Spinal immobilization, Treatment or Torture?

Spinal “Immobilization”Treatment or

Torture?

By Luke Winkelman, PM, NRP, EMS-I 2017

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Glossary• Spinal Immobilization • Spinal Motion Restriction - SMR• Spinal Cord Injury - SCI• Dogma• Sacred Cow• Evidence Based Medicine - EBM

History of SMR

• First Mentioned in 1965 by Col. Louis C Kossuth[1]

• “move a victim from the vehicle with a minimum of additional trauma”

• “due regard to maximum gentleness”

History of SMR

• 1967 by J.D. Farrington, MD in position article: “Death In A Ditch”[2]

i. “…frequently mishandled injuries, made worse by hasty and rough movement from a vehicle or other accident scene...”

• 1968 by J.D. Farrington in: ‘Extrication of victims-surgical Principles.’[3]

i. “[I]mmobilization and in-line traction are the basic principles of extrication.”

History of SMR

• The first EMT text to include Spinal Immobilization using rigid board was Emergency Care and Transportation of the Sick and Injured. [4]

• American Academy of Orthopedic Surgeons, 1971

The Spine

• Structure

• Protection

• Flexibility

Injuries to the Spine

• Lost productivity• Can be fatal• Significant psychosocial impact• High medical cost

Cost Of Spinal Cord Injury

• 253,000 people in US living with SCI• 12,000 new cases each year• In the US MVC related SCI estimated $34.8

billion per year -Spinal Cord Injury Information Network[5]

• SCI cost first year, $1,023,924• SCI cost years 2+, $171,808 -National Spinal Cord Injury

Statistical Center[6]

Everybody Get’s a Backboard

MOI Indicators

• Fall from 2-3 times the patient’s height

• Fall distance not the strongest indicator

• Portion of body to strike first

• Surface that stops the fall

• Age, co-morbid pathophysiology

MOI Indicators

• Death in same compartment

• Extended Extrication

• Vehicle Damage• Cabin intrusion >= 12 inches• Rollover/roof deformity

Mechanism of Injury

https://www.youtube.com/watch?v=0HAGMb_jAdU [7]

MOI ALONE NOT RELIABLE

• Worst indicators: "motorcycle crash with separation of rider," "pedestrian hit by motor vehicle," "motor vehicle crash with rollover," and "motor vehicle crash with death of occupant."

• Best Indicators: "ejection from a vehicle" and "prolonged extrication time.“ - Kohn et’al. Acad Emerg Med. 2004[8]

MOI ALONE NOT RELIABLE

• Medics showed 80% accuracy predicting disability by using patient and scene assessment with MOI indicators.

• Decreased when MOI was only factorVaca FE, et al J Emerg Med. 2009 [9]

MOI Case Study

• A CLIMBER fell 1,000ft down mountain

• Walked away• Was found standing

up, reading a map.NBC News 2011 [10]

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What are the odds?

Likelihood of Spine Injury

• “2000–6000 Newtons of force to fracture the cervical spine” Maiman DJ, Sances A Jr, Myklebust JB, et al 1983 [11]

• Just under 1 million pt.'s immobilized, only 2–3% of these patients actually had spinal injuries, most were stable. Goldberg W, Mueller C, Panacek E, et al. 2001 [12]

• Common Blunt injuries (MVCs, falls from standing & heights, assaults) only 1.2%–3.3% had spinal injury and of those only 0.4%–0.7% had potential to worsen. Kwan I, Bunn F. 2005; [13]

Likelihood of Spine Injury

• 7 months, Phoenix AZ

• 228 blunt force trauma patients

• 122 complaints of neck pain • 3(0.98%)cervical injuries – stability

unknown -Am J Emerg Med. 1989 [14]

Blunt Force-MOI

No Injury Injury

Unstable InjuryStable Injury

3-5% [15]

No Damage-YETDamage Done

Conscious Obtunded

0.4-0.7% [16]

NNT=1032NNH=66Haut, Elliott R., et al 2010 [17]

0.38% [17]

SMR- Who MAY benefit???

