Care of the Spine Injured Athlete

Inter-Association Task Force:

Appropriate Care of the Suspected Spine Injured Athlete

MaryBeth Horodyski, EdD, LAT, ATC, FNATA Professor, Director of Research

University of Florida, Gainesville, FL

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Disclosures Laerdal Foundation

NOCSAE

NCAA

Southwestern Medical Foundation

Stryker

SEATA

Methods An electromagnetic tracking

device (Liberty - Polhemus Inc., Colchester, VT) To quantify the amount of

segmental motion generated

Receivers of the tracking device were fastened directly to the vertebrae at the level of the instability

Live subjects taped to the forehead and sternum

Methods: Variables Measured Dependent variables:

Angular motion (o) Flexion/extension Right and left lateral flexion Right and left rotation

Linear displacement (mm) Anteroposterior displacement Medial/lateral displacement Distraction/compression

Independent variables: Technique Injury condition

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NATA Position Statement: Acute Management of the Cervical

Spine-Injured Athlete Prevention strategies

Emergency planning and preparation

Maintaining or creating neutral alignment

Assessing and maintaining the airway

Stabilizing and transferring

Managing the equipment-laden athlete

Considerations in the emergency department Swartz et al, 2009

Original document published 2001 Writing team first met in 1998

Updated document currently under review by approximately 24 participating organizations

Appropriate Care of the Spine Injured Athlete

6

I am Someones Child

We are NOT on the Same Page!

Management of spinal cord injured patients is typically not standardized or consistent within a single institution! Changes in EMS spine boarding protocols

Treatment strategies are usually based on Institutional or personal provider experiences Physician training Resources available at the treatment facility

We are NOT on the Same Page!

Many times we may not be fully aware of what is best care

Best care likely encompasses a variety of treatment strategies Acceptable success rates Reasonable inherent risks

Terminology

Spinal immobilization???

Spinal motion restriction (SMR) Restrict motion of c-spine area

Cervical collars Patient driven Spine board and other devices

Premise of SMR is to prevent further harm to the spinal cord or spinal column

When to Use SMR NEXUS criteria or Canadian C-Spine rules

Key factors for SMR Blunt trauma or high energy MOI Altered level of consciousness or any of the following

Drug or alcohol intoxication Inability to communicate Distracting injury

Mid-line spinal pain and/or tenderness Focal neurologic signs and /or symptoms

Numbness and/or motor weakness

Anatomic deformity of the spine National Association of EMS Physicians and American

College of Surgeons Committee on Trauma. EMS Spinal Precautions and the Use of the Long Backboard. Prehosp Emerg Care.

When to Use SMR

ATLS (9th edition) advocates the following Awake, alert, sober, neurologically normal, no neck

pain or midline tenderness, no pain during active rotation or flex/ext

When in doubt, leave the immobilization in place

When to Use SMR

My research colleagues say: Either one would work. You just have to pick one and

be consistent. It is still a gamble that you won't miss a c spine injury.

Agreed. Doesn't matter too much since all major trauma centers go straight to CT anyway.

We use NEXUS in Norway, to clear spines pre-hospital.

ATTENTION!!! Shift in prehospital care methods

Some locations in the US No longer using spine boards for maintaining spinal

precautions EMS Management of Patients with Potential Spinal

Injury Approved by the ACEP Board of Directors January 2015

Too many patients are unnecessarily placed on spine boards for transportation to the appropriate medical facility Systemic harm to patient

Harm to the Patient??? Immobilization with the long spine board can

contribute to negative outcomes to the patient Pulmonary function Occipital and sacral pressures Intracranial pressures Pain Tissue breakdown

Lerner et al, J Natl Assoc EMS Physicians. 1998 Bauer et al, Ann Emerg Med. 1988 Sheerin and de Frein, J Emerg Nurs Cordell et al, Ann Emerg Med. 1995

This is it!

Athletic programs must have an Emergency Action Plan (EAP) developed in conjunction with the local Emergency Medical System (EMS).

Appropriate Care of the Spine-Injured Athlete

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EAP This is not a good example

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EAP

Scene safety Activate EMS Get emergency equipment

to the athlete

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Direct EMS to the Scene They need an exact location.

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Consider EMS response time How long will you have to care for the athlete before

help arrives

EAP: Other Considerations Develop plan in conjunction with local EMS

All levels of school administration are involved

and aware of the plan

Emergency equipment maintenance is documented

Documentation of staff training Everybody including team physicians have to be up to

speed

Updated yearly and after each activation 21

EAPs Must Cover All Venues..

And All Threats

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Game Time

Time Out! Sports medicine teams should conduct a Time

Out before each athletic event.

