NCM 121 – SPINE INJURIES

LECTURER: Alfonso Miguel Lenard S. Tan, EMT, RN

SPINE INJURIES EMERGENCY MEDICAL CARE OF SPINAL INJURIES

The cervical, thoracic, and lumbar portions of the spine  Remember to follow standard precautions.
can be injured in a variety of ways.  Maintain the patient’s airway while keeping the spine
in the proper position, assess respirations, and give
 Compression injuries can result from a fall, supplemental oxygen.
regardless of whether the patient landed on his or
her feet or experienced a direct blow to the crown of MANAGING THE AIRWAY
the skull, coccyx, or top of the head.  Perform the jaw-thrust maneuver to open the
o Forces that compress the patient’s vertebral airway.
body can cause herniation of disks, o Do not use the head tilt–chin lift maneuver
subsequent compression on the spinal cord because it extends the neck and may further
and nerve roots, and fragmentation into the damage the cervical spine.
spinal canal.  After you open the airway, consider inserting an
 Motor vehicle crashes or other types of oropharyngeal airway.
trauma can overextend (hyperflex) the cervical  Have a suctioning unit available.
spine and damage the ligaments and joints.  Provide supplemental oxygen.
 Rotation-flexion injuries of the spine result from
rapid acceleration forces. IMMOBILIZATION OF THE CERVICAL SPINE
o More likely to happen at C1 and C2  Establishing and maintaining the airway is
o Injuries to this area of the spine are your first priority.
considered unstable due to the location and  Immobilize the head and trunk so that bone
lack of bony and soft-tissue support. fragments do not cause further damage.
 Any one of these unnatural motions, as well as  Even small movements can cause significant injury
excessive lateral bending, can result in fractures or to the spinal cord.
neurologic deficit.  Never force the head into a neutral, in-line position;
 When the spine is pulled along its length do not move the head any farther if the patient
(hyperextension), it can cause fractures in the spine reports any of the following symptoms:
as well as ligament and muscle injuries. o Muscle spasms in the neck
 When bones of the spine are altered from traumatic o Substantial increased pain
forces, they can fracture or move out of place. o Numbness, tingling, or weakness in the
o When injuries pinch, pull, or penetrate the arms or legs
spinal cord, permanent damage may occur. o Compromised airway or ventilations
o Common findings include pain and  In these situations, stabilize the patient in his or her
tenderness on palpation. current position.
o You may feel or observe a deformity of the
spine (“step-off”) where the spinous process CERVICAL COLLARS
may be palpable.  Provide preliminary, partial support.
o If you suspect these types of injuries, take  Should be applied to every patient who has a
extra precautions when stabilizing the spine. possible spinal injury based on the MOI, history, or
signs and symptoms.
 Cervical collars do not fully immobilize the cervical
spine. Therefore, you must maintain manual support
until the patient has been completely secured to a
long or short backboard or vacuum mattress.

COLLEGE OF NURSING | DISASTER NURSING | NCM 121 (PRELIM)

