Treat a Casualty with a Spine Injury

 

INTRODUCTION

 The nervous system is well protected by the bony structures of the skeletal system.  The brain lies within the skull.  The spinal cord lies inside the spinal column with the major nerves lying deep within the body.  Despite being well protected, the nervous system can be injured from trauma induced impact.  These injuries are extremely serious and can lead to paralysis and death.

 

Anatomy of the spine and the central nervous system

Spinal column

(1)        Structure

(a)        Made of series of irregularly shaped bones

(b)        Each vertebrae (except the C1 and C2) have a drum-shaped body located toward the front serving as the weight-bearing part

(c)        Disks of cartilage between the vertebral bodies act as shock absorbers and provide flexibility

(d)        At the center of each vertebrae is a large hole (foramen) for the spinal cord

(e)        Bones in the column are named and numbered from top to bottom based on location

(i)         Cervical

*           7

*           First cervical bone called the atlas supports the head

*           Second cervical bone called the axis serves as a pivot for turning the head from side to side

(ii)        Thoracic

*           12

*           Ribs attach

(iii)       Lumbar

*           5

*           Located at small of back

*           Heavier and larger to support more weight

(iv)       Sacral

*           5 separate bones as child

*           Fuse to form one bone as an adult

(v)        Coccyx (4 fused bones) - tailbone

(2)        Function

(a)        Provide structure and support for body

(b)               Houses and protects the spinal cord

 

Divisions of the nervous system

(1)        Central nervous system (CNS)

(a)        Brain

(i)         Controls all functions of the body, voluntary and involuntary

(ii)        Occupies cranial cavity, covered by membranes, fluid and bones of the skull

(b)        Spinal Cord

(i)         Structure

*           Enclosed in vertebral column

*           Internal portion made of gray matter with white matter surrounding it

(ii)        Function

*           Reflex activities - transfer and integration of messages that enter the cord

*           Conducts sensory impulses from afferent nerves upward through ascending tracts to the brain

*           Conduct motor impulses from the brain down through descending tracts to the mucles

(2)        Peripheral nervous system - all nerves outside CNS

(a)        Cranial nerves - carry impulses to and from the brain

(b)        Spinal nerves - carry messages to and from the spinal cord

 

Identify immobilization devices

Manual

(1)        Description

(a)        Stabilization of the C-spine by hand

(b)        Applied in conjunction with securing the airway, prior to application of the cervical collar

(2)        Indications

(a)        Initially applied on all suspected spinal injury patients and unconscious patients. Provides temporary stabilization until the cervical collar is applied and the head is secured to the long spine board

(b)        AT NO TIME should the head/neck be twisted or excessively moved.  This may create a spinal injury.

 

Cervical collar

(1)        Description

(a)        A firm collar to assist in cervical stabilization

(b)        Cervical collars alone do not provide adequate in-line immobilization.  Manual stabilization must not be released before the patient is fully secured to a long spine board.

(c)        Cervical collars DO NOT immobilize the cervical spine.  Cervical collars keep the head in a neutral position.

(2)        Indications - same as manual stabilization

(a)        Initially applied on all suspected spinal injury patients and unconscious patients. Provides temporary stabilization until the cervical collar is applied and the head is secured to the long spine board

(b)        AT NO TIME should the head/neck be twisted or excessively moved.  This may create a spinal injury.

 

Too large of a cervical collar will hyperextend the head/neck, and too small of a cervical collar will hyperflex the head/neck and cause further injury.

 

Kendrick extrication device (KED)

(1)        The KED is a common device

(2)        Description

(a)        A short spinal stabilization device used to extricate patients from vehicles or confined spaces

(b)        Used to stabilize the head, the neck, and the spine until the patient can be secured to a long spine board

(3)        Indications

(a)        Used when the patient is found in a sitting position or in a vehicle

(b)        When a long spine board cannot be inserted into a vehicle or aircraft because of obstructions

 

Manual head stabilization can be released only after the head is secured to the KED.  Ensure that the straps and the cravats do not impede breathing.

 

Long spine board

(1)        Description

(a)        A long board made of wood, metal, or plastic

(b)        The only device which provides complete spinal immobilization when the patient is properly secured

(2)        Indications

(a)        When a patient with suspected spinal injuries is found in a lying or standing position

(b)        A patient extracted using a short board is then moved to the long board for complete spinal immobilization

 

Even with the collar in place, medic one maintains the head and neck in a neutral position until the logrolling maneuver is completed, and the patient's head is secured to the long spine board.  The head, neck, and pelvis are kept in-line during the log roll.

 

Identify and treat injuries to the spine

Initial assessment of a casualty with a spine injury

(1)        Ensure open airway

(2)        Assess breathing

(3)        Assess circulation.  Look for major hemorrhage.     

 

Secondary assessment of a casualty with a spine injury

(1)        Consider mechanism of injury

(a)        Falls

(b)        Blunt Trauma

(c)        Penetrating trauma to the head, neck, or torso

(d)        Vehicle accidents

(2)        Assessment of the responsive casualty

            The patientís ability to walk should never be a factor in determining whether a patient needs to be treated for a spine injury.  20 percent of all spine injuries are seen walking around the accident scene.

