If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation.

- Rogue Medic

C-Spine Death Knell with Rogue Medic

 


Picture credit from Voodoo Medicine Man.

 

I was on John Broyles’ 1-Union-801 podcast this weekend.

C-Spine Immobilization 19 Jan 12 also posted on the ProMed Network as C-Spine Death Knell with Rogue Medic.

On EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, and David Aber also discuss the problems with “spinal immobilization” in Spinal Clearance or Nonsense | BLS 12 Leads.

Several people have commented that I jinxed myself by mentioning that it was quiet at work. The idea of a jinx has even less credibility than the current form of “spinal immobilization.” PS – Not that it proves anything, but it continued to be quiet for the rest of the night. This jinx idea is just based on a misunderstanding of reversion to the mean.[1] Reversion to the mean is real. Jinxes are just products of overactive imaginations at work.

First, I need to mention a couple of mistakes I made during the show. MAO (MonoAmine Oxidase) Inhibitors are not contraindications for morphine. MAO inhibitors do potentiate morphine but that is not a bad thing, as long as we know what we are doing. Narrow angle glaucoma is also not a contraindication for morphine. Generally, stimulant drugs will be the ones that are a concern with narrow angle glaucoma, because those drugs can raise the pressure in the eye.
 

Here are the major problems with “spinal immobilization.”

Does “spinal immobilization” work?

We don’t know and we don’t want to know.

PHTLS (Prehospital Trauma Life Support) made it clear in their most recent text that patients with penetrating injuries should not be immobilized, unless there was an indication of neurological deficit.

In this PHTLS podcast Dr. Jeffrey Guy makes a huge mistake.

 

Haut and his coauthors are very cautious to point out that spinal immobilization has been shown to be well worth the time and effective at saving lives as well as disability of patients who sustain blunt trauma in the form of car accidents and similar events.[2]

 

Not only is there no evidence of any benefit from “spinal immobilization,” the authors of the study explicitly state that there is no evidence in the first sentence of the article.
 

Spine immobilization is often part of the current prehospital treatment for patients with penetrating injuries to the head, neck, or torso, although there are no definitive studies that demonstrate its benefit.1,2 [3]

 

Is there any evidence of harm?

There is plenty of evidence of harm to patients who do not have spinal injuries, but what is much more important is that there is evidence of worse neurological outcomes in the patients treated with “spinal immobilization.”
 


 

Of 334 immobilized patients with acute blunt traumatic spinal or spinal cord injuries, 21% had significant disability.[4]

Of 120 not immobilized patients with acute blunt traumatic spinal or spinal cord injuries, only 11% had significant disability.

There does not appear to be any possibility of selection bias by paramedics or doctors choosing to use the treatment only on the worst patients. Everyone in the US was immobilized. Nobody in Malaysia was immobilized.

There is a difference in the types of injuries between the samples. More falls in Malaysia. More vehicular collisions in the US. Is the difference in the types of injuries the reason that patients were twice as likely to end up disabled with “spinal immobilization”?

What about Cochrane Reviews? What do they state about evidence for “spinal immobilization”?

There is no evidence of benefit. There is strong possibility of harm.

But wouldn’t it be unethical to study “spinal immobilization”?
 

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.[5]

 

How can we advocate for “spinal immobilization” based only on a weak hypothesis?

How can we advocate for “spinal immobilization” with only evidence of harm?

Why don’t we want to know if there is a better way of protecting patients from disability?

Why don’t we want to know if we are protecting patients from disability?
 

If we assume that we know all that we need to know,
 

do we deserve any credibility?
 

In Thinking, Fast and Slow, Daniel Kahneman spends a lot of time discussing the problems that come from assuming that what you see is all there is.
 


Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher
 

We need to stop pretending that we know what we are doing and find out if what we are doing works.

At Street Watch: Notes of a Paramedic, there is a description of the continuing fall from grace of “spinal immobilization” – Another Nail in the Board. Go read it.

At Mill Hill Ave Command, there is a review of a recent study of the methods of extrication from vehicles and the amount of movement of the cervical spine – In order to protect the c-spine, should we stop helping?. Go read it.

All that I am asking for is evidence that “spinal immobilization” works.

If this were something less harmful than “spinal immobilization,” such as homeopathy, would doctors oppose finding out if it works?

If “spinal immobilization” does cause disability, is there a reason we should not know?

If “spinal immobilization” does cause disability, shouldn’t we stop as soon as possible?
 

Where is the evidence of safety?
 

Where is the evidence of benefit?
 

Without evidence, this is witchcraft.

Footnotes:

[1] Regression toward the mean
Wikipedia
Article

[2] Spine Immobilization Following Penetrating Trauma
PHTLS podcast
PHTLS (Prehospital Trauma Life Support)

http://www.phtls.org

1/18/2010 12:00 PM
Podcast page

[3] Spine immobilization in penetrating trauma: more harm than good?
Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
J Trauma. 2010 Jan;68(1):115-20; discussion 120-1.
PMID: 20065766 [PubMed - indexed for MEDLINE]

[4] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed - indexed for MEDLINE]

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

[5] Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed - indexed for MEDLINE]

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

REVIEWER’S CONCLUSIONS:
We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.

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Comments

  1. Well, at least the research is starting to get done. With the New Haven, CT and Alameda County, CA changes, the data will start piling up.

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