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2014 Spine Protection and Other Trends

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Spinal Protection and other Trends PSOW 2014 SStteevveenn JJ.. SSttrroommaann,, MMDD,, FFAACCEEPP,, FFAAAAEEMM,, CCCCEEMMTT//PP
EMS IS the Practice of Medicine 2 -approved as a subspecialty by the ABMS 9/2010 -first Boarded EMS Physicians 12/31/2013
3 Wish List… Disclosure… …Patient Care
Topics of the day: •Spinal Protection •Video Laryngoscopy •Some words about Ketamine •“Our ever evolving toolbox…”
Spinal Injuries HHooww BBiigg aa PPrroobblleemm?? AA LLiittttllee AAnnaattoommyy RReevviieeww GGeenneerraall AAsssseessssmmeenntt // DDooccuummeennttaattiioonn SSppiinnaall CCoorrdd IInnjjuurriieess TTrraaddiittiioonnaall MMaannaaggeemmeenntt SSppiinnee IInnjjuurryy CClleeaarraannccee vvss SSppiinnaall PPrrootteeccttiioonn
Incidence of SCI 10,000 - 20,000 ssppiinnaall ccoorrdd iinnjjuurriieess ppeerr yyeeaarr IInncciiddeennccee ~~ 8822%% ooccccuurr iinn mmeenn ~~ 6611%% ooccccuurr iinn 1166--3300 yyoo CCoommmmoonn ccaauusseess MMVVCC ((4488%%)) FFaallllss ((2211%%)) PPeenneettrraattiinngg iinnjjuurriieess ((1155%%)) SSppoorrttss iinnjjuurriieess ((1144%%))
Morbidity Mortality 40% of trauma patients wwiitthh nneeuurroo ddeeffiicciittss wwiillll hhaavvee tteemmppoorraarryy oorr ppeerrmmaanneenntt SSCCII MMaannyy mmoorree vveerrtteebbrraall iinnjjuurriieess tthhaatt ddoo nnoott rreessuulltt iinn ccoorrdd iinnjjuurryy MMoosstt ccoommmmoonnllyy iinnjjuurreedd vveerrtteebbrraaee CC55--CC77 CC11--CC22 TT1122--LL22
Prevention-The First Concept in Trauma Care TTrraaiinniinngg//EEdduuccaattiioonn iinn pprrootteeccttiivvee hhaannddlliinngg aanndd mmoovveemmeenntt ooff tthhee iinnjjuurreedd ppaattiieenntt IInnjjuurryy PPrreevveennttiioonn PPuubblliicc EEdduuccaattiioonn,, EEMMSS CCoommmmuunniittyy SSeerrvviiccee PPrroojjeeccttss SSeeccoonnddaarryy IInnjjuurryy PPrreevveennttiioonn TTrraaiinniinngg//IInntteeggrraattiioonn ooff EEMMRRss TTeerrttiiaarryy HHoossppiittaall CCaarree
Anatomy Review 3333 VVeerrtteebbrraaee ((……MMuullttiippllee JJooiinnttss……)) SSppiinnee ssuuppppoorrtteedd bbyy ppeellvviiss kkeeyy lliiggaammeennttss aanndd mmuusscclleess ccoonnnneecctt hheeaadd ttoo ppeellvviiss aanntteerriioorr lloonnggiittuuddiinnaall lliiggaammeenntt aanntteerriioorr ppoorrttiioonn ooff tthhee vveerrtteebbrraall bbooddyy mmaajjoorr ssoouurrccee ooff ssttaabbiilliittyy pprrootteeccttss aaggaaiinnsstt hhyyppeerreexxtteennssiioonn ppoosstteerriioorr lloonnggiittuuddiinnaall lliiggaammeenntt ppoosstteerriioorr vveerrtteebbrraall bbooddyy wwiitthhiinn tthhee vveerrtteebbrraall ccaannaall pprreevveennttss hhyyppeerrfflleexxiioonn
Anatomy Review BBoonnee SSttrruuccttuurree ooff tthhee SSppiinnee CCeerrvviiccaall TThhoorraacciicc LLuummbbaarr SSaaccrraall//CCooccccyyxx
Anatomy Review Vertebral body •posterior portion forms part of vertebral foramen •increases in size from cervical to sacral •spinous process •transverse process Vertebral foramen •opening for spinal cord Intervertebral disk •shock absorber (fibrocartilage)
Motor Sensory Dermatomes DDeerrmmaattoommee SSppeecciiffiicc aarreeaa iinn wwhhiicchh tthhee ssppiinnaall nneerrvvee ttrraavveellss oorr ccoonnttrroollss IImmppoorrttaanntt iinn aasssseessssiinngg lleevveell ooff SSCCII PPlleexxuuss ppeerriipphheerraall nneerrvveess rreejjooiinn aanndd ffuunnccttiioonn aass ggrroouupp CCeerrvviiccaall PPlleexxuuss ddiiaapphhrraaggmm aanndd nneecckk
Dermatomes CC33,,44 mmoottoorr:: sshhoouullddeerr sshhrruugg sseennssoorryy:: ttoopp ooff sshhoouullddeerr CC33,, 44,, 55 mmoottoorr:: ddiiaapphhrraaggmm sseennssoorryy:: ttoopp ooff sshhoouullddeerr CC55,, 66 mmoottoorr:: eellbbooww fflleexxiioonn sseennssoorryy:: tthhuummbb CC77 mmoottoorr:: eellbbooww,, wwrriisstt,, ffiinnggeerr eexxtteennssiioonn sseennssoorryy:: mmiiddddllee ffiinnggeerr CC88,, TT11 mmoottoorr:: ffiinnggeerr aabbdduuccttiioonn aadddduuccttiioonn sseennssoorryy:: lliittttllee ffiinnggeerr TT44 mmoottoorr:: lleevveell ooff nniippppllee TT1100 mmoottoorr:: lleevveell ooff uummbbiilliiccuuss
Dermatomes LL11,, 22 mmoottoorr:: hhiipp fflleexxiioonn sseennssoorryy:: iinngguuiinnaall ccrreeaassee LL33,,44 mmoottoorr:: qquuaaddrriicceeppss sseennssoorryy:: mmeeddiiaall tthhiigghh,, ccaallff LL55 mmoottoorr:: ggrreeaatt ttooee,, ffoooott ddoorrssiifflleexxiioonn sseennssoorryy:: llaatteerraall ccaallff SS11 mmoottoorr:: kknneeee fflleexxiioonn sseennssoorryy:: llaatteerraall ffoooott SS11,, 22 mmoottoorr:: ffoooott ppllaannttaarr fflleexxiioonn SS22,,33,,44 mmoottoorr:: aannaall sspphhiinncctteerr ttoonnee sseennssoorryy:: ppeerriiaannaall
SCI Overview
Assessment of Spinal Injury MMeecchhaanniissmm ooff IInnjjuurryy –– NNoott aallll MMOOIIss lleeaadd ttoo SSCCII SSeevveerree mmeecchhaanniissmm ooff iinnjjuurryy iiss ccoonnssiisstteenntt wwiitthh SSCCII OOtthheerr MMOOIIss ddoonn’’tt ccoorrrreellaattee ttoo tthhee rriisskk ooff SSCCII EEDD ““FFiieelldd CClleeaarraannccee PPrroottooccoollss”” aarree iinn ccoommmmoonn uussee EExxaamm aanndd HHiissttoorryy ffiinnddiinnggss hheellpp iiddeennttiiffyy tthhee ppootteennttiiaall SSCCII RReemmeemmbbeerr:: DDoo NNoo HHaarrmm!!
Assessment of Spinal Injury TTrraaddiittiioonnaall AApppprrooaacchh BBaasseedd oonn MMOOII ((CCCCRR)) EEmmpphhaassiiss oonn ssppiinnaall iimmmmoobbiilliizzaattiioonn iinn:: uunnccoonnsscciioouuss ttrraauummaa vviiccttiimmss ppaattiieennttss wwiitthh aa ““mmoottiioonn”” iinnjjuurryy NNoo cclleeaarr cclliinniiccaall gguuiiddeelliinneess oorr ssppeecciiffiicc ccrriitteerriiaa ttoo eevvaalluuaattee ffoorr SSCCII SSiiggnnss:: ppaaiinn,, tteennddeerrnneessss,, ppaaiinnffuull mmoovveemmeenntt ddeeffoorrmmiittyy,, iinnjjuurryy oovveerr ssppiinnaall aarreeaa,, sshhoocckk ppaarreesstthheessiiaass,, ppaarreessiiss,, pprriiaappiissmm
CCaannaaddiiaann CC--SSppiinnee RRuulleess ((CCCCRR))
Assessment of Spinal Injury TTrraaddiittiioonnaall AApppprrooaacchh NNoott aallwwaayyss pprraaccttiiccaall ttoo ““iimmmmoobbiilliizzee”” eevveerryy ““mmoottiioonn”” iinnjjuurryy MMoosstt ssuussppeecctteedd iinnjjuurriieess wweerree mmoovveedd ttoo aa nnoorrmmaall aannaattoommiiccaall ppoossiittiioonn NNoo eexxcclluussiioonn ccrriitteerriiaa uusseedd ffoorr mmoovviinngg ppaattiieennttss BBaasseedd oonn tthhee 11999999 NNAAEEMMSSPP PPoossiittiioonn PPaappeerr NNEEXXUUSS aanndd CCCCRR
Assessment of Spinal Injury NEXUS CCrriitteerriiaa ((aannsswweerr YYeess oorr NNoo)) FFooccaall NNeeuurroollooggiicc DDeeffiicciitt?? MMiiddlliinnee SSppiinnaall TTeennddeerrnneessss?? AAlltteerreedd LLOOCC?? DDiissttrraaccttiinngg IInnjjuurryy PPrreesseenntt?? IInnttooxxiiccaatteedd?? IIff nnoonnee ooff tthhee aabboovvee ccrriitteerriiaa aarree pprreesseenntt,, tthhee CC--SSppiinnee ccaann bbee cclleeaarreedd cclliinniiccaallllyy bbyy tthheessee ccrriitteerriiaa..