So What If We Stopped?

• What if the patient was their own best immobilizer?

• “Conventional techniques ~ up to four times more cervical spine movement during extrication than controlled self-extrication (Rigid Collar and patient then self extricating)”-Engsberg JR et al; J Emerg Med. 2013 [18]

So What If We Stopped?

• Malaysia vs New Mexico 5 year study– 120 pt’s seen at University of Malaya

• None immobilized

• 11% neurologic disability

– 334 pt’s seen at University of New Mexico• All immobilized w/ C-Collar• 21% neurologic disability -Acad Emerg Med. 1998 [19]

The Science Behind “Immobilization”

…….Still waiting…….

Not Science

What could it hurt?

Pressure Ulcers

• Est. 14.8% of acute care patients have pressure ulcers Amlung SR, et al; 1999 [21]

• 29 wk cost per healthcare acquired ulcer $129,248 -Am J Surg. 2010 [22]

• Per ulcer cost $9.1-11.6 Billion/yr –Association for Healthcare Resource &

Materials Management [23]

• “Spinal immobilization for unconscious patients with multiple injuries” Craig Norris, MD BMJ 2004 [24]

Respiratory Compromise

• Backboard Only Ann Emerg Med. 1988 [25]

i. 15 volunteers

ii. “Significant difference” in FVC and FEV1.

• Backboard & C-Collar Prehosp Emerg Care. 1999 [26]

i. 39 volunteers

ii. Wooden backboard or vacuum mattress.

iii. 15% decrease in FEV1 on average. (worse at extremes of age).

iv. Vacuum mattress more comfortable.

Back Pain

• 21 healthy volunteers• Immobilized for 30 minute period. • Results: headache, sacral/lumbar pain, jaw pain

most common. • 55% subjects moderate to severe symptoms. • 29% developed symptoms 48 hours post

removal -Chan D Ann Emerg Med. 1994 [27]

Pop out the collar!

Journal of Trauma, 1983 [28]

Displaces Unstable Fractures

• Unstable cervical fractures created in 7 fresh human cadavers

• Rigid collar

• Assessed movement

• Avg 7.7mm±6.8mm axial plane

• Avg 2.9mm±2.5mm cranial-caudal plane

-J Trauma. 2011 [29]

Displaces Unstable Fractures

• Ankylosing Spondylitis– 15 patients with traumatic

injury able to walk immediately following the injury,

– 12 deteriorated– 6 of these were due to over

extension of the kyphotic spine (40% were complete injuries).

10-year review. Thumbikat P, et al; 2007 [30]

Cost Of a C-Collar

The EMS Store [31]

Cost Of a C-Collar

• Obligatory radiological exams >$200 [32]

• 5% patients who complain of neck pain following blunt force have c-spine injury Ersoy G et’al Eur J Emerg Med. 1995 [33]

Increased ICP

• 90% of pt’s with C-collar experienced significant increases in ICP, 100% experienced decrease in GCS - 10 consecutive pt’s Mobbs ET AL, ANZ J. Surg. 2002; [34]

• Estimates of ~34% of trauma pt’s meeting current immobilization criteria have a head injury, and are susceptible to rise in ICP-Daniel Kwan, MD 2014 [35]

Increased Risk of Aspiration

• Decreased ability to open mouth

• Difficulty swallowing

• Head Injury patients at increased risk for emesis.

Br J Neurosurg. 1996 [36]

Difficult to Manage Airway

• Collar vs Manual Inline Stabilization– 50 surgical patients– MILS Intubation success 66% better

than collar and board -Heath KJ. Anesthesia 1994 [37]

MILS vs none• 200 Elective surgery patients• 50% failure rate in 30 seconds

with MILS vs 5.7% without. -Thiboutot F, et al. 2009 [38]

Delayed Care/Resuscitation

• 30,956 Patients• No group of penetrating trauma patients had any survival

benefit with spine immobilization. • Spine immobilization was independently associated with

significantly decreased survival. • Significantly decreased survival for GSW and for

hypotensive groups -Haut ER, Kalish BT, Efron DT, et al. 2010 [39]

So What If We Stopped?

