Spinal Injuries

It's awesome that the Epic Rescue thread in the Lost and Found forum drifted (partly) on to spinal injury. It's an important topic for this community as we will always be the first ones taking care of our own when they get hurt. Here's some info to add to the discussion:

The Wilderness Medicine Training Center has a great summary of appropriate spinal injury care in the backcountry.

The link rgold posted on focused spine assessment is excellent.

The SCANCRIT emergency medicine critical care blog has a good explanation of the pitfalls of cervical collar use with a list of supporting literature at the bottom of the page.

My thoughts:

If the injured is fully alert and does not have other incapacitating injures, does not have new neurologic deficits based on your assessment and is able to walk, it’s likely safe for them to carefully self evacuate. They may still have a stable spinal fracture. They should seek medical attention post evacuation if there’s any question. If anything changes during evacuation, stop, reassess and reconsider your options which may include calling for a formal rescue.

Spinal fractures are common. Associated spinal cord injuries are rare. Neurologic manifestations are almost always evident at the time of injury. It takes 2 - 6 kN of focused energy to fracture the spine of a healthy adult. If cord injury is going to happen, it's going to happen then. As part of our care or evacuation, it would be difficult to impart anything close to the force needed to worsen a cord or column injury. If you do have a patient who you are concerned might have a cord injury or unstable fracture, gently handling is always indicated.

It is possible to to have delayed (secondary) injury that manifests over time. Secondary injury is caused localized swelling, low blood oxygen or low blood pressure. It is not related to whether the patient was "immobilized" or not.

Cervical collars do not immobilize the spine. They may cause vertebral distraction (axial stretching) They do increase intracranial pressure. They make it harder to maintain the patient’s airway or for the patient to maintain their own airway. There’s nothing in the medical literature that supports their use.

The bottom line for me is that if your patient has an incapacitating injury, isn’t fully alert, has evidence of a neurologic injury or is not able to self evacuate, call for a formal rescue if available. Otherwise, use your best judgement and common sense.

Anyone have other thoughts?

Cheers!

Yes thought: Get some frigging WFR training.

For context, the Epic Rescue thread had some good posts on spinal injuries and whether or not the injured climber should or shouldn't have been immobilized or SAR called or not.

The internet is no substitute for WFR or WEMT training. I've been impressed with the patient care I've seen WFR's provide. If you spend time more than a rope length off the ground or off the beaten path, WFR training can be lifesaving for your partner and give you the knowledge to make good decisions.

Hopefully this thread can provide some info and spark some interest that keeps folks from just winging it...

Obviously the C-collar has it's drawbacks and possible adverse effects. What's important to note though, I feel, on a forum like MP, is that one of the sources the OP cites still recommends using the c-collar in difficult extractions and for "stabilizing the neck during stretcher carrying in difficult terrain." I've never been involved in an extraction with a liter where the patient was able to lie perfectly still, conscious or not.
This is obviously a good topic to cover, but if people reading this don't have a WFR/WEMT etc, go get training before you start making decisions based on an internet forum. Yes, it's expensive, yes its time consuming, but it is some of the best money you'll ever spend.

Yes, a very interesting topic. After reading Jim's College of Emergency Physicians take on Spinal Injury Management link in the other thread, I realized the changes discussed are likely of greater impact to the urban responder who may be trained immobilize everyone and let the hospital sort things out.

Out in the backcountry I'm unlikely to have a backboard and collar stuffed away in my bag, and when the Big One finally hits the SF Bay Area there's a good chance they'd be similarly unavailable. It seems to me that the trend from the articles is that the current WFR wilderness-only protocol may be considered as appropriate for the urban cases as well, and the impact on the wilderness protocols may mostly be an increase in the number of patients considered appropriate for a walk out. I also see the articles as reassuring for a rescuer who might be worried about doing further damage while moving the patient if they don't have a backboard and collar at hand.

As an urban professional having treated // extricated critically ill patients in wilderness settings I want to put it out there that cervical collars can play a huge role. There is a shift in not boarding everyone and selectively collaring.

