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We'll have several different sections reporting in - recent research, local topics, or highlighting areas of the Sponsor Hospital Council of Greater Bridgeport protocols.

*** Keep in mind - this website does not replace your protocols, and these posts do not reflect SHCGB or Bridgeport Hospital policies. This is a place to discuss research, controversies, or discuss possible future protocols. When in doubt, check your current protocols through the official source.

Saturday, December 15, 2012

In order to protect the c-spine, should we stop helping?

There have been some interesting recent evolutions in long-held beliefs about managing the possible cervical-spine fracture, however, and a recent study adds an interesting development.
The Study

The new study, Cervical Spine Motion during Extrication, makes an interesting contribution to the research, uses intriguing methods, and is very relevant to EMS. 

It is usual practice for EMS to go through great efforts to maintain cervical spine immobilization after an MVC. The patient will often have both a cervical collar and a "short board," or KED, applied. The EMS crew will then go through elaborate efforts to move the patient onto a long board right from the car seat, avoiding any active participation by the patient.


The ideal
The somewhat messy reality

This is a lot of effort, but the hope is that, by avoiding motion of the cervical spine, there will be no further, or "secondary," trauma to the spine. The actual risk of secondary injury is controversial, but immobilization is the current usual practice. 

Well, a natural question to ask is: Does it work? Do these multiple devices and great physical efforts avoid motion of the cervical spine? 

Well, this question has been approached in a number of ways in the past, but Missouri researchers took a new approach. They used a simulated extrication scenario, and tracked motion of the cervical spine using video motion capture, the technique used to, among there things, render Tom Hanks into a cartoon character.

Looks kind of creepy to me, but Hanks can get away with anything.
Note the little dots on Tom's head, hands, and shoulders. By tracking the movement of these points, a computer can compare degrees of flexion, etc., of the neck.

For the simulated extrication scenarion, they used a mock-up of a Corolla that had been in a bad head-on MVC. They recreated the postions of all the posts with PVC, replaced the surfaces with chicken wire, and replaced the seatback with Plexiglass. This way, they could record the extrication from all angles.



The participants were all paramedics with more than 5 years of experience - some of them also played the victim, along with some non-EMS people.

The victims exited the vehicle in 4 different ways:
  1. They were instructed to get out on their own, and walk over to the backboard and lie down.
  2. They first had a cervical collar placed, but still had to get out on their own.
  3. Collar was placed, and then the EMTs proceeded to maneuver the patient onto the board while "holding c-spine," instructing the victim to not offer assistance.
  4. A collar was placed, as well as a KED, before being moved onto the board.
(For what it's worth, method #4 is what I was taught by the good folks at SOLO in Conway, New Hampshire, when I first got my wilderness EMT. It took me awhile before I felt comfortable with method #3, that everyone in the "real world" was using!)

So how much neck motion did they see? A lot! 
 

Looking at the graphs, you can see how much motion, in each plane, they observed with each extrication method. 

Now here's the weird thing: method #2 (c-collar and "get out on your own") showed significantly less cervical motion than both methods #1 and #4

For example, take a look at "Graph C" from just above:


In other words, "Here's a collar, now please step out of the vehicle" produced less neck motion than "Don't move! We'll do all the moving for you."

Interpretation
The results are seemingly paradoxical, but it squares with some of my experience. Placing the KED and moving the patient to the backboard always seemed to go smoothly if the patient was slender, short, and driving a large car. 

Smaller car, bigger person - it doesn't go so smoothly...


E.g. Try putting a KED on Klump.
Also, it's worth highlighting the change in protocols that a few EMS agencies have already rolled out, actually prior to the publication of this study.

For example, in the last year Xenia FD in Ohio, as well as New Haven, CT, have started using method #2 for certain lower-risk trauma. A number of other agencies are said to be following suit. 

