List Archives

Tue May 12 19:32:12 BST 2009

Hey, look, everybody: a nurse from Maine is going to disagree with one
of the top trauma surgeons on the planet.  Only on the Trauma-List.

Long spine boards are transport devices.  They're just big frigging
splints with handles.  They can (and at my hospital, always do) come off
at the end of the secondary survey.  Five or ten minutes, tops.  We've
never chopped a cord.  The secret is in simply assuming the patient has
a spinal injury, handling them prudently, and moving on.

Just as you can unwrap a splint from a wrist fracture and put it on a
pillow on the patient's lap, so can you take a spine fracture off a long
board.  (Okay, you can't put it on his lap; but you catch my meaning.)
Cripes, we keep KNOWN fractures lying in the ICU for days sometimes: bed
rest, log-roll only.  What's so different about the ED?  (If anything,
stretcher mattresses are more splinty.)  As for moving from one table to
another, we use a "smooth mover:" a big, slippery, and fairly flexible
plastic board.  With handles.  Wrap one in a bath blanket and put it on
the trauma stretcher before the patient arrives.  Voila.

You may be right about pressure ulcers; but a) I think there's at least
some data associating chronic back pain with relatively short durations
of conventional long-boarding.  (I want to say 2-4 hours, but it's been
awhile since I looked.)  Try this: stop by your local rescue squad and
volunteer to be properly long-boarded for the season finale of Survivor.
You might be amazed at how one's perspective can change.  The notion of
"a cooperative patient on a spine board" gets oxymoronic pretty quick.

Even still, imagine: there's a car wreck near Edmundston, NB, Canada.
The clinic there receives one of the victims who has been appropriately
long-boarded by first responders at the scene, maybe up to an hour ago.
They do some plain films (I'm not sayin', I'm just sayin') and suspect a
subtle spine fracture.  The patient's an American, and anyhow, the
closest hospital of any size is just across the border in Fort Kent, ME,
USA.  Transfer is arranged, maybe another ninety minutes later.  The
patient is seen in Fort Kent.  An hour or two more.  They agree, but
there's no neurosurgeon in Fort Kent.   So they in turn transfer to
Bangor.  But it's snowing hard, so a typical four-hour drive turns into
five and a half.  Then he gets seen in our ED...  

Dr. McSwain, before Maine had a trauma system, we would occasionally see
patients on long boards for upwards of TWELVE HOURS.  They ALREADY had
serious skin breakdown on day zero.  Since then, we've even begun to
recommend that the system hospitals disboard their patients during the
ED interval; or at least conscientiously roll them for a back rub every
hour or so.  If not for that, our decubes would be way higher.

Finally, the data may or may not show fracture mobility in a cervical
collar; but most of the data are from thoroughly relaxed injury models
(cadavers).  And there is little if any evidence of preventable
iatrogenic injury among collar wearers in vivo.

Beware Provider Spinal Fixation.  Suspicion is 95% of treatment.  The
rest is essentially rest.

Pret

	-----Original Message-----
	From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of McSwain, Norman E
Jr.
	Sent: Tuesday, May 12, 2009 11:30 AM
	To: Trauma and Critical Care mailing list
	Subject: RE: C-Spine Clearance by ED
TriageNurses_CAUTION-------------------------------

	I strongly disapprove of the use of the word "clear" the spine
to indicate the removal of the backboard in the field. "Clearing" is
done with proper radiograph images or physician examination by a
physician based on ATLS standards, to assure that there is no fracture
or unstable area between the vertebra

	1) I disagree with the rush to take off the spine board. There
is NO, I repeat, NO data that indicates pressure ulcer formation within
3-4 hours. Yes it is uncomfortable but not as uncomfortable as loss of
spinal function when the fracture or unstable spine causes a
quadriplegia or paraplegia. Leave it in place until proper radiographic
studies can be obtained, if there is any concern.. Three to four hours
is enough tine in any hospital to get the appropriate physical exam or
imaging studies to make the first level of decisions and to the a)
removal of the spine board and b) removal of the c-collar.

