Selective Immobilization/Cervical Spine Clearance

[CFRBryan347768]

I was just wondering what everyone thought about it, do you think you should be selective, or immobilize everybody that could have sustained an injury?

(The Pod Cast Can Be Found On ITunes, Prehospital Trauma Life Support)

 

[karaya]

What were you taught?

 

[mdkemt]

What were you taught?

This is so true. Personally if I suspect I always immobilize. I am not about to risk someones health for poor judgement. Better to be safe then sorry.

MDKEMT

 

[KEVD18]

its pretty simple for me. if theres something to indicate c-spine precautions, they get em. if not, nope.

 

[Epi-do]

Here, only medics can clear c-spine, and only under certain circumstances. If a patient is impaired for any reason, is unable to communicate with EMS personel, or has any type of distracting injury, then c-spine cannot be cleared. If you are a basic, you cannot clear c-spine at all.

 

[Ops Paramedic]

Does your queston refer to suspeted c-spine injuries in specific?

Not all injuries, as per say require spinal immobolisation, for example a fracture of the forearm obtained by blunt force trauma. But should you suspect or mechanism indicates that there was trauma to the c-spine, or forces involved could have damaged the spine, then, yes we immobilise.

As for the clearing of c-spine prehospital, we generally don't do it. That is reserved for circumstances such as a shortage resources, ie at a multiple/mass casualty scene. As per Epi do, we also follow an algorythm, and this only performed by ALS. You would also try and get another ALS to do it with you, just for safety sake...

 

[mikeylikesit]

I have yet to clear a c-spine in my area...i don't want to chance it, provided my x-ray vision is faulty.

 

[medicdan]

C-spine clearance has always been a part of Wilderness guidelines (not protocols) based on the premise that the patient is A&Ox4, no impairment by legal or illegal drugs, and no distracting pain. Then the spine is palpated 2-3x looking for DCAPBTLS or pain, then a ROM test. If all is clear, c-spine is clear.

This process is in the Basic SOP in Maine and New Hampshire, and has been for a while, and I know BostonEMS allows their Basics to perform the check. I have heard from several people in different circles that there has yes to be a patient who, after this has been performed properly, has fallen through the cracks and indeed had a spinal injury. That is amazing.

 

[CFRBryan347768]

I was taught if you think they need it do it, ha

 

[Jon]

I don't clear C-spine.

but I'm a little more selective than "Oh my, you were in a MVC, so I'm going to strap you to a hard board just for kicks, even though you have no complaints."

If you are complaining of back/neck pain, you will go on a board. If you have significant MOI and no pain, you will go on a board. Beyond that... you probably WON'T go on a board.

 

[BossyCow]

Combination of MOI and PE. If I have a pt who was in a low speed MVA with no pain, no tenderness to palp of the spine, no sign of trauma to the head, no seatbelt rash, with full mobility without pain or tenderness, I'm not going to wrestle them onto a backboard so I can lift them.

If I see significant intrusion into the vehicle, or evidence of greater physical forces at work, I'm going to recommend backboard even if the pt says they are fine. Significant Mechanism of Injury without complaint of the pt gets a backboard as does significant complaint of injury without obvious MOI.

Wilderness med is a different kettle of fish entirely. We do train to clear c-spine in the field but when its a two day pack out from a wilderness area, its a lot more debilitating to the pt and to the crew to remain backboarded. Different of course if airlift is a possibliity. Again you have to look at the whole picture. We can't just rubber stamp pt care and say 'We always do this'.

 

[boingo]

We utilize a comibination of the Canadian C-spine and NEXUS criteria when deciding to c-spine immobilize.

 

[mycrofft]

Clearing C-Spine

I had occasion to look into this as my em poyer thinks they want unexperienced nurses spineboarding people to move them for no apparent net benefit.
One study showed that when EMT's and Paramedics were em powered to use an algorithm to clear or to immob prehospitally, the hospital personnel had significant amounts of disagreement with field provider...but it did not say if these disagreements later proved valid.
Another study showed that continued spine board application post-ER, even on the way to take the xrays of the neck, did not offer a significant improvement in patient outcome. (I imagine that their gurney-pushers are slow and safe too).
Personally, after thirty or so years, I've come to dislike such blanket standards such as "If they hurt over the clavicle, 'board 'em".

 

[skyemt]

more and more counties are moving towards selective immobilization. usually based on MOI plus some criteria met in the PE.

the problem with immobilizing everyone who could "possibly" have a spinal injury is that, especially for transports longer than 20 minutes, you can 'give' someone back pain that they did not even have in the first place, plus the expense of unnecessary x-rays and tests.

i know our county is changing to selective immobilization base on the "Maine" protocol, which has been highly successful in eliminating unnecessary trips to the hospital on a longboard.

 

[Airwaygoddess]

Maine C-spine protocal

Is there a Maine EMS link to look this up? I would be interested in reading it.

 

[medicdan]

Is there a Maine EMS link to look this up? I would be interested in reading it.

The best I can do comes from the 2005 protocols on the Maine EMS website. Please excuse my crude cuts-- its page 69, Green 6.
http://mainegov-images.informe.org/dps/ems/documents/2005_Protocols.pdf

 

[mycrofft]

Thanks for the direction to the Maine protocols

Heads up, the 2002 ones are still posted on the Net, I imagine the 2005 ones replace them?

I am encouraged that clinical signs and symptoms have replaced blind protocol. I'm a little chagrined when mechanism of injury is basically thrown out, then weasled back in later, but I hvae to admit that my experience supports their finding; snapped necks in minor crashes, and intact ones in horrendous ones. I guess I want it both ways.

 

[traumateam1]

Depends on what "hat" I am wearing.
As an OFA III First Aid Attendant I can rule out C-Spine.
As an Advanced Medical First Responder I cannot rule out C-Spine.
If MOI suggests a possible C-Spine problem then they usually get the hardcollar and clamshell until BCAS takes over. Of course they cannot (well EMR's or PCPIV's) rule out C-Spine, just the Docs.

Although...I have ruled out C-Spine several times while acting under OFA III ^_^

 

[Airwaygoddess]

C-spine

The best I can do comes from the 2005 protocols on the Maine EMS website. Please excuse my crude cuts-- its page 69, Green 6.
http://mainegov-images.informe.org/dps/ems/documents/2005_Protocols.pdf

Thank you Emt student!

 

[rescuepoppy]

Selective clearing of c-spine is should be based on a case by case basis considering the moi and patient complaints. Always listen to your patient I am speaking from personal experience. Early last month I was involved in a mvc in a southwestern state, this was a head on in which I was driving a flat bed truck the driver of the other car was etoh and doa. My truck rolled over off the road. I was blessed to be under the care of the resident para-god for that county,I know these are rare but just my luck. I repeatedly told him that my neck was not hurting but did not feel right, he wanted to clear me under their protocol, after refusing he relented to c-spine me. After x-rays and mri I was found to have an unstable fracture of c-4. So I am not saying not to clear c-spine in the field just be very careful when doing so. By the way I am doing great and working my way back to normal.