Category Archives: trauma

Spinal Immobilization

So, do we have to put every trauma patient into a collar and on a backboard? Probably not, but the practice is go ingrained in our EMS culture that it happens with high frequency.

There was a landmark article in the New England Journal of Medicine by Jerome Hoffman in 2000 that looked at 34,000 patients to develop a rule set for clinical clearance of the cervical spine. The absence of the following criteria place the patient into a low probability of injury and did not require imaging:

  1. the absence of tenderness at the posterior midline of the cervical spine
  2. the absence of a focal neurologic deficit
  3. a normal level of alertness
  4. no evidence of intoxication
  5. absence of clinically apparent pain that might distract the patient from the pain of a cervical-spine injury

If the above patients did not require any form of imaging, then those same patients would not require spinal immobilization.

The topic of reviewing and reconsidering how we handle prehospital spinal immobilization is rising and there are several recent articles challenging the status quo.

In the March edition of JEMS, there was an article entitled “Research Suggests Time for Change in Prehospital Spinal Immobilization“. EMSWorld has the following articles: “Evidence Against Backboards“, and “Does Spinal Immobilization Help Patients“.

According to Dr. Bledsoe’s review of the literature, he states that there is no evidence that backboards immobilize the spine, backboards can cause pain, make airway management more difficult, impair respirations, and place the patient at risk of aspiration. Additionally, there is no evidence that backboards improve patient outcomes. Dr. Bledsoe is similarly critical of cervical collar usage.


  1. The application of NEXUS or Canadian C-Spine criteria to prehospital patients can identify those that do not need a C-collar.
  2. Understand that there is no significant evidence that the use of backboards improves patient outcomes, and we should work to reduce their usage.








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Damage Control Resuscitation

Trauma lessons learned during the Afghanistan and Iraqi wars lead the military to release Joint Theater Trauma System Clinical Practice Guideline discussing elements of Damage Control Resuscitation. Those elements along with the use of tourniquets lead to the creation of the following EMS Draft Protocol.

EMS Protocol Draft

Damage Control Resuscitation

7 August 2013


Based on knowledge gained from the military regarding trauma resuscitation, there is new evidence advancing the initial care and resuscitation of patients suffering from significant hemorrhage. This protocol is an update and replacement of the current approach to trauma patient resuscitation.

The use of large volume crystalloid infusion is known to decrease the ability of patients to form clots and therefore should be limited to patients who are rapidly deteriorating despite other interventions.



This protocol is indicated for use in all trauma patients, appearing to be at least 16 years of age, with ongoing significant hemorrhage (SBP < 90 mmHg and/or heart rate > 110 bpm), or who are considered to be at risk of significant hemorrhage.


In patients with evidence of significant hemorrhage:

  • Apply tourniquets to extremities as indicated
  • Use firm, continuous direct pressure to site of continuing bleeding
  • Application of hemostatic gauze (e.g. Trauma Gauze) as indicated


Limit the infusion of crytalloids in patients with SBP > 90 mmHg.

Give 250-500 mL boluses of crystalloid every 10 minutes:

  • Hypotensive patients (SBP < 90 or absent radial pulse)
  • Patients with isolated head trauma (necessitating a higher blood pressure to maintain cerebral perfusion pressure)


Patients meeting the above indications AND are within 3 hours of injury:

  • 1 gram TXA in 100 mL infused over 10 minutes

Use with caution in patients with past history of DVT/PE or hypercoaguable condition.


If time permits, notify the receiving facility that the patient will likely meet Massive Transfusion Protocol criteria.


(1) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23–32.

(2) Tranexamic acid decreases mortality following wartime injury: the Military Application of Tranexamic acid in Trauma Emergency Resuscitation Study (MATTERS) MAJ Jonathan J. Morrison, MB ChB, MRCS, RAMC(V), LT COL (sel) Joseph J. Dubose, MD, USAF MC, COL Todd E. Rasmussen, MD, USAF MC, SURG CAPT Mark Midwinter, BMedSci, MD FRCS RN. Arch Surg. 2012; 147:113-119.

(3) Joint Theater Trauma System Clinical Practice Guideline. Damage Control Resuscitation At Level IIb/III Treatment Facilities. July 2012.

Additional Resources:


damage control resuscitation

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