Multicenter prospective validation of prehospital clinical spinal clearance criteria

Patterns of change in prehospital spinal motion restriction: A retrospective database review

BACKGROUND

Acute management of trauma patients with potential spine injuries has evolved from uniform spinal immobilization (SI) to spinal motion restriction (SMR). Little research exists describing how these changes have been implemented. This study aims to describe and analyze the practice of SMR in one emergency medical services (EMS) agency over the time frame of SMR adoption.

METHODS

This was a retrospective database review of electronic patient care reports from 2009 to 2020. The effects of key practice changes (revised documentation and a collar-only treatment option) were analyzed in an interrupted time series using the rate of SI/SMR as the primary outcome. Secondary outcomes included patient age, sex, acuity, mechanism of injury, treatment provided, cervical collar size, and positioning. These were assessed for changes from year to year by Poisson regression. Associations between patient and treatment characteristics were investigated with binomial logistic regression.

RESULTS

There were 25,747 instances of SI/SMR included. Among all patients, the median age was 40 (interquartile range 24-56), 58% (14,970) were male, and 20% (5062) were high-acuity. The rate of SI/SMR declined from 31.2 to 12.7 treatments per 100 trauma calls per month. The proportion of high-acuity patients increased by 9.6% per year on average (95% CI 8.7%-10.0%). When first available, collar-only treatment was provided to 47% of patients, rising by 6.3% per year (95% CI 3.2%-9.5%) to 60% in 2020. Collar-only treatment (compared to board-and-collar) was more likely to be applied to low-acuity patients (as compared to high): odds ratio 3.01 (95% CI 2.64-3.43).

CONCLUSIONS

This study shows decreasing SI/SMR treatment and changing patient and practice characteristics. These patterns of care cannot be attributed solely to formal protocol changes. Similar patterns and their possible explanations should be investigated elsewhere.

Immobilization in Emergency Medical Service - Are CSR and NEXUS-Criteria Considered? A Matched-Pairs Analysis Between Trauma Patients Treated by Onsite EMS Physicians and Patients Treated by Tele-EMS Physicians

Background

The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over- as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS- and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device.

Methods

A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter.

Results

Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard.

Conclusion

It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS- and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.

Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: A scoping review

·

There is a need for a patient-centred approach to the prehospital spinal management approach, which considers the associated risks, available personnel and limited resources.

·

There is limited evidence supporting the use of the NEXUS and CCR decision tools in the prehospital setting.

·

Prehospital spinal motion restriction decision tools should focus on reducing unnecessary spinal motion restriction and its associated adverse effects

·

Developing a decision tool with more context-specific prehospital instructions for selective spinal motion restriction is of value.

Introduction

The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners.

Method

We performed a focused scoping review of published literature on the prehospital use of clinical c-spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis.

Results

Following screening, forty-two articles were included in this scoping review. No studies conducted specifically in low resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting.

Conclusion

This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety, and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation, and a lack of context-specific evidence. These may provide important considerations for future guideline development.

Evaluating prehospital care of patients with potential traumatic spinal cord injury: scoping review

PURPOSE

To gain insight into current research regarding prehospital care (PHC) in patients with potential traumatic spinal cord injury (TSCI) and to disseminate the findings to the research community.

METHODS

In March 2019, we performed a literature search of publications from January 1990 to March 2019 indexed in PubMed, gray literature including professional websites; and reference sections of selected articles for other relevant literature. This review was performed according to Arksey and O'Malley's framework.

RESULTS

There were 42 studies selected based on the inclusion criteria for review; 18 articles regarding immobilization; 12 articles regarding movement, positioning and transport; four for spinal clearance; three for airway protection; and two for the role of PHC providers. There were some articles that covered two topics: one article was regarding movement, positioning and transport and airway protection, and two were regarding spinal clearance and the role of PHC providers.

CONCLUSION

There was no uniform opinion about spinal immobilization of patients with suspected TSCI. The novel lateral trauma position and one of two High Arm IN Endangered Spine (HAINES) methods are preferred methods for unconscious patients. Controlled self-extrication for patients with stable hemodynamic status is recommended. Early and proper identifying of potential TSCI by PHC providers can significantly improve patients' outcomes and can result in avoiding unwanted spinal immobilization. Future prospective studies with a large sample size in real-life settings are needed to provide clear and evidence-based data in PHC of patients with suspected TSCI.