	2) The backboard provides an excellent device to move the
patient onto and off of the CT, ICU bed or even the OR table. It is a
waste hospital personnel effort not to take advantage of this device

	3) The data strongly indicates that the c-collar only provides
50% of less of motion reduction of the c-spine. In a cooperative patient
the spine board board can provide much of the rest. 

	4) EMS personal should look for reasons to immobilize the
c-spine. Not for reasons to avoid use of the device. The PHTLS program
has a very good algorithm on page 235 of the 6th edition. The 7th
edition due out in late summer of 2010 will not be significantly
different.

	5) Clearing of the c-spine requires a knowledge of neuroanatomy,
neurophysiolgy, detailed physical examination, and clinical experience.
Most, if not all EMS and nursing personnel (without special training) do
not have that knowledge. 

	6) It requires perhaps 5-15 minutes to do a detailed neuro exam
of a patient. Transportation to the medical center should NOT be delayed
in the field to perform this unneeded testing. This is physician level
decision making and should be done in the hospital and not in the field.

	This process MAY change in the future. It is NOT here today.
Current accepted national standards such at ATLS and PHTLS should be
used unless under the control of a research protocol.

	Norman

	Norman McSwain MD
	Trauma Director, Charity Hospital
	Professor of Surgery, Tulane University
	New Orleans LA
	504 988 5111
	norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

	From: trauma-list-bounces at trauma.org on behalf of Gross, Ronald
	Sent: Tue 5/12/2009 9:41 AM
	To: 'Trauma and Critical Care mailing list'
	Subject: RE: C-Spine Clearance by ED
TriageNurses_CAUTION-------------------------------

	Ken,
	Pray tell then, just how YOU "clear " the C-spine after trauma?
	Ron

	-----Original Message-----
	From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of KMATTOX at aol.com
	Sent: Monday, May 11, 2009 8:53 PM
	To: trauma-list at trauma.org
	Subject: Re: C-Spine Clearance by ED Triage
Nurses_CAUTION-------------------------------

	I am becoming INCREASINGLY concerned about our traditional and
historic
	attitudes toward the cervical spine post trauma.   It is now
acknowledged
	that STEROIDS have NO place in the therapy of spine injury and
neurologic
	deficit.   The talks by the neurosurgeons at the Las Vegas
Trauma Meeting were
	extremely convincing and brilliant.      NOW NEW INFORMATION.

	We ALL must be careful regarding C-Spine clearance.  It seems
that the
	traditional physical examination, lateral x-ray, and most
recently CT scanning,
	 MISS the very damaging upper neck "INTERNAL DECAPITATION"
injuries.
	Yes, totally miss these  injuries.    I have been reading and
listening to
	some absolutely  frightening public health information,
epidemiologic data,
	and devistating  preventable injuries.     We have begun to not
have the
	nurse, emergency physician, trauma surgeon, or even radiologist
clear the
	c-spine following traditional CT scanning.   It seems that a who
new  VOMIT is
	being written up for the literature as I type this e-mail
message

	k

	In a message dated 5/11/2009 7:25:08 P.M. Central Standard Time,
	krin135 at aol.com writes:

	What is the group's opinion of C-spine clearance by  Emergency
Department
	triage
	nurses using the Nexus Low-Risk Criteria or  Canadian C-Spine
Rule.  Has
	this
	been a successful initative in some  hospitals ?

	I teach the Nexus Criteria  (including how to do the physical
portion) to
	any nurse or paramedic willing  to stand still long enough
	to hold the patient's head still. Most  hospitals I have worked
at since
	first the Maine Protocols and then the Nexus  criteria
	came out still require physician clearance of a patient 'in full
board.'
	I've worked with enough good nurses and medics to have
	been willing  to sign off on them if the powers that be would
have allowed
	it.

	ck
	Charles S. Krin, DO

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