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Penetrating Injury
Gunshot wounds that have traversed the spinal column
may produce unstable injuries and caution should be
exercised. Gunshot wounds to the cranium alone are not
associated with a risk of cervical spine trauma. It
is not necessary to immobilise stab injuries. Spinal
immobilisation devices may interfere with the recognition
and management of life-threatening conditions.
Techniques of immobilisation and
patient handling
The spine should be protected at all times during the
management of the multiply injured patient. The ideal
position is with the whole spine immobilised in a neutral
position on a firm surface. This may be achieved manually
or with a combination of semi-rigid cervical collar,
side head supports and strapping. Strapping should be
applied to the shoulders and pelvis as well as the head
to prevent the neck becoming the centre of rotation
of the body.
Prehospital
Manual spinal protection should be instituted immediately.
The application of definitive immobilisation devices
should not take precedence over life-saving procedures.
If the neck is not in the neutral position, an attempt
should be made to achieve alignment. If the patient
is awake and co-operative, they should actively move
their neck into line. If unconscious or unable to co-operate
this is done passively. If there is any pain, neurological
deterioration or resistance to movement the procedure
should be abandoned and the neck splinted in the current
position.
Long spine (rescue) boards are valuable primarily for
extrication from vehicles. Repeated transfers to and
from the board may compromise spinal protection and
induce a significant amount of spinal movement. Patients
may also be transferred on a scoop stretcher and/or
vacuum mattress. There is little place for the short
spine board or spinal extrication devices in the prehospital
environment.
In-hospital
The spine board should be removed as soon as possible
once the patient is on a firm trolley. Prolonged use
of spine boards can rapidly lead to pressure injuries.
Full immobilisation should be maintained. Manual protection
should be reinstated if restraints have to be removed
for examination or procedures (eg. intubation).
The log-roll is the standard manoeuvre to allow examination
of the back and transfer on and off back boards. Four
people are required, one holding the head and coordinating
the roll, and three to roll the chest, pelvis and limbs.
The number and degree of rolls should be kept to an
absolute minimum. Rigid transfer slides (eg. Patslide)
are useful for transferring the patient from one surface
to another (eg CT scanner, operating table).
Patients who are agitated or restless due to shock,
hypoxia, head injury or intoxication may be impossible
to immobilise adequately. Forced restraints or manual
fixation of the head may risk further injury to the
spine. It may be necessary to remove immobilisation
devices and allow the patient to move unhindered.
Anaesthesia may be necessary to allow adequate diagnosis
and therapy. Intubation of the trauma victim is best
achieved via rapid sequence induction of anaesthesia
and orotracheal intubation, though the technique used
should ultimately depend on the skills of the operator.
The collar should be removed and manual, in-line protection
re-instituted for the manoeuvre. The routine use of
a gum elastic bougie is recommended, minimising cervical
movement by allowing intubation with minimal visualisation
of the larynx.
Spinal immobilisation
is a priority in multiple trauma, spinal clearance is
not.
Transfer to Secondary Units
Patients may require transfer to other
units for definitive care of other injuries such as
head or pelvic trauma. There should be no unnecessary
delays in the transport of these patients. Transfer
should not wait for unnecessary diagnostic procedures
that will not alter management. This includes radiological
imaging of the spine.
The spine should be immobilised and
protected for the transfer. Split-scoop stretchers and
vacuum mattresses are more appropriate for transfer
than rigid spinal (rescue) boards, which should be reserved
for primary extrication from vehicles, rather than as
devices for transporting patients.
References
Bauer D, Kowalski R. Effect of spinal immobilization
devices on pulmonary function in the healthy, nonsmoking
man. Ann Emerg Med. 1988 Sep;17(9):915-8
Chendrasekhar A, Moorman DW, Timberlake GA. An evaluation
of the effects of semirigid cervical collars in patients
with severe closed head injury. Am Surg. 1998 Jul;64(7):604-6
Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ,
et al. Pain and tissue-interface pressures during
spine-board immobilization. Ann Emerg Med 26(1):
31-36, 1995
Cross DA, Baskerville J. Comparison of perceived
pain with different immobilization techniques. Prehosp
Emerg Care. 2001 Jul-Sep;5(3):270-4
Hamilton RS and Pons PT. The efficacy and comfort
of full-body vacuum splints for cervical-spine immobilization.
J Emerg Med 14(5): 553-559.
Hauswald M, McNally T. Confusing extrication with
immobilization: the inappropriate use of hard spine
boards for interhospital transfers. Air Med J. 2000
Oct-Dec;19(4):126-7
Hunt K, Hallworth S, Smith M. The effects of rigid
collar placement on intracranial and cerebral perfusion
pressures. Anaesthesia. 2001 Jun;56(6):511-3
Kolb JC, Summers RL, Galli RL. Cervical collar-induced
changes in intracranial pressure. Am J Emerg Med.
1999 Mar;17(2):135-7
Kwan I, Bunn F, Roberts I. Spinal immobilisation
for trauma patients. Cochrane Database Syst Rev.
2001;(2):CD002803
Watts D, Abrahams E, MacMillan C, et al Insult after
injury: pressure ulcers in trauma patients. Orthop
Nurs. 1998 Jul-Aug;17(4):84-91
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