  To be effective, a rigid cervical collar must be the o You or the patient is in danger
correct size for the patient. o You need to gain immediate access to other
 The cervical collar should rest on the shoulder girdle patients
and provide firm support under both sides of the o The patient’s injuries justify urgent removal
mandible, without obstructing the airway or
ventilation. STANDING PATIENTS
 Once the patient’s head and neck have been  Immobilize the patient to a long backboard before
manually stabilized, assess the pulse, motor proceeding with assessment.
functions, and sensation in all extremities. Then  This process requires three (3) EMTs.
assess the cervical spine area and neck. o Begin by establishing manual, in-line
stabilization and applying a cervical collar.
PREPARATION FOR TRANSPORT Instruct the patient to remain still.
SUPINE PATIENTS o Position the board upright directly behind
the patient. The EMTs should be positioned
 Immobilize a supine patient by securing the patient
with one on either side of the patient, and
to a long backboard or vacuum mattress.
the third directly behind the patient,
 Another procedure to move a patient from the
maintaining in-line stabilization.
ground to a backboard is the four-person log roll.
o The two EMTs at the patient’s sides grasp
 You may also slide the patient onto a backboard or
the handholds at shoulder level or slightly
vacuum mattress.
above by reaching under the patient’s arms.
Carefully lower the patient as a unit under
VACUUM MATTRESS
the direction of the EMT at the head.
 An alternative to the long backboard. o The EMT at the head must ensure that the
 Molds to the specific contours of the patient’s body, patient’s head stays against the board and
reducing pressure-point tenderness and therefore must carefully rotate his or her hands as the
providing better comfort patient is being lowered to maintain in-line
 Also provides thermal insulation stabilization.
 Excellent for the elderly or a patient with abnormal
curvature of the spine
SPINAL IMMOBILIZATION DEVICES
 The drawback is its thickness - requires careful
 During assessment, pain in the spine may be missed
patient movement to maintain spinal stabilization
because of shock or because the patient’s attention
 Cannot be used for patients who weigh >350 lbs.
is directed to more painful injuries.
 Can be used on a supine, sitting, or standing patient
 Because any manipulation of the unstable cervical
 Patient can be moved onto the vacuum mattress
spine may cause permanent damage to the spinal
with a scoop stretcher or a log roll.
cord, you must assume the presence of spinal injury
in all patients who have sustained head injuries
SITTING PATIENTS
 Use manual in-line stabilization or a cervical collar
 Some patients with a possible spinal injury will be in and long backboard.
a sitting position, such as after a vehicle crash.  Short backboards
 Use a short backboard or other short spinal o The most common short backboards are the
extrication device to restrict movement of the vest-type device and the rigid short board.
cervical and thoracic spine. o Designed to immobilize and restrict
 Then, secure the short backboard to the long movement of the head, neck, and torso.
backboard. o Used to immobilize noncritical patients
 The exceptions to this rule are situations in which who are found in a sitting position and
you do not have time to first secure the patient to have possible spinal injuries
the short board, including the following situations:

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  Long backboards  You and your partner should not move at the same
o Provide full body spinal immobilization and time.
motion restriction to the head, neck, torso,  You should first consult with medical control about
pelvis, and extremities. your decision to remove a helmet.
o It is used to immobilize patients who are
found in any position, sometimes in Alternate method
conjunction with short backboards.  Steps to the alternate method:
o Remove the chin strap.
HELMET REMOVAL o Remove the face mask (cut or unscrew the
plastic clips).
 As you plan your care of a patient wearing a helmet,
o Pop the jaw pads out of place with a tongue
ask yourself the following questions:
depressor.
o Is the patient’s airway clear?
o Place your fingers inside the helmet during
o Is the patient breathing adequately?
removal of the helmet.
o Can I maintain the airway and assist
o The person at the side of the patient
ventilations if the helmet remains in place?
controls the head by holding the jaw with
o Can the face guard be easily removed to
one hand and the occiput with the other.
allow access to the airway without removing
o Insert padding behind the occiput to prevent
the helmet?
neck extension.
o How well does the helmet fit?
o The person at the side of the patient’s chest
o Can the patient move within the helmet?
is responsible for making sure that the head
o Can the spine be immobilized in a neutral
and neck do not move during removal of the
position with the helmet on?
helmet.
 A helmet that fits well prevents the patient’s head
o Remember that small children may require
from moving and should be left on, provided:
additional padding to maintain the in-line
o There is no impending airway or breathing
neutral position.
problems.
 Advantage: it allows the helmet to be removed with
o It does not interfere with assessment and
the application of less force, thereby reducing the
treatment of airway or ventilation problems.
likelihood of motion occurring in the neck
o You can properly immobilize the spine.
 Disadvantage: it is slightly more time consuming
o There is any chance that removing it will
further injure the patient.
 Remove a helmet if: PATIENT ASSESSMENT
o It is a full-face helmet. Always suspect a possible head or spinal injury any time
o It makes assessing or managing airway you encounter one of the following MOIs:
problems difficult, and removal of a face  Motor vehicle collisions (including motorcycles,
guard to improve airway access is not snowmobiles, and all-terrain vehicles)
possible.  Pedestrian–motor vehicle collisions
o It prevents you from properly immobilizing  Falls (>20 feet [adult]; >10 feet [pediatric])
the spine.  Blunt trauma
o It allows excessive head movement.  Penetrating trauma to the head, neck, back, or torso
o The patient is in cardiac arrest.  Rapid deceleration injuries
 Hangings
Preferred method  Axial loading injuries: injuries where load is applied
 Removing a helmet should always be at least a two- along the vertical or longitudinal axis of the spine
person job. (falling from a height and landing on the feet in an
 Technique for helmet removal depends on the actual upright position)
type of helmet worn by the patient.  Diving accidents

