8.9. HELP FOR SPINE INJURIES

(Adapted based on evidence using the National Model Guidelines for Prehospital Care Based on Evidence-Based Medicine).

Related titles

Absent.

The purpose of providing EMD

1. Determining patients who need immobilization in case of spinal cord injury.
2. Minimizing secondary spinal injury in patients who have or may have unstable spinal cord injury.
3. Minimization of trauma by using appropriate immobilization means.

Inclusion criteria

Traumatic mechanism of damage.

Exclusion criteria

There are no recommendations.

Management of the patient

Status assessment

1. Assess the scene to determine the mechanism of injury.
The mechanism alone should not determine the need for spinal immobilization – however, certain mechanisms are associated with high risk, including:

a) road accident (including cars, all-terrain vehicles, snowmobiles);
b) spine injuries due to axial load;
c) fall from a height of more than 3 meters.

2. Examine the patient before moving for signs associated with spinal injury. Pay attention to:

a) state of consciousness;
b) neurological disorders;
c) pain or sensitivity in the back;
d) any signs of intoxication ;
g) other serious injuries, especially those related to body injuries.

Treatment and intervention

1. Use a cervical collar if you have one or more of the following signs:

a) the patient complains of neck or back pain;
b) any tenderness or pain in the neck or midline back;
c) any mental state disorders (including excitement);
d) any neurological disorders;
e) signs of alcohol or drug intoxication;
e) presence of other serious (distracting) injuries;
e) torticollis in children;
e) lack of adequate communication, which prevents a correct examination;
g) in the absence of the above signs, a cervical collar may not be applied to the patient.

2. With a penetrating neck injury, the patient does not need immobilization of the neck regardless of the presence or absence of neurological symptoms. As a result of immobilization, an injury or violation of the patency of the respiratory tract may not be noticed in time, so these cases are associated with an increased mortality rate.

3. In case of need for evacuation:

a) from the car: after using a neck collar (if necessary), children in child seats, adults must be able to evacuate on their own. If infants/newborns are secured to the seat by means of special belts, the child should be removed without unfastening;
b) other situations requiring release: a long board may be used for release using the lift and slide technique (rather than the rolling).

4. Removing the helmet:

a) if the helmet needs to be removed, it is recommended to first remove the visor, and then manually remove the helmet with the parallel neck support in a neutral position – the patient should lie on the ground, the neck and shoulders should be controlled by placing hands in order to maintain a neutral position of the cervical spine;
b) evidence is insufficient to provide recommendations for other types of helmet removal.

5. Do not transport patients on long hard boards unless clinically indicated. An example of such a situation would be to facilitate the immobilization of a patient with multiple limb injuries or an unstable condition where moving the patient off the backboard may delay transport and/or further care. In such situations, the boards should have a soft backing to prevent secondary injuries to the patient.

6. The patient should be transported to the nearest appropriate hospital (the guideline “Field Triage of Injured Patients” (Appendix 5) should be used.

7. Patients with severe kyphosis or ankylosing spondylitis may not tolerate cervical collars. Such patients should be transported in a comfortable position using rolled towels or sandbags.

Patient safety

1. Be aware of the potential for airway patency or aspiration in the immoblysed patients with nausea/vomiting or bleeding in the face/oral cavity.
2. Straps that are too tight can restrict chest movement and lead to hypoventilation.
3. Prolonged immobilization on a transport board can lead to ischemic pressure injuries to the skin.
4. Long-term immobilization on a transport board can cause severe discomfort to the patient.
5. Children breathe abdominally, so restraint straps should go through the chest and pelvis, not through the abdomen, if possible.
6. The child has a disproportionately large head in relation to the body. When securing a child on a spinal board, the board should have a recess for the head or the body should be elevated approximately 1-2 cm to accommodate the larger head size and avoid flexion of the neck during immobilization.
7. If verbal contact with the patient is absent or limited, avoid interventions that increase spinal mobility.
8. The best position for all back injury patients is the horizontal supine position. There are 3 situations that require raising the head of the bed at an angle of 30 degrees:

a) respiratory insufficiency;
b) suspicion of severe TBI;
c) to facilitate the convenience (compliance) of the patient.

Useful information for training

1. Evidence is insufficient to support or refute the use of manual stabilization prior to spinal evaluation for potential injury when the patient is wary of spontaneous head/neck movement. Rescuers should not perform manual stabilization in this situation, as the patient’s pain alone will limit the patient’s movements, and forced immobilization in this scenario may unnecessarily increase discomfort and anxiety.
2. Some patients with musculoskeletal instability may be prone to cervical spine injuries. However, the evidence does not support or refute that these patients should be treated differently than those without these conditions. These patients should be treated according to the Spinal Cord Injury Care guideline, just like other patients without these conditions.
3. Age in itself should not be a decisive factor in the provision of care at the pre-hospital stage for spinal cord injury, however, the possibilities of a physical examination should be taken into account, taking into account the age of the patient. A communication barrier with infants/newborns or the elderly with dementia may interfere with the ability to examine the patient in detail.
4. Precautionary measures for the spine should be taken into account both in treatment and in preventive therapy. Patients who are likely to benefit from immobilization should receive such treatment.
5. Patients who are unlikely to benefit from immobilization, who have a low likelihood of spinal cord injury, should not be immobilized.
6. Immobilization of patients on a gurney using a neck collar and fixation straps without a long transport board is allowed.
7. Use a spinal board to transfer patients whose injuries limit mobility and those who meet criteria for spinal precautions. Remove the long shipping board as soon as possible.

Corresponding evaluation results

1. State of consciousness.
2. Standard neurological examination.
3. Signs of intoxication.
4. Signs of a combined injury with other severe injuries.

Key elements of documentation

1. Complaints about pain in the neck or spine.

2. Pain in the back.

3. State of consciousness/number of points according to SHKG.

4. Neurological examination.

5. Signs of intoxication.

6. Signs of polytrauma.

7. Description of the injury mechanism.

8. Document the patient’s measurements:

a) any and all obstacles in providing care to the patient;
b) mental status and neurological assessment;
c) vital signs regarding the level of responsiveness and SHKG;
d) indicators of alcohol and drug use.

9. Age of the patient.

10. If the patient is a minor: name of relatives/guardian, their contact details.

Criteria for the effectiveness of aid provision

1. Percentage of patients with a high probability of injury, given the mechanism of injury and/or with signs or symptoms of cervical spine injury, who were fitted with a cervical spine brace.
2. Percentage of patients with an unknown mechanism of injury and who were put on a corset to fix the cervical vertebrae (a higher percentage creates a negative aspect of care).
3. Percentage of injured patients who were transported on a long transport board (the goal is as low as possible).
4. The percentage is curedpatients with an injury of the cervical spine or an unstable fracture of the cervical spine who were not fitted with a cervical corset.