Prehospital Emergency Care

ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20

New Immobilization Guidelines Change EMS

Critical Thinking in Older Adults With Spine
Trauma

Linda Underbrink, Alice “Twink” Dalton, Jan Leonard, Pamela W. Bourg,

Abigail Blackmore, Holly Valverde, Thomas Candlin III, Lisa M. Caputo,
Christopher Duran, Sherrie Peckham, Jeff Beckman, Brandon Daruna, Krista
Furie & Debra Hopgood

To cite this article: Linda Underbrink, Alice “Twink” Dalton, Jan Leonard, Pamela W. Bourg,
Abigail Blackmore, Holly Valverde, Thomas Candlin III, Lisa M. Caputo, Christopher Duran,
Sherrie Peckham, Jeff Beckman, Brandon Daruna, Krista Furie & Debra Hopgood (2018): New
Immobilization Guidelines Change EMS Critical Thinking in Older Adults With Spine Trauma,
Prehospital Emergency Care, DOI: 10.1080/10903127.2017.1423138

To link to this article: https://doi.org/10.1080/10903127.2017.1423138

Published online: 06 Feb 2018.

Submit your article to this journal

Article views: 10

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ipec20
 NEW IMMOBILIZATION GUIDELINES CHANGE EMS CRITICAL THINKING IN
OLDER ADULTS WITH SPINE TRAUMA
Linda Underbrink, RN, Alice “Twink” Dalton, RN, MS, NRPM, CNS, Jan Leonard, MSPH,
Pamela W. Bourg, PhD, RN, TCRN, FAEN, Abigail Blackmore, MSN, RN,
Holly Valverde, MPH, BSN-RN, CEN, Thomas Candlin III, NREMT-P, Lisa M. Caputo, MA,
Christopher Duran, RN, BSN, MBA, Sherrie Peckham, RN, BSN, Jeff Beckman, MD,
Brandon Daruna, NREMT-P, Krista Furie, RN, BSN, Debra Hopgood, BA, NREMT-P
ABSTRACT
Objective: The impact of immobilization techniques on older
adult trauma patients with spinal injury has rarely been
studied. Our advisory group implemented a change in the
immobilization protocol used by emergency medical services
(EMS) professionals across a region encompassing 9 trauma
centers and 24 EMS agencies in a Rocky Mountain state using
a decentralized process on July 1, 2014. We sought to deter-
mine whether implementing the protocol would alter immo-
bilization methods and affect patient outcomes among adults
ࣙ60 years with a cervical spine injury. Methods: This was
a 4-year retrospective study of patients ࣙ60 years with a
cervical spine injury (fracture or cord). Immobilization tech-
niques used by EMS professionals, patient demographics,
injury characteristics, and in-hospital outcomes were com-
pared before (1/1/12–6/30/14) and after (7/1/14–12/31/15)
Received September 19, 2017, from Foothills RETAC, Lakewood,
Colorado (LU, LMC); Mountain View Fire Rescue, Emergency Ser-
vices, Boulder, Colorado (ATD); St. Anthony Hospital, Trauma
Services, Lakewood, Colorado (JL, PWB, AB); Lutheran Medi-
cal Center, Emergency Department/Trauma Services, Wheatridge,
Colorado (HV); St. Anthony Hospital, Prehospital Services, Lake-
wood, Colorado (TC); Longmont United Hospital, Emergency
Department/Trauma Services, Longmont, Colorado (CD); Good
Samaritan Medical Center, Emergency Department/Trauma Ser-
vices, Lafayette, Colorado (SP, JB); Gilpin Ambulance Service,
Gilpin County, Colorado (BD); Boulder Community Hospital
Emergency Department/Trauma Services, Boulder, Colorado (KF,
DH); NREMTP Boulder Community Hospital Emergency Depart-
ment/Trauma Services, Boulder, Colorado (DH). Revision received
December 12, 2017; accepted for publication December 28, 2017.
The authors would like to acknowledge and thank the medical facil-
ities that agreed to participate in this study: St. Anthony Hospital,
Lutheran Medical Center, Good Samaritan Medical Center, Avista
Hospital, Boulder Community Hospital, Longmont United Hospi-
tal, Mountain Valley Medical Center-Kremmling, Mountain Valley
Medical Center-Granby, and Denver Health East Grand Community
Clinic.
The authors have no conflicts of interest to disclose.
Address correspondence to Linda Underbrink, RN, 10127 W. Dart-
mouth Place #201, Lakewood, CO 80227. E-mail: linda.u@msn.com
Color versions of one or more of the figures in the article can be found
online at www.tandfonline.com/ipec.
