EMS Field Cervical Spine Assessment Protocol

EMS Field CervicalEMS Field CervicalSpine Assessment ProtocolSpine Assessment Protocol

VVEMSTodd Lang, MD

EMS Medical Director

Why do this?

• Current practice it totally variable• Clear, reproducible local standard• Easy tool to measure compliance• Formal training in cspine evaluation• Can modify in future to incorporate new

data

ObjectivesObjectives

• Discuss Risk & Benefit of C Spine Immobilization

• Identify ways to safely lower use of C Spine Immobilization

• Review structure and function of the nervous system

ObjectivesObjectives

• Identify situations in which full immobilization is indicated

• Identify situations in which full spinal immobilization is not indicated

• Review VVEMS spinal assessment protocol

• Maintain appropriate level of suspicion for this dangerous but rare condition

We use the words “Spinal Assessment” to indicate that we are evaluating the spine for risk of injury. We are not “Clearing” it or guaranteeing that there are no injuries. We are using medical evidence to formulate a policy to balance the risks and benefits of immobilization for the bulk of our patients.

Terminology

Who can use this protocol?Who can use this protocol?

• Only those EMS providers who have successfully completed the training for the VVEMS Spinal Assessment.

• This be the didactic portion• Then, pass the test• Then use it!

What is “NEXUS?”What is “NEXUS?”

• National Emergency X-radiography Utilization Study

• Prospective study with 34,069 patients• Evaluated decision rule to identify patients

with cervical injury by clinical exam who did not need radiography

How do we decide in the ED?

• Two main studies• NEXUS• Canadian C-Spine Rule

NEXUSNEXUS

• Out of 34,069 patients, the decision rule identified 810 of 818 patients with injury– 2% of blunt trauma patients had cervical injury– Two patients classified as “unlikely to have

injury” actually had a cervical injury.– One of the two one missed patients required

surgery.

NEXUS

• Did not include MOI• Did include: altered LOC/intoxication,

Midline tenderness, distracting injury, neuro exam,

• Up to age 60

Stable, GCS 15 pts.

A dangerous mechanism is considered to be a fall from an elevation of >=3 feet or 5 stairs; an axial load to the head (e.g., diving); a motor vehicle collision at high speed (>100 km per hour) or with rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision.

A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle.

Canadian C Spine Rule

Does C-Spine Immobiliztion Work?

• No one really knows.

Hauswald Study

• Compared Malaysian patients to New Mexico patients.

• Worse outcomes from New Mexico spinal cord injuries: more likely to have disability

• Not definitive, but very provocative• No evidence to the contrary, either, yet

Benefits of ImmobilizationBenefits of Immobilization

• “Standard of Care”• May prevent injury worsening• Thought to prevent liability

• Not so convincing, are they?

Harms of C-spine Immobilzation

• Pain• Anxiety• More radiographs and CT scans• Money• Pressure sores• Harder to manage airway• Change in lung function

Why immobilize anyone?Why immobilize anyone?

• Unstable cervical injury is rare.• Any protocol needs to:

– emphasize safety (sensitivity) over efficiency (specificity)

– balance the small benefit of avoiding spinal immobilization in the many patients without injury against the possibly catastrophic harm associated with failing to immobilize the rare patient with significant spinal injury

The SkullThe Skull• Made up of bones that

form immovable joints• Know the “helmet” bones

of the skull:– Frontal, parietal, temporal,

and occipital– Important in describing

injury location• Mandible =

– the lower jaw bone• Maxilla =

– the upper jaw bone

SkullSkull

• Temporal bone (Basilar) skull fractures often diagnosed by exam– Raccoon eyes– Battle’s sign

• The middle meningeal artery runs within the temporal and parietal bones– Fractures associated with

epidural bleeding

Skull Exam

• Lumps, dents, wounds: describe by location and size and structures seen

• Ears: blood or not, TM normal or not• GCS: don’t say “in & out.” Use a number.• Pupils/CN exam• Jaw function, voice, airway

CSF (cerebrospinal fluid) bathes brain and spinal cord

– Patient with closed head injury who has a “runny nose” is leaking CSF (basilar skull fracture)

– Can also come out of ears

The SpineThe Spine

• Cervical (7)• Thoracic (12)• Lumbar (5)• Sacral 5 (1 fused)• Coccyx 4(1 fused)

The VertebraeThe Vertebrae• The spinal cord rests

between the bony processes and body of the vertebrae.