• “Most patients who do have spinal injuries are mechanically ‘stable’ at least in the short term—stable in that significant force would need to be applied to the injured site to cause further damage.” -Hauswald et al 2012 [40]

The Short of the Longboard

EndangeredENDANGERED!

Technique

Technique

• Log roll? There’s GOT to be a better way

Surg Neurol Int. 2012 [41]

Technique

• The awkward log roll“[S]tatistically significant displacements of the injured spine.”

• Still no deterioration Hyldmo, et’al. 2015 [42]

Poor Skill Performance

• 50 SMR subjects

• 15 (30%) at least one strap unsecured• 44 (80%) at least 2cm slack in straps

-Duke University 2007 [43]

Liability

Liability

• 1987-1992 only 76 cases of EMS lawsuits• Over 40% (31)of cases were dismissed• Only 5 cases paid out $1+ Million• Most were ambulance crash related• Immobilization suits were less frequent than

Refusal, Consent, Abandonment, & Improper restraint -World Association for Disaster and Emergency Medicine 1994 [44]

• 95% of EMS lawsuit “Root cause” is provider poor attitude and patient dissatisfaction- PWW 2010 [45]

Liability

• 2002 Case Study [45,46]

• 24 yo intoxicated male• Fell 8 ft from the top of a wall • Pt. reports his head and neck hurt• ”Get up, are you drunk?” “Get up, or we’re going

to call the police”• “Snatched him up and threw each arm over their

shoulders and dragged him to the stretcher”

Liability

• 2002 Case Study Cont’d [45,46]

• Could not move his arms or legs• Pt reports his neck “Snapped back”• “It was like somebody hit a light switch and I just

went completely numb”• Expert witness- “Mr. Smith’s quadriplegia is

directly attributable to the actions of the paramedics.”

Liability[47]

[48]

2015 IDPH EMS ProtocolIDPH EMS [49]

Positions

• NAEMSP• “Patients without a mechanism of injury with the potential

for causing spinal injury or those patients without one of the above clinical findings may safely have spinal immobilization omitted. ~ should be transported in a position of comfort.”[50]

Positions

• NASEMSO[51]

Positions

• NAEMSP & ACS Joint Statement• “Long backboards are commonly used to attempt to

provide rigid spinal immobilization ~~ However, the benefit of long backboards is largely unproven”

• “Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks” [52]

Positions

• International Liaison Committee On Resuscitation2015 draft [53]

The Wise Guys

Systems that have removed the LSB from spinal immobilization protocols[54]

•State of New Hampshire

•State of Pennsylvania

•Harris County Texas (ESD 5)•Chaffee County Colorado•Alberta Canada

•South Australian Ambulance Service

•Johnson County Kansas

•Sedgwick County Kansas (Witchita)

The Wise Guys

https://www.youtube.com/watch?v=OyFsV2CP15A [55]

Baby Steps

• We were immobilizing anyone that fell from a standing height

• Now - significantly less LSB use

• Tomorrow’s headlines:

