spinal immobilization v 2 feb 2011

Spinal Immobilisation Techniques and

Devices.

A GUIDE FOR EDUCATION & COMPETENCY

Compiled by: Wendy Porteous - V 2 - 2011

ACKNOWLEDGEMENTS Thank you to: Pat Standen, Di Woods for reviewing the document and providing their expert advice; and

Ballarat Health Services and Ambulance Victoria for so generously allowing their clinical practice guidelines

to be used as a guide.

Thanks to Emergency Technologies and Anthony Hann for the use of the resources available in their publication – A Photographic Guide to Prehospital Spinal Care. It can be downloaded from www.emergencytechnologies.com.au PURPOSE The purpose of this guide is to assist educators in the Grampians Region to design their own Health Service

specific package for Registered Nurses Division 1 & 2 required to manage patients with suspected or actual

spinal column injuries in an emergency situation. The aim of this guide is to provide generic information

based on principles of care.

It is the responsibility of each individual practitioner and Health Service to ensure appropriate education for all equipment and that competency in the use of the equipment is maintained. For information regarding this Guide contact: Pat Standen Trauma, Emergency & Critical Care Coordinator | Service & Workforce Development | Grampians Region Department of Health 35 Armstrong Street South, Ballarat, Victoria, 3350 Email: [email protected] Phone: 03 5333 6026 Version Date Major Changes Page No 1.0 December 2009 2.0 February 2011 DISCLAIMER: Care has been taken to confirm the accuracy of the information presented in this guide, however, the authors, editors and publisher are not responsible for errors or omissions or for any consequences from application of the information in the guide and make no warranty, express or implied, with respect to the contents of the publication. Every effort has been made to ensure the clinical information provided is in accordance with current recommendations and practice. However, in view of ongoing research, changes in government regulations and the flow of other information, the information is provided on the basis that all persons undertake responsibility for assessing the relevance and accuracy of its content.

Spinal Immobilisation Techniques and Devices Version 2/2011 2

Contents

Introduction 5

Anatomy & Physiology of the Spine 5

Aetiology of Spinal Cord Injury 30 Primary Spinal Cord Injury 30 Hyperextension Injury 31 Flexion Injury 32 Compression / Axial Loading 33 Distraction 34 Rotation 35 Penetration 36

Secondary Spinal Cord Injury 37

Pathological Changes following Injury 37 Neurogenic Shock 38 Post Traumatic Ischaemia 39 Calcium entry into the cells 39 Increased Extracellular Potassium 39 Failure to immobilise unstable fractures 39 Functional Classifications 40 Tetraplegia 40 Tetraparesis 40 Paraplegia 40 Paraparesis 40 Spinal Cord Injuries 41 Complete Injuries 41 Incomplete Injuries 42 Central Cord Syndrome 42 Brown – Sequard Syndrome 43 Anterior Cord Syndrome 43 Cauda Equina Syndrome 44 Signs & Symptoms of Spinal Cord Injury 45 Mechanisms of spinal Cord Injury 51 Spinal Immobilisation 52 Indications 52 Cautions 52 Patient preparation 53 Procedural steps 53 Age specific considerations 55 Spinal Clearance 57


Considerations of Spinal Cord Injury in Paediatrics 58 Manual In-Line Immobilisation 60 Motor Cycle Helmet Removal 64 Log-Rolling 72 Semi-Rigid Extrication Collars 76 Stifneck Collar 77 Vertebrace Collar 85 Philadelphia Collar 90 Spinal Boards / Back Boards 96 Maintenance of Neutral In-Line Position of the Head 97 Immobilisation of the Head to the Device 100 Head Blocks / Head Immobilisers 101 Vacuum Mattresses 103 Extrication Vests 105 Jordon (Donway) Lifting Frame 112 Clinical Practice Guidelines and Competency Assessments 114 Bibliography, References and Further Reading 125


INTRODUCTION Spinal trauma, if not recognised and properly managed can result in irreversible damage

and leave a patient paralysed for life. Some patients sustain immediate spinal cord

damage as a result of trauma. Others sustain an injury to the spinal column that does not

initially damage the cord; cord damage may result later with movement of the spine.

Because the central nervous system is incapable of regeneration, a severed spinal cord

cannot be repaired. The consequences of inappropriately moving a patient with a spinal

column injury, or allowing the patient to move, can be devastating.

Anatomy and Physiology of the Spine The Nervous System is made up of all the nerve tissue in the body including the brain,

brainstem, spinal cord, nerves and ganglia. It is divided into two parts:

Central Nervous System (CNS). Peripheral Nervous System (PNS).

Brain and Spinal Cord


CENTRAL NERVOUS SYSTEM The Central Nervous System (CNS) is that part of the nervous system that consists of the

brain and spinal cord.

The average adult human brain weighs 1.3 to 1.4 kg. The brain is thought to contain

approximately 100 billion nerve cells (also known as neurons) and trillions of "support

cells" called glia.

The spinal cord is approximately 43 cm long in the average adult female and 45 cm long in

average adult male. It weighs approximately 35 to 40 gms. The spinal cord is protected by

a series of structures including the vertebral column, muscles, ligaments, cerebral spinal

fluid, and the meninges.

PERIPHERAL NERVOUS SYSTEM The Peripheral Nervous System (PNS) is the nervous system found outside the spinal

cord. Nerves in the PNS connect the CNS with sensory organs, other body organs,

muscles, blood vessels and glands.

The PNS is divided into two major parts:

Somatic nervous system Autonomic nervous system SOMATIC NERVOUS SYSTEM The somatic nervous system is under voluntary control.

It consists of peripheral nerve fibres that send sensory information to the brain, and motor

nerve fibres that send messages to the skeletal muscles.

AUTONOMIC NERVOUS SYSTEM The autonomic nervous system looks after those neurons that are not under conscious

control and regulates key functions, including the activity of the heart muscle, smooth

muscles (e.g. abdomen), and the glands.

It is divided into two parts:

Sympathetic nervous system Parasympathetic nervous system


SYMPATHETIC NERVOUS SYSTEM The Sympathetic Nervous System is the system that involves the fight/flight responses of

the body including accelerating the heart rate, constricting blood vessels, raising blood

pressure, producing sweating, increasing blood supply to the muscles and accelerating

respiration.

The Sympathetic Nervous System fibres come out of cell bodies in the spinal cord from T1

to L2 and secrete adrenaline & nor-adrenaline.


PARASYMPATHETIC NERVOUS SYSTEM The Parasympathetic Nervous System is the system that slows down the body including

slowing the heart rate, dilating the blood vessels, lowering blood pressure and slowing

respiration.

The Parasympathetic Nervous System fibres come out of the cranial nerves 3, 5, 9 & 10,

and from the spinal cord at the sacral levels of S2 to S4.

FLOWCHART OF THE NERVOUS SYSTEM


NEURONS Cells of the nervous system are called nerve cells or neurons. These are the basic

information processing unit of the nervous system, and are responsible for generating and

conducting nerve impulses via an electrochemical process. The human brain has some

100 billion neurons. Neurons come in many different shapes and sizes. Some of the

smallest neurons have cell bodies that are only 4 microns in diameter (1 micron is equal to

one thousandth of a mm). Some of the larger neurons have cell bodies measuring 100

microns in diameter.

Neurons differ from other cells in the body because:

Neurons have specialized extensions called dendrites (bringing information to the cell

body) and axons (which take information away from the cell body).

Neurons communicate with each other via an electrochemical process.


Dendrites are thread like extensions of the cell body’s cytoplasm forming a tree like

formation. Unlike axons, dendrites are not surrounded by an outer covering.

Dendrites comprise most of the receptive surfaces of a neuron.

The dendrites main purpose is to conduct nerve impulses towards the neuron’s cell body.

CELL BODY The cell body is the main part of the neuron and is composed of substances to keep the

neuron alive.

It consists of nucleus, cytoplasm & endoplasmic reticulum.

Cell bodies are found in the grey matter (H shape) of the spinal cord.

AXON The axon’s purpose is to conduct nerve impulses away from the cell body. Most axons are

covered with a myelin sheath for axon protection and to improve conduction of the nerve

impulse down the axon.

Myelinated axons are found in the white matter of the spinal cord.


OLIGODENDROCYTES Oligodendrocytes are a form of neuroglial cells (type of connective tissue) found in the

CNS that forms a myelinated wrapping around the CNS axons.

Oligodendrocytes surround neurons, providing both mechanical & physical support, and

electrical insulation between neurons; dramatically increase the speed of conduction

through the axon.

Oligodendrocytes form the white matter of the spinal cord.

SCHWANN CELLS Schwann cells are a form of neuroglial cells found in the PNS that form a myelinated

sheath wrapping around the PNS neuron’s axons.

The purpose of this myelinated sheath is to provide an insulating layer surrounding the

axon that dramatically increases the speed of conduction through the axon.

NODES OF RANVIER Nodes of Ranvier are regions of exposed neuronal plasma membrane on a myelinated

axon that occur every 1 - 2 cm down the axon.

The nodes contain very high concentrations of voltage gated ion channels and are the site

of propagation of action potentials (which reduces the capacitance of the neuron), allowing

much faster transmission of the nerve impulse down the axon.

SYNAPTIC CLEFT Communication from neuron to neuron, or neuron to muscle & sensory receptor (including

pain, temperature and pressure receptors) occurs at the synaptic cleft, by a process called

the synapse.

The synapse process occurs by:

An impulse moves down the axon to the synaptic knob.

Calcium channels in the synaptic knob are stimulated and open allowing calcium to enter

the synaptic knob.

Calcium stimulates synaptic vesicles which move towards and fuse with the presynaptic

membrane.

Synaptic vesicles release neurotransmitter substances including acetylcholine (between

nerves & skeletal muscle), nor-adrenaline and acetylcholine (between nerves & visceral

organs) and a range of other substances (for neuron to neuron).


Neurotransmitters pass across the synaptic cleft to the post synaptic membrane.

The neurotransmitters combine with the receptors on the post synaptic membrane and if

strong enough, stimulates an excitatory or inhibitory reaction.


SPINAL CORD The spinal cord is a bundle of neurons (approximately 13.5 million) that forms the main

pathway for information connecting the brain and the peripheral nervous system.

The human spinal cord is about 43 to 45 cm long, 9 to 14 mm wide, and weighs

approximately 35 gms. It is a continuation of the brainstem beginning at the foramen

magnum and extending down to the last of the 2nd lumbar vertebra. Nerves that branch

from the spinal cord at the lumbar and sacral levels must run in the vertebral canal for a

distance before they exit the vertebral column. This collection of nerves in the vertebral

canal is called the cauda equina (which means "horse tail").

The central grey matter of the spinal cord is made up of the nerves’ cell body, dendrites

and unmyelinated axons, with the white matter formed by the myelinated axons.