Prehospital Protocols Reducing Long Spinal Board Use Are Not Associated with a Change in Incidence of Spinal Cord Injury

Introduction: Many emergency medical services (EMS) agencies have de-emphasized or eliminated the use of long spinal boards (LSB) for patients with possible spinal injury. We sought to determine if implementation of spinal motion restriction (SMR) protocols, which reduce LSB use, was associated with an increase in spinal cord injury (SCI). Methods: This retrospective observational study includes EMS encounters from January 1, 2013 to December 31, 2015 submitted by SMR-adopting ground-based agencies to a state EMS database with hospital discharge data. Encounters were excluded if SMR implementation date was unknown, occurred during a 3-month run-in period, or were duplicates. Study samples include patients with traumatic injury (TI), possible spinal trauma (P-ST), and verified spinal trauma (V-ST) using hospital discharge ICD-9/10 diagnosis codes. The incidence of SCI before and after implementation of SMR was compared using Chi-squared and logistic regression. Results: From 1,005,978 linked encounters, 104,315 unique encounters with traumatic injury and known SMR implementation date were identified with 51,199 cases of P-ST and 5,178 V-ST cases. The incidence of SCI in the pre-SMR and post-SMR interval for each group was: TI, 0.20% vs. 0.22% (p = 0.390); P-ST, 0.40% vs. 0.45% (p = 0.436); and V-ST, 4.04% vs. 4.37% (p = 0.561). Age and injury severity adjusted odds ratio of SCI in the highest risk cohort of patients with V-ST was 1.097 after SMR implementation (95% CI 0.818-1.472). Conclusion: In this limited study, no change in the incidence of SCI was identified following implementation of SMR protocols. Prospective evaluation of this question is necessary to evaluate the safety of SMR protocols.

Current Topics in the Management of Acute Traumatic Spinal Cord Injury

Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last three decades, there have been considerable advancements in the management of patients with traumatic SCI. The advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit (ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.

Towards Evidence-Based Guidelines in Neurological Surgery

Neurological surgery practice is based on the science of balancing probabilities. A variety of clinical guidance documents have influenced how we collectively practice our art since the early 20th century. The quality of the science within these guidelines varies widely, as does their utility in positively shaping our practice. The guidelines development process in neurological surgery has evolved significantly over the last 30 yr. Historically based in expert opinion, as a specialty we have increasingly relied on objective medical evidence to guide our clinical practice. We assessed the changing practice guidelines development process and the impact of scientifically robust guidelines on patient care. The evolution of the guidelines development process in neurological surgery was chronicled. Several subspecialty guidelines were extracted and reviewed in detail. Their impact on practice patterns was evaluated. The importance of evidence-based research and practice guidelines development was discussed. Evidence-based practice guidelines serve to chronicle multiple acceptable treatment options and help us move towards more standardized care for specific disease processes. They help refute false "standards of care." Guidelines-based care supported by solid medical evidence has the potential to streamline patient care and improve patient outcomes. The guidelines development process identifies areas, issues, and strategies for which little medical evidence exists, as well as topics that need focused scientific investigation and future study. The production of evidence-based practice recommendations is a vital part of furthering our specialty. Guidelines development advances our science, augments the resident education process, and protects our practice from undue external influence.

Cervical Spine Injury Risk Factors in Children With Blunt Trauma

BACKGROUND

Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model.

METHODS

We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model.

RESULTS

Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%-97.2%) sensitive and 45.6% (44.0%-47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%-98.1%) sensitive and 50.3% (48.7%-51.8%) specific.

CONCLUSIONS

Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development.

Removal of the Long Spine Board From Clinical Practice: A Historical Perspective

Since the early 1970s, initial management of patients with suspected spinal injuries has involved the use of a cervical collar and long spine board for full immobilization, which was thought to prevent additional injury to the cervical spine. Despite a growing body of literature demonstrating the detrimental effects and questionable efficacy of spinal immobilization, the practice continued until 2013, when the National Association of EMS Physicians issued a position statement calling for a reduction in the use of spinal immobilization and a shift to spinal-motion restriction. This article examines the literature that prompted the change in spinal-injury management and the virtual elimination of the long spine board as a tool for transport.

Value of prehospital assessment of spine fracture by paramedics

BACKGROUND

Current guidelines state that trauma patients at risk of spine injury should undergo prehospital spine immobilization to reduce the risk of neurological deterioration. Although this approach has been accepted and implemented as a standard for decades, there is little scientific evidence to support it. Furthermore, the potential dangers and sequelae of spine immobilization have been extensively reported. The role of the paramedic in this process has not yet been examined. The aim of this study was to evaluate the accuracy of prehospital evaluations for the presence of spine fractures made by paramedics.

METHODS

All patients who presented with prehospital spine immobilization at our level II trauma center between January 2013 and January 2014 were prospectively included in a database. Prior to the diagnosis, paramedics recorded the probability of a spine fracture after a prehospital examination. These predictions were compared with patient outcomes. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated.

