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Introduction
  • Trauma to the spine may cause injuries involving the spinal cord, vertebrae or both.
  • Spinal cord injury (SCI) can be identified when neurologic function above the injury is intact and function below the injury is absent or markedly diminished. Specific manifestations will depend on the exact level of injury.
  • This guideline applies to the entire spinal column, including cervical, thoracic and lumbar spine.

Read the complete article; Spinal Cord Injury (SCI) in the Medical Library > Pathophysiology.

Clinical Presentation
  • Spinal assessment is a complex process that carries a high degree of clinical risk, thorough assessment is required to make an informed decision.
  • Officers should consult the NEXUS Clinical Decision Rule (CDR) as indicated in the spinal assessment clinical skill. NEXUS has been based on a large prospective observational study and can be used to identify patients at very low risk of cervical spine injury.
  • Concerning children, no dedicated clinical decision tool for paediatric cervical spine trauma exists[1].
  • Patients at the extremes of age (i.e. children and the elderly, or typically those ≥ 65 years of age) can be difficult to assess adequately. In both these patient groups, if the assessing clinician has any concern, immobilisation must be applied until full history and assessment (inclusive of imaging) prove spinal precautions could be discontinued.
Exclusion Criteria
Exclusion Criteria
Risk Assessment

It is important to assess and consider the entire spinal column, not only the cervical spine. If there is any thoracic or lumbar pain, consider against asking the patient to move themselves and instead lifting the patient for extrication, particularly in circumstances where additional support or resources are available

  • C-Spine assessment is performed using clinical judgement and findings from examinations, the NEXUS Clinical Decision Rule can be used to aid this decision.
  • Prior to clearance a thorough primary/secondary and Neurological survey must be completed.
  • Asses high risk factors that limit the ability to clear C spine
  • Patients with no neurological deficit may self-extricate short distances (a few steps)
  • Careful clinical judgment should be used, if self-extrication is likely to aggravate the injury then alternative methods of extrication should be used.
  • Ensure a Lanyard is placed and education is given on self-splinting prior to self-extrication.
  • Once on the stretcher apply head blocks and treat although a spinal injury is present.

High risk factors include:

  • Age: Older than 65 years
  • Known pre-existing spinal conditions (e.g. ankylosing spondylitis, rheumatoid arthritis, spinal surgery, spinal stenosis etc.)
  • Dangerous mechanism(s) of injury, including but not limited to:
    • Fall: ≥ 1 meter OR 5 stairs
    • High axial loading to the head (e.g. diving, rugby scrum, surfing etc.)
    • Motor Vehicle Collision at high speed (≥ 60km/hr)
    • Motor Vehicle Rollover
    • Ejection from a vehicle
    • Accidents involving motorised recreational vehicles (e.g. quad-bikes, ATV's, motorbikes, etc.)
    • Bicycle collision
    • Pedestrian/s struck by vehicle
  • Abnormal neurological status
    • Obvious or subtle numbness, tingling or strength deficit in peripheries which was not present prior to the incident/injury
If the patient is co-operative: Unable to clear C-spine with Nexus

In the absence of neurological signs, a co-operative pain free patient will generally not require a semi-rigid cervical collar. Patients that are able to self extricate without aggravation of their injury may be encouraged to take a few steps to the stretcher. Ensure a lanyard has been placed around the neck and they have received education about self splinting, to keep their head and neck as still as possible prior to movement. If the patient has or begins to experience neck pain, weakness in limbs or neurological signs during self-extrication attempts they should stop and the situation should be reassessed.

If a patient is unable to extricate themselves without assistance a spinal injury should be assumed. It is important that the patient moves themselves and is not assisted by the practitioner. If a patient getting up from the floor is going to aggravate their injury alternative methods such as a scoop stretcher should be used. 

In the co-operative patient the following steps (spinal precautions) should be used:

  • A lanyard should be placed around the patients neck prior to mobilistaion 
  • The patient should be provided with advice to keep their head and neck as still as possible and the reasons for this. The advice can be similar to the following: 

"Evidence indicates no benefit to routine application of a Semi-Rigid collar in the absence of neurological symptoms. Because we cannot clear your neck we ask that you stay in a comfortable neutral position and avoid moving your head and neck as much as possible."

  • Position patient supine, or semi-recumbent if more comfortable.
  • Headblocks should be utilised to limit lateral movement and as a reminder (if appropriate for the patient)
If the patient is unco-operative: Unable to clear C-spine with Nexus

An unco-operative patient who refuses to follow commands and advice, however, maintains capacity to do so will generally not tolerate a semi-rigid collar. Forcefully attempting to apply a semi-rigid collar may result in increased movement or agitation thus preventing the goal of the collar. Good clinical judgement is required with a careful analysis of risk vs. benefit. Organic causes of agitation and significant mechanisms of injury must be ruled out wherever practicable prior to adopting this approach.

