as Trauma Standby (because of mechanism + LOC, and obvious head trauma) P 118, BP 130/89, 3 L NC 99%, RR 24, GCS 14 To CT In CT patient complained of mid back pain on transfer to table.
Large Scalp Laceration T 1-2 spinous process fx
Event: 75 M Fall from stool at home while painting in garage; large scalp laceration EMS Arrived with patient lying on garage floor significant bleeding from scalp Patients reports syncope with positive LOC HX Coumadin for Afib, CHF, COPD, home O2-2 L P 65, BP 96/56, Sat 85%, RR 20, GCS 15 Pt C/O neck pain and soreness to left side of neck, denies cervical pain with palpation, concern for large amount of blood from head laceration. Pressure dressing placed on scalp with continued bleeding..
What further examination should be conducted on scene? Does this patient need to be immobilized? How?
1308: Arrived as Trauma Standby (because of head trauma, amount of blood loss, and reports of hypotension) P 100, BP 99/45, 3 L NC 92%, RR 24 Procedure: Scalp laceration stapled and bleeding controlled 1323: To CT 1413: Vit K and K centra given CT revealed C2 lateral mass fx non displaced First C-collar not placed until after CT Neurosurgery consult: advised Miami J for 6-8 weeks at all times Patient admitted to Trauma Services
Large Scalp Laceration C2 Lateral Mass fx
Event: 20 M Ejected from full size truck during roll over found 40 ft from vehicle Highway speeds EMS: Arrived with patient on ground c/o extreme back pain Repetitive questioning Laceration on scalp bleeding Assessment reveals patient unable to feel or move lower extremities P 110, BP 130/93, RR 28, O2 Sat 97% RA, GCS 14 20 min transport time to first facility
What further examination should be conducted on scene? Does this patient need to be immobilized? How?
1045: Patient arrives as trauma activation: P 109, BP 129/62, 2 L NC, O2 Sat 98%, GCS 14, mild confusion, repetitive questioning Physical examine reveals no feeling or movement in lower extremities, back board removed during exam taken to CT CT finding- Compression fracture with facet dislocation at T12 with spinal cord injury Surgical intervention required Plans to transfer to Level II Trauma Center
T12 compression fx Complete Paraplegic
Should the patient be re-back boarded for transport? Other options vacuum mattress scoop? What if the patient still has some intact extremity sensation how would this change the care?
General approach for patients at risk: Spinal motion restriction basically flat on stretcher with C- Collar NO backboard for long transports Per Dr. Eileen Bulger, MD Harborview
1) Backboard advised for extrication only 2) The use of backboards can cause more damage than good 3) Re-backboard a patient for intra-facility transport is not recommended 4) Include a complete assessment and documentation 5) Discuss with your medical director in your local area Thank you for your participation! You can find the presentations and references on the Spring Fever Trauma Conference page: http://montana.providence.org/events/st-patrickhospital/professional-events/spring-fever-trauma-conference/.