Original article Emerg Med J: first published as 10.1136/emermed-2014-204553 on 11 September 2015. Downloaded from Confirmation of suboptimal protocols in spinal immobilisation? Mark Dixon,1 Joseph O’Halloran,2,3 Ailish Hannigan,4 Scott Keenan,5 Niamh M Cummins6 1Paramedic Studies ABSTRACT Department, Graduate Entry Background Spinal immobilisation during extrication Key messages Medical School, University of fi Limerick, Limerick, Ireland of patients in road traf c collisions is routinely used 2 despite the lack of evidence for this practice. In a Physical Education and Sport What is already known on this subject? Sciences Department, previous proof of concept study (n=1), we recorded up ▸ In most countries road traffic collisions are the University of Limerick, Limerick, to four times more cervical spine movement during main cause of cervical spine injuries. Ireland extrication using conventional techniques than self- 3Department of Sport and ▸ There are several techniques in use for spinal controlled extrication. Exercise Science, University of immobilisation during prehospital extrication; Objective The objective of this study was to establish, Portsmouth, Portsmouth, UK however, the evidence for these is currently 4Graduate Entry Medical using biomechanical analysis which technique provides poor. School, University of Limerick, the minimal deviation of the cervical spine from the Limerick, Ireland ▸ In a previous proof of concept study (n=1), we 5 neutral in-line position during extrication from a vehicle Fire and Rescue Service, recorded up to four times more cervical spine in a larger sample of variable age, height and mass. Limerick City and County movement during extrication using Council, Limerick, Ireland Methods A crew of two paramedics and four fire- 6 conventional techniques than self-controlled Centre for Prehospital fighters extricated 16 immobilised participants from a extrication. Research, Graduate Entry vehicle using six techniques for each participant. Medical School, University of Limerick, Limerick, Ireland Participants were marked with biomechanical sensors What might this study add? and relative movement between the sensors was ▸ In a larger sample size of haemodynamically Correspondence to captured via high-speed infrared motion analysis stable patients, controlled self-extrication Mark Dixon, Paramedic Studies cameras. A three-dimensional mathematical model was caused less movement of the cervical spine Department, Graduate Entry Medical School, University of developed and a repeated-measures analysis of variance than extrications performed using traditional Limerick, Limerick, Ireland; was used to compare movement across extrication emergency medical services rescue equipment. [email protected] techniques. ▸ These results add to the growing body of Results Controlled self-extrication without a collar evidence suggesting that current rescue Received 1 December 2014 resulted in a mean movement of 13.33° from the techniques may not be providing optimal care Revised 15 April 2015 fi Accepted 22 July 2015 neutral in-line position of the cervical spine compared to for post-road traf c collisions patients. Published Online First a mean movement of 18.84° during one of the 11 September 2015 equipment-aided extrications. Two equipment-aided techniques had significantly higher movement (p<0.05) http://emj.bmj.com/ than other techniques. Both height (p=0.003) and mass criteria for the review.3 The authors of this study (p=0.02) of the participants were significant concluded that the effect of spinal immobilisation independent predictors of movement. on mortality, neurological injury, spinal stability Conclusions These data support the findings of the and adverse effects in trauma patients remains proof of concept study, for haemodynamically stable uncertain. patients controlled self-extrication causes less movement It appears that traditional prehospital extrication of the cervical spine than extrications performed using techniques used by the emergency medical services on September 26, 2021 by guest. Protected copyright. traditional prehospital rescue equipment. (EMS) have evolved through pragmatism rather than being introduced following evidence-based sci- entific research. Conservative treatment of sus- pected spinal injuries and overtriage by prehospital INTRODUCTION practitioners occurs because of the severe conse- 4 Open Access In most countries road traffic collisions (RTC) are quences of spinal cord injuries (SCI). However, Scan to access more 1 free content the main cause of cervical spine injuries. Since the the potential for adverse clinical effects and dis- 1960s it has been standard practice to immobilise comfort as a result of immobilisation has been well – patients with suspected spinal