Spinal Injuries

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

I have no medical training but in my experience spinal injuries are kind of hard to call. I had a spinal compression fracture last fall and no one knew about it until I got a to a trauma center, this was after being examined by a WFR and spending a couple hours in the Yosemite clinic (they tried to have me walk out on crutches and I just about passed out).

wemjournal.org/article/S108…(13)00071-9/abstract

I posted this in the other thread, but figured it might be more appropriate here.

J

Jacob Smith wrote: I have no medical training but in my experience spinal injuries are kind of hard to call.

Agreed. That is what I've tried to emphasize all along. Even the experts often can't make the call without diagnostic equipment. I've heard of spinal injuries undiagnosed for extended periods of time.

So we are back to making a judgement call out in the wilderness. And from I understand Jim R's initial comments are quit valid.

Jim R:
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....

Spinal fractures are common. Associated spinal cord injuries are rare.

Joe Forrester wrote:http://www.wemjournal.org/article/S1080-6032(13)00071-9/abstract I posted this in the other thread, but figured it might be more appropriate here. J

Conclusions
Limited evidence supports the current rationale for stabilizing the potential spine injury in the austere environment.

Thank you. It is good to see research supporting the experience and judgement that has been posted here.

I've had two friends evacuated by rescue in the last two summers with spinal injuries. In one case severe back pain following a focused impact incapacitated the victim. Rescue with appropriate stabilisation seemed and likely was important. In the other case walking out probably was safe for the victim. However the fall was extremely severe so caution was warranted. Lower limb injuries would have made the walk out difficult though.

Jeremy B. wrote: 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…

Jeremy B
I took a glance at the studies that had full text access. There does seem to be some evidence that cervical collars can increase ICP, but there are some serious limitations to those studies. Nearly all of the authors state that jugular venous obstruction is the hypothesized cause, but cannot really explain why. There is more to the story than just compression of the veins of the neck. I stand by what I said about measuring ICP. All of the authors using ultrasound or traditional measurements state that the relationship between JVD and ICP is inferred. It's not a bad inference, but it is not a proven relationship. There are many cardiovascular and pulmonary conditions cause JVD without any clinically significant rise in ICP. Cor pulmonale, cardiac tamponade, tension pneumothorax, etc. In studies 107-111 they measured jugular vein size via US and then inferred that it caused a corresponding increase in ICP.

"Because this was a study of healthy volunteers, we did not monitor subjects’ ICP before and after collar application and thus are unable to prove that changes in internal jugular vein size are responsible for the increase in ICP seen with rigid cervical collar application. Subsequent research on this topic should focus on a population of patients in whom invasive or noninvasive ICP monitoring is feasible."

Only reference 112 actually measured ICP, and I didn't see any reference to US in their article (This device was used- lhsc.on.ca/Health_Professio… - be sure to scroll to the bottom to see where it is drilled into the skull). They also monitored CV parameters as well. They conclude - "Our study has confirmed that application of a rigid cervical collar causes a small, sustained rise in ICP in patients with severe traumatic head injury. The mean rise in ICP measured in our study was 4.6 mmHg and this is similar to that described previously [2]. This small rise in ICP is unlikely to be of clinical significance in the majority of patients and, importantly, CPP was not compromised in any patient during our study. However, the range of ICP increases following application of the rigid collar was large. The maximum rise was 12 mmHg and this might be clinically significant, especially if prolonged."

In the end, I think yes, something is going on here with cervical collars and ICP. However, there isn't really conclusive evidence yet that it is a causal relationship or clinically significant. In the true scientist's response - there needs to be more research.

Going back to the original point, I do agree that there needs to be a serious reevaluation of how and when spinal immobilization is used. For conscious patients with no distracting pain and no back or neck pain, it doesn't seem to make a lot of sense. As one of the authors suggested, first responders escpecially need new algorithms about how and when to apply spinal immobilization practices.

