2014 Spine Protection and Other Trends

Spinal Protection and other TrendsPSOW 2014

Steven J. Stroman, MD, FACEP, FAAEM, CCEMT/PSteven J. Stroman, MD, FACEP, FAAEM, CCEMT/P

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EMS IS the Practice of Medicine

-approved as a subspecialty by the ABMS 9/2010-first Boarded EMS Physicians 12/31/2013

3Wish List… Disclosure… …Patient Care

Topics of the day:

•Spinal Protection•Video Laryngoscopy•Some words about Ketamine

•“Our ever evolving toolbox…”

Spinal Injuries

How Big a Problem?How Big a Problem? A Little Anatomy ReviewA Little Anatomy Review General Assessment / DocumentationGeneral Assessment / Documentation Spinal Cord InjuriesSpinal Cord Injuries Traditional ManagementTraditional Management Spine Injury Clearance vs Spinal ProtectionSpine Injury Clearance vs Spinal Protection

Incidence of SCI

10,000 - 20,000 spinal cord injuries per year10,000 - 20,000 spinal cord injuries per year IncidenceIncidence

~ 82% occur in men~ 82% occur in men ~ 61% occur in 16-30 yo~ 61% occur in 16-30 yo

Common causesCommon causes MVC (48%)MVC (48%) Falls (21%)Falls (21%) Penetrating injuries (15%)Penetrating injuries (15%) Sports injuries (14%)Sports injuries (14%)

Morbidity & Mortality 40% of trauma patients with neuro deficits will have 40% of trauma patients with neuro deficits will have

temporary or permanent SCItemporary or permanent SCI Many more vertebral injuries that do not result in Many more vertebral injuries that do not result in

cord injurycord injury Most commonly injured vertebraeMost commonly injured vertebrae

C5-C7C5-C7 C1-C2C1-C2 T12-L2T12-L2

Prevention-The First Concept in Trauma Care

Training/Education in Training/Education in protective handling and protective handling and movementmovement of the injured patient of the injured patient

Injury PreventionInjury Prevention Public Education, EMS Community Service ProjectsPublic Education, EMS Community Service Projects

Secondary Injury PreventionSecondary Injury Prevention Training/Integration of EMRsTraining/Integration of EMRs Tertiary Hospital CareTertiary Hospital Care

Anatomy Review 33 Vertebrae 33 Vertebrae (…Multiple Joints…)(…Multiple Joints…)

Spine supported by pelvisSpine supported by pelvis key ligaments and muscles connect head to pelviskey ligaments and muscles connect head to pelvis

anterior longitudinal ligamentanterior longitudinal ligament anterior portion of the vertebral bodyanterior portion of the vertebral body major source of stabilitymajor source of stability protects against hyperextensionprotects against hyperextension

posterior longitudinal ligamentposterior longitudinal ligament posterior vertebral body within the vertebral canalposterior vertebral body within the vertebral canal prevents hyperflexionprevents hyperflexion

Anatomy Review Bone Structure of Bone Structure of

the Spinethe Spine CervicalCervical

ThoracicThoracic

LumbarLumbar

Sacral/CoccyxSacral/Coccyx

Anatomy ReviewVertebral 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 DermatomeDermatome

Specific area in which the spinal nerve Specific area in which the spinal nerve travels or controlstravels or controls

Important in assessing level of SCIImportant in assessing level of SCI PlexusPlexus

peripheral nerves rejoin and function peripheral nerves rejoin and function as groupas group

Cervical PlexusCervical Plexus diaphragm and neck diaphragm and neck

Dermatomes C3,4C3,4

motor: shoulder shrugmotor: shoulder shrug sensory: top of shouldersensory: top of shoulder

C3, 4, 5C3, 4, 5 motor: diaphragmmotor: diaphragm sensory: top of shouldersensory: top of shoulder

C5, 6C5, 6 motor: elbow flexionmotor: elbow flexion sensory: thumbsensory: thumb

C7C7 motor: elbow, wrist, finger motor: elbow, wrist, finger

extensionextension sensory: middle fingersensory: middle finger

C8, T1C8, T1 motor: finger abduction & motor: finger abduction &

adductionadduction sensory: little fingersensory: little finger

T4T4 motor: level of nipplemotor: level of nipple

T10T10 motor: level of umbilicusmotor: level of umbilicus

Dermatomes L1, 2L1, 2

motor: hip flexionmotor: hip flexion sensory: inguinal creasesensory: inguinal crease

L3,4L3,4 motor: quadricepsmotor: quadriceps sensory: medial thigh, calfsensory: medial thigh, calf

L5L5 motor: great toemotor: great toe, foot , foot

dorsiflexiondorsiflexion sensory: lateral calfsensory: lateral calf

S1S1 motor: knee flexionmotor: knee flexion sensory: lateral footsensory: lateral foot

