The Balance of Risks and Harms in Trauma Immobilization

In a recent online-first publication in the EMJ, McDonald et al canvas the literature regarding selective immobilization protocols in trauma. Their most significant finding, unfortunately, is the low quality of the evidence and the high degree of bias present across included studies. This limits the authors’ attempted analysis of sensitivity and specificity of selective immobilization protocols.

From a qualitative standpoint, however, their data bears examination. The included studies or prehospital immobilization range in size from 3 to 504 spinal injuries. Within these cohorts, 76 patients were identified with injuries who did not undergo immobilization. None of these patients had any reported neurologic deterioration in spine of their missed immobilization.

This small snapshot ties into another recent publication, in AEM, looking specifically at cases of neurologic deterioration in the context of failed prehospital immobilization. These authors identify 41 qualifying cases across 12 studies. Most patients had normal function at the scene, but many had substantial disability or death following a period of non-immobilization.

This leads, then, to two related questions raised by each of these authors. The first: how do we reform our prehospital protocols to reduce unnecessary immobilization, while potentially still capturing those few with spinal injuries. The second: how much benefit does pre-hospital immobilization convey regarding long-term outcomes? McDonald et al report their sensitivity and specificity based simply on the presence of an injury, but, long-term disability is the patient-oriented outcome. To truly address and refine pre-hospital immobilization strategies, further study should be designed and powered to detect – if possible – the presence of subsequent neurologic deterioration. Only then, when deterioration rates can be compared between the immobilized and non-, will we have a better grasp of the value of continued, dogmatic, pre-hospital trauma care.

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