Elderly Fall - Board/Collar

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Simusid

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I'm a new EMT-B and I've only been on a small number of calls. So far they have all been medical. Last night we had a call for an 88 YOF that fell and hit her head at a restaurant.

We got on scene to find her seated in a chair in the small foyer entrance. Her daughter said that she did not trip but had fallen backwards, fell behind the inner door and hit her head. They had picked her up and seated her in the chair and we found her in that position. Pt was notably frail and probably weighed under 100 lbs. She was alert, moving her head and had no complaint of neck pain. She did have a complaint of hand pain and there was a minor abrasion on one hand. She remembered the fall and did not black out.

My medic decided to board and collar her. We had her stand up and we did a standing takedown. It was obvious pretty quickly that she had a pre-existing spinal issue and laying her flat caused her quite a bit of pain initially. Luckily, this subsided in about 5 minutes and the rest of the call was routine.

Given the Pt age, frailty, potential MOI (stated she hit her head), and need for transport (family wanted her checked) I can see the need for caution. I can see that we set the bar pretty low on board/collar usage. My question is, would you have done the same? For an elderly patient who has fallen from a standing position what is your criteria for not boarding for transport?

As an alternative, I'm now thinking we could have used a KED because of her pain laying flat on the board.
 
Duh... I just remembered that while the KED might work, the pt would still end up on the backboard so my idea to use it to alleviate pain from lying flat was wrong.

Ten points from Gryffindor!
 
Absolutely. I've had one instance where a patient fell backward, while suffering from Vertigo. The patient had a C3 fracture. But the patient was walking, talking, breathing. No terrible complaints, except head pain. My partner(s) decided that since the patient was walking, there was no need for spinal precautions. Hold up! No. Don't think so. We did a similar maneuver, except I laid a folded blanket under her upper back and bottom and we padded the voids.

I'd be more concerned of a spinal injury for the backward fall victim, than a forward fall on a level surface. Lots of bad things can happen from a blow to the high spine, back of the head. That's an area where you don't want to exacerbate an injury. You can always put a blanket on the backboard when immobilizing the patient. They make several devices for comfort in patients who may be on the board longer; or who have pressure point issues. Mats, pads, inflatable devices, I believe one is called the back raft. Expensive, yes, but if you carefully selected who to use them for, I'm sure it would pay off.
 
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You may also consider looking into con-ed courses that specifically focus on treating the Elderly trauma patient. I've attended one, I believe it was called Geriatric Education for EMS.

Yup.

http://www.gemssite.com/
 
No.

- She has no neck pain and no distracting injury
- She remembers the fall and does not have a neuro deficit
- There is no evidence of back or neck trauma
- Awake, alert and co-operative with no intox

I would check her motor reflexes, palpate the neck and back (incl midline) looking for pain, ask about any spinal history.

We do not even carry long boards anymore as our policy is very liberal and recognizes the lack of evidence supporting thier use; although I do conceed absence of evidences does not mean evidence of absence.
 
Just a matter of interest. As the pt didn't pass out and remembers the fall.
Did she say why she thought she fell?
I assume there was nothing on the floor that made her slip backwards?
A spilt drink for instance...being a restaurant.
Did she feel dizzy or lightheaded before she fell?
Did anyone take a Blood Glucose Reading?
I have to agree with Mr Brown, here in NZ we do not follow the strong C-spine protocols you have there. Given the list he stated.
As someone else did say on this thread.
That's not to say that this incident should not have been handled in this regard, C-spine can be a factor.
Also with an elderly pt falling.... you have fractures of hips and (NOF) neck of femurs to think about.
Doesn't sound like it with your pt...but there can always be a curve ball thrown into the mix at times.

Cheers Enjoynz
 
MrBrown said:
No.

- She has no neck pain and no distracting injury
- She remembers the fall and does not have a neuro deficit
- There is no evidence of back or neck trauma
- Awake, alert and co-operative with no intox

I would check her motor reflexes, palpate the neck and back (incl midline) looking for pain, ask about any spinal history.

