Tools
EMS Immobilization Techniques
Introduction
Emergency medical services (EMS) personnel remain the first-line responders for the majority of out-of-hospital emergencies, including trauma situations. The ATLS guidelines (advanced trauma life support), developed in the 1980s, remain the gold standard for assessing and prioritizing the management of life-threatening injuries in a time-efficient, logical manner. Immobilization of the spine has been an essential part of the teaching in addition to pelvic binders and splinting of long bone fractures. Different types of medical equipment have been developed to enhance effectiveness and ease of application, while also providing flexibility and vital access for the management of airway and other procedures.
The need for spinal immobilization is determined during scene assessment and patient evaluation. Consider spinal immobilization when the mechanism of injury creates a high index of suspicion for head or spinal injury. Altered mental status and neurologic deficit are also indicators that spinal immobilization should be considered.[1][2][3][4] The traditional ATLS teaching for adequate spinal immobilization of a patient in a major trauma situation is a well-fitted hard collar with blocks and tape to secure the cervical spine, in addition to a backboard to protect the rest of the spine. Other devices currently in use are the scoop stretcher and the vacuum splint. The Kendrick extrication device protects the spine while the casualty is in a seated position during rapid extrication from a vehicle or other situations with limited access, allowing a full backboard. This, however, still requires the EMS to pay attention to limiting cervical spine movement using in-line mobilization until fitted.[5]
The 10 edition of the ATLS guidelines and the consensus statement of the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, National Association of EMS Physicians (NAEMSP) states that in the situation of penetrating trauma, there is no indication for spinal movement restriction this in keeping with a retrospective study of the American trauma data bank showed a very low number of unstable spinal injuries needing surgery in the context of penetrating trauma.[6] The study also demonstrates that the number needed to treat to achieve a potential benefit was far higher than the number needed to harm, at 1032 compared with 66. However, in the case of significant blunt trauma, the restrictions continue to be indicated in the following situations:
- Low Glasgow coma scale or evidence of alcohol and drug intoxication
- Midline tenderness in the back of the cervical spine
- Obvious spinal deformity.
- The presence of other distracting injuries
Issues of Concern
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Issues of Concern
There is a growing body of evidence and concern that field triaging has led to the overuse of spinal immobilization methods and that some patients are potentially coming to harm.[7][8][9][10]. Potential problems with spinal immobilization:
- Discomfort and distress for the patient.[11]
- Lengthening the prehospital time with a potential delay of important investigations and treatment, in addition to interfering with other interventions.[11]
- Restriction of respiration can occur when straps limit chest wall movement, and respiratory function is already reduced in the supine position compared with upright positioning. This effect is particularly significant in patients with blunt or penetrating chest trauma.[12][13] The use of such restraints may also increase the difficulty of intubation.[14]
- The case of patients with ankylosing spondylitis or preexisting spinal deformity, where actual harm could be caused by forcing the patient to conform to the predetermined position of a rigid cervical collar and backboard.[15]
A new Scandinavian literature review, which was carried out to assess the available evidence on spinal movement restrictions, provides valuable insights into comparing methods of prehospital spine stabilization and evaluating the strength of the evidence.[16]
Hard Collar
The hard collar has been used since the mid-1960s to stabilize the cervical spine, with low-quality evidence supporting a positive influence on neurological outcomes after cervical spine injury, but also with notable risks, including increased intracranial pressure and dysphagia.[17] It also suggests that an alert, cooperative patient with muscle spasm from injury is unlikely to experience significant displacement, as shown in cadaveric studies assessing the effect of injury. Balancing the risks and benefits of this intervention is therefore advised. The American Association of Neurological Surgeons, however, continues to recommend the hard collar for cervical spine stabilization in pre-hospital settings.[18]
Hardboard
The original spinal longboard has been used in conjunction with the hard collar, blocks, and straps to achieve spinal immobilization. There is currently evidence of the potential harm, especially pressure sores, over the sacrum.[19][20] This is particularly true in the case of spinal injury with no protective sensation. The soft vacuum mattress offers a more gentle surface that protects against the effects of pressure sores while providing enough support when extended above the level of the head.[16]
Blocks
Blocks have been part of the in-line mobilization strategy for spine stabilization. It seems effective when strapping the patient onto a spinal board to achieve a degree of immobilization, with no added benefit from using the hard collar in conjunction.[21]
Vacuum Mattress
When comparing the vacuum mattress with hardboard alone, the mattress offers greater control and less movement during application and lifting.[22] Given the risk of pressure sores, the mattress appears to be a better option for patient transport.
Clearing the Spine
The NEXUS criteria: an alert person not intoxicated without having any distracting injury has a very low probability of injury in the absence of midline tenderness, neurological deficiency. This seems to be a sensitive screening tool with 99% sensitivity and 99.8% negative predictive value.[23] However, other observational studies have suggested that an alert patient with a cervical spine injury should seek to stabilize his spine, and that the presence of distracting injuries (excluding the chest) does not affect clinical examination findings of the cervical spine; therefore, the spine can be cleared clinically without further imaging.[24] Other studies also report similar findings in the thoracolumbar spine.[25][24]
Clinical Significance
While prehospital spinal immobilization has been performed for decades, current data indicate that not every patient needs to be immobilized. Now, the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma recommend limited use of spinal immobilization. These latest guidelines indicate that the number of patients who may benefit from immobilization is very small. The committee went on to state that empirical utilization of the spinal backboards during transport should be used with caution, as in some cases their potential risks outweigh the benefits. Further, in patients who have sustained penetrating trauma and have no obvious neurological deficit, the use of spinal immobilization is not recommended. The EMS worker must use clinical acumen before deciding to use the spinal board.[26] Finally, spinal immobilization has been associated with back pain, neck pain, and making it very difficult to perform some procedures, including imaging. Spinal immobilization has also been associated with respiratory difficulties, especially when large chest straps are applied.
While many EMS organizations have adopted these new spinal immobilization guidelines, this is not universal. Some EMS systems fear litigation if they do not immobilize patients. Patients who should have spinal immobilization include the following:
- Blunt trauma
- Spinal tenderness or pain
- Patients with an altered level of consciousness
- Neurological deficits
- An obvious anatomic deformity of the spine
- High energy trauma in a patient intoxicated from drugs, alcohol, or a distracting injury.
References
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