Assessment of Spinal Injury in Spinal injjuurriieess aarree rreellaattiivveellyy uunnccoommmmoonn:: MMaannyy aarree ssttaabbllee
Assessment of Spinal Injury TTrraaddiittiioonnaall AApppprrooaacchh DDeevviicceess,, ssuucchh aass sshhoorrtt aanndd lloonngg bbaacckkbbooaarrddss,, oorr eexxttrriiccaattiioonn vveessttss,, ooffffeerr rreessttrriiccttiioonn ooff mmoovveemmeenntt,, bbuutt DDOO NNOOTT ““iimmmmoobbiilliizzee”” PPootteennttiiaall HHaarrmm aaccccoommppaanniieess rriiggiidd ssppiinnaall rreessttrriiccttiioonn,, eessppeecciiaallllyy iiff pprroolloonnggeedd……
Assessment of Spinal Injury ““mmoovveemmeenntt ddeevviicceess”” hheellpp rreellooccaattee ppaattiieennttss ttoo ssttaabbllee eennvviirroonnmmeennttss,, oorr pprreeppaarree ffoorr ttrraannssppoorrtt.. TThheeyy ffaasstteenn eexxtteerrnnaallllyy,, bbuutt ddoonn’’tt pprreevveenntt sskkiinn aanndd mmuussccllee ffrroomm ccoonnttiinnuuiinngg ttoo ggeenneerraattee mmoovveemmeenntt aaccrroossss tthhee bboonnyy sskkeelleettoonn.. TThhee ssppiinnee bbooaarrdd hhaass bbeeeenn tthhee eexx ffaaccttoo ttooooll ooff cchhooiiccee ffoorr 5500 yyeeaarrss,, ddeessppiittee llaacckk ooff eevviiddeennccee ttoo iittss bbeenneeffiitt
Historical Long Spine Board Use s Introduced 1960’s,, bbaasseedd oonn rraattiioonnaall ccoonnjjeeccttuurree ““GGOOMMSSAATT””
Historical Long Spine Board Use ““Survey of the accident vviiccttiimmss,, ffiirrmm iimmmmoobbiilliizzaattiioonn aanndd iinn--lliinnee ttrraaccttiioonn aarree tthhee pprriinncciipplleess ooff eexxttrriiccaattiioonn..”” 11996666 11997777 EEMMTT CCuurrrriiccuulluumm
Historical Long Spine Board Use PPrreessuummppttiioonnss IImmmmoobbiilliizzeess aallll sseeggmmeennttss ffrroomm jjooiinntt aabboovvee ttoo jjooiinnttbbeellooww tthhee iinnjjuurreedd sseeggmmeenntt NNoo eevviiddeennccee ttoo ddaattee tthhaatt tthhiiss iiss ccoorrrreecctt CC CCoollllaarr uussee bbaasseedd oonn eessttaabblliisshheedd tthheerraappyy ffoorr kknnoowwnn ssppiinnaall lleessiioonnss oorr ppoosstt--ooppeerraattiivvee ccaarree
Evidence to the Contrary What about the iinndduuccttiioonn oorr ddeevveellooppmmeenntt ooff ppaaiinn?? Healthy volunteers developed significant pain in the cceerrvviiccaall aanndd lluummbbaarr rreeggiioonnss 2211%% ooff tthhee ttiimmee** Results in: DDeellaayy ooff rreemmoovvaall ffrroomm bbooaarrdd UUnnnneecceessssaarryy iimmaaggiinngg ((8844%% cceerrvviiccaall,, 3322%% lluummbbaarr)) PPaaiinn DDeellaayy iinn ddiissppoossiittiioonn ooff ppaattiieenntt **BBaarrnneeyy,, CCoorrddeellll,, aanndd MMiilllleerr,, PPaaiinn AAssssoocciiaatteedd wwiitthh IImmmmoobbiilliizzaattiioonn oonn RRiiggiidd SSppiinneebbooaarrddss.. AAnnnn EEmmeerrgg MMeedd,, 11998899..
Evidence to the Contrary Rigid spine boards hhaavvee bbeeeenn iimmpplliiccaatteedd iinn tthhee eeaarrllyy ddeevveellooppmmeenntt ooff pprreessssuurree uullcceerrss Prolonged localized pressure leads to impaired ccaappiillllaarryy cciirrccuullaattiioonn,, ttiissssuuee hhyyppooxxiiaa aanndd nneeccrroossiiss.. TThhee rraattee ooff pprreessssuurree ssoorree nneeccrroossiiss iiss ddiirreeccttllyy rreellaatteedd ttoo lleevveell ooff aapppplliieedd pprreessssuurree aanndd ttoo ttiimmee..** *Cordell, Hollingsworth, Olinger, Stroman, Nelson. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med, 1995.
Evidence to the Contrary 3 Pressure of about 355 mmmmHHgg wwiillll ssiiggnniiffiiccaannttllyy rreedduuccee bblloooodd ffllooww tthhrroouugghh tthhee ccaappiillllaarryy bbeedd.. PPrreessssuurree mmaappppiinngg sseennssoorrss rreevveeaalleedd tthhee hhiigghheesstt ttiissssuuee iinntteerrffaaccee pprreessssuurreess aatt tthhee ssccaappuullaaee,, ssaaccrruumm,, aanndd hheeeellss..** Pressure produced: SSppiinnee bbooaarrdd == 114477 mmmmHHgg ((uunnppaaddddeedd)),, oorr 111155 ((ppaaddddeedd)) VVaaccuuuumm MMaattttrreessss == 3377 mmmmHHgg *Cordell, Hollingsworth, Olinger, Stroman, Nelson. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med, 1995.
Evidence to the Contrary Time: The average rigid spine board time in a Level I TTrraauummaa CCeenntteerr wwaass ddeetteerrmmiinneedd ttoo bbee 112200 mmiinnuutteess..11 Another study found an average of 64 minutes ((wwiitthhoouutt iimmaaggiinngg)),, oorr eexxcceeeeddiinngg 118800 mmiinnuutteess ((wwiitthh iimmaaggiinngg)).. Time on a spine board exceeded 7 hours when ttrraannssffeerr ttoo aa LLeevveell II TTrraauummaa CCeenntteerr ooccccuurrrreedd22 11BBaarrnneeyy,, CCoorrddeellll,, aanndd MMiilllleerr,, AAnnnn EEmmeerrgg MMeedd,, 11998899.. 22CCoooonneeyy,, eett..aall..,, IInntt JJ EEmmeerrgg MMeeddiicciinnee,, 22001133,,
Evidence to the Contrary One study of spinal cord iinnjjuurryy ffoouunndd tthhaatt aallll ppaattiieennttss wwhhoo ddeevveellooppeedd uullcceerraattiioonnss rreeccaalllleedd nnoo aatttteemmppttss ttoo rroollll tthheemm oorr rreemmoovvee tthhee bbooaarrdd iinn tthhee ffiirrsstt ttwwoo hhoouurrss aaffeerr tthhee iinnjjuurryy.. By contrast, all patients who did not develop uullcceerraattiioonnss hhaadd tthhee pprreessssuurree rreelliieevveedd wwiitthhiinn tthhee ffiirrsstt ttwwoo hhoouurrss bbyy rreemmoovvaall ooff tthhee ssppiinnee bbooaarrdd..
Evidence to the Contrary There has been ddeemmoonnssttrraatteedd aa ddiirreecctt rreellaattiioonnsshhiipp bbeettwweeeenn ttiimmee dduurraattiioonn oonn tthhee ssppiinnee bbooaarrdd aanndd ddeevveellooppmmeenntt ooff pprreessssuurree uullcceerrss wwiitthhiinn tthhee ffiirrsstt eeiigghhtt ddaayyss ooff hhoossppiittaalliizzaattiioonn.. UUpp ttoo 3311%% ooff ttrraauummaa ppaattiieennttss wwiillll ddeevveelloopp pprreessssuurree uullcceerrss aass tthhee rreessuulltt ooff iimmmmoobbiilliizzaattiioonn oonn aa bbaacckkbbooaarrdd..
*Berg, et.al., Prehospital Emergency Care, 2010. ssiiggnniiffiiccaanntt rreedduuccttiioonnss iinn llooccaalliizzeedd ttiissssuuee ooxxyyggeennaattiioonn iinn hheeaalltthhyy ppaattiieennttss.. a A period as short ass 3300 mmiinnuutteess ccaann pprroodduuccee Evidence to the Contrary
Device Attempts to Correct Ehob Waffle Mattress Expansion Control Overlay With Pump is ideal for:- Pressure ulcer prevention- Treatment through stage IV - Pain management. The Back Raft is a low-cost, inflatable air mattress and spinal stabilization device that improves patient comfort and virtually eliminates the risk of pressure sores and other secondary injury during transport.
Evidence to the Contrary b Restriction to movement byy LLSSSS aanndd ssttrraappss rreessuullttss iinn:: rreedduucceedd FFoorrcceedd VViittaall CCaappaacciittyy ((FFVVCC)),, tthhee mmaaxxiimmuumm vvoolluummee eexxhhaalleedd aafftteerr ddeeeeppeesstt iinnssppiirraattiioonn,, RReedduucceedd FFoorrcceedd EExxppiirraattoorryy VVoolluummee ((FFEEVV11)) RReedduucceedd FFoorrcceedd EExxppiirraattoorryy FFllooww ((FFEEFF))11 ((OOvveerraallll rreedduuccttiioonnss ooff 1155--2200%%)) 15. The results were replicated in children, ages 6-15.22 11BBaauueerr KKoowwaallsskkii,, AAnnnnaallss ooff EEmmeerrggeennccyy MMeeddiicciinnee,, 11998888.. 22SScchhaaffeerrmmeeyyeerr,, eett..aall,, AAnnnnaallss ooff EEmmeerrggeennccyy MMeeddiicciinnee,, 11999911..
Result in the inability for adequate self ventilation… rreessppiirraattoorryy ppaatthhoollooggyy Additional reductions, based on patient’s underlying tthhoorraacciicc iinnjjuurriieess Reductions are accentuated iinn tthhee ffaaccee ooff aaiirrwwaayy oorr Evidence to the Contrary
Cochrane Review of Immobilization 2009: UUnncceerrttaaiinn EEffffeeccttiivveenneessss REVIEWER'S CONCLUSIONS: We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Low prevalence-Immobilization of 50-100 people for every patient at risk of SCI
Malaysia Military Study vs. EMS vs 120 without immobilization vs.. 333344 @@ UUnniivv.. ooff NNeeww MMeexxiiccoo ddiidd.. OOuuttccoommee:: LLiittttllee oorr nnoo eeffffeecctt oonn oouuttccoommee ooff bblluunntt ssppiinnaall iinnjjuurryy Hauswald, et. al. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998 Mar;5(3):214-9.
Difficulties in ED exam (due to board) Increased risk of soft tissue injury Increases safety risk to providers (Work Comp) AAddddiittiioonnaall TThhoouugghhttss:: Evidence to the Contrary
Assessment Overview Decision to apply ssppiinnaall iimmmmoobbiilliizzaattiioonn iinn ppaasstt bbaasseedd wwaass ssoolleellyy oonn mmeecchhaanniissmm ooff iinnjjuurryy Utilize EMS Spinal Immobilization AAllggoorriitthhmm ttoo ddeetteerrmmiinnee wwhheenn ssppiinnaall iimmmmoobbiilliizzaattiioonn iiss NNOOTT nneeeeddeedd 42
iinnvvoollvviinngg tthhee hheeaadd,, ssppiinnee oorr ttrruunnkk other high impact, high force or high velocity conditions confounding factors such as osteoporosis, extreme age sports injury (with force or velocity) • ****ssttaabbbbiinngg • ****gguunn sshhoott violent situations occurring near the spine patient fall greater than 3 times the patient’’s height high speed motor vehicle collision PPoossiittiivvee MMOOII Þ SShhoouulldd RReeqquuiirree SSppiinnaall MMaannaaggeemmeenntt Consider Mechanism ooff IInnjjuurryy KKiinneemmaattiiccss SCI General Assessment
SCI General Assessment Consider Mechanism ooff IInnjjuurryy KKiinneemmaattiiccss NNeeggaattiivvee MMOOII Þ DDoo NNoott RReeqquuiirree SSppiinnee bbooaarrdd force or impact does not suggest a potential spinal injury • ddrrooppppeedd aa rroocckk oonn ffoooott • ttwwiisstteedd aannkkllee wwhhiillee rruunnnniinngg • iissoollaatteedd mmuussccuulloosskkeelleettaall iinnjjuurryy • ssiimmppllee ffaallll ffrroomm ssttaannddiinngg ppoossiittiioonn • llooww ssppeeeedd mmoottoorr vveehhiiccllee ccoolllliissiioonn
Hypoperfusion Neurogenic Shock CCaarrddiioovvaassccuullaarr iimmppaaiirrmmeenntt Diaphragmatic breathing Apnea Inability to maintain airway (SB reduces mouth opening 20%) AAiirrwwaayy aanndd//oorr BBrreeaatthhiinngg iimmppaaiirrmmeenntt ABCs SCI General Assessment
No difficulty in communication No Distracting injuries Understands Recalls events surrounding injury No impairment (drugs, alcohol) Cooperative Brain injury also? LLeevveell ooff CCoonnsscciioouussnneessss Neurologic Status: SCI General Assessment
PPrriiaappiissmm pain (pinprick), sharp vs dull, symmetry weakness, numbness, paresthesia SSeennssaattiioonn ((PPoossiittiioonn aanndd PPaaiinn)) Foot plantar flexors (gas pedal) {S1,2} ““Hitchhike Hitchhike”” {T1} Spread fingers of both hands and keep apart with force Shrug shoulders PPaallppaattee oovveerr eeaacchh ssppiinnoouuss pprroocceessss MMoottoorr ffuunnccttiioonn Assess FFuunnccttiioonn SSeennssaattiioonn SCI General Assessment
Spinal Cord Injuries PPrriimmaarryy IInnjjuurryy ooccccuurrss aatt tthhee ttiimmee ooff iinnjjuurryy mmaayy rreessuulltt iinn cord compression direct cord injury interruption in cord bblloooodd ssuuppppllyy SSeeccoonnddaarryy IInnjjuurryy ooccccuurrss aafftteerr iinniittiiaall iinnjjuurryy mmaayy rreessuulltt ffrroomm swelling/inflammation ischemia movement of body ffrraaggmmeennttss
Spinal Cord Injuries **LLeessss mmoovveemmeenntt iiss nnootteedd bbyy ppaattiieenntt sseellff-- eexxttrriiccaattiinngg tthhaann bbyy EEMMSS pprroovviiddeerrss ppllaacciinngg oonn aa bbooaarrdd..