(a)        Inquire about the mechanism of injury

(b)        Does your neck or back hurt?  Where?

(d)        Can you move your hands and feet?

(e)        Can you feel me touching your fingers/toes?  Paralysis or loss of sensation of the upper and/or lower extremities - the most reliable signs of a spinal cord injury if the patient is conscious

(f)         Inspect for:

(i)         Contusions

(ii)        Deformities

(iii)       Lacerations

(iv)       Punctures

(v)        Penetrations

(vi)       Swelling

(g)        Palpate for areas of tenderness or deformity

(h)        Assess the equality of the strength of the extremities.

(i)         Handgrip

(ii)        Gently push feet against hands

(i)         Assess level of consciousness (LOC)

(3)        Assessment of the unresponsive casualty

(a)        Determine the mechanism of injury from witnesses

(b)        Inspect for:

(i)         Contusions

(ii)        Deformities

(iii)       Lacerations

(iv)       Punctures

(v)        Penetrations

(vi)       Swelling

(c)        Palpate for areas of tenderness or deformity.

(i)         Tenderness with gentle palpation in area of injury

(ii)        Deformity - obvious deformities are rare (i.e., "stepoffs")

(d)        Check response to painful stimuli by pinching between the thumb and index finger of the patient or pinch the skin on top of each foot.

(e)        Impaired breathing - may indicate damaged spinal nerves, which send information to the respiratory center of the brain

(i)         Diaphragmatic breathing

(ii)        Panting

(f)         Life-threatening C-spine injuries occur with spinal column injuries from C-1 to T-8 due to damage to the spinal nerves and/or brain stem, which interrupt nerve transmission to the respiratory center

(g)        Priapism - persistent erection of the penis often associated with a spinal cord injury

(h)        Incontinence (bowel and/or bladder)

(i)         Soft tissue injury with trauma

 


 

Provide Emergency Care of a casualty with a spine injury

(1)        Establish and maintain manual in-line stabilization of the head and the neck during the initial assessment.  Continue to maintain stabilization until the patient is properly secured to a long backboard.

(2)        Assess airway, breathing, and circulation during the initial assessment.  If necessary, open the airway using the jaw thrust.

(3)        Continually assess pulse and motor and sensory functions in all extremities.

(4)        Apply the proper size rigid cervical collar.

(a)        Cervical collars are referred to as extrication collars.

(b)        Stiff collars

(c)        Rigid collars

(d)        C-collars

(5)        If patient is found in a lying position, immobilize the patient to a long spine board using the log roll method

(a)        One soldier medic must maintain in-line stabilization

(b)        The soldier medic at the head directs the movement of the patient

(c)        One to three other soldier medics control the movement of the rest of the body

(d)        Quickly assess the posterior body if not already done in the initial assessment

(e)        Position the long spine board under the patient

(f)         Roll the patient onto the board at the command of the soldier medic holding the head

(g)        Pad the voids between the patient and the board

(i)         Under the head and torso as needed

(ii)        Pad under the shoulders to the toes on the infant and child to establish a neutral position

(h)        Immobilize the torso to the board by applying straps across the chest and pelvis.

(i)         Immobilize the patient's head to the board

(j)         Fasten the legs proximal to and distal to the knees

(k)        Reassess and record pulse, motor, and sensation

(6)        If patient is found in a sitting position, immobilize the patient to a short spine board.  See handout for procedures - if available

(7)       If patient is found in a standing position, immobilize the patient to a long spine board

(a)        One soldier medic stands behind the patient and maintains in-line stabilization and another soldier medic positions the board behind the patient.  A soldier medic stands on each side of the patient and one additional soldier medic at the foot facing the patient.

(b)        The soldier medics on both sides of the patient reach with the hand closest to the patient under the arm to grasp the board and use the hand to secure the head

(c)        Once the position is assured, the medics on the sides place the leg closest to the board behind the board and begin to tip the top backward.  The soldier medic at the foot of the board secures the board and the patient to prevent them from sliding, and the board is brought into a level horizontal position.

(8)       Assist with ventilation as needed

(9)        Care for other injuries

(10)      Perform a rapid extraction if indicated

(11)      Transport considerations

(a)        Transport immediately

(b)        Monitor for signs/symptoms of neurogenic shock

(c)        Continue neurological assessment and monitor vital signs every 3-5 minutes

(d)        Initiate two large bore IVs 0.9% Normal Saline

 

Identify injuries to the neck

Signs and symptoms

(1)        Loss of voice or hoarseness

(2)        Signs of airway obstruction when the mouth and nose are clear

(3)        Contusions on or depressions in the neck

(4)        Deformity, swelling, contusions, depressions, and open wounds

(5)        Lacerations may produce profuse arterial or venous bleeding.