Spinal Cord

• Extends from foramen magnum to second lumbar vertebra

• Segmented

– Cervical

– Thoracic

– Lumbar

– Sacral

• Gives rise to 31 pairs of spinal nerves

• Not uniform in diameter throughout length

http://www.glittra.com/yvonne/neuropics/spinalcross.gif


SPINAL NERVES

Spinal nerves are collections of axons of the peripheral nervous system.

A total of 31 pairs of spinal nerves emerge from the spinal cord which includes:

Cervical - 8

Thoracic - 12

Lumbar - 5

Sacral - 5

Coccygeal - 1

The motor nerves leave the spinal cord anteriorly whilst the sensory nerves enter the cord

posteriorly.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ


BLOOD SUPPLY TO THE SPINAL CORD There are 3 arteries running the length of the spinal cord:

One anterior spinal artery supplies the anterior two-thirds of the spinal cord.

Two posterior spinal arteries supply the posterior one-third of the spinal cord.

Additional arteries known as segmental radicular arteries enter the vertebral canal at the

same points that spinal nerves enter and leave the spinal cord.

Veins run parallel with the arteries and are continuous with the venous drainage system of

the brain.

The internal vertebral venous plexus are a group of spinal veins found both anterior and

posterior (usually 3 of each) that drain into numerous radicular veins. These form a

network of thin walled, valveless veins in the extradural (epidural) space draining the

spinal cord.

The external vertebral venous plexus surrounds the vertebral column and communicate

freely with the internal vertebral venous plexus, also draining the spinal cord.

http://www.frca.co.uk/images/spinal-cord5.jpg


MENINGES

The brain and spinal cord are surrounded by a protective lining known as the meninges

which is designed to keep out infection

There are 3 layers of the meninges:

• Dura Mater forms the outer most layer. It is a tough, fibrous, tubular sheath that

extends down to S2 (even thought the spinal cord terminates at L1-L2).

• Arachnoid forms the middle layer. It is a delicate membrane sheath that also

extends down to S2.

• Pia Mater forms the inner layer. It adheres closely to the surface of the spinal cord,

enclosing a network of blood vessels & gives rise to denticulate ligaments.


CEREBRAL SPINAL FLUID Cerebral spinal fluid (CSF) is a clear odourless fluid produced from plasma by a structure

(called the choroid plexus) in the lateral, third and fourth ventricles of the brain. CSF flows

from the ventricles into the subarachnoid space. Approximately 100 mL of CSF flows

around the brain and spinal cord.

The CSF has four functions including:

1. Protection: the CSF protects the brain and spinal cord from damage by acting to

cushion blows to the head and torso (to lessen the impact).

2. Buoyancy: because the brain is immersed in fluid, the net weight of the brain is

reduced from about 1.4 kg to about 50 gm. Therefore, pressure at the base of the

brain is reduced.

3. Excretion of waste products: the one-way flow from the CSF to the blood takes

potentially harmful metabolites, drugs and other substances away from the brain.

4. Endocrine transport throughout the brain: the CSF transports hormones throughout

the brain and spinal cord where they may act.


DENTICULATE LIGAMENTS

The denticulate ligaments extend from the spinal cord at 21 points between nerve roots, to

suspend the spinal cord within the dural sac.

These ligaments help prevent the spinal cord being knocked against the vertebrae during

motion.

http://www.anatomy.tv/StudyGuides/Images/Denticulateligament.jpg


SPINAL COLUMN The individual bones of the spinal column (also referred to as vertebral column) are known

as the vertebrae.

The vertebrae provide significant protection and support to the spinal cord. Vertebrae also

take the majority of the weight placed upon the spinal column.

There are 31 to 33 vertebrae that, when stacked on top of each other, create the spinal

column. The variation in number of vertebrae is due to the fusing of the sacral and

coccygeal vertebrae which numerous texts classify differently.

The normal spinal column forms an "S" like curve when looking at it from the side. This

allows for an even distribution of weight. The "S" curve helps a healthy spine withstand all

kinds of stress. The cervical section curves slightly inward, the thoracic section curves

outward, and the lumbar section curves inward. Even though the lower portion of the spine

holds most of the body's weight, each section relies upon the strength of the other sections

to function properly.

The body of each vertebra is a large, round portion of bone. The body of each vertebra is

attached to a bony ring. When the vertebrae are stacked one on top of each other, these

rings creates a hollow tube known as the spinal canal, through which the spinal cord

passes.

VERTEBRAE

The vertebrae are the individual bones of the spinal column, and are made of a hard outer

shell called cortical bone, with an internal component being soft and spongy cancellous

bone.

The anatomy of the vertebrae consists of:

• The Body is the large round section at the front of the vertebrae and takes most of

the weight placed on the spinal column.

• The Spinal Canal also known as the vertebral foramen is where the spinal cord is

located.

• The Transverse Processes are where the back muscles attach to the vertebrae.


• The Spinous Process is the bony portion opposite the body of the vertebrae.

• The Lamina extends from the body to cover the spinal canal.

• The Facets connect each vertebra together and allows the vertebral column to

move.

• The Pedicle is a bony projection that connects to both sides of the lamina.

• The Neural Foramen is the opening between each pair of vertebrae where the

nerve roots exit the spine.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ


SPINAL SECTIONS The spinal column is made up of 33 vertebrae, although some medical textbooks range

from 27 to 33 due to the fused bones of the sacral and coccygeal sections.

The 5 sections of the spinal column are:

• Cervical spine (7)

• Thoracic spine (12)

• Lumbar spine (5)

• Sacral spine (5)

• Coccyx spine (4)

http://www.jeffersonhospital.org/images/staywell/125634.GIF


http://www.jeffersonhospital.org/images/staywell/125634.GIF

CERVICAL SPINE The cervical section (also called cervical spine) consists of the first seven vertebrae of the

vertebral column and is the most mobile of all the sections.

The first two vertebrae in the cervical spine, the atlas and the axis differ from the other

vertebrae as they are designed specifically for significant rotation.

The cervical spine's shape has a lordotic curve. The lordotic shape is like a backward "C".

Think of the spine as having an "S" like shape, and the cervical region being top of the "S".

http://www.spineuniverse.com/anatomy/vertebral-column

THORACIC SPINE The thoracic section (also called thoracic spine) consists of the next 12 vertebrae of the

spinal column.

Each thoracic vertebra connects to ribs and form part of the posterior wall of the thorax

(the rib cage area between the neck and the diaphragm).

This section of the spine has very narrow, thin intervertebral discs, therefore limiting

movement between vertebrae in comparison to the lumbar or cervical sections of the

spine. There is also less space in the spinal canal for the nerves.

The thoracic spine's curve is called kyphotic because of its shape, which is a regular "C"

shaped curve with the opening of the "C" in the front.



LUMBAR SPINE The lumbar section (also called lumbar spine) consists of the next 5 (stubby) vertebrae.

These vertebrae are the largest in the entire spinal column, and need to be as they carry

two thirds of the body’s weight. Thus the larger area of the spinal canal in each of the

lumbar vertebrae allows more space for the spinal cord to move laterally.

The lumbar sections shape is similar to the cervical section in that it has a lordotic curve (a

backward "C"). Remembering that the spinal column is an ‘S’ shape, the lumbar spine is

the bottom of the "S". This lordotic curve is the result of walking and standing erect.

This group of vertebrae are very mobile and during bending takes 50% of the upper body

weight (the other 50% by the hips). As a result, great pressure is placed onto the lumbar

sections discs, often causing them to rupture in later life.



SACRAL SPINE The sacral section (also called sacral spine) consists of the next 5 vertebrae (6 on rare

occasions). These are fused together to form a single bone.

The sacral spine is joined to the pelvic girdle forming the posterior section of the pelvis. It

transmits the weight of the body to the pelvis.

http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19464.jpg

COCCYXL SPINE The coccygeal section (also called coccygeal spine) consists of the final either 2 or 4

vertebrae. These are also fused together.

http://www.almostzara.com/wp-content/uploads/sacrum-coccyx-250x274.jpg


http://www.almostzara.com/wp-content/uploads/sacrum-coccyx-250x274.jpg

VERTEBRAL DISCS A vertebral disc is found between each of the vertebrae from the cervical to lumbar.

The main purpose of each disc is to act as a shock absorber. Each disc also spreads

stress placed on the spine, assists in movement between vertebrae and provides stability.

Each disc is composed of two parts, a tough outer coating and a softer inner substance. At

birth, the discs are of a watery substance that with age dehydrates to form a more jelly like

substance.

http://www.spineuniverse.com/conditions/spinal-fractures/anatomy-spinal-fractures


SPINAL LIGAMENTS Spinal ligaments assist in providing structural stability to the spinal column. Two main

ligament systems exist in the spinal column:

• Intrasegmental systems.

• Intersegmental systems.

The intrasegmental system which includes the ligamentum flavum, interspinous and

intertransverse ligaments join individual vertebrae together.

The intersegmental system consisting of the anterior longitudinal ligaments, posterior

longitudinal ligaments, and the supraspinous ligaments. These join and stabilise large

sections of the spinal column.

http://static.spineuniverse.com/displaygraphic.php/138/dp_ligaments-BB.gif


http://static.spineuniverse.com/displaygraphic.php/138/dp_ligaments-BB.gif

MUSCLES OF THE SPINAL COLUMN The muscles around the spinal column are referred to as paraspinal muscles. More than

30 muscles and tendons help to provide balance, stability, and mobility to the spinal

column.

There are many minor muscles surrounding the spinal column connecting anywhere from

2 to 9 vertebrae (with each assisting in some movement between all the vertebrae and the

rest of the skeleton). The two main muscles that extend up and down the spinal column

are the trapezius and the latissimus dorsi.


AETIOLOGY OF SPINAL CORD INJURY

INTRODUCTION Trauma to the head, neck, shoulders, torso and / or pelvis as a result of motor vehicle

collisions, falls, sporting injuries and other traumatic events may lead to damage of the

spinal vertebrae, the protective supports of the spinal column (muscles, ligaments or discs)

or to the spinal cord itself. Primary and secondary SCI can develop either through

vertebrae lacerating, pinching or compressing the spinal cord, overstretching of the spinal

cord, or cessation of the blood supply to the spinal cord. A progressive tissue destruction

process of the spinal cord can also develop. Primary and secondary SCI or progressive

tissue destruction appear to be caused by both mechanical factors such as blood vessel

compression or laceration, and the chemical factors such as vasodilating endorphins,

which precipitate an ischaemic or hypoxic state following a high impact injury.