© 2018 National Association of EMS Physicians
doi: 10.1080/10903127.2017.1423138
1
implementation of the Spinal Precautions Protocol using
bivariate and multivariate analyses. Results: Of 15,063 adult
trauma patients admitted to nine trauma centers, 7,737 (51%)
were ࣙ60 years. Of those, 237 patients had cervical spine
injury and were included in the study; 123 (51.9%) and 114
(48.1%) were transported before and after protocol imple-
mentation, respectively. There was a significant shift in the
immobilization methods used after protocol implementation,
with less full immobilization (59.4% to 28.1%, p < 0.001) and
an increase in the use of both a cervical collar only (8.9% to
27.2%, p < 0.001) and not using any immobilization device
(15.5% to 31.6%, p = 0.003) after protocol implementation.
While the proportion of patients who only received a cervical
collar increased after implementing the Spinal Precautions
Protocol, the overall proportion of patients who received a
cervical collar alone or in combination with other immobi-
lization techniques decreased (72.4% to 56.1%, p = 0.01). The
presence of a neurological deficit (6.5% vs. 5.3, p = 0.69) was
similar before and after protocol implementation; in-hospital
mortality (adjusted odds ratio = 0.56, 95% confidence inter-
val: 0.24–1.30, p = 0.18) was similar post–protocol implemen-
tation after adjusting for injury severity. Conclusions: There
were no differences in neurologic deficit or patient dispo-
sition in the older adult patient with cervical spine trauma
despite changes in spinal restriction protocols and resulting
differences in immobilization devices. Key words: spinal
injuries; spinal cord injuries; geriatrics; clinical protocols;
trauma; prehospital emergency care
PREHOSPITAL EMERGENCY CARE 2018; Early Online:1–8
INTRODUCTION
Approximately 17,000 Americans experience a new
spinal injury each year, with each case involving an
average of 11 days in the hospital and risking long-
term secondary injuries, including neurological deficits
of incomplete tetraplegia, incomplete paraplegia, and
complete paraplegia (1). Spinal immobilization using
a backboard, cervical collar, and head immobilization
device has been commonly used in the field for trauma
patients suspected of having a spinal injury for the
latter half of the 20th century. Immobilization was
assumed to reduce the risk of neurological deteriora-
tion by restricting mobilization to prevent the exacer-
bation of the injury during extrication, transport, and
evaluation, thereby avoiding secondary injury (2). Rec-
ommendations for full spinal immobilization exist for
2 PREHOSPITAL EMERGENCY CARE
specific, defined patients; otherwise, there is little evi-
dence supporting the benefits of spinal immobilization
(3). On the contrary, a number of studies have illus-
trated an increase in pain and discomfort (4, 5), delayed
resuscitation (6), increased intracranial pressure (7),
failed airway management efforts (8, 9), and pres-
sure ulcers (10), contributing to further injury (11) and
resultant incorrect treatment due to increases in false-
positive diagnosis due to immobilization (4) among
other negative consequences (12) associated with the
practice. These findings have led to early removal of
the backboard as best practice (13).
In response to evidence dissuading the use of full
immobilization for all suspected spinal cord injuries,
the National Association of EMS Physicians and the
American College of Surgeons Committee on Trauma
released a position statement for use of spinal precau-
tions in the field in 2013 (14). The paper recommends
the cautious use of backboards for immobilization and
provides a list of characteristics that may necessitate, or
rule out, the need for immobilization (14). The state of
Maine instituted a policy that allowed for Emergency
Medical Services (EMS) discretion regarding prehospi-
tal immobilization methods, resulting in a high sensi-
tivity for appropriate immobilization of patients with
suspected spinal fracture (15). Other selective immo-
bilization protocols have led to findings demonstrat-
ing that EMS professionals’ decisions are predictive of
patients who correctly required immobilization due to
spinal injuries (16). A 1997 study also found that pro-
viding an assessment to EMS professionals in the field
may result in a high level of agreement between EMS
professionals and physicians (17).
Goals of the Investigation
Adult trauma patients ࣙ60 years make up 15.4% of
spinal cord injuries sustained and face higher mor-
tality rates and are significantly undertriaged when
compared to their younger counterparts (18, 19).
Despite this, few studies have exclusively examined
the impact of spinal immobilization on older adult
trauma patients. The Foothills Regional Emergency
Medical & Trauma Advisory Council (RETAC) imple-
mented the Spinal Precautions Protocol to guide the
use of field spinal immobilization for 24 EMS trans-
porting agencies on July 1, 2014. The goals of the mul-
ticenter study were to examine older adult (ࣙ60 years)
trauma patients with a cervical spine fracture or cer-
vical cord injury and compare the type of spinal pre-
cautions used by EMS and identify changes in hospital
outcomes before and after protocol implementation.
METHODS
Study Design and Setting
We conducted a retrospective, observational study of
older adult (ࣙ60 years) trauma patients with a cer-
2018 EARLY ONLINE
vical spine injury (fracture or cord) before and after
the Foothills RETAC implemented a Spinal Precautions
Protocol on July 1, 2014.
