EMS Field Cervical Spine Assessment Protocol VVEMS Todd 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 Objectives • 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 Objectives • 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 Terminology 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. 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?” • 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 NEXUS • 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 Canadian C Spine Rule 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 highspeed vehicle. 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 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? • 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 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 Skull • 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 Spine • • • • • Cervical (7) Thoracic (12) Lumbar (5) Sacral 5 (1 fused) Coccyx 4(1 fused) The 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 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 nerves “C3,4,5 keeps the diaphragm alive!” • • • • • • • C1 C2 C3 C4 C5 C6 C7 neck rotation and sensation spontaneous breathing spontaneous breathing diaphragm, shrugging shoulders flexion of elbow extension of elbow Cases Requiring Full Immobilization Patients meeting any of the following criteria must be fully immobilized. 1. 2. 3. 4. 5. 6. 7. 8. Higher Risk or unknown mechanism of injury Altered LOC (GCS<15, or changed) Presence of other distracting painful injury Subjective spine pain Subjective neurological deficit Objective neurological deficit Objective midline spine tenderness Any pain with unassisted neck motion MOI with some risk • • • • Fall MVA High energy injury Even minor MOI in right (wrong!) patient Higher 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 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 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 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 Pain • Patient complains of cervical or thoracic spine pain. • “Do you have any neck or back pain?” • If yes, immobilize. Objective 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 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 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 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 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 Tool Higher risk MOI? No Altered level of alertness? No Distracting injury? No Yes Yes Yes Yes Objective or subjective neurological deficit? No Neck pain or tenderness? No Yes Yes Pain with unassisted neck motion? No Transport without full spinal immobilization Full Spinal Immobilization 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 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 Yes No Pertinent Positives Guiding 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 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 Conclusion • 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. Conclusion • 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?