injuries using a cer- documented.5 7 Unnecessary immobilisation due to vical collar and backboard.2 Spinal immobilisation overtriage also places an increased burden on is based on the premise that minimising movement ambulance services and emergency departments. can reduce the risk of secondary neurological injur- Recently, the emergency medicine community ies occurring if the patient has sustained an has started critically examining the rationale for – unstable spinal fracture. However, the current evi- routine immobilisation of trauma patients.8 11 A dence base for spinal immobilisation techniques proof-of-concept study undertaken by the authors To cite: Dixon M, during prehospital extrication is poor. In a demonstrated that up to four times more cervical O’Halloran J, Hannigan A, Cochrane systematic review of the literature on spine movement occurs when traditional EMS et al. Emerg Med J spinal immobilisation of trauma patients, no rando- rescue equipment (rigid collar, long spinal board – 2015;32:939 945. mised controlled trials (RCT) met the inclusion (LSB) and short extrication jacket (SEJ)) is used in Dixon M, et al. Emerg Med J 2015;32:939–945. doi:10.1136/emermed-2014-204553 939 Original article Emerg Med J: first published as 10.1136/emermed-2014-204553 on 11 September 2015. Downloaded from comparison to haemodynamically stable patients self-extricating vehicle stabilisation and standard Fire Service Safety Procedures under paramedic instructions.12 The primary aim of this study were in place within the vehicle itself and in the surrounding was to build on these findings by increasing the sample size and areas. including a range of male and female participants of variable age, height and mass to represent the general adult population Biomechanical analysis of potential RTC patients. Reflective markers were placed on the participants in a horizon- tal plane at the level of the zygoma and in a parallel horizontal METHODS plane consistent with the anatomical marking of the clavicles. fl Study design Re ective markers were also placed in a single vertical alignment Ethical approval for this cross-sectional study was obtained along the anterior midline from the frontal bone to the xiphoid fi from the Scientific Research Ethics Committee at the University process ( gure 1A). Narrowing of the horizontal planes repre- fl Hospital Limerick. A power calculation was not possible as sents exion of the cervical spine and widening of the horizon- fi there are no previous studies with sufficient data to estimate tal planes represents extension of the cervical spine ( gure 1B). variability in cervical spine movement between participants. A Lateral movement deviating to the left and right of the midline fi sample size of 15 participants was considered adequate to esti- represents lateral movement of the cervical spine ( gure 1C). mate variability.13 The most important consideration is that the Transverse left or right movement around the midline axis fi participants are representative of the general adult population in represents rotation of the cervical spine ( gure 1D). The move- order to ensure that study findings are potentially transferable ments of the participants were captured using three-dimensional to the real-world setting. (3D) motion analysis cameras (Cortex, Motion Analysis Corporation, California, USA). Infrared cameras (n=12) sam- pling at 200 Hz were set up and calibrated (to an accuracy of Setting and participants 0.1 mm) around the vehicle (figure 2). The cameras recorded The study location was Limerick City Fire and Rescue Station. the movement of the markers in 3D space. Following data Volunteers were recruited from the University of Limerick capture, biomechanical analysis of the movement of the markers campus community via email and were divided into three mass in all three planes was conducted. The movements in these categories: <65, 65–80 and >80 kg. Exclusion criteria included planes are combined to produce an absolute angle of movement age <18 years, prior knowledge of extrication procedures and reflecting combined anterior–posterior, medial–lateral and rota- underlying medical conditions which may be affected by the tional movement of the head relative to the torso throughout extrication, including but not limited to arthritis, degenerative the extrication process. spinal conditions, previous back or neck injuries and pregnancy. On arrival at the Fire Station, the participants were briefed on the study and received a video induction. Participants were then Protocol for immobilisation and extrication techniques provided with a study information sheet and written informed The order of the immobilisation and extrication techniques was consent was obtained. Height and mass were measured on cali- randomised for