Immobilising the spine

 

 

Generally accepted that immobilising spine during treatment, movement or transfer will stop more damage to existing injuries (eg broken neck or spine) — but limited evidence that immobilisation alters outcomes. If trying to immobilise spine gets in the way of other activities (eg maintaining airway) — delay immobilisation

Immobilise spine 

  • Any time there is suspicion of spinal injury OR if trauma and any of the following —
    • Limb weakness, numbness, tingling (neurological concerns)
    • Reduced coma scale score
    • Mid-line cervical spine tenderness
    • Painful injury that may mask (distract from) spinal injury - if evidence of spinal injury
    • Intoxication (unless person is resistant) - if evidence of spinal injury

No need to immobilise spine  

  • For extraction from vehicle if alert and cooperative, no neurological symptoms and person able to get out by themselves, even if they have minor head wound or neck discomfort— reassess once they are out
  • Stab or gunshot wounds to head or neck, but no signs of spinal injury

Attention

  • Immobilised person cannot look around and cannot sit up or roll over to vomit — requires constant vigilance, never left alone, suction always ready, ensure they can see your face when communicating
  • Consider Lateral trauma position as a safer alternative to supine especially if on your own or during transport 
  • Back boards and scoop stretchers are for extrication only – remove as soon as possible to prevent pressure injury, especially in patients with paralysis or intubated patients

Manual in-line immobilisation

Attention

  • Keep head and neck in-line with spine at all times
  • Ask helper to look after person and their head, even after collar on and/or immobilised by straps
    • Give reassurance
    • Monitor breathing and level of consciousness
    • Person may become unstable or vomit
  • Make sure back pockets are empty, nothing caught under person
  • Mind your back when lifting, bend your knees
  • Read manufacturer’s instructions, practise using boards and stretchers
    • Many types of stretchers
    • For scoop stretcher — know how to make leg support longer or shorter, take 2 halves apart, put back together

What you need

  • Helpers
  • Light-weight cushioning or rolled towels to support head
  • Folded blankets, sheets, towels etc for extra padding
  • Cervical collar, measured for right size
  • Scoop stretcher or immobilisation board
  • Triangular bandages. Use ordinary ones if you have nothing else

What you do

  • Apply collar — see below
  • Log-roll onto side, check back, put board/stretcher under person, log-roll onto back on board/stretcher
  • Put light-weight cushioning or rolled towels either side of head
  • Secure person so their body can't move in any direction
  • Do not restrict breathing, cut off blood or nerve supply to hands or feet, flatten IV lines etc
  • Straps secured to board/stretcher, firm but not tight
  • Strap body, with arms across chest, before strapping head
  • Fix chin strap across collar's rigid frame and secure to board/stretcher — Figure 3.51

Figure 3.51   
  • Unstrap forehead before making any changes to torso position
  • Always tie feet together before strapping rest of legs
  • When board/stretcher picked up, check there is no movement of person or loosening of straps
  • Remove rigid back board on transferring to a mattress — ambulance or clinic

Taking off crash helmet

Attention

  • Airway always takes priority. Need to remove helmet to fully assess and maintain airway, assess head and neck
  • Note: Some emergency services have a policy of not taking off helmets before person reaches hospital unless there is no airway

What you need

  • Helper 1
  • Helper 2

What you do

  • Lie person flat on back if you can
  • Tell person what you are doing

Helper 1

  • Keep head still with
    • Knees on either side of head
    • Hands on either side of helmet with fingers hooked lightly underneath — Figure 3.52

Helper 2

  • Cut or undo chin strap
  • Put thumbs on upper jaw with fingers around back of lower head (not covered by helmet), stabilise head — Figure 3.52
  • Be prepared for weight of head, don't let head drop back when helmet comes off

Figure 3.52   

Helper 1

  • If person wearing glasses — let go of helmet and take glasses off
  • Grip helmet under lower edge on either side, very gently expand it outward
  • At same time tilt helmet forward slightly (to pass over back of skull) and use backward and forward movement to ‘walk’ helmet over nose and off head — Figure 3.53

Figure 3.53   
  • Be very gentle, it may take some minutes to remove helmet
  • Helper 1 takes over from Helper 2 — Figure 3.54, manually immobilises neck in in-line position — Figure 3.55

Figure 3.54   

Figure 3.55   

Measuring and putting on cervical collar

Emergency procedure to prevent further damage to cervical spine (neck) after trauma

Collars are packaged flat, need to be made up into circular band. Can look confusing when you are stressed. Measure and put on cervical collars as part of your routine emergency practice

Use collar type currently recommended in your jurisdiction

Attention

  • Make sure you keep neck immobilised while you measure and fit collar. Someone needs to keep hold of head until whole body fully immobilised
  • Cervical collar must fit properly — not too big or too small. Person must not be able to move head inside collar
  • Putting on cervical collar only the first step. To complete immobilisation — see Manual in-line immobilisation

