Nightmare: trauma, neurovascular is good before backboard but gone after (paralyzed)

[J B]

Has this ever happened to anyone?

Basically you arrive at scene, patient is a&ox4. Stabilize c-spine, assess pulse/motor/sensory and everything seems okay. After you get them on the backboard, motor and sense are gone from extremities. Sometime between you getting there and putting them on the backboard, some damage occurred to the spinal cord and now they're paralyzed.

Also, what if the act of straightening out the c-spine from the position you found them in causes paralysis?

I'm still a student, but just thinking that this would probably be a lot worse than having a patient die on you....

 

[Handsome Robb]

Happened to me. Vent dependent quadriplegic from drunkenly riding his bicycle into a construction trench one night. Progressed from numbness tingling to full paralysis from the neck down, lost his respiratory drive soon after we got to the trauma bay.

Often the damage is already done or there's no way around it happening no matter how careful you are. There isn't a whole lot of clearance in your spinal canal and your spinal cord is fragile. Also, swelling is progressive. It's very possible the swelling caused the paralysis and it didn't have anything to do with how you handled the patient.

I understand where you're coming from about paralysis being worse than death and I partially agree however if you're paralyzed you can still see your loved ones, talk to them, receive hugs and kisses from them....that sounds better than being dead to me...

If you're asking about can we be held responsible? If you didn't follow your protocols or performed a skill negligently then you could potentially be held accountable.

 

[Medic Tim]

I was on a transfer a few years ago where we were taking A pt with a confirmed c4 c5 unstable fx ( confirmed by ct)The pt was sitting in a position of comfort with a c collar on. Pt was a/ox4 with good pms and no pain or discomfort. My partner( senior medic) refused to take him unless he was on a board in full smr. I objected and the doc did as well. The doc finally gave in so he was boarded in the Er while he was in the hospital bed. Guy was over 6 ft tall and around 260 lb. I refused to take part and another crew and some nurses had at it. It was not a pretty sight.

as soon as he was on the board he was having a lot of pain and discomfort in his neck and all down his back. By the time we reached out destination (3 hours later )he had no feeling in his legs and paresthesia from his shoulders down. He is currently in a wheelchair . Unsure what his full condition is.

I can't say for certain it would have happened if we had transported with the c collar and poc but I am pretty sure the board or the process made the injury worse.

 

[Rialaigh]

Has this ever happened to anyone?

Basically you arrive at scene, patient is a&ox4. Stabilize c-spine, assess pulse/motor/sensory and everything seems okay. After you get them on the backboard, motor and sense are gone from extremities. Sometime between you getting there and putting them on the backboard, some damage occurred to the spinal cord and now they're paralyzed.

Also, what if the act of straightening out the c-spine from the position you found them in causes paralysis?

I'm still a student, but just thinking that this would probably be a lot worse than having a patient die on you....

Like robb said often times it is the swelling that occurs post injury that can cause paralysis.

If you want some interesting reading on spinal cord injuries check out the hypothermia protocols some places are running. We had a boy in the area here (high school age) fall from a ropes course, paralysis in arms and legs. He was taken to an area level 1 trauma center, instead of surgery they placed him in a tub of ice water for I believe it was 48 hours and brought his body temp down to like 92 degrees. He walked out of that hospital neuro intact no deficits like 2 weeks later no surgeries required or anything. They saw off the scans that the damage was done but with quick swelling reduction there was the possibility of reversal. I think on acute traumatic spinal injuries we may see this happening more often, From what I have read it shows real promise.


Careful handling of these patients combined with SAFE and rapid transport to a level 1 trauma center puts them in the best hands for recovery. beyond that the only thing you can really manage is airway and hypotension.

 

[J B]

I was on a transfer a few years ago where we were taking A pt with a confirmed c4 c5 unstable fx ( confirmed by ct)The pt was sitting in a position of comfort with a c collar on. Pt was a/ox4 with good pms and no pain or discomfort. My partner( senior medic) refused to take him unless he was on a board in full smr. I objected and the doc did as well. The doc finally gave in so he was boarded in the Er while he was in the hospital bed. Guy was over 6 ft tall and around 260 lb. I refused to take part and another crew and some nurses had at it. It was not a pretty sight.

He's a+ox4 so can't he refuse certain treatments if he wants, including backboard? After being fully informed of risks of boarding vs not boarding by the doc, medic, etc, the patient has the final say in this situation, no?

 

[chaz90]

He's a+ox4 so can't he refuse certain treatments if he wants, including backboard? After being fully informed of risks of boarding vs not boarding by the doc, medic, etc, the patient has the final say in this situation, no?

