Updates in EMS-Backboards

Roberto C. Portela, MD, FACEP
Pitt County Medical Director
EMS Fellowship Associate Director
Clinical Assistant Professor
East Carolina University
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It is based in hard evidence
Immobilization to prevent spinal cord injury
Minimize movement while extricating patients
There is no harm to patient
žWell…not
really
Oops!!!
ž Delayed
onset paraplegia due to failure to
recognize injury and protect patient from the
consequences of his unstable spine
¡
Hours to days
ž Discussed
¡
only 2 patients
Observational study, patient interview
ž “This
man would surely have been protected
from the paraplegic condition had the spinal
instability been recognized and precautions
taken.”
ž “The importance of proper first-aid was
deduced from the fact that 29 patients
developed further paralysis through faulty
handling.”
ž
J Trauma. 1965 Nov;5(6):703-8. The removal of
injured personnel from wrecked vehicles. Kossuth LC
ž
Death in a Ditch. 1967. Farrington JD
ž
J Trauma. 1968 Jul;8(4):493-512. Extrication of
victims-surgical principles. Farrington JD
J.D. Farrington
“Carefully splint the
injured spine, avoiding
abnormal or excessive
motion.
ž Be sure that the injured
person is properly splinted
and transported on a long
backboard or special
stretcher without bending
or twisting the spine in any
direction.”
ž
ž American Academy
of Orthopedic Surgeons
(AAOS)published first guidelines for EMS.
ž Advocated use of spinal immobilization using a
backboard and C-collar for trauma patients
with signs and symptoms of spinal injury.
Spinal immobilization for trauma patients
“We did not find any randomized controlled trials that met the
inclusion criteria. The effect of spinal immobilization
on mortality, neurological injury, spinal stability and adverse
effects in trauma patients remains uncertain. Because
airway obstruction is a major cause of preventable death
in trauma patients, and spinal immobilization, particularly of the
cervical spine, can contribute to airway compromise, the
possibility that immobilization may increase mortality
and morbidity cannot be excluded. Large prospective studies are
needed to validate the decision criteria for spinal immobilization
in trauma patients with high risk of spinal injury. Randomized
controlled trials in trauma patients are required to establish the
relative effectiveness of alternative strategies for spinal
immobilization.”
ž At
least five million immobilized per year
ž About 2% of injuries presenting to the ED
ž Approx. 54 cases of SCI per million population
(17,000 per yr)
Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. 2013 Sep;30(9):720-3.
doi: 10.1136/emermed-2012-201847.
Spinal Cord Injury Statistics. Birmingham, AL: National Spinal Cord Injury Association
Resource Center; 2016.
ž 33,922
patients enrolled, 21 centers
ž Cervical spine injury was present in 818 (2.40%)
Lowery DW, Wald MM, Browne BJ, Tigges S, Hoffman JR, Mower WR; NEXUS Group.
Epidemiology of cervical spine injury victims. Ann Emerg Med. 2001
ž Assigned
to either LSB or stretcher mattress only
ž C-collar, foam head blocks
ž Driven on a closed course at a low speed
ž The stretcher mattress significantly reduced
lateral movement during transport.
Wampler DA, Pineda C, Polk J, Kidd E, Leboeuf D, Flores M, Shown M, Kharod
C, Stewart RM, Cooley C. The long spine board does not reduce lateral motion
during transport-a randomized healthy volunteer crossover trial. Am J Emerg
Med. 2016 Apr;34(4):717-21.
ž “None
of the three immobilization techniques
was successful in eliminating head motion or
neck rotation.”
ž “Movement of the trunk contributed
substantially to the lateral bending that
occurred across the neck”
Perry SD, McLellan B, McIlroy WE, Maki BE, Schwartz M, Fernie GR. The efficacy
of head immobilization techniques during simulated vehicle motion. Spine
(Phila Pa 1976). 1999;24:1839- 1844.
ž Video
motion capture used to quantify the
ROM of the head relative to the torso
ž Four different extrication techniques
ž Significant decrease in movement for all
motions when the driver exited the vehicle
unassisted with C-collar
Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS.
