Insanity of

Immobilization?: A
Extrication Device
Becomes a Splint
J Brent Myers MD MPH
Director | Medical Director
Wake County Dept of EMS
Raleigh, NC, USA
The Plan
How did we get here?
What does the evidence say?
What should we do now?
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The pessimist complains about the wind;
The optimist expects it to change;
The realist adjusts his sails.
- William Arthur Ward
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J of Trauma, 2010; 68:115-121
What Does This Tell Us?
Retrospective Review of National
Trauma Database
Limitations include only 4.3% of over
45,000 penetrating trauma patients had
spinal immobilization
Regression was performed to control
for other variables
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What Does This Tell Us?
Overall mortality was 8.1%, with 14.7%
mortality in the immobilized group and
7.2% in the non-immobilized group
Odds of death 2.06 for immobilized vs.
non-immobilized
Only 0.01% (30 total patients out of
over 45,000) had incomplete spinal
injury and underwent surgery
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A Few Numbers
Number needed to treat to provide
benefit: 1,032
Number needed to treat to confer harm:
66
Thus, immobilization of the spine in
penetrating trauma harms 15 patients
for every one it potentially helps
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J of Trauma 1989; 29:1497-99
What Does This Tell Us?
Retrospective review of 61 patients
transferred for spinal injury
70% cervical spine injuries
18% thoracic spine injuries
12% lumbar spine injuries
Method of transfer
40% ground
55% rotor wing
5% fixed wing
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What Does This Tell Us?
No particular method of immobilization
was proscribed
95% had some type of long board
Various mechanisms of towel rolls, rigid
collars, etc. were utilized
4 patients had cervical traction

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What Does This Tell Us?
The exact method of immobilization
had no demonstrated associated with
outcome:
No patient had ascending neuro deficit
16 of 39 patients with partial deficits had
improvements prior to hospital discharge
10 of 22 patients with complete deficits
had improvements prior to hospital
discharge
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Annals of EM 1994; 23: 48-51
What Did They Do?
21 healthy volunteers with no history of
back disease were placed on a
backboard for 30 minutes
100% of these volunteers developed
symptoms
55% said they were moderate to severe
29% developed additional symptoms over
subsequent 48 hours
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What Symptoms Did They
Develop?
During the observation period:
Occipital headache 76%
Sacral pain 9%
Lumbar pain 7%
Mandible pain 7%
Most common delayed symptom was
headache (12%)
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J of Trauma 1983;23: 461-65
What Did We Learn?
Tape and sandbags are the only way to
truly immobilize the c-spine
Hard collar, soft collar, and
Philadelphia collars all allow too much
movement
If we we really want to immobilize, this
is it
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PEC 2010;14:419-24
What Did We Learn?
73 healthy volunteers were placed on
the spine board
After 30 minutes, they were removed
and tissue oxygenation was measured
There was clear evidence of
hypoperfusion of the sacral area during
the 30 minutes
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Bauer D and Kowaloski R, Annals of EM
1988;17:915-918
What Did We Learn?
15 healthy male volunteers age 23 to 28
were placed on long spine board or
KED
Forced vital capacity (FVC), Forced
Expiratory Capacity in 1 Second
(FEC1), Forced Midexpiratory Flow
(FEF), and FEC1:FVC ratio were
measured
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What Did We Learn?
In both the LSB and KED situation, all
parameters except the FEC1:FVC ratio
were adversely affected
The clinical implications of apparent
restrictive disease in these healthy
volunteers as it relates to injured
trauma patients is not known
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This study . . . poses a question that
challenges another sacred cow of EMS
training and practice. Specifically it asks
whether out-of-hospital spinal
immobilization truly has a positive effect on
neurologic outcome. This question, which
was perhaps unimaginable a few years ago,
addresses a subject that hits hard at the
core of EMS
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Academic EM 1998;5(3):203-4
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PEC 2013;17:392-93
Who Needs Full Deal?
Blunt Trauma and Altered LOC
Spinal pain or tenderness
Spinal Deformity
Neurologic complaint
High energy mechanism and
distraction/intoxication/inability to
communicate
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Who Does NOT Need Full
Deal?
Cleared blunt trauma patients may not
need full immobilization:
GCS 15/no intoxication/no distration
No pain
No deficits
Patient with penetrating trauma without
neuro deficits should NOT receive
immobilization
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