The days of immobilizing anyone with any mechanism that might possibly cause a spinal injury are coming to an end. I’m not just talking about the standard selective spinal immobilization guidelines that have been spreading across the country over the last ten years, including the BLS level. I am talking about spinal immobilization boards being used for nothing other than to aid in moving patients.
Progress is slow, but lately, this engine has gathered mighty steam. Rogue Medic in The Slow, Agonizing Death of Conventional Spinal Immobilization recently reported that members of the National Association of Emergency Medical Services Physicians were circulating the following draft statement for the larger group’s consideration:
The National Association of EMS Physicians believes that:
There is no demonstrated outcome benefit of maintaining rigid spinal immobilization with a long backboard during EMS transport of a trauma patient.
The long backboard can induce respiratory compromise, patient agitation and additional pain. Further, the backboard can decrease tissue perfusion at pressure points, leading to the development of pressure sores.
A long backboard or similar device may be useful to facilitate spinal precautions during patient extrication.
Patient time on long backboards should be minimized.
Securing a trauma patient to an EMS stretcher without a long backboard whether or not a cervical collar is being used is acceptable for maintaining spinal precaution during transport.
Implementation of protocols that deemphasize the use of the long backboard should involve all affected partners in the EMS system.
NAEMPS recently held their annual meeting. I don’t know if they formally addressed the issue, but their Facebook page mentions that a study on the biomechanics of spinal immobilization won the prize for best scientific presentation. The bottom line of the study, (BIOMECHANICAL ANALYSIS OF SPINAL IMMOBILIZATION DURING PREHOSPITAL EXTRICATION: A PROOF-OF-CONCEPT STUDY by Mark Dixon, Joseph O’Halloran, Niamh Cummins, University College Dublin) “Standard extrication techniques cause up to four times more cervical spine movement during extrication than controlled self-extrication.” The presentation evidently received a standing ovation.
In Prehospital spine immobilization for penetrating trauma–review and recommendations from the the Prehospital Trauma Life Support Executive Committee, published in the Journal of Trauma in 2011, the authors recommended the following:
• There are no data to support routine spine immobilization in patients with penetrating trauma to the neck or torso.
• There are no data to support routine spine immobilization in patients with isolated penetrating trauma to the cranium.
• Spine immobilization should never be done at the expense of accurate physical examination or identification and correction of life-threatening conditions in patients with penetrating trauma.
• Spinal immobilization may be performed after penetrating injury when a focal neurologic deficit is noted on physical examination although there is little evidence of benefit even in these cases.
Mark Hauswald the author of the startling 1998 study that showed that unimmobilized spinal patients in Malaysia did better than the immobilized spinal patients in New Mexico, recently published an outstanding article in the September 2012 Emergency Medical Journal called A re-conceptualisation of acute spinal care.
He writes: “There is little scientific support for many of the recommended interventions and there is evidence that at least some methods now used in the field are harmful. Specific treatments that are irrational and which can be safely discarded include the use of:
Backboards for transportation
Cervical collar use except in specific injury types
Immobilization of ambulatory patients on backboards
Prolonged attempts to stabilize the spine during extrication
Mechanical immobilization of uncooperative or seizing patients
Forceful in line stabilization during airway management.”
In our state, the Yale New Haven Sponsor Hospital Program recently released the following statement for their sponsored EMS services:
“Effective immediately, long backboards will no longer be utilized for spinal immobilization of ambulatory patients. Patient who are ambulatory at the scene, but who require cervical immobilization based on our selective spinal immobilization protocol, will be placed in the position of comfort, limiting movement of the neck during the process. This change in procedure is the first step toward eventually using long boards only when needed to facilitate extrication, and not during transport.”
Our region is considering draft language to limit the use of long boards for ambulatory patients, patients with penetrating trauma and patients during interfacility transport, as well as to remind paramedics that the goal is to limit force against the neck. Patients who are agitated, seizing, or have difficulty breathing should not be forced onto a long back board to protect against the theoretical possibility of a spine injury.
This is a huge change for EMS, but we should all welcome it. Spinal immobilization was a concept instituted in the belief that it might prevent rare spinal injuries from growing worse. There was never any solid evidence to support it, and now more and more evidence is piling up that the practice is not only uncomfortable for patients, but harmful.