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Slide 1-

Spinal Motion Restriction Refresher 2019 Update AZ DHS BEMS
Slide 2-

Why are we doing a refresher? Overall, we have had excellent success with the roll-out of SMR across Arizona The incidence of spinal cord injury has NOT increased since the roll-out of SMR However, there have been cases of missed cervical spine injuries All of these cases have been due to protocol non-compliance***
Slide 3-

How Does SI Hurt? Cervical collars Proven to increase ICP Transfer force to ends Obscure neck injuries Produce axial distracting force Make airway management more difficult
Slide 4-

How Does SI Hurt? Rigid long back boards Cause iatrogenic pain Cause 15-20% reduction in respiratory capacity Causes delays in transport Possible risk of pressure ulcers
Slide 5-

Backboards Still reasonable for… Blunt trauma with ALOC Spine pain/tenderness and neuro complaint Anatomic deformity of spine High-energy mechanism or ALOC, distracting injury, inability to communicate IMPORTANT!!!
Slide 6-

SMR Indications Apply spinal motion restriction to any patient identified by the SMR algorithm to have a potential spine injury that might benefit from splinting and packaging A complete patient assessment should be performed prior to application of SMR This requires MORE critical thinking than simply putting everyone in a collar & strapping them to a backboard Remember, EMS is not “clearing” the patient’s cervical spine
Slide 7-

Who needs SMR Screening? Fall Injury MVC Pedestrian Struck Bicyclist Struck ATV accident Altered & Found down Head injury Diving injury Contact sports injury Horseback riding injury Motorcycle accident
Slide 8-

Spinal Motion Restriction Includes: Cervical collar with patient in supine position on gurney Supine position with vacuum mattress Supine position on scoop stretcher, secured with straps Child car seat with supplemental padding Supine position on long spine board, secured with straps and supplemental padding ***Level of SMR dependent on pt condition, comorbidities, & ability to tolerate position***
Slide 9-

The Big Change for SMR is Supine Positioning
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SMR Adult Blunt Trauma
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Adults: Low Risk Patients Minor rear-end collisions Ambulatory on scene at any time No neck pain on scene No midline cervical spine tenderness or anatomic abnormality MUST BE GCS = 15, reliable, no distracting injuries, no intoxication, no neuro complaints or findings***
Slide 12-

Adult Low Risk Patients Ages15-65 ***These patients do not need a collar or backboard***
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Slide 14-

** add slide for reminder decreasing movement verbage/increase pt safety. If refusal, please document.
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Adult High Risk Patients Age > 65!!! Positive exam or complaint (deformity, midline pain, numbness, tingling or weakness)
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Adult High Risk Patients Step 3 from the trauma triage criteria (ACS criteria) Adult fall > 20 feet (One story is equal 10 feet) Ejection from automobile Death in the same passenger compartment Vehicle intrusion > 12 inches, occupant site. > 18 inches, any site Motorcycle crash > 20mph Auto vs. Pedestrian/Bicyclist (Thrown, run over, or with significant impact)
Slide 17-

Adult High Risk Patients Diving injuries or axial loading Sudden acceleration/deceleration Bending forces to the neck and torso Violent impacts to the head, neck, torso or pelvis (excludes isolated penetrating trauma) Presence of numbness or parasthesias
Slide 18-

Adult High Risk Patients ***You should STRONGLY CONSIDER SMR packaging these patients*** As in, “default to a collar/supine at a minimum, until patient condition obviously deteriorates because of it.” If patient does not tolerate this, document on ePCR.
Slide 19-

Adult High Risk Patients If a patient meets high risk mechanism criteria, strongly consider SMR Cervical collar and supine position on gurney, scoop stretcher, vacuum mattress, or backboard If patient is unable to tolerate a collar, supine position, or backboard this MUST be clearly documented in the ePCR If needed, hold manual c-spine instead of forcing a collar onto patient
Slide 20-

Unreliable Patients Uncooperative Evidence of drug or alcohol intoxication and/or use Do they have decision making capacity??? Painful or distracting injuries Language barrier or inability to communicate Dementia, developmental delay **All of these patients must get some form of SMR. If you cannot apply a cervical collar, you must document why.**
Slide 21-