RESULTS

One hundred and thirty-nine patients were included that positive predictive value was 22%, negative predictive value was 95%, sensitivity was 92%, specificity was 30%, and accuracy was 41%.

CONCLUSIONS

The results of this study suggest that paramedics cannot accurately predict spinal fractures.

Methods for Collecting Paired Observations From Emergency Medical Services and Emergency Department Providers for Pediatric Cervical Spine Injury Risk Factors

OBJECTIVES

Cervical spine injuries (CSIs) after blunt trauma in children are rare, but cause substantial morbidity and mortality. Emergency medical services (EMS) and emergency department (ED) providers routinely use spinal precautions and cervical spine imaging, respectively, during the management of children experiencing blunt trauma. These practices lack evidence, and there is concern that they may be harmful. A pediatric CSI risk assessment tool is needed to inform EMS and ED provider decision making. Creating this tool requires prospective data collection from EMS and ED providers at the time of patient evaluation. The purpose of this article is to describe the methods used to prospectively capture paired EMS and ED provider observations of children cared for after blunt trauma. Given the rarity of prospective observational research with EMS, the novel use of Research Electronic Data Capture (REDCap) in this study, and the potential to inform future studies, we are publishing our methodology in advance of outcome data related to the risk assessment tool.

METHODS

The study was conducted at four tertiary children's hospitals as a prerequisite for a planned larger study to derive a CSI risk assessment tool. We created a web-based, branch-logic questionnaire using the REDCap data collection system. The survey was administered via tablet computer to ED providers evaluating children with blunt trauma and, if applicable, to EMS providers who provided patient care at the scene. We collected information regarding factors determined a priori to be plausibly associated with CSI in children. Eligible children presenting to the ED after blunt trauma with at least one of the following one of the following were included: prehospital EMS spinal precautions, ED trauma team evaluation, or cervical spine imaging in the ED. Exclusions included penetrating trauma, language barrier, or state's custody. Enrollment occurred when research coordinators (RCs) were available, generally 12-16 hours/day. RCs approached EMS providers prior to departing the ED and ED providers after they completed their patient assessments. An ED provider survey was required for enrollment. Enrolled children were followed for 28 days to determine the presence of CSI (primary outcome) by subsequent imaging or by patient/family telephone follow-up for those without imaging.

RESULTS

Over 18 months, we prospectively enrolled 4,144 of 5,764 (71.9%) eligible children, including 74 of 110 (67.3%) children diagnosed with CSI. Enrollment during RC hours was 85.9%. Fifty-three enrolled children were withdrawn from the study. Of those in the final study cohort, 36.5% arrived by EMS scene response in spinal precautions. The remaining 63.5% arrived by EMS scene response without spinal precautions or by private vehicle or interfacility transfer. EMS scene response providers completed surveys for 60.2% of enrolled children arriving in spinal precautions. RCs missed the EMS providers for 37.1% of children; however, EMS declined participation for only 2.6%.

CONCLUSIONS

Our method of data collection demonstrates the ability to prospectively capture paired observations from EMS and ED personnel for children undergoing evaluation after blunt trauma. While this methodology will be used to implement and evaluate a CSI tool in future studies, it may also be adapted to studies requiring prospective data collection from EMS and ED personnel.

The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury

The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.

Imaging investigations in Spine Trauma: The value of commonly used imaging modalities and emerging imaging modalities

Traumatic spine injuries can be devastating for patients affected and for health care professionals if preventable neurological deterioration occurs. This review discusses the imaging options for the diagnosis of spinal trauma. It lays out when imaging is appropriate and when it is not. It discusses strength and weakness of available imaging modalities. Advanced techniques for spinal injury imaging will be explored. The review concludes with a review of imaging protocols adjusted to clinical circumstances.

Quantifying the Risk of Spinal Injury in Motor Vehicle Collisions According to Ambulatory Status: A Prospective Analytical Study

BACKGROUND

The association between ambulation at the scene of a motor vehicle collision (MVC) and spinal injury has never been quantified.

OBJECTIVE

To evaluate the association between ambulation and spinal injury in patients involved in a MVC.

METHODS

Prospective analytical-observational cohort study. Inclusion: patients sustaining traumatic injury in a MVC. Exclusion: < 18 years old, pregnancy.

PRIMARY OUTCOME

spinal injury defined as injury to the cervical, thoracic, or lumbar spinal cord, bones, or ligaments. Secondary outcome: Injury resulting in neurological deficit, need for surgery, or death. A generalized linear model was used to evaluate the association between outcome and predictor variables. Risk ratios [RR] were reported with a point estimate and 95% confidence interval (CI). A two-tailed alpha of < 0.05 was the threshold for statistical significance.

