Spinal Immobilization

[ny10570 745]

First off, I am fully aware of how rare significant spinal trauma is in your typical MVA. That being said, it does happen. So why is it we are so relaxed about properly applying the collar and immobilizing. Everyone just gets a small collar and then they're asked to slide onto the board. If they're stable get out the KED and do it the right way. Car is banged up and you can't get at the patient without them moving, let fire get to work. I have yet to meet the ff who bitches about cutting a car. If nothing else when you do finally get the legit injury you'll be proficient and comfortable with your equipment. Most Westchester agencies wouldn't dream of walking a patient to the bus yet as soon as its an accident they have no qualms about compromising c-spine just because they think its bull. Don't take this as me advocating collars and boards for everyone and every accident. If the mechanism is insufficient and the physical exam is clear they should up and moving. I'm a huge fan of field clearing c-spine. What this is all getting at is, if you're going to do it, do it right. Thanks for reading, I'll put the soapbox away now.

Edited February 18, 2008 by ny10570

[WAS967 97]

At present our protocols regarding spinal immobilization are old and antiquated. The old way of thinking, where we immobilize everyone just because there is a dented fender is kind of moot. Comparing cars of today with cars of yesterday we often see very low impact accidents result in thousands of dollars worth of damage to a vehicle. Cars now are designed to absorb the kinetic energy of an accident so as to not transfer it to the people inside. Take a car from the 70s and put it into the same accident and it would probably just need a new bumper. Problem is the person inside gets hit a LOT harder.

Spinal immobilzation IMHO is actually OVER used. If you pull up to an accident where the car is pretty banged up, but the person got out of the car PTOA and is walking around with nothing but a few scraped and bruises, no complaint of pain anywhere, no distracting injuries (fractures to extremities with contant pain, intoxication that could mask pain, etc), would you immobilize them? My answer would be no. Right now our protocols don't support this way of thinking but that will (hopefully) be changing soon. New protocols (BLS) are on the way (unsure if it's regional or state) that allow us to immobilize patients based on presentation....ie....we rule them IN for spinal injury, not rule OUT. Any person who is uncomplicated, who has a spinal injury, WILL complain of pain. Be it simple whiplash to a displacement of the cervical vertebra.

[The first person to bring up a call in Brooklyn where there was supposedly a patient that was walking around fine after a severe accident and supposedly RMA'd then turned around and turned his neck and collapsed and died cause he supposedly had an unstable axis/atlas fracture - gets smacked.]

Certainly the kinematics and mechanism of trauma should NOT be ignored. Use it to HELP formulate a plan for treating your patient, but don't let it DICTATE your treatment plan. If the person wants to RMA but you think they should go, show them the car and use that to help convince them to go get checked. (I always tell people that in an MVA there is no fault insurance and there should be no cost involved in them going to get checked out).

Here's another thought. Do this. Take a backboard and toss it on a stretcher. Lay down on it and have someone strap you in and block you in. Then have them drive around town a bit. Then ask yourself - "How do you feel?". I bet you'll be damned uncomfortable. Now think of other treatments we provide. Are there treatments we provide that aim to make a person uncomfortable? Then why do we do it with immobilization? Also, how well does a regular longboard actually immobilize the spine? (Answer: Not very well at all). If we REALLY wanted to do a GOOD job at spinal immobilization, we'd all be carrying those full body vacuum sand splints.

So my way of thinking is simple - treat the patient. No neck or back pain? No pain on flexion/extension/rotation? No PMS involvement leading you to suspect a spinal injury? No distracting injuries? No immobilzation. Plain and simple.

[/soapbox]

[firemoose827 324]

[The first person to bring up a call in Brooklyn where there was supposedly a patient that was walking around fine after a severe accident and supposedly RMA'd then turned around and turned his neck and collapsed and died cause he supposedly had an unstable axis/atlas fracture - gets smacked.]

I would like to bring up another story I heard about c-spine injury. (Without getting smacked...PLEASE!LOL)

When I took my EMT-CC class the instructor told us of a call he did a month ago. Hes a county EMS Coordinator/Paramedic, he responded to an accident, 1 car rollover. The responding ambulance was advised that the PT had exited the vehicle and was seated on the tire. Upon the Medics arrival the crew were doing a standing backboard take down anyway, and when asked they said "As a precaution" simply.

