Vermont EMS District 3 Spinal Immobilization Protocol

Report
EMS Field Cervical
Spine Assessment Protocol
VVEMS
Todd Lang, MD
EMS Medical Director
Why do this?
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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
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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
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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!”
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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.
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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
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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
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Language
GCS/Capacity/reproducibility
Hearing
Ability to sense pain
LOC/Intox
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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:
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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
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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!
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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:
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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
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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?

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