Spinal Immobilization free essay sample

These resources have been analysed and a conclusion drawn from them in regards to spinal immobilisation in the pre-hospital setting. Method: This assignment uses an evidence based approach; the author explores spinal injuries and the current management of them in the pre-hospital setting across a number of countries. The author relates current practice with recent literature and draws a final conclusion from the findings. Conclusion: Prehospital care for patients with acute traumatic spinal injuries requires great care to avoid secondary injury; recognition of otential injury is of great importance. Although injuries to the spinal cord occur in 2% of the patients that paramedics immobilize, pre-hospital management and treatment can play a significant role in the patient’s outcome. There is growing evidence that full body immobilization can be of more harm than good if not done correctly. Introduction Traumatic spinal cord injuries are severe, life threatening and life altering . Managing the risk of spinal cord injury in trauma patients is an understandable concern for medical professionals. We will write a custom essay sample on Spinal Immobilization or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Spinal immobilization is initiated on a regular basis in pre-hospital setting for patients at risk of a spinal cord injury. In the past immobilization has been thought to be a relatively harmless procedure. There is now, however, growing evidence that this approach can be harmful, pre-hospital spinal immobilization in trauma patients should be questioned and explored. There is a large amount of literature on pre-hospital immobilization; the purpose of this paper is to review the current literature and make a recommendation for New Zealand practice. This paper explores current pre-hospital management of spinal cord injuries, the literature around cervical spine immobilization and full body immobilization. Spinal cord injury Spinal cord injury is injury to the spine with any localised damage to the spinal cord or to the roots that lead to some functional loss, either loss of motor function (paralysis) or sensory loss (paresthesias). Spinal cord injuries are caused by the spine being forced beyond its normal range, injury can be caused by hyperflexion, hyperextension, rotation, compression, or penetrating injury of the spinal cord. The leading causes of injury to the spinal cord includes car accidents (40%), falls (21%), acts of violence (15%), sporting injury (13%) (Sanders, 2012) Spinal injuries may be classified into sprains, strains, fractures, dislocations and/or actual cord injuries. Spinal cord injuries are further classified as complete or incomplete and may be the result of pressure, contusion or laceration of the spinal cord (Marieb amp; Hoehn, 2010). It is very important for paramedics and emergency personal to know that pain from a spinal cord injury is not necessarily localized to the area of the injury. In 18% of cervical, 63% of thoracic and 9% of lumbar injuries, the pain is located elsewhere (Bernhard, Gries, Kremer, amp; Bottiger, 2005). Current Management Pre-hospital management of acute spinal cord injury is of critical importance, it has been estimated that 25% of spinal cord damage may occur or be aggravated after the initial event (Bernhard, Gries, Kremer, amp; Bottiger, 2005). Pre-hospital treatment of patients with a spinal cord injury involves recognition of patients at risk and appropriate immobilisation (Tintinalli, 2011). Spinal immobilization and spinal precautions are common practices in the pre-hospital setting of patients with trauma. Despite this practice, spinal cord injuries are rare, approximately 2%, and are often obvious at the scene. Several rules exist that are designed to help pre-hospital providers clinically clear the cervical spine this helps reduce the need for radiography and reduce adverse effects from spinal immobilization (Alejandro amp; Schiebel, 2006). The goal of pre-hospital management of spinal cord injuries is to reduce neurological deficit and to prevent any additional loss of neurological function. Therefore, prehospital management at the scene should include a rapid primary evaluation of the patient, resuscitation of vital functions (airway, breathing, and circulation), a more detailed secondary assessment, and finally transportation to definitive care. In addition, after arriving at the scene, it is important to evaluate the scene and to understand the mechanism of injury in order to identify the potential for spinal cord injuries (Bernhard, Gries, Kremer, amp; Bottiger, 2005). Currently in New Zealand according to St John (2011) clinical