SuspectedSuspected SpinalSpinal InjuryInjury

BureauBureau ofof EmergencyEmergency MedicalMedical ServicesServices DepartmentDepartmentNewNew YorkYork ofof HealthHealthStateState

MLREMS Version -090308 1 LearningLearning OutcomeOutcome

EMSEMS providersproviders needneed toto useuse appropriateappropriate clinicalclinical decisiondecision makingmaking toto applyapply spinalspinal immobilizationimmobilization toto thethe patientspatients whowho needneed itit basedbased onon MOI,MOI, physicalphysical findings,findings, andand patientpatient history.history.

MLREMS Version -090308 2 LearningLearning OutcomeOutcome

EMSEMS providersproviders needneed toto useuse appropriateappropriate clinicalclinical decisiondecision makingmaking toto applyapply spinalspinal immobilizationimmobilization toto thethe patientspatients whowho needneed itit basedbased onon MOI,MOI, physicalphysical findings,findings, andand patientpatient history.history.

MLREMS Version -090308 3 ObjectivesObjectives

„„ DescribeDescribe thethe historyhistory andand rationalerationale forfor SpinalSpinal ImmobilizationImmobilization „„ ReviewReview anatomyanatomy && pathophysiologypathophysiology ofof thethe spinespine „„ ExplainExplain thethe newnew NYSNYS DOHDOH andand MLREMSMLREMS protocolsprotocols forfor SuspectedSuspected SpinalSpinal InjuryInjury „„ GiveGive EMSEMS providersproviders thethe toolstools toto makemake anan appropriateappropriate decisiondecision onon spinalspinal immobilizationimmobilization

MLREMS Version -090308 4 MLREMS Version -090308 5 MLREMS Version -090308 6 MLREMS Version -090308 7 CervicalCervical SpineSpine InjuriesInjuries inin PerspectivePerspective „„ 2.4%2.4% ofof bluntblunt traumatrauma patientspatients experienceexperience somesome degreedegree ofof musculoskeletalmusculoskeletal injuryinjury toto thethe spinespine „„ ApproximatelyApproximately 20,00020,000 spinalspinal cordcord injuriesinjuries aa yearyear inin UnitedUnited StatesStates „„ $1.25$1.25 millionmillion toto carecare forfor aa singlesingle patientpatient withwith

MLREMS Version -090308 permanentpermanent SCISCI 8 „„ 15,00015,000 –– 20,00020,000 SCISCI perper yearyear „„ HigherHigher inin menmen betweenbetween agesages ofof 1616 –– 3030 „„ CommonCommon causes:causes: ƒ Motor vehicle crashes – 2.1 million per year (48%) ƒ Falls (21%) ƒ Penetrating injuries (15%) ƒ Sports injuries (14%) „„ EducationEducation inin properproper handlinghandling andand transportationtransportation cancan decreasedecrease SCISCI

MLREMS Version -090308 9 HistoricallyHistorically

„„ ImmobilizationImmobilization basedbased onon MOIMOI –– eveneven ifif therethere werewere nono signssigns andand symptomssymptoms „„ LackLack ofof clearclear clinicalclinical guidelinesguidelines „„ EMSEMS providersproviders diddid poorlypoorly withwith fullfull spinalspinal immobilizationimmobilization „„ MotorMotor vehiclesvehicles hadhad fewerfewer safetysafety featuresfeatures „„ PatientsPatients spentspent extendedextended amountsamounts ofof timetime inin immobilizationimmobilization devicesdevices atat E.D.E.D.