PRIMARY SPINAL CORD INJURY A primary SCI is the mechanical disruption of axons by the initial mechanical injury. This

can be caused by the following types of forces:


Hyperextension Hyperextension injuries appear in 19% to 38% of SCI and occur when the spine is arched

backwards beyond normal limits. This type of injury is seen most commonly in the upper

cervical section of the spinal cord as there is nothing to restrain the head until the occiput

hits the lower cervical section. Thoracic and lumbar hyperextension injuries are less

common, but often result in fractures to the lamina or vertebral body, or prolapse of a disc.

Hyperextension injuries are often caused by:

• Collisions in motor vehicles without head rests

• Rear end collisions in motor vehicles


Hyperflexion Hyperflexion injuries appear when the spine is arched forwards beyond normal limits.

Injuries to the cervical segment occur when the head is pushed forward until the chin

makes contact with the chest, fracturing the vertebrae at the front of the cervical spine and

tearing the supporting ligaments at the back.

Hyperflexion injuries are often caused by:

• Motor vehicle collisions with lap or lap/sash seatbelts but no SRS airbags.


Compression / Axial loading Axial loading can occur in several ways. Most commonly, this compression of the spine

occurs when the head strikes an object and the weight of the still moving body bears

against the stopped head, such as when the head of an unrestrained occupant strikes the

windshield or when the head strikes an object in a shallow water diving incident.

Compression and axial loading also occurs when a patient sustains a fall from a

substantial height and lands in the standing position. This drives the weight of the head

and thorax down against the lumbar spine while the sacral spine remains stationary.

Compression injuries occur when the spinal cord is compressed following impact, often

resulting in injuries at C5-6 and T12-L1. This type of injury often causes a burst vertebral

body.

Compression injuries are often caused by:

• Diving injuries.

• Impacting windscreens in motor vehicle collisions.


Distraction Distraction injuries are an overstretching of the spinal cord.

Distraction injuries are often caused by:

• Hanging injuries.

• Playground injuries to children.


Rotation Rotational injuries occur when head and body rotate in opposite directions resulting in

twisting of the muscle, ligaments, vertebrae and / or spinal cord.

Rotational injuries are often caused by:

• Motor vehicle rollovers.

• Ejections from a motor vehicle.


Penetration Penetrating injury represents a special consideration regarding the potential for spinal

trauma. In general, if a patient did not sustain definite neurologic injury at the moment the

trauma occurred, there is little concern for a spinal injury. This is because of the

mechanism of injury and the kinematics associated with the force involved. Penetrating

objects generally do not produce unstable spinal fractures as does blunt force injury

because penetrating trauma produces little risk of unstable ligamentous or bony injury. A

penetrating object causes injury along the path of penetration. If the object did not directly

injure the spinal cord as it penetrated, the patient will not likely develop a spinal cord injury.


SECONDARY SPINAL CORD INJURY

Secondary SCI is a cascade of ongoing events caused by the initial primary cord injury,

which damages axons secondarily to the initial primary injury, that otherwise should have

survived. If the cause of secondary SCI can be predicted and controlled, further

neurological dysfunction may be limited, reversed or prevented.

Causes of secondary SCI are thought to include but are not limited to:

Pathological changes following injury

Following the initial injury to the spinal cord, petechial bleeding (caused by the leaking of

blood cells from capillaries) occurs in the grey matter of the spinal cord, as well as in the

surrounding white matter.

Between 12-24 hours after the initial injury, the grey and white matter in the central region

of the spinal cord loses its structure and becomes a region of dead tissue. The spinal

cords unique blood supply is the probable cause of these changes, and is thought to assist

in further structural damage to the spinal cord, and ongoing neurological dysfunction.

Microscopically, there is a breakdown of the capillary structure and disruption of the blood /

spinal cord barrier. Significant swelling develops in the surrounding white matter as the

bleeding to the central region of the spinal cord continues.

Swelling also interferes with the transmission impulses at the synaptic cleft.

Changes begin to appear to the axon of the spinal nerve including rupture of the outer

membranous covering of the axon, breakdown of the axon’s cytoplasm, disruption of the

axon’s myelin sheath and separation of the myelin sheath from the axon itself. Damage to

the myelin severely compromises transmission of nerve impulses throughout the spinal

cord.

Macrophages (white blood cells that engulf and digest debris) move in to remove any

destroyed spinal cord tissue.

Eventually, a fluid filled cavity (syrinx) surrounded by non conducting glial scar tissue is left

behind within the spinal cord. The syrinx has now formed a barrier that inhibits the

reconnection of axons.


Neurogenic shock

Neurogenic shock, also known as vasogenic shock, usually occurs within 30 - 60 minutes

following suppression of the autonomic nervous system’s ability to maintain

vasoconstriction below the level of SCI.

The autonomic nervous system, through the sympathetic nervous system, maintains the

muscles of the veins and arteries in a partially contracted state. However, with the loss of

sympathetic stimulus, the vascular muscles cannot maintain this contraction and the arter-

ies and veins dilate, drastically expanding the size of the circulatory system, with a corre-

sponding reduction of blood pressure.

These cardiovascular effects may worsen ischaemic lesions in the injured spinal cord.


Post traumatic ischaemia

Following a severe injury, blood flow to the spinal cord, especially in the veins and in the

capillaries supplying the grey matter, is reduced. Causes for the reduced blood flow are

unclear, but may include one or more of the following:

• Direct mechanical irritation producing vasospasm.

• Release of biochemical agents such as noradrenaline or cAMP.

• Products of lipid peroxidation and arachidonic acid metabolism which are

vasoactive causing vasoconstriction and tissue infarction.

Calcium entry into the cells

A dramatic fall in extracellular calcium is seen after an acute injury as the calcium moves

into the cells. Calcium moving into the cells causes activation of phopholipases and

phosphatases.

Phospholipases results in breakdown of membrane phospholipids and the release of free

fatty acids. Free fatty acids are converted to eicosanoids such as prostaglandins, which

are potent vasoconstrictors, restricting blood flow to the spinal cord.

Excitatory amino acids are also released after injury (primarily glutamate) which also

increases intracellular calcium by activating NMDA receptors, and further compounds the

problem.

Increased calcium levels also disrupt a range of cellular processes including transport,

secretion, metabolism and ion permeability.

Increased Extracellular Potassium

The transmission of nerve impulses in neurons requires the appropriate levels of sodium

and potassium inside and outside the cells.

An increase in extracellular potassium (produced by damage to a relatively small

percentage of cells in a particular region) depolarizes intact cells and prevents action

potential conduction, which directly affects spinal cord function.

Failure to immobilise unstable fractures

Failure to stabilise and immobilise an unstable fracture has the potential to allow the

movement of fragments of bone towards the spinal cord causing either pressure on the

spinal cord or actually cutting the spinal cord.


FUNCTIONAL CLASSIFICATIONS Tetraplegia: Also known as quadriplegia refers to a loss of motor and sensory function in

the cervical section of the spinal cord. Arms and legs are affected.

Tetraparesis: Also known as quadraparesis is a condition where the arms and legs are

not paralysed, but are weakened or have reduced motor or sensory function.

In Australia 54% of SCI are at the tetraplegic level.

Paraplegia: Refers to a loss of motor and sensory function in the thoracic, lumbar or

sacral sections of the spinal cord. The SCI patient will still have arm function.

Paraparesis: Is where the legs are not paralysed, but are weakened or have reduced

motor or sensory function.

The remaining 46% of SCI are at the paraplegic level.


SPINAL CORD INJURIES

Primary injury occurs at the time of impact or force application and may cause cord

compression, direct cord injury (usually from sharp or unstable bony fragments), and/or

interruption of the cord’s blood supply. Secondary injury occurs after the initial insult and

can include swelling, ischaemia, or movement of bony fragments. Cord concussion results

from the temporary disruption of the spinal cord functions distal to the injury. Cord

contusion involves bruising or bleeding into the spinal cords tissues, which may also result

in a temporary loss of cord function distal to the injury. Spinal shock is a neurological

phenomenon that occurs for an unpredictable variable period of time after spinal cord

injury, resulting in loss of all sensory and motor function, flaccidity and paralysis, and loss

of reflexes below the level of the spinal cord injury. Cord contusion is usually caused by a

penetrating type of injury or movement of bony fragments. The severity of injury resulting

from the contusion is related to the amount of bleeding into the tissue. Damage to or

disruption of the spinal blood supply can result in cord ischaemia. Cord compression is

pressure on the spinal cord caused by swelling, which may result in tissue ischaemia and

in some cases, may require decompression to prevent a permanent loss of function. Cord

laceration occurs when cord tissue is torn or cut. Neurological deficits may be reversed if

the cord has sustained only slight damage; however, it usually results in permanent

disability if all spinal tracts are disrupted.

INCOMPLETE - COMPLETE CLASSIFICATIONS SCI is classified as either complete or incomplete injuries:

Complete Injuries: Complete SCI are a total loss of motor function (paralysis) and sensory perception as a

result of complete interruption of the ascending and descending nerve tracts in the spinal

cord.

In Australia, approximately 43% of SCI are complete. Due to the small diameter of the

spinal canal, 60% of thoracic SCI are often complete, while only 40% of cervical SCI and

14 % of lumbar & sacral SCI are complete.


Incomplete Injuries:

The majority of SCI in Australia (67%) are incomplete injuries, i.e. there is some function of

either motor and / or sensory function below the level of the SCI.

Poor management of the patient with incomplete SCI can cause progressive worsening of

spinal cord function.

Incomplete SCI are further divided according to the area of SCI and include:

Central Cord Syndrome - is most often seen in hyperextension injuries, with most

damage to the spinal cord being in the centre of the cord itself. In this syndrome, there is

greater loss of function in the upper extremities, as the nerves to these areas are

concentrated more towards the centre of the spinal cord, whilst lower extremity nerves are

found towards the outside of the spinal cord.

The majority of patients will walk again and have a return of motor and sensory function to

the lower extremities and trunk, but tend to have poor recovery of hand function owing to

irreversible central gray matter destruction.


Brown-Séquard Syndrome - occurs when only one side of the spinal cord is damaged.

Motor function and positional awareness is lost on the body side with the injury, but loss of

touch, pain and temperature perception occurs on the opposite side of the body.

This syndrome has a good prognosis for recovery with more than 90% of patients

regaining bladder & bowel control. Most patients will also regain some strength in their

lower extremities and be able to walk again.

Figure 8. Brown-Séquard syndrome.

Anterior Cord Syndrome -occurs most often in flexion injuries which primarily damages

the anterior spinal artery and also the anterior 2/3 of the spinal cord. There is paralysis of

motor function, as well as loss of touch, temperature and pain perception. The ability to

sense the position, location, orientation and movement of the body and its parts remain.

Anterior cord syndrome has the worst prognosis of all spinal cord syndromes with only

10% to 15% of patients showing functional recovery. Prognosis is however good if

recovery is seen to progress during the first 24 hours.


Figure 6.Anterior cord syndrome.