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 SCENE SIZE-UP Spinal Immobilization Considerations
Scene Safety  When assessing a patient, be aware that any
 Evaluate every scene for hazards to your health and unnecessary movement of the patient can cause
the health of your team or bystanders. additional injury.
 Be prepared with appropriate standard precautions o Assess the patient in the position found.
before you approach the patient ina motor vehicle o Determine whether or not a cervical collar
crash. needs to be applied.
 Gloves, a mask, and eye protection should be the  Begin by assessing the scene to determine the risk
minimum standard precautions that you use. of injury.

 Call for ALS as soon as possible when a serious MOI  Then, form a general impression of your patient
or complicated presentation is evident. based on his or her level of consciousness and the

 Law enforcement may be needed to control traffic or chief complaint.

crowds.  If the patient is absolutely clear in his or her thinking

and does not have any neurologic deficits, spinal
Mechanism of Injury/Nature of Illness pain or tenderness, evidence of intoxication, or other
 Look for indicators of the MOI. illnesses or injuries that may mask a spinal injury,
 Consider how the MOI produced the injuries you may consider not placing the patient in spinal
expected. restriction.

 Continue to consider the MOI while assessing a o Many jurisdictions allow EMTs to screen

patient. patients and to refrain from providing spinal

restriction on the basis of specific criteria.
 The backboard is rigid and often places the patient
PRIMARY ASSESSMENT
in an anatomically incorrect position for a long
Focus on identifying and managing life-threatening
period of time.
concerns.
o Circulation to areas of skin may become
 Threats to circulation, airway, or breathing are
compromised, leading to complaints of pain,
considered life threatening and must be treated
ischemia to the skin, and, if left long
immediately.
enough, necrosis.
 Life-threatening external hemorrhage must be
o Some patients, especially bariatric patients,
addressed before airway and breathing concerns.
could experience respiratory compromise
 Most head injuries are considered mild and result in
while lying flat.
no or limited permanent disability.
o Consider placing padding under the patient
o A number of patients with head or spine
to help minimize the risk of injury, and try to
injuries will not require much intervention
minimize the amount of time a patient is on
other than a thorough assessment and
a long backboard.
continued observation during transport.
 Apply a cervical collar as soon as you have assessed
o In patients who have problems with ABCs or
the airway and breathing and provided necessary
have other conditions for which you decide a
treatments.
rapid transport to the closest appropriate
o Helps maintain spinal immobilization as you
hospital is needed, rapid immobilization of
treat the airway and breathing.
the spine and quick loading into the
o The best time to apply the cervical collar
ambulance may be indicated.
depends on the patient’s injuries and the
o Reduction of on-scene time and recognition
seriousness of his or her condition.
of a critical patient increases the patient’s
o Once the cervical collar is on, do not remove
chances for survival or a reduction in the
it unless it causes a problem with
amount of irreversible damage.
maintaining the airway.