RESULTS

There were 704 patients analyzed. Nonambulatory patients were 2.29 times more likely to sustain a spinal injury, compared to ambulatory patients (RR 2.29, 95% CI 1.34-3.91). Patients ≥ 65 years of age were 3.27 times more likely to sustain a spinal injury (RR 3.27, 95% CI 1.66-6.45). Patients with a Glasgow Coma Scale score ≤ 8 were 4.93 times more likely to sustain a spinal injury (RR 4.93, 95% CI 1.86-13.10).

CONCLUSION

In this prospective analytical-observational study evaluating the association between ambulatory status and spinal injury in patients involved in MVCs, we observed that those patients who were nonambulatory were more than two times as likely to have a spinal injury compared to those patients who were ambulatory at the scene.

Characteristics of Trauma Patients With Potential Cervical Spine Injuries Underimmobilized by Prehospital Providers

STUDY DESIGN

This study was a retrospective chart review to determine characteristics of patients under-immobilized by prehospital providers.

OBJECTIVE

Our goal was to examine the characteristics of patients who met the criteria for spinal immobilization but were inappropriately cleared.

SUMMARY OF BACKGROUND DATA

Many emergency medical services (EMS) use selective spinal immobilization (SSI) based on the NEXUS criteria. However, there is been research examining patients who are under-immobilized by EMS.

METHODS

This was a retrospective chart review over 18 months of a single EMS service. We reviewed all charts dispatched as "motor vehicle crash" (MVC) or "fall". We then determined, whether the patient met the criteria for SSI under Pennsylvania protocols, which mirror the NEXUS criteria.

RESULTS

Our EMS system responded to 1151 falls and MVCs over the study period. Seventy-six patients were immobilized leaving 1075 patients who had clinical clearance of their cervical spine. Of these patients, 4/1075 (0.3%) were considered to be under-immobilized. All 4 of these patients had intoxication or altered mentation mentioned in their charts. Two of these patients had CT scans of their cervical spine, with both being negative. One patient eloped from the ED before any imaging, and 1 patient was clinically cleared.

CONCLUSION

EMTs are very proficient in following the SSI guidelines with an under-immobilization rate of approximately 0.3% in our study. However, all patients who were under-immobilized were under the influence of alcohol. There were no patients who were not immobilized and had cervical spine injuries. This was a limited chart review involving only 2 dispatch categories. EMTs should be cautious while evaluating patients with possible spinal injuries who are under the influence of alcohol.

LEVEL OF EVIDENCE

4.

Comparison of three prehospital cervical spine protocols for missed injuries

Introduction

We wanted to compare 3 existing emergency medical services (EMS) immobilization protocols: the Prehospital Trauma Life Support (PHTLS, mechanism-based); the Domeier protocol (parallels the National Emergency X-Radiography Utilization Study [NEXUS] criteria); and the Hankins’ criteria (immobilization for patients <12 or >65 years, those with altered consciousness, focal neurologic deficit, distracting injury, or midline or paraspinal tenderness).To determine the proportion of patients who would require cervical immobilization per protocol and the number of missed cervical spine injuries, had each protocol been followed with 100% compliance.

Methods

This was a cross-sectional study of patients ≥18 years transported by EMS post-traumatic mechanism to an inner city emergency department. Demographic and clinical/historical data obtained by physicians were recorded prior to radiologic imaging. Medical record review ascertained cervical spine injuries. Both physicians and EMS were blinded to the objective of the study.

Results

Of 498 participants, 58% were male and mean age was 48 years. The following participants would have required cervical spine immobilization based on the respective protocol: PHTLS, 95.4% (95% CI: 93.1–96.9%); Domeier, 68.7% (95% CI: 64.5–72.6%); Hankins, 81.5% (95% CI: 77.9–84.7%). There were 18 cervical spine injuries: 12 vertebral fractures, 2 subluxations/dislocations and 4 spinal cord injuries. Compliance with each of the 3 protocols would have led to appropriate cervical spine immobilization of all injured patients. In practice, 2 injuries were missed when the PHTLS criteria were mis-applied.

Conclusion

Although physician-determined presence of cervical spine immobilization criteria cannot be generalized to the findings obtained by EMS personnel, our findings suggest that the mechanism-based PHTLS criteria may result in unnecessary cervical spine immobilization without apparent benefit to injured patients. PHTLS criteria may also be more difficult to implement due to the subjective interpretation of the severity of the mechanism, leading to non-compliance and missed injury.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

EMS spinal precautions and the use of the long backboard - resource document to the position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma

Field spinal immobilization using a backboard and cervical collar has been standard practice for patients with suspected spine injury since the 1960s. The backboard has been a component of field spinal immobilization despite lack of efficacy evidence. While the backboard is a useful spinal protection tool during extrication, use of backboards is not without risk, as they have been shown to cause respiratory compromise, pain, and pressure sores. Backboards also alter a patient's physical exam, resulting in unnecessary radiographs. Because backboards present known risks, and their value in protecting the spinal cord of an injured patient remains unsubstantiated, they should only be used judiciously. The following provides a discussion of the elements of the National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACS-COT) position statement on EMS spinal precautions and the use of the long backboard. This discussion includes items where there is supporting literature and items where additional science is needed.