General principles for consideration:

  • Forceful placement of a semi-rigid collar is not recommended for the reasons above.
  • The most feasible option is to continue to try manual stabilisation and repeatedly instruct the patient to remain still. The use of headblocks is encouraged and should be strongly considered. It is important that the head is not taped or strapped down.
  • Ensure thorough documentation of the event and the situation
Should a significant mechanism of injury be present, consideration should be given to traumatic causes of agitation (i.e. cerebral irritation from a Traumatic Brain Injury [TBI] or similar). Organic causes of agitation such as hypoxia and/or deranged blood glucose levels should also be assessed and eliminated. Sedation for TBI should be considered where applicable and appropriate spinal stabilisation thereafter.
Interhospital Transfers:

Follow guidance of medical staff.

In the absence of neurological signs, a co-operative pain free patient will generally not require a semi-rigid cervical collar. If a patient is able to self-extricate they should be encouraged to do so. The patient should also be instructed to keep their head and neck as still as possible. If the patient has or begins to experience neck pain, weakness in limbs or neurological signs during self-extrication attempts they should stop and the situation should be reassessed.

If a patient is unable to extricate themselves without assistance a spinal injury should be assumed unless able to be ruled out via the clinical decision rule. It is important that the patient moves themselves and is not manipulated by the practitioner.

In the co-operative patient the following steps (i.e. spinal precautions) should be considered:

  • The patient should be provided with advice to keep their head and neck as still as possible and the reasons for this. The advice can be similar to the following: 

"Evidence indicates no benefit to routine application of a Semi-Rigid collar in the absence of neurological symptoms. Because we cannot clear your neck we ask that you stay in a comfortable neutral position and avoid moving your head and neck as much as possible."

  • Position patient supine, or semi-recumbent if more comfortable.
  • Headblocks should be utilised to limit lateral movement and as a reminder (if appropriate for the patient) but are not routinely required.
  • Ensure a warning lanyard is placed.
If the patient is unco-operative:

An unco-operative patient who refuses to follow commands and advice, however, maintains capacity to do so will generally not tolerate a semi-rigid collar. Forcefully attempting to apply a semi-rigid collar may result in increased movement or agitation thus preventing the goal of the collar. Good clinical judgement is required with a careful analysis of risk vs. benefit. Organic causes of agitation and significant mechanisms of injury must be ruled out wherever practicable prior to adopting this approach.

General principles for consideration:

  • Forceful placement of a semi-rigid collar is not recommended for the reasons above.
  • The most feasible option is to continue to try manual stabilisation and repeatedly instruct the patient to remain still. The use of headblocks is encouraged and should be strongly considered. It is important that the head is not taped or strapped down.
  • Ensure thorough documentation of the event and the situation
Should a significant mechanism of injury be present, consideration should be given to traumatic causes of agitation (i.e. cerebral irritation from a Traumatic Brain Injury [TBI] or similar). Organic causes of agitation such as hypoxia and/or deranged blood glucose levels should also be assessed and eliminated. Sedation for TBI should be considered where applicable and appropriate spinal stabilisation thereafter.
Interhospital Transfers:

Follow guidance of medical staff.

Management

General Principles:

  • If TBI is present and cervical injury cannot be ruled out, when possible position the patient to approximately 15 degrees to maximise cerebral drainage.
  • Head block use is recommended to limit lateral movement.
  • Avoid the triple airway manoeuvre if cervical injury is suspected.
  • Once an advanced airway has been placed, the preferred option is to stabilise using appropriate padding, a warning lanyard and headblocks. A semi-rigid collar can be used, though is not recommended.
Cervical collars placed prior to ambulance arrival:

In situations where a semi-rigid Cervical Collar has been placed prior to ambulance arrival the following principles should be considered and followed:

  • Engage in collegial handover and discussion around the reasons behind the decisions to place a cervical collar and St John Ambulance requirements to assess as per our Clinical Practice Guidelines
  • Investigate if it is appropriate for the cervical spine to be cleared using the NEXUS clinical decision rule
  • St John Ambulance Clinical Practice Guidelines should be followed if the patient cannot be cleared. This may mean replacing the collar with a different device.
  • Appropriate discussion should take place prior to this undertaking.
  • It is important to communicate with the patient the rationale behind the decisions that are being made. It is also important to emphasize that this decision is not a criticism of care that has been provided, rather a requirement of St John Ambulance guidelines. The initial care provider should also be involved in this discussion.
  • If conflict with other providers arises, do not insist. Extricate and begin transport. Once underway further private discussion can be had with the patient, and the appropriate pathway of management can continue.
Primary Care

