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 Chelsea C. White IV, MD, EMT-P, Robert M. Domeier, MD, Michael G. Millin, MD, MPH, and the Standards and Clinical Practice Committee, National Association of EMS Physicians ABSTRACT designed to guide practitioners in understanding of the new position statement. Each item in the position Field spinal immobilization using a backboard and cervical is quoted and followed by a discussion and a review collar has been standard practice for patients with suspected spine injury since the 1960s. The backboard has been a com- of the literature. ponent of field spinal immobilization despite lack of effi- cacy evidence. While the backboard is a useful spinal protec- • “Long backboards are commonly used to attempt tion tool during extrication, use of backboards is not without to provide rigid spinal immobilization among EMS risk, as they have been shown to cause respiratory compro- trauma patients. However, the benefit of long back- mise, pain, and pressure sores. Backboards also alter a pa- boards is largely unproven.” tient’s physical exam, resulting in unnecessary radiographs. Because backboards present known risks, and their value in protecting the spinal cord of an injured patient remains HISTORY OF THE BACKBOARD unsubstantiated, they should only be used judiciously. The following provides a discussion of the elements of the Na- Field spinal immobilization using a cervical collar and tional Association of EMS Physicians (NAEMSP) and Amer- a backboard has been standard practice for patients ican College of Surgeons Committee on Trauma (ACS-COT) with suspected spine injury since the 1960s. Prior to position statement on EMS spinal precautions and the use that time no formal immobilization practice was used of the long backboard. This discussion includes items where and advanced first aid was the highest level of training there is supporting literature and items where additional sci- for ambulance personnel. ence is needed. Key words: EMS; spinal injury; backboards For personal use only. A 1966 report by Geisler et al. attributed “delayed PREHOSPITAL EMERGENCY CARE 2014;Early Online:1–9 onset of paraplegia” in hospitalized patients with spinal fractures to “failure to recognize the injury and protect the patient from the consequences of his un- INTRODUCTION stable spine.”2 This retrospective study of the surgical management of spinal column injury includes a dis- The National Association of EMS Physicians cussion of only two patients, one who incurred a de- (NAEMSP) and the American College of Surgeons pressed skull fracture from a motor vehicle crash in Committee on Trauma (ACS-COT) have published 1955, but was otherwise “observed to move all four a new position paper on “EMS Spinal Precautions 1 limbs.” The authors write that after the patient began Prehosp Emerg Care Downloaded from informahealthcare.com by 50.80.22.209 on 02/26/14 and the Use of the Long Backboard.” This paper is to develop paraplegia with a sensory level at T10, an the resource document for the position paper and is x-ray identified a thoracic spine fracture and the pa- tient was taken to operative management with a de- compressive laminectomy. The patient eventually de- veloped permanent paralysis at the T4 level, leading Received March 12, 2013 from the Department of Emergency the authors to write that the patient “would surely Medicine, University of New Mexico School of Medicine, Albu- have been protected from the paraplegic condition had querque, New Mexico (CCW), Department of Emergency Medicine, the spinal instability been recognized and precautions St. Joseph Mercy Hospital, Ann Arbor, Michigan (RMD), and De- partment of Emergency Medicine, Johns Hopkins University School taken.” Further, the authors write that “the importance of Medicine, Baltimore, Maryland (MGM). Revision received Jan- of proper first-aid was deduced from the fact that 29 uary 10, 2014; accepted for publication January 13, 2014. patients [in their dataset] developed further paralysis 2 The authors report no conflicts of interest. The authors alone are re- through faulty handling.” sponsible for the content and writing of the paper. After the publication of the report by Geisler et al., Address correspondence to Robert M. Domeier, MD, Department the medical community subscribed to the belief that of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI patients with blunt-force trauma (primarily from mo- 48197, USA. tor vehicle crashes) should be immobilized on rigid doi: 10.3109/10903127.2014.884197 devices to minimize the risk of delayed paralysis in 1 2 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2014 EARLY ONLINE the setting of occult spinal column injury. Farrington, low cost of the device and its convenience as a pa- in 1968, described the placement of a cervical collar tient transport device with no perceived downside to and a long or short backboard as necessary to keep the backboard and cervical collar, in the United States, the head and neck from sagging during extrication.3 spinal