Question about Neck/Spine Injuries

[Amelia]

I'm learning about Head/Neck/Spine injuries, and I'm sure this will come up in class, but as I'm reading though these chapters, I can't help but keep thinking about the following:

What do we do when (I know it will happen) we are dispatched to a car accident, and the pt. is unconscious with his head flopped over? How do we safely and effectively straighten and apply manual stabilization minimizing further damage to the neck/spine? My thought is that we gently lift (minimally) and slowly straighten and pray that there's no crepitus? Like I said- haven't gotten to that part yet. All of the pictures in my book start with "Do your ABCs" then the spine is automatically manually stabilized against the headrest.

Thanks guys!

 

[Brandon O]

This is basically the gist of it. In theory you can try to immobilize it in place, but this is essentially impossible. Gently neutralize it (unless there's some resistance, I suppose), and collar that.

 

[voodoomedic90]

As far as what to do is really determined by the MOI. If the pt is unconscious and the MVA is that severe, then spinal issues are less of a worry as we are more worried about such things like airway, major bleeding, other life threats. With that said, extrication would be an issue. Put the head midline, if you feel any resistance then splint the best as you can, in whatever position you can manage. BUT DOCUMENT! DOCUMENT! DOCUMENT! I hope this helps

 

[Amelia]

Voodoo- We just learned that tonight! And I"m not too worried about documentation- I have a BA in Brit Lit (yeah, I know) so I tend to write essays anyway. I do appreciate the input and you're absolutely right. Thanks!

 

[OnceAnEMT]

All of the above nailed it. I had a similar concern, especially coming from a profession where c-spine fx is the holy grail of injuries (read: AT). It varies by protocol and your comfort level, as it should. Its definitely a judgement thing, and you really gotta feel it. It's a whole lot easier with a conscious Pt who tends to do it themselves, but I suppose that's a luxury

 

[Amelia]

Luxury- especially in an auto accident for sure. I know that most of this stuff we'll cover, but it distracts me if I have questions. Sometimes she says is "Stay Tuned!" because she wants us to be hooked into what we're learning and take the initiative. Well, my initiative is to torture everyone here with my plethora of questions.

 

[voodoomedic90]

I am glad I can help. But as far as documentation, you can document all that that you want, but if what is documented isn't pertinent to the pt, then it will be discredited in a court room. For this pt I would document something to the effect of; I was taught SOAP charting. If you are unfamiliar with what that is, please ask, I love to teach and help as much as I can:

ATF UNK AGE MALE INVOLVED IN MVA. UNK SPEED. FRONT AND SIDE CURTAIN AIRBAGS DEPLOYED, DEFORMITY NOTED TO STEERING WHEEL, DEFORMITY NOTED TO WINDSHIELD. VEHICLE HAS SEVERE DAMAGE TO DRIVER FRONT; DRIVER SIDE, DRIVER REAR. WITH APPROX 2 FT OF INTRUSION INTO PT DRIVER COMPARTMENT. NO OTHER VEHICLES; ON SCENE; NOTED TO BE INVOLVED IN MVA. PT IS UNCOUNSCIOUS/ ALERT TO PAINFUL STIMULI; GCS 6. SKIN W/P/D; DEFORMITY NOTED TO DISTAL EXTREMITIES. WITH FD ASSISTANCE EXTRICATION WAS COMPLETED; WITH PULSES INTACT BEFORE AND AFTER PT MOVEMENT, PT ATTEMPTS TO WITH DRAWL FROM PAINFUL STIMULI BEFORE AND AFTER MOVEMENT. ATTEMPT TO PUT PT HEAD AND NECK MIDLINE WHERE UNSUCCESSFUL DUE TO NOTED RESISTANCE. PULSES NOTED BEFORE AND AFTER ATTEMPT, SKIN W/P/D DISTALLY BEFORE AND AFTER. PT PLACED INTO FULL SPINAL PRECAUTIONS WITH TOWELS AND PILLOWS USED TO STABILIZE HEAD/NECK. HEAD-TO-TOE ASSESSMENT REVEALS COMPOUND FRACTURE TO L. FEMUR. BLEEDING CONTROLED WITH DRY; STERILE DRESSING. LEG SPLINTED TO SPINAL BOARD, TOWELS/PILLOWS USED TO FILL VOIDS. PULSES NOTED BEFORE AND AFTER SPLINTING. HEENT - UNABLE TO PLACE HEAD/ NECK MIDLINE. OPA PLACED TO MAINTAIN AIRWAY. V/S: BP: 96/62 HR: 126 RR: 6 @ 99% R.A.(PRIOR TO BVM VENTILATIONS) BREATHING ASSISTED WITH BVM @ 14/M WHILE CONNECTED TO 100% O2. PT TX TRAUMA CODE 3. BILAT IVS ESTABLISHED ENROUTE. L. ARM 18G N.S. LOCK; R. ARM 14G IV FLUIDS GIVEN W.O. BLEEDING STILL CONTROLED, V/S: BP: 106/70; HR 122; RR 14 ASSISTED 99% 15L O2. PT TAKEN TO BED 3 U/A TO TRAUMA CENTER. REPORT GIVEN TO PHYSICIAN. UNIT OOS DUE TO DECON.

This documentation still has a few holes in it that I would address, but that would be the general picture I would paint for this scenario.

 

[Amelia]

That's fantastic. Do you know how the pt. did after the accident? Sounds like his vitals were improving...