As it turned out, when the PT went for x-rays they found a fractured vertabrae in his neck that hadnt displaced or moved. If he had turned his head fast or sneezed or any kind of violent movement he would have either been paralyzed or been killed. Just wanted to share that after seeing your post.

Certainly the kinematics and mechanism of trauma should NOT be ignored. Use it to HELP formulate a plan for treating your patient, but don't let it DICTATE your treatment plan. If the person wants to RMA but you think they should go, show them the car and use that to help convince them to go get checked. (I always tell people that in an MVA there is no fault insurance and there should be no cost involved in them going to get checked out).

Here's another thought. Do this. Take a backboard and toss it on a stretcher. Lay down on it and have someone strap you in and block you in. Then have them drive around town a bit. Then ask yourself - "How do you feel?". I bet you'll be damned uncomfortable. Now think of other treatments we provide. Are there treatments we provide that aim to make a person uncomfortable? Then why do we do it with immobilization? Also, how well does a regular longboard actually immobilize the spine? (Answer: Not very well at all). If we REALLY wanted to do a GOOD job at spinal immobilization, we'd all be carrying those full body vacuum sand splints.

So my way of thinking is simple - treat the patient. No neck or back pain? No pain on flexion/extension/rotation? No PMS involvement leading you to suspect a spinal injury? No distracting injuries? No immobilzation. Plain and simple.

Very well put and you have good points. The longboard realy doesnt do a complete job of immobilization, but yet everyone treats them as "Divine Intervention" and if the pt is in one they cant get hurt. More advancements in C-spine injury detection and care in the field need to be addressed and implemented.

[Engfire 0]

A question for all of you NY guys do you guys have a spinal clearance checklist that must be followed before you can clear c-spine. I my local standing order it is an optional skill that our medical director is not comfortable with us partacing and I can understand why, and even if we did their is a approx 12 step checklist that the local EMS council has developed, and I am pretty sure that even if the Pt has self extricated themselves that not a reason for not backboarding.

During a recent lecture in my medic class our instructor who is a hospital EMS coordinator told us of a story about a local dept that did not board a gunshot Pt who was shot side to side because the bullet was in and out. Not to mention they did not take this Pt to a trauma center, but thats a different story.

Edited February 18, 2008 by Engfire

[louis 1]

All your Answers to spinal imbolization is correct. But don't go to the hospital with a MVA patient and their not collared and boarded. Protect the patient and yourself. Board and Collar. If the patient does'nt want it have them sign the back of the PCR and document that patient refuses. Have a cop witness it. Trust me after all said and done and two years have past when your Ambulance Corp. gets a letter pertainig to a lawsuit by the victim. Make sure Board and Collared.

[20y2 43]

CYA medicine is bad medicine. I can not wait for these horrible protocols relating to the blind boarding of MVAs and shots to go the way of blodletting.

[STAT213 332]

All your Answers to spinal imbolization is correct. But don't go to the hospital with a MVA patient and their not collared and boarded. Protect the patient and yourself. Board and Collar. If the patient does'nt want it have them sign the back of the PCR and document that patient refuses. Have a cop witness it. Trust me after all said and done and two years have past when your Ambulance Corp. gets a letter pertainig to a lawsuit by the victim. Make sure Board and Collared.

ummm...NO.

There is A LOT of research pointing to the fact that long spine boards do more harm than good. Immobilizing someone just because they have been in an MVA is uneeded. NYS is WAY behind the times - again, what a shock - in terms of this. I clear c-spines in the field all the time. All it takes is following the pathway and documentation. If they don't have neck pain, there is no reason to immobilize them.

Now, NYS BLS protocol requires immobilization with anyone with a mechanism, right. So, do the right thing with your protocols and do what is best for you patient. And, go to the protocol review meetings and ask for changes.

Just because its in protocol somewhere does not mean its right.