The Foothills RETAC is a not-for-profit multidis-
ciplinary advisory council made up of physicians,
nurses, EMS professionals, and public health profes-
sionals statutorily charged with integrating all mem-
bers of the health care continuum and advising on
all matters concerning emergency medical and trauma
care within a 5-county region of Colorado. Their area
covers 4,000 square miles and 920,000 people. The orga-
nization advises 9 designated trauma centers and 24
EMS agencies. The trauma centers include one Level
I and two Level II American College of Surgeons–
verified trauma centers and three Level III, two Level
IV, and one Level V state-verified trauma centers. The
participating EMS agencies range from a call volume
of 10 to 48,000 transports per year and include private,
public, county-based, and fire-based agencies.
Selection of Participants
We compared cohorts of older adult patients with cer-
vical spine injury admitted 2.5 years prior (1/1/12–
6/30/14) and 1.5 years after (7/1/14–12/31/15) imple-
mentation of the Spinal Precautions Protocol. Patients
were included in the study if they were ࣙ60 years, were
transported by one of the 24 participating EMS agen-
cies, were admitted to one of the 9 participating trauma
centers, and had a diagnosis of cervical cord injury
and/or cervical spine fracture. The following Interna-
tional Classification of Diseases 9th revision (ICD-9)
diagnosis codes were used to identify patients with a
cervical fracture and/or cervical cord injury:
r ICD-9 805.00 through 805.18: Cervical fracture with-
out cord injury
r ICD-9 806.00 through 806.19: Cervical fracture with
cord injury
r ICD-9 952.00 through 952.09: Cord injury without
cervical fracture
We excluded patients who arrived to the hospital
without vital signs, arrived to the emergency depart-
ment (ED) by private vehicle or other triage, were
transferred to the medical facility from another med-
ical facility, or had missing information pertaining to
the type of immobilization devices used. The data were
collected by trauma nurse registrars and coordinators
at each facility according to state reporting criteria.
Interventions
Prior to protocol development and implementation,
the Foothills RETAC required all EMS agencies to
transport all patients with a suspected spinal injury
fully immobilized on a backboard with a cervical
collar and head immobilization device. On July 1, 2014,
L. Underbrink et al. PREHOSPITAL SPINAL IMMOBILIZATION TECHNIQUES IN OLDER ADULTS 3

the Foothills RETAC adopted the Spinal Precautions Table 1. Categories used to define immobilization
Protocol, used by the neighboring Denver metro EMS techniques
medical directors since 2009, to align their protocol Spinal Immobilization
with the evolving evidence on the topic. As demon- Code in Trauma
strated in Figure 1, the Spinal Precautions Protocol is a Registries Definition Category
logic flowchart that allows EMS professionals to prac- FULL Backboard and cervical Full
tice discretion when choosing immobilization methods collar and head
for patients aged 12 and older with a suspected spinal immobilization
cord injury. The protocol provides evidence-based cri- device
CCO Cervical collar only Cervical collar
teria (14) that identify patients most at risk for a spinal CC and SS Cervical collar and Other
injury who would benefit from placement of a cervi- scoop stretcher
cal collar or receiving full immobilization. This proto- SS and HID Scoop stretcher and Other
col is different from previously published protocols, as head immobilization
device
it provides guidance for both full immobilization and HID and Tape Head immobilization Other
the use of cervical collars alone. The protocol requires device and tape
patients with midline spine tenderness, neurological SS Scoop stretcher Other
deficits, potentially distracting injuries, alteration in Other Other or mix of above Other
None No immobilization None
mental state, or barriers to spinal evaluation to receive used
a cervical collar. Further, patients with neurological
deficits and/or patients unable to comply with direc-
tions would receive full immobilization. Comparable
studies, in contrast, have listed mechanism of injury as wide variety of immobilization devices were uti-
a criterion for immobilization but have not provided an lized throughout the agencies involved in this study.
option for use of only a cervical collar or a dichotomous For the purposes of this study, immobilization types
assessment to guide EMS on immobilization choices were categorized as full spinal immobilization, cer-
(15, 17). vical collar–only immobilization, no immobilization,
The Spinal Precautions Protocol, originally devel- or other immobilization (Table 1). Full immobilization
oped by the partner organization Denver Metro EMS was defined as the concurrent use of a rigid back-
Physicians, was introduced within the diverse group board, scoop stretcher, or full body vacuum splint with
of 24 EMS agencies of the Foothills RETAC during the a cervical collar and head immobilization device. Other
spring of 2014. The meetings to introduce the proto- immobilization included a variety of possible head
col included the respective education coordinators of immobilization devices, such as a head block, scoop,
each agency. A decentralized approach was enacted or vacuum splint, which may or may not include the
to effectively manage the agencies with contrasting use of a backboard or cervical collar. No immobiliza-
sizes, geography, and agency types and ensure that tion was defined as the absence of any rigid backboard,
the protocol would be enacted in a timely manner. scoop stretcher, full vacuum splint, cervical collar, or
The medical directors assumed individual responsibil- head immobilization device of any kind. The presence
ity for incorporating, enacting, and monitoring the pro- of a neurological deficit was identified though ICD-9
tocol by July 1, 2014, in their individual EMS agen- codes. Patient disposition at discharge was recorded by
cies. An additional quality assessment requirement for the trauma registrars and categorized as home, long-
each EMS agency that included collecting information term acute care, inpatient rehabilitation facility, skilled
on patient safety and protocol adherence was to be nursing facility, other, transfer, and died/hospice.