50 Force Applied by EMS: 10 Newtons Force Required for SCI: 6000 Newtons Did EMS “Cause” the SCI?
Immobilization vs Motion Restriction Rule: All or None? (collar, board, CID, tape, straps…) CCaauuttiioonn wwiitthh ““ppaarrttiiaall”” ssppiinnee sspplliinnttiinngg?? Secure joint above and below? TTrreeaatt tthhee ssppiinnee aass aa lloonngg bboonnee?? Traditional Treatment: Stabilization of the spine begins in the initial assessment PPrreevveenntt sseeccoonnddaarryy iinnjjuurryy Primary Goal Management of SCI
Management of SCI Neutral positioning ooff hheeaadd aanndd nneecckk iiff aatt aallll ppoossssiibbllee aalllloowwss ffoorr tthhee mmoosstt ssppaaccee ffoorr ccoorrdd mmoosstt ssttaabbllee ppoossiittiioonn ffoorr ssppiinnaall ccoolluummnn DDoonn’’tt ffoorrccee iitt
Traditional Management of SCI Cervical Motion Restriction MMaannuuaall mmeetthhoodd RRiiggiidd ccoollllaarr ccoommeess llaatteerr IInntteerriimm ddeevviiccee ((KKEEDD)) MMoovvee ttoo lloonngg bbooaarrdd oorr ffuullll bbooddyy vvaaccuuuumm sspplliinntt MMaannuuaall ccoonnttiinnuueess uunnttiill ttrruunnkk aanndd hheeaadd sseeccuurreedd ““CCIIDD””
Tape along (even duct tape) is not enough pillows, blankets, towels curvature of the lower back is normal - fill it ffiillll aallll tthhee vvooiiddss especially during transport on board or in vehicle MMaaiinnttaaiinnss aannaattoommiiccaall ppoossiittiioonn LLiimmiittss mmoovveemmeenntt oonn bbooaarrdd Don Don’t ’t forget the Padding Management of SCI
Management of SCI Securing to the Board (Historical) SSttrraappss,, TTaappee,, CCrraavvaattss,, wwhhaatteevveerr TToorrssoo ffiirrsstt then legs and feet and head EEvveenn ppaattiieennttss eexxttrriiccaatteedd wwiitthh aa KKEEDD aarree sseeccuurreedd ttoo tthhee bbooaarrdd
Even SSttrraapp PPaatttteerrnnss RReesseeaarrcchheedd…… Management of SCI
Procedure for Complete Spinal Immobilization TTrraaddiittiioonnaall 5577
Procedure for Complete Spinal Immobilization (Historical)
Procedure for Complete Spinal Immobilization (Historical)
CC--ccoollllaarr oorr hheeaadd iimmmmoobbiilliizzaattiioonn ddeevviiccee C-spine hyperextension due to improperly applied aapppplliieedd hheeaadd iimmmmoobbiilliizzaattiioonn ddeevviiccee C-spine movement by inadequate or improperly sshhiimm tthhee bbooddyy Movement possible due to little or no padding to Inadequate strapping allows excessive movement oonn bbaacckkbbooaarrdd Spine not supported due to improper positioning IImmpprrooppeerrllyy ssiizzeedd CC--CCoollllaarr Common Treatment Mistakes (Spine board and collar)
• hhoorrssee ccoollllaarr • bbllaannkkeett oorr ttoowweell rroollllss Improvise with Difficult to find a correctly sized rigid collar Lots of voids to fill Vacuum mattress Short board underneath Pad underneath Elevate the entire torso if large occiput PPeeddiiaattrriicc PPaattiieenntt CCoonnssiiddeerraattiioonnss Management of SCI
no cardiac arrest no interference in airway assessment or management can perform spinal motion restriction with helmet on no impending airway or breathing problems good fit with little or no head movement within Leave in place if: ttoo aaiirrwwaayy aanndd vveennttiillaattiioonn Removal should be limited to emergent need for access Management of SCI HHeellmmeetteedd PPaattiieennttss
aanndd ffoorr rreemmoovvaall Various helmets create different problems for patient bicycle) Recreational (motorcycle, bicycle)--prefer removal Racing (motorcycle, car racer)- prefer removal • SShhoouullddeerr ppaaddss aanndd hheellmmeett ggoo ttooggeetthheerr Sports (football, hockey) Types of Helmets HHeellmmeetteedd PPaattiieennttss Management of SCI
aanndd ffoorr rreemmoovvaall Various helmets create different problems for patient bicycle) Recreational (motorcycle, bicycle)--prefer removal Racing (motorcycle, car racer)- prefer removal • SShhoouullddeerr ppaaddss aanndd hheellmmeett ggoo ttooggeetthheerr Sports (football, hockey) Types of Helmets HHeellmmeetteedd PPaattiieennttss Management of SCI
“Clearing” Protocols SSppiinnaall CClleeaarraannccee CCuurrrreenntt PPrraaccttiiccee FFiirrsstt iinniittiiaatteedd iinn MMaaiinnee wwiitthh aa ssttaattee--wwiiddee pprroottooccooll NNooww mmuucchh mmoorree ccoommmmoonn iinn UUSS AAsssseessss sscceennee aanndd MMOOII AAsssseessss nneeuurroo ssttaattuuss IImmmmoobbiilliizzee Most MOIs Prevent further injury CYA No 100% method to rruullee oouutt iinn tthhee ffiieelldd fear of litigation devastating ccoonnsseeqquueenncceess ppoossssiibbllee
Treat with Spinal Protection Difficult to determine Injury may or may not be possible 3. Uncertain Mechanism (Most Common) No reasonable probability of spinal injury 2. Negative or Obviously Minimal Mechanism High likelihood of spinal injury Violent impact 1. Positive or Obvious Severe Mechanism One ooff tthhrreeee ppaatthhss iiss cchhoosseenn:: When should the screening tool be used?
“Clearing” Protocols o No significant MOI orr eevviiddeennccee ooff ssppiinnee iinnjjuurryy NNoo nneecckk oorr bbaacckk ppaaiinn ((PPaallppaattee aallll)) NNoorrmmaall NNeeuurroo EExxaamm ((nnoo mmoottoorr//sseennssoorryy lloosssseess)) NNoorrmmaall LLeevveell ooff CCoonnsscciioouussnneessss Adult Adult, , Reliable Patient w/o anxiety reaction or ““nnoorrmmaallllyy”” aabbnnoorrmmaall mmeennttaall ssttaattuuss No ETOH or drugs No language barriers NNoo ddiissttrraaccttiinngg iinnjjuurriieess oorr ppeenneettrraattiinngg iinnjj nneeaarr ssppiinnee
“Distracting Injury” II’’mm nnoott ssuurree wwhhaatt iitt iiss,, bbuutt II’’llll kknnooww iitt wwhheenn II sseeee iitt……
Excludes “Extremes of Age” AAggee 55 AAggee 6655
Penetrating Trauma? Based on exam
Immobilization with a Backboard SHOULD NOT be performed: PENETRATING TRAUMA of the: HHeeaadd NNeecckk TToorrssoo AANNDD No evidence of spinal injury
Reviewing our SPINAL PROTECTION care today
Position Statement: EMS Spinal Precautions and the Use of the Long Backboard National Association ooff EEMMSS PPhhyyssiicciiaannss AAmmeerriiccaann CCoolllleeggee ooff SSuurrggeeoonnss CCoommmmiitttteeee oonn TTrraauummaa 22001133
Principles of Treatment Protect spinal cord ffrroomm sseeccoonnddaarryy iinnjjuurryy WWee hhaavvee lliittttllee oorr nnoo eeffffeecctt oonn pprriimmaarryy iinnjjuurryy FFooccuuss oonn pprreevveennttiioonn ooff sseeccoonnddaarryy iinnjjuurryy 76
Spinal Immobilization Algorithm PPaattiieenntt MMeennttaattiioonn:: DDeeccrreeaasseedd LLeevveell ooff CCoonnsscciioouussnneessss?? NNoo YYeess --------------------------------------------------------IImmmmoobbiilliizzee EETTOOHH//DDrruugg IImmppaaiirrmmeenntt?? NNoo YYeess --------------------------------------------------------IImmmmoobbiilliizzee SSuubbjjeeccttiivvee AAsssseessssmmeenntt:: CCeerrvviiccaall//TThhoorraacciicc//LLuummbbaarr SSppiinnaall ppaaiinn?? NNoo YYeess --------------------------------------------------------IImmmmoobbiilliizzee NNuummbbnneessss//TTiinngglliinngg//BBuurrnniinngg//WWeeaakknneessss?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee OObbjjeeccttiivvee AAsssseessssmmeenntt:: CCeerrvviiccaall//TThhoorraacciicc//LLuummbbaarr DDeeffoorrmmiittyy oorr TTeennddeerrnneessss?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee OOtthheerr SSeevveerree IInnjjuurryy?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee OOtthheerr SSeevveerree IInnjjuurryy?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee PPaaiinn ww//CCeerrvviiccaall RRaannggee ooff MMoottiioonn?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee MMAAYY TTRREEAATT//TTRRAANNSSPPOORRTT WWIITTHHOOUUTT SSPPIINNAALL PPRREECCAAUUTTIIOONNSS 7777
Once We Decide to Immobilize/Protect: HOW? RRiiggiidd CCeerrvviiccaall CCoollllaarr SSeeccuurreedd ffiirrmmllyy ttoo EEMMSS SSttrreettcchheerr BBeesstt UUssee FFoorr:: Ambulatory patients at scene Prolonged use, interfacility transfer No other backboard indication
Stratify the Patients for Protection: 1. Uninjured: Ambulatory, no pain or complaint ssttaatteedd,, oorr oonn eexxaamm TTrreeaattmmeenntt:: NNoonnee rreeqquuiirreedd 2. MOI/Complaint TTrreeaattmmeenntt:: CC CCoollllaarr,, ccoott ssttrraappss,, mmiinniimmaall mmoovvtt.. 3. Severe MOI/LOC/Deficits TTrreeaattmmeenntt:: CC CCoollllaarr//VVaaccuuuumm//……LLSSSS?? MMiinniimmaall mmoovvtt..
