The one constant in EMS is change. Ask anyone who has worked the streets for some time and they might tell you about the oral screw, rotating tourniquets and pneumatic antishock garments that used to be part of their practice. These devices and procedures have gone by the way of the dial-up internet service, as the evidence to benefit patients was lacking.
Spinal immobilization appears to be moving in that direction. EMS systems from Florida to Texas to Kansas to Missouri and others across the country are rapidly moving toward selective spinal restriction protocols. Is your system getting with this sea change in EMS practice?
Universal c-spine precautions
EMS curriculum in the 1980s was very clear: just about any injury mechanism would automatically result in an EMS provider immobilizing the patient’s spine.[1] This “universal” approach was thought to be fairly harmless and believed to prevent further injury to a patient with a potential spinal cord injury.
Immobilization was defined as the use of a rigid collar, a hard long board, and method of restricting the motion of the body, neck and head while lying on the board. Spinal immobilization was considered so essential that it remains a National Registry mandatory practical examination item for EMS providers.[2]
The practice became so prevalent that many patients wound up being backboarded by field providers as proof of legally defensible medicine. The problem was there was no proof that spinal immobilization made any difference in patient care.
It’s about the patient, not the MOI
One of the major studies that first looked at the effectiveness of spinal immobilization was published in 1998.[3] Researchers formulated a series of criteria that could be applied to patients who had experienced a mechanism of injury (MOI) that would normally prompt cervical radiography (X-rays) in the emergency department.
Patients who displayed no cervical spine tenderness, signs of intoxication, altered mental status, or significant and painful distracting injuries were thought to be at low risk for a spinal cord injury. The study found that in a population of more than 34,000 patients, the criteria could accurately identify 99.6 percent of the patients who did not have a spinal injury after an MOI.
In reality, the patient with an actual injury will experience some sort of discomfort or neuro logic deficit shortly after the incident occurred. The Prehospital Trauma Life Support Committee of the American College of Surgeons has recommended discontinuing the routine use of spine boards on patients with blunt force MOI unless the patient meets clinical criteria.[4] The committee went even further in penetrating trauma, saying to not use backboards at all unless neurologic deficits are noted.[5]
More harm than good?
There have been multiple studies over the past decade that have demonstrated the potential harm of spinal immobilization, including causing pain and discomfort, increasing respiratory difficulties, and increasing the movement of the cervical spine during immobilization.[6, 7, 8, 9]
The bottom line is, immobilizing a patient’s spine is not a benign procedure. Like everything else in medicine, competent practitioners must carefully assess each patient and weigh the pros and cons of this procedure. Will the benefits of application outweigh its harm? Current data strongly suggests that in most cases, it will not.
Don’t throw out the baby with the bath water
Conversely, EMS providers should not conclude that spinal immobilization is never indicated.
Patients should be evaluated carefully and spinal restriction criteria precisely applied when making a determination to immobilize. Not doing so may result in an inappropriate decision, and result in transporting a patient with an actual spinal cord injury without appropriate spinal motion restriction. .
Such a large swing in practice guidelines may have created confusion during this transition. But like the transition from dial-up to highspeed internet, a new era is here. Carefully review local guidelines and make sure you are adequately trained before applying them.
References
1. U.S. Department of Transportation, National Highway Traffic Safety Administration. Emergency Medical Technician—Ambulance: National Standard Curriculum. Washington, DC: U.S. Government Printing Office, 1984.
2. National Registry of Emergency Medical Technicians. Spinal Immobilization (Supine patient). https://www.nremt.org/nremt/downloads/E212%20Spinal%20Immobilization%20Supine.pdf. Retrieved 12/15/2014.
3. Hoffman JR, Wolfson AB, Todd K, Mower WR. (1998). “Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS).” Ann Emerg Med. 32 (4): 461–9.
4. National Association of EMTs. Prehospital Trauma Life Support, 6th Edition. Mosby Publishing: 2006.
5. Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. Prehospital spine immobilization for penetrating trauma—review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma, 2011; 71: 763–9
6. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med, 1998; 5: 214–9.
7. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Preh Emerg Care, 1999; 3: 347–52
8. Chan D, Goldberg RM, Mason J, Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med, 1996; 14: 293–8.
9. Lador R, Ben-Galim P, Hipp JA. Motion Within the Unstable Cervical Spine During Patient Maneuvering: The Neck Pivot-Shift Phenomenon. J Trauma, 2011; 70: 247-251.
