To Backboardor Not To Backboard?

Spinal Clearance Protocols

Will Smith, MD, EMT-PMedical Director

Grand Teton National Park andJackson Hole Fire/EMS, Jackson, WY

www.wildmedconsulting.com

ObjectivesDiscuss current standard of care and

protocols regarding spine injuries.Review research on spine injuries and

evaluation/treatment standards.How to implement spine assessment

protocols into your system.

Spinal Immobilization1960-70’s

EMS standards developedConsensus and Common Sense

Thought to be best practiceNow changing?

Who needs to be immobilized?

Even if they walked away from this?

Spinal ImmobilizationDo we immobilize for:

Mechanism of Injury?

Symptoms and/or Physical finding?

Spinal ImmobilizationLittle research

Never been shown to improve outcomesHauswald, Acad Emerg Med 1998Malaysia vs. New Mexico

Spinal ImmobilizationBUT - Standard of Care (in U.S.)

One of the most common EMS proceduresMillions of patients immobilized each yearNot necessarily in other parts of the world

Most Current EMS ProtocolsApply spinal immobilization to all

patients with potential for spine injurybased on mechanism of injury

If in doubt - IMMOBILIZE!

The ResearchNo RCT to asses spinal immobilization

on trauma patient mortality, neurologicinjury, spinal stability, or adverse effectssustainedKwan, Cochrane Database 2001/2007 #2803

The ResearchNEXUS

Hoffman, et. al. - NEJM, July 2000

Canadian C-Spine RuleStiell, et. al. - JAMA, Oct 2001

NEXUSMajor Research - moves to a standard of

clinical spine clearance in emergencydepartments

Decreased imaging in 12.6 % (4,309 pts)N=34,069 patients

NEXUS All 5 criteria met = No Xray

1. No midline cervical tenderness2. No focal neurological defect3. Normal alertness4. No intoxication5. No painful distracting injury

Canadian C-Spine RuleMajor Research -Slightly different protocol - more if/then

Age listed as a factorMechanism still plays a roleRange of motion of neck final test

www.caep.ca

Malaysian /New Mexico Study5 yr retrospective chart review of 2

university hospitalsLess neurologic disability in

unimmobilized Malaysian patientsHauswald, Acad Emerg Med 1998

Disproves many theories that previouslyjustified widespread spine immobilization

Taking this to the field…Wilderness EMS

Rural EMS

Urban EMS

Wilderness EMSExtended Transport

2 hours to daysRisks of Spinal Immobilization

Decubitus ulcers, pt. discomfortAirway concerns - vomit, blood, etc.Extrication problems, rescuer risks

Risk vs. Benefit of Spinal Immobilization

Wilderness EMS

Wilderness EMSFocused Spine AssessmentAccepted protocol for Wilderness First

Responders (WFR)WMA, NOLS/WMI, SOLO

Risk vs. benefit of spinal immobilization

Rural EMSProlonged Transport

15 minutes to 1-2 hours

Pt. uncomfortable, no provider riskAirway concerns - vomit, blood, etc.Early stage 1 Decubitis Ulcers (redness)

Urban EMSRapid Transport

Less than 15 minutesPresent to emergency departments

Spine clearing protocolsNEXUS, Canadian C-Spine Rule

Xrays or CTs

Little risk to patients or EMS providersAirway concerns -vomit, blood, etc.

Flight EMSPatient’s cleared in referral ED’s by CT

and board certified EM physicians placedback on boards for transfer to traumacenters.

Why change what we’re doing?Patient ComfortAirway CompromiseBreathing CompromiseSkin CompromisePatient/Provider safety in certain settings

Some places have…MaineMichiganCaliforniaNational Park Service

Malaysia (by default)

Focused Spinal AssessmentProtocol Implementation

Review ResearchReferences are a startDo your own as well!

Medical Director / Medical ControlSupportCritical for success

Focused Spinal AssessmentProtocol Implementation

Review Established ProtocolsState of MaineNational Park Service

State of Maine

www.maine.gov/dps/ems

National Park Service

NPS EMS Field Manual, Version 02/05, Procedure 1150

Wilderness Medical Associates

www.wma.org

Focused Spinal AssessmentProtocol Implementation

Develop Protocol that works for yoursystemAge >65 get collar?Peds excluded?

Focused Spinal AssessmentProtocol Implementation

Good QA/QI programEducation of EMS ProvidersOngoing Review of Decisions and

Outcomes

SummaryNot everyone with blunt trauma needs

spinal immobilization in the ED or in thefield

Selective immobilization can and shouldbe done by prehospital providers

Questions???

Copy of lecture noteswww.wildmedconsulting.com