Spinal motion restriction: an educational and implementation program to redefine prehospital spinal assessment and care

INTRODUCTION

Prehospital spine immobilization has long been applied to victims of trauma in the United States and up to 5 million patients per year are immobilized mostly with a cervical collar and a backboard.

OBJECTIVE

The training of paramedics and emergency medical technicians on the principals of spine motion restriction (SMR) will decrease the use of backboards.

METHODS

The training for SMR emphasized the need to immobilize those patients with a significant potential for an unstable cervical spine fracture and to use alternative methods of maintaining spine precautions for those with lower risk. The training addressed the potential complications of the use of the unpadded backboard and education was provided about the mechanics of spine injuries. Emergency medical services (EMS} personnel were taught to differentiate between the critical multisystem trauma patients from the more common moderate, low kinetic energy trauma patients. A comprehensive education and outreach program that included all of the EMS providers (fire and private), hospitals, and EMS educational institutions was developed.

RESULTS

Within 4 months of the policy implementation, prehospital care practitioners reduced the use of the backboard by 58%. This was accomplished by a decrease in the number of patients considered for SMR with low kinetic energy and the use of other methods, such as the cervical collar only.

CONCLUSION

The implementation of a SMR training program significantly decreases the use of backboards and allows alternative methods of maintaining spine precautions.

Cervical spine fractures in elderly patients with hip fracture after low-level fall: an opportunity to refine prehospital spinal immobilization guidelines?

BACKGROUND

Conventional prehospital spine-assessment approaches based on low index of suspicion and mechanism of injury (MOI) result in the liberal application of spinal immobilization in trauma patients. A painful distracting injury (DI), such as a suspected hip fracture, historically has been a sufficient condition for immobilization, even in an elderly patient who suffers a simple fall from standing and exhibits no other risk factors for spinal injury. Because the elderly are at increased risk of hip fracture from low-level falls, and are also particularly susceptible to the discomfort and morbidity associated with immobilization, the prevalence of cervical spine (c-spine) fracture in this patient population was examined.

METHODS

Hospital billing records were used to identify all cases of traumatic femur fracture in Minnesota (USA) in 2010-2011. Concurrent diagnosis and external cause codes were used to estimate the prevalence of c-spine fracture by age and MOI.

RESULTS

Among 1,394 patients with femur fracture, 23 (1.7%) had a c-spine fracture. When the MOI was a fall from standing or sitting height and the patient age was ≥ 65, the prevalence dropped to 0.4% (2/565). The prevalence was similar when the definition of hip fracture additionally included pelvis fractures (0.5%; 11/2,441). Eight of the 11 patients with c-spine fracture had diagnosis codes indicative of criteria other than the DI that likely would have resulted in immobilization (eg, head injury and compromised mental status).

CONCLUSIONS

C-spine fracture is extremely rare in elderly patients who sustain hip fracture as a result of a low-level fall, and appears to be accompanied frequently by other known predictors of spinal injury besides DI. More research is needed to determine whether conservative use of spinal immobilization may be warranted in elderly patients with hip fracture after low-level falls when the only criteria for immobilization is the distracting hip injury.

Blunt cervical spine injury in children

PURPOSE OF REVIEW

We present data from recently conducted research regarding the diagnosis of blunt cervical spine injury (CSI) in children.

RECENT FINDINGS

Research in the prehospital setting to evaluate the need for cervical spine immobilization in children, regardless of clinical findings or mechanism of injury, suggests that low-risk prediction rules may be safely utilized by prehospital providers, although more data is needed. Their size, developing skeleton and unique anatomy leave children vulnerable to particular injury patterns, namely cephalad bony fractures and ligamentous and spinal cord injuries without radiographic abnormality. Low-risk clinical prediction rules have been developed but need to be further validated. For those children at higher risk of CSI, diagnostic imaging strategies are evolving, with computed tomography and MRI becoming more prominent.

SUMMARY

Evidence in the management of children with CSI has expanded in recent years, but further large prospective studies are needed. We present a review of some recent developments influencing clinical practice.

National athletic trainers' association position statement: preventing sudden death in sports

OBJECTIVE

To present recommendations for the prevention and screening, recognition, and treatment of the most common conditions resulting in sudden death in organized sports.