completed through the EMS Agency Quality Improve-
ment Programs. Input from the medical directors was
emphasized throughout the training period to achieve
Analysis
agency-level buy-in. While protocol education differed The chi-square test was used for categorical variables
to meet the unique setting of each agency, the EMS and the Kruskal-Wallis and Student’s t tests were
medical directors provided training through didac- used for continuous variables to examine differences
tic training sessions or consolidated EMS educational before and after the implementation of the Spinal
groups. Materials were provided to EMS agencies elec- Precautions Protocol. Multivariate logistic regression
tronically by the Foothills RETAC. analysis was used to calculate the odds ratio (OR)
for the post-, compared to pre-, protocol period on
the outcome in-hospital mortality/hospice to adjust
Key Outcome Measures for significant baseline variables. A p value < 0.05
Outcomes of interest included immobilization type, the was used to indicate statistical significance. Statistical
presence of a neurological deficit, patient disposition analyses were performed using SAS software (version
at discharge, and in-hospital mortality/hospice. A 9.3, Cary, NC).
4 PREHOSPITAL EMERGENCY CARE
FIGURE 1. Spinal Precautions Protocol.
Human Subject Committee Review
This study was approved by institutional review
boards at St. Anthony Hospital (Lakewood, CO) and
Lutheran Hospital (Wheat Ridge, CO).
RESULTS
Characteristics of Study Participants
Of the 15,063 adult trauma patients admitted to 9
trauma centers, 7,737 (51%) were ࣙ60 years; 237 (1.6%)
patients had a diagnosis of cervical spine fracture or
cervical cord injury and met the study inclusion crite-
ria. One hundred twenty-three (51.9%) patients were
admitted prior and 114 (48.1%) were admitted after
2018 EARLY ONLINE
the Spinal Precautions Protocol was implemented. The
overall patient population presented with moderate
injury severity, a median Injury Severity Score (ISS) of
10, and Glasgow Coma Scale (GCS) score of 15, with
injuries primarily due to falls (65.0%). In aggregate,
most patients (94.1%) did not have a neurologic deficit
upon discharge. After in-hospital treatment, nearly
half (42.6%) of the patients were admitted to a skilled
nursing facility and 14.8% expired in-hospital or were
sent to hospice. Demographic and injury characteris-
tics of age, sex, GCS score, cause of injury, and type of
injury sustained were similar between the two cohorts.
Patients in the pre-protocol population had a higher
median ISS compared to their post-protocol counter-
parts (10 vs. 9, p = 0.02, Table 2).
L. Underbrink et al. PREHOSPITAL SPINAL IMMOBILIZATION TECHNIQUES IN OLDER ADULTS 5

Table 2. Comparison of demographic and injury spinal cord injury (p = 0.69). Patient disposition after
characteristics, pre– and post–protocol implementation hospital treatment also remained similar between the
Pre-Implementation Post-Implementation
groups. Skilled nursing facility continued to be the
(n = 123) (n = 114) p most common disposition, with 50 patients (40.7%)
and 51 patients (44.7%) being referred after hospi-
Age, mean (SD) 77.4 (10.7) 78.9 (9.5) 0.26
tal treatment (p = 0.52), respectively. Last, there was
Male, n (%) 63 (51.2%) 59 (51.8%) 0.93
Cause of injury, n (%) 0.14 a significant decrease in rates of death/hospice after
Fall 74 (60.2%) 80 (70.2%) implementing the Spinal Precautions Protocol, from 24
Motor vehicle 30 (24.4%) 25 (21.9%) patients (19.5%) to 11 patients (9.7%) before and after
accident
Other 19 (15.5%) 9 (7.9%)
protocol implementation, respectively (p = 0.03); how-
ISS, median (IQR) 10 (8–17) 9 (5–13) 0.02 ever, after adjusting for injury severity, this association
GCS score, median 15 (14–15) 15 (14–15) 0.42 no longer existed (adjusted OR = 0.56, 95% confidence
(IQR) interval: 0.24–1.30, p = 0.18).