 

[ecphotoman]

I'm learning about Head/Neck/Spine injuries, and I'm sure this will come up in class, but as I'm reading though these chapters, I can't help but keep thinking about the following:

What do we do when (I know it will happen) we are dispatched to a car accident, and the pt. is unconscious with his head flopped over? How do we safely and effectively straighten and apply manual stabilization minimizing further damage to the neck/spine? My thought is that we gently lift (minimally) and slowly straighten and pray that there's no crepitus? Like I said- haven't gotten to that part yet. All of the pictures in my book start with "Do your ABCs" then the spine is automatically manually stabilized against the headrest.

Thanks guys!

Have someone hold cspine while two of you pull the pt out using a KED. Using a short board or full board instead is unsafe, but sometimes is the only option if your company doesn't provide you with a KED. Just document all your interventions and anything you may fear will come back in the form of litigation.

 

[chaz90]

Have someone hold cspine while two of you pull the pt out using a KED. Using a short board or full board instead is unsafe, but sometimes is the only option if your company doesn't provide you with a KED. Just document all your interventions and anything you may fear will come back in the form of litigation.

How does using a KED help with the difficulty the OP mentioned? Also, how is using a short board or LBB instead of a KED any more unsafe than the others?

 

[chaz90]

It's as simple as Brandon O wrote. As long as you're still stuck using a backboard just move the head to neutral and "immobilize" it there. If they were paralyzed before you got there you're not going to fix/hurt them, and if no SCI exists you're probably not going to do further damage by gently moving the head inline.

 

[Amelia]

Thats what I was thinking- I just wanted to double-triple check.

 

[ecphotoman]

How does using a KED help with the difficulty the OP mentioned? Also, how is using a short board or LBB instead of a KED any more unsafe than the others?

Our agency(ICEMA) and the neighboring REMSA are going towards the NSAID rule for C-spine. We are now being trained to avoid long and shirt boards unless they meet the NSAID rule criteria. The rationale behind it is that the long board will place undue pressure on the lower spine and cause more harm than good. I'm just going off of our latest protocol update. I've used the KED countless times for vehicle extrications, it supports the neck on the way out of the vehicle and I've never had an issue with it.
http://www.emsworld.com/article/10987099/prehospital-spinal-injury-care-and-backboards


I don't know, that's just the way we've started doing it out here.

 

[Jim37F]

If the patient is ambulatory we generally just have them walk out of the car and into our gurney.

If they're not ambulatory, then generally we'll slide a board under them on the seat, and just kind of slowly and gently slide them sideways, down, and back until they're properly positioned on the board and carry them to the gurney (where under the old protocols they got strapped into the board complete with headblocks and all, new protocol says we only have to strap them to the board if there's back pain, abnormal spinal exam such as step offs or other deformity, tenderness, instability, or crepitus to the spinal column, or if there's any neurological deficit noted...otherwise no back pain, deficits, or other abnormal findings we can remove the board. Of course some of the older, saltier medics who resist change will strap them in anyway just 'cause of the mechanism and justify it under the line about providers judgement, but funnily enough they tend to work mostly at the stations that only get a couple calls a day...

I feel like I'm trouble what with voodoo's report screaming at me like that

 

[ecphotoman]

If the patient is ambulatory we generally just have them walk out of the car and into our gurney.

If they're not ambulatory, then generally we'll slide a board under them on the seat, and just kind of slowly and gently slide them sideways, down, and back until they're properly positioned on the board and carry them to the gurney (where under the old protocols they got strapped into the board complete with headblocks and all, new protocol says we only have to strap them to the board if there's back pain, abnormal spinal exam such as step offs or other deformity, tenderness, instability, or crepitus to the spinal column, or if there's any neurological deficit noted...otherwise no back pain, deficits, or other abnormal findings we can remove the board. Of course some of the older, saltier medics who resist change will strap them in anyway just 'cause of the mechanism and justify it under the line about providers judgement, but funnily enough they tend to work mostly at the stations that only get a couple calls a day...

I feel like I'm trouble what with voodoo's report screaming at me like that

Were running in to that quite often. People are resistant to change, but if your medical director advises otherwise good luck getting any backing if you screw the pooch.

 

[Jim37F]

Those are pretty much the new county SMR guidelines we're all supposed to follow now, plus our medical director did an inservice training for the whole department so everyone was supposed to have been brought up to speed (I say supposed to because the inservice was one day for each shift and what with overtime and trades and people getting calls during the scheduled time period means not everyone ended up going to the one day training session).

 

[ecphotoman]

Those are pretty much the new county SMR guidelines we're all supposed to follow now, plus our medical director did an inservice training for the whole department so everyone was supposed to have been brought up to speed (I say supposed to because the inservice was one day for each shift and what with overtime and trades and people getting calls during the scheduled time period means not everyone ended up going to the one day training session).

It was in our last protocol update and now its part of our 24hour refresher course. In about another year everyone should have cycled through, I hope lol.

 

[Amelia]

Yup! We got the brand new algorithm of when to backboard and when not to. I guess it came out this year?

 

[voodoomedic90]

that wasn't really a pt I had ever, it was purely an example

 

[voodoomedic90]

111111111

It's as simple as Brandon O wrote. As long as you're still stuck using a backboard just move the head to neutral and "immobilize" it there. If they were paralyzed before you got there you're not going to fix/hurt them, and if no SCI exists you're probably not going to do further damage by gently moving the head inline.

what does SCI mean?