Is a backboard for transport only, or immobilization while in the ER?

Published

I posted this question in another thread about a nurse getting an MVC patient who had not been immobilized on a back board for transport to her ER, but I wanted to move it to it's own thread so I can get my question answered without hijacking that other post:

****************************************

Ok, I've looked through my TNCC book and my Emergency Nursing book, because I just hate to ask this question and risk looking like a total MORON! I've been in ER for a year now and SHOULD KNOW the answer to this question...but I've actually asked it of several people at work, and gotten different answers! (and the books just say HOW to immobilize using the backboard, not why).

So here goes: is the purpose of the backboard to immobilize the spine for transport only, or the entire time they're in the ER, until their spine is cleared via xray or CT?

I've had docs immediately take the pt off the backboard, based on their conversation and physical assessment, although they were pending results of xrays/CTs. I've had other docs insist that the pt stay on the backboard until the L-spine film is taken (but not read, just xrays have been shot) because the board helps get a better picture. But once the xray's been taken, they'll have the pt off the board, before the xrays have been read. And then I've got another doc who won't let us take the pt off the board until all films have been read and their spine has been cleared (could be an hour or two in the minor MVCs!).

We also have been told that one of the very important issues in the traumas is getting the pt off the board as quickly as possibly, because of the issue of skin breakdown.

So...what's the purpose of the board IN THE ER?

Oh, by the way, until their spine is cleared via xrays/CT, we do keep them lying flat, with the c-collar on, we log roll them off if we're taking them off the board, etc. But we very often put the pt on a soft bed before any xray/ct results have come back.

VS

what benefit does the patient remaining on the Long EXTRICATION board have above a patient with correct immobilsation applied on a modern Emergency department pressure relieving trolley mattress ?

It restricts the patients movement. I don't know what world you live in, but the reality is many patients are disoriented due to head wounds or being drunk. Try telling a drunk guy who was just in an accident to not move and watch how well he listens.

Specializes in Spinal Cord injuries, Emergency+EMS.
It restricts the patients movement. I don't know what world you live in, but the reality is many patients are disoriented due to head wounds or being drunk. Try telling a drunk guy who was just in an accident to not move and watch how well he listens.

so you advocate the assault and battery of all patients in case someone who is intoxicated might possibly make an injury worse.

is physically restraining a person on a hard surface and causng them discomfort and injury acting in their best interests?

i'll tell you what world i live in one where physical restraint is not the default choice and where preventing iatrogenic injury which will prolong rehabilitation is as important as a perceived fear of litigation.

Specializes in Spinal Cord injuries, Emergency+EMS.
Tell that to the lawyer and watch him eat you alive!

so patient with a correctly fitted collar, with head blocks and base in place on a trolley ( with straps or remaining in a vac mattress if necessary) in a static building is not immobilised ....

This is not logical. First, many services don't have this equipment due to cost. Second, they take longer to apply. As a trauma nurse you should know how precious those first minutes are.

time to definitive care is impoortant, however i f patient is not time critical you can and should take the time to ensure that their extrication is managed as well as it can be.

I would love to see the research and the journals that say this. I am certainly glad I am not a patient at your hospital. You are dead wrong about this.

from JRCALC 2006 (pg 291 of the pdf)

" the value of routine out of hospital spinal immobilisation and any benefits may be outweighed by the risks of rigid collar immobilisation, including:

1. airway difficulties

2. raised intra-cranial pressure

3. increased risk of aspiration

4. restricted respiration

5. dysphagia

6. skin ulceration

7. can induce pain, even in those wth no injury "

pg 294

"Precautions

the restless patient

there are many reasons for the patient to be restless and it is important to rule out reversible causes e.g. hypoxia, pain, fear. If , despite appropriate measures the patient remains restless, then immobilisation techniques may need to be modified "

pg 295

" transportation of spinal cases

... patients can tolerate a 30 minute journey on a long extrication board. the recieving ED staff should be told how long the patient has already been on the board so they can make an appropriate judgement on the timing of it's removal ... the extrication board should be removed as soon as possible on arrival in hospital

two full pages of references follow

the JRCALC guidelines can be down loaded from

http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines

the neck and back trauma guideline

http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/neck_and_back_trauma_2006.pdf

Specializes in ER.