Backboards Still reasonable for… Blunt trauma with ALOC Spine pain/tenderness and neuro complaint Anatomic deformity of spine High-energy mechanism or ALOC, distracting injury, inability to communicate IMPORTANT!!!
Slide 22-

Isolated Penetrating Trauma No role for SMR in Isolated Penetrating Trauma **Applies to both Adults and Pediatrics**
Slide 23-

SMR Peds Blunt Trauma
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Pediatric High Risk Patients Step 3 from the trauma triage criteria (ACS criteria) Pediatric fall > 10 feet or 2-3 times the height of the child Speed > 55 MPH Ejection from automobile Death in the same passenger compartment Vehicle intrusion > 12 inches, occupant site. > 18 inches, any site Head on or roll over collision Motorcycle crash > 20mph Auto vs. Pedestrian/Bicyclist (Thrown, run over, or with significant impact)
Slide 25-

Pediatric High Risk Patients Diving injuries or Axial loading Sudden acceleration/deceleration Bending forces to the neck and torso Violent impacts to the head, neck, torso or pelvis (excludes isolated penetrating trauma) Presence of numbness, parasthesias, or weakness Altered LOC (GCS less than 15)
Slide 26-

Pediatric Physical Assessment Palpate the spine – pain or deformity? Self-Limited movement of the neck = predictive of injury  Use collar with log roll precautions Wrist/Hand extension bilaterally (no longer grips) Foot plantar flexion bilaterally (push foot down) Foot dorsiflexion bilaterally (pull foot up) Check sensation in all extremities Evaluate for numbness/tingling/parasthesias
Slide 27-

Backboards Still reasonable for… Blunt trauma with ALOC Spine pain/tenderness and neuro complaint Anatomic deformity of spine High-energy mechanism or ALOC, distracting injury, inability to communicate IMPORTANT!!!
Slide 28-

Case Studies
Slide 29-

Case #1 0540: Fall Injury 55 yo male, fell from standing at home, c/o lac to eyebrow, admit to 3 beers, found on ground Clear speech, A/Ox4, motor exam nl, no TTP, FROM, sensory grossly intact
Slide 30-

Case #1 En route to hospital now C/o tingling in both hands How does this change your initial SMR decision? What do you think happened while en route?
Slide 31-

Case #2 1430: Fall Injury 58 yo obese male found on bathroom floor – very small space Denied falling, just too weak in legs Complex extrication, A/Ox4, motor intact, no TTP
Slide 32-

Case #2 Hx of cervical spinal stenosis C/O severe burning and tingling in hands “But they always tingle to some degree…” Does it matter that tingling may be old? Does it matter if he fell? Can you trust story?
Slide 33-

Central Cord Syndrome
Slide 34-

Case #3 1815: 962 91 yo male, front passenger, T-boned to PS, moderate damage, found sitting in PS C/O severe R ribcage pain, crying, difficult to assess due to pain Motor intact, sensory intact, spine intact, ?TTP
Slide 35-

Case #3 Patient screaming in pain once on backboard supine HR 130, RR 30, obvious distress Now what can you do?
Slide 36-

Case #4 1448: Fall Injury 87 yo female, slip on wet sidewalk, found on ground, c/o R hip pain RLE rotated, shortened, TTP hip, A/Ox4, motor/sensory intact, head normal, neck, back no TTP Hip pain severe, tearful, yelling at times
Slide 37-

Case #4 Isolated hip fractures and spine injury Do we need to SMR all hip fractures > 65? Study showed: 1394 patients with hip fracture, 23 (1.7%) had c-spine fracture as well Of those > 65 (565 patients), standing or sitting mech only, only 2 (0.4%) had c-spine fractures Both had other criteria to apply collar: head injury, ALOC
Slide 38-

Case #4 Isolated hip fractures and spine injury Do we need to SMR all hip fractures > 65? Yes, SMR that hip fracture if you have sign or history of head injury, any ALOC, or other SMR indicators But, pain from hip fracture alone might not mandate SMR
Slide 39-