Cauda Equina Syndrome - involves injury to the peripheral nerves rather than the spinal

cord itself (as the cord ends at L2). While initial injury may result in anything from partial to

complete cessation of motor & sensory function, as the peripheral nerves have the ability

to repair themselves, this injury can often repair itself to some degree.


SIGNS & SYMPTOMS OF SCI

The use of signs & symptoms alone to determine the presence of SCI has been found in

multiple studies to be ineffective and will miss 40% - 60% of patients with SCI.

A multitude

of reasons exist for the these missed injuries including distracting injuries or events,

alcohol consumption, drug usage, unconsciousness or an altered conscious state, and

communication difficulties due to extremes of age, language barriers or intellectual

disabilities.

Attempts to diagnose the actual level of injury should also be discouraged. Reasons for

this include 40% - 60% of patients will have no pain over the damaged area due to a range

of issues as listed above. Various studies show persons suffering traumatic fractures to

the spinal column will have a 20% - 66% occurrence of a secondary fracture elsewhere in

the spinal column.

A range of signs & symptoms may be seen in the potential or actual SCI patient and

include:

Bradycardia

The control centre for the heart rate is found in the medulla’s vasomotor centre of the

brainstem and is under control of the Autonomic Nervous System. The Autonomic

Nervous System’s sympathetic nerves (which come from the spinal cord T1 to L2) speed up

the heart rate, whilst the parasympathetic nerves (which are mainly cranial nerves) slow

the heart down.

A bradycardia in SCI occurs due to interruption of the brainstem’s communication to the

spinal cord resulting in the loss of the sympathetic control.

The parasympathetic system can now act unopposed, without the sympathetic influence,

leading to a slowing of the heart rate.

The bradycardia can be effectively treated in the acute stage with Atropine.


Hypotension

The control centre for vasoconstriction and vasodilation of the blood vessels is found in the

medulla’s vasomotor centre of the brainstem and is under control of the Autonomic

Nervous System. The Autonomic Nervous System’s sympathetic nerves (which come

from the spinal cord T1 to L2) constrict the blood vessels, with the parasympathetic nerves

having only a minor effect on dilation of the blood vessels.

Hypotension in SCI occurs due to interruption of the brainstem communication to the

spinal cord resulting in the loss of the sympathetic control thus resulting in dilation of the

peripheral blood vessels and therefore hypotension. Hypotension leads to ischaemic SCI.

SCI induced hypotension (also called neurogenic shock) can be treated in the acute stage

with carefully controlled fluid replacement to avoid pulmonary oedema, or by

vasoconstricting drugs such as Metaraminol or Adrenaline. Both of these drugs have a

short half life, therefore repeated doses or infusions are often required.

Hyperthermia / Hypothermia

The loss of the sympathetic control results in dilation of the peripheral blood vessels

causing peripheral vasodilation below the level of injury. This dilation causes skin to

initially feel warm. As time progresses, hypothermia develops as the loss of muscle

contraction due to paralysis causes a significant reduction in body heat production. Dilation

of the blood vessels close to the skin also results in heat loss by convection.

Acute treatment of SCI induced hypothermia is aimed at maintaining normal body

temperature by the use of blankets.

Breathing Difficulty

The diaphragm provides 70% of normal inspiration / expiration effort, with the intercostal

muscles accounting for only 30% of respiratory effort.

A sensation of shortness of breath will occur if the SCI is in the thoracic region of the

spinal cord (T1-12) as the intercostal muscles, which allow chest expansion for respiration,


are now paralysed. The higher the level of injury; the greater the sensation of

breathlessness experienced.

Emergency care of a SCI patient with breathing difficulties should include supplemental

oxygen to cater for up to 30% reduction in respiratory ability, and the removing of any

restrictions placed on the diaphragm to contract.

Diaphragmatic Breathing

SCI injuries above T1 results in a total loss of the intercostal muscles that assist with

respiration, placing total reliance on the diaphragm for breathing.

To assist the patient’s diaphragmatic respiration, emergency care should include

supplemental oxygen to cater for the 30% reduction in respiration, and the removing of any

restrictions placed on the diaphragm to contract


Respiratory Arrest

Nerve supply for the diaphragm comes from the phrenic nerve which exits the spinal cord

at C4, with some innervation also from C3 and C5.

Phrenic Nerve

http://www.baileybio.com/plogger/images/anatomy___physiology/08._powerpoint_-_peripheral_nervous_system/phrenic_nerve.jpg

SCI injuries at C1-3 will cause a loss of all muscles for respiration, resulting in the inability of

the patient to breath.

Paralysis and Numbness

Paralysis and / or numbness in the trauma patient may be indicators of significant damage

to the spinal cord itself. Such symptoms may occur in one or more limbs. In a small

number of cases, it may also be a temporary effect caused by a sudden temporary

cessation of the autonomic nervous system that occurs following trauma (spinal shock)

which may last hours to weeks.

Acute care, when paralysis or numbness is present, is to reduce any ongoing ischaemia or

swelling that may be causing the loss of motor or sensory function. This can include


http://www.baileybio.com/plogger/images/anatomy___physiology/08._powerpoint_-_peripheral_nervous_system/phrenic_nerve.jpg

supplemental oxygen therapy, the use of methylprednisolone to help reduce inflammation,

and maintaining adequate blood flow to the spinal cord by ensuring adequate perfusion

(both pulse and blood pressure). Immobilisation of the spinal column to prevent further

bone movement damaging the spinal cord is also beneficial.

Heaviness and Tingling

Heaviness and / or tingling sensations in one or more limbs are indicators of possible

pressure being exerted on the spinal cord by either a bone or through swelling, but

suggest that the cord is still intact.

Acute care when heaviness and / or tingling sensations are present is to prevent further

bone movement that may be pressing on the spinal cord by immobilisation of the spinal

column, and to reduce any ongoing ischaemia or swelling that may be causing the sensory

changes by giving supplemental oxygen therapy, and maintaining adequate blood flow to

the cord by ensuring adequate perfusion (both pulse and blood pressure) to reduce

ischaemic injury. The use of methylprednisolone to help reduce inflammation is also an

option.

Pain or Tenderness

Pain or tenderness over any portion of the spinal column is a sufficient indicator to suspect

potential SCI damage. It is however, only stated as being present in 40% - 60% of SCI

patients due to a range of reasons including natural release of endorphins, distracting

injuries, unconscious patient, drug usage, alcohol consumption, neuropathy in the elderly,

communication difficulties due to extremes of age, etc.

Pain management in the emergency setting for SCI should include the use of drugs such

as Penthrane™ or Morphine to reduce pain to a comfortable and tolerable level.

Deformity

Deformity is a definite indication that significant damage has occurred to the spinal

vertebrae, but it is only seen in 3% of SCI. This is in part due to the anatomy of the spinal

column. At C1 to C5 no vertebra bone can be felt on examination. From C6 to L5 only the


posterior aspect of the spinous process is palpable. As a result, there exists controversy

as to whether the patient assessment should include palpation of the spinal column to

determine if such deformity exists, especially if the patient needs to be moved to examine

this area.

Priapism

Priapism is a sustained erection of the penis in a male that occurs following the loss of

sympathetic nerve control resulting in dilation of blood vessels in the lower body including

the deep and dorsal arteries of the penis.


MECHANISMS OF SCI

As stated earlier, only 40% - 60% of spine-injured patients exhibit signs & symptoms of

their injury. Using this as the only criteria for recognition would exclude a large percentage

of patients with potential or actual SCI.

It has been well established that if ‘Mechanisms’ and ‘Pattern’ of injury are also included in

the assessment for a potential SCI, then very few patents will be missed.

Mechanisms of Injury: Patterns of Injury:

Occupants of high-speed MVC’s.

Pedestrians hit by vehicles travelling > 30 kph.

Patients ejected from motor vehicles.

Patients in a motor vehicle which has rolled over following an MVC.

Patients in a motor vehicle where there is a death of another occupant.

Patients falling greater than 2 ½ times their height.

Patients hit by falling object, falling greater that 2 ½ times their height.

Motorcyclists, cyclists > 30 kph.

Explosions.

Entrapments > 30 mins.

Penetrating injury to the head, chest, abdomen, or pelvis.

Significant blunt trauma to the head, chest, abdomen, or pelvis

This should not be considered a definitive list, but should be used as a guide to the more

common injuries leading to potential SCI. Patients with lesser mechanisms of injury can

also suffer SCI, as seen in falls in which >40% of falls in Australia that resulted in SCI oc-

curred from a height of below 1 metre.


SPINAL IMMOBILISATION

INDICATIONS

- To immobilise the spine of a patient with actual or potential spinal injury. The decision

to immobilise the spine is usually based on mechanism of injury and not physical

findings. A high index of suspicion should accompany the following mechanisms and

patient presentations.

o motor vehicle crashes

o falls

o head, neck, or facial trauma

o multiple trauma

o Trauma with a history of loss of consciousness, altered level of consciousness, or

intoxication.

If in doubt, immobilise.

CAUTIONS

1. Evacuation should precede immobilisation in the presence of an environmental

hazard, such as fire or noxious fumes, or risk of drowning.

2. Realignment of the head to a neutral position is recommended and may improve

neurological function. If realignment manoeuvres cause additional pain or muscle

spasm or compromise the airway, the manoeuvres should be stopped immediately

and the patient immobilised in the position found. If the patient holds the head

rigidly angulated or is unable to move the head, realignment is contraindicated, and

the patient should be immobilised in the position found.

3. Pre-existing spinal deformities secondary to conditions such as arthritis or

ankylosing spondylitis may require modification of these procedures to align the

head and neck in a position neutral for that patient.

4. Suction should be immediately available in the event the immobilised or partially

immobilised patient begins to vomit.


PATIENT PREPARATION

1. Stabilise the head manually in the position found, and, instruct the patient not to

move. Large bore oral suction should be immediately available in case the patient

vomits.

2. Instruct the patient to remain as still as possible and let the carers do all the work.

3. Instruct the patient to alert you immediately if any of the manoeuvres cause

increased neck pain, numbness or tingling of the extremities, or difficulty breathing.

4. Assess and document neurological status, including movement and sensation of all

extremities.

PROCEDURAL STEPS

1. Return the patient’s head to a neutral position. Place your thumbs along the

mandible and your index and middle fingers on the occipital ridges to avoid soft

tissue compression and secure a firm hold on the patient. This manual stabilisation

should be maintained until the patient is securely immobilised to a spine board with

a cervical collar in place.

. 2. Apply a semi-rigid cervical collar. If possible, remove jewellery from the ears and

neck before collar placement. A correctly sized collar should extend from the

shoulders to the mandible. Refer to manufacturer’s instructions for sizing different

brands of collars.