Summary: Backboard oorr NNoott,, SSppiinnaall PPrrootteeccttiioonn//PPrreeccaauuttiioonn aammoonngg aatt--rriisskk ppaattiieennttss iiss PPAARRAAMMOOUUNNTT!! Appropriate protection with collar cervical collar, , aaddeeqquuaattee sseeccuurriittyy ttoo ssttrreettcchheerr,, mmiinniimmaall mmoovveemmeenntt//ttrraannssffeerrss,, aanndd mmaaiinnttaaiinniinngg iinn--lliinnee ssttaabbiilliizzaattiioonn dduurriinngg mmoovveemmeenntt//ttrraannssffeerrss
SPINAL PROTECTION CARE EMT AND PARAMEDIC PROTOCOL DRAFT Patients with blunt traumatic injuries with mechanism concerning for spinal injury should be assessed for spinal injury.
Have no midline back or neck pain or tenderness upon palpation. injuries or severe pain) No evidence of a distracting injury (fractures, major burns, crush (numbness/weakness in an extremity) No history of new/temporary neurological deficit No evidence of intoxication (alcohol/drug) or altered mental status Conscious, cooperative and able to communicate effectively age 5 , 65 following conditions apply: Patients may have all spinal immobilization omitted if ALL of the NO spinal protection necessary PROTOCOL DRAFT SPINAL PROTECTION CARE
neck 45 degrees to either side of midline and if still no pain, NO immobilization is indicated. If ALL of the above criteria are met, have patient move their There is no major mechanism for severe injury NO spinal protection necessary PROTOCOL DRAFT SPINAL PROTECTION CARE
SPINAL PROTECTION CARE PROTOCOL DRAFT Spinal Protection measures indicated If, after assessment, spinal protection is indicated: Spinal protection consists of keeping the head, neck and spine midline. The neck can be stabilized with a well-fitted cervical collar, head blocks, blanket rolls or other immobilization techniques. Patients who are already walking or standing should be laid directly on the ambulance stretcher and secured to the stretcher with seatbelts. Backboards and scoops are designed and should only be used to extricate and move patients.
SPINAL PROTECTION CARE PROTOCOL DRAFT Spinal Protection measures indicated Once extricated and moved, patients should be taken off the backboard or scoop stretcher if possible, and be placed directly on the ambulance stretcher. It is acceptable to leave a patient on a backboard for transport, but every effort should be made to secure the patient to the stretcher and not the backboard. Decisional patients have the right to refuse aspects of treatment including spinal immobilization. If a patient refuses immobilization after being informed of possible permanent paralysis, do not immobilize them and document the patient’s refusal in your medical record.
SPINAL PROTECTION CARE PROTOCOL DRAFT Patients with Penetrating Trauma (Gunshot or stab to head, chest, or abdomen) Patients with penetrating traumatic injuries should only be immobilized if a focal neurological deficit is noted on physical exam (although there is little evidence of benefit even in these cases)
Trainers (Technical Colleges, Hospitals) NNeeuurroossuurrggeeoonn)) Customers (ED Doctors, Trauma Surgeon, CCoouunncciillss)) Industry Colleagues (Agency, Medical Directors, Within (Individual Champion, Crew, Organization) Stakeholder Discussions Implementation of Change
Oversight and QA Run Documentation (movement, neuro exam, etc) In-Service for ED Nurses (Managers) FFaacciilliittiieess,, TTrraauummaa CCoooorrddiinnaattoorrss ((DDaattaabbaassee)) Notification of Customers (EDs, Trauma Care Training of Personnel (internal) Protocol Development / Approval Roll Out Implementation of Change
Will Video Kill Direct Laryngoscopy?
WILL VIDEO KILL DIRECT LARYNGOSCOPY? CASE: 35 yo MCA victim, arrives combative (with/without spineboard), injury to head (unhelmeted), along with multiple extremity fractures, and a firm abdomen.
Salvage (NVA, Device change, Provider change, Bougee, surgical) Preferred technique (VL, DL) What is in your decision tree? Do you use the DL or VL? (or NVA) A decision is made to RSI/RSA the patient. LARYNGOSCOPY? WILL VIDEO KILL DIRECT
*Walls,et. al, National Emergency Airway Registry, 2011 RSI used in 2/3 of cases 87% of intubations are performed by ED Physicians* Some quick facts: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
*Yeatts, Dutton, Hu, et. al, J Trauma Acute Care Surg. 2013;75:212-9. desaturation, first pass success Secondary: Subgroup survival, duration of attempt, Outcome: Mortality VL (GlideScope) vs. DL Trauma Patients at Baltimore Shock Trauma survival; a randomized controlled trial.” “Effects of video laryngoscopy on trauma patient LARYNGOSCOPY? WILL VIDEO KILL DIRECT
*Yeatts, Dutton, Hu, et. al, J Trauma Acute Care Surg. 2013;75:212-9. randomized to VL group A possible increased mortality for most severe CHI, VL and DL had similar mortality Conclusions: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
*Baldino, Walsh, Peek, Clayton, Morristown Medical Center, NJ. Overall Intubation Success (97-85%) First Attempt Success (80 vs 79%) (Glidescope) with Video-Assisted Laryngoscopy Changes in Intubation Success Over the First Year NAEMSP Poster Presentations: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
*DiCroce, Lubin, Penn State Hershey Medical Center, Hershey, PA Overall Intubation Success (96.6%). (VL=100%, DL=93.3%) First Attempt Success (74.1%) n=56 (VL) and 60 (DL) Study Period 2 years (C-Mac) Rates During Critical Care Transport The Impact of Video Laryngoscopy on Intubation Success NAEMSP Poster Presentations: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
*DiCroce, Lubin, Penn State Hershey Medical Center, Hershey, PA Better view with VL. No significant difference in number of attempts. Success Rates During Critical Care Transport The Impact of Video Laryngoscopy on Intubation Conclusions LARYNGOSCOPY? WILL VIDEO KILL DIRECT
*Escott, et. al, Baylor College of Medicine/EMS Collaborative Research Group. Concluded as least as safe and effective as DL in pre-hospital use First Pass Rate 71% (VL) vs 65% (DL) (King Vision) 227 intubations by 153 paramedics. Mean DL experience = 9 years. Four Month Run-in Period by Paramedics Video vs. Direct Laryngoscopy: Multi-site Review of the NAEMSP Poster Presentations LARYNGOSCOPY? WILL VIDEO KILL DIRECT
First Pass Success in both groups was 80% Desaturation 80% was greater in VL group (50 vs 40 sec) VL had increased time for placement (56 sec vs 40 sec) Mortality in VL and DL groups was similar Take Home Points for Consideration: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
Where are we on RSI? RSA? MFI?
Procedure Sedative SFI: Procedure (ETT, NVA) Paralytic (SCh, Rocuronium, Vecuronium) Sedative (midazolam, etomidate, ketamine) RSI / RSA /MFI RSI/RSA:
Out of hospital SFI rates from 25-87% In an ED setting , first pass RSI 91%, SFI 84%. If apparent relaxation occurs, proceed with intubation ppaarraallyyttiicc Sedative (midazolam, etomidate, ketamine), without a SFI: Sedation Facilitated Intubation(SFI)
ppaarraallyyttiicc)),, ffaaiilliinngg ttoo ooppttiimmiizzee llaarryynnggoossccooppyy Sedative alone will not overcome muscle tone (like a aabbiilliittyy ttoo pprrootteecctt aaiirrwwaayy Critically ill or injured may become apneic, without Variable effects of dosing in healthy vs ill patient Problematic Sedation Facilitated Intubation(SFI)
Sedation Facilitated Intubation(SFI) Result SSttiicckkiinngg aa bbiigg ppiieeccee ooff ssuurrggiiccaall sstteeeell ddoowwnn aa ppaattiieenntt’’ss mmoouutthh wwhhoo ccaann ssttiillll ggaagg aanndd vvoommiitt,, bbuutt hhaass tthhee iinnaabbiilliittyy ttoo pprrootteecctt tthheeiirr aaiirrwwaayy……aallll wwhhiillee ddeeccrreeaassiinngg yyoouurr cchhaanncceess ooff ssuucccceessss……
ssiittuuaattiioonn ttoo aa tteeaamm lleessss aabbllee ttoo ssuucccceeeedd?? Why do we legislate a potentially more dangerous ooppttiioonn Single advanced provider limited to SFI as an ppaarraammeeddiiccss pprreesseenntt ffoorr uussee.. f Requirement foorr RRSSII / RRSSAA ttoo hhaavvee ttwwoo Implications for Wisconsin EMS?
Wide safety margin (EMS dream) Reduction in chronic pain? Fibromyalgia? Suicide reduction? Anticonvulsant? Neuroprotective? Administer IV, IM, and yes, IN… Sedation, induction, asthma, pain Incredibly versatile! Some Passing Thoughts on Ketamine
Tachycardia and hypertension (transient) Emergence and vomiting Adverse Events: Rare and easily treatable ssuurrrroouunnddiinnggss oorr ooff ppaaiinnffuull ssttiimmuullii Develops trance-like state, patient in not aware of NMDA antagonist in brain Some Passing Thoughts on Ketamine
Some Passing Thoughts on Ketamine Cautions: Tachycardic aanndd HHyyppeerrtteennssiivvee ppaattiieennttss Layed to Rest: NNOOTT CCOONNTTRRAAIINNDDIICCAATTEEDD IINN HHEEAADD IINNJJUURRYY KKeettaammiinnee ddooeess NNOOTT iinnccrreeaassee IICCPP
Some Passing Thoughts on Ketamine Cautions: Tachycardic aanndd HHyyppeerrtteennssiivvee ppaattiieennttss Layed to Rest: NNOOTT CCOONNTTRRAAIINNDDIICCAATTEEDD IINN HHEEAADD IINNJJUURRYY KKeettaammiinnee ddooeess NNOOTT iinnccrreeaassee IICCPP CCoosstt?? 220000mmgg,, aabboouutt $$1188 ((SSttrreeeett vvaalluuee $$500--$$11500/11000000mmgg))
Medical Direction TTrraaiinniinngg PPrraaccttiiccee//OOvveerrssiigghhtt QQAA
Questions?

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2014 Spine Protection and Other Trends

  • 1. Spinal Protection and other Trends PSOW 2014 SStteevveenn JJ.. SSttrroommaann,, MMDD,, FFAACCEEPP,, FFAAAAEEMM,, CCCCEEMMTT//PP
  • 2. EMS IS the Practice of Medicine 2 -approved as a subspecialty by the ABMS 9/2010 -first Boarded EMS Physicians 12/31/2013
  • 3. 3 Wish List… Disclosure… …Patient Care
  • 4. Topics of the day: •Spinal Protection •Video Laryngoscopy •Some words about Ketamine •“Our ever evolving toolbox…”
  • 5.
  • 6.