immobilization with the backboard and cervical The backboard was designed to assist in minimizing collar became nearly universal standard practice for all spinal movement during complex extrication maneu- trauma patients with a mechanism of injury that could vers by freeing the hands of rescuers from actively potentially cause spine injury. holding spinal precautions. Farrington also described The backboard may have its most helpful impact a technique for spinal traction to be used in extrication. in facilitating safe extrication and movement of un- Although spinal traction has fallen out of use in favor conscious or impaired patients. Like a scoop stretcher, of spinal precautions using in-line spinal stabilization, Stokes basket, or similar lifting device, the backboard the backboard and cervical collar remain. serves as both a means to reduce patient movement In 1971, the American Academy of Orthopedic Sur- and as a patient conveyance when moving a patient geons published one of the first guidelines for EMS from the site of injury. When the patient is strapped treatment. Emergency Care and Transportation of the to the backboard, rescuers can more easily maintain a Sick and Injured advocated the use of spinal immo- patient’s position while moving over uneven terrain. bilization using a backboard and cervical collar for trauma patients with signs and symptoms of spinal • 4 “The long backboard can induce pain, patient ag- injury. Concern that rescuers could inadvertently itation, and respiratory compromise. Further, the worsen unstable spinal injuries during extrication and backboard can decrease tissue perfusion at pres- transport led to the adoption of field spinal immobi- sure points, leading to the development of pressure lization protocols utilizing cervical collars and back- ulcers.” boards, a combination intended to splint the entire spine and protect against additional injury.5–7 In 1979, Bohlman linked delayed paralysis in 100 of SIDE EFFECTS OF BACKBOARDS 300 hospitalized cervical spine fracture patients with concern that the causative injuries were being un- Protecting the patient with a potential spine injury is derappreciated by emergency physicians. Bohlman at- an important component of EMS trauma care. While tributed the resulting spinal cord injuries to spinal cord the backboard can be an important spinal protection tissue hypoxia due to cord compression from edema or adjunct during extrication, use of the backboard is not without side effects. Some of these have been previ- For personal use only. contusion, or from direct injury to the spinal cord vas- cular supply. No injuries or deficits were attributed to ously investigated. post-injury spinal manipulation by emergency physi- 8 cians or prudent rescuers. Pain EMS providers were suspected of similar underap- preciation of spinal injuries. From this concern arose The conditions leading to the creation of pressure the theory that EMS providers were placing spinal sores also inflict considerable pain in patients on back- injury patients at risk for delayed paralysis and sec- boards. Pain is not limited to areas of contact with the ondary injury during improper packaging and han- backboard, as backboards can also cause pain in the dling in the field.9–11 It was because of this concern lower back and cervical spine due to the anatomically Prehosp Emerg Care Downloaded from informahealthcare.com by 50.80.22.209 on 02/26/14 that EMS providers began applying spinal immobiliza- incorrect positioning caused by a flat backboard. Ex- tion, using backboards and cervical collars, based on isting painful conditions can be exacerbated and new mechanism of injury alone, even if the patients were pain can develop in areas that were not painful prior asymptomatic, for fear of exacerbating occult spinal to the application of the backboard. Pain may improve injuries.12 Field providers were instructed to approach or resolve for some patients once they are removed 13 the patient, hold cervical spine immobilization man- from the backboard. Lower back and cervical pain ually until a cervical extrication collar was placed, has been reported to persist in previously pain-free, maintain spinal precautions through extrication onto a healthy volunteers 24 hours after being subjected to 14 backboard, and maintain immobilization with a cervi- only one hour on a backboard. cal collar and backboard until cleared by a physician.2,3 Thus, the term “spinal immobilization” came to in- Unnecessary Radiological Testing clude both the concept – limiting spinal motion – and the method by which it was achieved – backboard and It can be difficult for the receiving trauma team to dis- cervical collar. tinguish between pain caused by injury and pain that With the potential benefits of the backboard seen resulted from application and use of the backboard. as prevention of spinal cord injury in a patient with Clinicians may be forced to perform imaging studies unstable fracture and no cord injury at presentation, on areas that are painful solely due to the backboard, C.