C-spine... a joke?

[HNcorpsman]

so i recently went through a class taught by a Dr. Hagmann, a retired COL in the army, he still is an emergency physician today...

anyways he was explaining the subject of C-spine, and how it has become such a big issue... he started off with a story of a paramedic. the paramedic came upon a PT who was shot in the jaw... upon arrival the pt was breathing and alert but had alot of bleeding from the jaw, he was also sitting up spitting onto the ground... so what are we trained to do when someone gets shot? C-spine... well he told the PT to lay down, once pT lays down he starts to choke and gag, eventually he stops breathing... he tries to get the PT to breath again using basic treatment, no good.. so he tries to intubate, no good, after several tries... so he does what he has to do and gives and emergency cric... he gets it. he then tries to control the bleeding, but wait the pT looks a little pale (shock) so then he gives the PT an IV and then the bleeding gets worse... because the IV the fluids raised his blood pressure (cause more bleeding) and diluted the blood... the PT eventually codes on the way to the hospital, and does not make it... all the medic had to do was control the bleeding.. the PT would have been still here today.

anyways the Dr. explained that in some years from now... they will probably
begin to "clear" c-spine in the field, and it will be the paramedics call.. this is what he explained

NO c-spine IF...
1. if no mechanism
a.falling on flat ground
b. gunshot wound
2. if no pain on range of motion
3.no tenderness,
4. no step offs
5. no numbness or tingling

C-spine if
1. axillary load (hitting top of head)
a.diving into swimming pool
b.ejecting out of plane
c.dropping hatch on head
2.traction load (pulling head)
a. hanging
b. parachuting
3. flexion/extension(whiplash)
a.car accident
b. ejected from vehicle

to clear c-spine ask these questions
1. was there a mechanism?
2.is there pain in the neck?
3.is there tenderness?
4. are there any step offs?
5. is there distal neuro? tingling?
6. is there pain in range of motion?

 

[akflightmedic]

Mate, we have already been doing this in the field for many years.

We do not not "clear" C-spine, but by asking those same questions and using the same criteria you listed we do employ "Selective Spinal Immobilization" or SSI for short.

 

[HNcorpsman]

really? when i went through EMT school they just said if the PT fell down, or got shot or something violent like that, you just had to C-spine no matter what...

 

[Smash]

C-spine clearance has been used for years mostly using the NLC or CCR. It's safe and effective and can be used with confidence irrespective of
mechanism or age.

C-spine might not be the big deal it is typically made out to be by us, but I wouldn't call it a joke either.

 

[HNcorpsman]

yeah sorry about that.. its definitely NOT a joke, but it just seems like some people over due things and think that they need to c-spine everyone, instead of just doing the basics...

 

[Ridryder911]

Although, I definitely agree c-spine immobilization is over done we need to be careful and not be on a slippery slope either on not immobilizing. Your scenario as well could had been of the patient was properly immobilized and placed onto their lateral side and proper suctioning might have prevented an event from occurring as well.

I agree, my service has had selective cervical immobilization for over 15 years now, kinda old news. But, it is a catch 22 if you should had c-spined, you had better, than not.

R/r 911

 

[MrBrown]

Some of what we do in EMS I can only figure we do because "we thought it was good in the seventies or eighties so we continue to do it". Examples:

- Spine imobilization/long spine boards
- 50% dextrose
- MAST pants
- Atropine in cardiac arrest
- Drugs down ET tubes
- Basic life support
- High concenration oxygen
- Trendelenburg position for hypovolemia or shock
- Endotracheal intubation (in trauma and traumatic brain inury)
- ... did I cover every procedure yet?

Most of the procedures and drugs listed above have very limited evidence to support them or have evidence (allbeit some of it is limited at this time) to negate it's benefit.

We do not use (or even carry) longboards; we threw them out years ago but rather use collars and the Ferno scoop stretcher.