MLREMS Version -090308 10 WhyWhy notnot board/collarboard/collar andand XrayXray everybody?everybody? „„ ImmobilizationImmobilization isis uncomfortable:uncomfortable: increasedincreased timetime immobilizedimmobilized == increasedincreased pain,pain, riskrisk ofof aspiration,aspiration, vulnerablevulnerable position,position, etc...etc... „„ >800,000>800,000 U.S.U.S. PatientsPatients receivereceive cervicalcervical radiographyradiography eacheach yearyear „„ PatientPatient exposureexposure toto radiationradiation „„ >>97%97% ofof xx--raysrays areare negativenegative „„ CostCost exceedsexceeds $175,000,000$175,000,000 eacheach yearyear

MLREMS Version -090308 11 SecondarySecondary InjuryInjury versusversus PrimaryPrimary InjuryInjury

„„PrimaryPrimary InjuryInjury ––SpinalSpinal InjuryInjury thatthat occurredoccurred atat timetime ofof traumatrauma „„ SecondarySecondary InjuryInjury ––SpinalSpinal InjuryInjury thatthat occursoccurs afterafter thethe traumatrauma ––possiblypossibly secondarysecondary toto mishandlingmishandling ofof unstableunstable fracturesfractures

MLREMS Version -090308 12 ReviewReview ofof AnatomyAnatomy && PhysiologyPhysiology

„„ SpinalSpinal ColumnColumn –– 3232 -- 3434 separate,separate, irregularirregular bonesbones –– HeadHead (15(15--2222 lbs)lbs) BalancesBalances onon TopTop CC--SpineSpine –– SupportedSupported byby PelvisPelvis –– LigamentsLigaments andand MusclesMuscles connectconnect headhead toto pelvispelvis –– InjuryInjury toto LigamentsLigaments maymay causecause excessexcess movementmovement ofof vertebraevertebrae –– VertebralVertebral ForamenForamen -- canalcanal formedformed forfor cordcord

MLREMS Version -090308 13 Vertebral Spinous foramen process

Body

MLREMS Version -090308 14 AnatomyAnatomy && Physiology,Physiology, cont.cont.

„ Cervical – 7 Vertebrae – Considered “Joint Above” when splinting – Atlas (C1) and Axis (C2) „ Thoracic – 12 Vertebrae – Ribs connected forming rigid framework of thorax

MLREMS Version -090308 15 MLREMS Version -090308 16 AnatomyAnatomy && Physiology,Physiology, cont.cont.

„ LumbarLumbar – 5 Vertebrae (largest vertebral bodies) – Flexible and Carries majority of body weight

„ SacrumSacrum – 5 fused bones – Considered “Joint Below” with pelvis when splinting

MLREMS Version -090308 17 AnatomyAnatomy && Physiology,Physiology, cont.cont.

„ CoccyxCoccyx – 2-4 fused bones – “Tailbone” „ VertebralVertebral StructuresStructures – Body – Transverse Process – Spinous Process – Intervertebral Disks - fibrocartilage “shock absorber”

MLREMS Version -090308 18 „„ CervicalCervical (7)(7) „„ ThoracicThoracic (12)(12) „„ LumbarLumbar (5)(5) „„ SacrumSacrum (5)(5) „„ CoccyxCoccyx (4)(4)

MLREMS Version -090308 19 AnatomyAnatomy && Physiology,Physiology, cont.cont. „ CentralCentral NervousNervous SystemSystem (CNS)(CNS) – Brain ƒ Largest most complicated portion of CNS ƒ Continuous with spinal cord ƒ Responsible for all sensory and motor functions – Spinal Cord ƒ Within the Vertebral Column ƒ Begins at Foramen Magnum and ends near L2 (cauda equina) ƒ Dural Sheath

MLREMS Version -090308 20 AnatomyAnatomy && Physiology,Physiology, cont.cont.

„ CNSCNS Cont.Cont. – Ascending Nerve Tracts ƒ Carries impulses and sensory information from the body to the brain (I.e. touch, pressure, pain, tenderness, body movements, etc.) – Descending Nerve Tracts ƒ Carries motor impulses from brain to body (e.g. muscle tone, sweat glands, muscle contraction, control of posture)

MLREMS Version -090308 21 AnatomyAnatomy && Physiology,Physiology, cont.cont.