S1, 2S1, 2 motor: foot plantar flexionmotor: foot plantar flexion

S2,3,4S2,3,4 motor: anal sphincter tonemotor: anal sphincter tone sensory: perianalsensory: perianal

SCI Overview

Assessment of Spinal Injury

Mechanism of Injury Mechanism of Injury – – Not all MOIs lead to SCINot all MOIs lead to SCI

Severe mechanism of injury is consistent with SCISevere mechanism of injury is consistent with SCI Other MOIs donOther MOIs don’’t correlate to the risk of SCIt correlate to the risk of SCI

ED & “Field Clearance Protocols” are in common useED & “Field Clearance Protocols” are in common use Exam and History findings help identify the potential SCIExam and History findings help identify the potential SCI Remember: Do No Harm!Remember: Do No Harm!

Assessment of Spinal Injury Traditional ApproachTraditional Approach

Based on MOI (CCR)Based on MOI (CCR) Emphasis on spinal immobilization in:Emphasis on spinal immobilization in:

unconscious trauma victimsunconscious trauma victims patients with a patients with a ““motionmotion”” injury injury

No clear clinical guidelines or specific criteria to evaluate for SCINo clear clinical guidelines or specific criteria to evaluate for SCI Signs:Signs:

pain, tenderness, painful movementpain, tenderness, painful movement deformity, injury over spinal area, shockdeformity, injury over spinal area, shock paresthesias, paresis, priapismparesthesias, paresis, priapism

Canadian C-Spine Rules (CCR)Canadian C-Spine Rules (CCR)


Not always practical to Not always practical to ““immobilizeimmobilize”” every every ““motionmotion”” injury injury Most suspected injuries were moved to a normal Most suspected injuries were moved to a normal

anatomical positionanatomical position No exclusion criteria used for moving patientsNo exclusion criteria used for moving patients

Based on the 1999 NAEMSP Position PaperBased on the 1999 NAEMSP Position Paper NEXUS and CCRNEXUS and CCR

Assessment of Spinal Injury NEXUS Criteria (answer Yes or No)NEXUS Criteria (answer Yes or No)

Focal Neurologic Deficit?Focal Neurologic Deficit? Midline Spinal Tenderness?Midline Spinal Tenderness? Altered LOC?Altered LOC? Distracting Injury Present?Distracting Injury Present? Intoxicated?Intoxicated?

If none of the above criteria are present, the C-Spine If none of the above criteria are present, the C-Spine can be cleared clinically by these criteria.can be cleared clinically by these criteria.

Assessment of Spinal Injury Spinal injuries are relatively uncommon:Spinal injuries are relatively uncommon:

Many are stableMany are stable


Devices, such as short and long backboards, or extrication Devices, such as short and long backboards, or extrication vests, offer vests, offer restriction of movementrestriction of movement, but , but DO NOT DO NOT “immobilize”“immobilize”

Potential Harm accompanies rigid spinal restriction, Potential Harm accompanies rigid spinal restriction, especially if prolonged…especially if prolonged…

Assessment of Spinal Injury ““movement devices” movement devices” help relocate patients to stable help relocate patients to stable

environments, or prepare for transport. They fasten environments, or prepare for transport. They fasten externally, but don’t prevent skin and muscle from externally, but don’t prevent skin and muscle from continuing to generate movement across the bony continuing to generate movement across the bony skeleton.skeleton.

The spine board has been the ex facto tool of choice The spine board has been the ex facto tool of choice for 50 years, despite lack of evidence to its benefitfor 50 years, despite lack of evidence to its benefit

Historical Long Spine Board Use Introduced 1960’s, based on rational conjectureIntroduced 1960’s, based on rational conjecture

““GOMSAT”GOMSAT”

Historical Long Spine Board Use

““Survey of the accident victims, firm immobilization Survey of the accident victims, firm immobilization and in-line traction are the principles of extrication.”and in-line traction are the principles of extrication.”

19661966

1977 EMT Curriculum1977 EMT Curriculum

Historical Long Spine Board Use PresumptionsPresumptions

Immobilizes all segments from joint above to jointbelow Immobilizes all segments from joint above to jointbelow the injured segmentthe injured segment

No evidence to date that this is correctNo evidence to date that this is correct

C Collar use based on established therapy for known C Collar use based on established therapy for known spinal lesions or post-operative carespinal lesions or post-operative care

Evidence to the Contrary

What about the induction or development of pain?What about the induction or development of pain? Healthy volunteers developed significant pain in the cervical Healthy volunteers developed significant pain in the cervical

and lumbar regions 21% of the timeand lumbar regions 21% of the time** Results in:Results in:

Delay of removal from boardDelay of removal from board Unnecessary imaging (84% cervical, 32% lumbar)Unnecessary imaging (84% cervical, 32% lumbar) PainPain Delay in disposition of patientDelay in disposition of patient

*Barney, Cordell, and Miller, *Barney, Cordell, and Miller, Pain Associated with Immobilization on Rigid Pain Associated with Immobilization on Rigid SpineboardsSpineboards. Ann Emerg Med, 1989.. Ann Emerg Med, 1989.