[JohnnyOV 2]

Spinal immobilzation IMHO is actually OVER used. If you pull up to an accident where the car is pretty banged up, but the person got out of the car PTOA and is walking around with nothing but a few scraped and bruises, no complaint of pain anywhere, no distracting injuries (fractures to extremities with contant pain, intoxication that could mask pain, etc), would you immobilize them? My answer would be no. Right now our protocols don't support this way of thinking but that will (hopefully) be changing soon. New protocols (BLS) are on the way (unsure if it's regional or state) that allow us to immobilize patients based on presentation....ie....we rule them IN for spinal injury, not rule OUT. Any person who is uncomplicated, who has a spinal injury, WILL complain of pain. Be it simple whiplash to a displacement of the cervical vertebra.

[The first person to bring up a call in Brooklyn where there was supposedly a patient that was walking around fine after a severe accident and supposedly RMA'd then turned around and turned his neck and collapsed and died cause he supposedly had an unstable axis/atlas fracture - gets smacked

[/soapbox]

I wont bring up the brooklyn call, but I will bring up the call in yorktown, where the guy crashed a rented dealers lambo into a few yards / fences / wall. He was walking around and fine on scene and refuse transport / medical care. The next time i spoke to the medics, he had called 911 complaining of severe neck pain. They took him to the hospital to find he had a c-spine fracture after completing x-rays.

[Guest alsfirefighter]

WAS and STAT great posts.

I'm with WAS and we have a progressive medical director who is comfortable with c-spine clearance and I do it often as well as many of my colleagues and we have had a 100% success rate. So in many cases the patients I assess on scene do arrive at the hospital with no spinal immoblization. I don't play the CYA game. As STAT said there are cases where it can cause more injuries and we all have treated the elderly who have fallen, suffer from osteoporosis and many elderly females have an obvious kyphosis to their back. You are going to cause the potential for further injury or create injury in the case of preventive spinal immobilization.

Moose in the instance you discuss (and its an awesome experience that you shared...thanks!) with a good physical assessment of palpating each individual cervical vertabrae that patient would have generally experienced pain with palpation. Those cases are extremely rare where they are asympomatic. I had a friend that I went through Paramedic school with who had a similiar instance where he was struck in the head by a tree limb. He said it knocked him silly but he eventually got up and was stiff for several days but thought nothing of it. For several months he would deal with stiffness and pain, went to the doctor nothing showed up on x-ray and again he went along thinking it would subside. It didn't. Finally he got a CT scan and that is when they found he had a compression fracture. The key is he had reportable pain and while the area he lived in they did x-ray only (he should have been CT'd immediately but that's beside the point as well) most spinal injuries of any spinal region will progress with pain. Anyone who has had a patient with severe pain to the spine knows that 99% of the time its a fracture upon diagnosis at the ED. And when I say pain...I mean pain..not "my back hurts" and putting them on a board makes them even unhappier.

The key is good physical assessment in conjunction with MOI. In motor vehicle accidents I account for the age of the car and how it reacted to the impact and the forces involved. The speed of travel plays huge in my mind and whatever speed they state I take that into account plus about 5-10 mph and the condition of the interior of the car. Steering wheel...seat belt use with or without airbag deployment and what is the condition of the seat belt at its connection point. Ripped stitching means a good amount of force. But I couple that with a good initial assessment and another before making a final determination.

[helicopper 1,050]

I wont bring up the brooklyn call, but I will bring up the call in yorktown, where the guy crashed a rented dealers lambo into a few yards / fences / wall. He was walking around and fine on scene and refuse transport / medical care. The next time i spoke to the medics, he had called 911 complaining of severe neck pain. They took him to the hospital to find he had a c-spine fracture after completing x-rays.

So immobilization wasn't an issue, was it?

The point about protocols being out of date is very true. Our field protocols seldom keep up with research or in-hospital treatment practices. There should be a balance for pre-hospital personnel to make board/no board decisions based upon an assessment of the incident, vehicle, and patient.

There are probably as many negative outcomes from immobilization as there are from not immobilizing.