  • 7. Spinal Injuries HHooww BBiigg aa PPrroobblleemm?? AA LLiittttllee AAnnaattoommyy RReevviieeww GGeenneerraall AAsssseessssmmeenntt // DDooccuummeennttaattiioonn SSppiinnaall CCoorrdd IInnjjuurriieess TTrraaddiittiioonnaall MMaannaaggeemmeenntt SSppiinnee IInnjjuurryy CClleeaarraannccee vvss SSppiinnaall PPrrootteeccttiioonn
  • 8. Incidence of SCI 10,000 - 20,000 ssppiinnaall ccoorrdd iinnjjuurriieess ppeerr yyeeaarr IInncciiddeennccee ~~ 8822%% ooccccuurr iinn mmeenn ~~ 6611%% ooccccuurr iinn 1166--3300 yyoo CCoommmmoonn ccaauusseess MMVVCC ((4488%%)) FFaallllss ((2211%%)) PPeenneettrraattiinngg iinnjjuurriieess ((1155%%)) SSppoorrttss iinnjjuurriieess ((1144%%))
  • 9. Morbidity Mortality 40% of trauma patients wwiitthh nneeuurroo ddeeffiicciittss wwiillll hhaavvee tteemmppoorraarryy oorr ppeerrmmaanneenntt SSCCII MMaannyy mmoorree vveerrtteebbrraall iinnjjuurriieess tthhaatt ddoo nnoott rreessuulltt iinn ccoorrdd iinnjjuurryy MMoosstt ccoommmmoonnllyy iinnjjuurreedd vveerrtteebbrraaee CC55--CC77 CC11--CC22 TT1122--LL22
  • 10. Prevention-The First Concept in Trauma Care TTrraaiinniinngg//EEdduuccaattiioonn iinn pprrootteeccttiivvee hhaannddlliinngg aanndd mmoovveemmeenntt ooff tthhee iinnjjuurreedd ppaattiieenntt IInnjjuurryy PPrreevveennttiioonn PPuubblliicc EEdduuccaattiioonn,, EEMMSS CCoommmmuunniittyy SSeerrvviiccee PPrroojjeeccttss SSeeccoonnddaarryy IInnjjuurryy PPrreevveennttiioonn TTrraaiinniinngg//IInntteeggrraattiioonn ooff EEMMRRss TTeerrttiiaarryy HHoossppiittaall CCaarree
  • 11. Anatomy Review 3333 VVeerrtteebbrraaee ((……MMuullttiippllee JJooiinnttss……)) SSppiinnee ssuuppppoorrtteedd bbyy ppeellvviiss kkeeyy lliiggaammeennttss aanndd mmuusscclleess ccoonnnneecctt hheeaadd ttoo ppeellvviiss aanntteerriioorr lloonnggiittuuddiinnaall lliiggaammeenntt aanntteerriioorr ppoorrttiioonn ooff tthhee vveerrtteebbrraall bbooddyy mmaajjoorr ssoouurrccee ooff ssttaabbiilliittyy pprrootteeccttss aaggaaiinnsstt hhyyppeerreexxtteennssiioonn ppoosstteerriioorr lloonnggiittuuddiinnaall lliiggaammeenntt ppoosstteerriioorr vveerrtteebbrraall bbooddyy wwiitthhiinn tthhee vveerrtteebbrraall ccaannaall pprreevveennttss hhyyppeerrfflleexxiioonn
  • 12. Anatomy Review BBoonnee SSttrruuccttuurree ooff tthhee SSppiinnee CCeerrvviiccaall TThhoorraacciicc LLuummbbaarr SSaaccrraall//CCooccccyyxx
  • 13. Anatomy Review Vertebral body •posterior portion forms part of vertebral foramen •increases in size from cervical to sacral •spinous process •transverse process Vertebral foramen •opening for spinal cord Intervertebral disk •shock absorber (fibrocartilage)
  • 14. Motor Sensory Dermatomes DDeerrmmaattoommee SSppeecciiffiicc aarreeaa iinn wwhhiicchh tthhee ssppiinnaall nneerrvvee ttrraavveellss oorr ccoonnttrroollss IImmppoorrttaanntt iinn aasssseessssiinngg lleevveell ooff SSCCII PPlleexxuuss ppeerriipphheerraall nneerrvveess rreejjooiinn aanndd ffuunnccttiioonn aass ggrroouupp CCeerrvviiccaall PPlleexxuuss ddiiaapphhrraaggmm aanndd nneecckk
  • 15. Dermatomes CC33,,44 mmoottoorr:: sshhoouullddeerr sshhrruugg sseennssoorryy:: ttoopp ooff sshhoouullddeerr CC33,, 44,, 55 mmoottoorr:: ddiiaapphhrraaggmm sseennssoorryy:: ttoopp ooff sshhoouullddeerr CC55,, 66 mmoottoorr:: eellbbooww fflleexxiioonn sseennssoorryy:: tthhuummbb CC77 mmoottoorr:: eellbbooww,, wwrriisstt,, ffiinnggeerr eexxtteennssiioonn sseennssoorryy:: mmiiddddllee ffiinnggeerr CC88,, TT11 mmoottoorr:: ffiinnggeerr aabbdduuccttiioonn aadddduuccttiioonn sseennssoorryy:: lliittttllee ffiinnggeerr TT44 mmoottoorr:: lleevveell ooff nniippppllee TT1100 mmoottoorr:: lleevveell ooff uummbbiilliiccuuss
  • 16. Dermatomes LL11,, 22 mmoottoorr:: hhiipp fflleexxiioonn sseennssoorryy:: iinngguuiinnaall ccrreeaassee LL33,,44 mmoottoorr:: qquuaaddrriicceeppss sseennssoorryy:: mmeeddiiaall tthhiigghh,, ccaallff LL55 mmoottoorr:: ggrreeaatt ttooee,, ffoooott ddoorrssiifflleexxiioonn sseennssoorryy:: llaatteerraall ccaallff SS11 mmoottoorr:: kknneeee fflleexxiioonn sseennssoorryy:: llaatteerraall ffoooott SS11,, 22 mmoottoorr:: ffoooott ppllaannttaarr fflleexxiioonn SS22,,33,,44 mmoottoorr:: aannaall sspphhiinncctteerr ttoonnee sseennssoorryy:: ppeerriiaannaall
  • 18. Assessment of Spinal Injury MMeecchhaanniissmm ooff IInnjjuurryy –– NNoott aallll MMOOIIss lleeaadd ttoo SSCCII SSeevveerree mmeecchhaanniissmm ooff iinnjjuurryy iiss ccoonnssiisstteenntt wwiitthh SSCCII OOtthheerr MMOOIIss ddoonn’’tt ccoorrrreellaattee ttoo tthhee rriisskk ooff SSCCII EEDD ““FFiieelldd CClleeaarraannccee PPrroottooccoollss”” aarree iinn ccoommmmoonn uussee EExxaamm aanndd HHiissttoorryy ffiinnddiinnggss hheellpp iiddeennttiiffyy tthhee ppootteennttiiaall SSCCII RReemmeemmbbeerr:: DDoo NNoo HHaarrmm!!
  • 19. Assessment of Spinal Injury TTrraaddiittiioonnaall AApppprrooaacchh BBaasseedd oonn MMOOII ((CCCCRR)) EEmmpphhaassiiss oonn ssppiinnaall iimmmmoobbiilliizzaattiioonn iinn:: uunnccoonnsscciioouuss ttrraauummaa vviiccttiimmss ppaattiieennttss wwiitthh aa ““mmoottiioonn”” iinnjjuurryy NNoo cclleeaarr cclliinniiccaall gguuiiddeelliinneess oorr ssppeecciiffiicc ccrriitteerriiaa ttoo eevvaalluuaattee ffoorr SSCCII SSiiggnnss:: ppaaiinn,, tteennddeerrnneessss,, ppaaiinnffuull mmoovveemmeenntt ddeeffoorrmmiittyy,, iinnjjuurryy oovveerr ssppiinnaall aarreeaa,, sshhoocckk ppaarreesstthheessiiaass,, ppaarreessiiss,, pprriiaappiissmm
  • 21. Assessment of Spinal Injury TTrraaddiittiioonnaall AApppprrooaacchh NNoott aallwwaayyss pprraaccttiiccaall ttoo ““iimmmmoobbiilliizzee”” eevveerryy ““mmoottiioonn”” iinnjjuurryy MMoosstt ssuussppeecctteedd iinnjjuurriieess wweerree mmoovveedd ttoo aa nnoorrmmaall aannaattoommiiccaall ppoossiittiioonn NNoo eexxcclluussiioonn ccrriitteerriiaa uusseedd ffoorr mmoovviinngg ppaattiieennttss BBaasseedd oonn tthhee 11999999 NNAAEEMMSSPP PPoossiittiioonn PPaappeerr NNEEXXUUSS aanndd CCCCRR
  • 22. Assessment of Spinal Injury NEXUS CCrriitteerriiaa ((aannsswweerr YYeess oorr NNoo)) FFooccaall NNeeuurroollooggiicc DDeeffiicciitt?? MMiiddlliinnee SSppiinnaall TTeennddeerrnneessss?? AAlltteerreedd LLOOCC?? DDiissttrraaccttiinngg IInnjjuurryy PPrreesseenntt?? IInnttooxxiiccaatteedd?? IIff nnoonnee ooff tthhee aabboovvee ccrriitteerriiaa aarree pprreesseenntt,, tthhee CC--SSppiinnee ccaann bbee cclleeaarreedd cclliinniiccaallllyy bbyy tthheessee ccrriitteerriiaa..
  • 23. Assessment of Spinal Injury in Spinal injjuurriieess aarree rreellaattiivveellyy uunnccoommmmoonn:: MMaannyy aarree ssttaabbllee
  • 24. Assessment of Spinal Injury TTrraaddiittiioonnaall AApppprrooaacchh DDeevviicceess,, ssuucchh aass sshhoorrtt aanndd lloonngg bbaacckkbbooaarrddss,, oorr eexxttrriiccaattiioonn vveessttss,, ooffffeerr rreessttrriiccttiioonn ooff mmoovveemmeenntt,, bbuutt DDOO NNOOTT ““iimmmmoobbiilliizzee”” PPootteennttiiaall HHaarrmm aaccccoommppaanniieess rriiggiidd ssppiinnaall rreessttrriiccttiioonn,, eessppeecciiaallllyy iiff pprroolloonnggeedd……
  • 25. Assessment of Spinal Injury ““mmoovveemmeenntt ddeevviicceess”” hheellpp rreellooccaattee ppaattiieennttss ttoo ssttaabbllee eennvviirroonnmmeennttss,, oorr pprreeppaarree ffoorr ttrraannssppoorrtt.. TThheeyy ffaasstteenn eexxtteerrnnaallllyy,, bbuutt ddoonn’’tt pprreevveenntt sskkiinn aanndd mmuussccllee ffrroomm ccoonnttiinnuuiinngg ttoo ggeenneerraattee mmoovveemmeenntt aaccrroossss tthhee bboonnyy sskkeelleettoonn.. TThhee ssppiinnee bbooaarrdd hhaass bbeeeenn tthhee eexx ffaaccttoo ttooooll ooff cchhooiiccee ffoorr 5500 yyeeaarrss,, ddeessppiittee llaacckk ooff eevviiddeennccee ttoo iittss bbeenneeffiitt
  • 26. Historical Long Spine Board Use s Introduced 1960’s,, bbaasseedd oonn rraattiioonnaall ccoonnjjeeccttuurree ““GGOOMMSSAATT””
  • 27. Historical Long Spine Board Use ““Survey of the accident vviiccttiimmss,, ffiirrmm iimmmmoobbiilliizzaattiioonn aanndd iinn--lliinnee ttrraaccttiioonn aarree tthhee pprriinncciipplleess ooff eexxttrriiccaattiioonn..”” 11996666 11997777 EEMMTT CCuurrrriiccuulluumm
  • 28. Historical Long Spine Board Use PPrreessuummppttiioonnss IImmmmoobbiilliizzeess aallll sseeggmmeennttss ffrroomm jjooiinntt aabboovvee ttoo jjooiinnttbbeellooww tthhee iinnjjuurreedd sseeggmmeenntt NNoo eevviiddeennccee ttoo ddaattee tthhaatt tthhiiss iiss ccoorrrreecctt CC CCoollllaarr uussee bbaasseedd oonn eessttaabblliisshheedd tthheerraappyy ffoorr kknnoowwnn ssppiinnaall lleessiioonnss oorr ppoosstt--ooppeerraattiivvee ccaarree
  • 29. Evidence to the Contrary What about the iinndduuccttiioonn oorr ddeevveellooppmmeenntt ooff ppaaiinn?? Healthy volunteers developed significant pain in the cceerrvviiccaall aanndd lluummbbaarr rreeggiioonnss 2211%% ooff tthhee ttiimmee** Results in: DDeellaayy ooff rreemmoovvaall ffrroomm bbooaarrdd UUnnnneecceessssaarryy iimmaaggiinngg ((8844%% cceerrvviiccaall,, 3322%% lluummbbaarr)) PPaaiinn DDeellaayy iinn ddiissppoossiittiioonn ooff ppaattiieenntt **BBaarrnneeyy,, CCoorrddeellll,, aanndd MMiilllleerr,, PPaaiinn AAssssoocciiaatteedd wwiitthh IImmmmoobbiilliizzaattiioonn oonn RRiiggiidd SSppiinneebbooaarrddss.. AAnnnn EEmmeerrgg MMeedd,, 11998899..