We do not even carry long boards anymore as our policy is very liberal and recognizes the lack of evidence supporting thier use; although I do conceed absence of evidences does not mean evidence of absence.
Click to expand...
Given a chance, that's about how I'd clear c-spine... and I'm looking for a mechanism that supports a potential spinal injury. If I see a positive mechanism, I'll dig much deeper into the situation.

Also, with the elderly, if their back has a very characteristic curvature... I'm going to want to use a vac mat or lots of padding to help limit both movement and pain...
enjoynz said:
Just a matter of interest. As the pt didn't pass out and remembers the fall.
Did she say why she thought she fell?
I assume there was nothing on the floor that made her slip backwards?
A spilt drink for instance...being a restaurant.
Did she feel dizzy or lightheaded before she fell?
Did anyone take a Blood Glucose Reading?
I have to agree with Mr Brown, here in NZ we do not follow the strong C-spine protocols you have there. Given the list he stated.
As someone else did say on this thread.
That's not to say that this incident should not have been handled in this regard, C-spine can be a factor.
Also with an elderly pt falling.... you have fractures of hips and (NOF) neck of femurs to think about.
Doesn't sound like it with your pt...but there can always be a curve ball thrown into the mix at times.

Cheers Enjoynz
Click to expand...
With the elderly and falls, I also wonder about hip/femoral neck fractures, especially with elderly patients with obvious osteoporosis type problems.
 
I would. If there is ANY chance of spinal injury, I believe it's better to immobilize. Would you rather immobilize someone who didn't have a spinal injury or NOT immobilize someone who did?
 
We do not even carry long boards anymore as our policy is very liberal and recognizes the lack of evidence supporting their use.
Click to expand...



:blink:

Must be a NZ thing, b/c I read all the EMS magazines and journals; and I've never been told that we don't need spine boards. I've been taught by the pioneers of EMS, and they are still firm on the belief that if one has a spinal fracture, you keep the head, arms, legs, and trunk firmly immobilized.
 
dewd09 said:
:blink:

Must be a NZ thing, b/c I read all the EMS magazines and journals; and I've never been told that we don't need spine boards. I've been taught by the pioneers of EMS, and they are still firm on the belief that if one has a spinal fracture, you keep the head, arms, legs, and trunk firmly immobilized.
Click to expand...

I wouldn't trust EMS journals and trade magazines as far as I can throw them. They aren't exactly the same calibre of publication as NEJM, the Lancet, JPHEC, JTrauma etc as not designed for the publication of EMS related research i.e. not a peer-reviewed scientific journal and lets face it; most in EMS have never taken a course in research methods or statistics.

As for the application of a long spine board I am mixed on it's application but I am generally in favour of not going overboard (blocks, collar, board and tape) based simply upon the emperical notion of "we need to prevent getting sued" or "this helps" (does it?).

So much in prehospital medicine has been debunked over the several decades from MAST pants to the golden hour; we give a lot less fluid for trauma than the days gone by; intra-cardiac adrenaline has been removed etc etc

Interestingly this studyhttp://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum found less movement on the scoop stretcher than on a long back board
 
medichopeful said:
I would. If there is ANY chance of spinal injury, I believe it's better to immobilize. Would you rather immobilize someone who didn't have a spinal injury or NOT immobilize someone who did?
Click to expand...

I don't think its as simple as that. An airway, for example, becomes more difficult to manage with a collar on. Have you ever worn those bloody things in a prac or whatever? Try it out, its very illuminating. Its bloody uncomfortable. I spent 25 mins in one getting extricated from a car in the "Outdoor Simulation Centre" (Read: smashed up old bomb out the back of uni). I very nearly vomited towards the end just from the discomfort and disorientation of wearing the thing and I was imagining if I was in pain and scared s***less how much more likely I'd be to chuck. I'd certainly feel like idiot if my otherwise healthy pt suffered an iatrogenic aspiration because of the vague notion they might have a spinal injury. There are other issues too, of course, which I'm sure you're already aware of and everyone else is probably much better equipped to talk about. I just thought I'd mention that one, and to (if you haven't already) try getting realistically immobilised for a lengthy period. It makes the dangers of spinal immob much clearer.