3. Log roll the patient to a supine position on a long back board. The team leader

should maintain alignment of the head and coordinate the team’s movements. A

useful landmark for maintaining head position is to keep the nose aligned with the

umbilicus. At least three additional people are preferred for this movement: one to


roll the shoulders and hips, one to roll the hips and legs, and one to place the back

board under the patient.

4. Place a pad underneath the head if necessary to prevent hyperextension when the

head is lowered to the board.

5. Secure the torso and legs to the board with straps or adhesive tape. Strap under

the armpits at the level of the axillae, across the upper arms, abdomen, hips, distal

thighs, and lower legs.

6. Stabilise the head bilaterally with foam blocks or towel rolls, place adhesive tape

directly on the skin across the patient’s forehead and onto the board. The use of sand bags for lateral stabilisation is discouraged because the weight of the sandbags could increase head movement if the board is tipped to the side.

7. Reassess and document neurological status, including movement and sensation of

all extremities.

8. Discontinue manual stabilisation of the head at this point.

9. Have suction available at all times, and be prepared to turn the patient on the board

should vomiting occur.


AGE-SPECIFIC CONSIDERATIONS

1. Young children present challenges in the assessment of pain. Take into

consideration the mechanism of injury to aid in the decision to immobilise.

2. If a child is frightened and fighting, attempts at immobilisation may increase

movement.

3. Children who are younger than 7 years of age have a relatively large head

compared with their trunk size. As a result, placement on a standard back board

may cause excess flexion. To achieve neutral alignment, padding should be placed

under the trunk and shoulders, or a back board with a “cut-out” for the head may be

used. Optimal position results in the external auditory meatus in line with the

shoulders.

4. Paediatric and infant semi-rigid collars are available. If an appropriate sized collar is

not available, a folded towel around the neck may help prevent flexion. Tape across

the forehead and head blocks are crucial in this instance. Care must be taken to

ensure that the towel around the neck is not too tight.

5. Standard head blocks may be too large to be effective with small children. Rolled

towels or small blankets can be substituted.

6. Geriatric patients may be at increased risk for skin breakdown because of thinner

skin, poor peripheral circulation, loss of subcutaneous padding, and concomitant

disease processes.


COMPLICATIONS

1. Further damage to the spine or the spinal cord as a result of movement.

2. Respiratory compromise secondary to tight straps across the chest, aspiration of

vomitus, an improperly sized or placed cervical collar, or excessive neck flexion in

young children.

3. Increased intracranial pressure and reduced venous drainage from the head as a

result of excessive tightness of the collar.

4. Pain related to backboard and collar. Using a vacuum mattress instead of a

backboard may help eliminate this problem.

5. Tissue breakdown secondary to prolonged contact of bony prominences with the

back board or stiff cervical collar.

6. Supine hypotension in pregnant patients (secondary to the pressure of the gravid

uterus on the inferior vena cava). This can be minimized by tilting the back board to

the patient’s left by 15-20 degrees.


SPINAL CLEARANCE The use of signs & symptoms of SCI in conjunction with mechanisms and patterns of injury

provide an excellent level of diagnosis of potential or actual SCI. But it also leads to many

patients being unnecessarily immobilised. Pain does not appear in 40-60% of patients.

The reasons include:

Altered Conscious State

Any patient with an altered conscious state or a period of unconsciousness may be

confused and not able to answer questions regarding pain or injuries correctly.

Alcohol or Drug Use

Any patient who has ingested alcohol or consumed illicit drugs again may be confused and

not able to answer questions regarding pain or injuries correctly.

Distracting Injuries

Distracting injuries are those injuries which cause sufficient pain to distract the patient from

spinal pain that may be present. Such injuries are long bone fractures, but may also

include amputations, dislocations and other injuries causing significant distracting pain to

the patient.

Distracting Event

Distracting events are situations that cause the patient to be sufficiently distracted from

spinal pain that may be present. Such events include a parent whose child has been

critically injured, and as such is unaware or unwilling to admit to their own pain until the

child is adequately cared for.

Modifying Factors

Modifying factors refer to problems of communication with the patient. Such situations

include:

In young children where communication is limited.

Patients where a language barrier exists.

Patients with intellectual disabilities which makes communication difficult.

The elderly (>65 yrs of age) due to neuropathy and / or other diseases that affect pain

perception.


CONSIDERATIONS of SCI in PAEDIATRICS

INTRODUCTION

Paediatric spinal care requires a modified approach to immobilisation to that of the adult

patient. The following discusses the essential differences in treating the child patient

versus the adult patient.

HEAD SIZE

Children under the age of 8 years have what is often referred to as the “Charlie Brown

Effect’, that is the head is larger than the body, with the majority of the enlarged head of

the child posterior to the spinal column. It has been shown that if the child was therefore to

be placed on a flat board, the head would be pushed into a hyperflexed position.

It is essential therefore to place padding under the complete torso from the shoulder down

to the buttocks. Methods where padding is placed only under the shoulders causes

hyperflexion of the thoracic and lumbar spine.

To overcome this, always place firm padding

under the child’s entire torso. While this will elevate the torso more than required in many

cases, the gap under the head can then be padded out. This technique overcomes the

chances of under judging the amount of padding required under the patient’s torso and

removes the need for additional log rolls until correct padding is found.


TYPES OF SCI in Children

Spinal fractures in children are a rare occurrence

with the majority of SCI being elongation

of the spinal cord and shearing damage to the nerves in the spinal cord.

This is due to the

fact that the muscles and ligaments in the child’s spinal column are much weaker in

comparison to the adult. As a result, these muscles and ligaments are unable to resist

tractional forces effectively.

As a result, SCI in children often occur without x-ray findings. Therefore never rule out SCI

in children on x-ray alone.

LOCATIONS OF SCI

SCI in paediatrics totals only 3% of all SCI patients.

Location of the cervical spine injury in

children is most commonly in the upper spine C1 - C2, while in adults the most common

injury appears to be C5 - C6.

It is well established that no Cervical Collar provided

acceptable immobilisation; therefore Cervical Collars must be used in conjunction with a

Cervical Extrication Device or a Long Spine Board.

SHOULD YOU IMMOBILISE THE PAEDIATRIC PATIENT WITH A POTENTIAL SCI?

There is much controversy as to whether a child should be immobilised. Isolated case

reports of SCI occurring in the child struggling against the procedure have been

documented.

There is an opposing view however that young children will often stop fighting

when snugly immobilised. Full spine immobilisation in paediatrics is still considered to be

appropriate despite rare cases of secondary SCI occurring. It should however be done

with careful consideration to prevent the child from becoming agitated and struggling.


MANUAL IN-LINE STABILISATION

INTRODUCTION

With the detection of, or suspicion of a potential or actual SCI, the first procedure in spinal

management is to stabilise the cervical section of the spinal column. This can rapidly be

achieved by the use of Manual In-Line Stabilisation of the head.

The aim of Manual In-Line stabilisation is twofold:

• To provide immediate temporary stabilisation of the cervical spine.

• To join the head to the chest to stabilise the neck.

LIMITATIONS OF MANUAL IN-LINE STABILISATION

There are a number of limitations to Manual In-Line Stabilisation when used in isolation:

Manual In-Line Stabilisation alone, without the support of other immobilisation devices, has

never been proven to be safe. Further splinting will be required before transport or

movement. A semi-rigid Cervical Collar will at best provide only 50% immobilisation.

Therefore, Manual In-Line Stabilisation should be maintained even after a Cervical Collar

has been applied, and until full spinal immobilisation has been applied to adequately

stabilise the cervical spine.

It provides no thoracic / lumbar spinal support to the patient.

It does not take the weight of the patient’s head off the cervical spine.

It should only be used whilst the patient is not being moved.

DANGERS OF MANUAL IN-LINE STABILISATION

A number of dangers may be associated with Manual In-Line stabilisation:

If the patient’s teeth are clamped closed when performing Manual In-Line Stabilisation, the

airway may be compromised if the patient vomits.

Neck pressure increases intracranial pressure, therefore the hands must be carefully

positioned.

Do not place traction to the patient’s head.

The patient’s head must be immobilised in relation to their chest to prevent neck

movement. Failure to achieve this means the neck becomes the pivoting point.


STABILITY DURING MANUAL IN-LINE STABILISATION

To gain the greatest amount of stability, the immobiliser fans their fingers to obtain the

greatest amount of contact as possible with the patient’s head.

The immobiliser should rest their elbows on a stable object such as the ground, seat, bed

or their own torso; this will prevent swaying of the immobiliser’s arms as they become

tired.

MANUAL IN-LINE STABILISATION: BEHIND

© Emergency Technologies 2004

From behind the patient, the immobiliser places their hands over the patient’s ears.

Then places the thumbs of each hand against the posterior aspect of the patient’s skull

and at the same time the immobiliser places both of their little fingers just above the

patient’s angle of the mandible.

The immobiliser now places their index and ring fingers of each hand on either side of the

appropriate cheek bone of the patient.

If the patient’s head is not in the neutral in-line position, slowly realign it, unless contra-

indicated.

The immobiliser brings their arms in at the elbows and rests their arms against the seat,

headrest or their own torso.


MANUAL IN-LINE STABILISATION: SIDE

The immobiliser stands at the side of the patient, then passes one arm (the arm closest to

the patient’s back) over the patients shoulder, and cups the back of the patient’s head with

the hand belonging to this arm.

Between where the upper molars insert in the maxilla and the inferior margin of the

zygomatic arch, there is an indentation ideal for grasping. The immobiliser places the

thumb and first finger of their other hand on the patient’s cheeks so that it grasps the

patient, in the above indentation.

If the patient’s head is not in the neutral in-line position, slowly realign it, unless contra-

indicated.

The immobiliser brings their arms in at the elbows and rests their arms against the seat,

headrest or their own torso.



Manual in line immobilisation from the Front

Manual In line immobilisation for a supine patient


MOTORCYCLE HELMET REMOVAL

INTRODUCTION

Treatment of the motorcycle trauma patient generally requires removal of the patient’s

helmet to allow easy access to the patient’s airway and to allow proper examination of

their face, ears and skull. Despite the need to remove the helmet, personnel are in

general, poor at performing the Helmet Removal Technique safely and correctly.

TYPES OF HELMETS

Four basic motorcycle helmets are currently in use:

http://en.wikipedia.org/wiki/File:White_full-face-helmet.jpg


http://upload.wikimedia.org/wikipedia/commons/a/a9/White_full-face-helmet.jpg

http://en.wikipedia.org/wiki/File:White_full-face-helmet.jpg

http://en.wikipedia.org/wiki/File:Nolan102.jpg

http://en.wikipedia.org/wiki/File:MotoX_Helmet.jpg

http://en.wikipedia.org/wiki/File:Open-face_helmet.JPG


http://upload.wikimedia.org/wikipedia/en/d/d3/Nolan102.jpg

http://upload.wikimedia.org/wikipedia/commons/b/b2/MotoX_Helmet.jpg

http://upload.wikimedia.org/wikipedia/commons/d/de/Open-face_helmet.JPG

http://en.wikipedia.org/wiki/File:Nolan102.jpg

http://en.wikipedia.org/wiki/File:MotoX_Helmet.jpg

http://en.wikipedia.org/wiki/File:Open-face_helmet.JPG

For the helmet to fit correctly on the motorcycle rider and not fall of in a crash, it must be a

firm fit with the rider’s skin moving with the helmet. The rider’s sides & top of head, as well

as their cheeks, should move with the helmet when the rider shakes their head. This

required firm fit will potentially result in movement of the cervical spine during the removal.