  • 30. Evidence to the Contrary Rigid spine boards hhaavvee bbeeeenn iimmpplliiccaatteedd iinn tthhee eeaarrllyy ddeevveellooppmmeenntt ooff pprreessssuurree uullcceerrss Prolonged localized pressure leads to impaired ccaappiillllaarryy cciirrccuullaattiioonn,, ttiissssuuee hhyyppooxxiiaa aanndd nneeccrroossiiss.. TThhee rraattee ooff pprreessssuurree ssoorree nneeccrroossiiss iiss ddiirreeccttllyy rreellaatteedd ttoo lleevveell ooff aapppplliieedd pprreessssuurree aanndd ttoo ttiimmee..** *Cordell, Hollingsworth, Olinger, Stroman, Nelson. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med, 1995.
  • 31. Evidence to the Contrary 3 Pressure of about 355 mmmmHHgg wwiillll ssiiggnniiffiiccaannttllyy rreedduuccee bblloooodd ffllooww tthhrroouugghh tthhee ccaappiillllaarryy bbeedd.. PPrreessssuurree mmaappppiinngg sseennssoorrss rreevveeaalleedd tthhee hhiigghheesstt ttiissssuuee iinntteerrffaaccee pprreessssuurreess aatt tthhee ssccaappuullaaee,, ssaaccrruumm,, aanndd hheeeellss..** Pressure produced: SSppiinnee bbooaarrdd == 114477 mmmmHHgg ((uunnppaaddddeedd)),, oorr 111155 ((ppaaddddeedd)) VVaaccuuuumm MMaattttrreessss == 3377 mmmmHHgg *Cordell, Hollingsworth, Olinger, Stroman, Nelson. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med, 1995.
  • 32. Evidence to the Contrary Time: The average rigid spine board time in a Level I TTrraauummaa CCeenntteerr wwaass ddeetteerrmmiinneedd ttoo bbee 112200 mmiinnuutteess..11 Another study found an average of 64 minutes ((wwiitthhoouutt iimmaaggiinngg)),, oorr eexxcceeeeddiinngg 118800 mmiinnuutteess ((wwiitthh iimmaaggiinngg)).. Time on a spine board exceeded 7 hours when ttrraannssffeerr ttoo aa LLeevveell II TTrraauummaa CCeenntteerr ooccccuurrrreedd22 11BBaarrnneeyy,, CCoorrddeellll,, aanndd MMiilllleerr,, AAnnnn EEmmeerrgg MMeedd,, 11998899.. 22CCoooonneeyy,, eett..aall..,, IInntt JJ EEmmeerrgg MMeeddiicciinnee,, 22001133,,
  • 33. Evidence to the Contrary One study of spinal cord iinnjjuurryy ffoouunndd tthhaatt aallll ppaattiieennttss wwhhoo ddeevveellooppeedd uullcceerraattiioonnss rreeccaalllleedd nnoo aatttteemmppttss ttoo rroollll tthheemm oorr rreemmoovvee tthhee bbooaarrdd iinn tthhee ffiirrsstt ttwwoo hhoouurrss aaffeerr tthhee iinnjjuurryy.. By contrast, all patients who did not develop uullcceerraattiioonnss hhaadd tthhee pprreessssuurree rreelliieevveedd wwiitthhiinn tthhee ffiirrsstt ttwwoo hhoouurrss bbyy rreemmoovvaall ooff tthhee ssppiinnee bbooaarrdd..
  • 34. Evidence to the Contrary There has been ddeemmoonnssttrraatteedd aa ddiirreecctt rreellaattiioonnsshhiipp bbeettwweeeenn ttiimmee dduurraattiioonn oonn tthhee ssppiinnee bbooaarrdd aanndd ddeevveellooppmmeenntt ooff pprreessssuurree uullcceerrss wwiitthhiinn tthhee ffiirrsstt eeiigghhtt ddaayyss ooff hhoossppiittaalliizzaattiioonn.. UUpp ttoo 3311%% ooff ttrraauummaa ppaattiieennttss wwiillll ddeevveelloopp pprreessssuurree uullcceerrss aass tthhee rreessuulltt ooff iimmmmoobbiilliizzaattiioonn oonn aa bbaacckkbbooaarrdd..
  • 35. *Berg, et.al., Prehospital Emergency Care, 2010. ssiiggnniiffiiccaanntt rreedduuccttiioonnss iinn llooccaalliizzeedd ttiissssuuee ooxxyyggeennaattiioonn iinn hheeaalltthhyy ppaattiieennttss.. a A period as short ass 3300 mmiinnuutteess ccaann pprroodduuccee Evidence to the Contrary
  • 36. Device Attempts to Correct Ehob Waffle Mattress Expansion Control Overlay With Pump is ideal for:- Pressure ulcer prevention- Treatment through stage IV - Pain management. The Back Raft is a low-cost, inflatable air mattress and spinal stabilization device that improves patient comfort and virtually eliminates the risk of pressure sores and other secondary injury during transport.
  • 37. Evidence to the Contrary b Restriction to movement byy LLSSSS aanndd ssttrraappss rreessuullttss iinn:: rreedduucceedd FFoorrcceedd VViittaall CCaappaacciittyy ((FFVVCC)),, tthhee mmaaxxiimmuumm vvoolluummee eexxhhaalleedd aafftteerr ddeeeeppeesstt iinnssppiirraattiioonn,, RReedduucceedd FFoorrcceedd EExxppiirraattoorryy VVoolluummee ((FFEEVV11)) RReedduucceedd FFoorrcceedd EExxppiirraattoorryy FFllooww ((FFEEFF))11 ((OOvveerraallll rreedduuccttiioonnss ooff 1155--2200%%)) 15. The results were replicated in children, ages 6-15.22 11BBaauueerr KKoowwaallsskkii,, AAnnnnaallss ooff EEmmeerrggeennccyy MMeeddiicciinnee,, 11998888.. 22SScchhaaffeerrmmeeyyeerr,, eett..aall,, AAnnnnaallss ooff EEmmeerrggeennccyy MMeeddiicciinnee,, 11999911..
  • 38. Result in the inability for adequate self ventilation… rreessppiirraattoorryy ppaatthhoollooggyy Additional reductions, based on patient’s underlying tthhoorraacciicc iinnjjuurriieess Reductions are accentuated iinn tthhee ffaaccee ooff aaiirrwwaayy oorr Evidence to the Contrary
  • 39. Cochrane Review of Immobilization 2009: UUnncceerrttaaiinn EEffffeeccttiivveenneessss REVIEWER'S CONCLUSIONS: We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Low prevalence-Immobilization of 50-100 people for every patient at risk of SCI
  • 40. Malaysia Military Study vs. EMS vs 120 without immobilization vs.. 333344 @@ UUnniivv.. ooff NNeeww MMeexxiiccoo ddiidd.. OOuuttccoommee:: LLiittttllee oorr nnoo eeffffeecctt oonn oouuttccoommee ooff bblluunntt ssppiinnaall iinnjjuurryy Hauswald, et. al. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998 Mar;5(3):214-9.
  • 41. Difficulties in ED exam (due to board) Increased risk of soft tissue injury Increases safety risk to providers (Work Comp) AAddddiittiioonnaall TThhoouugghhttss:: Evidence to the Contrary
  • 42. Assessment Overview Decision to apply ssppiinnaall iimmmmoobbiilliizzaattiioonn iinn ppaasstt bbaasseedd wwaass ssoolleellyy oonn mmeecchhaanniissmm ooff iinnjjuurryy Utilize EMS Spinal Immobilization AAllggoorriitthhmm ttoo ddeetteerrmmiinnee wwhheenn ssppiinnaall iimmmmoobbiilliizzaattiioonn iiss NNOOTT nneeeeddeedd 42
  • 43. iinnvvoollvviinngg tthhee hheeaadd,, ssppiinnee oorr ttrruunnkk other high impact, high force or high velocity conditions confounding factors such as osteoporosis, extreme age sports injury (with force or velocity) • ****ssttaabbbbiinngg • ****gguunn sshhoott violent situations occurring near the spine patient fall greater than 3 times the patient’’s height high speed motor vehicle collision PPoossiittiivvee MMOOII Þ SShhoouulldd RReeqquuiirree SSppiinnaall MMaannaaggeemmeenntt Consider Mechanism ooff IInnjjuurryy KKiinneemmaattiiccss SCI General Assessment
  • 44. SCI General Assessment Consider Mechanism ooff IInnjjuurryy KKiinneemmaattiiccss NNeeggaattiivvee MMOOII Þ DDoo NNoott RReeqquuiirree SSppiinnee bbooaarrdd force or impact does not suggest a potential spinal injury • ddrrooppppeedd aa rroocckk oonn ffoooott • ttwwiisstteedd aannkkllee wwhhiillee rruunnnniinngg • iissoollaatteedd mmuussccuulloosskkeelleettaall iinnjjuurryy • ssiimmppllee ffaallll ffrroomm ssttaannddiinngg ppoossiittiioonn • llooww ssppeeeedd mmoottoorr vveehhiiccllee ccoolllliissiioonn
  • 45. Hypoperfusion Neurogenic Shock CCaarrddiioovvaassccuullaarr iimmppaaiirrmmeenntt Diaphragmatic breathing Apnea Inability to maintain airway (SB reduces mouth opening 20%) AAiirrwwaayy aanndd//oorr BBrreeaatthhiinngg iimmppaaiirrmmeenntt ABCs SCI General Assessment
  • 46. No difficulty in communication No Distracting injuries Understands Recalls events surrounding injury No impairment (drugs, alcohol) Cooperative Brain injury also? LLeevveell ooff CCoonnsscciioouussnneessss Neurologic Status: SCI General Assessment
  • 47. PPrriiaappiissmm pain (pinprick), sharp vs dull, symmetry weakness, numbness, paresthesia SSeennssaattiioonn ((PPoossiittiioonn aanndd PPaaiinn)) Foot plantar flexors (gas pedal) {S1,2} ““Hitchhike Hitchhike”” {T1} Spread fingers of both hands and keep apart with force Shrug shoulders PPaallppaattee oovveerr eeaacchh ssppiinnoouuss pprroocceessss MMoottoorr ffuunnccttiioonn Assess FFuunnccttiioonn SSeennssaattiioonn SCI General Assessment
  • 48. Spinal Cord Injuries PPrriimmaarryy IInnjjuurryy ooccccuurrss aatt tthhee ttiimmee ooff iinnjjuurryy mmaayy rreessuulltt iinn cord compression direct cord injury interruption in cord bblloooodd ssuuppppllyy SSeeccoonnddaarryy IInnjjuurryy ooccccuurrss aafftteerr iinniittiiaall iinnjjuurryy mmaayy rreessuulltt ffrroomm swelling/inflammation ischemia movement of body ffrraaggmmeennttss
  • 49. Spinal Cord Injuries **LLeessss mmoovveemmeenntt iiss nnootteedd bbyy ppaattiieenntt sseellff-- eexxttrriiccaattiinngg tthhaann bbyy EEMMSS pprroovviiddeerrss ppllaacciinngg oonn aa bbooaarrdd..
