Acute spinal injury movement and transport
Having determined that a patient cannot be prehospital cleared from suspicion of spinal injury, we have to provide effective spinal care until ED arrival. Primary SCI happens at the time of trauma and not much can be done about that. Secondary injury follows from oedema, haemorrhage, inflammation and eventual cell death around the primary (Anwar et al. 2016; Witiw and Fehlings 2015). We may be able to reduce this through correct management. That’s part three.
We’ve already covered helmet removal, manual inline stabilisation and neutral position in part two. What’s next?
Cervical collars are invariably at the forefront of consideration, along with immobilisation. One at a time.
Cervical collars first. The intent is to immobilise the cervical spine. Even correctly sized and fitted, they only sort of do that. Other methods including manual stabilisation are necessary to best reduce movement and, they don’t do anything for the rest of the spine (Kreinest et al. 2017). They irritate many people with their discomfort, can force the neck into poor alignment and, importantly, can interfere with jugular venous return causing rise in intracranial pressure (Connor et al. 2015; Davies et al 1996; Holly et al. 2002; Kreinest et al. 2017; Lida et al. 1999, Morris et al 2003; Peck et al. 2015; Phillips and Nutbeam. 2017; Purvis et al. 2017; Raphael and Chotai 1994).
All that said, cervical collars remain recommended in those patients who cannot be effectively cleared, provided properly sized and fitted. There is a move toward soft collars that provide less movement restriction but far fewer complications. Importantly, they still provide a flag to all that spinal precautions are being used and the patient requires further assessment.
Extrication. In many cases self-extrication of conscious and mobile patients can reduce pain and injury movement. If they reasonably can, let the patient get themselves out of the vehicle or predicament (Cowley et al. 2017).
Patients might be found already ambulating at a scene. This does not preclude them from receiving subsequent spinal care. If such a person needs to be placed on an ambulance stretcher, allow them to sit upright first. Bring the back of the bed up to the patient and pad beneath the occiput into a neutral position. Only then lower the back to place the patient supine. This stops the head becoming a pendulum weight on the neck as the patient changes from upright to supine.
The spineboard remains useful for extricating people from vehicles as do tools such as the Kendrick Extrication Device®. The spineboard is no longer used for whole body immobilisation after extrication (Moss et al. 2014; White et al. 2014). They are associated with discomfort, pressure area development and airway management difficulty and impaired patient ventilation (Ala et al. 2016; Peck et al. 2015). Where available, a scoop stretcher can be useful for lifting (Krell et al. 2006; Moss et al. 2014) and vacuum mattress used for spine support in transport (Moss et al. 2014; Rahmatalla et al. 2018, Wampler et al. 2016).
Log rolling as a coordinated team is necessary when performed. Even better is avoiding log rolling in the first place. Scoop stretcher use and avoiding rolling patients onto spineboards for the purpose of immobilisation helps reduce necessity.
Whichever method of spinal immobilisation is employed, ensure the head and the body are equally supported and immobilised. Do not secure one part of the body without the other whereby half of the patient – or one side of the fracture – could still move about. Immobilisation of penetrating trauma patients isn’t necessary and can cause adverse delays for no patient benefit (Connor et al. 2015; Kreinest et al. 2017).
General care in movement and transport of the SCI patient includes padding between bony prominences and supporting limbs that the patient cannot support themselves. Arms and legs hanging limply can be injured and cause strain on the joints and muscles.
Drive the car carefully and slowly if possible. Stopping and starting directs forces along the spine. Helicopter transport is very effective at avoiding this. By road, gentle driving minimises unwanted patient movements. All the time, have one rescuer sit by the patient’s head gently supporting and reminding them not to move their head. Speak to them in their natural line of sight. Sitting to one side encourages the patient to turn their head to look at you when they speak. Remember, spinal care is a package of methods and not just any one action or procedure.
