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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.[2]

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.[3] 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
The combination of the above factors has lead many EMS systems to implement spinal motion restriction (SMR) protocols that allow providers greater flexibility in the management of trauma patients, up to and including “clearing” the need for any SMR at all. In the hospital setting, the National Emergency X-radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR) are both effectively used to evaluate patients with possible spinal injury.[7] Many EMS protocols are based on these two systems.

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
There is evidence to suggest that the body of a trauma patient with a spinal fracture will self-splint immediately following the traumatic event; the muscles around the fracture will spasm, and motion of the spinal column will be significantly reduced.[8] The concept of limited handling involves allowing alert, cooperative patients to move and position themselves with as little assistance as possible.[9]

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.[9]

Scoop stretchers, lifts, and the loss of the log roll 
When done correctly, a minimum of four rescuers is required to complete a log roll maneuver. In theory, one rescuer maintains manual stabilization of the cervical spine and coordinates a smooth turning of the patient onto their side so a backboard may be placed and the back of the patient examined. The patient is then rolled onto the board, and moved into proper position with a linear or axial sliding motion. A study analyzing movement of the spine during various patient handling techniques showed that the log roll maneuver causes significant lateral and axial movement.[10] There is considerable evidence that the log roll maneuver produces an unacceptable amount of movement when handling a patient with a potential spinal injury.[11]

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.[1]

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.[12]

Vacuum splints
The use of half- and full body vacuum splints in place of a rigid long board is desirable for patients who require full immobilization, or those with extended transport times.9 Vacuum splints are more comfortable than rigid backboards or scoop stretchers, and have a low incidence of pressure injuries. A full body vacuum splint also provides more effective immobilization than a backboard.[13] Smaller, half body splints can be used as part of a modified SMR approach, helping support the head and neck while still allowing the patient to chose a position of comfort.

Thinking outside the board
For patients who meet the criteria for modified SMR, creative thinking can be used to maximize patient comfort while adequately supporting the head and neck. Within the boundaries of local protocol, providers can use a variety of means to restrict patient movements.

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.[1] 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.  

References

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.

About the Author

Shawna Renga, AS, NREMT-P, currently works as an instructor for the United States Coast Guard Medical Support Services School in Petaluma, Calif., providing EMT training for helicopter rescue swimmers and Coast Guard corpsmen. She also works part-time for a private ambulance company, and lives with her husband and two sons in Sausalito.
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