Collars when correctly sized DO NOT cause "axial loading" or cervical traction, and the idea that they increase ICP is something that I can't imagine where that comes from. A properly placed collar will not inhibit airway management of a conscious patient. Similarly you can in fact manage an unresponsive patients airway with a collar and SHOULD do so if they have a possible spinal injury. If they're vomiting roll them to the side, stabilize neck in collar etc. ever try to manage a truly unresponsive patient with a possible neck injury? Without a collar their neck flops like a fish. This is not good care. The only time I remove a collar is to intubate and once the airway is placed collar goes right back on. That's not "because that's just the way we do it" we do it this way because that is the best practice.

The literature supports cervical collar use. I don't want anyone to come away from this board thinking that collars are bad. In the backcountry if there is possible moi for a spinal injury and any degree of tenderness to the cervical spine for gods sake place a collar or improvise one. This has actually been one of the few spinal precautions that's shown benefit - over long spine boards which have been found to be ineffective. My area is moving to use these only as extrication tools.

Finally - if you do have to rappel with a possible spinal injury patient practice a tandem rappel. This way you are with them to support neck/back and be capable of responding to changes in patient status during the rappel.

Jim R wrote:My thoughts: If the injured is fully alert and does not have other incapacitating injures, does not have new neurologic deficits based on your assessment and is able to walk, it’s likely safe for them to carefully self evacuate. They may still have a stable spinal fracture. They should seek medical attention post evacuation if there’s any question. If anything changes during evacuation, stop, reassess and reconsider your options which may include calling for a formal rescue. Spinal fractures are common. Associated spinal cord injuries are rare.

Thank you very much for validating some of what I already had presumed and posted.

I have done a basic wildness first aid course but I would say that my most of my medical knowledge has come from experience an (un)common sense. I've broken enough bones over the years that I'm happy with my self assessment.

Not if they have any spinal tenderness! You might actually become paralyzed from these kinds of decisions, especially if you think oh I have a WFR I can totally call neck/back pain insignificant. Reading this is kind of terrifying

I really appreciate the professional advice everyone is offering on this topic.

As far as appropriately sizing a collar goes, any rules of thumb applicable when improvising a neck collar?

I'd imagine one could use the padded hip belts off a backpack to stabilize the head, but how can you determine if the size is "correct"?

For an improv collar consider carrying a SAM splint - they're great. Use them every day at work for fractures and have seen them used as improvised collars. For other improvised collars consider the bill of a hat with the concave section under the injured persons chin, padding on each side and gentle dressing holding it all together. Don't want anything tied around the neck too tight!

Thoughts on proper immobilization:
Talk to them! Tell the injured person to keep looking straight ahead. Coach them to support their head and not to turn their head from left to right and up or down. Forgetting this important aspect of immobilization makes attempts at immobilization null because you really need patient compliance for this to go well.

As far as sizing - the position of comfort / 'position of function' should be used. For the neck this means that you should have the person looking straight ahead with the neck in a neutral position, not looking up or down. The collar should not 'feel' like its pushing their head into an uncomfortable position or pushing up against the whole neck - this is called cervical traction and has no place outside of a patient under neuro/ortho care.

If they cannot move to a neutral position without pain/discomfort splint in that position found.

Once you think it looks right ask the person if they feel like the collar is adequately immobilizing their neck. If it's not stop and fix until you've got it right.

Thanks for answering my question Medic 741.
I see the importance of having the patient focused on remaining perfectly immobile and the baseball cap under the chin idea is brilliant.

Are there any statistics on climber/hiker falls where the person sustained further injuries due to being transported improperly after a fall?

Jim R wrote:Cervical collars do not immobilize the spine. They may cause vertebral distraction (axial stretching) They do increase intracranial pressure. They make it harder to maintain the patient’s airway or for the patient to maintain their own airway. There’s nothing in the medical literature that supports their use.

This is the worst, must uninformed piece of information I have seen to date.

Does it eliminate all motion? No. Does it inhibit rotation, flexion, extension, and side-bending? Greatly.

To have a high cervical fracture and not have a collar put on is crazy. Maybe that's why they follow up with "actually, in bad situations for carrying, maybe its a good idea." Because the gross immobilization that a collar gives is important.