Evidence to the Contrary Rigid spine boards have been implicated in the early Rigid spine boards have been implicated in the early

development of pressure ulcersdevelopment of pressure ulcers

Prolonged localized pressure leads to impaired Prolonged localized pressure leads to impaired capillary circulation, tissue hypoxia and necrosis. The capillary circulation, tissue hypoxia and necrosis. The rate of pressure sore necrosis is directly rate of pressure sore necrosis is directly related related to to level of applied pressurelevel of applied pressure and and to time.*to time.*

*Cordell, Hollingsworth, Olinger, Stroman, Nelson. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med, 1995.

Evidence to the Contrary Pressure of about 35 mmHg will significantly reduce Pressure of about 35 mmHg will significantly reduce

blood flow through the capillary bed. Pressure blood flow through the capillary bed. Pressure mapping sensors revealed the highest tissue interface mapping sensors revealed the highest tissue interface pressures at the scapulae, sacrum, and heels.pressures at the scapulae, sacrum, and heels.**

Pressure produced:Pressure produced: Spine board = 147 mmHg (unpadded), or 115 (padded)Spine board = 147 mmHg (unpadded), or 115 (padded) Vacuum Mattress = 37 mmHgVacuum Mattress = 37 mmHg

*Cordell, Hollingsworth, Olinger, Stroman, Nelson. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med, 1995.

Evidence to the Contrary Time:Time: The average rigid spine board time in a Level I The average rigid spine board time in a Level I

Trauma Center was determined to be 120 minutes.Trauma Center was determined to be 120 minutes.11

Another study found an average of 64 minutes Another study found an average of 64 minutes (without imaging), or exceeding 180 minutes (with (without imaging), or exceeding 180 minutes (with imaging).imaging).

Time on a spine board exceeded Time on a spine board exceeded 7 hours 7 hours when when transfer to a Level I Trauma Center occurredtransfer to a Level I Trauma Center occurred22

11Barney, Cordell, and Miller, Ann Emerg Med, 1989.Barney, Cordell, and Miller, Ann Emerg Med, 1989.22Cooney, et.al., Int J Emerg Medicine, 2013Cooney, et.al., Int J Emerg Medicine, 2013, ,

Evidence to the Contrary One study of spinal cord injury found that all patients One study of spinal cord injury found that all patients

who developed ulcerations recalled no attempts to roll who developed ulcerations recalled no attempts to roll them or remove the board in the first two hours afer them or remove the board in the first two hours afer the injury.the injury.

By contrast, all patients who did not develop By contrast, all patients who did not develop ulcerations had the pressure relieved within the first ulcerations had the pressure relieved within the first two hours by removal of the spine board.two hours by removal of the spine board.

Evidence to the Contrary There has been demonstrated a direct relationship There has been demonstrated a direct relationship

between time duration on the spine board and between time duration on the spine board and development of pressure ulcers within the first eight development of pressure ulcers within the first eight days of hospitalization. Up to 31% of trauma patients days of hospitalization. Up to 31% of trauma patients will develop pressure ulcers as the result of will develop pressure ulcers as the result of immobilization on a backboard. immobilization on a backboard.

Evidence to the Contrary A period as short as 30 minutes can produce A period as short as 30 minutes can produce

significant reductions in localized tissue oxygenation significant reductions in localized tissue oxygenation in healthy patientsin healthy patients..

*Berg, et.al., Prehospital Emergency Care, 2010.*Berg, et.al., Prehospital Emergency Care, 2010.

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 Restriction to movement by LSS and straps results in:Restriction to movement by LSS and straps results in:

reduced Forced Vital Capacity (FVC)reduced Forced Vital Capacity (FVC), the maximum volume , the maximum volume exhaled after deepest inspiration,exhaled after deepest inspiration,

Reduced Forced Expiratory Volume (FEV1)Reduced Forced Expiratory Volume (FEV1) Reduced Forced Expiratory Flow (FEF)Reduced Forced Expiratory Flow (FEF)11

(Overall reductions of 15-20%)(Overall reductions of 15-20%) The results were replicated in children, ages 6-15.The results were replicated in children, ages 6-15.22

11Bauer & Kowalski, Annals of Emergency Medicine, 1988.Bauer & Kowalski, Annals of Emergency Medicine, 1988.22Schafermeyer, et.al, Annals of Emergency Medicine, 1991.Schafermeyer, et.al, Annals of Emergency Medicine, 1991.