JBennett wrote: J Going back to the original point, I do agree that there needs to be a serious reevaluation of how and when spinal immobilization is used. For conscious patients with no distracting pain and no back or neck pain, it doesn't seem to make a lot of sense. As one of the authors suggested, first responders escpecially need new algorithms about how and when to apply spinal immobilization practices.

I am a full time ALS provider for a couple of EMS services, and over the past 2 years we have switched from backboard everything (OMG! Look at that Mechanism of Injury!), to having protocols and algorithms for clearing c-spine. This is within the scope of IEMT and Paramedic, but not in the scope of AEMT, EMT, EMR, or WFR (could be wrong on WFR). Reason for this being as ALS, one has many years of training and experience to reach that point, they can make a more informed judgement call on injuries than someone who took a WFR last week and no medical training prior to that. With that said, in the backcountry with no phone service or any other forms of communication, miles from vehicle, you got to do what you got to do, whatever it takes to get the patient to medical care. Use common sense to accomplish this. I agree with OP, if they can walk, let them walk, but if it hurts them too much, then don't. Is spinal still a risk? Yep. Judgement call by those there, weigh the options, then decide what is best course of action is.

Some c-collars do immobilize the c-spine, but they are specialty equipment, and I will bet that none of you carry an X Collar in your pack. For the most part c-collars only remind the patient to not move their head. Yes it does offer very minimal support, not enough on it's own to be considered immobilization. Now back to common sense, if you need a c collar, probably shouldn't move them, let SAR or EMS do that, but I know that there are times when that waiting is not an option, again, weigh the options, use best judgement. As far as collars causing JVD or increased ICP, we are taught that collars may do this, personally, have never seen it happen.

ICP is a major concern with climbing trauma, seems that is the reason for most of the climbing fatalities out there. Nasty stuff, it's fast, patients fight with superhuman strength, and the only remedy is getting them to the appropriate facility right now, which for like where I run, is still a 45 minute helicopter ride, plus whatever time it takes to get to patient, and get patient to helicopter, etc. Head trauma, with altered mental status, is automatic spinal precaution for us. What has been found is that ICP will elevate faster with traditional supine back boarding, where as some of the newer methods, such as a vacuum mattress where patient can be immobilized in a semi fowler position, granting no pain in doing so, the ICP elevates slower with the head being at the higher position. Makes sense, fluid is subject to gravity, gravity never fails. Same is being found with hemothorax, edema, and other internal injury issues. Will even help with pneumothorax, the lungs don't have to work as hard when the body is more upright than when supine, and have to keep lungs working as easy as they can until they can get a chest dart. Just things to think about when you do have to immobilize.

William Kramer wrote: This is within the scope of IEMT and Paramedic, but not in the scope of AEMT, EMT, EMR, or WFR (could be wrong on WFR).

WEMTs and WFRs learn the focused spinal assessment as an option to only be used in the wilderness setting, after completing full patient assessment (during which manual spinal stabilization is maintained).

I think the WMS guidelines are a great default for the climbing community.

Last December’s Wilderness Medical Society Practice Guidelines for Spine Immobilization in the Austere Environment 2014 wemjournal.org/article/S108…(14)00272-5/fulltext says this in regard to immobilization in the back country:

“Despite a lack of evidence clearly supporting spinal immobilization, an absence of documented cases of neurologic deterioration as a result of inadequate immobilization, and in the face of accumulating data challenging both the philosophical and theoretical grounds of immobilization, no randomized controlled trials have yet been performed in an attempt to validate its ongoing use or stratify any risk-benefit ratio.”

also,

“In the austere environment, the goal of spinal assessment and care should not be to definitively rule out or recognize all forms of spine injury. Rather, the goal should be to minimize the risk of missing or exacerbating a potentially unstable spine injury. The risk of missing such an injury should be appropriately calibrated against the risk of exposing rescuers to the potential for serious injury or causing further injury to the patient beyond that which occurred during the index traumatic event.”

