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1、EMS Field CervicalSpine Assessment ProtocolVVEMSTodd Lang, MD EMS Medical Director1VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Why do this?Current practice it totally variableClear, reproducible local standardEasy tool to measure complianceFormal training in cspine evaluationCan m
2、odify in future to incorporate new data2VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议ObjectivesDiscuss Risk & Benefit of C Spine ImmobilizationIdentify ways to safely lower use of C Spine ImmobilizationReview structure and function of the nervous system3VermontEMSDistrict3SpinalImm
3、obilizationProtocol佛蒙特州的EMS区3脊柱固定协议ObjectivesIdentify situations in which full immobilization is indicatedIdentify situations in which full spinal immobilization is not indicated Review VVEMS spinal assessment protocolMaintain appropriate level of suspicion for this dangerous but rare condition4Verm
4、ontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议We use the words “Spinal Assessment” to indicate that we are evaluating the spine for risk of injury. We are not “Clearing” it or guaranteeing that there are no injuries. We are using medical evidence to formulate a policy to balance the ris
5、ks and benefits of immobilization for the bulk of our patients.Terminology5VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Who can use this protocol?Only those EMS providers who have successfully completed the training for the VVEMS Spinal Assessment.This be the didactic portionThen,
6、pass the testThen use it!6VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议What is “NEXUS?”National Emergency X-radiography Utilization StudyProspective study with 34,069 patientsEvaluated decision rule to identify patients with cervical injury by clinical exam who did not need radiogr
7、aphy7VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议How do we decide in the ED?Two main studiesNEXUSCanadian C-Spine Rule8VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议NEXUSOut of 34,069 patients, the decision rule identified 810 of 818 patients with injury2% of blun
8、t trauma patients had cervical injuryTwo patients classified as “unlikely to have injury” actually had a cervical injury.One of the two one missed patients required surgery.9VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议NEXUSDid not include MOIDid include: altered LOC/intoxication,
9、Midline tenderness, distracting injury, neuro exam, Up to age 6010VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Stable, GCS 15 pts. A dangerous mechanism is considered to be a fall from an elevation of =3 feet or 5 stairs; an axial load to the head (e.g., diving); a motor vehicle co
10、llision at high speed (100 km per hour) or with rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision. A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit
11、by a high-speed vehicle.Canadian C Spine Rule11VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Does C-Spine Immobiliztion Work?No one really knows.12VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Hauswald StudyCompared Malaysian patients to New Mexico patients.Worse ou
12、tcomes from New Mexico spinal cord injuries: more likely to have disabilityNot definitive, but very provocativeNo evidence to the contrary, either, yet13VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Benefits of Immobilization“Standard of Care”May prevent injury worseningThought to p
13、revent liabilityNot so convincing, are they?14VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Harms of C-spine ImmobilzationPainAnxietyMore radiographs and CT scansMoneyPressure soresHarder to manage airwayChange in lung function15VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EM
14、S区3脊柱固定协议Why immobilize anyone?Unstable cervical injury is rare.Any protocol needs to: emphasize safety (sensitivity) over efficiency (specificity)balance the small benefit of avoiding spinal immobilization in the many patients without injury against the possibly catastrophic harm associated with fa
15、iling to immobilize the rare patient with significant spinal injury16VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议The SkullMade up of bones that form immovable jointsKnow the “helmet” bones of the skull:Frontal, parietal, temporal, and occipitalImportant in describing injury locati
16、onMandible = the lower jaw boneMaxilla =the upper jaw bone17VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议SkullTemporal bone (Basilar) skull fractures often diagnosed by examRaccoon eyesBattles signThe middle meningeal artery runs within the temporal and parietal bonesFractures asso
17、ciated with epidural bleeding18VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Skull ExamLumps, dents, wounds: describe by location and size and structures seenEars: blood or not, TM normal or notGCS: dont say “in & out.” Use a number.Pupils/CN examJaw function, voice, airway19Vermont
18、EMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议CSF (cerebrospinal fluid) bathes brain and spinal cordPatient with closed head injury who has a “runny nose” is leaking CSF (basilar skull fracture)Can also come out of ears20VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议The Sp
19、ineCervical (7)Thoracic (12)Lumbar (5)Sacral 5 (1 fused)Coccyx 4(1 fused)21VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议The VertebraeThe spinal cord rests between the bony processes and body of the vertebrae.The spine of the vertebra is superficial and can be palpated when performi
20、ng a physical exam. 22VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Spinal CordPart of the central nervous system (CNS)Nerves leaving each vertebra have a specific function.Bathed in cerebrospinal fluid (CSF).Protected by bony vertebrae.23VermontEMSDistrict3SpinalImmobilizationProto
21、col佛蒙特州的EMS区3脊柱固定协议Cervical nerves“C3,4,5 keeps the diaphragm alive!”C1C2neck rotation and sensationC3spontaneous breathingC4spontaneous breathingC5diaphragm, shrugging shouldersC6flexion of elbowC7extension of elbow24VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Cases Requiring Ful
22、l Immobilization1.Higher Risk or unknown mechanism of injury2.Altered LOC (GCS65) falling out of bed or from standing height.Ejection or fall from motorized or human powered transportation device.Axial load (diving).Unwitnessed loss of consciousness/syncope with head trauma27VermontEMSDistrict3Spina
23、lImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Mechanism of InjuryA relatively weak tool, but one which is easy and free.One which has been used more in the past than in the present and futureNo really good data to tell us “what MOI can give you a spinal injury?”We will use this as a part of our first revis
24、ion of spinal immobilization protocol28VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Altered Level of AlertnessClearance of the cervical spine requires that the patient be calm, cooperative, clinically sober, and alert. Includes patients that are poor historians.Children and toddler
