The efficacy and comfort of full-body vacuum splints for cervical-spine immobilization

Current practice in clinical cervical spinal clearance: implication for EMS

OBJECTIVES

To examine the practice of clinically "clearing" the cervical spine (c-spine) of trauma patients brought to the ED by EMS with cervical immobilization in place, and to examine developing trends in prehospital c-spine clearance.

METHODS

A 12-question survey form was mailed to the physician medical directors of 300 randomly selected EDs. Questions examined ED clinical clearance practices, EMS clearance protocols and research, and attitudes toward prehospital clearance. Estimated clinical clearance rates were requested.

RESULTS

A total of 173 surveys were returned (58%). At 21 hospitals (12%), c-spine films are obtained for all immobilized trauma patients; clinical clearance is never attempted. Of the remaining 151 hospitals, on average, clinical clearance is attempted for 65.5% of these patients (range 3-100%, interquartile range 50-100%) and is successful (films are not obtained) for 53.7% of attempts (range 0-100%, interquartile range 35-75%). No differences exist in either attempt rate or success rate between trauma centers and non-trauma centers, or between academic/university hospitals, community teaching hospitals, and community non-teaching hospitals (t-test or ANOVA, p > 0.05). Seventy-two respondents (42%) reported significant variation in clinical clearance practice patterns among their ED physicians. Seventy-three respondents (42%) feel that EMS providers should immobilize all trauma patients, while 99 (57%) feel it is reasonable for trained EMS providers to attempt clinical clearance on low-risk trauma patients.

CONCLUSIONS

There is tremendous variation in the ED practice of clinically clearing cervical spines. This, and a lack of support from many ED directors, may hinder attempts at development of research and standardized protocols for pre-hospital c-spine clearance.

Spinal trauma: new guidelines for assessment and management in the out-of-hospital environment

The keys to appropriate management of patients with spinal trauma lie in attending to life-threatening injuries, avoiding unnecessary movement of the spinal column, and carefully documenting patient reliability, MOI, history, physical examination findings, interventions, and responses to interventions. Who should be immobilized? Any victim of trauma complaining of neck or back pain, any patient with neurologic symptoms compatible with a spinal cord injury, and any patient who has an altered mental status or distracting injury should be immobilized. Given that not a single survivor of an SCI from World War I was alive by the start of World War II, one can appreciate the advances that have been made in the care of patients with spinal cord injuries. Exciting research is being conducted to explore the possibility of spinal cord regeneration by implanting tissue over which axons would regrow and make the appropriate connections, and pharmaceutical companies are spending millions to find an agent that will successfully salvage cells in human trials; however, a cure still seems elusive. Despite the marvels of modern research, prevention is still the key, including public education relative to wearing seat belts, instructing parents in the use of child restraint devices, encouraging people to jump rather than to dive when testing the depth of water (first time, feet first), enforcing driving under the influence laws, and outlawing such practices as spear tackling in football. In the meantime, EMS and ED personnel have a phenomenal opportunity to truly act as patient advocates by becoming familiar with new immobilization guidelines, honing their assessment skills, and providing anticipatory, compassionate care to those with neurologic deficits.