[ONEEYEDMIC 68]

I cringe when I see crews bring out the KED. For one I believe that it takes too long and there is way too much movement. Although I was trained in it, I don't think I actually used it. It was faster and easier and I think safer for my partner and I to stabalize the neck and do less movement with the PT right onto a backboard and onto the stretcher. With the KED you have to stabalize the neck. move the PT foward, back, strap and maybe move again if the straps get caught you have to move again. Then you have to turn and put the PT on the backboard. I just think it is a waste of time.

[WAS967 97]

As it turned out, when the PT went for x-rays they found a fractured vertabrae in his neck that hadnt displaced or moved. If he had turned his head fast or sneezed or any kind of violent movement he would have either been paralyzed or been killed. Just wanted to share that after seeing your post.

Says who? I sincerely doubt he would have just dropped dead from a sneeze. Any impinging of the spinal column or nerves would most definatly deal a LOT of pain (trust me I know - been there done that). There are many different types of fractures involving the vertebra from full blown shattering (really bad) to chipped spinal processes (not so bad).

As for KED, the biggest problem is people just plain aren't adept at using it. A team of providers who are adept at using the KED can have it on in less than a minute. (Mind you, I'm not a huge fan of them either.)

[NWFDMedic 58]

I wish I would have read this thread 2 days ago. I just threw out the statistics on the large scale "selective spinal immobilization" protocol. From memory, the bounds of the study were as follows: (1) the patient must not complain of neck or back pain on palpation, (2) the patient must be conscious, alert, and oriented, (3) there must not be a distracting injury, (4) I forget the fourth criterion, but I vaguely seem to remember something about penetrating trauma. EMT's and paramedics were allowed to board any patient based on their judgment of the mechanism, regardless of whether the patient ruled into these criteria if I'm not mistaken, which may skew results a bit because the skill level of providers does vary.

The bottom line was in something like 20,000 cases, only 1 patient was not immobilized who was later found to have an unstable cervical fracture. That would be 0.005% of the cases and I believe the footnote said that this case was even not noted on the initial x-ray in the hospital, but don't quote me on that. There were also a handful of patients that were not immobilized who had stable cervical fractures, ones that apparently pose little risk of being worsened by lack of immobilization.

The last I heard about selective spinal immobilization was that it was in front of SEMAC and they were hammering out the particulars of a protocol that the lot of doctors could agree upon.

[nycemt728 49]

Ok so alot of people here are talking about being progressive, new studies so and so forth...thats all well and good and while I agree tha alot of MVA pts are ambulatory, asymptomatic, or have no signifigant MOI, protocol is still protocol. We all can quote study after study on somthing, CPR effectivness on the back, compressions only CPR, compressions on the abdomen...but you don't see anyone being progressive there and doing it b/c they feel its what is best for the pt. I'm not saying current NY protocol is correct, up to standard or anything of the sort, but until it changes, in todays sue crazy society, the sad reality is its much safer for the EMT to stick to the protocols, however outdated they may be.

[NWFDMedic 58]

Ok so alot of people here are talking about being progressive, new studies so and so forth...thats all well and good and while I agree tha alot of MVA pts are ambulatory, asymptomatic, or have no signifigant MOI, protocol is still protocol. We all can quote study after study on somthing, CPR effectivness on the back, compressions only CPR, compressions on the abdomen...but you don't see anyone being progressive there and doing it b/c they feel its what is best for the pt. I'm not saying current NY protocol is correct, up to standard or anything of the sort, but until it changes, in todays sue crazy society, the sad reality is its much safer for the EMT to stick to the protocols, however outdated they may be.

Undoubtedly correct. I'm not saying to go out and stop immobilizing people, we MUST follow the NYS BLS Protocol as much as it irks me to immobilize someone who barely has any paint scratched on their car. :angry: I would hope there arent providers or agencies out there making up their own rules.

[helicopper 1,050]

Ok so alot of people here are talking about being progressive, new studies so and so forth...thats all well and good and while I agree tha alot of MVA pts are ambulatory, asymptomatic, or have no signifigant MOI, protocol is still protocol. We all can quote study after study on somthing, CPR effectivness on the back, compressions only CPR, compressions on the abdomen...but you don't see anyone being progressive there and doing it b/c they feel its what is best for the pt. I'm not saying current NY protocol is correct, up to standard or anything of the sort, but until it changes, in todays sue crazy society, the sad reality is its much safer for the EMT to stick to the protocols, however outdated they may be.

