Core Principles for Spinal Immobilization

1. Core Principles for Spinal Immobilization January 2014

2. Rule #1 True spinal injuries are extremely rare, and even more rarely occur in the absence of spinal line pain and/or neurologic deficits.

3. Rule #2 Mechanism of injury without subjective complaints or objective findings of spinal injury is generally a poor predictor of spinal injury. • Substantial spinal injuries are best recognized with diligent patient histories and physical exam. • Alert and oriented patients with true spinal injuries tend to exhibit pain and tenderness to palpation, and generally vigorously self-splint. • Mechanism of injury should be carefully considered in high- risk patients (the elderly and the young) and in those patients for whom an accurate history and physical examination cannot be obtained.

4. Rule #3 Elderly patients are more likely to have spinal injuries after a traumatic event. • These patients should be more conservatively managed, and there should be a greater suspicion for occult – hidden – spinal injuries, especially in those patients with chronic confusion/dementia.

5. Rule #4 Spinal immobilization should not increase patient discomfort, immobilization that increases pain should be avoided. • Backboards should be appropriately padded to prevent pain and pressure sores.

6. Rule #5 The goal of immobilization is to prevent further spinal injury during patient extrication, treatment, and transport. • Patients with suspected spinal injuries should be maintained in what is for them a “neutral”, in-line position. • This position will vary from patient to patient depending on the presence of arthritis or other spinal abnormalities • A patient’s cervical spine should never be moved if movement increases pain, neurologic deficits, or neck spasms.

7. Rule #6 A range of immobilization strategies – from partial to complete immobilization of the spine – may be utilized depending on the mechanism of injury, complaints, physical findings, and co- morbidities of the patient. • The best candidates for full head-to-toe immobilization are victims of a high impact mechanism with multi-system injuries. • Patients may be partially or completely immobilized in a semi-fowler’s position. • Patients who are laid supine will be substantially more comfortable with their knees elevated.

8. Rule #7 Immobilization should be accomplished using the most appropriate equipment for the specific circumstance. • Acceptable equipment includes long backboards, vacuum splints, pneumatic splints, stiff cervical collars, soft collars, KEDs, straps, head immobilization devices, tape as well as soft materials such as pillows and pull sheets. • Ill-fitting equipment is worse than no equipment at all. • Pull sheets, other flexible devices, and concave “scoops” should be employed for moving patients whenever possible; backboards may be useful for transportation.

9. Rule #8 Spinal movement and discomfort are reduced by allowing patients to self-extricate when possible, and to place themselves onto gurneys and spinal immobilization devices. • Back-boarding patients from a standing position is discouraged. • Logrolling patients can be very uncomfortable and may lead to increased spinal movement. Other techniques may be preferred.

10. Rule #9 Full spinal immobilization of penetrating trauma patients increases mortality and morbidity. Alert, neurologically intact victims of penetrating trauma without spinal pain do not need spinal immobilization.

11. Rule #10 Athletes who have suffered a potential spine injury should have protective equipment removed, especially if it interferes with the maintenance of neutral spinal alignment. A general exception is the football helmet, which in conjunction with shoulder pads usually maintains a neutral cervical spine. If removal is necessary, the helmet and pads should be taken off at the same time. The face shield will often need to be removed to allow access to the patient’s airway.

12. Rule #11 Responders should document all history and exam findings on the Prehospital Care Report. The patient’s neurologic status pre-and post-immobilization, along with all spinal immobilization interventions, should also be documented.

13. Rule #12 In patients without neck or spinal pain or tenderness, neuro deficits, ALOC, or distracting injury, spinal immobilization may be withheld as long as the patient can be accurately evaluated. • An example of a distracting injury is an injury that causes severe pain such as a deformed/open long bone fracture.

14. Rule #13 If there is any doubt about the evaluation of a patient’s spine, it is always better to immobilize the patient and defer further spinal evaluation to the ED staff.

15. These principals represent the new standard of care for possible spinal injuries in the prehospital setting.

16. Scenarios • 1) 63 year old female, restrained driver, rear-ended another car at 30mph. Airbags deployed, moderate front end damage, no passenger space intrusion. Patient still seated in car on your arrival. Complains of right shoulder pain, abrasions to both forearms and mild neck stiffness when turning her head side to side. Denies loss of consciousness, no neuro deficits and appears anxious and worried. Vital signs all within normal limits except for HR of 52. Medical History – Hypertension, arthritis “all over” Meds – ASA 81mg, Tenormin, Celebrex, Norco prn

17. Scenarios • 2) 25 year old male involved in high speed rollover MVA. Patient was the restrained front seat passenger of a large truck that swerved to miss deer and rolled multiple times into the ditch. Major vehicle damage, no airbag deployment. Patient self extricated and is sitting on the side of the freeway talking to CHP. Patient only complaint is his right ankle is “a little sore” and bleeding. Denies loss of consciousness. You note patients right ankle to be deformed, with a possible open angulated fracture. Patient denies pain to spinal column on palpation and has no neuro deficits. Patient admits to having “2 beers and a couple shots” throughout the course of the evening. Vital signs all normal except for a HR of 105.

18. Scenarios • 3) 80 year old female with a complaint of lower lumbar back pain post ground level mechanical fall from standing. No loss of consciousness, neck pain or neuro deficits. Alert, oriented and all vital signs within normal limits. • 4) 45 year old male with a complaint of right anterior chest wall pain and neck pain post motorcycle accident. Patient reports the bike lost front wheel traction while in a turn at 40 MPH. Patient has recall of events and denies loss of consciousness. Vital signs normal except respiratory rate of 22 , no neuro deficits. Alert, oriented and unable to lay flat due to pain and respiratory difficulty. • 5) 25 year old female with hematoma above left eye. Patient in law enforcement custody who are requesting patient be transported. Heavy ETOH, uncooperative, agitated and will not tolerate restraint. Alert to person, place and events, but confused to time/date. No neck pain or neuro deficits. Vital signs within normal limits.

19. Scenarios • 6) 3 year old female in 5 point restraint car seat involved in MVA at 40 mph. Patient won’t talk but acting appropriate per parent and appears unharmed. Skin signs and vital signs within normal limits.

20. Treatment • 1) Self extricate to gurney, soft or hard collar and transport in position of comfort. • 2) Full spinal immobilization • 3) Transport in position of comfort on gurney • 4) Collar, KED, short vacuum splint if tolerated. Position on gurney in semi-fowlers. • 5) Collar, gurney and coach to remain still • 6) Transport in car seat with additional padding as appropriate.