Type of injury, n (%)
Cervical fracture, 115 (93.5%) 108 (94.7%) 0.69
no cord injury
Cervical fracture 8 (6.5%) 5 (4.4%) 0.47
DISCUSSION
and cord injury This study of older adult trauma patients (ࣙ60 years)
Cord injury, no 0 (0%) 1 (0.9%) 0.48
cervical fracture with a cervical spine injury demonstrated a shift in the
types of immobilization devices used after providing
GCS, Glasgow Coma Scale; IQR, interquartile range; ISS, Injury Severity Score;
EMS professionals with evidence-based criteria to sup-
SD, standard deviation.
P-values < 0.05 are shown in bold. port their choices of immobilization methods. There
was a considerable decrease in full immobilization and
any cervical collar use, while the use of cervical collars
Outcomes only and of no immobilization increased after imple-
menting the Spinal Precautions Protocol. Although the
As tabulated in Table 3, there was a significant shift
type of immobilization devices changed, with less full
in immobilization types used before and after pro-
immobilization, the outcomes did not. There were no
tocol implementation. The use of full immobilization
changes in the presence of neurological deficits, in-
decreased from 59.4% prior to protocol implementation
hospital disposition, or in-hospital mortality/hospice
to 28.1% post–protocol implementation (p < 0.001).
after adjusting for differences in the injury severity
Conversely, there was an increase in the use of cervi-
among the pre- and post-protocol groups.
cal collars as the sole adjunct for treatment (8.9% vs.
As the older adult population grows and experiences
27.2%, p < 0.001) and an increase in not using any
changes in vision, coordination, and balance, there is an
immobilization device (15.5% vs. 31.6%, p = 0.003) after
increased incidence of falls and motor vehicle crashes
protocol implementation. Although the proportion of
(20). The increases in the incidence of trauma have con-
patients who received solely a cervical collar increased
tributed to the nearly fourfold increase in the propor-
after implementing the Spinal Precautions Protocol, the
tion of older adult patients with cervical spine injury
overall proportion of patients who received a cervical
seen in the United States (18), revealing the need to
collar alone or in combination with other immobiliza-
ensure that the immobilization recommendations for
tion techniques decreased (72.4% vs. 56.1%, p = 0.01).
the general population can be safely applied to the
Patient outcomes did not differ between groups
older adult population.
before and after protocol implementation. The pres-
In our study, the overall cervical cord injury rate of
ence of a neurological deficit remained low through-
5.9% is lower than one may expect. Previous studies
out the study, with just 8 patients (6.5%) pre-protocol
from around the world have reported wide ranges of
and 6 patients (5.3%) post-protocol experiencing a
cervical cord injuries. At a trauma center in Iran, only
3.6% of patients admitted with cervical spine injuries
had a cord injury (21). A trauma center in Oslo, Nor-
Table 3. Comparison of immobilization type, pre– and
way, reported that 10% of patients with a cervical
post–protocol implementation
spine fracture had a spinal cord injury (22). In con-
Pre- Post- trast, a multicenter European study and a Canadian
Implementation Implementation study found that approximately 23% of patients with a
(n = 123) (n = 114) p
cervical spine trauma sustained a cervical cord injury
Immobilization type, n (%) (23, 24). In multivariate analysis, Hasler et al. found
Full 73 (59.4%) 32 (28.1%) < 0.001 increasing age, being male, and having a GCS score less
Cervical collar only 11 (8.9%) 31 (27.2%) < 0.001
Other 20 (16.3%) 15 (13.2%) 0.50
than 15 were all associated with a higher risk of cervi-
None 19 (15.5%) 36 (31.6%) 0.003 cal cord injury. In addition, the mechanisms of injury
most associated with cervical cord injuries were sports,
6 PREHOSPITAL EMERGENCY CARE
followed by motor vehicle accidents and falls from
more than 2 meters (23). Our study only included
patients ࣙ60 years. Although Hasler et al. found an
increase in the risk of cord injury with age, Jackson
et al. reported that the proportion of patients ࣙ65 in
the National Spinal Cord Injury Database was 8.5%,
whereas 51.6% were 16 to 30 years and 24.1% were 31
to 45 years (23, 25). In addition, nearly half of our study
population was female, the primary cause of injury was
falls (65%), and 72% of the population had a GCS score
of 15. The low rate of cord injury observed in our study
may be due to the demographics and injury character-
istics of our study population.
In the pre-implementation period of this study, fewer
than 60% of the patients were transported using full
immobilization. This rate appears low considering that
the Foothills RETAC required all EMS agencies to
transport patients with a suspected spinal injury fully
immobilized. Ultimately, the type of spinal precautions
used was at the discretion of the treating EMS person-
nel. Patients with medical conditions such as chronic
obstructive pulmonary disease, asthma, pneumonia, or
congestive heart failure may not be good candidates for
full immobilization. Since our study population was
ࣙ60 years, it is possible that some patients had these
comorbidities. It is also possible that the EMS provider
did not recognize the seriousness of the injury based
on the reported symptoms or the mechanism of injury
and did not use spinal precautions. Unfortunately, as
described in the limitations, we did not have details on
the patients’ pre-injury status or the ability to account
for why patients received a specific immobilization
type.