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References

References• [1] http://journals.lww.com/jtrauma/Citation/1965/11000/THE_REMOVAL_OF_INJURED_PERSONNEL_FROM_WRECKED.4.aspx• [2] “Death in a Ditch,” by J.D. Farrington, MD, FACS May/June 1967 edition of the American College of Surgeons Bulletin• [3] http://journals.lww.com/jtrauma/Citation/1968/07000/EXTRICATION_OF_VICTIMS_SURGICAL_PRINCIPLES_.2.aspx• [4] Emergency Care and Transportation of the Sick and Injured. AAOS, 1971 LC Call No.: RC87.A528• [5] www.spinalcord.uab.edu• [6] https://www.nscisc.uab.edu/• [7] https://www.youtube.com/watch?v=0HAGMb_jAdU• [8] https://www.ncbi.nlm.nih.gov/labs/articles/14709422/• [9] https://www.ncbi.nlm.nih.gov/pubmed/19561820• [10] http://www.nbcnews.com/id/41334296/ns/world_news-europe/t/almost-flying-climber-survives--foot-fall/#.VO-YcvnF-OU• [11] https://www.ncbi.nlm.nih.gov/pubmed/6621839• [12] https://www.ncbi.nlm.nih.gov/pubmed/11423806• [13] https://www.ncbi.nlm.nih.gov/pubmed/15748015• [14] http://www.ncbi.nlm.nih.gov/pubmed/2920074• [15] https://www.ncbi.nlm.nih.gov/pubmed/11423806• [16] https://www.ncbi.nlm.nih.gov/pubmed/11597285• [17] https://www.ncbi.nlm.nih.gov/pubmed/20065766• [18] http://www.ncbi.nlm.nih.gov/pubmed/23079144• [19] http://www.ncbi.nlm.nih.gov/pubmed/9523928• [20] http://www.naemsp.org/pdf/spinal.pdf• [21] http://www.ncbi.nlm.nih.gov/pubmed/11794440• [22] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950802/• [23] http://www.ahrmm.org/cqo-movement/files/leading-practices/hapu-uva-executive-summary.pdf• [24] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC515204/• [25] https://www.ncbi.nlm.nih.gov/pubmed/3415063• [26] https://www.ncbi.nlm.nih.gov/pubmed/10534038• [27] https://www.ncbi.nlm.nih.gov/pubmed/8273958• [28] https://www.ncbi.nlm.nih.gov/pubmed/6864837

References• [29] https://www.ncbi.nlm.nih.gov/pubmed/21217496• [30] https://www.ncbi.nlm.nih.gov/pubmed/18091492• [31] http://www.theemsstore.com/store/product.aspx/productId/1175/• [32] http://www.jcl.com/hospitals/average-pricing-information/x-rays#72040• [33] http://www.ncbi.nlm.nih.gov/pubmed/9422206• [34] http://www.neurospineclinic.com.au/pdfs/journal-articles/hard-collar-icp.pdf• [35] http://www.slideshare.net/danielkkwan/ems-sspinal-immobilization-time-for-a-change slide-17• [36] https://www.ncbi.nlm.nih.gov/pubmed/8922712• [37] http://www.ncbi.nlm.nih.gov/pubmed/7802175• [38] https://www.ncbi.nlm.nih.gov/pubmed/19396507• [39] https://www.ncbi.nlm.nih.gov/pubmed/20065766• [40] https://www.ncbi.nlm.nih.gov/pubmed/22962052• [41] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3422095/• [42] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4573694/• [43] http://www.ncbi.nlm.nih.gov/pubmed/17613902• [44] http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8435291&fileId=S1049023X0004142X• [45] https://www.ncemsf.org/about/conf2010/presentations/stark_liability.pdf• [46]http://www2.ca3.uscourts.gov/opinarch/011895.txt• [47] http://archive.boston.com/news/local/articles/2006/08/24/injured_woman_drowns_under_rescue_boat/?camp=pm• [48] http://www.emsworld.com/news/10706794/settlement-reached-in-nh-fatal-airboat-rescue-lawsuit• [49] http://www.idph.state.ia.us/ems/common/pdf/ems_protocols.pdf• [50] http://www.naemsp.org/Documents/Position%20Papers/POSITION%20IndicationsforSpinalImmobilization.pdf• [51] http://www.nasemso.org/Projects/ModelEMSClinicalGuidelines/documents/NASEMSO-Model-EMS-Clinical-Guidelines-DRAFT.pdf

Page 172• [52] http://www.naemsp.org/Documents/Position%20Papers/POSITION%20EMS%20Spinal%20Precautions%20and%20the%20Use

%20of%20the%20Long%20Backboard.pdf• [53] http://www.scancrit.com/wp-content/uploads/2015/02/ILCOR-Cervical-Collar-Guidelines-DRAFT-2015.pdf• [54] https://www.facebook.com/groups/emtstudygroup/permalink/351267485065814/• [55] https://www.youtube.com/watch?v=OyFsV2CP15A

Questions?