Something one of my lecturers mentioned (and I can certainly see how this would be true since trying it out) said that in a lot of circumstances esp if the pt is a little upset and/or non compliant, that he prefers to simply ask them to lay still and provides them with some supports to help them help themselves because they get very upset when collarded and boarded and tend to end up moving more. The thing that shocked me most when I got boarded was how much it really doesn't actually stop you from moving. And you are constantly uncomfortable and trying to squirm into a more comfy position. I reckon I'd be better off just lying still. I might add though that this is applied within reason. This is for the pt-who-maybe-should-maybe-shouldn't-technically-fits-the-criteria-but-not-really-sure-if-he-should type situation, not for bonefied spinal injuries.

MrBrown said:
I wouldn't trust EMS journals and trade magazines as far as I can throw them. They aren't exactly the same calibre of publication as NEJM, the Lancet, JPHEC, JTrauma etc as not designed for the publication of EMS related research i.e. not a peer-reviewed scientific journal and lets face it; most in EMS have never taken a course in research methods or statistics.

As for the application of a long spine board I am mixed on it's application but I am generally in favour of not going overboard (blocks, collar, board and tape) based simply upon the emperical notion of "we need to prevent getting sued" or "this helps" (does it?).

So much in prehospital medicine has been debunked over the several decades from MAST pants to the golden hour; we give a lot less fluid for trauma than the days gone by; intra-cardiac adrenaline has been removed etc etc

Interestingly this studyhttp://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum found less movement on the scoop stretcher than on a long back board
Click to expand...

+69395. I wouldn't bother with those trade magazines. They have pretty pics for looking at on the bus, buts that's about the extent of it. The only purpose I think they serve is to get expert opinions to put particular research in context. Like Bledsoe's columns in JEMS (and JEMS is a cut above some of those magazines I reckon) when he actually references articles and discusses them a little.
 
Outstanding Mr. Brown, I wondered if the selective spinal immobilization criteria was going to make a presence in this thread. In the US we are slowly moving in that direction, as well. However, other selective spinal immobilization criteria specifically does not allow someone of that age to not be immobilized (Canadian). Dewd09, there is continuing research in to this field within the US, and the accumulated data is not showing a need for the abundant use of spinal immobilization that we use in the states. Also, if you do review the data, in the context of the stated call, you might see that the backboard may be contraindicated.
 
Melclin said:
I don't think its as simple as that. An airway, for example, becomes more difficult to manage with a collar on. Have you ever worn those bloody things in a prac or whatever? Try it out, its very illuminating. Its bloody uncomfortable. I spent 25 mins in one getting extricated from a car in the "Outdoor Simulation Centre" (Read: smashed up old bomb out the back of uni). I very nearly vomited towards the end just from the discomfort and disorientation of wearing the thing and I was imagining if I was in pain and scared s***less how much more likely I'd be to chuck. I'd certainly feel like idiot if my otherwise healthy pt suffered an iatrogenic aspiration because of the vague notion they might have a spinal injury. There are other issues too, of course, which I'm sure you're already aware of and everyone else is probably much better equipped to talk about. I just thought I'd mention that one, and to (if you haven't already) try getting realistically immobilised for a lengthy period. It makes the dangers of spinal immob much clearer.
Click to expand...

A well thought out post, my friend. Airway does take priority over basically everything else, including spinal precautions. If one doesn't have an airway, they will fairly quickly not have a heart beat, and subsequently be in a VERY bad situation. If there was a patient who could not wear a c-spine collar who could possibly have a spinal injury, I probably wouldn't make them wear it. I would probably just strap them down, immobilize the head the best i could, and go from there. But that is an absolute worse case scenario, and only if it dangerously affects their airway. If they are just uncomfortable with it, but can still breathe fine and it is not causing them to vomit, guess what they will be wearing. As far as I know, we don't have enough training to selectively decide whether or not somebody needs spinal precautions. So basically what I am trying to say is, it's better for the patient to be a bit uncomfortable than potentially paralyzed, unless that discomfort directly puts their airway in danger.

