We all knew or suspected there was something not right with the way we immobilise virtually all prehospital trauma patients for fear of causing spinal injury. Still, for some dogma to finally change it has to be endorsed by the academics and the faculties. This is why I am exited about the consensus statement on prehospital spinal precautions from the UK’s Faculty of Pre-Hospital Care. Instead of almost global spine and neck immobilisation of all trauma patients, someone finally tells us to use common sense. We can now start doing something about the overused, misunderstood and sometimes crazy practice that is spinal immobilisation. At least it is a step in the right direction.
Spinal injury is uncommon. The incidence in blunt trauma patients is between 0,5-3%. Fractures associated with spinal cord injury are mostly located in the cervical spine (50%) followed by thoracic spine (40%) and lumbar spine (10%). Of the C-spine fractures 50% occur in the C6/C7 junction and a third at the C2 level. Immobilisation for spinal protection is central in most trauma management guidelines.
Unfortunately, the evidence for it is virtually non-existent and the practice is mostly based on expert consensus and tradition. The little evidence supporting immobilisation of trauma patients that actually exists have been questioned in reviews as well as by clinicians.
They point out that the existing evidence is weak, that immobilisation is overused and that the procedure might be harmful. Fully immobilising a patient uses up a lot of scene-time that critically ill trauma patients really can’t afford. It raises ICP. It increases the risk of aspiration, decreases the patient’s ability to protect his own airway and generally makes airway management harder. Several authors have also pointed out that the alert and cooperative patient will develop a muscle spasm that is likely to be far better at protecting the spine than any the devices and gadgets we tend to apply on our patients.
The UK Faculty of Prehospital Care at the Royal College of Surgeons of Edinburgh held a number of meetings in 2012 with the aim of formulating consensus statements on patient handling, pelvic injuries and spinal injuries. In the paper on prehospital spinal injuries the authors make 7 recommendations.
The most important one, in my view, is…
In the conscious patient with no overt alcohol or drugs on board and with no major distracting injuries, the patient, unless physically trapped should be invited to self-extricate and lie on the trolley cot. Likewise, for the patient who has self-extricated, they can be walked to the vehicle and then laid supine, examined and then if necessary immobilised.
Now, this is progress. I don´t know how many times I have arrived on scenes where perfectly well patients, who might or might not have neck or back pain, have been immobilised using a KED-vest and a c-spine collar while still in their cars. Eventually the patient is slid out on a spineboard all the while some poor EMT is trying to perform manual stabilisation of the patient´s neck. It is a spectacle to behold, it takes forever and these patients are very uncomfortable and often absolutely terrified. Instead, just ask the patient to kindly step out of the car and lie down on the stretcher.
There may be potential to vary the immobilisation algorithm based on the patient’s level of consciousness.
Here the expert panel suggest that future guidelines should take into account the patient’s level of consciousness. An awake patient can probably protect his spine and back better than any of our gadgets can, but only if that patient is fully awake or until that patient is anaesthetised. As soon as the patient has sedation or anaesthesia he should be immobilised.
The long spinal board is an extrication device solely. Manual in-line stabilisation is a suitable alternative to a cervical collar.
The spinal board is an extrication device only and not a stretcher. A patient can well be extricated using spine board but shouldn’t be transported on it as it will result in detrimental and excessive logrolling as well as tissue pressure injury. Instead, the patient should be transported on a scoop stretcher which minimises log-rolling. The authors also recognise that manual stabilisation of the neck can be a superior alternative to the c-spine collar. Specifically in patients with a compromised airway, who have raised ICP or those who are combative or children.
‘Standing take-down’ practice should be avoided.
A standing take-down is when a standing or walking patient with neck-pain is placed against a spineboard and then the spineboard-patient complex is gently placed horizontally. For the reason outlined above this practice most of the time doesn’t make medical sense. Just politely ask the patient to lie down.
Penetrating trauma with no neurological signs does not require immobilisation.
We knew that. Studies have demonstrated how prehospital spine immobilisation is associated with higher mortality in patients with penetrating trauma.
An immobilisation algorithm may be adopted although the content of this remains undefined.
The consensus group doesn’t suggest an algorithm but say future algorithms could be based on selective immobilisation. This means various patients, based on their symptoms and injuries, would receive varying degrees of immobilisation. Instead of global immobilising of most trauma patients, immobilisation would be tailored according to what criteria the patient meets. Those criteria could be similar to the Nexus rules or the Canadian C-Spine Rules that have near 100% sensitivity for spinal cord injury.
Further research into effective, practical and safe immobilisation practice, and dissemination of this, is required.
Well, they had to write that.
The paper lives here:
Emerg Med J. 2013 Dec;30(12):1067-9. doi: 10.1136/emermed-2013-203207. Pre-hospital spinal immobilisation: an initial consensus statement. Connor D, Greaves I, Porter K, Bloch M; consensus group, Faculty of Pre-Hospital Care.