The age criterion used to define the older adult often
varies between 55 and 65 years (26–29). In this study,
older adults were defined as patients ࣙ60 years. Our
definition of older adult is in alignment with those
of the United Nations and a geriatric trauma service
developed by Mangram et al. known as G-60 (27, 28).
After 1 year with the G-60 service, a decrease in the
average ED length of stay, average ED–to–operating
room time, average surgical intensive care unit length
of stay, average hospital length of stay, and mortality
rate was observed in the G-60 group compared with
the control group; this study concluded that the older
patients had better outcomes with dedicated man-
agement strategies (28). In addition, in the Foothills
RETAC region, 21% of the population are ࣙ60 years,
whereas 14% are ࣙ65 years (30). Choosing 60 years as
the cutoff for our study enabled a larger sample size for
the study.
This study is unique in that it provided a logic
flowchart with three immobilization options to the
EMS providers: no immobilization, application of a cer-
vical collar, or full immobilization. The definition of full
immobilization was extended beyond the traditional
cervical collar and long rigid board to include a scoop
2018 EARLY ONLINE
stretcher, a vacuum splint, and other agency-approved
devices. Further, in contrast to other studies that incor-
porated mechanisms of injury as a starting point (15),
our protocol focused only on clinical symptoms. This
ensured that seemingly benign mechanisms of injury,
such as a ground-level fall, were treated equally with
otherwise more serious mechanisms, such as a motor
vehicle crash. The attention to clinical symptoms may
be especially important among the older adult popula-
tion, as older patients may sustain spinal cord injuries
from seemingly benign falls or injuries.
We attribute the success of the protocol implementa-
tion to our thorough outreach efforts, which focused on
the importance of feedback from EMS medical direc-
tors and remaining engaged with agencies, medical
directors, and other experts in the field. The trust of the
EMS directors to take individual responsibility for edu-
cating, implementing, and monitoring the Spinal Pre-
cautions Protocol was key to ensuring that the large
number of EMS agencies were ready to improve patient
care in a timely manner. The EMS directors were able to
independently overcome concerns related to a national
lack of protocol consistency and achieve EMS buy-
in to a significant deviation in a 30-year standard of
care. This method of preparing for a change in proto-
col is consistent with the experience of Rhodes et al.
(2016) in a similar implementation of an immobiliza-
tion guideline involving multiple agencies, multiple
receiving facilities, and multiple medical directors (31).
In addition, the competence of our EMS professionals
cannot be ignored. Their ability to make sound, skilled
decisions in the field, also supported by other stud-
ies (32), directly influenced our confidence moving for-
ward with the protocol.
This study has several limitations. First, we specifi-
cally studied older adult trauma patients (ࣙ60 years),
transported by ambulance, with a cervical spine cord
injury and/or cervical spine fracture. These results
are applicable for our study population but may not
be generalizable to the broader spine injury popu-
lation, such as those of different ages or with other
spinal injury types. Second, our study included 24
EMS agencies in 5 Colorado counties. While the
EMS agencies were diverse in size, the agencies were
located in the same geographic area with relatively
comparable demographics. The homogeneity of the
population limits our ability to generalize results and
recommendations to dissimilar trauma systems. Third,
medical directors were tasked with training their
respective EMS agencies, which varied in skill sets
and education. Our organization did not oversee the
training or test each agency’s knowledge of the tasks,
requiring our organization to trust the medical direc-
tors to adequately adopt and train agencies by the
presented deadlines. Fourth, we did not have the
ability to examine immobilized patients who did not
present with a cervical spine fracture to determine
L. Underbrink et al. PREHOSPITAL SPINAL IMMOBILIZATION TECHNIQUES IN OLDER ADULTS
protocol adherence or whether the protocol led to
additional false-positives of immobilizing additional
patients; this is an area for further research. Fifth,
we did not know patients’ pre-injury status, such
as comorbidities or whether they originated from a
community-dwelling setting; pre-injury health sta-
tus may have contributed to patient outcomes. Last,
given the retrospective nature of the study, we could
not account for the reasons some patients received a
specific immobilization type.
CONCLUSION
Prehospital choices involving immobilization devices
did not affect the incidence of neurological deficits,
mortality, or disposition, regardless of the immobi-
lization technique used, in the adult trauma patient
ࣙ60 years with suspected cervical spine injury. As the
population of older adult patients with cervical spine
trauma grows, it is our hope that other trauma groups
examine their own populations and establish evidence-
based spinal restriction/precaution protocols; since no
one treatment method has been proven to prevent
injury, other than avoiding the initial injury, it may be
that patients receive evaluation and treatment on an
individual basis. Measuring the effectiveness of spinal
restriction/precaution protocols in different environ-
ments and in the presence of other spinal injuries are
areas for further evaluation.
