EMS, Immobilization (Seated and Supine)


Article Author:
Ron Feller
Molly Furin


Article Editor:
Crystal Reynolds


Editors In Chief:
Ron Feller
Grant Goold
Kyle Cohen


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
7/5/2019 9:04:30 PM

Introduction

Spinal immobilization also referred to as spinal motion restriction (SMR) has been a long-standing practice that emergency medical services (EMS) personnel use in the field to maintain the normal anatomical alignment and restrict the motion of the spinal cord. The intent behind the spinal immobilization is to reduce the potential for injury or further injury to the spinal cord by completely immobilizing it, thereby restricting the lateral movement.

The need for spinal immobilization is determined when assessing the scene and patient. Consider spinal immobilization when the mechanism of injury creates a high index of suspicion for head or spinal injury. Altered mental status and neurologic deficit are also indicators that spinal immobilization should be considered.[1][2][3][4]

Issues of Concern

There are 2 questions concerning the use of spinal immobilization/spinal motion restriction. Are we doing more harm than good? Are we overusing these techniques? All emergency medical services providers understand how uncomfortable the patient will be in a spinal immobilization device, however, is the discomfort the patient suffers worth the protection from further injury?  Consider how long this patient will be immobilized, from the time emergency medical services secure the last strap they will be immobilized throughout the transport. Immobilization may continue while the patient is in the emergency department, and if the emergency department physician does not clear the patient, the patient will remain immobilized until a computed tomography (CT scan) is completed and read. This could take 2 to 3 hours depending on location. Using current procedures for clearing the cervical spine in the field can avoid these hours of discomfort for the patient. Unnecessary immobilization of patients can lead to increased pain, pressure sores, and respiratory compromise.

In 2017, one study showed that out of 997 patients only 2.2% (22/997) had spinal cord injury which left 98.8% (975/997) patients that did not necessarily need spinal immobilization. This is only one study; however, as more studies are completed, we may see similar results.

There are two primary positions used to restrict the motion of the spine, seated and supine. However, circumstances may require the utilization of different positions or methods. Emergency medical service personnel will determine the best way to immobilize a patient based on current circumstances and positioning of the patient. In all cases, completely immobilizing the spine requires the use of a long spine board even with the use of a short spine board or similar device.

There are multiple reasons why one should immobilize a patient in the seated position. This reason could be for a rescue operation from a confined space or after a motor vehicle collision. After a motor vehicle collision, emergency medical service personnel will make decisions about how to immobilize and extricate the patient. If the patient has any life-threatening conditions such as airway, breathing, or circulation problems, emergency medical services can use rapid extrication techniques to remove the victim from the vehicle while keeping the cervical spine immobilized. When the patient is not in need of rapid extrication, emergency medical services will determine the position and device to immobilize the patient based on the needs and circumstances of the situation. In some cases, they will use a device such as the short spine board or similar device like a Kendrick extrication device (KED) to remove the patient from the vehicle.

Full immobilization of any patient, even partially immobilized on a short spine board, requires the use of the long spine board. The design of the long spine board allows the immobilization of the spinal column from the cervical vertebrae to the coccyx. When secured to the long spine board correctly, any of the patient's lateral movements will be minimized, hence decreasing the potential for further injury. However, some research has shown that the use of the long spine board does not restrict the lateral movement.

Clinical Significance

Medical directors for emergency management service agencies have modified the protocols to decrease the number of unnecessary spinal immobilizations. An emergency management service agency in Oklahoma began implementation of the new protocol in 2013. In 2012, they had transported 2396 trauma patients; 29% of these patients received spinal immobilization. Since the implementation of the new protocol the number has been reduced each year, and in 2016, they transported 3706 trauma patients, 2% of these patients received spinal immobilization. They are projecting this number will be down to 1% in 2017. This is a decrease of 96%.[5][6][7]

The medics on scene must have the knowledge that patients who are alert enough to follow commands can typically maintain stabilization of their spine without assistance. The use of the long spine board does nothing to prevent neurological complications from a spinal injury and increases mortality in individual trauma patients. It may also restrict respiration, which some patients cannot tolerate.

