Spinal protocols

kindaquazie · Jul 16, 2009

This question has come up frequently on this board. In our hospital, a level one trauma center, we remove the patient from the backboard as soon as they get their CT scan. This occurs usually within the first few minutes of arrival if the patient is stable. If a thorough examination can be performed on an awake alert patient without distracting injuries, it is generally safe to take a patient off a backboard if propper technique is utilized. If the patient is thrashing about due to intoxication or head injury and cannot cooperate, they are frequently intubated until the extent of injury can be quantified. Inspection of the posterior aspect of the patient is also an essential part of the trauma assessment, and should not be delayed if the backboard can safely be removed. It is also very important to perform and document a thorough neurological and spinal examination prior to any intervention such a removal from the backboard. This is something that is often overlooked or not performed as thoroughly as needed.

Collars however should only be removed by a trauma surgeon or other highly qualified person. An RN should NEVER take a verbal order to remove a C-collar unless the patient has had an MRI of the neck. Otherwise, a qualified practitioner should examine the patient for pain and tenderness at the time the collar is removed. A CT scan cannot reveal soft tissue or ligamentous injury that may cause problems even if the boney structures are intact.

JStyles1 · Jul 16, 2009

at the level 1 i work at we as nurses do not remove back boards or c-collars without a md saying all is clear. simple as that. no room for error

Larry77, RN · Jul 16, 2009

We also do not remove the backboards without at least a verbal...usually the doc is at the bedside so they can finish their exam as we take it off.

I have noticed that backboards are becoming less and less popular though...I think this is a great thing...spinal precautions can easily be maintained with a cooperative patient without the injury and pain provoking backboard...

Guest219794 · Jul 22, 2009

Where I work as a nurse, we don't.

The state of Maine uses a well researched, evidence based spinal assement protocol pre-hospital that could easily adapted to RN's in the ER.

http://www.maine.gov/dps/ems/documents/spinal_assessment_book.pdf

It is simple, easy to use, and accurate.

mwboswell · Jul 22, 2009

Where I work as a nurse, we don't.
The state of Maine uses a well researched, evidence based spinal assement protocol pre-hospital that could easily adapted to RN's in the ER.
http://www.maine.gov/dps/ems/documents/spinal_assessment_book.pdf
It is simple, easy to use, and accurate.

Good for you that you picked up on the "Maine Protocol". It is one of the few in the country and it uses evidence based research (even though some research is limited)...

But it's a great starting point and other EMS systems have been looking at it.

If we get it addressed on the pre-hospital side, that eliminates many spine boards/c-collars from even coming into the E.D.

Good post!

GleeGum, BSN, RN · Jul 24, 2009

we are a level 1 trauma center and we do not take patients off the back board with out MD present to do the exam. This is a problem, in my opinion, for level 3's.

i'm impressed with what kindaquazie wrote about their ER - CT within minutes of arrival? what a dream.

Our MD's (some) do clear c-spine precautions based on the NEXIS criteria which I like.

Pmdc · Jul 26, 2009

I'd like to hear from ED nurses that work in ED's that are utilizing some type of policy/protocol to remove pt's from backboards before the MD/NP sees the pt.
You don't need to give me the details of your employer's policy, but I would like to know the process such as what pt's are appropriate for this and what clinical criteria or checklist do you use?
I'm looking to see what the general practice is currently before deciding if I want to pursue research further on this.
Thanks in advance!

We are not presently clearing C-spines by physical exam at my facility, but I think the time has come for properly trained RNs/Paramedics to perform this skill. Just from some of the research I've read regarding the complications of unnecessary immobilization, I wonder how much damage we've caused over the years by insisting that patients who otherwise meet the NEXUS 5-item assessment tool for spinal clearance to remain immobilized for extended times out of fear of liability. Is there no liability for unnecessary immobilization with resultant complications?

I used NEXUS (which included 34,069 trauma patients at 21 facilities throughout the U.S.) as the basis for my senior research project when completing my BSN. My project was very basic, especially in regards to the number of study participants, but the RNs I surveyed clearly demonstrated that, after a very short and informal educational session, they were capable of applying the 5-item assessment tool when assessing trauma patients in a scenario-type format. For those who are unfamiliar, the NEXUS criteria are as follows:

1. Altered Mental Status

2. Use of intoxicants

3. Focal neurological deficit

4. Presence of distracting injuries (fractures, deep soft tissue injuries, etc.)

5. Midline C-spine tenderness

Obviously, any patient who meets one or more of the criteria cannot be cleared by physical exam. How many patients brought in from minor MVCs could have the equipment removed based on this simple exam? Might this decrease pain and anxiety in many of these patients? Could it possibly improve throughput times for already taxed emergency departments?

MWBoswell, I am glad you're considering this as a topic to research. I hope the assessment is eventually taught in the TNCC course if continued research supports the exam's use by emergency nurses. I don't believe I've ever seen a position statement from the ENA on this topic. I really believe that this will be a topic of increasing interest in the coming years, especially with our aging population.

rnffemtguy, BSN, RN · Jul 27, 2009

Good for you that you picked up on the "Maine Protocol". It is one of the few in the country and it uses evidence based research (even though some research is limited)...
But it's a great starting point and other EMS systems have been looking at it.
If we get it addressed on the pre-hospital side, that eliminates many spine boards/c-collars from even coming into the E.D.
Good post!

I can't speak from the RN standpoint on this, but I can speak from the EMS side. New York just went to the Maine protocol for spinal immobilization.

We carry the check off sheets in our clipboards with the PCR's, and now have a protocol to follow when we believe that full spinal immobilization isn't warrated (ie low speed imapcts w/pt's ambulatory PTOA). As to whether this has impacted the number of needless spinal immobilizations we perform I personally don't see alot of difference. It is at the discretion of the EMT in charge to determine if immobilization protocols are going to be followed, but there alot of variables that come into play and the way the new protocols are written we still have the option to immobilize by discretion, and I, like any other EMT that has been around awhile, tend to er on the side of caution.

I think I have the protocol update on powerpoint, I'll have to see if I can find it.....

Just to add: What always gets my biscuits is the RN who yanks the collar off and litterally dumps the pt off the board and throws the stuff back at us as we're leaving the room, I always tell them I put that on the pt for a reason and tell the provider as I meet them in the door that I did have the pt immobilized :madface: (sorry, my rant for the night)