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April 30, 2015
Beyond backboards: Moving and extricating trauma patients
Spinal cord injury occurs when unstable, fractured vertebrae move and shift in an abnormal fashion, causing direct damage to the spinal cord. Swelling from the traumatic injury can also cause damage to the spinal cord.
In a normal spine, the vertebrae and ligaments form three columns - the anterior, middle, and posterior. Unstable fractures are defined as those where more than one of these columns is disrupted. In these rare situations, dramatic movement of the patient could, in theory, cause injury to the spinal cord as bone fragments or fractured vertebrae contact the spinal cord. It is this theoretical potential for injury that has driven the practice of using a rigid cervical collar, backboard, head blocks, and straps to attempt to immobilize the patient.
The evaluation and management of patients with potential spinal injuries has been a hotly debated topic in the EMS community in recent years. Historically, a significant mechanism of injury often prompted responders to fully immobilize patients to a rigid long board, regardless of patient presentation and physical exam findings.
The actual incidence of trauma-related spinal fracture is low, 2-5 percent, and the instances of unstable spinal fracture are even lower at less than 2 percent. In addition to the very low probability of trauma patients having an unstable spinal injury, there is now significant evidence that the traditional method of immobilizing a patient to a rigid long backboard causes a range of complications including new onset back pain, respiratory compromise, and pressure ulcers.[4,5,6]
A review of spinal motion restriction algorithms
NEXUS screening involves assessing for focal neurologic deficit, spine tenderness, level of consciousness, possible intoxication, and distracting injuries. CCR includes an additional qualification for patients over the age of 65, those with numbness or tingling in the extremities, and those with a significant mechanism of injury. Alert and oriented patients with no signs of intoxication or distracting injury may qualify for limited intervention, such as a cervical collar and position of comfort on the gurney or cot.
With these changes in SMR protocols providers are now faced with decisions regarding how and when to move a patient when spinal motion restriction is applied. Equipment such as scoop stretchers, soft tarps, KEDs, and vacuum splints may all be useful when moving a patient with modified spinal motion restriction.
The concept of minimal handling
Under a traditional approach of spinal immobilization, a patient might be moved a number of times - during a log roll, while being positioned on a backboard, during removal of clothing, transfer to the hospital bed, and removal from the backboard.
For unresponsive patients, or those with neurological deficit who require immobilization, providers should coordinate their efforts so that the patient only needs to be moved once. For example, a patient can be exposed, have their back examined, and be placed on the immobilization device in a single, coordinated lift or movement.
Scoop stretchers, lifts, and the loss of the log roll
Considering the potential complications of the log roll, and the shift towards more minimal handling of patients, the scoop stretcher is a viable tool to include when caring for patients with suspected spinal injury. A scoop stretcher has several benefits. First, it eliminates the need for a log roll, as the scoop can be applied with minimal patient movement. In addition, the structure of the scoop stretcher makes it a more appropriate device to use when fully immobilizing a patient, as it is curved and places less pressure on the patient’s back.
If a scoop stretcher is not available, viable, or allowed by protocol, a lift and slide technique can be used. In a lift and slide, rescuers perform a direct lift of the patient, maintaining anatomical positioning. The lift can be accomplished with five rescuers: one maintaining manual stabilization of the head and neck, three straddling the patient who performs the lift, and the last sliding a board under the patient. A similar technique, the six-rescuer lift, positions rescuers along either side of the patient rather than standing over. Compared to the log roll maneuver, these two techniques minimize potentially movement of the patient’s spine.
Thinking outside the board
For example, the responder may decide to allow the patient to self-extricate and place him or herself in a comfortable position on the gurney. At that time, pillows and blankets may be used to support the positioning of the patient and provide stability. Soft cervical collars or rolled blankets may be a more comfortable alternative to a rigid cervical collar, and maintaining continuous manual stabilization of the head and neck may also be effective. If self extrication is not appropriate, the KED may be of value both in extricating the patient and in for subsequent SMR.
With the continued advancement of SMR protocols, providers should consider each patient and their individual needs. Focusing on patient comfort, minimizing patient handling, and thinking creatively will allow responders to appropriately secure a trauma patient for transport.
1. Connor, D, et al. Prehospital Spinal Immobilisation: An Initial Consensus Statement*. Trauma 17.2 (2015): 146-150.
2. Bouland, Andrew J., J. Lee Jenkins, and Matthew J. Levy. Assessing Attitudes Toward Spinal Immobilization. Journal Of Emergency Medicine (0736-4679) 45.4 (2013): e117-e125.
3. Grossman MD, Reilly PM, Gillett T, Gillett D. National survey of the incidence of cervical spine injury and approach to cervical spine clearance in U.S. trauma centers. J Trauma, 1999; 47(4): 684–90.
4. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care, 1999; 3: 347–52.
5. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med, 1994; 23: 48–51.
6. Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med, 1995; 26: 31–6.
7. Michaleff, Zoe A., et al. Accuracy Of The Canadian C-Spine Rule And NEXUS To Screen For Clinically Important Cervical Spine Injury In Patients Following Blunt Trauma: A Systematic Review. CMAJ: Canadian Medical Association Journal 184.16 (2012): E867-E876.
8. Hauswald M and Braude D. Spinal immobilization in trauma patients: is it really necessary? Curr Opin Crit Care 2002; 8: 566–570.
9. Moss, R, K Porter, and I Greaves. Minimal Patient Handling: A Faculty Of Pre-Hospital Care Consensus Statement*. Trauma 17.1 (2015): 70-72
10. Conrad, Bryan P., et al. Eliminating Log Rolling As A Spine Trauma Order. Surgical Neurology International 3.4 (2012): S188-S197.
11. Conrad BP, Horodyski M, Wright J, Ruetz P, Rechtine GR. Log-rolling technique producing unacceptable motion during body position changes in patients with traumatic spinal cord injury. J Neurosurg Spine 2007;6:540-3.
12. Del Rossi, Gianluca, et al. The 6-Plus--Person Lift Transfer Technique Compared With Other Methods Of Spine Boarding. Journal Of Athletic Training (National Athletic Trainers’ Association) 43.1 (2008): 6-13.
13. Luscombe, M. D., and J. L. Williams. Comparison of a long spinal board and vacuum mattress for spinal immobilisation. Emergency medicine journal 20.5 (2003): 476-478.