25、sSome elderly: are they altered from usual?Generally, GCS must be 15 to clear spine29VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Reliable Physical ExamLanguageGCS/Capacity/reproducibilityHearingAbility to sense pain30VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议L
26、OC/IntoxWhat about “2 beers?”Chronic drunks?Chronic narcotics?Other drugs like meth?Just anxious?No clear answer from literatureProbably more to lose than to gain in this group by not immobilizing31VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Distracting InjuryOf variable useSome i
27、njuries are more distracting than othersNot part of Canadian C-S ruleIs part of NEXUS, but was left up to the attending physician to define itPart of EMS criteria for nowLess used in ED assessment now32VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Presence of Distracting InjuryAny i
28、njury that produces pain that impairs the patients ability to appreciate other injuries:Head injuryLong bone fracturesLarge lacerationsAbdominal or pelvic painLarge burnsMedical conditions: cardiac pain or difficulty breathingThis is an equivocal and poorly defined conceptWill remain a part of our E
29、MS algorithm.33VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Subjective Neurological DeficitPatient complains of numbness, tingling, pins and needles, shooting arm pain, etc.Patient complains of decreased strength or decreased ability to move limbsAny patient who describes transient
30、 numbness and tingling should be fully immobilized even if symptoms have resolved34VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Subjective Spine PainPatient complains of cervical or thoracic spine pain.“Do you have any neck or back pain?”If yes, immobilize.35VermontEMSDistrict3Spin
31、alImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Objective Neurological DeficitPatient cannot move an extremityPatients extremities are flaccid(Patient has abnormal motor reflexes)Generally: grips, push pull, flex/extend feet, intact gross sensory in all 4.36VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特
32、州的EMS区3脊柱固定协议Objective Spine TendernessPatient has tenderness upon palpation of the cervical or thoracic spine.You must palpate each cervical and thoracic vertebraContinue down spineApply an axial load to top of head37VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Practice exam!Demo
33、up front 2 peopleSame every time you do itYou wont forget a step that way.Stop at first positive sign and immobilize.Dont do ROM if they have pain, n/t, or other sign!38VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Other Exam AbnormalityYour physical exam reveals:SwellingBruising or
34、 rednessAbrasionsDeformity39VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Abnormal Motor or SensoryThis has room for error and was source of error in the studies of C-SPain down arm/leg, numb/tingle, even transient sxBony Tenderness (midline, on the spine)Pain with ROM40VermontEMSDi
35、strict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Beware the “Stinger”Transient shooting pain down the armCommon in footballThis is a subjective neuro sign and is grounds for concern and immobilizationYou cant get this without injury to a nerve41VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的E
36、MS区3脊柱固定协议Pain with Unassisted Neck MotionIf ALL of the previous criteria have been satisfied, the final step is to ask the patient to move their neck without your assistance.If the patient has any subjective pain, they need to be fully immobilized.“Look to the left and right. Now touch your chin to
37、 your chest. Now look back over your head.”42VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Bottom Line:Can they reliably, reproducibly, and convincingly understand you, cooperate, and pay attention for the exam and have a MOI that should not have broken their neck?If not, immobilize
38、.43VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Guiding PrinciplesThe VVEMS Spinal Assessment Protocol is designed to allow EMS providers to assess and transport those few blunt trauma patients for whom significant injury is unlikely without full immobilization.Once one criterion f
39、or immobilization is positive, immobilize and transport the patient.44VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Guiding PrinciplesPatients who satisfy all of the criteria in the Protocol and who request EMS transport may be transported without full spinal immobilization.All Prot
40、ocol criteria must be carefully evaluated and documented for all patients transported without full spinal immobilization.45VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议VVEMS C-Spine Assessment ToolHigher risk MOI?NoNoFull Spinal ImmobilizationAltered level of alertness?Distracting
41、injury?Objective or subjective neurological deficit?Pain with unassisted neck motion?Transport without full spinal immobilizationNoNoNoNoYesYesYesYesNoNoNoNoYesYesYesYesNeck pain or tenderness?NoNoYesYesYesYes46VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Sample DocumentationMVC lo
42、w speedGCS15, clear speechNo numb/tingle/pain down arms, moves all 4No sig injuriesNo spine tendernessNormal ROM w/o painImmob not indicated47VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Maine 2002 C-spine48VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议49VermontEMS
43、District3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Guiding PrinciplesEMS providers should involve online medical direction for any difficult cases, including patients who meet criteria for spinal immobilization, request EMS transport, and refuse immobilization.If a patient requests transport with
44、full immobilization, EMS providers should comply with their wishes independent of significant injury risk.50VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Guiding PrinciplesThe default management of any blunt trauma patient in the field is full immobilization.EMS providers must use f
45、ull c-spine immobilization for cases that are vague.Let us err on the side of caution because a single bad outcome will cause endless suffering51VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议ConclusionAlways use full immobilization for patients with an unknown or significant MOI.Eld
46、erly patients are more prone to orthopedic injuries and may not present with obvious signs and symptoms of injury. Contact online Medical Direction for questions in the field.52VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议ConclusionA patient with blunt trauma should be fully immobi
47、lized unless ALL criteria of the VVEMS Spinal Assessment Protocol are met.53VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Dont fall asleep at the wheel just because spine injuries are rare! Assess each patient carefully!54VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定
48、协议SourcesMaine 2002 Spinal Assessment Protocol Hauswald M, et al. Out-of-hospital spinal immobilization: its effect on neurologic injury EAST Practice Management Guidelines for Identifying Cervical Spine Injuries Following Trauma Canadian C-Spine ruleNEXUS paper55VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议Questions?56VermontEMSDistrict3SpinalImmobilizationProtocol佛蒙特州的EMS区3脊柱固定协议
