The document discusses spinal injuries and the traditional approach of fully immobilizing all suspected spinal injuries. It notes that this approach is being reevaluated as it may not be as necessary or beneficial as previously thought, as only a small percentage of immobilized casualties actually have spinal injuries. The document outlines several issues with full immobilization, such as increased risk of pressure sores and reduced respiratory function. It suggests that alternative devices like vacuum mattresses may provide sufficient immobilization without the same risks. The document advocates for a more selective approach to immobilization based on mechanism of injury and patient presentation to better balance risks of immobilization against benefits of potential spinal protection.

1. Stratford Upon Avon First Aid 1
Spinal Injuries

2. Stratford Upon Avon First Aid 2
Introduction to Spinal Injuries
• Spinal Injuries are a considerable concern
in a remote, industrial or hostile
environment given not only the very
serious consequences of such an injury
but also:

3. Stratford Upon Avon First Aid 3
Introduction to Spinal Injuries
• the increased likelihood of spinal injury
due to the prevalence of precipitating
Mechanisms of Injury which (with the
exception of vehicle accidents) are more
commonly seen in these environments
than in more domestic or urban settings.
• the implications and difficulties of
extended care and a protracted
evacuation from these environments.

4. Stratford Upon Avon First Aid 4
Introduction to Spinal Injuries
• The traditional approach of immobilising all
suspected spinal injuries with Cervical
Collar, Spinal Board, Blocks and Straps
has been the Gold Standard for at least 30
years but recently this dogma is being
challenged with increasing momentum as
erring on the side of caution may not, in
fact, be as necessary or beneficial as once
thought:

5. Stratford Upon Avon First Aid 5
Introduction to Spinal Injuries
• While any casualty with a suspected spinal
injury is typically immobilised, only 0.5%-
3% of these casualties are found to have
unstable spinal injury or injury to the spinal
cord.
• Of those fractures causing SCI, half
involve fractures of the cervical spine, with
37% due to thoracic spine injury and 11%
lumbar spine.

6. Stratford Upon Avon First Aid 6
Issues
• Spinal Boards are an extrication device
and not a stretcher.
• Due to the risk of pressure sores, the
casualty should be on one for no more
than 30 minutes (possibly extended with
padding).

7. Stratford Upon Avon First Aid 7
Issues
• Once immobilised a clinician will be
unwilling to ‘clear’ a spinal injury until
satisfied by not only X-Ray but also CT
scanning once in the ED. How long will
your casualty be immobilised for whilst
waiting for help and during transit?

8. Stratford Upon Avon First Aid 8
Issues
• Spinal boards increase the risk of
aspiration on vomit, potentially reduces
airway opening and reduce respiratory
efficacy (by an average of 15% on
average). These issues challenge the pre-
hospital axiom of ‘airway before injury’
“...the possibility that immobilisation may
increase mortality and morbidity cannot be
excluded.”

9. Stratford Upon Avon First Aid 9
Issues
• To position a casualty on a spinal board
requires log-rolling the casualty to 90⁰ on
their side. This practice does not limit
lateral movement of the casualty and can
destabilize clots in the hypotensive
casualty

10. Stratford Upon Avon First Aid 10
Issues
• Cervical Collars are not a panacea and
come with their own issues including
difficulty in application due to aggressive /
combative casualties or bulky clothing,
difficulty in correct sizing leading to
ineffective immobilisation, potentially
forced extension of the spine and
increased intracranial pressure.

11. Stratford Upon Avon First Aid 11
Issues
• Spinal boards do not provide the
immobilisation commonly believed, with
Vacuum Mattresses being significantly
more effective and without the associate
time-bound issues.

12. Stratford Upon Avon First Aid 12
Issues
• Kinematic research shows that the
damage done but reasonable movement
of a casualty during care is negligible to
that of the forces involved in the initial
injury which ‘is generally not sufficient to
cause further damage’. Furthermore, the
alert patient will probably develop a
position of comfort with muscle spasm
protecting a damaged spine.

13. Stratford Upon Avon First Aid 13
Issues
• A 2009 review concluded that the alert,
cooperative patient does not require
immobilisation even if a clinical decision
rule is positive; unless their conscious
level deteriorates as muscle spasm is a
superior method to an artificial procedure.

14. Stratford Upon Avon First Aid 14
Issues
• Despite the low incidence of Spinal or
Spinal Cord Injury and the potential issues
with unnecessary and/or prolonged
Immobilisation, because of the extreme
consequences of a mis-diagnosed or
mismanaged casualty as well as the
potential litigious costs it is
understandable that there is reluctance to
apply a more relaxed approach.

15. Stratford Upon Avon First Aid 15
Issues
• Structured guidance would allow the pre-
hospital practitioner to make an informed
decision which provides best care for the
casualty with a suspected spinal Injury
whilst negating the need to immobilise
those at low risk.

16. Stratford Upon Avon First Aid 16
The Method

17. Stratford Upon Avon First Aid 17
High Risk Mechanism of Injury?
• A fall from greater than 3 feet or 5 stairs
• A vertical load to the spine (e.g. diving)
• A motor collision at more than 60mph
Is the casualty;
• Under 16 years or over 65 years?
• Intoxicated
• Confused, disorientated, or with inappropriate / slurred
speech?
Pain?
• Do they have midline spinal pain anywhere along the
length of their spine?
Distracting Injury / Loss of Feeling
• Do they have any other significant injury?
• Do they have loss of feeling or pins and needles any
where?
NO
NO
NO
I
M
M
O
B
I
L
I
S
E
YES
YES
YES
YES
DO NOT IMMOBILISE
NO