Semi-rigid collars

What you do
Measure person for collar
  • Tell person what you are doing — even if unconscious 
  • Ask them to stay very still, not try to help
  • Clear the skin of all jewellery and debris, eg glass fragments 
  • With head in neutral position, draw imaginary line from top of shoulders and another from tip of chin. Use your fingers (or measuring tool in pack) to measure space between top of shoulder and chin — Figure 3.56
  • Choose right collar size by measuring same distance from lower edge of rigid plastic to black fastener on side — Figure 3.57 OR follow instructions in pack
  • Make up collar into circular band (follow instructions)

Figure 3.56   

Figure 3.57   
  • Fold in velcro band to prevent it sticking to hair, seat, glass, dirt etc
  • Ask helper to keep holding either side of head

THEN

  • Slide chin piece up chest wall until chin supported properly, with head still in neutral position — Figure 3.58

Figure 3.58   
  • Keeping firm, gentle grip on collar around neck and under chin (to keep head still), slide back of collar band around/under neck and bring velcro band round to fasten
  • OR If person obese or has lots of thick hair — may be easier to slide back of collar band around neck first — Figure 3.59, then position chin piece and fasten velcro band

Figure 3.59   
  • Tighten velcro until chin and neck fully supported — Figure 3.60
  • Check position and fit

Figure 3.60    
Check
  • Collar on straight — nose, chin, collar, umbilicus in straight line
  • Collar holding person’s head in neutral position — neck not hyperextended (tilted backward)
  • Chin resting securely on hard plastic chin support of collar
  • Ears not trapped under collar
  • Collar not pinching skin on shoulders or squeezing neck

If there are any problems — start again

Soft Collars

Soft cervical collar provide some support to the neck in trauma, may assist with comfort and provides both a tactile and visual cue for the person and clinicians that there is concern for cervical spine injury. There are different brands. Be familiar with the brand that your service uses

What you need
  • At least one helper — preferably two helpers
  • Appropriately sized soft collar

What you do
  • Clear the skin of all jewellery and debris, eg glass fragments
  • Ask the person to slowly turn the neck and head to a midline position. If unconscious, while protecting airway patency, gently turn the head to a neutral and midline position — do not force
  • Maintain this position manually with helper’s hands either side of the head — Figure 3.61
  • Measure from the chin to the sternal notch and select the appropriately sized collar — matching that distance with the width of the collar at the chin support/depression — Figure 3.61, Figure 3.62

Figure 3.61   

Figure 3.62   
  • Slide the collar behind the neck from the person’s right until the velcro strap is clearly visible — Figure 3.63
  • Secure the velcro strap — Figure 3.64

Figure 3.63   

Figure 3.64   
  • Assess airway patency
    • Look — for mask fogging and clearing, any sternal/rib recession, colour, oxygen saturation or capnography (if applied)
    • Listen — for stridor, gurgling
    • Feel — for air movement, resistance if using self-inflating resuscitator

Immobilising neck using cervical collar

Attention

  • If person still in vehicle and unable to get themself out or has weakness or sensory disturbance — use extrication device
  • Ideally neck should stay in neutral position. If bent or rotated when found — move gently to neutral position and immobilise
  • If airway not compromised — do not move head if
    • By doing so, their airway becomes blocked
    • It makes their neck spasm
    • It gives them more pain
    • It causes numbness or tingling of arms or legs
    • It causes loss of limb movement
  • If any of above — support head in that position

What you do

If person lying on back (supine) and head can be put in in-line neutral position

  • Put knees either side of head to stop it moving — Figure 3.65, check response and airway 
  • Put hands either side of head with index fingers in notch between upper teeth and lower jaw — Figure 3.66. Don’t cover ears

Figure 3.65   

Figure 3.66   
  • Gently bring head into line with spine and shoulders (neutral position)
  • Measure and fit cervical collar
  • Support head with cushioning/rolled blankets or towels
  • Make sure cushioning secured/taped
  • Have someone keep their knees or hands either side of head — Figure 3.67

Figure 3.67   

Log-rolling person

If person needs to be turned over (eg to check back or to put on back board) — use ‘log-roll’ technique

Attention

  • Minimum of 3 people needed when log-rolling to keep head, neck and body in straight line and protect spine from further injury. Do not try with less.
  • If its urgent, eg unconscious and vomiting, and only one or two of you, use Lateral trauma position

What you do

If person lying on back (supine) and head can be put in in-line neutral position

  • Put on a cervical collar
  • Helper in charge (Leader)
    • Supports head and neck throughout roll
    • Ensures helpers all roll person at the same time
  • Other helpers
    • Put board/stretcher beside person, if using
    • Put person’s arms by sides, palms turned inward or flexed over their chest
    • Kneel on one side of person, hold legs or part of body — Figure 3.68 (if only 2 helpers see hand positions Figure 3.70)