„ CNSCNS Cont.Cont. – Spinal Nerves ƒ 31 pairs originating from spinal cord ƒ Mixed Nerves - carry both sensory and motor functions – Dermatones ƒ Topographical region of body surface innervated by one spinal nerve ƒ Example: C-7/T-1 motor = finger abduction and adduction, sensory = little finger

MLREMS Version -090308 22 PathophysiologyPathophysiology ofof SpinalSpinal InjuriesInjuries

„ MechanismsMechanisms andand AssociatedAssociated InjuriesInjuries –– HyperextensionHyperextension – Cervical & Lumbar Spine – Disk disruption – Compression of ligaments – Fx with potential instability and bone displacement –– HyperflexionHyperflexion – Cervical & Lumbar Spine – Wedge Fx – Stretching of ligaments – Compression Injury of cord – Disk disruption with potential vertebrae dislocation

MLREMS Version -090308 23 Pathophysiology,Pathophysiology, cont.cont. (Mechanisms(Mechanisms andand CommonCommon Injuries)Injuries)

–– RotationalRotational – Most commonly Cervical Spine but potentially in Lumbar Spine – Stretching and tearing of ligaments – Rotational subluxation and dislocation – Fx –– CompressionCompression – Most likely between T12 and L2 – Compression fx – Ruptured disk

MLREMS Version -090308 24 Example of Wedge Fracture

MLREMS Version -090308 25 Pathophysiology,Pathophysiology, cont.cont. (Mechanisms(Mechanisms andand CommonCommon Injuries)Injuries) –– DistractionDistraction – Most common in upper Cervical Spine – Stretching of cord without damage to spinal column –– PenetratingPenetrating – Forces directly to spinal column – Disruption of ligaments – Fx – Direct damage to cord

MLREMS Version -090308 26 Pathophysiology,Pathophysiology, cont.cont.

„ SpecificSpecific InjuriesInjuries – Fractures to vertebrae – Tearing of Ligaments, Tendons and/or Muscles – Dislocation or Subluxation of vertebrae – Disk herniation / rupture

MLREMS Version -090308 27 Pathophysiology,Pathophysiology, cont.cont. (Specific(Specific Injuries)Injuries)

–– CordCord InjuriesInjuries – Concussion - temporary or transient disruption of cord function – Contusion - Bruising of the cord with associated tissue damage, swelling and vascular leaking – Compression - Pressure on cord secondary to vertebrae displacement, disk herniation and/or associated swelling

MLREMS Version -090308 28 Pathophysiology,Pathophysiology, cont.cont. (Specific(Specific Injuries)Injuries) ––CordCord InjuriesInjuries cont.cont. ƒƒ LacerationLaceration -- DirectDirect damagedamage toto cordcord withwith associatedassociated bleeding,bleeding, swellingswelling andand potentialpotential disruptiondisruption ofof cordcord ƒƒ HemorrhageHemorrhage -- OftenOften associatedassociated withwith aa contusion,contusion, lacerationlaceration oror stretchingstretching injuryinjury thatthat disruptsdisrupts bloodblood flow,flow, appliesapplies pressurepressure secondarysecondary toto bloodblood accumulation,accumulation, and/orand/or irritationirritation duedue toto bloodblood crossingcrossing bloodblood--brainbrain barrier.barrier. ƒƒ TransectionTransection -- PartialPartial oror completecomplete severingsevering ofof cordcord

MLREMS Version -090308 29 Pathophysiology,Pathophysiology, cont.cont. (Specific(Specific Injuries)Injuries) –– SpinalSpinal ShockShock ƒ Temporary insult affecting body below level of the injury – Flaccidity and decreased sensation – Hypotension – Loss of bladder and/or bowel control – Priapism – Loss of temperature control – Often transient if no significant damage to cord

MLREMS Version -090308 30 Pathophysiology,Pathophysiology, cont.cont. (Specific(Specific Injuries)Injuries)

–– NeurogenicNeurogenic ShockShock ƒ Injury disrupts brain’s control over body – lack of sympathetic tone – Arterial and vein dilation causing relative hypovolemia – Decreased cardiac output – Decrease release of epinephrine ƒ Decreased BP ƒ Decreased HR ƒ Decreased Vasoconstriction

MLREMS Version -090308 31 SignsSigns andand SymptomsSymptoms ofof SpinalSpinal CordCord InjuryInjury

„ Pain „ Paralysis „ Tenderness „ Paresthesias „ Painful Movement „ Paresis (weakness) „ Deformity „ Shock „ Soft Tissue Injury in „ Priapism area of spine (Bruise, Laceration, etc.)