(6)        Subcutaneous emphysema - is the presence of air in soft tissues causing a very characteristic crackling sensation on palpation

(7)        Special considerations - With any neck injury, the medic should be concerned with a possible C-spine compromise as well as airway obstruction

 

Treatment and transport considerations

(1)        Ensure a patent airway

(2)        Head and neck stabilization

(3)        Control bleeding

(a)        Severed neck artery

(i)         Apply direct pressure, or if possible, pinch the artery with the gloved thumb and forefinger/gauze pad until the bleeding stops

(ii)        Administer a high concentration of oxygen

(iii)       Apply an occlusive dressing

(b)        Severed neck vein

(i)         Apply direct pressure

(ii)        Apply an occlusive dressing

(iii)       Administer a high concentration of oxygen

(4)        Care for shock and administer a high concentration of oxygen for all neck injury patients

(5)        Transport the patient in a lateral recumbent position

(6)        Monitor vital signs every 3-5 minutes.  Assess for respiratory difficulties.

(7)        Any deep, open wound to the neck may have also cut the trachea and may need an occlusive dressing

(8)        Initiate two large bore IVs 0.9% Normal Saline

 


 

Spinal immobilization using backboards

Using a short backboard

(1)        Used for casualties who are in a position that does not allow for use of long backboard.

(2)        Priorities of evaluation and management are initiated before application of immobilization devices

(3)        The first soldier should immobilize neck in a neutral position at the same time that you begin airway evaluation

(4)        When casualty is stable, apply a semirigid extrication collar

(5)        Position backboard behind casualty

(a)        The first soldier continues to immobilize neck while backboard is slipped/eased into place 

(b)        Support the neck and back if casualty has to be moved forward

(6)        Secure casualty to the board: Move strap over a leg, down between both legs, back around the outside of the same leg, across the chest, and attach to the opposite upper straps that were brought across the shoulders

(7)        Tighten the straps until the casualty is securely held

(8)        Transfer casualty to a long backboard

(a)        Turn casualty so that his back is to the opening through which he is to be removed

(b)        Support the legs so that the upper legs remain at a 90-degree angle to the torso

(c)        Position long backboard under casualty and slide casualty and short backboard up into position on long backboard

(d)        Loosen straps on short board and allow legs to extend out flat

(e)        Retighten the straps

(f)         Secure casualty to long backboard and secure head with padded immobilization device

 

Using a long backboard

(1)        Log-rolling the supine casualty

(a)        Soldier 1 maintains spine immobilization in a neutral position.  DO NOT apply traction.

(i)         Apply a semirigid extrication collar

(ii)        Soldier 1 maintains the head and neck in neutral position until log-rolling maneuver is completed

(b)        Casualty is placed with legs extended in normal manner and arms (palms inward) extended by his sides.  Casualty will be rolled up on one arm with that arm providing proper spacing and acting as a splint for the body

(c)        Long backboard is positioned next to the body.  If one arm is injured, place the backboard on injured side so that the casualty will roll up on the uninjured arm

(d)        Soldier 2 and 3 kneel at casualty's side opposite the board

(e)        Soldier 2 is positioned at the midchest area and soldier 3 by upper legs

(f)         With knees, soldier 2 holds casualty's near arm in place

(i)         Soldier 2 reaches across casualty and grasps the shoulder and hips, holding casualty's far arm in place

(ii)        Usually, it is possible to grasp the casualty's clothing to help with roll

(g)        With one hand, soldier 3 reaches across the casualty and grasps the hip.  With the other hand, he holds feet together at lower legs.

(h)        Soldier 1 gives order to roll casualty

(i)         Soldier 1 carefully keeps head and neck in neutral position during the roll

(j)         Soldier 2 and 3 roll victim up on his side toward them 

(i)         Casualty's arms are kept locked to his side to maintain a splinting effect

(ii)        Head, shoulders, and pelvis are kept in line during the role

(k)        When casualty is upon his or her side, soldier 2 quickly examine back for injuries

(l)         Backboard is now positioned next to the casualty

(i)         Soldier 1 gives the order to roll casualty onto the backboard

(ii)        Head, shoulders, and pelvis are kept in line

(2)        Log-rolling the prone casualty

(a)        Casualty who in not breathing or who is in severe respiratory difficulty must be log-rolled immediately to manage the airway.  Unless the backboard is already positioned, you must log-roll the casualty, manage the airway, and then transfer the casualty to the backboard when ready to transport.

(b)        Casualty with profuse bleeding of the nose or mouth must not be turned to the supine position

(i)         Profuse upper airway bleeding in a supine casualty is a guarantee of aspiration

(ii)        Casualty will have to be carefully immobilized and transported prone or on his side, allowing gravity to help keep airway clear

(c)        Casualty with an adequate airway and respiration should be logrolled directly onto a backboard

 

SUMMARY

To provide your casualty with the highest chance of recovery, you must know the anatomy of the spine and central nervous system.  The most important point in management of the spine injured casualty is rapid assessment, treatment of decreased level of consciousness by hyperventilation and adequate airway management, rapid transport to the appropriate echelon of care, and frequent reassessment. You must immobilize the spine to prevent harm and paralysis. Neck movement worsens the injury of the casualty with a spinal injury.