Figure 3.68   
  • Leader calls to roll person when everyone in position
  • Helpers roll person onto side toward helpers, keeping head, neck, upper back, lower spine in straight line — Figure 3.69
  • Roll back onto board/stretcher if needed

Figure 3.69   

If person lying on stomach (prone)

  • Helper in charge (leader)
    • Supports head and neck in position head is facing — Figure 3.70 throughout the roll
    • Ensures helpers all roll person at the same time
  • Other helpers
    • Put board/stretcher beside person, if using
    • Put person’s arms by sides, palms turned inward
    • Kneel beside person, hold legs or part of body — Figure 3.70

Figure 3.70   
  • Leader calls to roll person when everyone in position
  • Helpers roll person onto side, away from direction head is facing, keeping head, neck, upper back, lower spine in straight line — Figure 3.71

Figure 3.71   
  • Keep rolling until person on back on board/stretcher, if using
  • Put on cervical collar

Lateral trauma position (modified HAINES roll)

Lateral trauma position or modified HAINES (High Arm IN Endangered Spine) position provides airway protection for an unconscious person with suspected spinal injury

Attention

Used when only one or two responders available  — roll and position person on their side without a cervical collar

What you do

  • Start with a supine person
  • Kneel alongside the chest
  • Take the arm that’s furthest from the responder and extend it above the person’s head
  • Bend the near arm across the persons chest with the hand on their opposite shoulder — Figure 3.72
  • Flex both knees and roll the person away so the responder is at the persons back and both lower limbs are flexed — Figure 3.73
  • Support persons head as they roll
  • Adjust position for alignment and stability

Figure 3.72   

Figure 3.73   

Using long boards — from lying position

Person lying on back, cervical collar fitted

Attention

  • Make sure back pockets empty, nothing caught between person and stretcher
  • Make sure scoop stretcher is properly orientated — head at head end
  • Scoop stretcher comes apart down centre of its length. Each half can be put under person lying on back without need to log-roll

What you do

  • Put padding (eg towels, clothing) on board where bottom, heels, elbows will go. Need padding for bumpy ride ahead
  • If not using scoop stretcher — log-roll person onto side, put board underneath, roll onto board
  • Secure body (torso) and arms with straps
  • Secure head
  • Keep head and neck in-line with spine
  • Do not flex backward — Figure 3.74 or forward — Figure 3.75

Figure 3.74   

Figure 3.75   
  • Padding may be needed to keep neck and spine in neutral position
    • Under head for adults and older children — Figure 3.76
    • From under shoulders to buttocks for child under 7 years — Figure 3.77

Figure 3.76   

Figure 3.77   
  • Put light-weight cushioning or rolled towels either side of head
  • Put more padding under elbows and heels
  • Tie feet together
  • Put rolled blankets either side of legs (if room) before strapping, to stop sideways movement
  • Using 4–6 helpers, lift board evenly. Someone stays at head of board to watch for and prevent movement of head and neck during lift
  • If movement — fix strapping
  • Put board evenly onto stretcher trolley

Using extrication device — from sitting in vehicle

Note: If the person is sober/cooperative and able to self-extricate, self-extrication is safer, even if they have neck or back pain — then assess and manage as potential spinal injury

What you need

  • 3 people, more if you have them
    • Helper 1 = head supporter
    • Helper 2 = device fitter
    • Helper 3 = lifter
  • Extra helpers to lift person out of vehicle

What you do

  • Work out best way to remove person after they have been strapped to device (eg side doors, back or front window) — depending on state of crashed vehicle

Helper 1

  • Get behind person (if possible)
  • Put hands either side of head, with thumbs against back of head and fingers over each cheek in notch between upper teeth and lower jaw — Figure 3.78. Don’t cover ears
  • Bring head in-line with spine and shoulders (neutral position)

Figure 3.78   

Helper 2

  • Fit cervical collar, undo seat belt
  • Release and position all straps on extrication device
  • Put device into place down length of person’s back
  • Extra padding may be needed behind head and/or shoulders to support head and spine in neutral position
  • Firmly strap person to device
    • Start with middle strap around torso
    • Then lower torso
    • Then straps under buttocks and between legs. Pull straps firmly, take care not to include gear stick
    • Finish with forehead strap
  • Check person firmly supported
  • Take over supporting head from Helper 1

Helper 1

  • Come around to front of person, hold and support head from this position so Helper 2 can let go
  • Keep holding person's head as they are taken out

Helpers 2 and 3

  • Prepare to remove person as worked out earlier
    • Examples: Take off vehicle door, bend door right back against side of frame, take glass out of back window

THEN

  • Put person straight onto ambulance/vehicle stretcher in device. Try not to move them any more than you have to
  • Unclip straps around groin and hips, try to straighten legs. Check person’s condition again — ABC
  • Leave device in place if not needed for another person. Strap person to long board or stretcher before moving them again
  • Have 2 helpers help guide head of stretcher as loaded into ambulance