EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.
Issue link: https://emsworld.epubxp.com/i/90070
SPINAL IMMOBILIZATION had completed spinal injuries prior to immobilization. The authors concluded that in order to potentially benefit one person with spinal immobilization, 1,032 people would have to be immobilized. But in order potentially harm/contribute to one death, just 66 would have to be. Many other case-control studies have also examined this issue.6,17–22 A recent systematic review of the litera- ture pointed out the low rate of unstable fractures and the relatively rare appear- ance of patients with unstable spine Main Points to Remember Ţ NJMMJPO UP NJMMJPO QBUJFOUT SFDFJWF TQJOBM JNNPCJMJ[BUJPO FBDI ZFBS JO UIF 6 4 Ţ 0G TFWFSFMZ USBVNBUJ[FE QBUJFOUT Ř IBWF DFSWJDBM TQJOF GSBDUVSFT Ţ *O TFWFSFMZ USBVNBUJ[FE QBUJFOUT XF BSF DPODFSOFE BCPVU UIF Ř XJUI VOTUBCMF DFSWJDBM TQJOF GSBDUVSFT BOE JOUBDU TQJOBM DPSET potential for unstable cervical spine fractures is much smaller. It is with this group that we must consider the trade- offs with the complications of cervical spine immobilization. Several studies have examined the rate of cervical fracture among generic blunt-trauma patients, whose mechanisms included MVCs, falls from standing, falls from heights and assaults. In these commonly encountered patients, the rate of cervical fracture is 1.2%–3.3%,1,9–12 and the rate of cervical spinal cord injury is 0.4%– 0.7%.13,14 One of the larger studies of blunt- trauma patients with high-energy mecha- nisms had clear inclusion criteria and used a well-defined endpoint of clinically important cervical spine injury (essen- tially an unstable cervical spine fracture). In this Canadian system, patients with blunt assaults and falls from standing are generally not assessed for cervical spine injury. Among this cohort of patients with high-energy mechanisms, the rate of clini- cally important cervical spine injury was 0.6%.1,15 This study outlined a clear method (the Canadian C-Spine Rule) for evaluating patients with normal GCS and determining by exam those who do not have clinically important cervical spine injuries. This method has been validated in the field.15 Other criteria have also been well studied Ţ Ř PG QBUJFOUT XJUI VOTUBCMF DFSWJDBM TQJOF GSBDUVSFT QSFTFOU XJUI B DPNQMFUFE TQJOBM JOKVSZ Ţ 1BUJFOUT XJUI B MFTTFS NFDIBOJTN PG JOKVSZ XJMM IBWF TVCTUBOUJBMMZ MPXFS SBUFT PG to safely discriminate a subgroup without risk of cervical spine fracture.10 Many EMS systems have incorporated these methods of clinical clearance. Trauma expert Peter Rhee, MD, and colleagues did a retrospective study of 4,390 blunt-assault patients and noted a cervical spine fracture rate of 0.4% and cervical spinal cord injury rate of 0.14%.6 Only 4 (0.03%) of 51 patients with frac- tures were considered to be unstable. There has been no study that specifically examines patients who fall from standing. The subgroup that has been most studied is those who have penetrating trauma. One recent study led by Johns Hopkins' Elliot Haut, MD, examined the national trauma registry for such patients.16 The authors demonstrated a doubling of mortality among patients who received cervical spine immobiliza- tion. It is unclear whether this implies causality or is a proxy for more severe injury. From more than 30,000 patients with penetrating trauma, 443 (1.43%) had spine fractures, and 116 (0.38%) had unstable spine fractures. Of those with unstable spine fractures, 86 (74%) VOTUBCMF DFSWJDBM TQJOF GSBDUVSF Ţ 5IF SBUF PG VOTUBCMF DFSWJDBM TQJOF GSBDUVSF WBSJFT QSFEJDUBCMZ CZ UIF NFDIBOJTN PG JOKVSZ Ţ 'PS QBUJFOUT XJUI B MFTTFS NFDIBOJTN PG JOKVSZ DPOTJEFS MFTT SFTUSJDUJWF NFUIPET PG immobilization. Ţ $MJOJDBM DMFBSBODF GPS BXBLF QBUJFOUT XJUIPVU EJTUSBDUJOH JOKVSZ TIPVME CF BQQMJFE XIFO BQQSPQSJBUF Ţ 'PS QBUJFOUT XJUI QFOFUSBUJOH USBVNB DFSWJDBM TQJOF JNNPCJMJ[BUJPO JT OPU IFMQGVM BOE MJLFMZ IBSNGVM fractures and no neurologic deficits.23 The authors, led by LSU's Lance Stuke, MD, concluded there is no data to support routine spine immobilization in patients with penetrating injury to the neck, head or torso. They recommended the use of spinal immobilization only in the setting of obvious focal neurologic deficits. Following this logic, we could reach the same conclusion for patients who have suffered blunt assault and less- than-high-energy blunt trauma. Complications There are clearly clinical complica- tions with cervical spinal immobiliza- tion as it is currently practiced. Pain is almost universal with the use of a hard board,24–26 as well as the radia- tion and expense of x-rays and CTs. One recent study concluded that expo- sure to ionizing radiation (mostly from iatrogenic causes) is the leading envi- ronmental factor associated with breast cancer.27 There are other potential prob- lems with unclear clinical significance, such as mild respiratory compromise,28 increased intracranial pressure29,30 and EMSWORLD.com | NOVEMBER 2012 75 Photos by Dan Limmer