 File photo An unidentified patient is strapped into a spinal stabilization apparatus. |
Have you ever had a medical nightmare? Not the ones we experience during our working day from time to time, but a dream where you are the patient? Generally, I don’t remember my dreams — although they supposedly occur nightly whether you ‘view’ them or not, just like the late show on television. However, I do recall a recent one. It involved my car leaving a perfectly good road when I failed to negotiate a curve. It rolled over repeatedly with me bouncing around inside. At some point, I was ejected from the vehicle, executed a perfect full forward dismount, and landed supine on the ground as the vehicle made one final bounce and rested a short distance away.
I remember thinking, “Am I dead? Time for a body check: air goes in and out, toes wiggle, fingers curl, eyelids blink and my back hurts from the impact. Good. I am alive.”
In slow motion, I experienced the EMTs arriving and providing the appropriate assessment and initial treatment, including manual spinal stabilization, despite my verbal protests.
“Great, now I get to spend time welded to a backboard and my butt is already going numb,” I thought.
But dreams aside, spinal stabilization or spinal immobilization is one of the most commonly performed EMT skills. (Note: stabilization more accurately reflects what we can accomplish in the field) It all started in the late 60’s and early 70’s when we decided that dragging someone out of a vehicle and putting them in the back of a hearse while unattended during transport was not optimum care. It just made sense to prevent excessive spinal movement in a patient who might have a spinal fracture. And it still does.
But what is the scientific evidence to support field stabilization of the spine? To be honest, there is none — none then, none now. Back then, there was no structure in place to perform prehospital research. And now, it would be difficult to get approval for a study that withholds field spinal stabilization.
So what do we currently know about this frequently practiced skill?
- Correctly performed spinal stabilization can effectively limit — but not eliminate — spine movement.
- Very few patients undergoing prehospital spinal stabilization have a spinal fracture.
- Potential adverse effects of spinal stabilization include: pain, pressure ulcers, respiratory compromise, and aspiration.
- There is little scientific proof that field spinal stabilization saves lives or limits disability.
One chart review (retrospective) study looked at outcomes in spinal fractures secondary to blunt trauma by comparing a system utilizing prehospital spine stabilization (University of New Mexico, USA: 334 patients) with a system that did not (University of Malaya, Malaysia:120 patients). Even with the limitations of the study (retrospective not prospective; omission of patients who died at scene or in transport; unmatched injury severity), the results deserve attention: neurological outcomes were worse in the patients receiving prehospital spine stabilization.
Although this is not enough evidence to “cease and desist” the practice of limiting excessive spinal movement in the field, it does add to the available knowledge directing us to improve the odds that the patient we put on a backboard is likely to benefit from stabilization. And anytime we stabilize the spine, we should minimize backboard complications.
There is a reason that ABC comes before D, even when we try to do them all at once. The provision of adequate ventilation, oxygenation and circulation is of primary concern in any patient, with or without a fractured spine. Injured body parts will suffer additional harm from insufficient delivery of oxygen and nutrients and incomplete removal of wastes such as carbon dioxide. Inadequate resuscitation can cause further damage. While taking appropriate spine stabilization, we must obtain and maintain adequate ABCs.
Appropriate spine stabilization is a two-part process: utilizing the proper technique and selecting the patient most likely to benefit from the treatment. This means foregoing spine stabilization in the patient at low risk for spinal injury. The National Association of EMS Physician’s position paper on Indications for Prehospital Spinal Immobilization was published in 1999. The paper states that prehospital spine stabilization is indicated in the patient who sustains a mechanism of injury with the potential for causing spinal injury and one or more of the following criteria:
- Altered mental status
- Evidence of intoxication
- A distracting painful injury (e.g. long-bone extremity fracture)
- Neurologic deficit
- Spinal pain or tenderness
Thus, you may selectively omit spine stabilization in the patient without significant mechanism of injury or in the patient with significant mechanism of injury if all of the five criteria above are absent.
The term ‘selective’ stabilization or immobilization has been utilized in literature to describe this process. This is NOT clearing a patient’s spine in the field. For the patient that meets criteria for prehospital spinal stabilization, fracture ‘clearance’ occurs in the receiving emergency department.
For those patients that are selected for stabilization of the spine, you can decrease the potential for adverse effects by utilizing a padded board or a vacuum splint device to help decrease pressure. Make sure your straps are appropriately tight, but not to the extent that would interfere with breathing. Keep your suction handy and always assume your backboarded patient will vomit. Maintain adequate ABCs and reassess frequently.
Fortunately, my personal nightmare improved with time. The EMTs determined I had absorbed enough energy to suspect possible spine injury. Although I was sober, alert, cooperative, and had no distracting painful injury or neurologic abnormalities — I did have back pain and tenderness on exam. They ‘selectively’ placed me on a padded backboard, packaged appropriately and carefully transported me to the hospital. It was not a dream I care to have on a recurring basis, but for a nightmare, it could have been worse.
References
The Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Pre-Hospital Cervical Spine Immobilization Following Trauma. September 20, 2001
Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization; its effect on neurologic Injury. Academic Emergency Medicine, 1998;5:214-219
Domeier RM. Indications for Prehospital spinal immobilization. National Association of EMS Physicians Standards and Clinical Practice Committee. Prehospital Emergency Care, 1999;3:251-253
Hankins DG, Rivera-Rivera EJ, Ornato JP, Swor RA, Blackwell T, Domeier RM. Spinal Immobilization in the Field: Clinical Clearance Criteria and Imiplementation. Prehospital Emergency Care, 2001;5:88-93
Domeier RM, Swor RA, Evans RW, Hancock JB, Fales W, Krohmer J, Frederiksen SM, Rivera-Rivera EJ, Schork MA. Multicenter Prospective Validation of Prehospital Clinical Spinal Clearance Criteria. Journal of Trauma, 2002;53:744-750