BACKGROUND

Cardiac conditions, head injuries, neck injuries, exertional heat stroke, exertional sickling, asthma, and other factors (eg, lightning, diabetes) are the most common causes of death in athletes.

RECOMMENDATIONS

These guidelines are intended to provide relevant information on preventing sudden death in sports and to give specific recommendations for certified athletic trainers and others participating in athletic health care.

Evaluation of the safety of C-spine clearance by paramedics: design and methodology

BACKGROUND

Canadian Emergency Medical Services annually transport 1.3 million patients with potential neck injuries to local emergency departments. Less than 1% of those patients have a c-spine fracture and even less (0.5%) have a spinal cord injury. Most injuries occur before the arrival of paramedics, not during transport to the hospital, yet most patients are transported in ambulances immobilized. They stay fully immobilized until a bed is available, or until physician assessment and/or X-rays are complete. The prolonged immobilization is often unnecessary and adds to the burden of already overtaxed emergency medical services systems and crowded emergency departments.

METHODS/DESIGN

The goal of this study is to evaluate the safety and potential impact of an active strategy that allows paramedics to assess very low-risk trauma patients using a validated clinical decision rule, the Canadian C-Spine Rule, in order to determine the need for immobilization during transport to the emergency department.This cohort study will be conducted in Ottawa, Canada with one emergency medical service. Paramedics with this service participated in an earlier validation study of the Canadian C-Spine Rule. Three thousand consecutive, alert, stable adult trauma patients with a potential c-spine injury will be enrolled in the study and evaluated using the Canadian C-Spine Rule to determine the need for immobilization. The outcomes that will be assessed include measures of safety (numbers of missed fractures and serious adverse outcomes), measures of clinical impact (proportion of patients transported without immobilization, key time intervals) and performance of the Rule.

DISCUSSION

Approximately 40% of all very low-risk trauma patients could be transported safely, without c-spine immobilization, if paramedics were empowered to make clinical decisions using the Canadian C-Spine Rule. This safety study is an essential step before allowing all paramedics across Canada to selectively immobilize trauma victims before transport. Once safety and potential impact are established, we intend to implement a multi-centre study to study actual impact.

Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines

An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.

National athletic trainers' association position statement: acute management of the cervical spine-injured athlete

OBJECTIVE

To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete.

BACKGROUND

The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment.

RECOMMENDATIONS

Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.

Summary of the National Athletic Trainers' Association position statement on the acute management of the cervical spine-injured athlete

The incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment. The objective of the National Athletic Trainers' Association (NATA) position statement on the acute care of the cervical spine-injured athlete is to provide the certified athletic trainer, team physician, emergency responder, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in an athlete. Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport such as football, hockey, or lacrosse; and imaging considerations in the emergency department.

The out-of-hospital validation of the Canadian C-Spine Rule by paramedics

STUDY OBJECTIVE

We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.

METHODS

We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury.

RESULTS

The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The kappa value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule.

CONCLUSION

This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.

Clinical clearance of spinal immobilization in the air medical environment: a feasibility study

BACKGROUND

Various decision algorithms have been developed for use in the prehospital setting to analyze those trauma patients who do not require spinal immobilization. The feasibility of applying these algorithms in the air medical transport environment has not been studied.

METHODS

All adult patients (>/=age 16) transported to three Level I trauma centers were eligible for the study. Medical crews completed a data collection sheet during transport which was later used to analyze whether the transported patient would be eligible for spinal clearance based on the absence of all of the following clinical findings: (1) abnormal level of consciousness; (2) evidence of intoxication; (3) distracting painful injury; (4) spinal tenderness or pain; or (5) abnormal neurologic examination. The outcomes were (1) the proportion of transported patients potentially eligible for spinal clearance and (2) the ability of the algorithm to predict spinal injury.

RESULTS

Three hundred twenty-nine patients were enrolled in the study. Forty-nine (15%) had spinal injuries with 12 (24%) considered unstable. Only 40 patients met criteria for deferring spinal immobilization; 4 of these patients had spinal fractures. The algorithm had a sensitivity of 90% and a specificity of 16%.

CONCLUSION

Clearance of spinal immobilization using prehospital clinical algorithms during air medical transport did not appear to be useful. These criteria were not found to be sensitive, specific, or predictive of spinal injury in this population of blunt trauma patients. Prehospital spinal immobilization clearance algorithms using existing criteria should not be adopted for patients transported by helicopter.