References
1. National Spinal Cord Injury Statistical Center [Inter-
net]. Spinal cord injury facts and figures at a
glance; 2016 [cited 2016 Nov 9]. Available from:
https://www.nscisc.uab.edu/Public/Facts%202016.pdf.
2. Butman AM, McSwain NE Jr, McConnell WK, Paturas JL,
Dineen JP, Feddersen A, Gorgen A, Murphy SM, OBrien J,
Drake-Olsen J, Vomacka RW. Pre-hospital trauma life support.
Akron, OH: Emergency Training; 1986.
3. Hauswald M. A re-conceptualisation of acute spinal care.
Emerg Med J. 2013;30(9):720–723. doi:10.1136/emermed-2012-
201847. PMID:22962052.
4. March JA, Ausband SC, Brown LH. Changes in phys-
ical examination caused by use of spinal immobi-
lization. Prehospital Emerg Care. 2002;6(4):421–424.
doi:10.1080/10903120290938067.
5. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect
of spinal immobilization on healthy volunteers. Ann Emerg
Med. 1994;23(1):48–51. doi:10.1016/S0196-0644(94)70007-9.
PMID:8273958.
6. Cooney DR, Wallus H, Asaly M, Wojcik S. Backboard time for
patients receiving spinal immobilization by emergency medical
services. Int J of Em Med. 2013;17(6):17.
7. Hunt K, Hallworth S, Smith M. The effects of rigid collar place-
ment on intracranial and cerebral perfusion pressures. Anesthe-
sia. 2001;56(6):511–513. doi:10.1046/j.1365-2044.2001.02053.x.
8. Kennedy FR, Gonzalez P, Beitler A, Sterling-Scott R,
Fleming AW. Incidence of cervical spine injury in
patients with gunshot wounds to the head. South Med J.
1994;87(6):621–623. doi:10.1097/00007611-199406000-00008.
PMID:8202771.
7
9. Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard
MR. Effect of manual in-line stabilization of the cervical
spine in adults on the rate of difficult orotracheal intubation
by direct laryngoscopy: A randomized controlled trial. Can
J Anaesth. 2009;56(6):412–418. doi:10.1007/s12630-009-9089-7.
PMID:19396507.
10. Ham W, Schoonhoven L, Schuurmans NJ, Leenen LP. Pressure
ulcers from spinal immobilization in trauma patient: A system-
atic review. J Trauma and Acute Care Surgery. 2014;76(4):1131–
1141. doi:10.1097/TA.0000000000000153.
11. Maarouf A, McQuown CM, Frey JA, Ahmed RA, Derrick L.
Iatrogenic spinal cord injury in a trauma patient with anky-
losing spondylitis. Prehospital Emerg Care. 2017;21(3):390–394.
doi:10.1080/10903127.2016.1263369.
12. Abram S, Bulstrode C. Routine spinal immobilization in
trauma patients: What are the advantages and disadvantages?
Surgeon. 2010;8(4):218–222. doi:10.1016/j.surge.2010.01.002.
PMID:20569942.
13. Ahn H, Singh J, Nathens A, MacDonald RD, Travers A, Tallon
J, Fehlings MG, Yee A. Pre-hospital care management of a
potential spinal cord injured patient: a systematic review
of the literature and evidence-based guidelines. J Neuro-
trauma. 2011;28(8):1341–1361. doi:10.1089/neu.2009.1168.
PMID:20175667.
14. National Association of EMS Physicians and American College
of Surgeons Committee on Trauma. EMS spinal precautions
and the use of the long backboard. Prehospital Emerg Care.
2013;17(3):392–393. doi:10.3109/10903127.2013.773115.
15. Burton JH, Dunn MG, Harmon NR, Hermanson TA, Brad-
shaw JR. A statewide, prehospital emergency medical service
selective patient spine immobilization protocol. J Trauma.
2006;61(1):161–167. doi:10.1097/01.ta.0000224214.72945.c4.
PMID:16832265.
16. Domeier RM, Frederiksen SM, Welch K. Prospective
performance assessment of an out-of-hospital protocol
for selective spine immobilization using clinical spine
clearance criteria. Ann Emerg Med. 2005;46(2):123–131.
doi:10.1016/j.annemergmed.2005.02.004. PMID:16046941.
17. Brown LH, Gough JE, Simonds WB. Can EMS
providers adequately assess trauma patients for cervi-
cal spinal injury? Prehosp Emerg Care. 1998;2(1):33–36.
doi:10.1080/10903129808958837. PMID:9737405.
