Safe Spinal Clearance Equals Better Care For Spinal Injuries: Part 2

In Part 1, I described why I believe EMS providers should have the same knowledge base that physician’s assistants do.  This would improve our ability to detect partial spinal cord injuries, and to not immobilize everyone else.  So what happens when we find an injury, or a patient who might have one?  Here’s what Dr. Ross has to say his EMS 1 column, Confessions of a Recovering Field Spine Clearance Addict — revisited:

Indeed, the issue of primary versus secondary spinal cord injury is debated in the literature. The primary injury is, of course, at the time of initial trauma. Secondary injury may occur as a result of poor immobilization and other treatment complications or from later cord swelling or bleeding.

I don’t believe that anyone has been able to elucidate how much secondary injury is a factor in patient outcome, and we don’t know what role non-immobilization plays in worsening secondary injury.

So if we should immobilize, is the way we immobilize effective? Dr. Ross goes on to describe the Hauswald study, where patients with spinal injuries in the US who were immobilized did worse than patients in Malaysia who were not immobilized.  Based on this study, and the lack of evidence supporting any benefit from spinal immobilization, many people believe that the practice should be abandoned.  In response, Dr. Ross writes:

Despite this strong sentiment, how many EMS systems have actually done away with spinal immobilization for fears of worsening injury from the procedure itself? I doubt very many.

Even if long board immobilization does not worsen spinal injuries (remember it is supposed to help), it is clear that it worsens head injuries.  Gravity helps relieve intracranial pressure, but we force head injured patients to lay flat and apply a collar that compresses their jugular veins.  Gravity also help protect airways from secretions, so lying patients flat increases their risk of aspiration.

So is there a better way to immobilize? Dr. Karl Sporer things so. His article, Why We Need To Rethink C-Spine Immobilization is in November’s EMS World.

For such a commonly performed procedure, there has been a remarkable lack of progress in recent years on alternative methods of immobilization. The vacuum splint has some promise and should be further evaluated, especially for severely injured patients.It poses significant logistical issues to work out, such as decontamination and acceptance by trauma centers.

For patients with a much lower likelihood of cervical spinal cord injury, such as victims of blunt assaults and falls from standing or alcohol-intoxicated patients with minor scalp or facial injuries, we can consider other, much less restrictive methods of immobilization. These could range from using the hard collar without a board to using a soft roll with tape. We should be asking the inventive among us or our more creative prehospital supply companies to develop new and novel methods to accomplish less-restrictive immobilization. Alameda County is embarking on such a protocol. Those with severe trauma will be immobilized with a hard collar and backboard or a vacuum splint. Those with less-severe trauma will have spinal restriction with a hard collar alone or some other combination of soft restrictive devices.

I like the vacuum splint better than hard boards, but patients still must lay flat. This does not help the ICP and airway issues for head injuries.

Dr. Ross would also like to embark on a study on the utility of the backboard.

Now we come to the challenge part, especially to those who argue we shouldn’t immobilize anyone. While I can’t buy this assertion in its entirety, I do think it’s fair to entertain whether the spine board has any real utility. As a result, I wonder how many readers would be willing to have their systems participate in a study looking at forgoing the spine board.

Now we’re getting somewhere.  Long-board immobilization may have sounded like a good idea 40years ago, but  it has never been validated.   Maybe a KED is better, maybe a vacuum splint, or  maybe nothing.  Despite the lack of evidence supporting any spinal immobilization, tradition is unlikely to change without evidence that something else, or nothing, is better.

Better spinal care starts with learning more about spinal injuries in initial education, and figuring out which patients do not have one.  Then we need to figure out the best way to manage patients who might have a spinal injury.  To do this we partner with hospitals, share data and do research, and base our practice on evidence.

Whatever the answer, the initial management of spinal injuries is an EMS problem that EMS people must figure out the best solution for.  No one will do this for us.


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