Spinal immobilization: Tipping the sacred cow once again
Spinal immobilization (SI) may be one of the most common trauma interventions implemented by pre-hospital professionals.
The goal of SI is to maintain an open spinal canal that allows flow of blood and cerebrospinal fluid (CSF) to the spinal cord. This has traditionally been accomplished by maintaining a neutral position. SI is also thought to reduce the risk of additional spinal injuries by limiting movement of bony fragments in unstable (displaced) fractures from causing further cord damage. How to most effectively achieve a neutral position remains a topic of enthusiastic professional discussion. It has driven our professional problem-solving as well as our industry's creative engineering for over three decades.
Scope of the Problem
The adverse effects of spinal immobilization
Dispelling myths and legends
The role of the pre-hospital professional
Successfully implemented by EMS agencies throughout North America for over a decade, pre-hospital professionals applied evidence-based physical exam criteria to select patients who were low-risk, or who met the spinal immobilization criteria outlined in the trial.6 The impetus for spinal clearance is also supported by recent literature that demonstrates that some trauma patients with penetrating trauma experience worse outcomes when spinal immobilization is implemented. In addition, there are a growing number of patients who refuse SI because it is uncomfortable.
It has been over ten years since Fresno County EMS and others successfully implemented selective immobilization protocols. Yet, many EMS entities have not implemented similar clearance protocols despite the growing body of evidence. Taking the "bull by the horns," some EMS agencies report increased patient satisfaction scores after implementation of SI protocols.
The spirit of spinal clearance reflects the case of other major trauma injuries -- mechanism of injury (MOI) may serve as a poor predictor of SCI. Therefore, a meticulous and systematic assessment process may best predict and identify trauma injuries.
For instances in which SI is indicated, EMS must advocate for the usage of more comfortable spinal immobilization devices. We must work proactively with ED staff to rapidly clear patients and remove them from immobilization. EMS agencies must seek opportunities to actively participate in the development of spinal clearance protocols. As patient advocates, we must demand active SI quality assurance programs, maintain our competencies, and stay informed of current evidence-based practices.
2. Bernhard, M., A. Gries, P. Kremer, and B. Bottiger. "Spinal Cord Injury (SCI)—Prehospital Management." Resuscitation 66, no. 2 (March 1, 2005): 127-39. doi:10.1016/j.resuscitation.2005.03.005.
3. Vaillancourt, C., M. Charette, A. Kasaboski, J. Maloney, G. A. Wells, and I. G. Stiell. "BioMed Central | Full Text | Evaluation of the Safety of C-spine Clearance by Paramedics: Design and Methodology." BioMed Central | The Open Access Publisher. February 1, 2011. Accessed July 18, 2011. http://www.biomedcentral.com/1471-227X/11/1.
4. Orledge, Jeffrey D., and Paul E. Pepe. "Out-of-hospital Spinal Immobilization: Is It Really Necessary?" Academic Emergency Medicine 5, no. 3 (March 1998): 203-04.
5. Hauswald, M., M. Hsu, and C. Stockoff. "Maximising Comfort and Minimizing Ischemia: A Comparison of Four Methods of Spinal Immobilization." Prehospital Emergency Care 4, no. 3 (2000): 250-52.
6. Stiell, Ian G., George A. Wells, Katherine L. Vandemheen, Catherine M. Clement, and Howard Lesiuk. "The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients." JAMA 286, no. 15 (October 17, 2001): 1841-848.
Dean Meenach, RN, BSN, CEN, CCRN, CPEN, EMT-P has taught and worked in EMS for more than 20 years and currently serves as Director of EMS Education/Paramedic Instructor and co-teacher in the Paramedic to RN Bridge Program at Mineral Area College. He has served as a subject matter expert, author, national speaker, and collaborative author in micro-simulation programs. Dean continues to serve patients part time as a member of a stroke team and in a pediatric and adult trauma center. He can be reached at firstname.lastname@example.org.
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