Selective Spinal Immobilization

KBEMS Approved 2/11/2015

Spine precautions are intended to prevent spinal cord injury in a patient presenting with an unstable spinal fracture, and to potentially prevent worsening cord injury. Traditional use of backboards for immobilization of patients has never been proven to be beneficial and newer studies show harm can occur from backboard immobilization without clear indications. Studies also show EMS providers are able to safely evaluate and identify patients with suspected spinal injuries in the field and employ selective spinal immobilization appropriately.

The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma believe that:  Long backboards are commonly used to attempt to provide rigid spinal immobilization among emergency medical services (EMS) trauma patients. However, the benefit of long backboards is largely unproven.  The long backboard can induce pain, patient agitation, and respiratory compromise. Further, the backboard can decrease tissue perfusion at pressure points, leading to the development of pressure ulcers.  Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks.  Appropriate patients to be immobilized with a backboard may include those with: o Blunt trauma and altered level of consciousness o Spinal pain or tenderness o Neurologic complaint (e.g., numbness or motor weakness) o Anatomic deformity of the spine o High-energy mechanism of injury and any of the following: . Drug or alcohol intoxication . Inability to communicate . Distracting injury

 Patients for whom immobilization on a backboard is not necessary include those with all of the following: o Normal level of consciousness (Glasgow Coma Score [GCS] 15) o No spine tenderness or anatomic abnormality o No neurologic findings or complaints o No distracting injury o No intoxication

 Patients with penetrating trauma to the head, neck, or torso and no evidence of spinal injury should not be immobilized on a backboard.  Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for: o Patients who are found to be ambulatory at the scene o Patients who must be transported for a protracted time, particularly prior to interfacility transfer o Patients for whom a backboard is not otherwise indicated  Whether or not a backboard is used, attention to spinal precautions among at-risk patients is paramount. These include application of a cervical collar, adequate security to a stretcher, minimal movement/transfers, and maintenance of inline stabilization during any necessary movement/ transfers.

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Patients should be removed from backboards as soon as practical in an emergency department.

References:

1. National Association of EMS Physicians: Ems Spinal Precautions And The Use Of The Long Backboard –Resource Document To The Position Statement Of The National Association Of Ems Physicians And The American College Of Surgeons Committee On Trauma. Prehosptial Emergency Care. (Jan/March 2014), 1‐9. doi: 10.3109/10903127.2014.884197 2. Vallancourt et al: The Out of Hospital Validation of the Canadian C-Spine Rule by Paramedics. Annals of Emergency Medicine. 2009 Nov 54 (5); 663-670. doi: 10.1016/j.annemergmed.2009.03.008

Page 404 Adult Trauma Protocol Selective Spine Immobilization

KBEMS Approved 2/11/2015

Spine Immobilizaon Evaluaon in the seƫng of trauma (age >8 yo and able to communicate)

If ANY of the following is true…. If ALL the following is true….

 Blunt trauma with altered level of conscious-  Normal level of consciousness (GCS ness 15)  Spinal pain or tenderness  No spine tenderness or anatomic ab-  Neurologic Complaint (numbness or motor normality weakness from traumaƟc injury)  No neurologic findings or complaints  Anatomic deformity of the spine  No distracƟng injury  High-energy mechanism of injury and any of  No intoxicaƟon. the following:  Drug or alcohol intoxicaƟon  Inability to communicate  DistracƟng injury NO long spine board ImmobilizaƟon is needed (see c-spine clearance for c-collar clearance)

Spine precauƟons SelecƟve Spine ImmobilizaƟon with C-Collar and PenetraƟng Long Backboard Trauma does NOT need ImmobilizaƟon Transport Ɵme > 20 minutes?

YES NO  Transport OFF long spine board but maintain spine precauƟons including C‐  Transport Immobilized to appropriate trauma collar center.  Log roll, scoop stretcher, slider or LBB transfer to hospital stretcher.

INTERFACILITY TRANSFERS DO NOT REQUIRE IMMOBILIZATION ON SPINE BOARDS FOR TRANSFER. SPINE PRECAUTIONS, WITH C‐COLLARS, SHOULD BE OBSERVED DURING TRANSPORT.

Page 405 Adult Trauma Protocol Selective Spine Immobilization

KBEMS Approved 2/11/2015

The Cervical Spine Evaluation

1. Any One High-Risk Factor Which Mandates Immobilization?

 Age ≥ 65 YES  Dangerous mechanism*  Numbness or tingling in extremities

C-Spine NO Immobilization

2. Any One Low-Risk Factor that may YES restrict Range of Motion Evaluation?  More than a simple rear-end MVC**  Non-Ambulatory at scene  Neck pain at scene when asked NO  Pain during midline c-spine palpation * Dangerous Mechanism  fall from elevation ≥ 3 feet / 5 stairs

NO  axial load to head, e.g. diving  MVC high-speed ≥65mph, rollover, ejec- tion 3. Patient Voluntarily Able to Actively Rotate Neck 45° Left and Right When  ATV Requested, Regardless of Pain?  Bicycle collision with object i.e. post, car

YES **Simple Rear-ended MVC Excludes:  Pushed into oncoming traffic No C-spine  Hit by bus / large truck Immobilization  Rollover  Hit by high speed vehicle (≥ 65 mph)

The C-Spine Rule is for alert (Glasgow Coma Scale score 15) and stable trauma patients for whom cervical spine inju- ry is a concern, including patients with either posterior neck pain with any blunt mechanism of injury or no neck pain but some visible injury above the clavicles.

Reference: Vallancourt et al: The Out of Hospital Validation of the Canadian C-Spine Rule by Paramedics. Annals of Emergency Medicine. 2009 Nov 54 (5);663-670. doi: 10.1016/j.annemergmed.2009.03.008

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