• The spine of the vertebra is superficial and can be palpated when performing a physical exam.

Spinal CordSpinal Cord• Part of the central

nervous system (CNS)– Nerves leaving each

vertebra have a specific function.

• Bathed in cerebrospinal fluid (CSF).

• Protected by bony vertebrae.

Cervical nervesCervical nerves“C3,4,5 keeps the diaphragm alive!”“C3,4,5 keeps the diaphragm alive!”

• C1• C2 neck rotation and sensation• C3 spontaneous breathing• C4 spontaneous breathing• C5 diaphragm, shrugging shoulders• C6 flexion of elbow• C7 extension of elbow

Cases Requiring Full ImmobilizationCases Requiring Full Immobilization

1. Higher Risk or unknown mechanism of injury2. Altered LOC (GCS<15, or changed)3. Presence of other distracting painful injury4. Subjective spine pain5. Subjective neurological deficit6. Objective neurological deficit7. Objective midline spine tenderness 8. Any pain with unassisted neck motion

Patients meeting anyany of the following criteria must be fully immobilized.

MOI with some risk

• Fall• MVA• High energy injury• Even minor MOI in right (wrong!) patient

Higher Risk MOIHigher Risk MOI• Violent impact to the head, neck, torso, or pelvis.• Sudden acceleration, deceleration, or lateral bending

forces to the neck or torso.• Falls from greater than 3 feet. Elderly patients (>65)

falling out of bed or from standing height.• Ejection or fall from motorized or human powered

transportation device.• Axial load (diving).• Unwitnessed loss of consciousness/syncope with head

trauma

Mechanism of Injury

• A relatively weak tool, but one which is easy and free.

• One which has been used more in the past than in the present and future

• No really good data to tell us “what MOI can give you a spinal injury?”

• We will use this as a part of our first revision of spinal immobilization protocol

Altered Level of AlertnessAltered Level of Alertness

• Clearance of the cervical spine requires that the patient be calm, cooperative, clinically sober, and alert.

• Includes patients that are poor historians.– Children and toddlers– Some elderly: are they altered from usual?

• Generally, GCS must be 15 to clear spine

Reliable Physical Exam

• Language• GCS/Capacity/reproducibility• Hearing• Ability to sense pain

LOC/Intox• What about “2 beers?”• Chronic drunks?• Chronic narcotics?• Other drugs like meth?• Just anxious?• No clear answer from literature• Probably more to lose than to gain in this

group by not immobilizing

Distracting Injury

• Of variable use• Some injuries are more distracting than

others• Not part of Canadian C-S rule• Is part of NEXUS, but was left up to the

attending physician to define it• Part of EMS criteria for now• Less used in ED assessment now

Presence of Distracting InjuryPresence of Distracting Injury• Any injury that produces pain that impairs the

patient’s ability to appreciate other injuries:– Head injury– Long bone fractures– Large lacerations– Abdominal or pelvic pain– Large burns– Medical conditions: cardiac pain or difficulty breathing

• This is an equivocal and poorly defined concept• Will remain a part of our EMS algorithm.

Subjective Neurological DeficitSubjective Neurological Deficit

• Patient complains of numbness, tingling, pins and needles, shooting arm pain, etc.

• Patient complains of decreased strength or decreased ability to move limbs

• Any patient who describes transient numbness and tingling should be fully immobilized even if symptoms have resolved

Subjective Spine PainSubjective Spine Pain

• Patient complains of cervical or thoracic spine pain.

• “Do you have any neck or back pain?”• If yes, immobilize.

Objective Neurological DeficitObjective Neurological Deficit

• Patient cannot move an extremity• Patient’s extremities are flaccid• (Patient has abnormal motor reflexes)• Generally: grips, push pull, flex/extend

feet, intact gross sensory in all 4.

Objective Spine TendernessObjective Spine Tenderness

• Patient has tenderness upon palpation of the cervical or thoracic spine.

• You must palpate each cervical and thoracic vertebra

• Continue down spine• Apply an axial load to top of head

Practice exam!

• Demo up front 2 people• Same every time you do it• You won’t forget a step that way.• Stop at first positive sign and immobilize.• Don’t do ROM if they have pain, n/t, or

other sign!