Case #5 62 y.o. female found by sister lying prone on ground with altered level of consciousness Last seen 2 days prior A & O x 2 (person & place) Incontinent to urine Left orbital swelling & bruising Back = intact, no pain or step-offs MS x 4 intact
Slide 40-

Case #5 Collar? Backboard? Patient transported without any collar or backboard Found to have diffusely metastatic cancer with brain lesions and lesions throughout the bones C7 pathologic fracture with spinal cord compression Underwent surgical repair of unstable fracture
Slide 41-

Case #6 91 y.o. female sitting on the toilet Fell forward, striking head No loss of consciousness Frontal hematoma GCS 15 and A & O x 4 No midlines cervical, thoracic, or lumbar spine tenderness No neurologic symptoms
Slide 42-

Case #6 Collar? Backboard? Patient transported without cervical collar or SMR Patient found to have Subdural hematoma and C1 fracture Underwent surgical repair
Slide 43-

Case #7 29 y.o. male police officer enters fire station to use the restroom Fire personnel heard noise, found officer on ground Officer not sure what caused him to fall Repetitive questioning (what is GCS score?) No midline cervical, thoracic, or lumbar spine tenderness No neurologic symptoms
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Slide 45-

Case #7 Collar? Backboard? Patient transported without collar or SMR GCS incorrectly scored as “15” Patient found to have vertebral fracture with vertebral artery dissection
Slide 46-

Vertebral Artery & Spine
Slide 47-

Car Seats?
Slide 48-

Car Seats Ok to use if: car drivable nearest car door undamaged no injuries to any occupant no airbag deployment no visible damage
Slide 49-

Car Seats
Slide 50-

Case #8 1235: Sports Injury 17 yo male, high school football game, rough tackle with hard head impact, brief LOC C/o headache, nausea, amnestic to event, but now A/Ox4; normal neuro exam, neck/back normal Was ambulatory on scene Trainer and private EMS applied full SMR: backboard/collar
Slide 51-

Schools, Pools, Sports Be a good neighbor Reach out to city pools, school sports programs Work with lifeguard, athletic trainer groups Make sure vision, concepts, expectations are aligned If already packaged, don’t change course unless something going wrong
Slide 52-

Case #9 1755: Fall from horse 38 yo female fall from horse, walked out 0.5 miles to road C/O neck/back soreness, +scalp abrasion diffuse back muscle TTP, neuro intact, GCS = 15, A/O x 4
Slide 53-

Case #9 May not need any SMR Patient transported in position of comfort ED work up negative Sister wrote complaint to Fire Chief and Mayor (no collar or backboard! “malpractice!”) Crew didn’t explain decision/protocol to patient or family
Slide 54-

Case #9 SMR is still considered new Patients, family, other health care professionals might not understand Make sure vision, concepts, expectations are aligned
Slide 55-

Case #10 1010: MVC 12 yo male, rear passenger, car struck from behind, mod damage Hx of Down’s Syndrome Was ambulatory on scene
Slide 56-

Case #10 Friendly on exam, follows commands, A/O to self, location, circumstance, day GCS = 15 Mild muscular neck TTP, neuro intact
Slide 57-

Pediatric Predictors of Spine Injury AMS, neuro deficits (same as adults) Neck pain, not midline tenderness Torticollis (stiffness), substantial torso injury, diving, high-risk MVC, and predisposing conditions What are predisposing conditions?
Slide 58-

Atlantoaxial Instability (AAI) Occurs in approximately 15% of people with Down Syndrome Typically asymptomatic Can result in instability (laxity) of the cervical spine More prone to spinal injuries with spinal manipulation (including SMR/collar use) Manipulation of neck for airway management can result in spinal cord injury in patients with AAI
Slide 59-

Atlantoaxial Instability Atlas Axis
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C-1 subluxed on C-2 compresses spinal cord
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Questions
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THANK YOU Presenter Name | Title presentersemail@azdhs.gov | 602-542-1025 azhealth.gov @azdhs facebook.com/azdhs