Strict or Precautionary

 

When I was a young paramedic in the late 1970s the protocols for using backboards were simple. Any patient with suspected trauma, minor or major, got a cervical collar before being tightly secured to a backboard with tape. Otherwise, a paramedic risked added continuing education, reprimand and a possible lawsuit. When in doubt immobilize to the point of mummification. Of course, patients complained during transport about discomfort. The lack of a bolster behind the knees caused backs to ache. Bounce over some railroad tracks and tightly taped foreheads hyperextended the patients’ necks, compromising the entire immobilization effort.

Today, these protocols are changing, according to the American College of Emergency Physicians (ACEP) and the National Association of EMS Physicians (NAEMSP).

In January of 2015, ACEP released a position statement regarding the EMS spinal precautions and the use of the long backboard. This statement says the benefit of long backboards to immobilize the spine is unproven. It can induce pain, patient agitation and respiratory compromise. It can also decrease tissue perfusion at the pressure points, leading to development of pressure ulcers. Long backboards should be used judiciously so that potential benefits outweigh the risks.

Use of backboard for spinal immobilization is prescribed in cases that include:

● Blunt trauma and altered level of consciousness

● Spine pain or tenderness

● Neurologic complaint (numbness or motor weakness)

● Anatomic deformity or the spine

● High-energy mechanism of injury including, drug or alcohol intoxication, inability to communicate and distracting injury.

Anybody see a lawsuit waiting to happen? For years paramedics have been told not to diagnose patients, only assess the damage and treat what is seen. At the risk of being overly dramatic, under these new protocols paramedics will need diagnostic abilities equivalent to Superman with X-ray vision.

Patients for whom spinal immobilization on a backboard is not necessary include:

● Normal level of consciousness (Glasgow Coma Score [GCS]15);

● No spine tenderness or anatomic abnormality;

● No neurologic finds or complaints;

● No distracting injury;

● No intoxication

There are some exceptions. Patients with penetrating trauma to the head, neck or torso and no evidence of spinal injury – here is where we will need Superman’s X-ray vision -- should not be immobilized on a backboard. Spinal precautions can be maintained using a rigid cervical collar and securing the patient firmly to the EMS stretcher. This may be appropriate for:

● Patients found ambulatory at the scene;

● Patients who must be transported for a protracted (drawn out) time, particularly prior to inter-facility transfer;

● Patients for whom a backboard is not otherwise indicated. This leaves us with two levels of spinal immobilization:

● Strict spinal immobilization (backboard and cervical collar);

● Spinal precautions (use cervical collar and secure the patient firmly to the stretcher).

Mechanism of injury rather than symptoms and physical findings persists as the primary indication for spinal immobilization in nearly all U.S. EMS systems. Transport should not aggravate spinal column injuries. However, George Lindbeck, MD, Virginia State EMS and Trauma Systems medical director, cites other considerations in his presentation “Spinal Immobilization: How Rigid Do We Need to Be?”

He outlines risks of airway compromise, aspiration, increased intracranial pressure, cutaneous pressure ulcers iatrogenic pain, increased difficulty in patient handling, combativeness, resistance and increased cost.

In an article called “An Evidence Review of Prehospital Spinal Immobilization” published in November 2015, the new Canadian guidelines/standard is mapped out in simple terms.

The figure on page 15 shows the Canadian C-spine (CCR)1

Modern EMS personnel have already changed their approach based on some of the criteria outlined in this article. In Dallas, TX, paramedics can now opt for or against the rigid backboard. But, ultimately, paramedics must follow any protocols outlined by their own medical director.

Trailblazer Sherrie C Wilson was the first female firefighterparamedic in the Dallas Fire Rescue Department. During her nearly 35-year tenure she experienced every short of human trauma including resilience, love and hate. Skills honed by firefighting and saving lives prepared her for further community service as a Health, Safety and Communications educator, advisor to EMS organizations, a leadership role in the American Heart Association, and as a National and International speaker, trainer, workshop presenter, author and show host. Now retired from the fire department, Sherrie serves as founder and president of Emergency Management Resources, LLC (www.emresources.net) and FireHouseCommunications. com, LLC (www.firehousecommunications.com). She also serves as adjunct faculty member for Texas A&M, Texas Engineering Extension Service (TEEX).