The section on C-collar use goes in-depth. Their recommendations on cervical collar use:

“The cervical collar (or improvised equivalent) should be considered one of several tools available to aid in immobilization of the cervical spine. It should not be considered adequate immobilization in and of itself, nor should it be considered necessary if adequate immobilization can be accomplished by other means, or if the presence of the collar in itself compromises emergent patient care.”

This is a good summary of where the EMS standard of care is in 2015 for rigid cervical collar use and spinal movement restriction. Most EMS systems aren’t there yet unfortunately.

Why EMS Should Limit the Use of Rigid Cervical Collars jems.com/articles/print/vol…

Some explicit points from the article relevant to some of the comments above:

- Because relatively high forces are needed to injure the spine, the comparatively low forces involved in patient movement are unlikely to worsen the injury.

- Involuntary muscle spasm adjacent to a fracture will act as a physiologic splint

- Awake patients with pain along the spine will voluntarily restrict spinal movement

- “There’s absolutely no evidence the C-spine can be immobilized to any significant degree.”

- Cervical collars increase intracranial pressure by restricting venous outflow from the skull while allowing arterial inflow. This can be devastating in patients who have an associated brain injury.

- “C-collars increase spinal motion in high C-spine injuries: Injuries of the high C-spine are among the most catastrophic spinal injuries that occur and involve the first (C1) through the fourth (C4) cervical vertebra as well as the joint between the skull and the first cervical vertebra (atlantooccipital joint). Application of a rigid C-collar causes the separation of C1 from C2, thus stretching the high spinal cord.”

It’s great to get everyone’s insight!

Obviously, if you’re concerned that your injured partner is at risk for a spinal cord injury, it’s important to assess, package gently and minimize unnecessary movement. Pad around their torso. Mimic a soft collar that will support the neck and head, maintain alignment and not restrict blood flow out of the head. Elevate the aligned torso and torso 15 - 30 degrees to facilitate venous outflow from the head. This also allows the lungs to fully expand as needed.

Consider packaging them on their side to protect the airway if that’s a concern. Equally important is to insulate and cover them to prevent or delay hypothermia. When you move them onto a litter, remember to lift with lots of hands rather than log-roll.

If someone with a possible cervical column injury chooses to hike out, it makes sense to improvise support for the head and neck guided by their comfort.

All of that is easier said than done if you’re off the ground or in uneven terrain.

If you’re remote and SAR isn’t coming, or afternoon storms are rolling in or the ice is still falling, you’re faced with selecting the least bad option.

If anyone has anything evidence-based that clearly supports the use of rigid cervical collars, please post it. I’d be psyched to see it!

Jim R wrote:This is a good summary of where the EMS standard of care is in 2015 for rigid cervical collar use and spinal movement restriction. Most EMS systems aren’t there yet unfortunately. Why EMS Should Limit the Use of Rigid Cervical Collars jems.com/articles/print/vol… Some explicit points from the article relevant to some of the comments above: - Because relatively high forces are needed to injure the spine, the comparatively low forces involved in patient movement are unlikely to worsen the injury. - Involuntary muscle spasm adjacent to a fracture will act as a physiologic splint - Awake patients with pain along the spine will voluntarily restrict spinal movement - “There’s absolutely no evidence the C-spine can be immobilized to any significant degree.” - Cervical collars increase intracranial pressure by restricting venous outflow from the skull while allowing arterial inflow. This can be devastating in patients who have an associated brain injury. - “C-collars increase spinal motion in high C-spine injuries: Injuries of the high C-spine are among the most catastrophic spinal injuries that occur and involve the first (C1) through the fourth (C4) cervical vertebra as well as the joint between the skull and the first cervical vertebra (atlantooccipital joint). Application of a rigid C-collar causes the separation of C1 from C2, thus stretching the high spinal cord.”

I think this discussion is great, this is a really important topic. Spinal care is definitely changing from what it used to be in really important ways EMS is becoming an evidence driven care specialty - and that's what's the most exciting.