I'll bring this up in class next time I see the teacher to see what his thoughts are on it.
 
Well, the correct name for the Scoop, is the Orthopedic Stretcher. Backboard with bigger holes.
 
MrBrown said:
No.

- She has no neck pain and no distracting injury
- She remembers the fall and does not have a neuro deficit
- There is no evidence of back or neck trauma
- Awake, alert and co-operative with no intox

I would check her motor reflexes, palpate the neck and back (incl midline) looking for pain, ask about any spinal history.

We do not even carry long boards anymore as our policy is very liberal and recognizes the lack of evidence supporting thier use; although I do conceed absence of evidences does not mean evidence of absence.
Click to expand...

We've cleared c-spine in the field for a number of years. Makes little sense to BB some patients, especially the frail oldsters. It just isn't beneficial and even harmful to BB some folks. A good assessment and CYA collar would have sufficed nicely for the patient in question.
 
dewd09 said:
:blink:

Must be a NZ thing, b/c I read all the EMS magazines and journals; and I've never been told that we don't need spine boards. I've been taught by the pioneers of EMS, and they are still firm on the belief that if one has a spinal fracture, you keep the head, arms, legs, and trunk firmly immobilized.
Click to expand...

I've been taught by the pioneers of EMS too. That's why I use rotating tourniquets in pulmonary edema, slap the MAST suit on anything that looks like it might have seen some trauma in the last week, pour 3 times the suspected blood volume lost of crystalloids into penetrating trauma patients, nasally intubate head injured patients... :rolleyes:

No but seriously, selective C-Spine clearance protocols are well established from good research and have been shown to be effectively applied by EMS staff.

The NLC has been shown to be effective in patients regardless of age. CCR has already been mentioned.

Try reading the actual journals where research is published, rather than the trade mags. Even the revered publication of JEMs needs to be read with much suspicion. The recent Bledsoe article concerning the future (or lack of) intubation in EMS for example should ring very big alarm bells as to it's impartiality.
 
Thanks for all the great info in this thread. It has been useful and interesting for me as a brand new EMT-B.

I'm going to see if we can investigate some patient comfort products for use with the longboard. I know we'd have to consider BSI as well as whether or not it is in our protocols (Massachusetts).
 
medichopeful said:
I would. If there is ANY chance of spinal injury, I believe it's better to immobilize. Would you rather immobilize someone who didn't have a spinal injury or NOT immobilize someone who did?
Click to expand...


I'd rather not immobilize someone who doesn't have it indicated and immobilize people who have it indicated in. The days of just plowing along and immobilizing everyone that might have a trauma injury is over.

Oh, and quick question for the people who want to board every trauma patient. Did you board and collar yourself last time you tripped? Yea... thought so.
 
Simusid said:
Given the Pt age, frailty, potential MOI (stated she hit her head), and need for transport (family wanted her checked) I can see the need for caution. I can see that we set the bar pretty low on board/collar usage. My question is, would you have done the same? For an elderly patient who has fallen from a standing position what is your criteria for not boarding for transport?
Click to expand...

Did anyone ask what the patient wanted or check to see if there was any reason why the patient was incompetent?
 
Remember... mechanism of injury is a VERY poor predictor of actual presence of injury. Trauma isn't, however, all that random. If you know what the MOI is and you have a good grasp of biomechanics, it can very much tell you where to look to find injury. For instance, if you stub your left big toe, I'm not going to check your right pinkie finger for a fracture. I'm going to check your left big toe, 1st metatarsal and associated structures... and that's it.

Oh, and if the nice little old lady is mentally competent to refuse and she wants to refuse... Even if the family wants her checked out... she doesn't get transported except by her consent.
 
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