Cervical spine motion during extrication. J Emerg Med. 2013 Jan;44(1):122-7.
ž 21
healthy volunteers without back disease
ž Placed in standard backboard for a 30-minutes
ž 100% developed pain in:
¡
Occipital, sacral, lumbar, and mandibular pain
ž 55%
graded their symptoms as moderate to
severe
Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal
immobilization on healthy volunteers. Ann Emerg Med. 1994 Jan;23(1):48-51.
ž 15
healthy, nonsmoking male volunteers
ž Immobilize in backboard and KED
ž Tested four pulmonary function parameters
ž Significant difference between prestrapping and
poststrapping values for:
¡
¡
¡
Forced Vital Capacity
Forced Expiratory Volume in 1 sec.
Forced Mid-Expiratory Flow
Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function
in the healthy, nonsmoking man. Ann Emerg Med. 1988 Sep;17(9):915-8.
ž 73
healthy volunteers in backboard
ž Baseline and 30 min. peripheral tissue oxygen
saturation measurements in sacral area
ž Pressure ulcer formation may begin prior to
admission with immobilization backboard
Berg G, Nyberg S, Harrison P, Baumchen J, Gurss E, Hennes E. Near-infrared
spectroscopy measurement of sacral tissue oxygen saturation in healthy
volunteers immobilized on rigid spine boards. Prehosp Emerg Care. 2010 OctDec;14(4):419-24.
ž Retrospective
analysis of penetrating trauma
patients in the National Trauma Data Bank
ž Compared patients with vs. without prehospital
spine immobilization
ž Prehospital spine immobilization is associated
with higher mortality in penetrating trauma
and should not be routinely used in every
patient with penetrating trauma
Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma:
more harm than good? J Trauma. 2010;68:115-20; discussion 120-1
žAmerican
College of Emergency
Physicians
žNational Association of EMS
Physicians
žPrehospital Trauma Life Support
ž Current
practices lack scientific support
ž Evolving evidence suggest harm
ž True spinal immobilization is impossible
ž Airway, hemorrhage and other time-critical
interventions should not be hindered
ž Backboards should not be use as precautionary
measures
ž Not to be used in penetrating trauma w/o
evidence of spinal injury
ž Joint
statement with ACS (COT)
ž Benefit of the backboard is largely unproven
ž Can induce pain, agitation, respiratory
compromise and pressure sores
ž Do no immobilize penetrating trauma w/o
evidence of spinal injury
ž Mechanism
of injury should no be the sole
factor to undergo spinal immobilization
ž “Because many pts do not have spinal injury, a
selective approach is… appropriate”
ž “Patients with penetrating trauma need not
undergo spinal immobilization”
ž Spinal
motion restriction
ž Sustain injury with a mechanism having the
potential for causing spinal injury
ž And at least one of the following:
1.
2.
3.
4.
5.
AMS
Evidence of intoxication
Distracting painful-injury
Neurological deficit
Spinal pain or tenderness
ž 5-year
¡
¡
retrospective, 2 university hospitals
120 patients seen at University of Malaya
334 patients seen at University of New Mexico
ž All
patients with acute blunt traumatic spinal
or spinal cord injuries transported directly
from the injury site
Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal
immobilization: its effect on neurologic injury. Acad Emerg Med. 1998
Mar;5(3):214-9.
ž Less
neurologic disability in the unimmobilized
Malaysian patients
(OR 2.03; 95% CI 1.03-3.99; p = 0.04)
ž Out-of-hospital
immobilization has little or no
effect on neurologic outcome in patients with
blunt spinal injuries
Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal
immobilization: its effect on neurologic injury. Acad Emerg Med. 1998
Mar;5(3):214-9.
The long spine boards are NOT considered
standard of care I most cases of potential
spinal injury
ž The
backboard is an excellent extrication device
ž No immobilization for penetrating trauma
ž Use spinal motion restriction when indicated
ž Use NEXUS or Canadian C-spine rules
ž Problems….
First, we need to stabilize the spine
Harm
Benefit
portelar@ecu.edu
portelar@ecu.edu