guidelines and Wellington free Ambulance (2011). If the patient has any of the following signs or symptoms they should have their cervical spine immobilised: 1. Tenderness at the posterior midline of the cervical spine or 2. Focal neurological deficit or 3. Decreased level of alertness or 4. Evidence of intoxication or 5. Clinically noticeable pain that may distract the patient from pain of a cervical spine injury. Australia’s Queensland Ambulance service has similar cervical immobilisation criteria to New Zealand, they use a clear flow chart to that is similar to the Canadian C-spine Rule but includes distracting injury and intoxication. Their other treatments focus on limiting neurological deficit and prevent secondary injury. This is achieved through appropriate spinal immobilisation, maintaining a high index of suspicion of spinal cord injury (Clinical pratice guidelines Trauma, 2011). Saskatchewan, Canada also use the Canadian C-Spine rule, this rule is only used if the patient is co-oprative and has a Glasco comoa scale (GCS) of 15. If the patient meets ther criteria for cervical spine immobilization they are also fully immobilised on a long spine board or scoop stretcher. Full immobilization includes the head, neck and spine; this is done to prevent any further injuries during transport. Canada also administers an anti-emetic (anti-nausea medication) to prevent any unwanted and preventable movement (Saskatchewan Emergency Treatment Protocol Manual, 2012). In the United States of America to determine whether it is appropriate to apply full spinal immobilization which can include rigid collar, backboard, three point restraining device and head immobilization device, in the prehospital setting the following is assesses. If any of the below findings are positive, full spinal immobilization is to be implemented (Emergency medical services pre-hospital treatment protocols, 2012). 1. Midline bony spinal tenderness to palpation 2. Physical findings with a neurologic deficit 3. Altered mental status to including substance abuse and loss of consciousness 4. The presence of additional painful or distracting injuries 5. The complaint of numbness 6. Language barrier i. e. patient not understanding the questions asked, dementia, speaks a different language, or mentally delayed 7. Pain in cervical region on movement 8. Children under the age of 12 9. Significant mechanism of injury or care provider judgment It appears that the United States of America fully immobilize the majority of suspected/ potential spinal cord injuries. Litigation associated with error in spinal management can be very costly, with the average payouts being $3 million per incident in the United States (Abram amp; Bulstrode, 2010). The Literature Cervical spine immobilization It is believed that movement of the non-immobilised patient with an unstable vertebral column injury places the spinal cord at risk of primary or worsening damage. There is a lot of evidence that cervical immobilisation can restrict movement, but evidence proving that cervical collard protect against secondary injury is lacking (Ramasamy, Midwinter, Mahoney, amp; Clasper, 2009). In prehospital care, paramedics are trained to immobilize all patients with possible spinal cord injury; in order to prevent additional neurologic injury. Many patients will be found to have no injury to the spine at all. Some will have an unstable fracture with an intact spinal cord; the goal is to prevent movement of the spine therefore preventing damage to the spinal cord. Others will unfortunately already have neurological disability on initial examination. In these patients, the goal is to prevent further cord injury (Peery, Bruice, amp; White, 2007). A number of risks may be associated with application of the cervical collar. If the jaw support of the collar clamps the teeth together, the airway may be compromised if the patient vomits. Cervical collars have also been found to place pressure on the neck this can cause an increase in intracranial pressure. Acute respiratory failure, hypoxia and hypoventilation have also been reporter (Bernhard, Gries, Kremer, amp; Bottiger, 2005; Hann, 2004; Abram amp; Bulstrode, 2010; Engsberg, et al. , 2013). A rise in intracrainal pressure (ICP) has been associated with a worse neurological outcome in patients suffering from a head injury. Cervical spine immobilisation has been foud to increase the ICP by approximatly 4. 