18. Fassett DR, Harrop JS, Maltenfort M, Jeyamohan SB, Ratliff
JD, Anderson DG, Hilibrand AS, Albert TJ, Vaccaro AR, Sha-
ran AD. Mortality rates in geriatric patients with spinal cord
injuries. J Neurosurg Spine. 2007;7(3):277–281. doi:10.3171/SPI-
07/09/277. PMID:17877260.
19. Garwe T, Stewart K, Stoner J, Newgard CD, Scott M, Zhang
Y, Cathey T, Sacra J, Albrecht RM. Out-of-hospital and inter-
hospital under-triage to designated tertiary trauma centers
among injured older adults: A 10-year statewide geospatial-
adjusted analysis. Prehosp Emerg Care. 2017;21(6):734–43.
doi:10.1080/10903127.2017.1332123. PMID:28121261.
20. Bonne S, Schuerer DJE. Trauma in the older adult: epidemi-
ology and evolving geriatric trauma principles. Clin Geri-
atr Med. 2013;29(1):137–150. doi:10.1016/j.cger.2012.10.008.
PMID:23177604.
21. Yadollahi M, Paydar S, Ghaem H, Ghorbani M, Mousavi
SM, Akerdi AT, Jalili E, Niakan MH, Khalili HA, Hagh-
negahdar A, Bolandparvaz S. Epidemiology of cervi-
cal spine fractures. Trauma Mon. 2016;21(3):e33608.
doi:10.5812/traumamon.33608. PMID:27921020.
22. Fredø HL, Rizvi SAM, Lied B, Rønning P, Helseth E. The epi-
demiology of traumatic cervical spine fractures: a prospective
population study from Norway. Scand J Trauma Resusc Emerg
Med. 2012;21(20):85. doi:10.1186/1757-7241-20-85.
23. Hasler RM, Exadaktylos AK, Bouamra O, Benneker LM, Clancy
M, Sieber R, Zimmermann H, Lecky F. Epidemiology and
8 PREHOSPITAL EMERGENCY CARE
predictors of cervical spine injury in adult major trauma
patients: a multicenter cohort study. J Trauma Acute Care Surg.
2012;72(4):975–981. doi:10.1097/TA.0b013e31823f5e8e. PMID:
22491614.
24. Hu R, Mustard CA, Burns C. Epidemiology of incident spinal
fracture in a complete population. Spine. 1996;21(4):492–499.
PMID:8658254.
25. Jackson AB, Dijkers M, Devivo MJ, Poczatek RB. A demo-
graphic profile of new traumatic spinal cord injuries: change
and stability over 30 years. Arch Phys Med Rehabil. 2004;85(11):
1740–1748. doi:10.1016/j.apmr.2004.04.035. PMID:15520968.
26. Franse CB, van Grieken A, Qin L, Melis RJF, Rietjens
JAC, Raat H. Socioeconomic inequalities in frailty and
frailty components among community-dwelling older cit-
izens. PLoS One. 2017;12(11):e0187946. eCollection 2017.
doi:10.1371/journal.pone.0187946. PMID:29121677.
27. United Nations, Department of Economic and Social Affairs,
Population Division. World Population Ageing 2013; 2013
[cited 2016 Nov 10]. Available from: http://www.un.org/
en/development/desa/population/publications/pdf/ageing/
WorldPopulationAgeing2013.pdf.
2018 EARLY ONLINE
28. Mangram AJ, Mitchell CD, Shifflette VK, Lorenzo M, Truitt MS,
Goel A, Lyons MA, Nichols DJ, Dunn EL. Geriatric trauma ser-
vice: a one-year experience. J Trauma. 2012;72:119–122.
29. Wan H, Goodkind D, Kowal P. U.S. Census Bureau, interna-
tional population reports, P95/16-1, an aging world: 2015.
Washington, DC: U.S. Government Publishing Office; 2016
[cited 2016 Nov 10]. Available from: https://www.census.gov/
content/dam/Census/library/publications/2016/demo/p95-
16-1.pdf.
30. Colorado Department of Local Affairs. Race by age
estimates–county; n.d. [cited 2017 Nov 11]. Available
from: https://demography.dola.colorado.gov/population/
race-estimate/#county-race-by-age-estimates.
31. Rhodes WJ, Steinbruner D, Finck L, Flarity K. Commu-
nity implementation of a prehospital spinal immobiliza-
tion guideline. Prehosp Emerg Care. 2016;20(6):792–797.
doi:10.1080/10903127.2016.1194932. PMID:27410996.
32. Dunn TM, Dalton A, Dorfman T, Dunn WW. Are emergency
medical technician-basics able to use a selective immobilization
of the cervical spine protocol? A preliminary report. Prehosp
Emerg Care. 2004;8(2):207–211. PMID:15060858.