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Extrication and C-Spine Immobilisation

Tim Noonan noonantim at ymail.com
Fri Jan 22 20:25:09 GMT 2010


5%? 

50%?

A couple of studies have looked at trauma patients and penetrating trauma patients. Neither study found any benefit from spinal immobilization. Nobody is likely to do any research that will determine if there is any benefit from spinal immobilization. So we are stuck, or our patients are stuck, with a procedure that is essentially untested. Somebody, at some point, assumed this would be good for removing patients from cars and other locations, but we have made it a transportation device. 

In the hospital, the patient is removed from the board. When the patient is transported to CT, or any other place in the hospital, how many are placed on a board again? Hospital stretchers bump into walls and other objects, so suggesting that there is no concern about movement is an indication of a lack of familiarity with in-hospital transport.



During the period  1988 through  1993, approximately 12,700 trauma patients were admitted to inpatient services at  the U.S.  hospital and  16.600 to the University  of Malaysia.

334 spinal injuries out of 12,700 trauma patients/trauma transfers in the US hospital. 2.62%

120 spinal injuries out of 16,600 trauma patients/trauma transfers in the Malaysian hospital. 0.72%

The U.S. figures  exclude patients with  bums,  drownings, and  isolated  injuries who  were  admitted  to  services other  than the  trauma  service. The Malaysian data  include the latter cases.


Out-of-hospital spinal immobilization: its effect on neurologic 
injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed - indexed for MEDLINE]


Of 30,956 penetrating trauma patients with complete in-hospital procedure data, 443 (1.43%) had an open spine injury. There were 116 (0.38%) patients who underwent surgery (n = 105, 0.34%) or halo placement (n = 11, 0.04%). Of these 116 patients, 86 (74%) had complete spinal cord injury and would not have benefitted from spine immobilization. Only 30 (0.01%) of the 30,956 patients had incomplete spinal cord injury and underwent operative spine stabilization. The number needed to treat with spine immobilization to potentially benefit one penetrating trauma patient was 1,032. The NNH with spine immobilization to potentially contribute to onedeath was 66.

The NNT = 1,032.

The number needed to kill was 66.

The study below this shows more than 52% indicating some harm.

This would make the true NNH was less than 2.

Compare that with this previous study.

The number needed to kill was 66.

The NNT was 1,032. 

One big problem with that NNT is that it presumes that the patient 

Spine immobilization in penetrating trauma: more harm than good?
Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell 
EE 3rd, Chang DC.
J Trauma. 2010 Jan;68(1):115-20; discussion 120-1.
PMID: 20065766 
[PubMed - in process]


Many asymptomatic patients stated they had protested being  placed  in  FSI, but  were  told  it  was “precautionary.” “policy,”  or  “they had  to.”  Of  interest, 17 patients  (13..2%)  responded  they were not even asked about the presence of neck or back  pain prior to FSI. 

Where is this exhibiting any kind of patient care?

We might as well be working for UPS with the way we package patients.

We have many states moving away from the fraud of mechanism of injury trauma activation, but we still defend this mechanism of injury spinal immobilization. Based on what?

Nobody knows.

We just revert to the scare stories of What if . . . ?

That is not medicine.

That is not patient care.

Imagine if we were to treat patients for actual medical conditions, rather than presenting another performance of Spinal Immobilization Theater.

Benefit to the patients? 

Maybe. Maybe not.

That is a synopsis of the full literature on spinal immobilization.

Conclusion 

In this population of alert and cooperative 
patients with no obvious distracting injuries or clinical signs of 
intoxication, 52% had no complaints of neck pain or  back pain yet were 
transported to the ED using FSI (Full Spinal Immobilization), which  
increased both  their level of discomfort and their EMS charges.


Unnecessary out-of-hospital use of full spinal immobilization.
McHugh TP, Taylor JP.
Acad Emerg Med. 1998 Mar;5(3):278-80. No abstract 
available. 
PMID: 9523943 [PubMed - indexed for MEDLINE]

Tim Noonan.





________________________________
From: Adam Sattar <sattar.adam at gmail.com>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Thu, January 21, 2010 9:03:36 PM
Subject: Re: Extrication and C-Spine Immobilisation

You make an Interesting point however, the research has shown that the
incidence is %5-50.

Adam

2010/1/22 <krin135 at aol.com>

> 1 per 10,000 cases?
>
> 1 per 10 cases?
>
> from my 30 odd years of experience, admittedly, mostly in lower volume,
> rural situations, I can count *maybe* 20 cases out of the many thousands of
> patients brought to the ED in "full board."
>
> maybe two of the cases were true 'whiplash' type high c spine  fracture,
> including one who came in supporting his own head, a couple of 'diving
>  into
> shallow water' c spine bomb burst fractures,  two or three low
>  thoracic/high
> lumbar fractures from 'crackback' injuries (abrupt retroflexion of  the
> torso due to a mid back impact). Most of the ones I have seen actually
>  involve
> axial compression of the spine in older patients with osteoporosis,
> resulting in compression fractures below T6 and on down to the sacrum.
>
> Everyone of those patients who was alert and cooperative was able to
> clearly identify the location of the pain, and every one of them left my ED
> neurologically intact, but not always in full package *after coordination
> with
> the receiving neurosurgical or trauma unit.* Things that were more likely
> to
>  lead to transport in full package included continued neurologic
> compromise,  unstable fractures, and other major trauma.
>
> Careful log rolling to reassess the posterior skin was generally done
> before transfer, and the boards were appropriately padded for patient
> comfort on
>  return to the board. Incidentally, appropriate use of padding in the
> voids,  along the sides of the patient and between the legs markedly
> increases
> not only  patient comfort but also patient stability.
>
> I started out working in rehab back in the mid 1970s, and kept a bit of an
> interest in the subject since then. Long bone fractures are common...kids
> wear  casts to school all the time. I don't recall seeing that many long
> term
> acute  care pediatric rehab hospitals around here in the US...
>
> again, please define "common" from your standpoint..
>
> ck
>
>
> In a message dated 1/21/2010 19:09:37 Central Standard Time,
> sattar.adam at gmail.com writes:
>
> Emphasis  on high incidence for SCIWORA in paediatric blunt  trauma
>
> Adam
>
> 2010/1/22 <krin135 at aol.com>
>
> > please  define "common"
> >
> > ck
> >
> >
> > In a message dated  1/21/2010 18:55:13 Central Standard Time,
> > sattar.adam at gmail.com  writes:
> >
> > It is  well established that spinal cord injuries  (SCI) and spinal cord
> > injuries  without radiological abnormality  (SCIWORA) are common in
> trauma
> > patients  particularly  paediatrics.
> > --
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