By David Neubert, MD
What happened: Called to the scene of a shooting, you encounter a patient that has been shot in the back and the arm. He has two gunshot wounds midline along his thoracic spine, and is face down in the street. He states that he is having trouble breathing and that he cannot move his legs.
On your exam he has no sensation or movement below the level of the injury. His breathing appears labored. The initial set of vital signs are HR 138, RR 26 shallow, SpO2 90 percent, BP 90/60.
Discussion Questions: Discuss these important questions about the patient’s signs and symptoms with your partner, company or squad.
- Should every patient with penetrating trauma be backboarded and have spinal immobilization?
- Does spinal immobilization have any proven benefit to patients?
- What are the current recommendations for patients with neurological deficits regarding spinal immobilization?
- Can EMS providers safely employ selective immobilization techniques?
Discussion on spinal immobilization:
There are no current articles that show a clinical benefit to immobilization of blunt trauma patients. The best study to data on this topic comes from Academic Emergency Medicine and compared the EMS system in New Mexico to a trauma center in Malaysia, where no EMS system existed, but otherwise all other variables — population, hospital volume, hospital resources, injury severity score of the patients — were the same [1]. This 5-year retrospective study of the two populations showed no clinical outcome benefit in immobilizing patients. The patients transported by personal vehicle or police car in Malaysia had similar clinical outcomes to those boarded and collared by EMS providers in New Mexico.
How about penetrating trauma victims? There is clear evidence of harm to patients immobilized that are the victims of penetrating trauma. A study from the Journal of Trauma reviewed more than 40,000 patient encounters and found that immobilized patients had an odds ratio of death of 2.06 over those not immobilized [2]. “The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.”
Spinal cord damage from transection of the spinal cord due to penetrating trauma is essentially irreversible. These patients often have internal injuries and airway or breathing compromise that is worsened by the delay in time and positioning caused by spinal immobilization.
Do cervical collars help to immobilize those with unstable fractures? Researchers, in an article published in the Journal of Emergency Medicine, studied cadavers with simulated unstable c-spine fractures, and the collar was not sufficient to stabilize the fracture [3].
An article in the Annals of Emergency Medicine in the 1980s reached a similar conclusion in cadaver studies, showing that any airway maneuver moves the spine, regardless of collar placement [4].
A Prehospital Emergency Care article shared findings that backboards increased pain, imaging and length of hospital stay in children, but did not affect final outcomes [5].
How about transport by police vehicle in lieu of EMS, a practice that is common in Philadelphia. A few researchers have studied this and have found that there is not a significant adverse effect to patients and that it may be beneficial to a majority of the patients [6]. This is a unique situation when trauma centers are often close-by and reflects many studies that show the faster the transport to definitive trauma care, the better the outcome for the patient. The caveat has to be added however that severe bleeding must be controlled quickly so police need to be trained in tourniquet placement and hemorrhage control.
So what is the final verdict on backboards, collars, immobilization and EMS?
It is clear that for patients with penetrating trauma do not backboard. Provide spinal motion restriction and consider placement of a collar as appropriate. Provide basic lifesaving interventions — bleeding control, airway management, chest seals, needle decompression, maintaining normothermia and rapid transport.
As for a patient with blunt trauma, the best method of transport has not been fully determined at this point. The use of vacuum mattresses by agencies in Europe is a promising development, but these are bulkier devices than backboards. Every effort should be taken to minimize the use of a backboard when possible and most systems have transitioned to spinal motion restriction in lieu of stricter immobilization protocols.
At this point the best advice is to learn either the NEXUS criteria or the Canadian C-Spine rule. Both rules are based on robust studies and provide a safe procedure to selectively defer immobilization [7, 8]. The Canadian Rule is a bit more sensitive than the NEXUS criteria, but NEXUS is a bit more intuitive to learn, and is the most common criteria used by emergency personnel in the U.S. Both have sensitivity numbers nearing 99 percent%.
This is a suggested selective immobilization protocol for EMS providers based on the NEXUS criteria [7, 8]:
- Must be low speed mechanism of injury not likely to cause significant spinal injury
- Patient must be sober with no alcohol or drugs on board
- Patient must be alert and oriented with a GCS of 15
- Patient must have no distracting injuries
- Patient must be neurologically intact with no deficits
- Patient must have no midline neck or back tenderness to palpation
- Patient must have no midline neck or back tenderness with full range of motion in neck
Midline neck or back tenderness is only checked once all other criteria are met, and must be checked with a slow range of motion of the neck. Stop immediately if any pain occurs and immobilize.
If all of the above criteria are not met, then perform spinal motion restriction. If there is any doubt, immobilize the patient and/or contact medical control
Several authors describe pre-hospital use of these techniques [9, 10].
It is encouraged that all providers discuss these articles and findings with their medical directors. Obviously always follow local and state protocols when applicable.
About the author
David Neubert, MD is an emergency physician that is board certified in Emergency Medical Services. He is medical director of Tac-Med, LLC, which provides on-line and hands on training in dynamic threat medical response for emergency responders. He can be contacted at: DNeubert@tac-med.org
References
- Out-of-hospital Spinal Immobilization: Its Effect on Neurologic Injury
- Spine immobilization in penetrating trauma: more harm than good?
- Cervical Collars are Insufficient for Immobilizing an Unstable Cervical Spine Injury
- Experimental cervical spine injury model: Evaluation of airway management and splinting techniques
- Potential Adverse Effects of Spinal Immobilization in Children
- Injury-adjusted Mortality of Patients Transported by Police Following Penetrating Trauma
- Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma
- The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma
- Can paramedics clear the cervical spine?
- Evaluation of the safety of C-spine clearance by paramedics: design and methodology