REASONS FOR HELMET REMOVAL

Controversy appears to exist in regard to leaving the rider’s helmet in-situ for transport to

hospital or removing it at the crash scene. In general, leaving a helmet on the rider will:

Interfere with administration of oxygen therapy.

Prevent the application of a Cervical Collar.

Cause an airway compromise if the patient vomits.

Place the head into hyperflexion due to the helmets bulk.

Hyperflexion caused by the helmet may occlude the airway in the unconscious rider.

REASONS FOR NOT REMOVING HELMET

Helmets are generally best left in place when:

A penetrating injury to the head has possibly occurred.

Increasing neurological deficit occurs during the removal of the helmet.


HELMET AND SPINE ALIGNMENT

Larger style helmets will often place the rider’s cervical spine into the hyperflexed position

and prevent correct placement of a Cervical Collar.

Therefore, if there is a need to keep the helmet in situ, padding will need to be placed

under the thoracic / lumbar spine.

No padding

Padding under torso with a blanket



HELMET REMOVAL TECHNIQUE

The following technique is the current teachings from the PHTLS course, approved by the

American College of Surgeons - Committee on Trauma, and offers the best technique for

full face motorcycle helmet removal. Two separate studies undertaken on cadavers using

this technique suggest that some spinal manipulation will occur,

and so the procedure

should be carried out with extreme care. If neurological deterioration occurs during the

procedure, cease the removal of the helmet and immobilise the patient with the helmet in

situ.

Procedure

Step 1

Person 1 kneels or lies above the patient’s head. Person 1 places their hands on either

side of the helmet, and brings the patient’s head into the neutral in-line position unless

contra-indicated



Step 2

Person 2 kneels alongside the patient’s torso, lifts the face shield, removes the patient’s

glasses, and undoes the helmet’s chin strap.


Step 3

Person 2 now grasps the patient’s mandible with one hand so that the thumb is at the

patient’s angle of the mandible on one side and the first two fingers are at the patient’s

angle of the mandible on the other side. Person 2 places their other hand under the

patient’s neck making contact with the occiput of the skull. Person 2 now takes over

Manual In-Line Stabilisation of the patient’s cervical spine.

©

Emergency Technologies 2004


Step 4

Person 1 now releases their hold on the sides of the helmet. Then holding the base of the

helmet by its sides, Person 1 gently spreads the helmet’s sides slightly apart.

Person 1 now rotates the helmet so that the lower end of the face piece is rotated towards

them, and elevates the helmet - clearing the patient’s nose.



Step 5

Person 1 then pulls the helmet off the patient’s head in a straight line until the patient’s

head begins to push upwards. The back of the helmet is then rotated vertically upwards at

about 30º following the curvature of the patient’s head and is removed.


Step 6

Person 1 again takes over Manual In-Line Stabilisation of the cervical spine until Full Spine

Immobilisation is completed.

If the head is not in the neutral in-line position, slowly realign it, unless contra-indicated.


Procedure for Log-Rolling a patient with a cervical spine injury (or suspected injury).

Aims: -

• to prevent further spinal cord injury and/or ascension of injury

• to facilitate assessment of the patient's dorsal surface

• to facilitate airway management without further spinal cord injury

• to minimise manual handling risks

Requirements: -

Requires a minimum of 4 people

1 person -maintaining the axial alignment of head & neck

3 people -maintaining body alignment

Don’t forget the person required to perform the procedure or treatment that necessitated

the log-roll.

Head Holding Person

This person manages cervical spine alignment and is in control of the roll. They must

ensure all members of the team are ready before proceeding and should give clear

instructions. Whilst the head hold person takes their position assistance may be required

to minimize head movement.

Photo 1: Shows 'head hold person' at the head of the bed with their hands alongside the

head gripping the shoulders whilst another person performs a shoulder brace to prevent

head movement.


Chest person

If possible should be the tallest person in the team who places hands over the patient’s

shoulder and lower back.

Hip person

This person is responsible for ensuring the lower spine is not twisted during the roll. Places

one hand near the lower hand of the 'chest' person on the patient's lower back and the

other under the patient’s thigh. A pillow may be inserted between the patient’s legs to help

maintain alignment.

Leg person

Each patient must be assessed on an individual basis for manual handling risks. A leg

person is required for tall or heavy patients or those in plaster. The weight of the leg

should be supported from underneath.


The rolling procedure

When the equipment is obtained, the patient is prepared and the personnel

understand their roles the procedure for log-rolling is as follows:

The procedure is explained to the patient and the cervical collar is checked.

The personnel take their positions as described previously.

The head hold person says “we will all roll on 'three'”. The count is made and all personnel

roll the patient together on 'three'.

The person who is to perform the procedure and is not a log-roll member reassures the

patient and supports the lines and airway until the patient is in a stable position on their

side.

Photo: Shows a patient in a stable position on their side. Note the alignment of the spine

and the position of the head hold person's hands


Completing the roll.

The head hold person asks if everyone is ready. When ready, the head hold person states

“we will roll back on 'three'”. The count is made and everyone rolls together.

The procedure person reduces creasing by gently pulling on the sheets as the patient is

lowered.

All personnel stay in place while the head hold person checks alignment.


SEMI-RIGID EXTRICATION COLLARS

The primary purpose of a cervical collar is to provide a high degree of

immobilisation for a patient’s cervical spine, while maintaining the cervical spine in neutral

alignment.

No collar can offer adequate immobilisation of the cervical spine when used in

isolation. It should be used with a spine board, head immobilisation devices, and strapping

appropriate for securing the patient’s body to the board.

Cervical collars do not immobilise. Because they only limit the range of flexion by

about 75 percent at best and the range of motion by 50 percent (or less), they do not in

themselves provide immobilisation of the head and neck. A cervical collar is an important

adjunct.

The unique primary purpose of a cervical collar is to rigidly maintain a minimum

distance between the head and neck so that any significant movement of one towards the

other, and the resulting intermittent compression of the cervical spine it would produce, are

eliminated. The upper margin of the cervical collar purchases the head anteriorly where it

is inserted under the angle and lateral portion of the mandible, and posteriorly where the

back section is inserted and secured below the posterior bulge of the occiput. The lower

edge of the collar, when properly secured, sits firmly on the shoulder girdle and portions of

the upper rib cage. Due to its rigidity and the minimum thickness between its outer edges

and the underlying bone, the collar transfers any unavoidable loading from the head

through the collar to the torso (or from the torso through the collar to the head), instead of

the neck. By maintaining the previous unloaded length between the shoulder girdle and

the head, the rigid cervical collar prevents the movement and cervical compression that

cannot be eliminated by manual or other mechanical devices. Therefore, to eliminate the

possibility of increased pressure being referred to the neck, a properly fitting cervical collar

must be included with other immobilization provided. The collar does not eliminate

movement of the head beyond its upper edge or of C6, and T1 at its lower edge. Although

it helps to limit movement, it must always be used in conjunction with another method or

device to provide adequate immobilisation.


The Stifneck Extrication Collar

http://www.laerdal.com/doc/7160026/Stifneck-Extrication.html#

The Stifneck Extrication Collar is a one piece, rigid cervical collar. Stifneck collars come in

a range of sizes:

Baby No-Neck

Paediatric

No-Neck

Short

Regular

Tall

Stifneck Select – which is adjustable to the equivalent of the No-Neck to Tall sizes.

Stifneck Select - Pediatric


They all use a simple sizing method. If properly fitted the low angle chin piece ensures

stable support, does not push the patient into extension or limit airway access due to

“clenched teeth”. The extra large tracheal hole gives exceptional access to the neck for

pulse checking and advanced airway techniques. The rear panel vents increase air flow for

improved comfort and allow early detection of blood and other fluids.

1. Proper sizing is critical for good patient care. Too short a collar may not provide

enough support, while too tall a collar may hyperextend. The key dimension on a

patient is the distance between an imaginary line drawn across the top shoulders,

where the collar will sit and the bottom plane of the patient’s chin.

2. Measure the patient.

You can easily size a patient using your fingers to measure the key dimension. The

key dimension is the distance between the trapezius, where the collar will sit, and

the bottom of the patient’s chin. On the collar, because the chin piece is aligned

with the sizing post; you can determine the key dimension by measuring the

distance between the sizing post and the lower edge of the rigid plastic on the

encircling band.


http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5167

The Key Dimension on the collar is the distance between the sizing post (back

fastener) and the lower edge of the rigid plastic encircling band (not the foam

padding).



3. Match the collar size to the patient

When the patient is being held in a neutral position, use your fingers to measure the

distance from the shoulder to the chin (Key Dimension.) You can then use your

fingers to select the size Stifneck Extrication Collar that most closely matches the

key dimensions of the patient.




4. Assembly and Pre-forming

Insert Fastener into Hole

The collar is assembled by moving the black fastener (sizing post) at the end of the

chin piece up the inside wall of the collar and then pushing the black fastener all the

way into the small hole. Press firmly

Before applying the Stifneck collar, hold it as shown.

Flex Collar

Flex the collar sharply inward until you can touch your thumb to your fingers. This

will pre-form the collar into a cylinder to simplify application.


5. Correct Application

With the patient's head held in neutral alignment, position the chin piece by sliding

the collar up the chest wall. Be sure that the chin is well supported by the chin piece

and that the chin extends far enough onto the chin piece to at least cover the

central fastener. Difficulty in positioning the chin piece may indicate the need for a

shorter collar.

6. Attaching the Velcro

Re-check the position of the patient's head and collar for proper alignment. MAKE

SURE THAT THE PATIENT'S CHIN AT LEAST COVERS THE CENTRAL

FASTENER IN THE CHIN PIECE. If it doesn't, tighten the collar further until proper

support is obtained. Select the next smaller size if you think further tightening of the

collar may cause the patient to become extended.


7. Supine Application

If the patient is supine, begin by sliding the back portion of the collar behind the

patient's neck. Be sure to fold the loop Velcro inward on the top of the foam padding

to prevent it from collecting debris that could limit its gripping ability. Once the loop

Velcro is visible, turn all of your attention to positioning the chin piece and attaching

the Velcro as described in two preceding steps.

