Notes – Spinal Care

Spinal Care

Patient Safety Considerations

  1. Be aware of potential airway compromise or aspiration in immobilized patient with nausea/vomiting, or with facial/oral bleeding
  2. Excessively tight immobilization straps can limit chest excursion and cause hypoventilation
  3. Prolonged immobilization on spine board can lead to ischemic pressure injuries to skin
  4. Prolonged immobilization on spine board can be very uncomfortable for patient
  5. Children are abdominal breathers, so immobilization straps should go across chest and pelvis and not across the abdomen, when possible
  6. Children have disproportionately larger heads. When securing pediatric patients to a spine board, the board should have a recess for the head, or the body should be elevated approximately 1-2 cm to accommodate the larger head size and avoid neck flexion when immobilized
  7. In an uncooperative patient, avoid interventions that may promote increased spinal movement
  8. The preferred position for all patients with spine management is flat and supine. There are three circumstances under which raising the head of the bed to 30 degrees should be considered:
    1. Respiratory distress
    2. Suspected severe head trauma
    3. Promotion of patient compliance

Notes/Educational Pearls

Key Considerations

  1. Evidence is lacking to support or refute the use of manual stabilization prior to spinal assessment in the setting of a possible traumatic injury, when the patient is alert with spontaneous head/neck movement
    1. Providers should not manually stabilize these alert and spontaneously moving patients, since patients with pain will self-limit movement, and forcing immobilization in this scenario may unnecessarily increase discomfort and anxiety
  2. Certain populations with musculoskeletal instability may be predisposed to cervical spine injury. However, evidence does not support or refute that these patients should be treated differently than those who do not have these conditions. These patients should be treated according to the Spinal Care guideline like other patients without these conditions
  3. Age alone should not be a factor in decision-making for prehospital spine care, yet the patient’s ability to reliably be assessed at the extremes of age should be considered. Communication barriers with infants/toddlers or elderly patients with dementia may prevent the provider from accurately assessing the patient
  4. Spinal precautions should be considered a treatment or preventive therapy
  5. Patients who are likely to benefit from immobilization should undergo this treatment
  6. Patients who are not likely to benefit from immobilization, who have a low likelihood of spinal injury, should not be immobilized
  7. Ambulatory patients may be safely immobilized on gurney with cervical collar and straps and will not generally require a spine board
  8. Reserve long spine board use for the movement of patients whose injuries limit ambulation and who meet criteria for the use of spinal precautions. Remove from the long board as soon as is practical

Pertinent Assessment Findings

  1. Mental status
  2. Normal neurologic examination
  3. Evidence of intoxication
  4. Evidence of multiple trauma with other severe injuries

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914107 – Injury-Spinal Cord
  • 9914073 – General-Spinal Precautions/Clearance

Key Documentation Elements

  • Patient complaint of neck or spine pain
  • Spinal tenderness
  • Mental status/GCS
  • Neurologic examination
  • Evidence of intoxication
  • Documentation of multiple trauma
  • Documentation of mechanism of injury
  • Document patient capacity with:
    • Any and all barriers to patient care in the NEMSIS element “Barriers to Patient Care” (eHistory.01-required of all software systems)
    • Exam fields for Mental Status and Neurological Assessment
    • Vitals for Level of Responsiveness and Glasgow Coma Scale
    • Alcohol and drug use indicators
  • Patient age
  • Patients under age and not emancipated: Guardian name, contact, and relationship

Performance Measures

  • Percentage of patients with high risk mechanisms of injury and/or signs or symptoms of cervical spine injury who are placed in a cervical collar
  • Percentage of patients without known trauma who have a cervical immobilization device placed (higher percentage creates a negative aspect of care)
  • Percentage of trauma patients who are transported on a long backboard (target is a low percentage)
  • Percentage of patients with a cervical spinal cord injury or unstable cervical fracture who did not receive cervical collar
  • EMS Compass Measures (for additional information, see http://www.emscompass.org)
    • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms
    • Trauma-01: Pain assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
    • Trauma-02: Pain re-assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
    • Trauma-04: Trauma patients transported to trauma center. Trauma patients meeting Step 1 or 2* or 3** of the CDC Guidelines for Field Triage of Injured Patients are transported to a trauma center
      • * Any value documented in NEMSIS eInjury.03 – Trauma Center Criteria
      • ** 8 of 14 values under eInjury.04 – Vehicular, Pedestrian, or Other Injury Risk Factor match Step 3, the remaining 6 value options match Step 4

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