I'm with Zippy on this one. Even if the patient has a fracture they do not stay on a board for the duration of their recovery. They have activity restrictions, and intense teaching. If someone comes in the front door of my ER we collar them and instruct them to lie still with HOB elevated until Xrays are completed and most of the time they are very compliant once they know the reason we request this.

If the patient is going to be on and off the stretcher in Xray and CT or for transport to another hospital I would prefer to keep the board in place. If they are just waiting on the stretcher they tend to squirm around so much trying to relieve the pressure areas that they are actually better off on the stretcher. If we try to keep someone on a board for more than 20 minutes it soon becomes a 1-1 situation because they are so uncomfortable.

Get them off the hard board ASAP, and "immobilize" with c collar and activity restrictions.

Specializes in Spinal Cord injuries, Emergency+EMS.
I'm with Zippy on this one. Even if the patient has a fracture they do not stay on a board for the duration of their recovery. They have activity restrictions, and intense teaching. If someone comes in the front door of my ER we collar them and instruct them to lie still with HOB elevated until Xrays are completed and most of the time they are very compliant once they know the reason we request this.

If the patient is going to be on and off the stretcher in Xray and CT or for transport to another hospital I would prefer to keep the board in place. If they are just waiting on the stretcher they tend to squirm around so much trying to relieve the pressure areas that they are actually better off on the stretcher. If we try to keep someone on a board for more than 20 minutes it soon becomes a 1-1 situation because they are so uncomfortable.

Get them off the hard board ASAP, and "immobilize" with c collar and activity restrictions.

thanks canoe head - exactly the kind of approach which balances sipnal immobilisation wit hthe prevention of iatrogenic injury ....

then of course there's the people who try and pressure relieve while on the board and struggle against the restraints - why does someone who doesn't meet any of the following criteria

1. someone under police arrest

2. someone placed in the case of the prison service or a secure mental health unit by the courts

3. someone who is detained under a section of the Mental health act and their risk assessment requires them to be retrained when outside the secure unit

4. someone who is acutely disturbed and requires restraint to prevent themselves injuting themseles or others and the risk assessment is such that physical retraint in the only acceptable resort after all othr approaches have been exhausted

need to be restrained i nthe Emergency department ( vs. during extrication or transport - you wear a seatbelt in a car or light aircraft, you don't sat in the home ... )

Specializes in Spinal Cord injuries, Emergency+EMS.

perhaps the british orthopaedic assocations vierws on the subject wll enlighten

http://www.library.nhs.uk/neurological/ViewResource.aspx?resID=154867&tabID=288&catID=12032

such as

" Skin

The risk of developing pressure sores following spinal cord injury is extremely high

due to:-

• Lack of sensation – the patient is unaware that there may be a problem

• Lack of muscle activity below the level of injury

• Circulation sluggish – reducing amount of oxygen to the skin

A pressure sore, taking an hour or so to develop, may delay the patient’s treatment by weeks and produce a permanently vulnerable scar. A pressure sore is a sign of neglect.

The patient must be turned regularly. Forty degrees side to side is minimum with

appropriate pillow supports. Ripple mattresses and other devices are often

insufficient for the prevention of skin problems in this vulnerable population. A

ripple mattress is ineffective in the prevention of heel sores and the ankles should be

supported with small pillow to ensure that the heels are not in contact with the bed. "

Specializes in Emergency, outpatient.

In the community hospital EDs I have worked in the US, removing the pt from the backboard signals freedom to move. No matter how clear you try to be with the pt and with ancillary personnel (read imaging) if you are not there physically with the pt in radiology (or back in the ED,) chances are the pt will not remain immobilized and straight, even with a collar in place. And if the board comes off, the blocks usually come off as well. End of immobilization, except maybe for the C-spine if the doc left the Stifneck in place. I think this is why doctors leave pts on the boards until films are cleared.

