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
NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA
• 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
NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA
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
NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA
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
NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA
Research basedknowledge consensus
Experience & userparticipation
Context
Knowledge basedprocedure
NORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMANORWEGIAN NATIONAL ADVISORY UNIT ON TRAUMA
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