The use of the long spine board is still controversial, however; most agencies are adapting their protocols to reduce the use of the long spine board to prevent further harm to their patient.

Guidelines

While prehospital spinal immobilization has been performed for decades, current data indicate that now every patient needs to be immobilized. Now the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma suggest a limit application of spinal immobilization. These latest guidelines indicate that the number of patients who may benefit from immobilization is very small. The committee went on to state that empirical utilization of the spinal backboards during transport should be used with caution as in some cases their potential risks outweigh the benefits. Further, in patients who have sustained penetrating trauma and have no obvious neurological deficit, the use of spinal immobilization is not recommended. The EMS worker must use clinical acumen before deciding to use the spinal board.[8]

While the actual benefits from the use of a spinal board for transportation are not available, there is ample evidence showing the risks. One large study revealed that the risk of disability was much greater in patients who have been immobilized compared to individuals who were not immobilized during transport. Further, data on spinal immobilization in patients who have suffered penetrating trauma show even worse outcomes. Several studies have shown higher mortality in patients with penetrating trauma who were immobilized. Today, the use of spinal immobilization in patients with neck trauma is not recommended.[9][10]

Finally, spinal immobilization has been associated with back pain, neck pain and making it very difficult to perform some procedures including imaging. Spinal immobilization has also been associated with respiratory difficulties, especially when large straps are applied across the chest.

While many EMS organizations have adopted these new guidelines on spinal immobilization, this is not universal. Some EMS systems fear litigation if they do not immobilize patients. Patients who should have spinal immobilization include the following:

  • Spinal tenderness or pain
  • Blunt trauma
  • Patients with an altered level of consciousness
  • Neurological deficits
  • Obvious anatomic deformity of the spine
  • High energy trauma in a patient intoxicated from drugs, alcohol, or a distracting injury.

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EMS, Immobilization (Seated and Supine) - Questions

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EMS, Immobilization (Seated and Supine) - References

References

Shank CD,Walters BC,Hadley MN, Current Topics in the Management of Acute Traumatic Spinal Cord Injury. Neurocritical care. 2018 Apr 12     [PubMed]
Hostler D,Colburn D,Seitz SR, A comparison of three cervical immobilization devices. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2009 Apr-Jun;     [PubMed]
Joyce SM,Moser CS, Evaluation of a new cervical immobilization/extrication device. Prehospital and disaster medicine. 1992 Jan-Mar;     [PubMed]
McCarroll RE,Beadle BM,Fullen D,Balter PA,Followill DS,Stingo FC,Yang J,Court LE, Reproducibility of patient setup in the seated treatment position: A novel treatment chair design. Journal of applied clinical medical physics. 2017 Jan;     [PubMed]
Lacey CM,Finkelstein M,Thygeson MV, The impact of positioning on fear during immunizations: supine versus sitting up. Journal of pediatric nursing. 2008 Jun;     [PubMed]
Tescher AN,Rindflesch AB,Youdas JW,Jacobson TM,Downer LL,Miers AG,Basford JR,Cullinane DC,Stevens SR,Pankratz VS,Decker PA, Range-of-motion restriction and craniofacial tissue-interface pressure from four cervical collars. The Journal of trauma. 2007 Nov;     [PubMed]
Meredith C,Taslaq S,Kon OM,Henry J, The cardiopulmonary effects of physical restraint in subjects with chronic obstructive pulmonary disease. Journal of clinical forensic medicine. 2005 Jun;     [PubMed]
Schmolke S,Gossé F, [A special instrument: the halo fixator]. Operative Orthopadie und Traumatologie. 2008 Mar;     [PubMed]
Chan TC,Vilke GM,Neuman T,Clausen JL, Restraint position and positional asphyxia. Annals of emergency medicine. 1997 Nov;     [PubMed]
De Lorenzo RA, A review of spinal immobilization techniques. The Journal of emergency medicine. 1996 Sep-Oct;     [PubMed]

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