Who is involved in the pregame time out Anyone who has a role in the EAP

MTO = Medical Time Out

Medical Staff and EMS meet before the event

Introductions and review of emergency procedures A quick synopsis of important components of the EAP The EAP should MTO overlap

It only takes a few minutes

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Access to Airway

Remove any existing barriers to expose airway Swartz et al, 2009

Keep motion to a minimum Research on airway management Jaw-thrust maneuver recommended

Prasarn et al, Spine Journal 2014 Often no longer taught in CPR classes

Maintain alignment of the cervical spine

Facemask Removal Combined tool approach

CSD and cutting tool resulted in 100% success

Average time: 37.84 15.37sec Copeland et al. Clin J Sport Med,

2007

On-field conditions throughout football season 98.6% (75/76) of removal

attempts were successful with combined tool approach

Average removal time 40.1 15.1 seconds

Gale et al. JAT, 2008

Quick Release Facemask Removal Removal time of quick release face guard

Riddell Quick Release Helmet After a season of football

Removal of facemask Satisfactory time and success rate Gruppen et al. JAT, 2012; Scibek et al. JAT, 2012

Quick release

More effective than other facemask removal techniques

Better success rate Swartz et al. JAT, 2010

Facemask: Other Options

Feed pocket mask through facemask The PMI (Pocket Mask Insertion) technique significantly

faster 19.86 5.92 seconds

QRM 50.37 13.13 seconds CSD 68.98 15.42 seconds

Toler et al. Clin J Sport Med, 2011

PMI time 14-19 seconds

Ray et al. JAT, 2002

Facemask Removal: Summary

Cordless screwdriver was the best way to remove a football helmet

Pruners should be carried as a backup in case the cordless screwdriver fails

Facemask removal practice and hardware inspection reduce chances of failure

Brandey et al. JAT, 2013

SMR: What is the Evidence?

Hand placement for stabilization Spine boarding techniques

Supine Prone

Centering on the spine board Other SMR devices Sports equipment removal

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Traditional Hand Hold

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Modified Hand Hold

Modified Hand Hold

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Hand Placement

* #

Axial rotation and lateral bending: Significant differences between techniques (p

Supine Patient Options

Log roll (traditional) Lift-and-slide (straddle lift or multi-person lift) Mechanical device (Scoop stretcher, motorized spine board)

Influencing factors Patient size Personnel

Number Relative strength Preparedness (practice)

Supine Patient - Spine Board Transfer Techniques

Log roll vs lift-and-slide vs multi-person lift (Del Rossi et al., JAT, 2008)

Supine Patient - Spine Board Transfer Techniques

Mechanical Transfer Devices Log roll vs scoop stretcher

(Krell et al., Prehosp Emerg Care, 2006)

31 healthy subjects Electromagnetic sensors

Forehead, C3 (surface), T12 (surface)

Results 6-8 degrees greater motion in all three planes during LR

compared to SS

LRLS

SCOOP

0

1

2

3

4

5

6

7

Ang

ular

Mot

ion

(deg

rees

)

Technique

Flexion - Extension

Axial Rotation

Lateral Flexion

LRLS

SCOOP

0

0.1

0.2

0.3

0.4

0.5

0.6

Line

ar T

rans

latio

n (c

m)

Technique

Medial - Lateral Translation

Distraction - Compression

Anterior - Posterior Displacement

*

Supine Patient - Spine Board Transfer Techniques

Mechanical Transfer Devices Log roll vs multi-person vs Scoop Stretcher

(Del Rossi et al., AJEM, 2010)

Eliminating the Log Roll When using log roll techniques for transfers

Sum of the largest displacements during the total sequence

2 times for flexion/extension 2.6 times for axial rotation 2.8 times for lateral bending

Prasarn et al. 2012 Spine Journal

No log roll Sum of the greatest displacements for the complete

sequence was significantly decreased Prasarn et al. 2012 Journal of Neurosurgery

Overall cumulative motion to the unstable spine can be reduced by approximately 50% if the log roll is avoided and alternative measures are employed

Conrad et al. 2012

Centering on the Spine Board

Flexion/extension No equipment less motion Football equipment more

motion

Significantly less lateral bending Significantly less medial/lateral

translation

DuBose DN et al., J Emerg Med. 2016

Supine Obese/Large Patient Spine Board Transfer Techniques

Personnel or strength concerns 2001 NATA Consensus Statement suggested adding

more personnel to 8 person > 8 New Task Force document has changed the term to multi-

person lift Log roll might be only other option

Equipment concerns

Scoop stretchers might be too narrow or too short to accommodate large patients

Check the size of your spine board Not - one size fits all!

