Selective rather than routine spinal immobilization for prehospital casualties
Dear Editor,
In their recent article (1), Coats and Davies imply that all victims
of motor vehicle collisions require spinal immobilization. This is not
true. Although immobilization has been the "standard procedure" in the
United States, Great Britain and many other counties, it is not the
standard world wide. Examples of areas where spine immobilization is not
the standard are Malaysia and large portions of Australia.
Spinal immobilization is not a benign procedure. It is uncomfortable
and adds time and expense to both prehospital and emergency department
care. Many patients are transported to the hospital only because they
are immobilized. Many of these patients receive radiographs only because
they arrive immobilized or develop back pain as a result of the
immobilization. We agree with the authors' point that we still do not know
if this is a beneficial procedure even in those patients with known or
high suspicion of spinal injury.
There is a growing body of literature which indicates that trauma
patients may be individually selected for immobilization by prehospital
care providers on the basis of simple criteria (2-5). These criteria
include neck pain or tenderness, reliability of the clinical exam, and
neurological deficit. The National Association of EMS Physicians has
endorsed these criteria through a position paper and they are steadily
gaining acceptance in U.S. EMS systems (6).
It is time that we scrutinize the widespread practice of immobilizing
all trauma patients and adopt the more reasonable approach of selective
immobilization.
Darren Braude, MD, MPH, EMT-P
Assistant Professor of Emergency Medicine
University of New Mexico
Robert M. Domeier, MD, FACEP
Saint Joseph Mercy Hospital
Ann Arbor, Michigan
References:
1. Coats TJ and Davies G. Prehospital care for road traffic casualties.
BMJ 2002;324:1135-1138
2. Domeier RM, Evans RW, Swor RA, Rivera-Rivera EJ, Frederiksen SM.
Prehospital Clinical Findings Associated with Spinal Injury. Prehospital
Emergency Care 1997;1:11-15.
3. Domeier RM, Evans RW, Swor RA, Hancock JB, Fales W, Krohmer J,
Frederiksen SM, Shork MA: The reliability of prehospital clinical
evaluation for potential spine injury is not affected by the mechanism of
injury. Prehospital Emergency Care 1999;3(4):332-337.
4. Stroh G, Braude D: Can an out-of-hospital cervical spine clearance
protocol identify all patients with injuries? An argument for selective
immobilization. Ann Emerg Med 2001;37(6):609-15.
6. Domeier RM. Position Paper, National Association of EMS Physicians:
Indications for prehospital spinal immobilization. Prehospital Emergency
Care 1999;3(3):251-253.
Competing interests:
No competing interests
28 May 2002
Darren A Braude
Assistant Professor of Emergency Medicine
Robert M. Domeier, Saint Joseph Mercy Hospital, Ann Arbor, Michigan
ACC 4-West, University of New Mexico, Albuquerque, NM 87131
Rapid Response:
Selective rather than routine spinal immobilization for prehospital casualties
Dear Editor,
In their recent article (1), Coats and Davies imply that all victims
of motor vehicle collisions require spinal immobilization. This is not
true. Although immobilization has been the "standard procedure" in the
United States, Great Britain and many other counties, it is not the
standard world wide. Examples of areas where spine immobilization is not
the standard are Malaysia and large portions of Australia.
Spinal immobilization is not a benign procedure. It is uncomfortable
and adds time and expense to both prehospital and emergency department
care. Many patients are transported to the hospital only because they
are immobilized. Many of these patients receive radiographs only because
they arrive immobilized or develop back pain as a result of the
immobilization. We agree with the authors' point that we still do not know
if this is a beneficial procedure even in those patients with known or
high suspicion of spinal injury.
There is a growing body of literature which indicates that trauma
patients may be individually selected for immobilization by prehospital
care providers on the basis of simple criteria (2-5). These criteria
include neck pain or tenderness, reliability of the clinical exam, and
neurological deficit. The National Association of EMS Physicians has
endorsed these criteria through a position paper and they are steadily
gaining acceptance in U.S. EMS systems (6).
It is time that we scrutinize the widespread practice of immobilizing
all trauma patients and adopt the more reasonable approach of selective
immobilization.
Darren Braude, MD, MPH, EMT-P
Assistant Professor of Emergency Medicine
University of New Mexico
Robert M. Domeier, MD, FACEP
Saint Joseph Mercy Hospital
Ann Arbor, Michigan
References:
1. Coats TJ and Davies G. Prehospital care for road traffic casualties.
BMJ 2002;324:1135-1138
2. Domeier RM, Evans RW, Swor RA, Rivera-Rivera EJ, Frederiksen SM.
Prehospital Clinical Findings Associated with Spinal Injury. Prehospital
Emergency Care 1997;1:11-15.
3. Domeier RM, Evans RW, Swor RA, Hancock JB, Fales W, Krohmer J,
Frederiksen SM, Shork MA: The reliability of prehospital clinical
evaluation for potential spine injury is not affected by the mechanism of
injury. Prehospital Emergency Care 1999;3(4):332-337.
4. Stroh G, Braude D: Can an out-of-hospital cervical spine clearance
protocol identify all patients with injuries? An argument for selective
immobilization. Ann Emerg Med 2001;37(6):609-15.
5. Domeier RM, Swor RA, Evans RW, Krohmer J, Hancock JB, Fales W,
Frederiksen SM, Shork MA: Multicenter Prospective Validation of
Prehospital Clinical Spinal Clearance Criteria. Journal of Trauma 2002;in
press.
6. Domeier RM. Position Paper, National Association of EMS Physicians:
Indications for prehospital spinal immobilization. Prehospital Emergency
Care 1999;3(3):251-253.
Competing interests: No competing interests