Controversies in "clearing" trauma to the cervical spine

Clearance of the traumatic cervical spine is a subject affecting most healthcare professionals dealing with trauma patients. There is a host of often contradictory literature making it hard for an interested reader to come to their own informed opinion based on the current evidence. This review aims to outline the relevant literature for the clearance of the traumatic cervical spine with the particular aim of highlighting the contradictions, controversies and unanswered questions still besetting this important subject. A brief, subjective opinion for a combined clinical and imaging protocol for clearance of the traumatic cervical spine is given.

A Retrospective Study of Five Clinical Criteria and One Age Criterion for Selective Prehospital Spinal Immobilization

Full spinal immobilization of blunt trauma victims is a widely accepted prehospital measure, applied in order to prevent (further) damage to the spinal cord. However, looking at the marginal evidence that exists for the effectiveness of spinal immobilization, and the growing evidence for the negative effects following immobilization, a more selective protocol might be able to reduce possible morbidity and mortality as good as the present prehospital immobilization protocol. In a retrospective study, the sensitivity of a selective prehospital immobilization protocol that adds an age criterion to five clinical spine clearance criteria is examined.

MATERIALS AND METHODS

Based on ICD-9 codes, all patients admitted to the trauma center diagnosed with spinal fractures with or without spinal damage were identified. The sensitivity of the combination of five clinical criteria (reduced awareness, evidence of intoxication, neurological deficit, pain of the spine on palpation, (significant) distracting injury) and an age criterion (65 years or older at time of accident) was determined. If one or more criteria were positive, standard full immobilization would be indicated. The other patients would not have been immobilized.

RESULTS

A total of 238 blunt trauma victims primarily admitted to the trauma center were included for this study. Median age of the included patients was 39 years (range 5-98), with 32.8% female. A total of 236 had at least one positive criterion (sensitivity 99.2%). The two missed patients were male, 40 and 41 years old. Radiology showed a small fissure in the arch of C2, and a transverse process fracture of L3, respectively. Both patients were discharged the next day without complications or medical interventions.

CONCLUSION

In this retrospective study, a selective protocol based on clinical criteria instead of trauma mechanism showed 99.2% sensitivity for spinal fractures with or without spinal cord damage. Based on this study and the current controversy surrounding spinal immobilization, a prospective study should be considered to evaluate the five clinical criteria and one age criterion in the prehospital setting.

Prehospital care of the injured: what's new

Emergency medical services (EMS) play a critical role in the trauma system as the point of initial patient care and stabilization and in determining the regional flow of patients and the commitment of resources to the critically injured. Trauma surgeons and emergency physicians need to be involved in the organizational planning of EMS systems to ensure that uniform patient care protocols are developed for triage and treatment. Ongoing efforts should focus on addressing national variability in care provided after injury to ensure optimal outcome for patients in all regions. Through additional research, the best practice and optimal EMS system design will continue to be defined.

A statewide, prehospital emergency medical service selective patient spine immobilization protocol

BACKGROUND

To evaluate the practices and outcomes associated with a statewide, emergency medical services (EMS) protocol for trauma patient spine assessment and selective patient immobilization.

METHODS

An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter data. Prehospital patient data were linked to a statewide hospital database that included all patients treated for spine fracture during the 12-month period following the spine assessment protocol implementation. Incidence of spine fractures among EMS-assessed trauma patients and the correlation between EMS spine immobilization decisions and the presence of spine fractures-stable and unstable-were the primary investigational outcomes.

RESULTS

There were 207,545 EMS encounters during the study period, including 31,885 transports to an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%) patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154 acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization interventions. This nonimmobilized group included 19 stable spine fractures and one unstable thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was 87.0% (95% confidence interval [CI], 81.7-92.3) with a negative predictive value of 99.9% (95% CI, 99.8-100).

CONCLUSIONS

The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected a decision not to immobilize greater than half of all EMS-assessed trauma patients.

Changing face of spine trauma care in North America

STUDY DESIGN

An evidence-based review and summary of literature from multiple disciplines involved in spine trauma.

OBJECTIVES

To outline epidemiologic, clinical, and research issues influencing spine trauma in a longitudinal perspective. In addition, to provide guidance to clinicians and researchers to ensure that philosophies pertaining to the betterment of spine trauma care are understood and supported.

SUMMARY OF BACKGROUND DATA

Epidemiologic data have provided insight into future demands the elderly patient with spine injury will place on the health care system. Regional trauma programs have emerged with further specialization resulting in regionalized spine trauma care. Evidence-based guidelines have streamlined imaging, and biomaterial advancements have facilitated the stabilization of the spinal column and decompression of the spinal cord. Promising experimental therapies promoting axonal regeneration and neuroprotective agents are beginning clinical trials, generating cautious optimism that effective therapies for spinal cord injuries will emerge. The unsustainable economics of increasing technology and patient expectations will make economic evaluation critical.