5 mmHg. This is relevent because head injuries occur in an average of 34% of trauma patients (Abram amp; Bulstrode, 2010). Galim, et al. 2012) applied cervical spine imobilisation to nine fresh cadervers in order to assitaine weather or not collars exacerbate cervical spine injuries. X-ray’s were taken befor and after application of the collar. Galim found after the application of the collar there was a grossly abnormal seperation of the verterbra in all nine cadervers. The average seperation mesurement was 7. 33 mm (see figure 1). The collars did not cause the injury, but th is appears to promote seperation between vertebrea. This seperation sugests collars push the head away from the body, this causes stretching of the soft tissue including the spinal cord. Galin, et al recognises that the use of cadervers could repersent worst case scernario because of the difference in muscle tone in compard to an unconscious patine. The result of a randomized controlled trial on healthy volunteers has provided some useful insight into cervical spine immobilization and its effectiveness in trauma patients (Alejandro amp; Schiebel, 2006). Figure 1 Hann (2004) found that in general only 55% of patients will fit perfectly into cervical immobilization collars. The majority of patients will have an ill-fitting Collar. True cervical immobilization is likely to be unobtainable. Even a halo frame (which has mental pins that are screwed into the skull), allows a small amount of motion. However, the rigid cervical immobilization collar remains the best and most effective for the needs of the prehospital setting (Hostler, Colburn, amp; Seitz, 2009). Ideally, only patients with unstable spines would have a cervical collar applied. But these patients cannot be identified in the pre-hospital setting; determining spinal injury out of hospital is not easy nor is it accurate (Horodyski, DiPaola, Conrad, amp; Rechtine, 2011). In both Canada and Australia the Canadian C-Spine Rule is used to determine which patients could benefit from immobilisation (see figure 2). In one study on 8,283 patients who were assessed by emergency services and the Canadian C-Spine rule was applied. The paramedic’s received a short online tutorial on how the C-Spine rule worked. This study found that paramedics were able to apply this rule reliably, and did not miss any cervical spine injuries. The rule was found to be accurate; only 12 patients had clinically significant spinal cord injuries (Vaillancourt, et al. 2009). Figure 2 Full spinal immobilization There is growing questioning of the need to fully immobilise a patient, with many suggestions that immobilisation does not prevent additional spinal cord injuries, however it may in fact cause such injuries (Krell, et al. ,2006; Alejandro amp; Schiebel, 2006; Bernhard, Gries, Kremer, amp; Bottiger, 2005; Peery, Bruice, amp; White, 2007). The use of a spinal board is com mon in attempt to provide rigid spinal immobilization in the pre-hospital setting for trauma patients with potential spinal injuries. Nevertheless, the benefit of long backboards is largely unproven (Alejandro amp; Schiebel, 2006). A number of studies in the literature do present complications when poor standards of immobilisation are performed. Issues include occipital, lumbar and sacral pain development when padding is inadequate or absent, increased respiratory compromise with incorrect chest strapping, pressure sore development due to inadequate padding and spinal miss-alignment again are as a result of inappropriate/ inadequate padding. Perry, Brice amp; White (2007) found that if a patient is lying on a spinal board which is poorly trapped, it is likely the patient would move more during transport than if they were places on the stretcher. Inadequate pre-hospital spinal immobilization was found to occur on a regular basis; the main problem being straps had greater than four centimetres slack. Straps that have a four centimetres or greater slack cannot sufficiently immobilise a patient with a potential spinal injury. Abram amp; Bulstrode (2010) has noted that correct immobilisation of the cervical spine, with placing a patient on a backboard with the straps tightened correctly, that the patients respiratory function can be restricted by up to 15%. If the patients head is strapped in place but the body is poorly immobilized, this creates a situation where the body can pendulum at the neck. This situation is potentially more dangerous than not immobilising at all because it allows transport forces to move the weight of the body against an unstable spine (Peery, Bruice, amp; White, 2007). The general theory of spinal immobilisation is that movements would be reduced if neck protection is used along with a backboard to aid smooth extrication form a motor vehicle. Engsberg, et al (2013) found a significant decrease in movement (as opposed to full assistance i. e. spine board) when the patient exited the vehicle