Evidence to the Contrary

Reductions are accentuated in the face of airway or Reductions are accentuated in the face of airway or thoracic injuriesthoracic injuries

Additional reductions, based on patient’s underlying Additional reductions, based on patient’s underlying respiratory pathologyrespiratory pathology

Result in the inability for adequate self ventilation…Result in the inability for adequate self ventilation…

Cochrane Review of Immobilization

2009: Uncertain Effectiveness2009: Uncertain Effectiveness

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

120 without immobilization vs. 334 @ Univ. of New Mexico did.120 without immobilization vs. 334 @ Univ. of New Mexico did.

Outcome: Little or no effect on outcome of blunt spinal injuryOutcome: Little or no effect on outcome of blunt spinal injury

Malaysia Military Study vs. EMS

Hauswald, et. al. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998 Mar;5(3):214-9.

Evidence to the ContraryAdditional Thoughts:Additional Thoughts:

Increases safety risk to providers (Work Comp)Increases safety risk to providers (Work Comp) Increased risk of soft tissue injuryIncreased risk of soft tissue injury Difficulties in ED exam (due to board)Difficulties in ED exam (due to board)

Assessment Overview

Decision to apply spinal immobilization in Decision to apply spinal immobilization in past based was solely on mechanism of injurypast based was solely on mechanism of injury

Utilize Utilize EMS Spinal Immobilization EMS Spinal Immobilization AlgorithmAlgorithm to determine when spinal to determine when spinal immobilization is immobilization is NOT NOT neededneeded

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SCI General Assessment Consider Mechanism of Injury & KinematicsConsider Mechanism of Injury & Kinematics

Positive MOI Positive MOI Should Require Spinal ManagementShould Require Spinal Management high speed motor vehicle collisionhigh speed motor vehicle collision fall greater than 3 times the patientfall greater than 3 times the patient ’’s heights height violent situations occurring near the spineviolent situations occurring near the spine

• **stabbing**stabbing• **gun shot**gun shot

sports injury (with force or velocity)sports injury (with force or velocity) confounding factors such as osteoporosis, extreme ageconfounding factors such as osteoporosis, extreme age other high impact, high force or high velocity conditions involving the other high impact, high force or high velocity conditions involving the

head, spine or trunkhead, spine or trunk

SCI General Assessment Consider Mechanism of Injury & KinematicsConsider Mechanism of Injury & Kinematics

Negative MOI Negative MOI Do Not Require Spine boardDo Not Require Spine board force or impact does not suggest a potential spinal injuryforce or impact does not suggest a potential spinal injury

• dropped a rock on footdropped a rock on foot

• twisted ankle while runningtwisted ankle while running

• isolated musculoskeletal injuryisolated musculoskeletal injury

• simple fall from standing positionsimple fall from standing position

• low speed motor vehicle collisionlow speed motor vehicle collision

SCI General Assessment

ABCsABCs Airway and/or Breathing impairmentAirway and/or Breathing impairment

Inability to maintain airway Inability to maintain airway (SB reduces mouth opening 20%)(SB reduces mouth opening 20%)

ApneaApnea Diaphragmatic breathingDiaphragmatic breathing

Cardiovascular impairmentCardiovascular impairment Neurogenic ShockNeurogenic Shock HypoperfusionHypoperfusion

SCI General Assessment Neurologic Status:Neurologic Status:

Level of ConsciousnessLevel of Consciousness Brain injury also?Brain injury also? CooperativeCooperative No impairment (drugs, alcohol)No impairment (drugs, alcohol) Understands & Recalls events surrounding injuryUnderstands & Recalls events surrounding injury No Distracting injuriesNo Distracting injuries No difficulty in communication No difficulty in communication

SCI General Assessment Assess Function & SensationAssess Function & Sensation

Palpate over each spinous processPalpate over each spinous process Motor functionMotor function

Shrug shouldersShrug shoulders Spread fingers of both hands and keep apart with forceSpread fingers of both hands and keep apart with force ““HitchhikeHitchhike”” {T1} {T1} Foot plantar flexors (gas pedal) {S1,2}Foot plantar flexors (gas pedal) {S1,2}

Sensation (Position and Pain)Sensation (Position and Pain) weakness, numbness, paresthesiaweakness, numbness, paresthesia pain (pinprick), sharp vs dull, symmetrypain (pinprick), sharp vs dull, symmetry

PriapismPriapism

Spinal Cord Injuries

Primary Injury Primary Injury occurs at the time of injuryoccurs at the time of injury may result in may result in

cord compressioncord compression direct cord injurydirect cord injury interruption in cord interruption in cord

blood supplyblood supply

Secondary InjurySecondary Injury occurs after initial injuryoccurs after initial injury may result frommay result from

swelling/inflammationswelling/inflammation ischemiaischemia movement of body movement of body

fragmentsfragments

Spinal Cord Injuries

**Less movement is noted by patient self-Less movement is noted by patient self-extricating than by EMS providers placing on extricating than by EMS providers placing on a board.a board.

Did EMS “Cause” the SCI?

