Immobilization May Harm.... New Study

[18G]

New research I just saw posted today from John Hopkins Medicine. Interesting.


Immobilizing the spines of shooting and stabbing victims before they are taken to the hospital — standard procedure in Maryland and some other parts of the country — appears to double the risk of death compared to transporting patients to a trauma center without this time-consuming, on-scene medical intervention, according to a new study by Johns Hopkins researchers.

The findings, published in January issue of The Journal of Trauma, suggest that prehospital spine immobilization for these kinds of patients provides little benefit and may lethally delay proven treatments for what are often life-threatening injuries. Wounds from guns and knives are often far from the spine, yet patients are routinely put in a cervical collar and secured to a board, the investigators say.

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[reaper]

Didn't know it took so much time? I guess now we have xray vision and can see the path that the bullet traveled, in the body?

 

[kittaypie]

what about the unpredictable path a bullet takes when entering the body?

 

[18G]

They are saying that the likely hood of a bullet or knife wound compromising the spine is much, much less and much less likely to kill a person versus the patient exsanguating onscene while providers immobilize the spine.

 

[kittaypie]

i agree, but i think it's a judgment call. if your patient is relatively stable and has some CMS compromise i would definitely c-spine.

if the patient is deteriorating (or has a good possibility of doing so), i might skip c-spine and transport rapidly. even doing that i would take care in keeping them as aligned as possible.

 

[AnthonyM83]

Simply adopt PHTLS recommendations and skip immobilization if patient has good neuros (motor and sensory) and is unstable. This has been their stance for a little bit now...

I've seen too many people waste time on-scene immobilizing or forcing someone to lie down and be strapped supine when they say they can't breathe in that position because of penetrating trauma.

Let's not forget the USC study comparing survival rates for private vehicles versus ambulance transport for patients with similar injury severities (provided they both went to a trauma center). Private vehicle transport had higher survival rates (study took place in urban setting). Less time wasted assessing, c-spining, starting lines, loading up, and driving safely...

 

[MrBrown]

I agree its far better to get your patient to surgery than to have him all nicely tied up onto a board

 

[Jeffrey_169]

i agree, but i think it's a judgment call. if your patient is relatively stable and has some CMS compromise i would definitely c-spine.

if the patient is deteriorating (or has a good possibility of doing so), i might skip c-spine and transport rapidly. even doing that i would take care in keeping them as aligned as possible.

I agree. If the pt. is circling the drain, then its time to move, doing the best you can to ensure C-Spine. However, if there is obvious SXS of c-spine injury it needs to be ensured before moving. The respiratory drive in an important factor, and without it, obviously, all you have is an expedited dead pt.

I saw a similar study a few years ago and it was more common sense really. If a car was on fire of in a lake would you not move the patient to prevent death? Sure. The same applies with a critical pt. If they are loosing blood rapidly there is no time for the KED or major c-spine precautions. It really is a judgment call and it depends upon the needs of the patient.

So many agencies, at least in the past, are so wrapped up in protocol that we don't know how to improvise and think outside the box. Certain agencies, in my experience, seem to think EMS is all or none and this is simply not the case. Each call we run on dictates a new set of challenges and individual pt. needs and the rigid rules of X + Y = Z are outdated and need to be revised. As our scope of practice and standards of care are improved and expanded, there needs to more focus and emphasis on education and clinical decision making and problem solving.

 

[AnthonyM83]

As well as needing updated protocols. One shouldn't have to break protocols for these common events (such as a GSW patient being unstable)*

*Not that GSW's are common everywhere, but that insability in GSW patients is common.

 

[MrBrown]

I agree with what both Anthony and Jeffrey are saying. Lets think about it laterally, so many times I have seen ambos forget that they're part of a larger clinical picture and that there are times where its better to put the fancy toys away and just take the patient to the hospital.

Now certianly in my system I venture a reasonable guess that officers would probably look past c-spine (it is taught that immobilising the c-spine is inappropriate if there are major abnormalities with the primary survey) but I am curious how many out there wouldn't?

 

[AnthonyM83]

To be clear, I would probably still c-spine for unstable blunt trauma (there might be exception, of course.

Studies suggest spinal damage with penetrating trauma happens at the time of the injury (unlike blunt trauma), so long as proper care in moving the patient given. So not immobilizing shouldn't be an exception...rather just basic trauma protocols which aren't that new anymore...

 

[46Young]

The study makes sense. However, unless this is accepted as a best practice, and written into protocol, I'm sticking with a board and collar to avoid any possible litigation. If this sounds callous towards the pt, then blame the legal system.

I suppose that you could quickly apply a KED and sit the pt up in at least a semi-fowler's position to help minimize airway obstruction or other respiratory compromise. In that case, it would be easy enough to justify skipping the board in lieu of a KED and collar. If they can't breathe, they die.

 

[rhan101277]

Its in our protocol here in Central Mississippi.

 

[41 Duck]

In my experience, though there is nothing specific stating that GSWs or stabbings MUST be immobilized, it is commonly done here in PA. I think it's the whole "gunshot" thing that gets people in a tizzy.

I've had an EMT tell me that the reason the PT was boarded and collared for a couple of .380s through his calf was because he had to go to the trauma bay, and if he brought a PT to the bay without being immobilized, he'd get in trouble. The sad thing is, the kid was probably right.


Later!

--Coop

 

[sdadam]

This isn't really ground breaking.

There was a huge retrospective study of penetrating trauma during the Vietnam war, (tens of thousands of patients) which concluded that penetrating trauma (unless to the neck) posed nearly no risk of spinal injury.

It's another one of those things that we due, just cause it seems like a good idea.

I hope this study helps get rid of long spine boards.

There was a decent conversation about spinal immobilization a few months ago, I can't remember the name, I posted a few studies, as did others, about how much of a joke c-spine is. I'll look up the study I mentioned in this post and put a link in when I get a chance.

Adam