METHODS

Evidence-based review of current literature and expert opinion.

CONCLUSIONS

Multicenter spine trauma registries with patient-reported outcomes will allow many questions around spine trauma to be answered using the highest levels of evidence. This process in synergy with technical and biologic developments should ensure progress toward optimal care of the spine trauma patient. Future challenges will be to treat the breadth and magnitude of the discoveries within the fiscal restraints of the health care system and ensure its affordability for society.

[Evidence based diagnostic procedures for the determination of suspected blunt cervical spine injuries. Development of an algorithm]

BACKGROUND

The aim of this study was to present existing publications, describing various diagnostic procedures as well as considering the evidence supporting them, to develop a recommendation for diagnosis.

MATERIAL AND METHODS

We reviewed relevant publications between 1966 and 2004 by a systemic literature search in MEDLINE, EMBASE, National Guideline Clearinghouse, Cochrane Library as well as a manual reference search. Keywords were cervical spine, cervical vertebrae, spinal, spinal cord, injury, trauma, fracture, dislocation, imaging, radiography, flexion, extension, fluoroscopy, computed tomography, computed scanning, and magnetic resonance imaging. The selected search results were then classified into levels of evidence.

RESULTS

From among a total of 10,000 publications, 137 relevant publications were stringently reviewed. The level of evidence is on the whole limited due to deficit data; therefore, only class II-III recommendations are possible. We developed an algorithm for the diagnostic approach to suspected trauma of the cervical spine. This clinical algorithm displays the complex diagnosis of cervical spine injury in a clear and logically structured process.

CONCLUSIONS

The diagnostic algorithm for cervical spine injury meets the presently required standards and maximizes care for the newly injured. The development, which can be followed using evidence-based medicine, is transparent and therefore aids the decision process when choosing an adequate diagnostic procedure.

EMS provider findings and interventions with a statewide EMS spine-assessment protocol

OBJECTIVE

To describe the utilization and findings with a statewide, prehospital spine-assessment protocol for emergency medical services (EMS) providers in a rural state.

METHODS

The study was a prospective sample of EMS patients evaluated by prehospital providers for trauma-related injury during a one-year investigation period. Prehospital providers prospectively completed supplementary spine data-collection forms that reported patient demographics and EMS provider findings with the spine-assessment protocol. Data were analyzed using descriptive statistics.

RESULTS

There were 207,545 EMS encounters during the study period, including 31,885 transports for acute trauma-related illness. Prehospital providers provided spine-assessment forms for 2,220 patient encounters. Providers reported a decision to immobilize 1,301 (59%) patients. For these immobilized patients, spine protocol findings included 416 (32%) patients deemed as unreliable, 358 (28%) with distracting injury, 80 (6%) with an abnormal neurologic examination, and 709 (54%) with spine pain or tenderness. Linkage of EMS and hospital data revealed seven acute spine fracture patients among the 2,220 reported encounters, all of whom were immobilized by EMS providers.

CONCLUSIONS

Use of this prehospital spine-assessment protocol resulted in an EMS provider decision not to immobilize approximately 40% of EMS trauma patients. Few spine fracture patients were encountered during the investigational period, though all were immobilized.

The National EMS Research strategic plan

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.

Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria

STUDY OBJECTIVE

We determine whether the use of an emergency medical services (EMS) protocol for selective spine immobilization would result in appropriate immobilization without spinal cord injury associated with nonimmobilization.

METHODS

A 4-year prospective study examined EMS and hospital records for patients after the implementation of an EMS protocol for selective spine immobilization. EMS personnel were trained to perform and document a spine injury assessment for out-of-hospital trauma patients with a mechanism of injury judged sufficient to cause a spine injury. The assessment included these clinical criteria: altered mental status, evidence of intoxication, neurologic deficit, suspected extremity fracture, and spine pain or tenderness. The protocol required immobilization for patients with a positive assessment on any of those criteria. Outcome characteristics included the presence or absence of spine injury and spine injury management.

RESULTS

The study collected data on 13,483 patients; 126 of the patients were subsequently excluded from the study because of incomplete data, leaving a study sample of 13,357 patients with complete data. Spine injuries were confirmed in the hospital records for 3% (n=415) of patients, including 50 patients with cord injuries and 128 patients with cervical injuries. Sensitivity of the EMS protocol was 92% (95% confidence interval [CI] 89.4 to 94.6%) resulting in nonimmobilization of 8% of the patients with spine injuries (33 of 415). None of the nonimmobilized patients sustained cord injuries. The specificity was 40% (95% CI 38.9 to 40.5%).

CONCLUSION

The use of our selective immobilization protocol resulted in spine immobilization for most patients with spine injury without causing harm in cases in which spine immobilization was withheld.