8. Final Adjustment

Once positioned, hold the collar in place by using the tracheal hole (as shown above) You

can avoid torquing the neck by using the tracheal hole as an anchor point while first pulling

laterally to tighten and then attaching the loop Velcro to the front so that it mates with, and

is parallel to, the hook Velcro. BE SURE TO MAINTAIN NEUTRAL ALIGNMENT

THROUGHOUT THIS PROCEDURE.


ADDITIONAL CONSIDERATIONS

1. Do not rely on any cervical collar by itself to adequately motion restrict a patient's

cervical spine. Collars are tools to aid in motion restriction. No collar by itself provides

sufficient motion restriction.

2. Do not use an improperly sized collar. Too large a collar may hyperextend a patient's

cervical spine; too small a collar may not provide appropriate stability. Special sizes of

Stifneck collars are available for children and other individuals with small frames.


• DO NOT ADJUST THE SELECT COLLAR ON THE PATIENT

• DO NOT RELY ON A COLLAR ALONE TO PROPERLY RESTRICT THE MOTION OF A PATIENT’S CERVICAL SPINE

• DO NOT USE AN IMPROPERLY SIZED COLLAR. TOO LARGE A COLLAR MAY HYPEREXTEND A PATIENT’S CERVICAL SPINE; TOO SMALL A COLLAR MAY NOT PROVIDE APPROPRIATE STABILITY.



The Vertebrace Extrication Collar

The Vertebrace Extrication Collar has a one piece construction, requiring no

assembly. From a flattened stored position the chin support flips up into place as the collar

is formed to fit the patient. A large anterior opening permits access to the neck for

cricothyrotomy or tracheostomy.

http://www1.mooremedical.com/gen_info/image.cfm?limage=31544_9-05.jpg

http://wound.smith-nephew.com/AU/node.asp?NodeId=3799

The Vertebrace is available in 6 sizes

Pedi-Short

Paediatric

X-Short

Short

Regular

Tall


http://www1.mooremedical.com/gen_info/image.cfm?limage=31544_9-05.jpg

http://wound.smith-nephew.com/AU/node.asp?NodeId=3799

A sizing guide/sizing post is needed to correctly fit the patient.


Instructions for Using the Sizing Guide 1. For suspected C-Spine injury requiring a collar the guide can be used in almost any

position the patient is found.

2. Position the guide alongside the patient’s head, resting the bottom edge on the

uppermost surface of the shoulder (trapezius muscle). Align the coloured end with

the front of the ear.

3. Read the colour area, with its letter size, that falls in line with the centre of the ear

opening (concha).

4. Each colour area, with its letter designation corresponds to one of the six sizes of

the Vertebrace.

Anatomically the concha falls in the same plane as the occiput. For maximum

support and extension resistance, each Vertebrace collar is sized to fit up against

this bony protuberance.


Application

1. Holding the collar out in front, grasp it in each hand on either side of the tracheal

opening. With your fingers on the inner surface, push towards yourself while

rotating yours wrists outward. The chin support will flip up over the walls of the

base.

2. Hold the collar as shown. Flex the plastic inward upon itself by touching your thumb

to your fingers

3. Preforming shapes the collar, simplifying application


4. Establish in line cervical immobilisation manually. Slide the back portion of the collar

with the contact closure strap behind the patient’s neck. Do not fasten closure yet.

5. Position the chin support beneath the patient’s chin, while maintaining manual

immobilisation. Avoid excessive movement of the patient’s head.

6. Secure the collar by firmly pulling on the contact closure and pressing the loop

portion against the mating hook portion.


The Philadelphia Collar

The Philadelphia Collar is a two piece cervical collar. It is made of non-toxic,

hypoallergenic Plastazote foam. It is said to offer total cervical arch support. The moulded

foam body has rigid plastic occipital and mandible posts. The Philadelphia collar is shaped

to fit chin and shoulder contours.

The Philadelphia collar is used more in a definitive care role rather than as an

extrication collar.

http://www.alphamedical.com/_borders/Cervic3.jpg

Remaining in the standard semi-rigid cervical extrication collar for long periods of time will

produce pressure areas and skin irritation. Therefore, any patient who requires continued

cervical spine immobilisation for prolonged periods (longer than 4 to 6 hours), will require

the collar to be changed to a Philadelphia collar.

Philadelphia Collar Sizes Neck Circumference Height

Small 10” – 12” 2 ¼ 3 ¼ 4 ¼ 5 ¼

Medium 13” – 15” 2 ¼ 3 ¼ 4 ¼ 5 ¼

Large 16” – 19” 2 ¼ 3 ¼ 4 ¼ 5 ¼

X-Large 19” + 2 ¼ 3 ¼ 4 ¼ 5 ¼

Sizing


http://www.alphamedical.com/_borders/Cervic3.jpg

1. Measure the neck circumference in inches. This determines the size of the collar.

(Measurement “B”)

2. Measure the distance from the inferior border of the mandible (the chin) to the

sternal notch. ( Measurement “A”) This determines the height of the collar.

Important Points 1. The neck should be in a neutral position.

2. The collar may need readjustment with position changes.

3. Corners of the collar may be trimmed/cut to relieve pressure areas, or to fit around

ears.

Pressure/Skin Checks 1. Monitor the skin condition particularly around the ears, occiput, chin and clavicles.

2. The Philadelphia Collar should be removed and skin checked at least once every 8-

10 hours.

3. Only one piece of the collar should be removed at a time.

ANTERIORLY – one person holds the head and maintains in line immobilisation,

the other removes the front piece.

POSTERIORLY – log roll the patient maintaining in line immobilisation. Remove the

back piece to check for pressure areas and to wash the skin.


PHILADELPHIA COLLAR FITTING INSTRUCTIONS

Sizing

• Consider the height and width of the patients neck

• Width sizes are small, medium and large

• Height sizes are measured in inches from the patients chin to the sternum.

• Start with a 3 ¼ inch collar and compare with the patients neck in a neutral

position to see if they require a larger or smaller collar in comparison.

• Remember that most patients lie with some degree of extension and the

height will need to be reassessed when the patient is sitting up.

• Have the next size up and down handy when fitting the collar in case you

need to make adjustments.

Application of the Philadelphia collar STEP 1. Have the patient lying in a supine position, instruct the patient not to move their head until

the collar is fitted. Maintain manual in-line spinal immobilisation.

STEP 2. Remove the extrication collar

STEP 3. The front piece of the Philadelphia collar is placed on the anterior neck


STEP 4. Make sure the chin fits snugly but is not pushing on the collar

Check that you cannot place more than one finger under the sternal portion (if so use next

size up)

STEP 5. Flatten the back piece and slide under the back of the patient’s neck (without causing

flexion)


STEP 6. Check the front piece is over the top of the back

Secure the Velcro straps over the top

STEP 7. Check there is no pressure on the patient’s shoulders or ears

You may trim soft edges of the collar with scissors to remove pressure on bony

prominence (e.g. clavicles) or ears (DO NOT cut while on the patient)


STEP 8. – Check for correct fit


SPINAL BOARDS / BACKBOARDS

Spine boards or back boards are many and varied in their composition, shape,

design and weight. The ideal spine board should be comfortable for the patient, rigid and

lightweight. Other desirable features are:

- Contoured design to allow the board to nest compactly.

- Impervious to fluids, and have no seams to allow for easy cleaning and

decontamination.

- Raised hand holds making it easy to pick up.

- Strap connection points.

- Radiolucent, MRI and CT compatible.

ttp://firstresponder.com.au/cart/imageh s/lsb.jpg


MAINTENANCE OF NEUTRAL IN-LINE POSITION OF THE HEAD

It is essential that the neutral in-line position in which the head has been placed

(and manually immobilised) be maintained when the manual immobilisation is superseded

by mechanical means. The neutral in-line position is defined as the position in which the

head is normally held while walking; or the position in which the head is placed so that with

the eyes centred exactly in their orbital range (neither rotated up, down, left nor right) a line

between the pupils and the point the eyes are focused on would be perpendicular to the

body’s centreline (an imaginary midpoint which would extend in a straight plumbline from

the centre of the skull to a point between the ankles).

In greater than 98% of the adult population, when the head is placed in a neutral in-

line position, the outermost measure of the occipital region at the back of the head is

between ½ and 3½ inches anterior to the plane of the posterior torso. Therefore, in most

adults, when their head is in the neutral in-line position a significant space occurs between

the back of the head and the device (the spine board). Suitable padding must be added

prior to securing the head or the head will move to hyperextension. Firm semi-rigid pads or

folded towels can be used. The amount of padding needed must be evaluated, and varies

from patient to patient. A few individuals require none. If too little padding is provided, or if

the padding is of an unsuitable spongy material, the head will be hyperextended when the

head straps are applied. If too much padding is inserted, the head will be moved into a

flexed position. It must be noted that the padding should be placed directly posterior to the

occipital area, not the neck.

In small children (under eight years old) the size of the head in relationship to the

rest of the body is much larger than in adults. The majority of the enlargement is of the part

of the head which lies posterior to the spinal column. Further, the muscles of a child’s back

are less developed than in adults. Therefore, when a small child’s head is in the neutral in-

line position the back of the head usually extends on to two inches beyond the posterior

plane of their back. If a small child is placed directly on a rigid surface, their head will

usually be moved into a position of flexion. As well as the danger of compromising the

spine that this presents in a child, such extreme flexion can kink the immature trachea and

produce airway compromise. The spine board needs to be modified, either by creating a


recess for the head in the board or by inserting padding under the torso to elevate it, in

order to be able to maintain the child’s head in a neutral position.

www.emergencytechnologies.com.au


http://www.emergencytechnologies.com.au/

No under torso padding

With under torso padding Padding placed under the torso should be of the appropriate thickness so that the head

can lie on the board in a neutral position: too much will result in extension, too little in

flexion.


IMMOBILISATION OF THE HEAD TO THE DEVICE

Once the rigid spine board has been immobilised to the torso and appropriate

padding has been inserted as needed, the head should be secured to the device. Due to

the rounded shape of the head, it cannot be stabilised on a flat surface with only straps or

tape. Use of these alone will still allow the head to rotate and move laterally. The head is

ovoid, being longer than it is wide and having almost completely flat lateral sides.

Adequate external immobilisation of the head, regardless of the method or device, can

only be readily achieved by placing pads or rolled towels on these flat sides and securing

them with straps or tape.

The side pieces, whether they are preshaped foam blocks or “homemade” rolled

towels, are placed firmly against the flat lateral planes of the head. Two straps or pieces of

tape surrounding these head pieces draw the sides together and mould their inner sides to

the exact shape of the head – preventing further movement. When packaged between the

blocks or towels, the head now has a flat posterior surface which can be realistically fixed

to a flat board. The upper head strap is placed tightly across the front of the lower

forehead (across the supra orbital ridge), and helps prevent anterior movement of the

head. The device holding the head – regardless of the type – also requires a lower strap to

help keep the side pieces firmly against the lower sides of the head and to further anchor

the device and prevent anterior movement of the lower head and neck. The lower strap

passes around the side pieces and across the rigid portion of the cervical collar.