Supine Patient - Summary

Multi-person lift generates less motion than LR

Horizontal slide may create less motion when centering a patient on the spine board

Scoop stretcher Appears to be as safe as LS

Consider multi-person and scoop stretcher as alternative to LR (supine patient)

Supine Patient Planning Ahead Using the Multi-Person Spine

Board Technique Still Recommended: Evaluating EMS Protocols

Horodyski et al, presented at NATA 2015

Six SMR techniques 2 person lift to gurney Log roll onto spine board, lift to

gurney, log roll off to gurney Scoop stretcher, lift onto gurney,

scoop stretcher off onto gurney

Supine Patient Planning Ahead Using the Multi-Person Spine

Board Technique Still Recommended: Evaluating EMS Protocols

Horodyski et al, presented at NATA 2015

Six SMR techniques Multi-person lift onto spine board,

lift board to gurney, 8 person lift off board onto gurney

Multi-person lift, strap to spine board, lift and secure to gurney

Multi-person lift to gurney, secure to gurney

Prone Patient

Options Log roll pull vs. log roll push Log roll 1x vs. log roll 2x

Influencing factors

History (convention) Personnel

Availability of spine board Preparedness (practice)

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Prone Patient Equipment-laden

Might this be a good time to initiate removal of equipment? An opportunity to improve

patient

Prone Patient Spine Board Transfer Techniques

Push vs Pull Cadaveric study

Thoracolumbar instability Conrad et al., J Spinal Cord Med, 2012

Prone Patient Spine Board Transfer Techniques

Significantly less motion with the Push technique Flexion/Extension; Axial Translation; Ant/Post Translation

Prone Patient Summary PRACTICE!

LR only option; but how many times should you

move the patient?

Decide in advance how the situation should be handled based on circumstances What technique

With every transfer there is the

potential or opportunity for motion to occur.

Spinal motion restriction Spine board is current gold-standard for prehospital

spinal motion restriction Full body vacuum mattress may provide good SMR

Pro and cons

Vacuum Mattress

Vacuum Mattresses Spinal motion restriction

Vacuum mattress vs spine board Johnson et al., AJEM, 1995

30 subjects Motion during lateral tilting (90o)

Cervical Stabilization Devices

A rigid cervical stabilization device should be applied to spine-injured athletes prior to transport with manual in-line stabilization until stabilization on a full-body immobilization device has been accomplished.

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Effectiveness of Cervical Collars

Application of one and two piece collar on unstable spine

Two piece collar had significantly more movement than the one piece Clinical relevance? - small difference

Collars can be placed and removed with manual in-line stabilization and (potentially) minimal risk

Prasarn et al., Trauma Acute Care Surg, 2012

Effectiveness of Cervical Collars Application of a cervical collar caused increased

separation at the injury site C1-C2 level Ben-Galim et al. J Trauma, 2010 Current study - significant difference in axial translation

during application of the X-collar

Rigid collars create pivot points that shift the center of rotation lateral to the spine and contribute to the intervertebral motion

Lador et al. J Trauma, 2011

Effectiveness of Cervical Collars

Cervical collars do not effectively reduce motion in an unstable cervical spine

Horodyski et al. J Emerg Med, 2011 Miller et al. Spine, 2010 Bearden et al. J Neurosurgery, 2007 Del Rossi et al. The Spine Journal, 2004

Cervical Collars - Summary Often cannot correctly apply cervical collars when the athlete is wearing equipment

Time of application and impact to beginning critical life saving procedures

Why do we put cervical collars on conscious trauma patients?

Benger J and Blackham J, Scand J Trauma Resuscitation Emerg Med, 2009

Equipment Removal

Who should do it? Equipment removal performed by those with

highest level of training and experience in removal techniques

Sports medicine teams and emergency room personnel must be familiar with a variety of safe sport-specific equipment removal techniques

Equipment Removal

Face mask should always be removed prior to transport Regardless of airway status

When deemed necessary by onsite medical personnel Helmet and shoulder pads may be

removed prior to transport

Equipment Removal Facilitates packaging

58

Facilitates ED physician evaluation

Facilitates ED diagnostic testing

Black & White or Gray ?