MLREMS Version -090308 32 MLREMS Version -090308 33 GeneralGeneral AssessmentAssessment

„ SceneScene SizeSize UpUp „ InitialInitial AssessmentAssessment –– IncludingIncluding manualmanual stabilization/immobilizationstabilization/immobilization ofof thethe cc--spinespine „ FocusedFocused HistoryHistory andand PhysicalPhysical ExamExam -- TraumaTrauma –– ReevaluateReevaluate MechanismMechanism ofof InjuryInjury (MOI)(MOI) –– SuspectedSuspected SpinalSpinal InjuryInjury ProtocolProtocol

MLREMS Version -090308 34 HighHigh RiskRisk MOIMOI -- ForcesForces oror impactimpact suggestsuggest aa potentialpotential spinalspinal injuryinjury

„ Sports Injuries „ HighHigh SpeedSpeed MVCMVC Sports Injuries „ OtherOther HighHigh ImpactImpact „ FallsFalls GreaterGreater thanthan 3x3x SituationsSituations pt.pt.’’ss bodybody heightheight „ ConsiderationConsideration toto „ AxialAxial LoadingLoading specialspecial pt.pt. PopulationPopulation „ ViolentViolent situationssituations –– pediatricspediatrics nearnear thethe spinespine –– geriatricsgeriatrics –– StabbingStabbing –– historyhistory ofof DownDown’’ss –– GunGun shotsshots –– spinaspina bifidabifida –– etc.etc. –– etc.etc.

MLREMS Version -090308 35 HighHigh RiskRisk MOIsMOIs

TheThe presencepresence ofof aa HighHigh RiskRisk MOIsMOIs doesdoes notnot alwaysshouldalwaysshould require requirebebe moremore treatment,treatment, suspicioussuspicious butbut ofof providersprovidersspinalspinal injuryinjury andand immobilizeimmobilize ifif theythey areare atat allall worriedworried aboutabout thethe possibilitypossibility ofof spinalspinal injuryinjury

,,

MLREMS Version -090308 36 SpecialSpecial PatientPatient RiskRisk FactorsFactors AssociatedAssociated withwith SpinalSpinal InjuryInjury „„ TrisomyTrisomy 2121 ((DownDown SyndromeSyndrome,, mongolism)mongolism) –– RiskRisk ofof AtlantoAtlanto--AxialAxial InstabilityInstability (AAI)(AAI) „„ AgeAge GreaterGreater thanthan 5555 –– RiskRisk ofof degenerativedegenerative arthritisarthritis ofof cervicalcervical spinespine „„ DegenerativeDegenerative BoneBone DiseaseDisease (including(including ostegenesisostegenesis imperfecta,imperfecta, oror ““fragilefragile bonesbones””)) –– RiskRisk ofof ““pathologicalpathological”” (disease(disease--related)related) fracturesfractures „„ SpinalSpinal TumorsTumors –– RiskRisk ofof ““pathologicalpathological”” (disease(disease--related)related) fracturesfractures

MLREMS Version -090308 37 NegativeNegative MOIMOI

„„ ForcesForces oror impactimpact involvedinvolved doesdoes notnot suggestsuggest aa potentialpotential spinalspinal injuryinjury –– DroppingDropping rockrock onon footfoot –– TwistingTwisting ankleankle whilewhile runningrunning –– IsolatedIsolated softsoft tissuetissue injuryinjury

MLREMS Version -090308 38 UncertainUncertain MOIMOI

„„ UnclearUnclear oror uncertaintyuncertainty regardingregarding thethe impactimpact oror forcesforces

–– TripTrip andand fallfall hittinghitting headhead –– FallFall fromfrom 22--44 feetfeet –– LowLow speedspeed MVCMVC withwith minorminor damagedamage

MLREMS Version -090308 39 MOI,MOI, cont.cont.

