Information of Interest

The question of when to immobilize a pateint’s spine in the field has been a point of controversy for many years.   Although the issue will never be fully settled because there is always an “art to medicine” I will attempt to bring some sanity to the issue in this and a subsequent article.

There are two types of trauma: blunt and penetrating. Lets start first with penetrating since there has been a recent major change in the protocols. I will cover penetrating this quarter and blunt next quarter.

For penetrating trauma:   You no longer have to immobilize the spine of patients with penetrating trauma who do not have a neurologic deficits.

S-139 TRAUMA: Spinal stabilization prn. (Except in penetrating trauma with neurological deficits.)

WHAT? HOW CAN THAT BE ? WHY?

Medical science has now been applied to something that in the past had just “happened” in prehospital care without data or scientific studies. The original PHTLS committee and course recommended spine immobilization for most blunt and penetrating trauma. They didn’t differentiate between the two and we just went along with it since it made sense. Certainly in blunt trauma when ligaments of the spinal column /vertebrae can be disrupted due to acceleration/ deceleration forces, instability of a neurologically intact spinal cord is possible and leads to the potential to make an intact cord become a non-intact cord.---and of course it seemed a GSW to the back might have bone or something hanging around that could pierce the cord if moved etc.   As it turns out a landmark study this year in the Journal of Trauma1 reviewed all the papers related to penetrating trauma and looked for bad outcomes when spinal immobilization was not applied. The studies all show that if at the time of injury there are not ANY neurologic deficits none develop later regardless of whether or not immobilization is applied or where the injury was. In fact, if immobilization is applied , it makes the outcome worse because of delay in scene time and because one covers up injuries that can be missed (like an expanding hematoma of the neck when the C collar is in place).   So this article recommends that “ in the face of a normal neurologic exam and penetrating trauma no matter where it is, the patient does not need spinal immobilization.”

There is one important caveat that is not addressed in detail in the paper or the protocol. All the patients had to have “no neurological deficits”. They were not clear on the extent of the exam. Common sense would say that if the patient is not conscious enough to adequately follow commands then they cannot be considered to have a normal neurological exam. So unconsciousness, head injury, shock, drugs/alcohol all which effects the ability of the patient to cooperate with a simple peripheral neurologic assessment would make your ability to be sure they are “neurologically intact” difficult …so you will likely need to immobilize those patients.

For patients with adequate mental status: what is a minimal neurologic exam that can screen out any neurologic deficits? Again the article doesn’t define this but you should be able to assure yourself that there are no motor or sensory deficits. The following is a recommendation of how to do that: I have given you a long version when time allows and you want to be detailed and a shorter version when you are in a rush.   You could do one in the field and the longer one en route.

Long Version:

Have the patient move all four extremities to demonstrate good strength. For both arms have them lift their arms then test bicep and tricep and grip strength. For the legs have the patient lift both legs, test quadriceps and hamstrings strength and then have them extend their foot (pull it towards their head) and push foot against your hand (planter flexion , push away from head)   Below are the details as to what Nerve roots each muscle group actually tests. What is outlined in Green show you the corresponding lines to the recommendations I made above.
Flexion at the elbow (C5, C6, biceps)

Extension at the elbow (C6, C7, C8, triceps)
Extension at the wrist (C6, C7, C8, radial nerve)
Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1)
Finger abduction (C8, T1, ulnar nerve)
Oppostion of the thumb (C8, T1, median nerve)
Flexion at the hip (L2, L3, L4, iliopsoas)
Adduction at the hips (L2, L3, L4, adductors)
Abduction at the hips (L4, L5, S1, gluteus medius and minimus)
Extension at the hips (S1, gluteus maximus)
Extension at the knee (L2, L3, L4, quadriceps)
Flexion at the knee (L4, L5, S1, S2, hamstrings)
Dorsiflexion at the ankle (L4, L5)
Plantar flexion (S1)

Short version: if you have very little time

If you look at the nerve roots each of the tests evaluates and you realize that where ever the penetrating wound is, if it has severed the cord in any way it would effect muscle groups innervated by the nerve roots at or BELOW the injury. Note that some penetrating trauma may only effect part of the cord and not sever it completely so you might see spotty neuro deficits. BOTTOM LINE: if you check

1. Bicep you have checked C5, C6
2. Grip you have checked C5,6,7,8,and T 1. (good to do biceps and grip as you can be fooled on grip)
3.Lifting the leg or Holding the knee straight (quadriceps) you have checked L2,3,4.
4.Moving the foot against resistance lifting to head (extension) and then pushing away from head (dorsiflexion)

you have checked L4,5, and S1.

So if you do the 4 (Red) tests only: you have done a quick and fairly adequate strength exam when you have limited time.

For the sensory side of the spinal cord: one should be confident the patient can feel normally in all areas below the injury site (look at the sensory dermatonal distribution of nerves in the illustration below). One can do a quick exam by confirming normal sensation with light touch (of your fingers) on the

1. Inside and outside of the both arms

2. Inside and outside of both legs as well

3. Both Left and Right sides of the thorax.: don’t need to do front and back as the dermatones are the same on the front and back : but need to do left and right side)

If you have done an appropriate neurological exam and it is normal: You are OK to not immobilize the spine in cases of penetrating trauma. Blunt trauma is a different kettle of fish with regards as to when to immobilize the spine and will be discussed next quarter. Do you know why it might differ? Stay tuned.

1.Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations From the Prehospital Trauma Life Support Executive Committee: Journal of Trauma-Injury Infection & Critical Care: September 2011 - Volume 71 - Issue 3 - pp 763-770

ER Transport Resource Tool by Josh

COVID-19 Advanced Airway Shower Cap and Filter

COVID-19 Advanced Airway Shower Cap and BVM​

​COVID-19 Advanced Airway Shower Cap

County Medical Director's Update

To Mobilize the Spine or Not: that is the question by Brad Schwartz, MD

COVID-19 Advanced Airway Shower Cap and BVM

COVID-19 Advanced Airway Shower Cap

To Mobilize the Spine or Not: that is the question
by Brad Schwartz, MD