  • 50. 50 Force Applied by EMS: 10 Newtons Force Required for SCI: 6000 Newtons Did EMS “Cause” the SCI?
  • 51. Immobilization vs Motion Restriction Rule: All or None? (collar, board, CID, tape, straps…) CCaauuttiioonn wwiitthh ““ppaarrttiiaall”” ssppiinnee sspplliinnttiinngg?? Secure joint above and below? TTrreeaatt tthhee ssppiinnee aass aa lloonngg bboonnee?? Traditional Treatment: Stabilization of the spine begins in the initial assessment PPrreevveenntt sseeccoonnddaarryy iinnjjuurryy Primary Goal Management of SCI
  • 52. Management of SCI Neutral positioning ooff hheeaadd aanndd nneecckk iiff aatt aallll ppoossssiibbllee aalllloowwss ffoorr tthhee mmoosstt ssppaaccee ffoorr ccoorrdd mmoosstt ssttaabbllee ppoossiittiioonn ffoorr ssppiinnaall ccoolluummnn DDoonn’’tt ffoorrccee iitt
  • 53. Traditional Management of SCI Cervical Motion Restriction MMaannuuaall mmeetthhoodd RRiiggiidd ccoollllaarr ccoommeess llaatteerr IInntteerriimm ddeevviiccee ((KKEEDD)) MMoovvee ttoo lloonngg bbooaarrdd oorr ffuullll bbooddyy vvaaccuuuumm sspplliinntt MMaannuuaall ccoonnttiinnuueess uunnttiill ttrruunnkk aanndd hheeaadd sseeccuurreedd ““CCIIDD””
  • 54. Tape along (even duct tape) is not enough pillows, blankets, towels curvature of the lower back is normal - fill it ffiillll aallll tthhee vvooiiddss especially during transport on board or in vehicle MMaaiinnttaaiinnss aannaattoommiiccaall ppoossiittiioonn LLiimmiittss mmoovveemmeenntt oonn bbooaarrdd Don Don’t ’t forget the Padding Management of SCI
  • 55. Management of SCI Securing to the Board (Historical) SSttrraappss,, TTaappee,, CCrraavvaattss,, wwhhaatteevveerr TToorrssoo ffiirrsstt then legs and feet and head EEvveenn ppaattiieennttss eexxttrriiccaatteedd wwiitthh aa KKEEDD aarree sseeccuurreedd ttoo tthhee bbooaarrdd
  • 56. Even SSttrraapp PPaatttteerrnnss RReesseeaarrcchheedd…… Management of SCI
  • 57. Procedure for Complete Spinal Immobilization TTrraaddiittiioonnaall 5577
  • 58. Procedure for Complete Spinal Immobilization (Historical)
  • 59. Procedure for Complete Spinal Immobilization (Historical)
  • 60. CC--ccoollllaarr oorr hheeaadd iimmmmoobbiilliizzaattiioonn ddeevviiccee C-spine hyperextension due to improperly applied aapppplliieedd hheeaadd iimmmmoobbiilliizzaattiioonn ddeevviiccee C-spine movement by inadequate or improperly sshhiimm tthhee bbooddyy Movement possible due to little or no padding to Inadequate strapping allows excessive movement oonn bbaacckkbbooaarrdd Spine not supported due to improper positioning IImmpprrooppeerrllyy ssiizzeedd CC--CCoollllaarr Common Treatment Mistakes (Spine board and collar)
  • 61. • hhoorrssee ccoollllaarr • bbllaannkkeett oorr ttoowweell rroollllss Improvise with Difficult to find a correctly sized rigid collar Lots of voids to fill Vacuum mattress Short board underneath Pad underneath Elevate the entire torso if large occiput PPeeddiiaattrriicc PPaattiieenntt CCoonnssiiddeerraattiioonnss Management of SCI
  • 62. no cardiac arrest no interference in airway assessment or management can perform spinal motion restriction with helmet on no impending airway or breathing problems good fit with little or no head movement within Leave in place if: ttoo aaiirrwwaayy aanndd vveennttiillaattiioonn Removal should be limited to emergent need for access Management of SCI HHeellmmeetteedd PPaattiieennttss
  • 63. aanndd ffoorr rreemmoovvaall Various helmets create different problems for patient bicycle) Recreational (motorcycle, bicycle)--prefer removal Racing (motorcycle, car racer)- prefer removal • SShhoouullddeerr ppaaddss aanndd hheellmmeett ggoo ttooggeetthheerr Sports (football, hockey) Types of Helmets HHeellmmeetteedd PPaattiieennttss Management of SCI
  • 64. aanndd ffoorr rreemmoovvaall Various helmets create different problems for patient bicycle) Recreational (motorcycle, bicycle)--prefer removal Racing (motorcycle, car racer)- prefer removal • SShhoouullddeerr ppaaddss aanndd hheellmmeett ggoo ttooggeetthheerr Sports (football, hockey) Types of Helmets HHeellmmeetteedd PPaattiieennttss Management of SCI
  • 65.
  • 66.
  • 67. “Clearing” Protocols SSppiinnaall CClleeaarraannccee CCuurrrreenntt PPrraaccttiiccee FFiirrsstt iinniittiiaatteedd iinn MMaaiinnee wwiitthh aa ssttaattee--wwiiddee pprroottooccooll NNooww mmuucchh mmoorree ccoommmmoonn iinn UUSS AAsssseessss sscceennee aanndd MMOOII AAsssseessss nneeuurroo ssttaattuuss IImmmmoobbiilliizzee Most MOIs Prevent further injury CYA No 100% method to rruullee oouutt iinn tthhee ffiieelldd fear of litigation devastating ccoonnsseeqquueenncceess ppoossssiibbllee
  • 68. Treat with Spinal Protection Difficult to determine Injury may or may not be possible 3. Uncertain Mechanism (Most Common) No reasonable probability of spinal injury 2. Negative or Obviously Minimal Mechanism High likelihood of spinal injury Violent impact 1. Positive or Obvious Severe Mechanism One ooff tthhrreeee ppaatthhss iiss cchhoosseenn:: When should the screening tool be used?
  • 69. “Clearing” Protocols o No significant MOI orr eevviiddeennccee ooff ssppiinnee iinnjjuurryy NNoo nneecckk oorr bbaacckk ppaaiinn ((PPaallppaattee aallll)) NNoorrmmaall NNeeuurroo EExxaamm ((nnoo mmoottoorr//sseennssoorryy lloosssseess)) NNoorrmmaall LLeevveell ooff CCoonnsscciioouussnneessss Adult Adult, , Reliable Patient w/o anxiety reaction or ““nnoorrmmaallllyy”” aabbnnoorrmmaall mmeennttaall ssttaattuuss No ETOH or drugs No language barriers NNoo ddiissttrraaccttiinngg iinnjjuurriieess oorr ppeenneettrraattiinngg iinnjj nneeaarr ssppiinnee
  • 70. “Distracting Injury” II’’mm nnoott ssuurree wwhhaatt iitt iiss,, bbuutt II’’llll kknnooww iitt wwhheenn II sseeee iitt……
  • 71. Excludes “Extremes of Age” AAggee 55 AAggee 6655
  • 73. Immobilization with a Backboard SHOULD NOT be performed: PENETRATING TRAUMA of the: HHeeaadd NNeecckk TToorrssoo AANNDD No evidence of spinal injury
  • 74. Reviewing our SPINAL PROTECTION care today
  • 75. Position Statement: EMS Spinal Precautions and the Use of the Long Backboard National Association ooff EEMMSS PPhhyyssiicciiaannss AAmmeerriiccaann CCoolllleeggee ooff SSuurrggeeoonnss CCoommmmiitttteeee oonn TTrraauummaa 22001133
  • 76. Principles of Treatment Protect spinal cord ffrroomm sseeccoonnddaarryy iinnjjuurryy WWee hhaavvee lliittttllee oorr nnoo eeffffeecctt oonn pprriimmaarryy iinnjjuurryy FFooccuuss oonn pprreevveennttiioonn ooff sseeccoonnddaarryy iinnjjuurryy 76
  • 77. Spinal Immobilization Algorithm PPaattiieenntt MMeennttaattiioonn:: DDeeccrreeaasseedd LLeevveell ooff CCoonnsscciioouussnneessss?? NNoo YYeess --------------------------------------------------------IImmmmoobbiilliizzee EETTOOHH//DDrruugg IImmppaaiirrmmeenntt?? NNoo YYeess --------------------------------------------------------IImmmmoobbiilliizzee SSuubbjjeeccttiivvee AAsssseessssmmeenntt:: CCeerrvviiccaall//TThhoorraacciicc//LLuummbbaarr SSppiinnaall ppaaiinn?? NNoo YYeess --------------------------------------------------------IImmmmoobbiilliizzee NNuummbbnneessss//TTiinngglliinngg//BBuurrnniinngg//WWeeaakknneessss?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee OObbjjeeccttiivvee AAsssseessssmmeenntt:: CCeerrvviiccaall//TThhoorraacciicc//LLuummbbaarr DDeeffoorrmmiittyy oorr TTeennddeerrnneessss?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee OOtthheerr SSeevveerree IInnjjuurryy?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee OOtthheerr SSeevveerree IInnjjuurryy?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee PPaaiinn ww//CCeerrvviiccaall RRaannggee ooff MMoottiioonn?? NNoo YYeess ----------------------------------------------------------IImmmmoobbiilliizzee MMAAYY TTRREEAATT//TTRRAANNSSPPOORRTT WWIITTHHOOUUTT SSPPIINNAALL PPRREECCAAUUTTIIOONNSS 7777
  • 78. Once We Decide to Immobilize/Protect: HOW? RRiiggiidd CCeerrvviiccaall CCoollllaarr SSeeccuurreedd ffiirrmmllyy ttoo EEMMSS SSttrreettcchheerr BBeesstt UUssee FFoorr:: Ambulatory patients at scene Prolonged use, interfacility transfer No other backboard indication
  • 79. Stratify the Patients for Protection: 1. Uninjured: Ambulatory, no pain or complaint ssttaatteedd,, oorr oonn eexxaamm TTrreeaattmmeenntt:: NNoonnee rreeqquuiirreedd 2. MOI/Complaint TTrreeaattmmeenntt:: CC CCoollllaarr,, ccoott ssttrraappss,, mmiinniimmaall mmoovvtt.. 3. Severe MOI/LOC/Deficits TTrreeaattmmeenntt:: CC CCoollllaarr//VVaaccuuuumm//……LLSSSS?? MMiinniimmaall mmoovvtt..