WhenWhen usingusing thethe SuspectedSuspected SpinalSpinal InjuryInjury protocol,protocol, aa positivepositive mechanismmechanism ofof injuryinjury isis notnot consideredconsidered meansmeans toto necessitatenecessitate fullfull immobilizationimmobilization …… BUTBUT…… shouldshould bebe usedused asas aa historicalhistorical componentcomponent thatthat maymay heightenheighten aa providerprovider’’ss suspicionsuspicion forfor aa spinalspinal cordcord injury.injury.

MLREMS Version -090308 40 CurrentCurrent PracticePractice WidespreadWidespread spinalspinal immobilizationimmobilization ofof allall adultadult andand pediatricpediatric traumatrauma

patients.patients.

MLREMS Version -090308 41 SpinalSpinal ImmobilizationImmobilization EducationEducation ––IdentifyIdentify AllAll PatientsPatients atat RiskRisk forfor SpinalSpinal InjuryInjury basedbased onon MechanismMechanism ofof InjuryInjury andand PatientPatient AssessmentAssessment ––ShiftShift fromfrom currentcurrent thinkingthinking ofof immobilizationimmobilization basedbased onon mechanismmechanism ofof injuryinjury alonealone.

MLREMS Version -090308 42 HistoryHistory ofof SpinalSpinal ImmobilizationImmobilization

„„MaineMaine SelectiveSelective SpinalSpinal ImmobilizationImmobilization –– EarlyEarly LeadersLeaders inin OutOut –– ofof –– HospitalHospital SelectiveSelective SpinalSpinal ImmobilizationImmobilization „„NationalNational EmergencyEmergency XX--RadiographyRadiography UtilizationUtilization

MLREMSStudyStudy Version -090308 (NEXUS)(NEXUS) 43 SpinalSpinal ImmobilizationImmobilization ProtocolsProtocols inin NewNew YorkYork StateState

TheThe followingfollowing groupsgroups ofof patientspatients

MLREMS Version -090308shouldshould bebe immobilized!immobilized! 44 MajorMajor TraumaTrauma ProtocolProtocol

„„AllAll AdultAdult andand PediatricPediatric TraumaTrauma PatientsPatients whowho meetmeet thethe MajorMajor TraumaTrauma ProtocolsProtocols

(T(T 66 ––7)7)

MLREMS Version -090308 45 MLREMS Version -090308 46 SignsSigns andand SymptomsSymptoms ofof SpinalSpinal CordCord InjuryInjury

„ Pain „ Paralysis „ Tenderness „ Paresthesias „ Painful Movement „ Paresis (weakness) „ Deformity „ Shock „ Soft Tissue Injury in „ Priapism area of spine (Bruise, Laceration, etc.)

MLREMS Version -090308 47 ConsiderConsider SpinalSpinal ImmobilizationImmobilization (( 11 ofof 2)2) NotNot MeetingMeeting MajorMajor TraumaTrauma ProtocolProtocol butbut patientpatient hashas oneone oror more:more: ––AlteredAltered MentalMental StatusStatus ––PatientPatient ComplaintComplaint ofof NeckNeck PainPain ––Weakness,Weakness, TinglingTingling oror NumbnessNumbness ––PainPain onon PalpationPalpation ofof PosteriorPosterior MidlineMidline NeckNeck

MLREMS Version -090308 48 MLREMS Version -090308 49 ConsiderConsider SpinalSpinal ImmobilizationImmobilization (2(2 ofof 2)2) „„HighHigh RiskRisk PatientsPatients ––NotNot MeetingMeeting MajorMajor TraumaTrauma ProtocolProtocol butbut patientpatient hashas oneone oror more:more: ƒƒ AlteredAltered MentalMental StatusStatus ƒƒ EvidenceEvidence ofof IntoxicationIntoxication ƒƒ DistractingDistracting InjuryInjury ƒƒ InabilityInability toto CommunicateCommunicate – AcuteAcute StressStress ReactionReaction ƒƒ ElderlyElderly MLREMS Version -090308– Age Greater than 65 years 50 WhatWhat isis anan AlteredAltered LevelLevel ofof Consciousness?Consciousness?