But that's the problem! CPR standards have changed almost annually for the last 20 years and NYS was quick to amend the protocols to reflect the new standards. In the last 20 years, there have been virtually no changes to the spinal immobilization protocol - and that (I think) is the main focus of the criticism here. The auto industry has changed so much in the past 20 years that you'd think there would be some corresponding evolution of the protocols. About the only thing that leaps to mind is the change in language so mechanism of injury (i.e. vehicle damage) is less of a factor in determining if someone is a major trauma.

You're right - we can't go free-lancing and ignoring protocol. Unfortunately, the SEMAC has been incredibly slow in adopting any sort of changes relating to this so the protocol does not reflect the latest and greatest.

[louis 1]

I cringe when I see crews bring out the KED. For one I believe that it takes too long and there is way too much movement. Although I was trained in it, I don't think I actually used it. It was faster and easier and I think safer for my partner and I to stabalize the neck and do less movement with the PT right onto a backboard and onto the stretcher. With the KED you have to stabalize the neck. move the PT foward, back, strap and maybe move again if the straps get caught you have to move again. Then you have to turn and put the PT on the backboard. I just think it is a waste of time.

You are right the KED is a pain in the a**. I think you hurt the patient more trying to get them out of the car with a KED on than without

[STAT213 332]

So I decided to look at the protocol and see what it says for myself. I was under the impression that it REQUIRED use of a KED to remove someone from a vehicle. I couldn't find that anywhere in there. I was also under the impression that you HAD to immobilize everyone involved in an MVC. Nope.

Only two protocols are relevant. One is the Muscoskeletal trauma one, and it is vague. "Manually stabilize the head and neck if trauma of the head and/or neck is suspected." Ok, I can work with that. I have to suspect trauma. Based on my training and knowledge of the manufacture of modern vehicles, I can conclude that someone without neck or head pain won't have a neck or head injury. It DOES NOT SAY immobilize everyone. If they don't complain of it, I can't suspect it, can I?

The General Approach protocol states "consider c-spine stabilzation." That's it. Ok, I considered it. And ruled it out. Sir, you'd like to be checked out after this minor fender bender, absolutely. Please walk to my ambulance and sit right there on the bench seat so I can get a seat belt around you.

Ok, all you protocol cop types, prove me wrong. If you can show me a KED protocol or special advisory, that'd be great. I couldn't find it.

[ny10570 745]

At this point there isn't much evidence to back up immobilizing everyone. Even NYS protocols allow you some leeway if you have faith in your clinical judgment. The big study on spinal immobilization was NEXUS (The National Emergency X-Radiography Utilization Study) begun in the late 90's. It was a retrospective study to determine just how well physical exam could determine who does and does not have a significant spinal injury. I don't have the numbers in front or me or my access to medline, but if I remember correctly of nearly 50,000 patients 1.6% suffered clinically significant c-spine injury. Injuries to the thoracic vertibre were more than twice as common as cervical injury. All it takes is 5 criteria t catch 99.9% of all spinal injuries in the study. Midline tenderness, neurological abnormality, altered level of consciousness, intoxication, or distracting injury. Yes to any of these questions gets immobilized and irradiated. Immobilization isn't a benign treatment. In the elderly skin breakdown can begin in as little as 20 minutes on a long board and 40 minutes in a healthy adult. Spending an hour on a board is a very real option in a busy ER that relies on radiographic c-spine clearing. CT scans are large doses of radiation (10 times that of a c-spine x-ray).

My other point in the beginning wasn't so much as why we immobilize, but how we do it when we immobilize. The collar, even when properly applied does not protect the c-spine. When combined with the long board or KED you now have "effective" immobilization. As more research goes into immobilization there is an increasing amount of literature that indicates people would be better off left alone. The biggest issue is trunk movement. If the body is allowed to move independent of the head we create the potential for displacing an unstable cervical injury. This is why holding the head and having the patient slide over to the board or duck their head out of the car is doing more harm than good. The KED is far from perfect, but I have yet to see a rapid extrication that was even close to protecting c-spine.