Force Required for SCI: Force Required for SCI: 60006000 Newtons Newtons

Force Applied by EMS: Force Applied by EMS: 1010 Newtons Newtons

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Management of SCI Primary GoalPrimary Goal

Prevent secondary injuryPrevent secondary injury Stabilization of the spine begins in the initial assessmentStabilization of the spine begins in the initial assessment Traditional Treatment:Traditional Treatment:

Treat the spine as a long bone?Treat the spine as a long bone? Secure joint above and below?Secure joint above and below?

Caution with Caution with ““partialpartial”” spine splinting? spine splinting? Rule: All or None? (collar, board, CID, tape, straps…)Rule: All or None? (collar, board, CID, tape, straps…)

Immobilization vs Motion RestrictionImmobilization vs Motion Restriction

Management of SCI

Neutral positioning of head and neck if at all Neutral positioning of head and neck if at all possiblepossible allows for the most space for cordallows for the most space for cord most stable position for spinal columnmost stable position for spinal column DonDon’’t force itt force it

Traditional Management of SCI

Cervical Motion RestrictionCervical Motion Restriction Manual methodManual method Rigid collar comes laterRigid collar comes later Interim device (KED)Interim device (KED) Move to long board or full body vacuum splintMove to long board or full body vacuum splint Manual continues until trunk and head securedManual continues until trunk and head secured ““CIDCID””

Management of SCI

DonDon’t’t forget the Padding forget the Padding Maintains anatomical positionMaintains anatomical position Limits movement on boardLimits movement on board

especially during transport on board or in vehicleespecially during transport on board or in vehicle

fill all the voidsfill all the voids curvature of the lower back is normal - fill itcurvature of the lower back is normal - fill it pillows, blankets, towelspillows, blankets, towels Tape along (even duct tape) is not enoughTape along (even duct tape) is not enough

Management of SCI

Securing to the Board (Historical)Securing to the Board (Historical) Straps, Tape, Cravats, whateverStraps, Tape, Cravats, whatever Torso firstTorso first

then legs and feet and headthen legs and feet and head

Even patients extricated with a KED are secured to Even patients extricated with a KED are secured to the boardthe board

Management of SCI Even Strap Patterns Researched…Even Strap Patterns Researched…

Procedure for Complete Spinal Immobilization TraditionalTraditional

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Procedure for Complete Spinal Immobilization (Historical)

Procedure for Complete Spinal Immobilization (Historical)

Common Treatment Mistakes(Spine board and collar)

Improperly sized C-CollarImproperly sized C-Collar Spine not supported due to improper positioning on Spine not supported due to improper positioning on

backboardbackboard Inadequate strapping allows excessive movementInadequate strapping allows excessive movement Movement possible due to little or no padding to shim the Movement possible due to little or no padding to shim the

bodybody C-spine movement by inadequate or improperly applied head C-spine movement by inadequate or improperly applied head

immobilization deviceimmobilization device C-spine hyperextension due to improperly applied C-collar or C-spine hyperextension due to improperly applied C-collar or

head immobilization devicehead immobilization device

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Management of SCI

Pediatric Patient ConsiderationsPediatric Patient Considerations Elevate the entire torso if large occiputElevate the entire torso if large occiput

Pad underneathPad underneath Short board underneathShort board underneath Vacuum mattressVacuum mattress

Lots of voids to fillLots of voids to fill Difficult to find a correctly sized rigid collarDifficult to find a correctly sized rigid collar

Improvise withImprovise with

• horse collarhorse collar

• blanket or towel rollsblanket or towel rolls

Management of SCI Helmeted PatientsHelmeted Patients

Removal should be limited to emergent need for access to Removal should be limited to emergent need for access to airway and ventilationairway and ventilation

Leave in place Leave in place if:if: good fit with little or no head movement withingood fit with little or no head movement within no impending airway or breathing problemsno impending airway or breathing problems can perform spinal motion restriction with helmet oncan perform spinal motion restriction with helmet on no interference in airway assessment or managementno interference in airway assessment or management no cardiac arrestno cardiac arrest

Management of SCI

Helmeted PatientsHelmeted Patients Types of HelmetsTypes of Helmets

Sports (football, hockey)Sports (football, hockey)

• Shoulder pads and helmet go togetherShoulder pads and helmet go together Racing (motorcycle, car racer)-Racing (motorcycle, car racer)-prefer removalprefer removal Recreational (motorcycle, bicycle)Recreational (motorcycle, bicycle)-prefer removal-prefer removal

Various helmets create different problems for patient Various helmets create different problems for patient and for removaland for removal

Management of SCI

Helmeted PatientsHelmeted Patients Types of HelmetsTypes of Helmets

Sports (football, hockey)Sports (football, hockey)

• Shoulder pads and helmet go togetherShoulder pads and helmet go together Racing (motorcycle, car racer)-Racing (motorcycle, car racer)-prefer removalprefer removal Recreational (motorcycle, bicycle)Recreational (motorcycle, bicycle)-prefer removal-prefer removal

Various helmets create different problems for patient Various helmets create different problems for patient and for removaland for removal

“Clearing” Protocols Spinal ClearanceSpinal Clearance

First initiated in Maine First initiated in Maine with a state-wide protocolwith a state-wide protocol

Now much more common Now much more common in USin US

Current PracticeCurrent Practice Assess scene and MOIAssess scene and MOI Assess neuro statusAssess neuro status ImmobilizeImmobilize

Most MOIsMost MOIs Prevent further injuryPrevent further injury CYACYA No 100% method to rule out in No 100% method to rule out in

the fieldthe field fear of litigationfear of litigation devastating consequences devastating consequences

possiblepossible

When should the screening tool be used?