Ala, A., Shams-Vahdati, S., Taghizadieh, A., Miri, S.H., Kazemi, N., Hodjati, S.R. and Jalilzadeh-Binazar, M., 2016. Cervical collar effect on pulmonary volumes in patients with trauma. European Journal of Trauma and Emergency Surgery, 42(5), pp.657-660.
Anwar, M.A., Al Shehabi, T.S. and Eid, A.H., 2016. Inflammogenesis of secondary spinal cord injury. Frontiers in cellular neuroscience, 10, p.98.
Connor, D., Greaves, I., Porter, K., Bloch, M. and consensus group, Faculty of Pre-Hospital Care, 2015. Prehospital spinal immobilisation: An initial consensus statement. Trauma, 17(2), pp.146-150.
Cowley, A., Hague, A. and Durge, N., 2017. Cervical spine immobilization during extrication of the awake patient: a narrative review. European Journal of Emergency Medicine, 24(3), pp.158-161
Davies, G., Deakin, C., & Wilson, A. (1996). The effect of a rigid collar on intracranial pressure. Injury, 27(9), 647–649.
Holly, L. T., Kelly, D. F., Counelis, G. J., Blinman, T., McArthur, D. L., & Cryer, H. G. (2002). Cervical spine trauma associated with moderate and severe head injury: incidence risk factors and injury characteristics. Journal of Neurosurgery, 96, S285–S291.
Kreinest, M., Ludes, L., Türk, A., Grützner, P.A., Biglari, B. and Matschke, S., 2017. Analysis of prehospital care and emergency room treatment of patients with acute traumatic spinal cord injury: a retrospective cohort study on the implementation of current guidelines. Spinal cord, 55(1), p.16.
Krell, J. M., McCoy, M. S., Sparto, P. J., Fisher, G. L., Stoy, W. A., Hostler, D. P. (2006). Comparison of the Ferno scoop stretcher with the long backboard for spinal immobilisation. Pre-hospital Emergency Care, 10, 46–51
Lida, H., Tachibina, S., Kithara, T., Horiike, S., Ohwada, T., Fujii, K., et al. (1999). Association of head trauma with cervical spine injury, spinal cord injury or both. Journal of Trauma, 46, 450–452.
Moss, R., Porter, K. and Greaves, I., 2015. Minimal patient handling: a Faculty of Pre-Hospital Care consensus statement. Trauma, 17(1), pp.70-72.
Peck, G.E., Shipway, D.J.H., Tsang, K. and Fertleman, M., 2018. Cervical spine immobilisation in the elderly: a literature review. British journal of neurosurgery, pp.1-5.
Purvis, T.A., Carlin, B. and Driscoll, P., 2017. The definite risks and questionable benefits of liberal pre-hospital spinal immobilisation. The American journal of emergency medicine, 35(6), pp.860-866.
Rahmatalla, S., DeShaw, J., Stilley, J., Denning, G. and Jennissen, C., 2018. Comparing the Efficacy of Methods for Immobilizing the Thoracic-Lumbar Spine. Air Medical Journal
Raphael, J. H., & Chotai, M. B. (1994). Effects of the cervical collar on cerebrospinal fluid pressure. Anaesthesia, 49(5), 437–439.
Wampler, D.A., Pineda, C., Polk, J., Kidd, E., Leboeuf, D., Flores, M., Shown, M., Kharod, C., Stewart, R.M. and Cooley, C., 2016. The long spine board does not reduce lateral motion during transport—a randomized healthy volunteer crossover trial. The American journal of emergency medicine, 34(4), pp.717-721.
White IV, C.C., Domeier, R.M., Millin, M.G. and Standards and Clinical Practice Committee, National Association of EMS Physicians, 2014. EMS spinal precautions and the use of the long backboard–resource document to the position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18(2), pp.306-314
Witiw, C.D. and Fehlings, M.G., 2015. Acute spinal cord injury. Clinical Spine Surgery, 28(6), pp.202-210.
Jeff Kenneally – www.prehemt.com