unassisted with a cervical collar in place to protect the neck. The results indicated that an unassisted cervical protected technique had significantly less range of motion than the unassisted unprotected and the fully assisted technique. In fact, with the addition of the cervical spine collar the level of protection was increased and range of motion was decreased in many instances (Engsberg, et al. , 2013). The use of backboards have been found to induce three to five as much movement than a scoop stretcher if the patient is on the ground (Krell, et al. , 2006). Abram amp; Bulstrode (2010) sugests that the risk of futher neurological injury due to inadiquate immobilisation may be overestermated. They back this statement up with a 5 year retrospective study. The neurological outcomes for patients where no routine pre-hospital immobilization was used were compared to trauma patients who received spinal immobilization. Two physicians acted independently, the patients were categorised into disabling r non-disabling. The trial found deterioration occurred less frequently and there was less over all neurological disability in the patients with no routine immobilization. It was suggested that, a large amount of force is required to damage the spine and injure the spinal cord; Abram amp; Bulstrode concluded that movement created during transport was unlikely to generate sufficient energy to res ult in additional injury. There were however weaknesses in this study. Patients who died at the scene or during transport were excluded. It was concluded that neurological deterioration in patients with spinal cord injury occurs in around 5% of patients even with good immobilization of the spine. Conclusion Immense care needs to be taken when providing medical care to an acutely injured patient with suspected spinal injury in the pre-hospital setting. Approximately 2% of all trauma patients will have sustained a spinal injury. Patients with acute traumatic spinal injury are at risk of neurologic deterioration which is thought to be due to secondary injury to the spinal cord. A potential cause of secondary injury is through unintentional manipulation of the spinal cord predominately in the setting of an unstable injury. Minimizing the chances of secondary injury can be challenging in the pre-hospital setting due to the location and accessibility of the patient, transport. Treatment that is initiated in the pre-hospital setting can lead to significant morbidity in other body areas, such as pressure areas, decreased respiratory effort. There is large variation in how care is administered in the pre-hospital setting from one country to another. There is a possibility that fill body immobilization may be contributing to mortality and morbidity in some patients, this warrants further investigation. The Canadian C-spine study showed that only 0. 14% of patients immobilized had clinically significant spinal cord injuries. New Zealand could improve their current practice by improving pre-hospital criteria to establish which patients really are at significant risk for needing spinal immobilization, this could reduce the number of patients exposed to the unnecessarily risks of spinal immobilization. Bibliography Abram, S. amp; Bulstrode, C. (2010). Routine spinal immobilization in trauma patients: What are the advantages and disadvantages. The Surgeon, 218-222. Ahn, H. , Singh, J. , Nathens, A. , MacDonald, R. D. , Travers, A. , Tallon, J. , . . . Yee, A. (2011, August). Pre-Hospital Care Management of a Potential Spinal Cord Injured Patient: A Systematic Review of the Literature and Evidence-Based Guidelines. Journal of Neurotrau ma, 8(28), 1341–1361. doi:10. 1089/neu. 2009. 1168 Ahn, H. , Singh, J. , Nathens, A. , MacDonald, R. D. , Travers, A. , Tallon, J. , . . . Yee, A. (2011, August). Pre-Hospital care management of a potential spinal cord injured patient: A systemic review of the literature and evidance-based guidelines. Journal of Neurolotrauma, 28, 1341-1361. doi:10. 1089/neu. 2009. 1168 Alejandro, A. , amp; Schiebel, N. (2006). Is routine spinal immobiilization an effective intervention for trauma patients? Emergency Medicine, 110-112. Bernhard, M. , Gries, A. , Kremer, P. , amp; Bottiger, B. (2005). Spinal cord injury Prehospital management. Resuscitation, 127-139. Clinical pratice guidelines Trauma. (2011, September). 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The Journal of Trauma, 12-16. doi:10. 1097/TA. ob013e3181be785a Hann, A. (2004, August 20). A photographic guide to prehospital spinal care: Edition 5. Retrieved April 2, 2013, from Emergency technologies: http://www. neann. com/pdf/psc. pdf Horodyski, M. , DiPaola, C. P. , Conrad, B.