„„ VerbalVerbal oror lessless onon thethe AVPUAVPU ScaleScale „„ GlascowGlascow ComaComa ScaleScale ofof 1414 oror LessLess „„ ShortShort TermTerm MemoryMemory DeficitDeficit

MLREMS Version -090308 51 WhatWhat isis Intoxication?Intoxication? „„PatientsPatients whowho havehave eithereither ––AA HistoryHistory ofof RecentRecent AlcoholAlcohol IngestionIngestion oror IngestionIngestion ofof OtherOther IntoxicantsIntoxicants ––EvidenceEvidence ofof IntoxicationIntoxication onon PhysicalPhysical ExaminationExamination

MLREMS Version -090308 52 WhatWhat isis aa DistractingDistracting PainfulPainful Injury??Injury??

„„ PainfulPainful InjuryInjury oror SeriousSerious IllnessIllness thatthat wouldwould the Symptoms Associated with SpinalMaskSpinalMaskthe CordCord Symptoms InjuryInjury Associated with

MLREMS Version -090308 53 DistractingDistracting InjuryInjury oror CircumstancesCircumstances „ PainfulPainful InjuryInjury – Obvious Deformity – Significant Bleeding – Impaled Object – Any painful injury that may distract the patient’s attention from another, potentially more serious (cervical spine) injury „ InabilityInability toto CommunicateCommunicate ClearlyClearly (small(small child,child, confusedconfused oror intoxicatedintoxicated adult)adult) „ EmotionalEmotional DistressDistress „ PresencePresence oror ExacerbationExacerbation ofof ExistingExisting MedicalMedical ConditionsConditions

MLREMS Version -090308 54 FundamentalFundamental PrinciplePrinciple

„„ PatientPatient CommunicationCommunication ––PatientsPatients withwith CommunicationCommunication DifficultiesDifficulties ––AcuteAcute StressStress ReactionReaction

MLREMS Version -090308 55 WhatWhat isis AcuteAcute StressStress Reaction?Reaction?

„A „A ““fightfight oror flightflight responseresponse thatthat cancan ”” overrideoverride anyany painpain fromfrom anan injuryinjury

MLREMS Version -090308 56 MLREMS Version -090308 57 KeyKey PointPoint

„„IfIf therethere isis ANYANY DOUBT,DOUBT, thenthen SUSPECTSUSPECT thatthat aa SPINESPINE INJURYINJURY isis PresentPresent andand TreatTreat AccordinglyAccordingly

MLREMS Version -090308 58 MLREMS Version -090308 59 TerminationTermination ofof ImmobilizationImmobilization OnceOnce spinalspinal immobilizationimmobilization hashas beenbeen initiated,initiated, itit mustmust bebe completed.completed. AnAn extrication/cervicalextrication/cervical collarcollar startsstarts thethe immobilizationimmobilization processprocess ManualManual StabilizationStabilization doesdoes NOTNOT startstart thethe immobilizationimmobilization processprocess

MLREMS Version -090308 60 DocumentationDocumentation „„NegligenceNegligence ––EitherEither anan omissionomission oror aa commissioncommission ofof anan actact ƒƒDocumentationDocumentation ofof rationalerationale toto ––ImmobilizeImmobilize ––NotNot ImmobilizeImmobilize

MLREMS Version -090308 61 RoutineRoutine PrehospitalPrehospital CareCare DocumentationDocumentation

„„ MechanismMechanism OfOf InjuryInjury „„ PatientPatient ChiefChief ComplaintComplaint „„ PhysicalPhysical ExaminationExamination FindingFinding ––InitialInitial AssessmentAssessment ––RapidRapid TraumaTrauma ExaminationExamination ––DetailedDetailed TraumaTrauma ExaminationExamination

MLREMS Version -090308 62 DocumentationDocumentation ofof RationaleRationale toto NotNot ImmobilizeImmobilize