The ICP thing is highly suspect IMO and the damage from collars, yeah I get that. I've seen more improperly placed collars than properly placed // sized collars. So if you motion restrict someone make sure to do it right. It's hard to do and performing this skill wrong can cause damages. No argument there.

If anyone is curious, this is the product that I was referring to when supporting c-collar use, it has the greatest applicability to climbing needs and has been found to be effective if manual stabilization isn't feasible during extrication for whatever reason. Regrettaby I can only share the abstract.

I use the X-collar and it's fantastic, I do agree that the 'old school' c-collar doesn't do a good job restricting motion and is often frustrating to use, uncomfortable etc. Before using an X-collar I agree that the traditional rigid collar doesn't do a good job here. This is a fantastic piece of equipment which is much easier for rescuers to use and does a much better job supporting the c-spine. I am in no way affiliated with this product // manufacturer

ncbi.nlm.nih.gov/pubmed/192…
xcollar.com/

LEGALLY there is something critical to consider if you're involved in an injury where you identify yourself as a WFR // EMT // WEMT // WAFR // paramedic // whatever:

IT IS A STANDARD OF CARE TO EMPLOY MOTION RESTRICTION. Yes, some studies support that spinal motion restriction is harmful etc but in your training you were taught how to utilize spinal immobilization // restriction devices or improvise them in a wilderness setting. Because the standard of care and best practice is to employ a collar in the US if you are trained you are expected to follow the standards of training.

As a professional responder I can attest that the legal system even for volunteers is UGLY. You never ever want to be on the sharp end of that stick.

Here's something very important to consider:

You're climbing at a crag with an extended (3 hour walkout). A nearby climber you don't know falls, complains of neck pain. You identify yourself as a WAFR.

Reading these mountain project posts and having a Wilerness First Aid or whatever you choose not to restrict his spinal movement with an improvised collar and instead shoulder his/her backpack and help him/her walk out thinking to yourself that you're doing the right thing.

If you identify yourself as a trained responder and you CHOSE not place a collar you have chosen not
to meet the expected standard of care for a spinal injury.

In this case it doesn't matter if your inaction made it worse or not, the fact that you did not apply cervical spinal immobilization as you were trained to can make a very, very, very easy case that you were negligent in your care. So you choose to act, identify yourself as a rescuer, choose not to follow standards of care, patient suffers paralysis or nerve damage and sues you.

Let me repeat that in this case it does not matter whether not placing a collar changed the injury at ALL. Any deficits resulting from that injury can very easily be proven to be your fault because you didn't follow your best practices training, and as a result, the deficits experienced by the victim may have been prevented through proper care.

Proving gross negligence resulting in damages in this case is so easy your victim probably wouldn't need a lawyer. The good samaritan law (if applicable in your state) does not protect from gross negligence leading to proven damages.

So... if you want to implement the decision not to collar a patient you have an option that protects you and is medically ethical. When you make contact IF the patient is competent and you feel like a collar / backboard / waiting for SAR isn't necessary identify yourself as your level of care and discuss their treatment options. It might go something like:

Hey I'm _____. I'm a _____. Can I help you?

(Primary // head to toe assessment)

I noticed that you have some pain in your neck when I touch your spine. You might have an injury which we should protect to prevent further injury. We can do this by supporting your neck with a collar (or whatever improvised thing) and waiting for Search and Rescue. This is the safest way to get you out. If you don't want the collar that's fine but I need you to know that you risk further injury which could include paralysis if you want to walk out.

If you introduce informed consent you're in a much better position if you choose not to collar someone.

OR if you have to move to safety from an exposed position:
we need to put a collar around your neck to move you safely. If you don't want me to put on or improvise a collar I need you to know that you might suffer paralysis or further injury. I've explained the risks, you can make this decision as a competent adult so if you don't want the collar that's fine but at least you accept and understand the risks.

So if you want to lose everything, and I mean everything by all means choose not to employ spinal motion restriction. I know this an insane tone to take but in this litigious society this conversation seems to have ignored some key realities that if someone were to follow advice on this board they would have a lot to lose.