NEW SPINAL PRECAUTION STANDARDS

July 31, 2015

Dane Van Horn B.S., CCEMT-P Field Supervisor - Life EMS Disclosure

I have no relevant financial relationships or conflicts of interest to disclose Objectives Overview

1. Research 2. Indications for Spinal Immobilization 3. "Nexus Exam" Spinal Assessment process. 4. General Guidelines 5. Special Considerations Why Are We Changing? What is the research consensus?

• Early studies demonstrated that spinal immobilization has little to no effect on neurologic function, or that its effect is uncertain. 1, 2

• As studies progressed, was discovered that spinal immobilization may actually be contributing to pt. morbidity and mortality. 3 Does spinal immobilization help?

Probably Not!

- Increases pain 4, 5, 6 - Contributes to airway compromise 8, 9 - Increases mortality of those suffering from 10, 11, 12 - May actually cause MORE movement of the neck and spine 7, 13, 14 Spinal Assessment

Changes highlighted in Red New Spinal Injury Assessment Criteria

Positive Mechanism +

- Altered Mental Status - Use of Intoxicants - Significant painful distracting injury - Motor and/or sensory deficit - Spine pain and/or tenderness

KCEMS Spinal Assessment Procedure New General Guidelines General Guidelines - New Protocols

The following apply to all patients with a Positive Spinal Assessment

● Long backboard or equivalent only required for extrication and movement to cot*. Long Backboard

● Only for patients with Neuro-Deficits

● Only required for extrication and movement to the cot*.

● Can be removed afterward*.

* The NATA recommends leaving patients with neuro- deficits on the backboard for transport.15 6+ Lift Technique

● Recommended by the NATA in place of log-roll

● 1 person at head

● 6+ rescuers equally distributed along body

General Guidelines - New Protocols

The following apply to all patients with a Positive Spinal Assessment

● Patients, who are stable, alert, and without neurological deficit should be allowed to self- extricate to cot after placing a c-collar.

Self-Extrication Procedure

● Do not have neuro deficits.

● Can move themselves to after c- collar placement.

● Limit spinal movement during process. Procedure After Removal of Extrication Device

● Place patient supine or in position of comfort.

● Head/neck should be padded to prevent excessive movement. General Guidelines - New Protocols

The following apply to all patients with a Positive Spinal Assessment

● Ambulatory patients with positive spinal assessment should have a c- collar placed and be moved directly to cot while limiting spinal movement.

New Special Considerations New Special Considerations

● You may forgo immobilizing combative/agitated patients

● If c-spine is hampering airway management, airway comes first.

• NATA recommends removal of protective athletic equipment prior to transport.15

Communication

• The Nata recommends each athletic program have an Emergency Action Plan (EAP) developed in conjunction with local EMS.15

• The EAP establishes a plan to integrate athletic team, EMS and hospitals to facilitate fast and efficient care.

The “Take Home” Message

● New perception of “spinal precautions.”

● Spinal immobilization still exists: o In a collar, on the cot o Backboard generally for movement only

● As always, use clinical judgment. Be aware of your local protocols.

Thank you! bronsonhealth.com References

1) Huaswald M, Ong G, et al. “Out-of-hospital spinal immobilization: its effect on neurologic injury.” Acad. Emerg. Med. 1998 Mar;5(3):214-9. 2) Kwan I, Bunn F, Roberts IG. “Spinal immobilization for trauma patients.” Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD002803. DOI: 10.1002/14651858.CD002803. 3) Abram S, Bulstrode C. “Routine spinal immobilization in trauma patients: what are the advantages and disadvantages?” Surgeon. 2010 Aug;8(4):218- 22. 4) Chan D, Goldberg R, et al. “The effect of spinal immobilization on healthy volunteers.” Annals of . Vol 23, Issue 1. 1994 Jan;48-51. 5) Chan D, Goldberg, RM, et al. “Backboard versus mattress splint immobilization: a comparison of symptoms generated.” J Emerg Med. 1996 May-Jun;14(3):293-8. 6) Lerner EB, Billittier AJ 4th, et al. “The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects.” Prehosp Emerg Care. 1998 Apr-Jun: 2(2):112-6. 7) Dixon M, O’Halloran J, et al. “Biomechanical analysis of spinal immobilization during prehospital extrication: a proof of concept study.” Emerg Med J. 2014 Sep;31(9):745-9. References continued

8) Bauer D, Kowalski R. “Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man.” Annals of Emergency Medicine. 1988 Sep;17(9):915-8.

9) Goutcher CM, Lochhead V. “Reduction in mouth opening with semi-rigid cervical collars.” Br J Anaesth. 2005 Sep;95(3):344-8. Epub 2005 Jul 8.

10) Stuke L, Pons P, et al. “Prehospital spine immobilization for penetrating trauma-review and recommendations from the Prehospital Trauma Life Support Executive Committee.” J Trauma. 2011 Sep;71(3):763-9.

11) Haut ER, Kalish BT, et al. “Spine immobilization in penetrating trauma: more harm than good?” J Trauma. 2010 Jan;68(1):115-20; discussion 120-1.

12) Vanderlan WB, Tew BE, et al. “Increased risk of death with cervical spine immobilization in penetrating cervical trauma.” Injury. 2009 Aug;40(8):880-3.

13) Del Rossi G, Rechtine GR, et al. “Is sub-occipital padding necessary to maintain optimal alignment of the unstable spine in the prehospital setting? A preliminary report.” J Emerg Med. 2013 Sep;45(3):366-71.

14) Engsberg JR, Standeven JW, et al. “Cervical spine motion during extrication.” J Emerg Med. 2013 Jan;44(1):122-7.

15) "NATA Releases Executive Summary of Appropriate Care of the Spine Injured Athlete Inter-Association Consensus Statement." National Athletic Trainers' Association. N.p., 24 June 2015. Web. 24 July 2015.