One of three paths is chosen:One of three paths is chosen: 1. Positive or Obvious Severe Mechanism1. Positive or Obvious Severe Mechanism

Violent impactViolent impact High likelihood of spinal injuryHigh likelihood of spinal injury

2. Negative or Obviously Minimal Mechanism2. Negative or Obviously Minimal Mechanism No reasonable probability of spinal injuryNo reasonable probability of spinal injury

3. Uncertain Mechanism 3. Uncertain Mechanism (Most Common)(Most Common) Injury may or may not be possibleInjury may or may not be possible Difficult to determineDifficult to determine Treat with Spinal ProtectionTreat with Spinal Protection

“Clearing” Protocols

No significant MOI or evidence of spine injuryNo significant MOI or evidence of spine injury No neck or back pain (Palpate all)No neck or back pain (Palpate all) Normal Neuro Exam (no motor/sensory losses)Normal Neuro Exam (no motor/sensory losses) Normal Level of ConsciousnessNormal Level of Consciousness

AdultAdult, , Reliable PatientReliable Patient w/o anxiety reaction or w/o anxiety reaction or ““normallynormally”” abnormal mental statusabnormal mental status

No ETOH or drugsNo ETOH or drugs No language barriersNo language barriers

No distracting injuries No distracting injuries or penetrating inj near spineor penetrating inj near spine

“Distracting Injury” I’m not sure what it is, but I’ll I’m not sure what it is, but I’ll know it when I see it…know it when I see it…

Excludes “Extremes of Age”

Age < 5Age < 5 Age > 65Age > 65

Penetrating Trauma?Based on exam

Immobilization with a Backboard SHOULD NOT be performed:

PENETRATING TRAUMA of the:PENETRATING TRAUMA of the: HeadHead NeckNeck TorsoTorso

ANDAND No evidence of spinal injury No evidence of spinal injury

Reviewing ourSPINAL PROTECTION

care today

Position Statement:EMS Spinal Precautions and

the Use of the Long Backboard

National Association of EMS PhysiciansNational Association of EMS Physicians

American College of Surgeons Committee on TraumaAmerican College of Surgeons Committee on Trauma

20132013

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Principles of Treatment

Protect spinal cord from secondary injuryProtect spinal cord from secondary injury We have little or no effect on primary injuryWe have little or no effect on primary injury Focus on prevention of secondary injuryFocus on prevention of secondary injury

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Spinal Immobilization AlgorithmPatient MentationPatient Mentation::

Decreased Level of Consciousness?Decreased Level of Consciousness?NoNo Yes ----------------------------ImmobilizeYes ----------------------------Immobilize

ETOH/Drug Impairment?ETOH/Drug Impairment?NoNo Yes ----------------------------ImmobilizeYes ----------------------------Immobilize

Subjective AssessmentSubjective Assessment::Cervical/Thoracic/Lumbar Spinal pain?Cervical/Thoracic/Lumbar Spinal pain?

No No Yes ----------------------------ImmobilizeYes ----------------------------Immobilize

Numbness/Tingling/Burning/Weakness?Numbness/Tingling/Burning/Weakness?NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

Objective Assessment:Objective Assessment:Cervical/Thoracic/Lumbar Deformity or Tenderness?Cervical/Thoracic/Lumbar Deformity or Tenderness?

NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

Other Severe Injury?Other Severe Injury?NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

Other Severe Injury?Other Severe Injury?NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

Pain w/Cervical Range of Motion?Pain w/Cervical Range of Motion?NoNo Yes -----------------------------ImmobilizeYes -----------------------------Immobilize

MAY TREAT/TRANSPORT WITHOUT SPINAL PRECAUTIONSMAY TREAT/TRANSPORT WITHOUT SPINAL PRECAUTIONS7777

Once We Decide to Immobilize/Protect: HOW?

Rigid Cervical CollarRigid Cervical Collar Secured firmly to EMS StretcherSecured firmly to EMS Stretcher

Best Use For:Best Use For: Ambulatory patients at sceneAmbulatory patients at scene Prolonged use, interfacility transferProlonged use, interfacility transfer No other backboard indicationNo other backboard indication

Stratify the Patients for Protection:

1. Uninjured: 1. Uninjured: Ambulatory, no pain or complaint stated, or on examAmbulatory, no pain or complaint stated, or on exam Treatment: None requiredTreatment: None required

2. MOI/Complaint2. MOI/Complaint Treatment: C Collar, cot straps, minimal movt.Treatment: C Collar, cot straps, minimal movt.