  • 80. Summary: Backboard oorr NNoott,, SSppiinnaall PPrrootteeccttiioonn//PPrreeccaauuttiioonn aammoonngg aatt--rriisskk ppaattiieennttss iiss PPAARRAAMMOOUUNNTT!! Appropriate protection with collar cervical collar, , aaddeeqquuaattee sseeccuurriittyy ttoo ssttrreettcchheerr,, mmiinniimmaall mmoovveemmeenntt//ttrraannssffeerrss,, aanndd mmaaiinnttaaiinniinngg iinn--lliinnee ssttaabbiilliizzaattiioonn dduurriinngg mmoovveemmeenntt//ttrraannssffeerrss
  • 81. SPINAL PROTECTION CARE EMT AND PARAMEDIC PROTOCOL DRAFT Patients with blunt traumatic injuries with mechanism concerning for spinal injury should be assessed for spinal injury.
  • 82. Have no midline back or neck pain or tenderness upon palpation. injuries or severe pain) No evidence of a distracting injury (fractures, major burns, crush (numbness/weakness in an extremity) No history of new/temporary neurological deficit No evidence of intoxication (alcohol/drug) or altered mental status Conscious, cooperative and able to communicate effectively age 5 , 65 following conditions apply: Patients may have all spinal immobilization omitted if ALL of the NO spinal protection necessary PROTOCOL DRAFT SPINAL PROTECTION CARE
  • 83. neck 45 degrees to either side of midline and if still no pain, NO immobilization is indicated. If ALL of the above criteria are met, have patient move their There is no major mechanism for severe injury NO spinal protection necessary PROTOCOL DRAFT SPINAL PROTECTION CARE
  • 84. SPINAL PROTECTION CARE PROTOCOL DRAFT Spinal Protection measures indicated If, after assessment, spinal protection is indicated: Spinal protection consists of keeping the head, neck and spine midline. The neck can be stabilized with a well-fitted cervical collar, head blocks, blanket rolls or other immobilization techniques. Patients who are already walking or standing should be laid directly on the ambulance stretcher and secured to the stretcher with seatbelts. Backboards and scoops are designed and should only be used to extricate and move patients.
  • 85. SPINAL PROTECTION CARE PROTOCOL DRAFT Spinal Protection measures indicated Once extricated and moved, patients should be taken off the backboard or scoop stretcher if possible, and be placed directly on the ambulance stretcher. It is acceptable to leave a patient on a backboard for transport, but every effort should be made to secure the patient to the stretcher and not the backboard. Decisional patients have the right to refuse aspects of treatment including spinal immobilization. If a patient refuses immobilization after being informed of possible permanent paralysis, do not immobilize them and document the patient’s refusal in your medical record.
  • 86. SPINAL PROTECTION CARE PROTOCOL DRAFT Patients with Penetrating Trauma (Gunshot or stab to head, chest, or abdomen) Patients with penetrating traumatic injuries should only be immobilized if a focal neurological deficit is noted on physical exam (although there is little evidence of benefit even in these cases)
  • 87. Trainers (Technical Colleges, Hospitals) NNeeuurroossuurrggeeoonn)) Customers (ED Doctors, Trauma Surgeon, CCoouunncciillss)) Industry Colleagues (Agency, Medical Directors, Within (Individual Champion, Crew, Organization) Stakeholder Discussions Implementation of Change
  • 88. Oversight and QA Run Documentation (movement, neuro exam, etc) In-Service for ED Nurses (Managers) FFaacciilliittiieess,, TTrraauummaa CCoooorrddiinnaattoorrss ((DDaattaabbaassee)) Notification of Customers (EDs, Trauma Care Training of Personnel (internal) Protocol Development / Approval Roll Out Implementation of Change
  • 89. Will Video Kill Direct Laryngoscopy?
  • 90. WILL VIDEO KILL DIRECT LARYNGOSCOPY? CASE: 35 yo MCA victim, arrives combative (with/without spineboard), injury to head (unhelmeted), along with multiple extremity fractures, and a firm abdomen.
  • 91. Salvage (NVA, Device change, Provider change, Bougee, surgical) Preferred technique (VL, DL) What is in your decision tree? Do you use the DL or VL? (or NVA) A decision is made to RSI/RSA the patient. LARYNGOSCOPY? WILL VIDEO KILL DIRECT
  • 92. *Walls,et. al, National Emergency Airway Registry, 2011 RSI used in 2/3 of cases 87% of intubations are performed by ED Physicians* Some quick facts: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
  • 93. *Yeatts, Dutton, Hu, et. al, J Trauma Acute Care Surg. 2013;75:212-9. desaturation, first pass success Secondary: Subgroup survival, duration of attempt, Outcome: Mortality VL (GlideScope) vs. DL Trauma Patients at Baltimore Shock Trauma survival; a randomized controlled trial.” “Effects of video laryngoscopy on trauma patient LARYNGOSCOPY? WILL VIDEO KILL DIRECT
  • 94. *Yeatts, Dutton, Hu, et. al, J Trauma Acute Care Surg. 2013;75:212-9. randomized to VL group A possible increased mortality for most severe CHI, VL and DL had similar mortality Conclusions: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
  • 95. *Baldino, Walsh, Peek, Clayton, Morristown Medical Center, NJ. Overall Intubation Success (97-85%) First Attempt Success (80 vs 79%) (Glidescope) with Video-Assisted Laryngoscopy Changes in Intubation Success Over the First Year NAEMSP Poster Presentations: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
  • 96. *DiCroce, Lubin, Penn State Hershey Medical Center, Hershey, PA Overall Intubation Success (96.6%). (VL=100%, DL=93.3%) First Attempt Success (74.1%) n=56 (VL) and 60 (DL) Study Period 2 years (C-Mac) Rates During Critical Care Transport The Impact of Video Laryngoscopy on Intubation Success NAEMSP Poster Presentations: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
  • 97. *DiCroce, Lubin, Penn State Hershey Medical Center, Hershey, PA Better view with VL. No significant difference in number of attempts. Success Rates During Critical Care Transport The Impact of Video Laryngoscopy on Intubation Conclusions LARYNGOSCOPY? WILL VIDEO KILL DIRECT
  • 98. *Escott, et. al, Baylor College of Medicine/EMS Collaborative Research Group. Concluded as least as safe and effective as DL in pre-hospital use First Pass Rate 71% (VL) vs 65% (DL) (King Vision) 227 intubations by 153 paramedics. Mean DL experience = 9 years. Four Month Run-in Period by Paramedics Video vs. Direct Laryngoscopy: Multi-site Review of the NAEMSP Poster Presentations LARYNGOSCOPY? WILL VIDEO KILL DIRECT
  • 99. First Pass Success in both groups was 80% Desaturation 80% was greater in VL group (50 vs 40 sec) VL had increased time for placement (56 sec vs 40 sec) Mortality in VL and DL groups was similar Take Home Points for Consideration: LARYNGOSCOPY? WILL VIDEO KILL DIRECT
  • 100. Where are we on RSI? RSA? MFI?
  • 101. Procedure Sedative SFI: Procedure (ETT, NVA) Paralytic (SCh, Rocuronium, Vecuronium) Sedative (midazolam, etomidate, ketamine) RSI / RSA /MFI RSI/RSA:
  • 102. Out of hospital SFI rates from 25-87% In an ED setting , first pass RSI 91%, SFI 84%. If apparent relaxation occurs, proceed with intubation ppaarraallyyttiicc Sedative (midazolam, etomidate, ketamine), without a SFI: Sedation Facilitated Intubation(SFI)
  • 103. ppaarraallyyttiicc)),, ffaaiilliinngg ttoo ooppttiimmiizzee llaarryynnggoossccooppyy Sedative alone will not overcome muscle tone (like a aabbiilliittyy ttoo pprrootteecctt aaiirrwwaayy Critically ill or injured may become apneic, without Variable effects of dosing in healthy vs ill patient Problematic Sedation Facilitated Intubation(SFI)
  • 104. Sedation Facilitated Intubation(SFI) Result SSttiicckkiinngg aa bbiigg ppiieeccee ooff ssuurrggiiccaall sstteeeell ddoowwnn aa ppaattiieenntt’’ss mmoouutthh wwhhoo ccaann ssttiillll ggaagg aanndd vvoommiitt,, bbuutt hhaass tthhee iinnaabbiilliittyy ttoo pprrootteecctt tthheeiirr aaiirrwwaayy……aallll wwhhiillee ddeeccrreeaassiinngg yyoouurr cchhaanncceess ooff ssuucccceessss……
  • 105. ssiittuuaattiioonn ttoo aa tteeaamm lleessss aabbllee ttoo ssuucccceeeedd?? Why do we legislate a potentially more dangerous ooppttiioonn Single advanced provider limited to SFI as an ppaarraammeeddiiccss pprreesseenntt ffoorr uussee.. f Requirement foorr RRSSII / RRSSAA ttoo hhaavvee ttwwoo Implications for Wisconsin EMS?
  • 106. Wide safety margin (EMS dream) Reduction in chronic pain? Fibromyalgia? Suicide reduction? Anticonvulsant? Neuroprotective? Administer IV, IM, and yes, IN… Sedation, induction, asthma, pain Incredibly versatile! Some Passing Thoughts on Ketamine
  • 107. Tachycardia and hypertension (transient) Emergence and vomiting Adverse Events: Rare and easily treatable ssuurrrroouunnddiinnggss oorr ooff ppaaiinnffuull ssttiimmuullii Develops trance-like state, patient in not aware of NMDA antagonist in brain Some Passing Thoughts on Ketamine
  • 108. Some Passing Thoughts on Ketamine Cautions: Tachycardic aanndd HHyyppeerrtteennssiivvee ppaattiieennttss Layed to Rest: NNOOTT CCOONNTTRRAAIINNDDIICCAATTEEDD IINN HHEEAADD IINNJJUURRYY KKeettaammiinnee ddooeess NNOOTT iinnccrreeaassee IICCPP
  • 109. Some Passing Thoughts on Ketamine Cautions: Tachycardic aanndd HHyyppeerrtteennssiivvee ppaattiieennttss Layed to Rest: NNOOTT CCOONNTTRRAAIINNDDIICCAATTEEDD IINN HHEEAADD IINNJJUURRYY KKeettaammiinnee ddooeess NNOOTT iinnccrreeaassee IICCPP CCoosstt?? 220000mmgg,, aabboouutt $$1188 ((SSttrreeeett vvaalluuee $$500--$$11500/11000000mmgg))
  • 110. Medical Direction TTrraaiinniinngg PPrraaccttiiccee//OOvveerrssiigghhtt QQAA

Notas do Editor

  1. Refer to NCEMS Policy # 6016.1 Display Assessment Algorithm on Overhead
  2. Refer to NCEMS Policy # 6016.1 Display Assessment Algorithm on Overhead