Applying straps to a pt lying on an ED stretcher constitutes applying restraint, and requires reams of documentation. A backboard and straps instituted by EMS do not require the same documentation. Go figure. :coollook:

I'm not saying it is right to leave Granny strapped down. I agree completely with getting everyone off the board ASAP. But the practice/reality is different. I try to get the docs to all my backboard pts quickly, and all the ED nurses I know do the same, especially if the pt is at increased risk of skin breakdown.

I'm not sure how y'all do it north of the border; that's how it looks in my nursing world.

Specializes in Emergency, outpatient.

Zippy, I read the whole paper at the link you posted for the British Orthopaedic Association. It was very interesting and is a great resource document for pts with documented spinal cord injury, from initial eval to transfer all the way to rehab, including lots of good info about skin breakdown in SCI patients on beds. But I couldn't find any information about the use of long backboards anywhere, including the transfer checklist. Strange.

Now you all have me curious about time limits. After a bit more googling to get specifics, here is what I found.

http://www.spineuniverse.com/pdf/traumaguide/1.pdf has a 34 page document titled: PRE-HOSPITAL CERVICAL SPINAL IMMOBILIZATION FOLLOWING TRAUMA; page 17 addresses initial onset of pressure sores directly by quoting Linares in the journal of Orthopedics (see the reference on pg 23 of the PDF.)

According to their study, we don't have a lot of time to get folks off that board--only 1-2 hours. That means we help to speed up the process, from MD assessment through radiology so we can get them off the board.

This is some of the Linares et al. study info from PubMed. It says enough for me: www.ncbi.nlm.nih.gov/pubmed/3575181 :bow:

Specializes in Spinal Cord injuries, Emergency+EMS.
In the community hospital EDs I have worked in the US, removing the pt from the backboard signals freedom to move. No matter how clear you try to be with the pt and with ancillary personnel (read imaging) if you are not there physically with the pt in radiology (or back in the ED,) chances are the pt will not remain immobilized and straight, even with a collar in place. And if the board comes off, the blocks usually come off as well. End of immobilization, except maybe for the C-spine if the doc left the Stifneck in place. I think this is why doctors leave pts on the boards until films are cleared.

systems design/ education issue , not a reason to unnecessarily restrain patients and cause iatorgenic injury - as radiographer is accountable for his / her omissions and the mossions or actions of an UAPs in the radiology dept who assists him/her.

a stif -neck type collar is one part of an immobilisation strategy - even an aspen type collar doesn't provide full immobilisation unless it's used with a thoracic brace component

as for those who doubted the evidence base for timely removal i hope the existance of anational Clinical guideline (JRCALC), a position paper from a relevant professional organisation ( the BOA paper) and the underpinning references to those and the references northshore cited answer your concerns.

put it this way i catch you giving one of my patients a pressure sore , not only would I encourage them to sue i'd help them go after your registration

so you advocate the assault and battery of all patients in case someone who is intoxicated might possibly make an injury worse.

Not at all. It's hardly a & b. If a pt was adamant about getting of the board I would explain the possible consequences then let them off if they persisted.

is physically restraining a person on a hard surface and causng them discomfort and injury acting in their best interests?

Many times yes. If I was the pt, I would want to be immobilized on a lbb until I was cleared by a doctor.

so patient with a correctly fitted collar, with head blocks and base in place on a trolley ( with straps or remaining in a vac mattress if necessary) in a static building is not immobilised ....

Not as well as when the pt is immobilized on a lbb. The matress allows for more movement.

time to definitive care is impoortant, however i f patient is not time critical you can and should take the time to ensure that their extrication is managed as well as it can be.

