NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Immobilizing the spine New national approach

Torben Wisborg, MD, PhD

Director Norwegian National Advisory Unit on Trauma

Professor, University of Tromsø

Consultant anaesthetist, Hammerfest Hospital, NORWAY

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Conflict of interest

• Director Norwegian National Advisory Unit on Trauma

– Governmental knowledge center

• No COI declared

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Norwegian National Advisory Unit on Trauma

www.traumatologi.no

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Inauguration May 2013

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Purpose

– «To coordinate trauma systems on a regional and national level. The activities should be in collaboration with National Advisory Unit onPrehopital Emergency Medicine (NAKOS).»

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Employees

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

www.traumatologi.no

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

www.traumatologi.no

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

www.traumatologi.no

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

National aim

Each inhabitant should have equal access to health careindependent of diagnosis, place of living, personal economy, gender, ethnical background and individual circumstances of life

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Protection of the spine- historical background

• 80’ies: A in ATLS primary survey – rigid cervical collar

• ATLS 9th Edition 2012: protection of cervical spine - undefined

• 2013: rigid cervical collar back again igjen

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Clinical criteria

Clinical criteria

Mechanism of injury

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Minor traffic collision, brand new police car vs. civilian car. Head light in police car destroyed. Due to smoke from the other car thedriver of that was offered a seat in the police car.When the rescue service arrived the «patient» complained of necktenderness. The roof of the police car was removed, the patientextricated on spine board with full immobilization.The police car condemned, at the cost of 500,000 SEK.

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

And so the rigid cervical collar is laid to rest in theEmergency Medical Service of Bergen, Norway…

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Spinal stabilization – the challenge

• Increasingly different procedures

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Pro’s and con’s

• Protection against secondary injuries

• Acts as a warning sign

• Airway obstruction

• Aspiration risk

• Pressure ulcers

• Increased intracranial pressure

• Time consuming

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• Cervical 50%

• Thoracic 20%

• Thoraco/lumbar 20%

• Lumbo/sacral 10%

Traumatic brain injury 5% spinal injury

25 % traumaticbrain injury

Spinal injury

Spinal injuriesIncidence in blunt trauma: 0.5-3 %

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

The task

• Reach consensus on a nationalprocedure/guideline for spinal stabilization

– Based on best available evidence

– Use AGREE methodology based on the«Appraisal of Guidelines for Research and Evaluation»

• From site of injury until spine clearance

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

The task force

• Multiprofessional

• Geographical, (gender), profession and medical specialty balanced composition

• National credibility

• Co-operation with the Norwegian Knowledge Centre for the Health Sciences

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Literature review

• Scoping search

• Guidelines

• Systematic reviews

• Medline / Embase

• Search concluded: March 2015

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Scoping search

• National and international guidelines– Guidelines International Network database (G-I-N),

National Guideline Clearinghouse, National Institutesof Health Consensus Development Program, National Institute for Health and Care Excellence (NICE)

• References– BMJ: Best Practice, Up to Date, McMaster

• Systematic reviews– Cochrane Library

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NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Systematic reviews

• Search in Cochrane Library Dec 16 2014– Reviews and other rewiews

• 100 hits – 1 systematic review included

– Trials • 1,188 hits – none included

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Extended search March 2015

• Mesh term –

– ”Wounds and Injuries”

• Medline, Embase

– from 2010 until March 2015

– 9,441 hits (titles & abstracts)

– 16 primary studies and 5 systematic reviewsincluded

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Research basedknowledge consensus

Experience & userparticipation

Context

Knowledge basedprocedure

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Immediate transport prioritized

Stabilization of spine results in unnecessary delay:Manual stabilization of neck and tranportation supine or in lateral trauma position

Spinal stabilization:• Cervical (one or several):

CollarHead blocksContinuous manual neck stabilization

• Thoracic or lumbar:Vacuum matressStretcher/scoop withstraps

Trauma patient

Critically injured patient?RF < 10 eller > 30

and/or

HR>120and/or

Lack of radial pulse

One or more:• Spinal pain and/or

• GCS < 15 and/or

• Intoxicated and/or

• Neurological signs and/or

• Distracting pain

Isolated penetratinginjury

No spinal stabilization

YES

YES

NO

NO(all items)

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Implementation…?

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA

Thanks for yourattention