July 2014
Brad Weir MD, EMTP, FAAEM, FACEP
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Standard of care in EMS for past forty years
Has been regarded as an essential
component for a large majority of trauma
patients
One of the main skills that all of us learned
in EMT class
Spinal Motion Restriction (SMR): current and
biomechanically more accurate term
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Evidence-based emergency medicine/systematic review
abstract. Is routine spinal immobilization an effective
intervention for trauma patients? Ann Emerg Med.
2006;47(1):110–112.
Spine immobilization in penetrating trauma: More harm than
good? J Trauma. 2010;68(1):115–120; discussion 120–121.
Prehospital spinal immobilization does not appear to be
beneficial and may complicate care following gunshot injury
to the torso. J Trauma. 2009;67(4):774–778.
Prehospital procedures before emergency department
thoracotomy: ‘Scoop and run’ saves lives. J Trauma.
2007;63(1):113–120.
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Moves from the concept of assuming almost
every trauma patient has an unstable spine
injury, to the reality that very, very few of
them do
Avoids the dangers of immobilizationinduced injury, extended scene time, etc.
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Brian E. Bledsoe, D.O.
Paramedic, physician. Lead author of
Paramedic Emergency Care.
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Wrote an article entitled “Spinal
Immobilization, Have We Gone too Far?”
which was published in JEMS
 IN
1994!
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Paramedic level care in Australia has used
backboard immobilization only for a very few
selective cases for over twenty years, with
outcomes as good for spinal cord injury as
the American system.
 “There
have been no reported
cases of spinal cord injury
developing during appropriate
normal handling of trauma
patients who did not have
a cord injury at the
time of trauma.”
 Domeier et al.
EMS Medical Directors and Trauma Surgeons
Joint Position statement in December 2012
 Paper follows NEXUS guidelines
 This was the main impetus for the new
Region VI protocol
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Consider that full immobilization:
◦ Increases aspiration risk and atelectasis.
◦ Makes airway management more difficult.
◦ Increases intracranial pressure.
◦ Increases the incidence of pressure sores
(sometimes in less than 1 hour).
◦ Is a pain in the back (try lying on a board
yourself).
◦ Frequently fails to achieve a neutral
alignment.
◦ Is difficult to remove without lumbar
movement.
◦ Increases combativeness in drunk
patients.
◦ Is expensive.
◦ Is time consuming to apply.
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NEXUS study, Canadian C-Spine study
Almost all fractures- and all unstable
fractures- could be identified based on
clearance criteria:
◦ Midline tenderness
◦ Lack of distracting injury or intoxication
◦ Neurologic deficit.
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Several major EMS systems have begun
protocols that dramatically reduce spinal
immobilization (Albuquerque, Indianapolis,
St. Louis)
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January 2013- NAEMSP meeting:
“There is no proven benefit to rigid
spinal immobilization as practiced in
the United States.”
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March 2013-Indianapolis EMS dramatically
reduced spine board utilization
Our current c-spine clearance protocol does not
address thoracic & lumbar spine and is seldom
used
Approved by Carle Level 1 Trauma services
Medical Directors
Discussion of Region VI protocol at May EMS
Medical Directors’ meeting
Notes:
1. The spine examination must be completed
by the Paramedic. Other responders may
apply c-collar and package the patient for
transport on a long spine board as
appropriate.
2. Penetrating trauma patients DO NOT require
transport on a long spine board.
3. Patients who are ambulatory on EMS arrival
generally DO NOT require full spinal motion
restriction on a long spine board UNLESS
any condition in Criteria A is present.
4. Patients outside these guidelines will be
treated by the judgment of the Paramedic
on scene, with the assistance of online
medical control if needed.
High Risk Spinal Injury Criteria: These include,
but are not limited to:
1. Ejection from motor vehicle
2. Separation from motorcycle/ATV
3. Vehicle rollover
4. Prolonged extrication
5. Pedestrian struck by vehicle at speed > 20
mph
High Risk Spinal Injury Criteria cont:
6.
7.
8.
9.
Falls > 3x patient’s height
Suspected dive into shallow water
Hanging
Signs of spinal cord injury from a blunt
mechanism
10.GCS < 14
11.Depressed or open skull fracture
A. Full spinal motion restriction (c-collar, CIDs,
and long board) should be used for High
Risk Spinal Injury Criteria AND any of the
following:
1.
2.
3.
4.
5.
6.
Unconscious during exam
Altered mental status
Intoxication
Language barrier
Neurologic deficit present or reported.
Any thoracic or lumbar spine deformity, or
midline tenderness on palpation or with
movement.
B. Cervical-collar-only motion restriction
should be applied to blunt trauma patients
with ANY of the following:
1. Presence of cervical deformity or midline
tenderness on palpation or movement.
2. Age > 65.
3. Distracting injury present.
4. High Risk Spinal Injury Criteria.
5. Paramedic’s discretion.
C. It is always acceptable to use a long spine
board for extrication. Patients who do not
meet any of the above criteria in (A) should
be logrolled off of the long board onto the
cot and be seat belted for transport. This
includes those patients packaged by other
responders. Patients with back pain should
be transported supine, and reasonable
effort to slide as a unit between EMS cot
and receiving hospital bed should be made.
D. Additional long spine board indications
include:
1. Lower extremity fractures- to support
splinted limb(s)
2. CPR- to enhance compressions
E. Pregnancy: Third trimester pregnant
patients who need to be immobilized on a
long spine board should have the board
tilted ~25 degrees into the left lateral
recumbent position.
F. Children: Secure children in their car
seats. If car seat is unavailable or child
was unsecured in a MVA, the child should
be fully immobilized so long as doing so
does not cause the child to struggle and
compromise the SMR effort