vermontemsdistrict3spinalimmobilizationprotocol：佛蒙特州的ems区3脊柱固定协议

1、EMS Field Cervical Spine Assessment Protocol,VVEMS Todd Lang, MD EMS Medical Director,Why do this?,Current practice it totally variable Clear, reproducible local standard Easy tool to measure compliance Formal training in cspine evaluation Can modify in future to incorporate new data,Objectives,Discuss Risk & Benefit of C Spine Immobilization Identify ways to safely lower use of C Spine Immobilization Review structure and function of the nervous system,Objectives,Identify situations in which ful

2、l immobilization is indicated Identify situations in which full spinal immobilization is not indicated Review VVEMS spinal assessment protocol Maintain appropriate level of suspicion for this dangerous but rare condition,We use the words “Spinal Assessment” to indicate that we are evaluating the spine for risk of injury. We are not “Clearing” it or guaranteeing that there are no injuries. We are using medical evidence to formulate a policy to balance the risks and benefits of immobilization for

3、the bulk of our patients.,Terminology,Who can use this protocol?,Only those EMS providers who have successfully completed the training for the VVEMS Spinal Assessment. This be the didactic portion Then, pass the test Then use it!,What is “NEXUS?”,National Emergency X-radiography Utilization Study Prospective study with 34,069 patients Evaluated decision rule to identify patients with cervical injury by clinical exam who did not need radiography,How do we decide in the ED?,Two main studies NEXUS

4、Canadian C-Spine Rule,NEXUS,Out of 34,069 patients, the decision rule identified 810 of 818 patients with injury 2% of blunt trauma patients had cervical injury Two patients classified as “unlikely to have injury” actually had a cervical injury. One of the two one missed patients required surgery.,NEXUS,Did not include MOI Did include: altered LOC/intoxication, Midline tenderness, distracting injury, neuro exam, Up to age 60,Stable, GCS 15 pts. A dangerous mechanism is considered to be a fall fr

5、om an elevation of =3 feet or 5 stairs; an axial load to the head (e.g., diving); a motor vehicle collision at high speed (100 km per hour) or with rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision. A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle.,Canadian C Spine Rule,Does C-Spine Immobiliztion Work?,No one really knows.

6、,Hauswald Study,Compared Malaysian patients to New Mexico patients. Worse outcomes from New Mexico spinal cord injuries: more likely to have disability Not definitive, but very provocative No evidence to the contrary, either, yet,Benefits of Immobilization,“Standard of Care” May prevent injury worsening Thought to prevent liability Not so convincing, are they?,Harms of C-spine Immobilzation,Pain Anxiety More radiographs and CT scans Money Pressure sores Harder to manage airway Change in lung fun

7、ction,Why immobilize anyone?,Unstable cervical injury is rare. Any protocol needs to: emphasize safety (sensitivity) over efficiency (specificity) balance the small benefit of avoiding spinal immobilization in the many patients without injury against the possibly catastrophic harm associated with failing to immobilize the rare patient with significant spinal injury,The Skull,Made up of bones that form immovable joints Know the “helmet” bones of the skull: Frontal, parietal, temporal, and occipit

8、al Important in describing injury location Mandible = the lower jaw bone Maxilla = the upper jaw bone,Skull,Temporal bone (Basilar) skull fractures often diagnosed by exam Raccoon eyes Battles sign The middle meningeal artery runs within the temporal and parietal bones Fractures associated with epidural bleeding,Skull Exam,Lumps, dents, wounds: describe by location and size and structures seen Ears: blood or not, TM normal or not GCS: dont say “in & out.” Use a number. Pupils/CN exam Jaw functio

9、n, voice, airway,CSF (cerebrospinal fluid) bathes brain and spinal cord,Patient with closed head injury who has a “runny nose” is leaking CSF (basilar skull fracture) Can also come out of ears,The Spine,Cervical (7) Thoracic (12) Lumbar (5) Sacral 5 (1 fused) Coccyx 4(1 fused),The Vertebrae,The spinal cord rests between the bony processes and body of the vertebrae. The spine of the vertebra is superficial and can be palpated when performing a physical exam.,Spinal Cord,Part of the central nervous system (CNS) Nerves leaving each vertebra have a specific function. Bathed in cerebrospinal fluid (CSF). Protected by bony vertebrae.,Cervical nerves “C3,4,5 keeps the diaphragm alive!”,C1 C2 neck rotation and sensation C3 spontaneous breathing C4 spontaneous breathing C5 diaphragm, shrugging shoulders C6 flexion of elbow C7 extension of elbow,Cases Requiring Full Immobilization,Higher Risk or unknown mechanism of injury Altered LOC (GCS15, or changed) Presence of other distractin

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