[Goose 188]

You're never going to be able to protect the c-spine 100%, 100% of the time. I would argue that more often than not if there is damage due to human error its likely because the patient got out and walked around on his/her cell phone for 10 minutes before you arrived. If you ask me, i think the KED does more harm than good, considering the maneuvering needed to get the device on correctly. I've always been privy to collar, manual stabilization, then go for the long board under the butt, rotate the patient and a long-axis slide up the board. In my mind, this most effectivly address a host of issues: C-spine, poss. life threats and timely transfer to definitive care.

Edited February 20, 2008 by Goose

[helicopper 1,050]

So I decided to look at the protocol and see what it says for myself. I was under the impression that it REQUIRED use of a KED to remove someone from a vehicle. I couldn't find that anywhere in there. I was also under the impression that you HAD to immobilize everyone involved in an MVC. Nope.

Only two protocols are relevant. One is the Muscoskeletal trauma one, and it is vague. "Manually stabilize the head and neck if trauma of the head and/or neck is suspected." Ok, I can work with that. I have to suspect trauma. Based on my training and knowledge of the manufacture of modern vehicles, I can conclude that someone without neck or head pain won't have a neck or head injury. It DOES NOT SAY immobilize everyone. If they don't complain of it, I can't suspect it, can I?

The General Approach protocol states "consider c-spine stabilzation." That's it. Ok, I considered it. And ruled it out. Sir, you'd like to be checked out after this minor fender bender, absolutely. Please walk to my ambulance and sit right there on the bench seat so I can get a seat belt around you.

Ok, all you protocol cop types, prove me wrong. If you can show me a KED protocol or special advisory, that'd be great. I couldn't find it.

Thanks for that dose of reality! It's amazing how the perspective has shifted away from the actual text of the protocol to "we have to do it to CYA". I know that I was brainwashed to believe that you had to err on the side of immobilizing but the review of the actual protocol has enlightened me.

Thanks STAT!

[ckroll 101]

You're never going to be able to protect the c-spine 100%, 100% of the time. I would argue that more often than not if there is damage due to human error its likely because the patient got out and walked around on his/her cell phone for 10 minutes before you arrived. If you ask me, i think the KED does more harm than good, considering the maneuvering needed to get the device on correctly. I've always been privy to collar, manual stabilization, then go for the long board under the butt, rotate the patient and a long-axis slide up the board. In my mind, this most effectivly address a host of issues: C-spine, poss. life threats and timely transfer to definitive care.

Maine has had a spine clearance protocol in effect since 1994 without undue loss of quality of life. Good clinical judgment is key, which requires good feedback. The practicioner needs to look at each patient and ask how do I rule IN immobilization, not rule it out. If one is looking for a reason not to do something, he or she will find it. If one approaches the patient looking for reasons to immoblize and finds none, then that patient is a good candidate for clearance. And yes, immobilizaton on a backboard can do harm.

I respectfully disagree on just about everything that the author has to say on KED's. Those who find them time consuming and bulky are not practicing enough with them. I am unmoved by arguments that one does not know how to use equipment and therefore finds it hard to use. The KED only helps the c-spine, so yes, there will be rotation at the hips. Nowhere in protocols does it say, put a cervical collar on here or splint a leg here, or use a KED here, yet we do not use this as reason to abandon them. Consider c-spine immobilization, at least as I practice it, means if the patient still sitting in a vehicle has neck and or back pain and he or she is not unstable, a KED with a collar is the only thing that constitutes adequate c-spine immobilization.

KEDs really limit rotation which may be key. A c-spine can tolerate a fair bit of front to back motion partly because it is sitting on top of a long flexible spine. Side to side and rotation is governed by the atlas/axis the major neck muscles. Rotation is almost guaranteed to dislodge an unstable c-spine. A collar alone can act as a fulcrum, limiting the ability to move the neck except at the atlas/axis and by the major neck muscles. It is why we collar and still stabilize. Anyone who thinks they can hold adequate rotational stabilization on an injured c-spine while directing a patient to swing from face forward to out the door and then rotate them down onto a board, pull that board out of a car and then block and spider the patient....well, I think that person overestimates their abilities.