3. Severe MOI/LOC/Deficits3. Severe MOI/LOC/Deficits Treatment: C Collar/Vacuum/…LSS? Minimal movt.Treatment: C Collar/Vacuum/…LSS? Minimal movt.

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Summary:

Backboard or Not, Spinal Protection/Precaution Backboard or Not, Spinal Protection/Precaution among at-risk patients is PARAMOUNT!among at-risk patients is PARAMOUNT!

Appropriate protection Appropriate protection with with cervical collarcervical collar, adequate , adequate security to stretchersecurity to stretcher, , minimal movement/transfersminimal movement/transfers, , and and maintaining in-line maintaining in-line stabilization during stabilization during movement/transfersmovement/transfers

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SPINAL PROTECTION & CARE

EMT AND PARAMEDIC

Patients with blunt traumatic injuries with mechanism concerning for spinal injury should be assessed for spinal injury.

PROTOCOL DRAFT

SPINAL PROTECTION & CAREPROTOCOL DRAFT

NO spinal protection necessary Patients may have all spinal immobilization omitted if ALL of the following

conditions apply: age > 5 , < 65 Conscious, cooperative and able to communicate effectively No evidence of intoxication (alcohol/drug) or altered mental status No history of new/temporary neurological deficit (numbness/weakness in an

extremity) No evidence of a distracting injury (fractures, major burns, crush injuries or severe

pain) Have no midline back or neck pain or tenderness upon palpation.


NO spinal protection necessary

There is no major mechanism for severe injury If ALL of the above criteria are met, have patient move their

neck 45 degrees to either side of midline and if still no pain, NO immobilization is indicated.


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 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.


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)

Implementation of Change

Stakeholder DiscussionsStakeholder Discussions Within (Individual Champion, Crew, Organization)Within (Individual Champion, Crew, Organization) Industry Colleagues (Agency, Medical Directors, Industry Colleagues (Agency, Medical Directors,

Councils)Councils) Customers (ED Doctors, Trauma Surgeon, Customers (ED Doctors, Trauma Surgeon,

Neurosurgeon)Neurosurgeon) Trainers (Technical Colleges, Hospitals)Trainers (Technical Colleges, Hospitals)

Implementation of Change

Roll OutRoll Out Protocol Development / ApprovalProtocol Development / Approval Training of Personnel (internal)Training of Personnel (internal) Notification of Customers (EDs, Trauma Care Notification of Customers (EDs, Trauma Care

Facilities, Trauma Coordinators (Database)Facilities, Trauma Coordinators (Database) In-Service for ED Nurses (Managers)In-Service for ED Nurses (Managers) Run Documentation (movement, neuro exam, etc)Run Documentation (movement, neuro exam, etc) Oversight and QAOversight and QA

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.


A decision is made to RSI/RSA the patient.

Do you use the DL or VL? (or NVA)

What is in your decision tree? Preferred technique (VL, DL) Salvage (NVA, Device change, Provider change, Bougee, surgical)


Some quick facts:

87% of intubations are performed by ED Physicians* RSI used in >2/3 of cases

*Walls,et. al, National Emergency Airway Registry, 2011


“Effects of video laryngoscopy on trauma patient survival; a randomized controlled trial.”

Trauma Patients at Baltimore Shock Trauma VL (GlideScope) vs. DL Outcome: Mortality Secondary: Subgroup survival, duration of attempt, desaturation,

first pass success

*Yeatts, Dutton, Hu, et. al, J Trauma Acute Care Surg. 2013;75:212-9.


Conclusions:

VL and DL had similar mortalityA possible increased mortality for most severe CHI,

randomized to VL group

*Yeatts, Dutton, Hu, et. al, J Trauma Acute Care Surg. 2013;75:212-9.


NAEMSP Poster Presentations:

Changes in Intubation Success Over the First Year with Video-Assisted Laryngoscopy

First Attempt Success (80 vs 79%) (Glidescope)Overall Intubation Success (97-85%)

*Baldino, Walsh, Peek, Clayton, Morristown Medical Center, NJ.


NAEMSP Poster Presentations: The Impact of Video Laryngoscopy on Intubation Success

Rates During Critical Care Transport Study Period 2 years (C-Mac) First Attempt Success (74.1%) n=56 (VL) and 60 (DL) Overall Intubation Success (96.6%). (VL=100%, DL=93.3%)

*DiCroce, Lubin, Penn State Hershey Medical Center, Hershey, PA


Conclusions

The Impact of Video Laryngoscopy on Intubation Success Rates During Critical Care Transport

No significant difference in number of attempts. Better view with VL.