Again, we don't have as much diagnostic equipment in the field as in house. All pt's should be treated the same in regards to how long you stay on scene with a trauma pt. Simply put, you get them to the closest appropriate facility as quickly as possible.

put it this way i catch you giving one of my patients a pressure sore , not only would I encourage them to sue i'd help them go after your registration

That comment just shows what a small, ignorant, hateful person you are. It's no ones desire to cause a pressure sore to a pt, but if it means saving them from living in a wheel chair the rest of their lives, you bet I will. Of course, we should do everything in our power to get the pt off the board as quickly as possible, but that doesn't mean putting their life in danger to prevent the off chance of a pressure sore.

Specializes in Spinal Cord injuries, Emergency+EMS.
Not at all. It's hardly a & b. If a pt was adamant about getting of the board I would explain the possible consequences then let them off if they persisted.

well

you have put them in fear of immediate harm without a lawful excuse ...

you have used physical force against a person without lawful excuse ...

Many times yes. If I was the pt, I would want to be immobilized on a lbb until I was cleared by a doctor.

would you ? or would the weeks if not months of pain and discomfort that you potential expose yourself to even if the immobilisation was completely unnecessary from a spinal bony injury point of view ?

Not as well as when the pt is immobilized on a lbb. The matress allows for more movement.

very much incorrect the easiest way to demonstrate this to climb aboard one of your ED trolleys with a sheet on the mattress get a colleague or two to push you about , now repeat hi with a long EXTRICATION board on the trolley as well - just to add to the fun don't use the straps ...

Again, we don't have as much diagnostic equipment in the field as in house. All pt's should be treated the same in regards to how long you stay on scene with a trauma pt. Simply put, you get them to the closest appropriate facility as quickly as possible.

incorrect

i'd rather wait 15 minutes with a stable patient for the fire and rescue service to do their worst to a Car or to secure me a path out , than risk exacerbating injuuries in a uncalled for mad dash

the RTC extrication instructors with the fire service tell all their students, firefighters, ambulance personnel, hospital medical team / immediate care scheme Nurses and Doctors you need 3 plans to get you patient out ...

plan a - the longest but safest way out - even if it means totally trashing a relatively undamaged car e.g. roof off or folded back, doors off, dash roll etc

plan b -an alternative if there is a problem in plan A or plan A simply isn't found to work in practice - sometimes this happens with a vehicle on it;s side or inverted ...

plan X - a rapid extrication for the time critical patient or if the patient becoms time critical during extrication

That comment just shows what a small, ignorant, hateful person you are. It's no ones desire to cause a pressure sore to a pt, but if it means saving them from living in a wheel chair the rest of their lives, you bet I will. Of course, we should do everything in our power to get the pt off the board as quickly as possible, but that doesn't mean putting their life in danger to prevent the off chance of a pressure sore.

a pressure related skin injury is a certainty in the immobilised patient if they are immobilised on a Long EXTRICATION board, the question is when and how bad ... again immobilise someone on a LEB leave them for 30 minutes then do a skin assessment

Along extrication board causes several points of high pressure and does not allow the spine to sit in its natural curves

exacerbating a bony injury and /or causing additional neurological symptoms is something which has a low probability if the patient is handled correctly ...

we do not nurse acute SCI patients on longboards once they are admitted to hospital even with unstable thoracic or lumbar fractures - they are nursed on flat bed rest with regular side to side turning/ 30 degree tilt as well as a alternating cell air mattress.

the attitudes displayed in this thread show extensive ignorance and a dogmatic patriarchial attitude towards patients.

Specializes in Emergency, outpatient.

Zippy, you are not reading the posts that are responding to you. Your descriptions of pt care are centered in prehospital(read before the ED)and in spinal cord units. I think you don't get it. You are too busy looking for the next sentence you can use to denigrate other nurses.

I think the vampireslayer's original question was answered long ago. And I, for one, learned something from the research I did with my last response to Zippy. All the rest of his ranting is useless to me.

I'm done with this thread, y'all. BBFN and talk to you guys elsewhere. :stone

+ Join the Discussion