A KED keeps the patient from looking at you and using their shoulders to assist in getting out, or ducking their head, which is what makes a KEDed patient such a challenge. Those are also the motions that will dislocate an unstable cervical spine. My advice is to practice with a KED until it works for you...and for the patient.

[helicopper 1,050]

Maine has had a spine clearance protocol in effect since 1994 without undue loss of quality of life. Good clinical judgment is key, which requires good feedback. The practicioner needs to look at each patient and ask how do I rule IN immobilization, not rule it out. If one is looking for a reason not to do something, he or she will find it. If one approaches the patient looking for reasons to immoblize and finds none, then that patient is a good candidate for clearance. And yes, immobilizaton on a backboard can do harm.

I respectfully disagree on just about everything that the author has to say on KED's. Those who find them time consuming and bulky are not practicing enough with them. I am unmoved by arguments that one does not know how to use equipment and therefore finds it hard to use. The KED only helps the c-spine, so yes, there will be rotation at the hips. Nowhere in protocols does it say, put a cervical collar on here or splint a leg here, or use a KED here, yet we do not use this as reason to abandon them. Consider c-spine immobilization, at least as I practice it, means if the patient still sitting in a vehicle has neck and or back pain and he or she is not unstable, a KED with a collar is the only thing that constitutes adequate c-spine immobilization.

KEDs really limit rotation which may be key. A c-spine can tolerate a fair bit of front to back motion partly because it is sitting on top of a long flexible spine. Side to side and rotation is governed by the atlas/axis the major neck muscles. Rotation is almost guaranteed to dislodge an unstable c-spine. A collar alone can act as a fulcrum, limiting the ability to move the neck except at the atlas/axis and by the major neck muscles. It is why we collar and still stabilize. Anyone who thinks they can hold adequate rotational stabilization on an injured c-spine while directing a patient to swing from face forward to out the door and then rotate them down onto a board, pull that board out of a car and then block and spider the patient....well, I think that person overestimates their abilities.

A KED keeps the patient from looking at you and using their shoulders to assist in getting out, or ducking their head, which is what makes a KEDed patient such a challenge. Those are also the motions that will dislocate an unstable cervical spine. My advice is to practice with a KED until it works for you...and for the patient.

Thanks for weighing in - you nailed it! Best post in the thread (no offense ALS)!!!

[chazEMT 5]

You're correct about the protocols STAT...but don't forget that our scope of practice is also defined by WHAT WE'RE TAUGHT...did you check the BLS cirriculum? I beleive that addresses the issue a bit more specifically.

I agree that the protocols & practice of spinal immobilization are antiquated...I also agree with previous posts that pointed out that, even though they might not make perfect sense, they are the PROTOCOLS, and disregarding them can open the door to trouble! Always have a REASON for what you do out there...based upon a good assessment and sound clinical judgement!

[ckroll 101]

Annals of Emergency Medicine June 2001 Stroh and Braude Can an out of hospital cervical spine clearance protocol identify all patients with injuries?

[Also known as the Fresno protocols, it is an early classic study advocating clearance in the field.]

Academy of Emergency Medicine March 1998 Out of Hospital spinal immobilization: its effect on neurological injury.

[Another early work comparing 2 university hospitals, one where trauma does not get immobilized on a backboard and one where it does and there was slightly better outcome without immobilization.]

A search for " spinal immobilization" "fresno" and "retrospective" will get to a lot of literature.

There are two related threads here, clearing spines in the field and the value of immobilization. Spinal injury, especially c-spine injury, needs to be stabilized for extrication. How we do it is another story. As the vast majority of trauma has no spinal component, the vast majority of patients do not need immobilization. Which is not logic enough globally to dismiss immobilization.

The patient who needs it , needs it. The patient who doesn't, doesn't. How we make the distinction is unimportant for the 99% who are uninjured but critical to the 1% who are. As EMS professionals we just cannot afford to get it right 'most' of the time. It all gets back to practice, experience and good judgement. Never pass up the opportunity to think about what you are doing. That said, it would be hugely helpful if the bureaucrats would give us a little spinal support here and write clean protocol for clearance in the field.