*DiCroce, Lubin, Penn State Hershey Medical Center, Hershey, PA


NAEMSP Poster Presentations Video vs. Direct Laryngoscopy: Multi-site Review of the

Four Month Run-in Period by Paramedics 227 intubations by 153 paramedics. Mean DL experience = 9 years. First Pass Rate 71% (VL) vs 65% (DL) (King Vision) Concluded as least as safe and effective as DL in pre-hospital use

*Escott, et. al, Baylor College of Medicine/EMS Collaborative Research Group.


Take Home Points for Consideration:

Mortality in VL and DL groups was similar VL had increased time for placement (56 sec vs 40 sec) Desaturation <80% was greater in VL group (50 vs 40 sec) First Pass Success in both groups was 80%

Where are we on RSI?RSA?MFI?

RSI / RSA /MFI RSI/RSA:RSI/RSA:

Sedative (midazolam, etomidate, ketamine)Sedative (midazolam, etomidate, ketamine) Paralytic (SCh, Rocuronium, Vecuronium)Paralytic (SCh, Rocuronium, Vecuronium) Procedure (ETT, NVA)Procedure (ETT, NVA)

SFI:SFI: SedativeSedative ProcedureProcedure

Sedation Facilitated Intubation(SFI) SFI:SFI:

Sedative (midazolam, etomidate, ketamine), Sedative (midazolam, etomidate, ketamine), without a without a paralyticparalytic

If apparent relaxation occurs, proceed with intubationIf apparent relaxation occurs, proceed with intubation

In an ED setting , first pass RSI 91%, SFI 84%.In an ED setting , first pass RSI 91%, SFI 84%. Out of hospital SFI rates from 25-87%Out of hospital SFI rates from 25-87%

Sedation Facilitated Intubation(SFI) ProblematicProblematic

Variable effects of dosing in healthy vs ill patientVariable effects of dosing in healthy vs ill patient Critically ill or injured may become apneic, Critically ill or injured may become apneic, without without

ability to protect airwayability to protect airway Sedative alone will not overcome muscle Sedative alone will not overcome muscle tone (like a tone (like a

paralytic), failing to optimize laryngoscopyparalytic), failing to optimize laryngoscopy

Sedation Facilitated Intubation(SFI) ResultResult

Sticking a big piece of surgical steel downSticking a big piece of surgical steel down

a patient’s mouth who can still gag and a patient’s mouth who can still gag and vomit, but has the inability to protect their vomit, but has the inability to protect their airway…all while decreasing your chances airway…all while decreasing your chances of success…of success…

Implications for Wisconsin EMS? Requirement for RSI / RSA to have two paramedics Requirement for RSI / RSA to have two paramedics

present for use.present for use.

Single advanced provider limited to SFI as an Single advanced provider limited to SFI as an optionoption

Why do we legislate a potentially more dangerous Why do we legislate a potentially more dangerous situation to a team less able to succeed?situation to a team less able to succeed?

Some Passing Thoughts on Ketamine

Incredibly versatile!Incredibly versatile! Sedation, induction, asthma, painSedation, induction, asthma, pain Administer IV, IM, and yes, IN…Administer IV, IM, and yes, IN…

Suicide reduction? Anticonvulsant? Neuroprotective?Suicide reduction? Anticonvulsant? Neuroprotective? Reduction in chronic pain? Fibromyalgia?Reduction in chronic pain? Fibromyalgia?

Wide safety margin Wide safety margin (EMS dream)(EMS dream)


NMDA antagonist in brainNMDA antagonist in brain Develops trance-like state, patient in not aware of Develops trance-like state, patient in not aware of

surroundings or of painful stimulisurroundings or of painful stimuli Adverse Events: Adverse Events: Rare and easily treatableRare and easily treatable

Emergence and vomitingEmergence and vomiting Tachycardia and hypertension (transient)Tachycardia and hypertension (transient)


Cautions: Tachycardic and Hypertensive patientsCautions: Tachycardic and Hypertensive patients

Layed to Rest:Layed to Rest:

NOT CONTRAINDICATED IN HEAD INJURYNOT CONTRAINDICATED IN HEAD INJURY

Ketamine does NOT increase ICPKetamine does NOT increase ICP


Cautions: Tachycardic and Hypertensive patientsCautions: Tachycardic and Hypertensive patients

Layed to Rest:Layed to Rest:

NOT CONTRAINDICATED IN HEAD INJURYNOT CONTRAINDICATED IN HEAD INJURY

Ketamine does NOT increase ICPKetamine does NOT increase ICP

Cost? 200mg, about $18 Cost? 200mg, about $18 (Street value $50-$150/1000mg)(Street value $50-$150/1000mg)

Medical Direction TrainingTraining Practice/OversightPractice/Oversight QAQA

Questions?

Health & Medicine

2014 Spine Protection and Other Trends