The use of a commercial head immobiliser is the fastest and easiest way to secure

the head. However, if these are not available, a blanket or towel rolled into a bolster and

placed at each side of the head is as effective.

Using sandbags or IV bags secured to the spine board alongside the head and

neck represents dangerous practice. Regardless of how well secured, these heavy objects

can shift and move. The combined weight of the sandbags can produce localised lateral

pressure against the cervical spine. Sandbags as adjuncts to cervical spinal immobilisation

require more attention from care providers rather than less. Sandbags are heavy and if the

extrication board / spinal board/ patient trolley is tipped or bumped side to side during

evacuation and transport, the sandbags can slide, resulting in lateral displacement of the

victim’s head and neck with respect to their torso.


HEAD BLOCKS / HEAD IMMOBILISERS

Head blocks or immobilisers are any device which can aid in the firm control of

head movement and help to maintain proper cervical spine alignment.

There are many devices available commercially, but rolled towels or blankets used

in conjunction with adequate taping will also suffice.

http://www.laerdal.info/images/s/AEJBHVQJ.jpg


http://www.laerdal.info/images/s/AEJBHVQJ.jpg

http://www.reepl.ru/img/other/StifneckPed.jpg

http://www.laerdal.com.au/images/l/AAKDTGIV.jpg


http://www.reepl.ru/img/other/StifneckPed.jpg

http://www.laerdal.com.au/images/l/AAKDTGIV.jpg

VACUUM MATTRESS

The vacuum mattress is a substitute to a back board. It provides fast, effective and

comfortable immobilisation by moulding to the specific contours of the patient’s body,

reducing pressure point tenderness. It is x-ray, MRI and CT compatible. The manual pump

can evacuate the mattress in 25 seconds and it weighs about 5 kg.

http://www.savelives.com/images_full/em9000_full.jpg

Vacuum mattresses contain numerous polystyrene beads encased in a flexible

outer shell. They are initially soft and malleable, but when the air is removed they become

rigid and conform to the shape of the patient.


Technique.

- After the splint has been flattened and smoothed out, the air is removed to make it rigid

in order to allow the patient to be log rolled onto the device.

- The air intake valve is then opened to allow air back into the system to soften it.

- The torso is secured using the supplied straps.

- Air is then removed from the mattress by one person using the pump.

- As air is evacuated, a second person should mould the mattress to the head and neck,

while a third person maintains inline, manual stabilisation of the head.

- The head is then secured with tape.


EXTRICATION VESTS

Kendrick Extraction Device / Medical Extraction Device

Extrication vests are unitized pre-assembled variations of a half backboard. Most of the

straps are pre-positioned as an integral part of the unit’s structure, avoiding a multitude of

loose parts and the time needed to position and secure each to the main unit. The vest

contains internals slats or rigid sections which, although allowing adjustment of the

circumference of the torso and head sections, make the back of the device longitudinally

rigid from the coccyx to the top of the head. This allows them to be flexible enough to form

exactly around the body of differently sized and proportioned patients while providing

adequate rigid in-line immobilisation of the head, neck, and torso for removing the patient

onto a long board. Since they are flexible around their circumference they can easily be

installed regardless of how confined the seat may be and, since they are form fitting and

do not extend significantly beyond the patient’s anatomical outline once applied, make

removal of the patient through a limited opening easier than with a completely rigid flat

device.

A variety of models are available and , although each has some differences in the

detail of their specific design and exact strapping method at the upper torso and buckles,

their primary design and use is dictated by the general anatomical factors common to all


patients and is therefore almost the same. Each model has a rigid posterior centre section

with a flap at each side to surround the lateral torso and a second flap superior to these on

each side to surround and secure the flat lateral sides of the head. The vests generally

include several straps to immobilise it to the patient’s upper torso, several to secure the

flaps and immobilise the mid-torso, and a pair of groin loops. The head flaps are secured

against the lateral sides of the head (and the head is prevented from anterior movement)

by a strap which is placed on the upper part of the head flaps around the forehead. A

second strap across the anterior portion of the cervical collar also connects the head flaps.


http://upload.wikimedia.org/wikipedia/commons/0/07/KED.jpg

Application of the KED

Ideally a minimum of three people are required to apply the KED

After preliminary stabilisation and application of a rigid cervical collar, one person

should continue to maintain manual in-line immobilisation throughout the entire

procedure.

With an attendant on either side of the patient, slide the KED into place behind the

patient’s back with a minimum of movement. The restraints should face away from

the patient.


http://upload.wikimedia.org/wikipedia/commons/0/07/KED.jpg

Centre the KED with the patient’s spine.

Once the KED is centred, pull the leg restraints (having the white buckles) from

behind the patient and lay them out of the way.

Wrap the chest flaps around the patient and move the KED up the patient’s trunk

and adjust so the chest flaps fit snugly under the patient’s arm pits.


Wrap the central waist strap (yellow) around the patient and secure firmly without

causing discomfort or restrict breathing, then repeat with the lower (red) strap.

Release leg straps, (black) pass one at a time under thigh to mid-thigh, using see-

sawing motion, work straps under patient’s legs and buttocks to crotch. Cross the

straps at the crotch, coupling to the receiver on the opposite side of the KED.

Secure the straps (white buckles) and adjust to firm fit.

Ensure the bottom of the KED is in contact with the lower back.

Fill any gap between the KED and the patient’s neck with a folded towel or other

padding.

Whilst the patient’s head remains manually immobilised wrap the head flaps

forward around the patient’s head.

Centre a forehead strap on the patient’s forehead, just above the eyebrows, pull

straight back and fasten to the KED head support Velcro.


Centre the chin strap on the patient’s chin and chin support of the collar, pull

straight back and fasten to the KED head support Velcro.

Take care not to hyperextend patient’s head and neck.

Finally, couple and tighten the upper chest restraint (green strap).

Firm (tighten) all straps from top to bottom.

i.e. – thigh

- Red

- Yellow

- Green

Other Uses of the KED

Pregnant Patient:

The chest flaps may be folded inward, leaving the patient’s abdomen exposed. Exercise

care in placement and tightening of restraints.


Small or Paediatric Patient:

Adjustments may be made by placing blankets or towels on the patient’s chest and

securing the KED.

Splinting:

The KED can be used to splint a fractured hip, invert the KED, allowing equal space above

and below the hip. Use the existing restraints to affix the KED to body and leg.

Use the KED in a similar manner for a fractured pelvis, except place the chest flaps over

the pelvic bone area.


JORDAN (DONWAY) LIFTING FRAME

http://www.ilcaustralia.org/images/NSW/4450002.jpg

The Jordan Lifting Frame offers a simple system for easy, safe lifting of patients

with suspected neck or spinal injuries. It is designed to be fitted around the patient with the

minimum of disturbance. The principle of the Jordan Lifting Frame recognises the need to

lift and transport patients as they lie – without moving them so minimizing further spinal

flexion, rotation or extension.

In the Jordan system the frame is readily built around and under the person

irrespective of the person’s position on the ground. After the main aluminium frame has

been positioned around the injured patient, a series of specially designed gliders are slid

under the body of six or seven strategic non-pressure points, tensioned according to the

patent’s weight and conveniently attached to the studs by a push fitment. Simple restraint

straps are employed where required to firmly hold and prevent the patient from moving

within the frame.


http://www.ilcaustralia.org/images/NSW/4450002.jpg

http://www.necksafe.com.au/equipment.htm

http://www.ilcaustralia.org/images/WA/4441003.JPG

https://spservices.co.uk/images/st191.jpg


http://www.necksafe.com.au/equipment.htm

http://www.ilcaustralia.org/images/WA/4441003.JPG

https://spservices.co.uk/images/st191.jpg

Clinical Practice Guidelines and Competency Assessments


Bibliography, References and further reading Ackland, HM. (2006).The Alfred Spinal Clearance Management Protocol. The Alfred Hospital, Melbourne, Australia.

Ajani AE, Cooper DJ, Scheinkestrel CD, Laidlaw J, Tuxen DV. (1998).Optimal assessment of cervical spine trauma in critical ill patients: A prospective evaluation. Anaesthesia and. Intensive Care; 26:487-491.

Albrecht RM, Kingsley D, Schermer CR et al. (2001). Evaluation of cervical spine in Intensive care patients following blunt trauma. World Journal of Surgery.;25:10891096

Albrecht RM, Malik S, Kingsley DD et al. (2003).Severity of cervical spine ligamentous injury correlates with mechanism of injury, not with severity of blunt head trauma. American Surgeon. 69:261-265.

Bache, J., Armitt, C., & Gadd, C. Practical Procedures in the Emergency Department. Mosby London 1998.

Bledsoe BE, Porter RS, Cherry RA. Trauma Emergencies. Paramedic Care: Principles and Practice, Volume 4. Upper Saddle River, NJ: Prentice Hall, 2001.

British Trauma Society. Guidelines for the initial management and assessment of spinal injury. Injury 34(6)(2003):405-425. Brooks RA, Willett KM, (2001). Evaluation of the Oxford Protocol for total spinal clearance in the unconscious trauma patient. Journal of Trauma.;50:862-867. Butman, A., Martin, S., Vomacka, R. & McSwain, N. Comprehensive Guide to Prehospital Skills: A skills manual for EMT-Basic, EMT-Intermediate, EMT-Paramedic. Mosby-Yearbook, St Louis. 1996. Chendrasekhar A, Moorman DW, Timberlake GA. (1998). An evaluation of the effects of semi rigid cervical collars in patients with severe closed head injury. American Surgeon; 64(7):604-606. Clancy M. (1999). Clearing the cervical spine of adult victims of trauma. Journal Accident & Emergency Medicine;16:208-214. Cline, J.R., Scheidel, E. & Bigsby, E.F. (1985). A Comparison of Methods of Cervical Spine Immobilisation Used In Patient Extrication and Transport. Journal of Trauma 25 (7):649-653. Cohen, B.J. (2005) Memmler’s Structure and Function of the Human Body. 8th Edition. Lippincott Williams & Wilkins. Philadelphia.


Cooper DJ. (2001). Cervical Spine Management Protocol: The Alfred Intensive Care Unit.. Melbourne.

Cooper DJ, Ackland HM. (2005). Clearing the cervical spine in unconscious head injured patients: The evidence. Critical Care Resuscitation.;7:181-184.

Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, et al. (1995). Pain and tissue-interface pressures during spine-board immobilization. Annals of Emergency Medicine, 26(1): 31-36,

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spinal immobilization v 2 feb 2011

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