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 Assessing for s/sx of a head or spine injury  Prehospital administration of high-flow oxygen is
 Begin by asking the responsive patient the following indicated for patients with head and spinal injuries.
questions:  Pulse oximeter values should not fall below 90% and
o What happened? ideally should be 95% or higher.
o Where does it hurt?  Hyperventilation (ventilating too fast or with too
o Does your neck or back hurt? much force)
o Can you move your hands and feet? o Should be reserved for specific conditions
o Did you hit your head? and performed under specific guidelines
 Confused or slurred speech, repetitive questioning, o Can increase the severity of head injuries
or amnesia in responsive patients are good o Should be avoided except in cases where
indications of a head injury. signs of herniation have been identified
 In the setting of trauma, assume your patient has a  Always assess airway and breathing prior to moving
head injury until your assessment proves otherwise. on to assessment of circulation.
o Decreased blood glucose level can mimic  A pulse that is too slow in the setting of a head
these symptoms. injury can indicate a serious condition in your
 If the patient is found unresponsive, emergency patient.
responders, family members, or bystanders may  If the pulse is present and adequate, you can
have helpful information. continue to evaluate your patient further.
 Unresponsive trauma patients should be assumed to  A single episode of hypoperfusion in a patient with a
have a spinal injury. head injury can lead to significant brain damage and
 Patients with a decreased level of responsiveness even death.
(AVPU scale) should be considered to have a spinal  Assess for signs and symptoms of shock and treat
injury based on their chief complaint. appropriately.
 Control bleeding.
Airway, Breathing, and Circulation Considerations o When bandaging the head:
 When a spinal injury is suspected, how you open  Be careful not to move the neck if
and assess the airway is important. spinal injuries are suspected.
o Begin by manually holding the patient’s  Do not apply pressure if a skull
head still while you assess the airway. fracture is suspected.
o Use a jaw-thrust maneuver to open the
airway. Manner of Transport
o If the jaw-thrust maneuver is ineffective, it  Several transport considerations should be kept in
is acceptable to use the head tilt–chin lift mind for patients with head trauma:
maneuver as a last resort. o Patients with impaired airways, open head
o An oropharyngeal or nasopharyngeal airway wounds, or abnormal vital signs, or patients
may assist in maintaining the airway. who do not respond to painful stimuli, may
 Vomiting may occur in the patient with a head need to be rapidly extracted from a motor
injury. vehicle and transported.
o The patient may need to be log rolled to the o Providing the patient with a patent airway
side and the mouth swept of secretions. and high-flow oxygen is paramount.
o Suctioning should be performed immediately o There is a probability of vomiting and
to remove smaller amounts of secretions. seizures, so suction should be readily
 Irregular breathing, such as Cheyne-Stokes available.
respirations, may result from increased pressure on o A head trauma patient may deteriorate
the brain because of bleeding or swelling in the rapidly and require aeromedical transport.
cranium.

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 o In supine patients, the head should be o Significant head injuries may cause the
elevated 30 degrees, if possible, to help pulse to slow and the blood pressure to rise.
reduce ICP. o With neurogenic shock, the blood pressure
o Remember to maintain immobilization of the may drop and the heart rate may increase
spine. to compensate.
 The use of lights and sirens may increase the o Respirations will become erratic with
patient’s level of distress. complications from both head and spine
 Patients who are conscious and aware of the injuries.
inability to move their limbs need to be offered o Hypotension may be present with cervical or
emotional support. high thoracic spine injuries. The heart rate
may become slow or fail to increase in
HISTORY TAKING response to hypotension.

Investigate the chief complaint.  In addition to hands-on assessment, you should use
 Obtain a medical history and be alert for injury- monitoring devices to quantify your patient’s
specific signs and symptoms as well as any pertinent oxygenation and circulatory status.
negatives. o Pulse oximetry and ETCO2 monitoring

 Using OPQRST may provide some background on should be utilized, if available.

isolated extremity injuries. o Maintain ETCO2 between 35 and 40 mmHg

 Any information you receive will be very valuable if o You may also use noninvasive methods to

the patient loses consciousness. monitor the blood pressure.

 If the patient is not responsive, attempt to obtain

the history from other sources, such as friends, Physical Examination Considerations