And thanks Chris192 for the positive feedback.

[ny10570 745]

Excellent posts Ckroll.

Someone just sent me chasing after an article out of Pediatrics published in Aug of 2001. They found the 5 criteria for c-spine clearance applied as well if not better to children older than 2 years of age(The authors felt there was not enough data, only 88 children less than 2 years of age of which none had spinal injury). While they also found distracting injuries to be more of an issue with children, resulting in fewer c-spine clearance candidates they estimate a 20% reduction in pediatric cervical spine imaging.

Proof that the KED works...

Cline JR, Scheidel E, et al: A comparison of methods of cervical immobilization used in patient extrication and transport. J Trauma 25:649-653,1985.

A radiographic comparison of pre-hospital cervical immobilization methods. Ann Emerg Med 16:1127-1131,1987

[ckroll 101]

Excellent posts Ckroll.

Someone just sent me chasing after an article out of Pediatrics published in Aug of 2001. They found the 5 criteria for c-spine clearance applied as well if not better to children older than 2 years of age(The authors felt there was not enough data, only 88 children less than 2 years of age of which none had spinal injury). While they also found distracting injuries to be more of an issue with children, resulting in fewer c-spine clearance candidates they estimate a 20% reduction in pediatric cervical spine imaging.

Proof that the KED works...

Cline JR, Scheidel E, et al: A comparison of methods of cervical immobilization used in patient extrication and transport. J Trauma 25:649-653,1985.

A radiographic comparison of pre-hospital cervical immobilization methods. Ann Emerg Med 16:1127-1131,1987

If memory serves, one of the three injured individuals not immobilized per Fresno was a 19 month old with an altas/axis fx...mother noticed he would not turn his head.... who had a full recovery with immobilization. The only adverse outcome was an elderly individual at the chiropractor with significant history.

Maine has had extensive review with the older population tagged as at risk for under immobilization. Clearance apparently is questionable at both ends of the age spectrum with very young children being unwilling or unable to report pain and the elderly either having ongoing pain or neuropathy that interferes with reporting.

Otherwise, spine clearance using 5 or 7 point criteria, in the field or at hospital without radiography has had very good results. One article makes the excellent point that pre-hospital it should be considered opting out of immobilization rather than clearing of the spine as only a physician can diagnose and treat. We, in fact are not clearing the spine, just opting out of a treatment option, having established that the treatment was not in the patient's interests.

Something like 33% of immobilization is unwarranted.... which means even given a clearance/opt out protocol, most patients will still meet criteria for immobilization. Children are the nightmare.

I had a youngster who pulled something heavy down from a height, needed some stitches to the back of his head and in fact probably met criteria for full spinal immobilization. But he had been running around after the accident and was happy in his mother's arms had no idea he was hurt, so I opted to fashion a horse collar out of a towel for soft support and leave him happy on the grounds that hard collaring and boarding would have lead to thrashing hysterics with much higher chance of adverse outcome if there was underlying injury. The doctor took it off without comment, but that is his choice.

I don't much mind boarding and collaring the otherwise healthy patient for whom the overkill is only an inconvenience. I think a lot about when the collar and board may do harm, which are the same populations at risk for under immobilization.

What would be useful and maybe this site is just the place is a convenient way to do literature searches. Punting back to "GOOD CLINICAL JUDGEMENT" is nice wiggle room, but wouldn't it be great if practicioners had ready access to someone who could search some of this stuff? Now that would be good clinical judgement. Could someone qualified volunteer to be "Ask the Doctor."?

[ny10570 745]

I tried the whole ask the doctor trick but it seems it comes down to opinions and rectums. Everyone has one and everyone else's stinks. I can't even get doctors to agree clearing without x-ray in the ER. Hopefully next week I can take a trip down to SIBL next weekend. One article I found was a research analysis done more than 10 years ago. I'm going to see what comes up now. As of right now I've got the ear of ER attendings from Jacobi, St. Vincents, and a few of the EMS fellows. If anyone has some specific questions I'll be happy o pass 'em along.