This notion that cervical collars increase ICP is interesting. Where is the data on this? Direct measurement of ICP is difficult to impossible. I hope that someone isn't trying to place pressure catheters in the cerebral ventricles of everyone who ever had a cervical collar. The disruption to venous return would be minimal. If you are compressing the neck veins that much you are most likely also occluding the carotids, which you would hopefully notice when your patient passes out.

Tom-onator wrote:Thanks for answering my question Medic 741. I see the importance of having the patient focused on remaining perfectly immobile and the baseball cap under the chin idea is brilliant. Are there any statistics on climber/hiker falls where the person sustained further injuries due to being transported improperly after a fall?

There aren't a lot of statistics because it is really difficult to tell what injuries came from the fall, what injuries were due to natural swelling of the injured area after the fall, and what injuries were from improper transport.

Medic741 wrote:Not if they have any spinal tenderness! You might actually become paralyzed from these kinds of decisions, especially if you think oh I have a WFR I can totally call neck/back pain insignificant. Reading this is kind of terrifying

Since when did anybody call neck/back pain insignificant!? But neck and back pain come in all sorts of flavours. I can get a sore neck from belaying....

JBennett wrote:Direct measurement of ICP is difficult to impossible. I hope that someone isn't trying to place pressure catheters in the cerebral ventricles of everyone who ever had a cervical collar.

Catheters you say?

A few links deeper into the SCANCRIT blog discovers the article below, from which references 107-112 are used to support the claims of increased ICP. The studies are few, and the populations obviously small (n=30, n=10, etc). Reference 112 measures the internal jugular vein dimensions via ultrasound, the others focused on measuring pressure. Have a skim, it'd be good to get your comments.

ncbi.nlm.nih.gov/pmc/articl…

Medic741 wrote:Finally - if you do have to rappel with a possible spinal injury patient practice a tandem rappel. This way you are with them to support neck/back and be capable of responding to changes in patient status during the rappel.

Have you tried conducting a tandem rappel while supporting a victims neck/back? ... with equipment that would be available on a 10 pitch free climb?

I've practiced tandem rappel more than once. My initial thoughts are this: if the neck/back needs support to prevent a spinal injury, it is probably not a good idea to rap (generally speaking).

Medic741 wrote: especially if you think oh I have a WFR I can totally call neck/back pain insignificant.

Whoa, where the hell did that come from? Why in the world would propose that's what a WFR would think?

Tom-onator wrote:I really appreciate the professional advice everyone is offering on this topic. As far as appropriately sizing a collar goes, any rules of thumb applicable when improvising a neck collar? I'd imagine one could use the padded hip belts off a backpack to stabilize the head, but how can you determine if the size is "correct"?

Rolled fleeces/sweatshirts around the back of the neck and crossed over the chest work reasonably well. Patient can hold the ends at maintain reasonable stability. This should be one of your last options to consider however - cervical collar definitely ranks above!

Example:
books.google.com/books?id=2…

patto wrote: Since when did anybody call neck/back pain insignificant!? But neck and back pain come in all sorts of flavours. I can get a sore neck from belaying....

Going out on a limb, I think he meant "spine pain" - pain / tenderness upon palpation if the spine itself. That's what I've always heard from instructors in response to questions about what pain / tenderness is significant.

Maybe someone with training higher than WFR can clarify.

Bill Lawry wrote: Have you tried conducting a tandem rappel while supporting a victims neck/back? ... with equipment that would be available on a 10 pitch free climb? I've practiced tandem rappel more than once. My initial thoughts are this: if the neck/back needs support to prevent a spinal injury, it is probably not a good idea to rap (generally speaking).

That's what comes to mind for me as well. With the bumping / jostling that could occur in any sort of raising / lowering, I'd consider this to be a last option, for when other more critical issues become a higher priority. Waiting for well-equipped rescuers is a small price to pay for preventing lifelong disability.

What stands out in my mind around this type of injury is a story I heard from one of my instructors: motor vehicle accident victim thought he was unhurt and stood up. When he did, it caused spinal cord injury, and he was instantly paralyzed.

Having spent a lot of time with an SCI patient and witnessing the enormous effect it had on her life, I would hate to bring that on someone by moving them when I shouldn't have.