Our spinal imobilization procedure is basically what you mentioned above; verbatim from our guidelines:

Patients who meet all of the following criteria (regardless of mechanism of injury) do not need cervical spine immobilisation:

• GCS 15, alert, cooperative and
• No neck or upper back tenderness on palpation or movement and
• Normal peripheral sensation and movement and
• No significant painful or emotional distractions.

These criteria may be used for children provided the child is old enough to understand and cooperate with taking a history and performing an examination.

If all of the above criteria are not met then the patient must have their cervical spine immobilised.

I could only find one study on PubMedhttp://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum that delt with LSB vs. scoop stretcher which concluded (allbeit the study was rather small) that the scoop stretcher caused less movement.

Another study on PubMedhttp://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum concludes that these guidelines are appropriate for use in determining which patients to immobilize and which to not. Again, this study is rather small.

To say "everybody should be immobilized" is (while seeking to benefit the patient) rather blanket and seemingly uneducated.

Perhaps it's time for further large, randomized trials?

 

[SeeNoMore]

"- Spine imobilization/long spine boards
- 50% dextrose
- MAST pants
- Atropine in cardiac arrest
- Drugs down ET tubes
- Basic life support
- High concenration oxygen
- Trendelenburg position for hypovolemia or shock
- Endotracheal intubation (in trauma and traumatic brain inury)"

Wow. That is kind of depressing. If most of what we do really of no consequence at all?

 

[spisco85]

There are lots of ways to immobilize a patient and like Rid said, proper suctioning would have prevented helped to prevent the death. In the case of a patient who has the possibility of an airway obstruction why not KED the patient and transport them sitting up?

 

[SeeNoMore]

"- Spine imobilization/long spine boards
- 50% dextrose
- MAST pants
- Atropine in cardiac arrest
- Drugs down ET tubes
- Basic life support
- High concenration oxygen
- Trendelenburg position for hypovolemia or shock
- Endotracheal intubation (in trauma and traumatic brain inury)"

I was reading this list over again. Surely some of this is exaggerated? Some type of spine immoblization in at least some cases must be beneficial?

And basic life support? How could that be of no proven use?

I would love to know more about this, I am not saying you are wrong. Im just confused.

 

[Sasha]

- MAST pants

MAST pants seem to be a good thing, in theory. I've heard the reason they were taken out of protocols is not because they didn't work, but because at the hospital they were not taken off properly, which really harmed the patient.

Services here are allowed to selectively C-Spine as well. Backboards are uncomfortable, and you should be smart about using them when appropriate instead of using blanket protocols.

 

[SeeNoMore]

I have also heard Sasha, that the primary difficulty with MAST is them being taken off improperly, which I can not figure out for the life of me. Who at the hospital is taking them off improperly? I am sure Nurses and Doctors know about the potential complications of MAST trousers?

In any event, it seems like they would be very useful in keeping the most vital areas of the body perfused and also for stablization. Though I suppose much less risky methods of stablizing like pelvic wraps exist with less potential complications.

 

[Sasha]

I have also heard Sasha, that the primary difficulty with MAST is them being taken off improperly, which I can not figure out for the life of me. Who at the hospital is taking them off improperly? I am sure Nurses and Doctors know about the potential complications of MAST trousers?

I heard instead of taking them off slowly one part at a time, they just cut them off, causing a wide range of problems such as rhabdomyolysis, drop in BP, compartment syndrome, etc.

Of course I don't know how true that is. They were not even taught in my EMT class because they are not the standard anywhere in Florida.

 

[medicdan]

Selective stabilization have indeed been around for a while-- particularily in Wilderness EMS. Several states allow their paramedics to clear, and another few allow their basics (Maine and New Hampshire come to mind).
Check out Maine's protocols:

 

[akflightmedic]

My only caution is semantics...

You are not "clearing" the cspine...that is for doctors or xrays to decide. You are merely being selective about who you cspine initially based on established parameters and a thorough assessment.

In order to clear a cspine, one must already be placed in it...I would most likely never remove cspine after one has been placed in it. (collar,LSB..)