Every emergency situation and every patient is different Individual circumstances must dictate appropriate actions No such thing as always and never

Helmet Removal Rescuer 1 maintains c-spine

stabilization Rescuer 2 cuts front of jersey using T

technique neck to waist sleeve to sleeve

Rescuer 2 opens front of pads to gain access to cervical spine and chest cut front of pads utilize quick release if available

Rescuer 2 takes control of c-spine from front: I have c-spine: you can release

Rescuer 1 removes helmet Rescuer 1 resumes c-spine control

Helmet Removal Rescuer 1 maintains c-spine

stabilization Rescuer 2 cuts front of jersey using T

technique neck to waist sleeve to sleeve

Rescuer 2 opens front of pads to gain access to cervical spine and chest cut front of pads utilize quick release if available

Rescuer 2 takes control of c-spine from front: I have c-spine: you can release

Rescuer 1 removes helmet Rescuer 1 resumes c-spine control

Helmet Removal Rescuer 1 maintains c-spine

stabilization Rescuer 2 cuts front of jersey using T

technique Rescuer 2 opens front of pads to gain

access to cervical spine and chest cut front of pads:

utilize quick release if available

remove helmet chin strap Rescuer 2 takes control of c-spine from

front: I have c-spine: you can release Rescuer 1 removes helmet Rescuer 1 resumes c-spine control

Helmet Removal

Rescuer 1 maintains c-spine stabilization

Rescuer 2 cuts front of jersey using T technique

neck to waist sleeve to sleeve

Rescuer 2 opens front of pads to gain access to cervical spine and chest cut front of pads utilize quick release if available

Rescuer 2 takes control of c-spine from front: I have c-spine: you can release

Rescuer 1 removes helmet Rescuer 1 resumes c-spine control

Helmet Removal

Rescuer 1 maintains c-spine stabilization

Rescuer 2 cuts front of jersey Rescuer 2 opens front of pads to gain access to cervical spine and chest

Rescuer 2 takes control of c-spine from front

Rescuer 1 removes helmet Rescuer 1 resumes c-spine

control

Helmet Removal Question

If the helmet is removed on-site prior to transport, does the facemask need to be removed ? Based upon the type

of helmet.

Motion: Translational Movement for Airway Access

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Motion: Rotational Movement for Airway Access

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Helmet Removal: Techniques

Helmet bladders should be left inflated when the helmet is removed

It takes longer to deflate helmet bladders and remove a helmet

It is not always possible to access all the bladders in a supine athlete

Beltz et al (http://www.nhmi.net/deflate.php)

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Helmet Removal: Techniques

After the helmet is removed, padding should be placed under the head to prevent hyperextension Del Rossi G et al., 2014 DeCoster LC et.al., Spine, 2012 Waninger KM et.al., Current Sports Medicine Reports, 2011

Shoulder pads can remain on if spinal alignment can be maintained

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Helmet Removal Study

A comparison between two removal techniques Facemask removal then helmet removal (FMH)

Direct helmet removal (Helmet) Both techniques, cheek pads were removed

Spinal alignment was maintained throughout the helmet removal process

Head was placed on padding to maintain spinal alignment

70

Helmet Removal Study

0

2

4

6

8

10

Flex/Ext Axial Rot Lat Bend

Degr

ees (

)

Means of Angular Displacement at C5-C6

FMH

Helmet

FMH caused significantly less flexion-extension (p=0.023) and axial rotation (p=0.023) than the Helmet technique.

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Helmet Removal Study

0123456789

Med/Lat Axial Trans Ant/Post

Mili

met

ers (

mm

)

Means of Translation Displacement at C5-C6

FMH

Helmet

FMH caused significantly less anterior-posterior (p=0.035), medial-lateral (p=0.013), and axial (p=0.028) translations than the Helmet technique.

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Shoulder Pad Removal: Circulation, CPR and Defibrillation

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High Quality CPR Saves Lives

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Shoulder Pad Removal

Various Techniques Multi-person lift Bi-valve pads Elevated torso technique Flat torso technique

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Shoulder Pad Removal

8 person lift cut pads in front and pull off from back

when athlete elevated Rescuer 9: pads clear

Bi-valve pads cut and/or release pads in front and back

Shoulder Pad Removal Elevated torso technique

side lift technique: Rescuer 1 stabilizes c-spine; Rescuers 2 and 3 elevate torso while Rescuer 4 removes pads

contraindicated if suspect thoracic or lumbar injury

Flat torso technique Rescuer 2 assumes c-spine

stabilization from front and Rescuers 1 and 3 slide pads out axially

Traditional Pad Removal

78

Elevated Torso Removal 79

Summary: Shoulder Pad Removal

Other considerations: cervical collar rib pads back pad difficulty or inability to

cut pads due to materials involved

Appropriate Care of the Spine Injured Athlete

Spine-injured athletes should be transferred to and transported on a rigid immobilization device

Suspected spine injured athletes should be transported to the most appropriate medical facility

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Why I do what I do!

82

Head Board

Look at me now!

Athletic Trainers

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THANK YOU