The evolution of paramedicine and how we manage patient care is ever evolving and changing with evidence of new research or the invention of new technology.The act of immobilizing a trauma patient to a long rigid board, known as a spine board recently has come into question and is a controversial topic.As practitioners we have an ethical responsibility to ensure we are employing current and best practices.Navigating the conversation about spinal immobilization while keeping to the standards set by regulation and protocols can be a challenge for a practitioner.
Using a backboard to immobilize and stabilize patients who have suspected spinal injuries has been in practice since the early 1970s.Spinal cord injuries are serious injuries that have life-lasting or life-threatening possibilities.It has been identified by Conner et al. (2014), that spinal injuries are relatively uncommon, occurring to approximately 0.5 per cent to 3 percent of patients who have sustained blunt trauma.The intent of securing the patient to the backboard is to minimize motion, subsequently reducing the secondary injuries.Peery, Brice & White (2007).Evidence suggests that in the prehospital environment it is impossible to prevent motion of a patient secured to a spine board regardless of equipment or technique used.Peery, Brice & White (2007)
A patient suspected of spinal injury can be transferred to a backboard using the logroll method.The process of logrolling a patient can cause further trauma, increase the patient’s pain and does not maintain spinal alignment.Moss, Porter & Greaves (2014) A principle to consider is to minimize further trauma by moving the patient as little as possible.Moss, Porter & Greaves (2014) A scoop stretcher is a tool that can be used to support the single movement principle.It is preferred to use the backboard for an extrication tool only.Alson& Copeland (2014)
Prior to securing a patient with suspect spinal injuries to a spine board, a principle has been to apply a rigid cervical collar.The theory was that the collar further aided in minimizing motion of a critical area of the body.The collar should be applied with the patient holding a neutral position.The neutral position is not clearly defined.Theodore, et al. (2013)There is evidence showing that the cervical collar is associated with an elevation of intracranial pressure and an increase in neck pain.Theodore, et al. (2013)A practitioner should be critically evaluating the patient to determine if they need a collar applied.When applying the collar, the practitioner should be ensuring it is fitted properly and loosened to decrease the patient’s discomfort.Theodore, et al. (2013)
Applying the appropriate treatment evaluating a patient witha suspected cord injury can be a daunting task for the practitioner.Using strong assessment skills and critically evaluating the patient for positive findings are favourable techniques in helping the practitioner to arrive at an appropriate decision whetherto apply spinal immobilize the patient.The consensus in the literature supports using selective immobilization. Connor, et al. (2013)Identifying patients who have suffered a positive mechanism of injury, have spinal pain or tenderness, abnormal sensory exam results or who are considered an unreliable patient should be considered for spinal immobilization.Connor, et al. (2013)As Theodore, et al (2013) stated, “Not all trauma patients must be treated with spinal immobilization during prehospital resuscitation and transport.”
A patient who is secured to a backboard is a risk for aspiration, a decrease in respiratory efficacy, an increase of intracranial pressure and decubitus ulceration, to name a few.Airway management is further compromised by the reduction in ability to open the airway fully. Connor et al. (2013)A patient secured to a backboard for any amount of time will experience pain and discomfort from the physical position they are expected to maintain.The pain experienced may mask or exacerbate symptoms and will lead to further assessment interventions, such as a CT scan.This is should be considered for our pediatric patients as a CT scan is not without risk.Leonard, Mao & Jaffe (2012)A patient secured to a backboard should be removed as quickly as possible from the backboard in order to reduce the risks identified above.
As we move forward as a profession and further evidence emerges about our practice of spinal immobilization, it becomes more apparent that this procedure is not without risk to the patient.As practitioners we need to ensure that we providing the best care for the patient’s condition.We should strive to ensure weare not causing further harm or injury to the patient, nor putting the patient at further risk.When deciding to whether or not to put a patient on a backboard, we should apply the following principles:a thorough assessment, consideration of mechanism of injury, consideration if the patient is considered a reliable patient, the amount of time the patient will remain secured to the board, the patient’s airway status, and if the patient is at risk with elevation of intracranial pressure.We need to critically evaluate our pediatric patients anduse extreme caution when determining whether to use spinal immobilization.When transporting a patient, we should remain cognizant of the patient’s condition and ensure they are being managed to reduce their pain, increase airway and respiratory efficacy, minimal alteration to mental status and aware of the potential for decubitus ulcerations to form.As a profession, evaluating wheter a patient should be spinally immobilized rather than applying this principle to all trauma patients is a shift in thinking.It will take time and experience for practitioners to become accustomed to this new way of thinking.It is important for patient care that we consider the principles and be critical of when we make the decision.
About The Author
Heather Verbaas is the Paramedic Practice and Communications Manager with the Alberta College of Paramedics. Her role includes setting the standards through research and evidence for the paramedic profession in the province of Alberta.
Theodore, N., Hadley, M.N., Aarabi, B., Dhall, S.S., Hurlbert, J.R., Rozzelle, C.J., … Walters, B.C. (2013)Prehospital Cervical Spinal Immobilization After Trauma.Nerosurgery 72:22-34. DOI: 10.1227/NEU.0b013e318276edb1
Connor, D., Greaves, I., Porter, K., et al. (2014) Pre-hospital spinal immobilization: an initial consensus statement.Emerg Med J 2013 30: 1067-1069. DOI: 10.1136/emermed-2013-203207
Leonard, J.C., Mao, J., Jaffe, D.M. (2012) Potential Adverse Effects of Spinal Immobilization in Children.Prehospital Emergency Care. 16:513-518. DOI: 10.3109/10903127.2012.689925
Moss, R,. Porter, K,. Greaves, I,.et al. (2014) Minimal patient handling: a faculty of prehospital care consensus statement. Emerg Med J 2013 30: 1065-1066. DOI: 10.1136/emermed-2013-203205
National Association of EMS Physicians an American College of Surgeons Committee on Trauma. (2013) EMS Spinal Precautions and the Use of the Long Backboard.Prehospital Emergency Care. 17:392-393. DOI: 10.3109/10903127.2013.773115
Peery, C.A., Brice, J., William, D.W., (2007) Prehosptial Spinal Immobilization and the Backboard Quality Assessment Study.Prehospital Emergency Care. 11:293-297. DOI: 10.1080/10903120701348172
Rozzelle, C.J., Aarabi, B., Gelb, D.E., Hurlbert, R.J., Ryken, T.C., Thodore, N., … Hadley, M.N. (2013) Management of Pediatric Cervical Spine and Spinal Cord Injuries. Neorsurgery. 72:205-226 DOI: 10.1227/NEU.0b013e318277096c