And although it's not a prehospital policy, Bridgeport Hospital is now encouraging nurses and EMTs to remove backboards as soon as patients arrive in the ED - no doctor involved! This shift in practice was prompted both by the risk to patients that backboards pose, and the scant evidence that supports their use once the patient has arrived at the hospital.

And you get your board back right away!

This study suggests that those policies may not be as risky as previously imagined, and may, in fact, be more conservative than the "usual practice!"

The Bottom Line
This study adds to the growing body of research that suggest that our approach to spinal care may be quite different in the near future!

(In the meantime, of course, please stick to your local protocols and guidelines.)

14 comments:

  1. Interesting aside, apparently the KED does not properly immobilize a patient anyways (per reading some in depth protocols, I believe where you got your first picture from).

    There is a competing product which features shoulder straps and a Swiss-Seat style harness for the legs that apparently provides full immobilization.

    Food for thought!

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    Replies
    1. Given that, literally, "nothing" was better than the KED, I would have to imagine that the other device would outperform the KED.

      Delete
  2. Comments over at my blog. No sense in letting a blog post length comment go to waste.

    Good post, it's nice to see a physician look at this issue critically.

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  3. This is not the first study of this nature. Look up by Dr Brian Bledsoe Spinal Immobilization: Have we gone too far, and Insanity. I truly see within the next few years the backboard itself may be exclusive to cardiac arrests.

    ReplyDelete
    Replies
    1. Thanks for the tip - I just read Bledsoe's article. I would like to think that some evolution has taken place since he wrote that in 1994 (e.g. spinal clearance in the field), but the main point is still relevant.

      Delete
    2. Bryan is a forward thinker. Still, there hasn't been that much progress since then and I don't see much on the horizon either.

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    3. "I truly see within the next few years the backboard itself may be exclusive to cardiac arrests."

      And honestly, if the goal is simply moving the patient and not any kind of spinal immobilization, tools like the Reeves Sleeve are much better choices - easier and faster to apply, better handholds, etc. If the backboard goes away as a spinal immobilization device, I can see it going away entirely.

      Delete
    4. Or a scoop stretcher. Which is much better suited for moving patients down tight stairs and narrow hallways.

      Or not transporting cardiac arrest patients who remain in cardiac arrest after treatment has failed.

      Different topic.

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  4. I thought I was losing my mind. Didn't this study come out years ago? I've certainly been citing it to people for years.

    Apparently, yes and no. http://www.ncbi.nlm.nih.gov/pubmed/19561822 Yes, it was done, just with three people instead of ten. Oh well. Similar results.

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    Replies
    1. Well, now we have p-values. Ya gotta have p-values.

      Delete
  5. Hi Brooks...

    Former Norwalk Hospital medic here, now in VT.

    UCLA did a study about 2 years ago, comparing fully immobilized traumas coming into to their Level 1 with similar patients and MOI going into Malaysia's only Level 1...the difference being in Malaysia almost no one gets immobilized.

    The take home? Immobilization was "helpful" in 2% of the cases reviewed.

    Cheers,
    Bill
    Twitter: vtmedic511

    ReplyDelete
    Replies
    1. Were you thinking about Out-of-hospital spinal immobilization: its effect on neurologic injury? (http://www.ncbi.nlm.nih.gov/pubmed/9523928)

      Ironically, it showed a slender, but statistically advantage to NOT immobilizing. There's a lot of valid criticism of that study, but it still produced such a paradoxical result - essential reading!

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    2. Yeah, that one...my bad for trying to pull it out of my ass...UNM, not UCLA.

      Delete
    3. That study is too flawed to draw any valid conclusions. Since there was no evaluation of the patient's condition on-scene, it only showed if there was additional damage at the hospital. It highlights the need for in-depth studies; but by itself doesn't say anything about the value of PRE-hospital spinal precautions.


      This newest study OTOH, is very promising because it happens in controlled, reproducible situations. A nice follow-up would be to measure the motion capture during immobilization in general, instead of focusing on vehicle extrication.

      Delete