A&Ox4 is not the be all end all to determination of competence. In all honesty, it's extremely inadequate and doesn't say much at all about the neurological status of the patient. That being said though, a competent patient does of course have the right to refuse treatment. Most defer to our judgment as medical professionals though and will follow what we recommend, even when we are sadly misguided about what we think is best.

 

[Aidey]

There are several case studies out there about patients who have deteriorated after intervention. I haven't seen any focusing on pre-hospital care, they all are hospital cases. There are a few involving patients with ankylosing spondylitis who either deteriorated or died after having their necks "straightened". Others were secondary to combative patients who ended up injuring themselves, or pts in who got spontaneously worse, or worsened after surgical intervention. There are a certain % (25ish I think) that will deteriorate no matter what. They aren't sure why, but they did find that there is a correlation to the pt developing a fever.

 

[Medic Tim]

He's a+ox4 so can't he refuse certain treatments if he wants, including backboard? After being fully informed of risks of boarding vs not boarding by the doc, medic, etc, the patient has the final say in this situation, no?

They absolutely do but when the doc and nurses and medic come to an agreement they usually follow it. I agree a and o x 4 is not the be all end all.

 

[Trailrider]

They absolutely do but when the doc and nurses and medic come to an agreement they usually follow it. I agree a and o x 4 is not the be all end all.

I guess it's just a matter of how you communicate the seriousness of the injury to the patient, and how they understand that there's a reason their on a back board, MOA, critical criteria met etc.




Then there is option 2. Form 10? h34r:

 

[phideux]

I was on a transfer a few years ago where we were taking A pt with a confirmed c4 c5 unstable fx ( confirmed by ct)The pt was sitting in a position of comfort with a c collar on. Pt was a/ox4 with good pms and no pain or discomfort. My partner( senior medic) refused to take him unless he was on a board in full smr. I objected and the doc did as well. The doc finally gave in so he was boarded in the Er while he was in the hospital bed. Guy was over 6 ft tall and around 260 lb. I refused to take part and another crew and some nurses had at it. It was not a pretty sight.

as soon as he was on the board he was having a lot of pain and discomfort in his neck and all down his back. By the time we reached out destination (3 hours later )he had no feeling in his legs and paresthesia from his shoulders down. He is currently in a wheelchair . Unsure what his full condition is.

I can't say for certain it would have happened if we had transported with the c collar and poc but I am pretty sure the board or the process made the injury worse.

If it was a C4-C5 fracture, confirmed by CT, with no other spinal problems further down, couldn't it have been more comfortable for the patient, and adequate support, to transport him collared and on a Short Board??? That way he can stay in a semi-sitting position instead of supine with all his weight on the hard board. Especially for a 3hr transport.

 

[VFlutter]

As Rob and others have mentioned the cause of deterioration after a SCI is progressive inflammation and resulting ischemia/infarction, at least in incomplete Injuries. If it is a complete injury then there really isn't much you can do. The exception being a step-off veterbrae which starts as an incomplete injury but turns into a complete after positiong the patient. This would be relatively rare and most likely would occur regardless of how you handle the patient. And by "step-off" I mean a visible and palpable dislocation of a vertebrae. Not a step off which is only seen on CT which in most cases is stable.

 

[Christopher]

Has this ever happened to anyone?

This falls under the realm of the Sasquatch case. Rarely written about, if ever.

Basically you arrive at scene, patient is a&ox4. Stabilize c-spine, assess pulse/motor/sensory and everything seems okay. After you get them on the backboard, motor and sense are gone from extremities. Sometime between you getting there and putting them on the backboard, some damage occurred to the spinal cord and now they're paralyzed.

It makes for good stories scaring EMT's.

Also, what if the act of straightening out the c-spine from the position you found them in causes paralysis?

Yep, this actually happens. Provided they are able to control and limit their own movements, you should not control or limit their movements.

I'm still a student, but just thinking that this would probably be a lot worse than having a patient die on you....

I'm very impressed by your question, most students start from the other side, typically, "OMG they didn't use a backboard: D. E. D. DEAD!"

As others have mentioned, and I'm going to reiterate due to its importance, most of the deterioration post injury is due to secondary inflammation. Also any time you get hypoxia or hypotension of the spinal cord you further worsen things.

Basically, you need to aggressively support airway, breathing, and circulation in true spinal injury patients to ensure they maintain a good MAP and CPP. This is far more important than the "warm and fuzzies" you get putting somebody on an non-immobilizing device such as an LSB.

So yes, most of the time this means your patient should be in Fowlers or Semi-Fowlers!