SPINAL IMMOBILIZATION

1. SPINAL IMMOBILIZATION Luis Enriquez RN, BS Los Angeles County USC Medical Center Level I Trauma Center

2. INDICATION FOR SPINAL IMMOBILIZATION • Spinal immobilization is an important skill for emergency personnel. • Spinal immobilization of trauma patients suspected of having spinal injury has been a cornerstone of emergency care • Current practices are based on: • The risk that a patient with an injured spinal column can develop or aggravate a spinal cord injury and deteriorate neurologically • Proper spinal immobilization reduces the risk by limiting movement at the site of injury. • The injury of concern is the unstable cervical fracture with the potential for further neurological deficits • Cervical spine injuries are rare (2 – 3% of blunt trauma patients X-rayed) • Consequences of spinal cord injury are devastating so a conservative approach has been advocated. • Current practice has become controversial and evidence base research data is limited. • Careful application of immobilization equipment is advice

3. SPINAL IMMOBILIZATION INDICATIONS • Significant mechanism of injury associated with high risk for spinal injury • Neck pain, tenderness, swelling, deformity of the spine • Any of the following after injury: • Altered Mental Status • Neurological deficit • Loss of consciousness • Intoxication • Distracting injury • Priapism • Communication barrier

4. MECHANISM OF INJURY • Automobile accidents: (40%) • High speed • Ejection. rollover • Falls: (28%) • Greater than 20 feet • Slip and fall: rare except in elderly • Diving into shallow pool • Interpersonal violence (15%) • Blunt • Penetrating • Sports (8%)

5. PRIMARY ASSESSMENT Spinal immobilization maintain during primary assessment • Airway assessment • Maintain spinal immobilization at all time • Airway management complicated by spinal immobilization • Can the patient cough and clear secretions • Breathing assessment • Patients with SCI can decompensate over time • Pay close attention to work of breathing • Determine if patient can take deep breath • Any difficulty breathing? • Circulatory Assessment • Neurogenic shock: potential for hypotension and bradycardia • Pregnant patients: Aortacava compression syndrome • Neurologic Assessment • Motor Function • Sensory Function

6. NEUROLOGIC ASSESSMENT • Assess motor function of all extremities • Determine lowest level of sensation to touch • Touch/Light touch • Gentle pinprick • Assess proprioception • Moving big toe and asking if up or down • What toe am I moving • Assess for • Location of pain • Loss of bladder and bowel control • Priapism • complaints of • “electric shocks” • Burning pain • Exaggerated reflex activity or spasms

7. SPINAL IMMOBILIZATION EQUIPMENT • Rigid cervical collars • Available in different sizes • Multiple manufactures • Adjustable • Long backboards, and straps • Designed as an extrication device • Multiple complications • Tape and foam blocks • Supports the head • Never use sandbags • May use towels if not available • Padding • Support and protection

8. SPINAL IMMOBILIZATION EQUIPMENT • Cervical collar • Do not achieve immobilization, limit movement only • Remind the patient and medical personnel not to move the head and neck • Head and torso must also be immobilize to prevent flexion, extension, rotation and lateral movement • Long spine backboard • Acts as a splint for the entire vertebral column • Modifications may need to be made with special populations

9. MODIFICATIONS • Child in a car-seat • Suspect a SCI • Leave immobilize In the car seat

10. MODIFICATION • Children under 8 years of age have proportionally bigger heads than adults. • Causes neck flexion when unmodified spinal immobilization is applied • Apply towels/sheet under the shoulders • To align spinal cord neutral position .

11. MODIFICATIONS 3RD Trimester pregnancy • Fetus can compress aorta • Cause hypotension • Tilt board (45 degrees) on left side

12. MODIFICATIONS

13. VOMITING & ASPIRATION • Always a risk with spinal immobilization • Have suction available • Never tape chin

14. POTENTIALLY HARMFUL EFFECTS OF IMMOBILIZATION • Airway compromise • Increased intracranial pressure • Cutaneous pressure ulcers • Iatrogenic pain • Headache • Back pain • Mandibular pain • Pressure ulcers • Increase difficulty handling patient • Aspiration risk • Combativeness in intoxicated patient • Cost

15. SPINAL IMMOBILIZATION PROCESS • Immobilization and primary assessment simultaneously • Manual stabilization upon arrival if spinal injury suspected • Maintain spinal precautions during airway, breathing, circulation assessment and management of ABC problems • Apply cervical collar before moving patient • C-Collar applied with neck in neutral position. • Manual stabilization of c-spine and log roll of patient may be required to achieve a neutral position before the patient can be safely immobilized • Before applying collar • Assess for tracheal alignment, jugular vein distension • Assess back of neck for injuries. • Collar must fit so as not to compromise circulation or airway, yet be rigid to support neutral cervical alignment • Use two rescuers in application of any device • Apply gentle continuous cervical stabilization in neutral axis of spine. • Do not use force to align neck or apply collar • If resistance is met, stop and secure patient in that position • If proper fitting collar is not available towel or blanket rolls may be used to support neutral head alignment

16. APPLYING LONG SPINAL BOARD • Requires a team approach • Assess motor and sensory status prior to immobilization • Leader maintains in-line stabilization • No traction • Use both hands to stabilize head and neck in neutral vertical position • Nose aligned with umbilicus • Remove earrings, necklaces • Apply collar per manufactures recommendations • Assess motor and sensory status after immobilization • Log roll patient onto or off a backboard and secure • Secure head using head blocks and tape • Recheck motor and sensory status

17. LOG ROLLING PATIENT • Requires: leader and 3 assistants • Leader at head of the bed • Initiates roll with count of 3 • Maintains spine straight • Nose aligned with umbilicus • Two assistants roll patient • Towards them (side rails?) • Crossing arms • Consider other injuries • 3rd assistant • Removes back board • Inspect posterior/palpates spine • Removes clothing/changes line • Patient rolled back on leaders count

18. SCENARIO • Hospital employee tripped and fell down a flight of stairs • Found at base of stairs in recovery position moaning • Able to answer questions complains of neck and shoulder pain

19. OBJECTIVES • Maintain cervical precautions though entire process • Perform Primary assessment • Perform neurological assessment • Log roll patient to supine position • Apply cervical collar • Log roll patient onto a backboard • Move patient on a gurney • Logroll patient off the back board and inspect posterior surfaces