family members, medical identification jewelry, and  Examine the entire body using DCAP-BTLS and
cards in wallets. examine the head, chest, abdomen, extremities, and
back.
 Gather as much SAMPLE history as you can while
preparing for transport.  Check perfusion, motor function, and sensation in all
extremities prior to moving the patient.
 A decreased or altered level of consciousness is the
SECONDARY ASSESSMENT
most reliable sign of a head injury.
 Remember that the ability to walk, move the
 Determine whether there is decreased movement
extremities, or feel sensation, as well as the absence
and/or numbness and tingling in theextremities.
of pain, does not necessarily rule out a spinal cord
 Look for blood or CSF leaking from the ears, nose,
injury.
or mouth and for bruising around the eyes and
 Instruct the patient to keep still and not to move the
behind the ears.
head or neck.
 Assess pupil size and reaction to light and continue
to monitor the pupils; any change in their reactions
Physical Examinations
over time may indicate progressive brain injury.
 May be a systematic head-to-toe, full-body scan or a
 Do not probe open scalp lacerations with your
systematic assessment that focuses on a certain
gloved finger because this may push bone fragments
area or region of the body.
into the brain.
 Patients with moderate or severe head injuries
 Do not remove an impaled object from an open
should receive lifesaving medical or surgical
head injury.
intervention at the closest appropriate trauma
hospital.
Neurologic Examination
 If time allows, perform a secondary assessment
 Perform a baseline assessment using the Glasgow
while en route.
Coma Scale (GCS).
 Obtaining a complete set of baseline vital signs is
essential.

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  Always use simple, easily understood terms when REASSESSMENT
reporting the level of consciousness.  Repeat the primary assessment.
 If your jurisdiction uses the Revised Trauma Score  Reassess vital signs and the chief complaint.
(RTS), then the findings from the GCS will be used  Recheck patient interventions.
in determining the RTS value. o These injuries can suddenly affect the
 Record levels of consciousness that fluctuates or respiratory, circulatory, and nervous
deteriorate. systems.
 As you proceed with your assessment, ask: o The patient’s condition should be reassessed
o Is the patient’s speech clear and at least every 5 minutes.
appropriate?
o Does the patient answer in a logical manner, Interventions
and is the patient able to make decisions?  Multiple interventions may be necessary in patients
o Is the patient aware of his or her current with head and spinal injuries; if something is not
location? working, try something else.
o Is the patient alert to person, place, time, o Compare baseline vital signs with repeated
and why you are at the scene? vital signs; changes will often tell you if
o Can the patient recall the events leading up treatments have been effective.
to the incident, or is there a period of o Watch carefully for changes in the pulse,
memory lapse? blood pressure, and respirations.
o Can the patient recall major current events? o Document changes in the level of
o Any person with a head injury that has consciousness.
resulted in a change of consciousness,  Rapid deterioration of neurologic signs following a
progressive development of signs and head injury is a sign of an expanding intracranial
symptoms of a concussion, or other causes hematoma or rapidly progressing brain swelling.
of concern should be evaluated by a o You will notice deterioration in a conscious
qualified healthcare provider. patient’s awareness of time, place, and
person (self), in that order.
Spine Examination o You must act quickly to evaluate and treat
 If there is a potential spine injury, examine the these patients.
spine.  If CSF is present, cover the wound with sterile gauze
 Inspect for DCAP-BTLS and check the extremities for to prevent further contamination, but do not
circulation, motor, or sensory problems. bandage it tightly.
 If there is impairment, note the level.  Your protocol should include the administration of
 Pain or tenderness when you palpate the spinal area high-flow oxygen and the application of a cervical
is a warning sign that a spinal injury may exist. collar, if indicated, as part of spinal immobilization.
 Other signs and symptoms include an obvious  Reassessment should take place as the patient is
deformity, numbness, weakness, or tingling in the transported to an appropriate trauma facility.
extremities, and soft-tissue injuries in the spinal
region. Communication and Documentation
 Injuries to the cervical area can limit the ability of  It is essential to maintain good communication with
the diaphragm to function fully and minimize the other providers and give complete and detailed
ability of the chest wall to fully expand. information to the destination facility.
 Additional signs include abdominal excursion, an  Hospitals may better prepare for seriously injured
inability to maintain body temperature, priapism, patients with more advanced warning and a
and a loss of bowel or bladder control. description of the most serious problems found
during your assessment.

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  Your documentation should include:
o The history you were able to obtain at the
scene
o Your findings during your assessment
o Treatments you provided
o How the patient responded to them. More
seriously injured patients should have
documented vital signs every 5 minutes.
 More stable patients should have documented vital
signs every 15 minutes.
 You may be requested to testify as a witness.

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