Tag Archives: Spine immobilization

General

Best Of: Spine Immobilization in Penetrating Trauma: More Harm Than Good?

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The EMS standard of care for blunt trauma patients has been to fully immobilize the spine before transporting to an emergency department. This is such a common practice that it is frequently applied to victims of penetrating trauma prior to transport.

A recent study in the Journal of Trauma calls this practice in question, and suggests that it may increase mortality! The authors reviewed data in the National Trauma Data Bank, looking at information on penetrating trauma patients. They found that approximately 4% of these patients underwent spine immobilization.

Review of mortality statistics found that the mortality in non-immobilized (7%) doubled to 14% in the immobilized group!

The authors also found that medics would have to fail to immobilize over 1000 patients to harm one who really needed it, but to fully immobilize 66 patients who didn’t need it to contribute to 1 death.

Although this type of study can’t definitely show why immobilization in these patients is bad, it can be teased out by looking at related research. Even the relatively short delays caused by applying collars and back boards can lead to enough of a delay to definitive care in penetrating trauma patients that it could be deadly. The assumption in all of these patients is that they are bleeding to death until proven otherwise.

A number of studies have suggested that a “limited scene intervention” to prehospital care is best. The assumption is that the most effective treatment can only be delivered at a trauma center, so rapid transport with attention to airway, breathing and circulation is the best practice.

While interesting, some real-life common sense should be applied by all medics who treat these types of patients. The reality is that it is nearly impossible to destabilize the spine with a knife, so all stab victims can be transported without a thought to spine immobilization. Gunshots can damage the spine and spinal cord, so if there is any doubt that the bullet passed nearby, at least simple precautions should be taken to minimize spine movement.

Reference: Spine Immobilization in Penetrating Trauma: More Harm Than Good? Haut et al, Johns Hopkins. J Trauma 68(1): 115-121, 2010.

General

Nursing Policy: Cervical Spine Immobilization

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The following is a sample nursing policy for c-spine immobilization.

Purpose: 

To outline the procedure for applying immobilizing the upper spine, including application of a cervical collar and “boarding” the patient. 

Policy: 

Application of a cervical collar and placing the patient on a backboard may be indicated for trauma patients with mechanisms of injury that place the patient at risk for spinal injury. This will not be necessary for patients with all of the following:

  • no posterior midline cervical tenderness
  • no evidence of intoxication
  • normal level of alertness (GCS 15)
  • no focal neurological deficit
  • no painful distracting injuries
  1. The MD or RN will maintain manual stabilization of the cervical spine until cervical collar is applied and patient is placed on backboard.
    * talk to the patient and tell them what you are doing- and not to move their head and neck
  2. Place hands on both sides of patient’s head with thumbs along mandible and fingers holding back of head. 
  3. Assistants will help with the rest of the application of the cervical collar and backboard. 
  4. Perform a baseline CMS assessment of the extremities. 
  5. Remove jewelry from the neck and ears. 
  6. Choose an appropriately sized collar by measuring the distance (with fingers) between the top of the shoulder where the collar will rest and the chin. This same number of fingers will fit between the fastener on the collar and the bottom edge of the rigid plastic of the collar. 
  7. Cervical collar is assembled by snapping the fastener into the hole on the side of the collar 
  8. Adjustable rigid cervical collars are measured from the bottom edge of the rigid plastic to the red circle denoting the size of the collar (red circle will move up or down as size of the collar is adjusted) 
  9. Slide the back of the collar behind the right side of the neck until the Velcro tab is visible on the left side of the neck. 
  10. Slide the chin portion up the chest until the chin fits in the collar. 
  11. Secure the Velcro when the collar is on straight (nose, circle on chin portion of collar, and umbilicus are in alignment). 
  12. Place the patient on a slide board with all team members working in a smooth fashion which moves the patient’s spine as little as possible. Patients already in bed will be log rolled and slider board inserted.
    * Do not obtain a rectal temperature while the patient is turned unless the MD specifically requests this.
  13. Recheck CMS. 
  14. The MD or RN can now remove hands from head. 
  15. Document both CMS checks and procedure in patient’s record.
General

How Long Do Trauma Patients Need To Be On A Backboard?

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EMS is very good about immobilizing the spine in trauma patients prior to transporting them to the Emergency Department. Healthcare personnel in the ED are not as good about getting people off of those rigid boards.

As always, it boils down to a risk and benefit assessment. What is the risk of keeping someone on a board, especially if they may have a spine injury? There is a well-known downside to spine immobilization: skin breakdown, which can occur in as little as 2 hours. Less appreciated is the fact that it is very uncomfortable lying on one’s back on any type of board, be it a spine board or even a simple plastic slider board.

What is the risk to the spine if it is indeed injured? In a cooperative patient, essentially zero. Think about it this way: what are spine-injured patients placed on once they are admitted to the hospital? A regular bed with a standard hospital mattress! They are kept on logroll precautions until they have an operative procedure or receive a brace.

The bottom line: All patients should be moved off the EMS spine board onto the ED cart unless they are being transferred to another hospital within an hour or less. The ED cart should have a regular mattress, but the patient must be cooperative. If they cannot or will not cooperate, and the probability of spine injury is high, they may need to be chemically restrained. A plastic slider board may be placed under the patient when they are ready to go to diagnostic studies, and should be removed immediately when they are complete. No board of any kind should ever be left under a patient for more than 2 hours.