MEMORANDUM

DATE:             November 23, 2015                                          

TO:                  Louisiana EMS Education Programs

CC:                  Louisiana EMS Providers

FROM:             Donnie Woodyard, Jr.

RE:                   SPINAL PRECAUTIONS – EMS EDUCATION, TESTING, PRACTICE

The Bureau of EMS is committed to ensuring that the Louisiana EMS System is prepared to provide excellent out-of-hospital medical care. With this commitment, it is important for the Bureau of EMS to publish advancements, adjustments, and changes to the standard of care and EMS educational guidelines.

In coordination with the position statements from the American College of Emergency Physicians, the National Association of EMS Physicians, the American College of Surgeons Committee on Trauma, and the American Heart Association, the Bureau of EMS is amending our EMS Education and EMS Examination standards related to the use of spinal immobilization and the long spine board (LSB) for the purpose of transporting a patient to emergency departments.

Although numerous esteemed committees of experts have published statements related to the utilization of long spine boards, the statement from the American College of Emergency Physicians provides a succinct analysis and a clear recommendation, accepted by the Louisiana Bureau of EMS as a standard of care:

The American College of Emergency Physicians believes that current out-of-hospital management practices of patients with potential spinal injury lack evidentiary scientific support. Practices which attempt to produce spinal immobilization include the use of backboards, cervical collars, straps, tape, and similar devices (e.g., sand bags, head wedges). Evolving scientific evidence demonstrates that some of these current out-of-hospital care practices cause harm including airway compromise, respiratory impairment, aspiration, tissue ischemia, increased intracranial pressure, and pain, and can result in increased use of diagnostic imaging and mortality.

 

Historically, the terms “spinal immobilization” and “spinal motion restriction” have been used synonymously. However, true “spinal immobilization” is impossible. “Spinal motion restriction” in this policy refers to the preferred practice, which attempts to maintain the spine in anatomic alignment and minimizes gross movement, and does not mandate the use of specific adjuncts.

 

EMS medical directors should provide evidence-based spinal motion restriction protocols and procedures that describe specific indications and contraindications for application of spinal motion restriction. The role of adjuncts (e.g., cervical collars) should be specifically addressed. The use of spinal motion restriction procedures and adjuncts should not interfere with critical airway management and other time-critical interventions, such as hemorrhage control, or rapid transport. Spinal motion restriction procedures may require modification for certain conditions (e.g., rescue, vehicle racing, contact or extreme sports) as determined by the EMS medical director.

 

Spinal motion restriction should be considered for patients who meet validated indications such as the NEXUS criteria or Canadian C-Spine rules. Spinal motion restriction should be considered for patients with plausible blunt mechanism of injury and any of the following:

• Altered level of consciousness or clinical intoxication

• Mid-line spinal pain and/or tenderness

• Focal neurologic signs and /or symptoms (e.g., numbness and/or motor weakness)

• Anatomic deformity of the spine

• Distracting injury[1]

 

Backboards should not be used as a therapeutic intervention or as a precautionary measure either inside or outside the hospital or for inter-facility transfers. Spinal immobilization should not be used for patients with penetrating trauma without evidence of spinal injury.

 

EMS medical directors should assure EMS providers are properly educated on assessing risk for spinal injury and neurologic assessment, as well as on performing patient movement in a manner that limits additional spinal movement in patients with potential spinal injury. Patient movement and transfer practices should be coordinated with receiving facility personnel.

 

Impact On EMS Education

EMS Education programs, at all levels of instructions, should amend EMS education to reflect the evidence based changes related to spinal precautions in the out-of-hospital environment.  EMS Practitioner training should now include the following general concepts:

·         Replacement of the concept of ‘spinal immobilization’ with ‘spinal motion restriction’ and ‘spinal precautions’

·         Spinal precautions should not be utilized for patients suffering from penetrating trauma, unless a specific neurological deficit indicative of a spinal injury is present on physical exam

·         Ability to utilize the NEXUS criteria or the Canadian C-Spine Rule to determine if a patient, with a substantial blunt traumatic injury, requires spinal precautions.

·         Application of a properly sized cervical collar for patients that have both a mechanism of injury and a positive clinical assessment

·         Utilization of scoop stretchers for movement and transfer of patients to stretchers with suspected spinal injuries

·         It is appropriate to transport patients with spinal precautions with a cervical collar directly on a stretcher-cot in a position of comfort, typically supine or in a semi-fowlers position

·         Long spine boards are an effective ‘extrication device’

 Cognitive Objectives

·         The student will be able to define Spinal Motion Restriction

·         The student will assess a patient for the need of Spinal Motion Restriction

·         The student will identify high risk vs low risk patients for spinal cord injury

·         The student will list what devices could be used for Spinal Motion Restriction

·         The student will list detrimental effects of traditional Spinal Immobilization

 

Psychomotor Objectives

·         The student will be able to demonstrate proper Spinal Motion Restriction techniques

·         The student will be able to remove a patient from a long backboard and on the ambulance stretcher

·         The student will be able to appropriately move a patient from supine, prone, seated and standing positions, to the ambulance stretcher while maintaining Spinal Motion Restriction

·         The student will demonstrate removing a patient from a long backboard to the ambulance stretcher with long backboard on the stretcher

·         The student will demonstrate proper patient transfer from the ambulance stretcher to the hospital stretcher while maintaining Spinal Motion Restriction

Affective Objectives

·         Student values the need for reduced traditional Spinal Immobilization

·         The student will appreciate the negative effects of Spinal Immobilization

·         The student will value the need for proper Spinal Motion Restriction in all patient movements

·         The student will value the team-work approach to maintaining Spinal Motion Restriction and patient transfers

Impact On Louisiana Administered NREMT Examinations

·         EMR and EMT Candidates should be able to demonstrate the safe and proper use of a long spine board, if indicated, as an extrication device or as a patient movement device, including the application of an appropriate strap system and the application of a cervical collar. 

·         For EMR and EMT Candidates, utilization of the long spine board will be a random skill station.

·         EMR and EMT Candidates should be able to differentiate between patients that do and do not require spinal motion restrictions / spinal precautions

·         Advanced-EMT and Paramedic exams will be administered in strict adherence with examination standards published by the National Registry of EMTs.

 

Impact Agency Specific EMS Protocols

EMS agency specific protocols are implemented by EMS Medical Directors and Parish Medical Societies.  Although this memo is specifically related to EMS Education and Examination standards, the Bureau of EMS recognizes the preponderance of evidence available that indicates traditional spinal immobilization techniques, including the broad application of the long spine board, have been correlated to negative impacts on patient outcomes.   The Bureau of EMS encourages EMS Medical Directors to review references to spinal immobilization in current operational protocols while considering the NASEMSP and ACEP position statements. 

 

Enc:     Bibliography
Reference Documents



[1] Note - There is an increasing amount of controversy in trauma literature surrounding the concept of a ‘distracting injury.’ A growing body of research suggests the concept of ‘distracting injury’ is poorly defined and, apart from the presence of chest trauma, unfounded. A distracting injury is more than the presence of a physiologic injury (ie., long bone fracture), the current concept implies the patient is distracted by so much pain a physical exam is unreliable.