March 30, 2015 – In a relatively shocking (or perhaps not so shocking to those who keep themselves informed) move, the New York City Regional Medical Advisory Committee has released potential protocols on spinal immobilization that mostly eliminates backboards. This is right on the heels of Pennsylvannia doing something similar statewide.
This is the proprosed change to the General Operating Procedures (GOP):
All patients should have spinal cord injury precautions taken during their assessment. Transporting a patient without a rigid longboard will not be considered a deviation from the standard of care. Application of spinal injury precautions includes the following treatment modalities.
• Application of an appropriately-sized rigid cervical collar
• Maintenance of patient in a supine position; if the patient is unable to tolerate that, the head of the stretcher
may be raised to position of comfort (maximum 45 degrees)
• Adequate security of the patient’s trunk and limbs to a padded stretcher
• Minimal movement / transfers
• Maintenance of inline stabilization during any movement / transfers
• Extrication of and conveyance of patients may be accomplished with a rigid longboard, but should be
removed via logroll maneuver with manual inline stabilization after the patient is moved to the EMS cot/stretcher. Patients in extremis may remain on the rigid longboard to expedite rapid transport.
The following patients, without evidence of spinal injury, have greater risk of harm than benefit if restrained to a rigid longboard:
• Ambulatory patients
• Patients with extended transport
• Inter-facility transfer patients
• Penetrating trauma to the head, neck or torso
• Patients with significant anatomical derangements (kyphosis, contractures)
NOTE: SPINAL CORD INJURIES THAT ARE NOT CAUSED BY THE INITIAL FORCE ARE NOT LIKELY TO BE CAUSED BY THESE MINIMAL PATIENT MOVEMENTS BY EMS.
DO NOT USE RAPID TAKE-DOWN.
Can I get a “whoop whoop“???
Here’s the actual protocol marked up for the DELETIONS IN RED and the ADDITIONS IN BLUE:
BASIC LIFE SUPPORT (EMT-B) PROTOCOLS
421 HEAD AND SPINE INJURIES
1. Establish and maintain airway control while stabilizing the cervical spine.
NOTE: Do not use a nasopharyngeal airway in patients with facial injuries or if severe head injury has occurred.
2. Patients meeting one or more of the following criteria, either at the time of evaluation or at any time following the injury in question, must
be immobilizedhave spinal injury precautions during care and transport. Do not use Rapid Takedown technique.
a. Altered mental status for any reason, including possible intoxication due to drugs or alcohol.
b. GCS <15 c. Complaint of, or inability of the provider to assess for, neck and/or spine pain or tenderness. d. Weakness, paralysis, tingling, or numbness of the trunk or extremities at any time since the injury. e. Deformity of the spine not present prior to the injury. f. Distracting injury or circumstances, including anything producing an unreliable physical exam or history. g. High risk mechanism (axial load such as diving or tackling, high-speed motor vehicle accidents, rollover accidents, falls greater than standing height). h. Provider concern for potential spinal injury.
NOTE: Once spinal immobilization has been initiated, it must be completed. Spinal immobilization may not be removed in the prehospital setting.
3. If necessary, initiate spinal immobilization, utilize the Rapid Takedown technique only if the patient is standing.
4. Administer oxygen.
5. Monitor breathing for adequacy.
NOTE: Monitor breathing continuously. Be alert for signs of hypoxia and/or increasing respiratory distress.
6. Control external bleeding.
7. If the patient meets any of the criteria described in #2, is not awake or is unstable,
immobilize the patient’sapply a rigid cervical collar.
head and spine with a rigid collar and appropriate immobilization device
Assess andContinue to monitor the Glasgow Coma Score. (See Appendix E.)
9. If the Glasgow Coma Scale (GCS) score is less than 8, ventilate the patient with high concentration oxygen at a rate of 12 breaths per minute for an adult patient and up to 20 breaths per minute for a pediatric patient.
Regional Emergency Medical Advisory Committee Public Notice New York City
￼￼￼￼￼￼10. If the Glasgow Coma Scale (GCS) score is less than 8, and active seizures or one or more of the following signs of brain herniation are present, hyperventilate the patient with high concentration oxygen at a rate of 20 breaths per minute for an adult patient and up to 25 breaths per minute for a pediatric patient.
a. Fixed or asymmetric pupils
b. Abnormal flexion or extension (neurologic posturing)
c. Hypertension and bradycardia (Cushing’s Reflex)
d. Intermittent apnea (periodic breathing)
e. Further decrease in GCS score of 2 or more points (neurologic deterioration)
NOTE: Do not hyperventilate unless the above criteria are met. 11. Assess for shock and treat, if appropriate. (See Protocol #415.)
12. Transport. (See Appendix F.)
Now it is important to remember that these are PROPOSED protocol changes, and are currently open for public comment, along with #430 EXCITED DELIRIUM EMOTIONALLY DISTURBED PATIENT. This means that until they get approved and put into effect, you can still torture your patients on backboards. This really is a huge step for New York City, and we can only hope the state will follow suit shortly.
You can download the PDF of the NYC REMAC Proposed Revised Protocols for Comment here.
Feel free to add any comments you have in the comment section…