 

[akflightmedic]

A doctor friend of mine (who happens to be med control for a very large county and several municipalities) in Florida discussed this with me at lunch the other day. He stated that he is moving closer to the near elimination of cspine precautions within his system as soon as he compiles enough documentation to support his case.

The very basic analogy he gave me was this:

When someone fractures a bone, do we straighten it or do we splint it in position of comfort?
Now say someone has received an injury and has pain in their neck or back, however prior to your arrival, they have found their position of comfort.

Why do we---as medical professionals---immediately determine we need to manipulate the person, cause more pain, possibly more injury and place them in a restrictive device to "protect" them, instead of simply splinting in the position of comfort they have already found?

 

[medicdan]

My only caution is semantics...

You are not "clearing" the cspine...that is for doctors or xrays to decide. You are merely being selective about who you cspine initially based on established parameters and a thorough assessment.

In order to clear a cspine, one must already be placed in it...I would most likely never remove cspine after one has been placed in it. (collar,LSB..)

Understood. Apologies for the misuse.

I'll also point out that I have never seen protocols that allow for selective use of specefic c-spine equipment (using a collar without a board, etc). Do they exist pre-hospital?

 

[SeeNoMore]

I was taught to splint a bone if there was time to decrease the possibility of further bleeding/tissue damage. Also if there was cyanosis/lack of distal pulses.

In any event, the point about PTs finding a position of comfort is interesting. However unresponsive pts would still I assume require movement to neutral in line positioning and standard collaring/boarding?

If you find out whether your Dr friend is indeed going to eliminate spinal precautions, or modify them, would you post and let us know? Very interesting.

 

[medicdan]

hat tip to Mr. C

Since it just came up; I'll deal with C-spine clearance later.

Prehospital C-spine stabilization:

http://www.emtlife.com/showthread.php?t=12256 Sasha finds some studies; MSDeltaFlt weighs in
http://www.emtlife.com/showthread.php?t=11148 A scenario where boarding may or may not be indicated.
http://www.emtlife.com/showthread.php?t=3386 A scenario where boarding wasn't indicated... or was it?
http://www.emtlife.com/showthread.php?t=8830 KEDs and why you should use them;
http://www.emtlife.com/showthread.php?t=5551 Tips for the KED on the practical exam and in the field.
http://www.emtlife.com/showthread.php?t=10368 Head immobilization methods
http://www.emtlife.com/showthread.php?t=2484 Securing patients: spider straps, quick clips, or webbing?
http://www.emtlife.com/showthread.php?t=6968 ED staff removing patients from the board and why it's sometimes justified.
http://www.ncbi.nlm.nih.gov/pubmed/17613902 How well are devices being applied?
I'm not going to cite all the studies, but a quick Pubmed search indicates that immobilization on long boards frequently causes pain, that the pain can take time to develop, and that padding the boards doesn't relieve the pain or prevent further symptoms very well.
http://www.ncbi.nlm.nih.gov/pubmed/15748015 A lit review: prehospital “immobilization” techniques do reduce movement, but they produce a number of well-documented adverse effects.​

 

[Shishkabob]

The very basic analogy he gave me was this:

When someone fractures a bone, do we straighten it or do we splint it in position of comfort?
Now say someone has received an injury and has pain in their neck or back, however prior to your arrival, they have found their position of comfort.

Why do we---as medical professionals---immediately determine we need to manipulate the person, cause more pain, possibly more injury and place them in a restrictive device to "protect" them, instead of simply splinting in the position of comfort they have already found?

Except your doctor friend has the same wrong thought process when it comes to Cspine tgat many in EMS do. Cspine isn't just "neutral in line". It veryuch is mainraing them in the position that does the most good.

In EMT I was taught cspine should be thought of as any other fx... You get one chance at most at setting it. If there is any amount of pain or discomfort when turning the head AT ALL, you stop and maintain the position of comfort.