Other Exam Abnormality

• Your physical exam reveals:– Swelling– Bruising or redness– Abrasions– Deformity

Abnormal Motor or Sensory

• This has room for error and was source of error in the studies of C-S

• Pain down arm/leg, numb/tingle, even transient sx

• Bony Tenderness (midline, on the spine)• Pain with ROM

Beware the “Stinger”

• Transient shooting pain down the arm• Common in football• This is a subjective neuro sign and is

grounds for concern and immobilization• You can’t get this without injury to a nerve

Pain with Unassisted Neck MotionPain with Unassisted Neck Motion

• If ALL of the previous criteria have been satisfied, the final step is to ask the patient to move their neck without your assistance.

• If the patient has any subjective pain, they need to be fully immobilized.

• “Look to the left and right. Now touch your chin to your chest. Now look back over your head.”

Bottom Line:

• Can they reliably, reproducibly, and convincingly understand you, cooperate, and pay attention for the exam and have a MOI that should not have broken their neck?

• If not, immobilize.

Guiding PrinciplesGuiding Principles

• The VVEMS Spinal Assessment Protocol is designed to allow EMS providers to assess and transport those few blunt trauma patients for whom significant injury is unlikely without full immobilization.

• Once one criterion for immobilization is positive, immobilize and transport the patient.

Guiding PrinciplesGuiding Principles• Patients who satisfy all of the criteria in the

Protocol and who request EMS transport may be transported without full spinal immobilization.

• All Protocol criteria must be carefully evaluated and documented for all patients transported without full spinal immobilization.

VVEMS C-Spine Assessment ToolVVEMS C-Spine Assessment ToolHigher risk MOI?

NoNo

Full Spinal Immobilization

Altered level of alertness?

Distracting injury?

Objective or subjective neurological deficit?

Pain with unassisted neck motion?

Transport without full spinal immobilization

NoNo

NoNo YesYes

YesYes

NoNo

NoNo

YesYes

YesYes

Neck pain or tenderness?

NoNo

YesYes

YesYes

Sample Documentation

• MVC low speed• GCS15, clear speech• No numb/tingle/pain down arms, moves all 4• No sig injuries• No spine tenderness• Normal ROM w/o pain• Immob not indicated

Maine 2002 C-spine

Vermont EMS District 3 Spinal Assessment Form

Date: ________________ Patient’s name: ________________________ Patient’s birth date: _____________________ EMS Service: __ ________________________ EMT-I: _______________________________ Mechanism of Injury:__ _____________________________________ ________________________________________________________________________________________________________________ Describe any findings that require immobilization precautions under “details.”

Immobilization

Criteria

Yes

No

Pertinent Positives

Significant mechanism of injury

Altered mentation or intoxication

Subjective spine pain

Objective spine tenderness

Subjective neurological deficit

Objective neurological deficit

Presence of other distracting (painful) injury

Pain with unassisted neck motion

Guiding PrinciplesGuiding Principles• EMS providers should involve online

medical direction for any difficult cases, including patients who meet criteria for spinal immobilization, request EMS transport, and refuse immobilization.

• If a patient requests transport with full immobilization, EMS providers should comply with their wishes independent of significant injury risk.

Guiding PrinciplesGuiding Principles

• The default management of any blunt trauma patient in the field is full immobilization.

• EMS providers must use full c-spine immobilization for cases that are vague.

• Let us err on the side of caution because a single bad outcome will cause endless suffering

ConclusionConclusion

• Always use full immobilization for patients with an unknown or significant MOI.

• Elderly patients are more prone to orthopedic injuries and may not present with obvious signs and symptoms of injury.

• Contact online Medical Direction for questions in the field.

ConclusionConclusion

• A patient with blunt trauma should be fully immobilized unless ALL criteria of the VVEMS Spinal Assessment Protocol are met.

Don’t fall asleep at the wheel just because spine injuries are

rare!

Assess each patient carefully!

Sources• Maine 2002 Spinal Assessment Protocol

http://www.maine.gov/dps/ems/docs/assessment%20book.pdf

• Hauswald M, et al. Out-of-hospital spinal immobilization: its effect on neurologic injury http://www.aemj.org/cgi/content/abstract/5/3/214

• EAST Practice Management Guidelines for Identifying Cervical Spine Injuries Following Trauma http://www.east.org/tpg/chap3.pdf

• Canadian C-Spine rule• NEXUS paper

Questions?Questions?