„„MechanismMechanism OfOf InjuryInjury isis MinorMinor ––PhysicalPhysical ExaminationExamination (Positives)(Positives) ––PhysicalPhysical ExaminationExamination (Negatives)(Negatives) ƒƒ AbsenceAbsence ofof signssigns ofof spinespine injuryinjury ƒƒ AbsenceAbsence ofof distractingdistracting injuryinjury ––PatientPatient waswas notnot oneone ofof thethe identifiedidentified highhigh riskrisk patientspatients

MLREMS Version -090308 63 NewNew NYSNYS BLSBLS ProtocolProtocol

SuspectedSuspected SpinalSpinal InjuryInjury (not(not meetingmeeting majormajor traumatrauma criteria)criteria)

MLREMS Version -090308 64 MLREMS Version -090308 65 MLREMS Version -090308 66 MLREMS Version -090308 67 MLREMS Version -090308 68 MLREMS Version -090308 69 FridayFriday NightNight LightsLights

„„ 1616 yearyear oldold malemale footballfootball playerplayer „„ MadeMade aa spearspear tackletackle duringduring thethe gamegame andand remainsremains downdown „„ AssessmentAssessment findsfinds tendernesstenderness toto thethe posteriorposterior ofof thethe neckneck

ShouldShould thethe patientpatient bebe immobilized?immobilized? WhyWhy oror WhyWhy not?not?

MLREMS Version -090308 70 MotorcycleMotorcycle AccidentAccident

„„ 3535 yearyear oldold femalefemale „„ SingleSingle vehiclevehicle accidentaccident inin thethe rainrain „„ LaidLaid thethe motorcyclemotorcycle downdown toto avoidavoid strikingstriking anotheranother carcar „„ PainPain toto leftleft elbowelbow && shouldershoulder „„ NoNo otherother unusualunusual findingsfindings

ShouldShould thethe patientpatient bebe immobilized?immobilized? WhyWhy oror WhyWhy not?not?

MLREMS Version -090308 71 TwoTwo Cars,Cars, TwoTwo DriversDrivers

„„ DriverDriver ## 11 –– Ambulatory,Ambulatory, Agitated,Agitated, 5050 yearyear oldold malemale –– RearRear endedended byby driverdriver ## 22 atat aa stoplightstoplight „„ DriverDriver ## 22 –– BeltedBelted andand stillstill inin vehiclevehicle 1919 yearyear oldold femalefemale –– CouldnCouldn’’tt stopstop inin time,time, struckstruck otherother vehiclevehicle

ShouldShould eithereither patientpatient bebe immobilized?immobilized? WhyWhy oror WhyWhy not?not?

MLREMS Version -090308 72 QA/QIQA/QI

„„ RegionalRegional reviewreview ofof PCRs.PCRs.

„„ AgencyAgency increasedincreased reviewreview ofof allall PCRsPCRs wherewhere spinalspinal immobilizationimmobilization waswas notnot used.used.

„„ OnOn--goinggoing educationeducation ofof providersproviders

MLREMS Version -090308 73 ReviewReview

WhatWhat areare thethe MOIsMOIs thatthat shouldshould leadlead toto spinalspinal immobilization?immobilization? WhatWhat otherother factorsfactors shouldshould alsoalso leadlead directlydirectly toto immobilization?immobilization? WhatWhat physicalphysical findingsfindings areare commoncommon indicatorsindicators ofof spinalspinal injury?injury? WhatWhat aspectsaspects ofof patientpatient historyhistory maymay makemake aa patientpatient atat higherhigher riskrisk forfor injuryinjury oror maskingmasking anan injury?injury?

MLREMS Version -090308 74 75 75

First, do no harm First, do no harm 090308 090308 - - Good Medical Care requires good clinical judgment; this can not be defined or legislated, but must be employed. When in doubt, decide favor of the patient and immobilize the spine. Good Medical Care requires good clinical judgment; this can not be defined or legislated, but must be employed. When in doubt, decide favor of the patient and immobilize the spine. „ „ MLREMS Version MLREMS Version „ „