Employ spinal precautions if any of the following assessment findings are present, associated with trauma as defined above:

  • GCS <15
  • Spinal pain / tenderness / deformity
  • Neurological deficit
  • Significant mechanism of injury in conjunction with:
    • Alcohol/drug intake
    • Distracting injury
    • Inability to communicate
Note: In Traumatic Cardiac Arrest, the principles outlined in the Major Trauma Guidelines takes preference over standard care.
Intermediate Care (EMT / Level 2)

A semi-rigid cervical collar should be placed if:

  • The patient is unconscious with a mechanism of injury suggestive of possible cervical spine involvement OR
  • The patient has neurological symptoms suggestive of spinal cord injury with a mechanism of injury suggestive of cervical spine involvement.

NOTE: Neurological symptoms suggestive of injury include (but are not limited to):

  • Tingling in any extremity
  • Numbness in any extremity
  • Weakness of any limb/s

If a semi-rigid collar is placed, it is preferable to lift and extricate the patient via the use a of scoop stretcher. The patient should be rolled as little as possible. They should NOT be walked.

  • Complete a SPEED assessment
  • Administer anti-emetic as per CPG
  • Consider pain relief
  • Consider applying cardiac monitor if trained and authorised
  • Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
  • Transport Priority 1 if patient time critical, pre-notifying receiving facility;
    • Should a time critical patient be transported on an extrication board or scoop, full spinal immobilisation equipment should be used (cervical collar, head blocks and spider harness).
    • The packaged patient must then be secured on the Ferno 50E stretcher.
    • For inter-facility transfers, the Vacuum Mattress should ideally be utilised if available as per Clinical Skill.
Advanced Care (AP)

A semi-rigid cervical collar should be placed if:

  • The patient is unconscious with a mechanism of injury suggestive of possible cervical spine involvement OR
  • The patient has neurological symptoms suggestive of spinal cord injury with a mechanism of injury suggestive of cervical spine involvement.

NOTE: Neurological symptoms suggestive of injury include (but are not limited to):

  • Tingling in any extremity
  • Numbness in any extremity
  • Weakness of any limb/s

If a semi-rigid collar is placed, it is preferable to lift and extricate the patient via the use a of scoop stretcher. The patient should be rolled as little as possible. They should NOT be walked.

  • Complete a SPEED assessment
  • Administer anti-emetic as per CPG
  • Consider pain relief
  • Consider applying cardiac monitor if trained and authorised
  • Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
  • Transport Priority 1 if patient time critical, pre-notifying receiving facility;
    • Should a time critical patient be transported on an extrication board or scoop, full spinal immobilisation equipment should be used (cervical collar, head blocks and spider harness).
    • The packaged patient must then be secured on the Ferno 50E stretcher.
    • For inter-facility transfers, the Vacuum Mattress should ideally be utilised if available as per Clinical Skill.
Critical & Extended Care (CCP, PSO)
  • As per Advanced Care (AP) guidelines
Additional Information
  • Patients should be padded appropriately to achieve their individual neutral spinal alignment (i.e. Most adult patients require a small amount of padding under the head, children may require padding under the torso, patients with increased thoracic kyphosis may require additional padding under the head at achieve the correct alignment).
  • If a semi-rigid collar is indicated but unable to be applied (for example due to injury, patient habitus etc.) alternative options such as head blocks and/or in-line manual stabilisation should be considered and all considerations and decisions documented accordingly.
  • Significant cervical spine injury due to hanging is uncommon. Routine cervical spine immobilisation is not required unless the body has fallen from a height greater to or equal to the height of the person.
  • Cervical spine immobilisation is generally not required if there is an isolated penetrating injury to the neck (e.g. stabbing or gunshot). When multiple mechanisms of injury suggestive of spinal involvement are present immobilisation criteria should apply.
  • When used the semi-rigid collar must be correctly sized and fitted to suit the patient. If this cannot be achieved the best approach should be reconsidered and alternative options such as head-blocks and/or manual in-line immobilisation should be considered. Patients may sit up on a slight incline (15 degrees) if they are experiencing difficulty breathing.
  • Patients who are co-operative, ambulant and without neurological symptoms may self extricate short distances and coached to keep their head and neck as still as possible.
  • Head blocks should be used to limit lateral movement if spinal precautions are indicated. Whenever possible, patients should be removed from scoop stretchers or extrication boards prior to transport due to risk of pressure injury.

References

The Royal Australian and New Zealand College of Radiologists. (2015). Paediatric Cervical Spine Trauma . Retrieved November 16, 2016, from RANZCR: http://www.ranzcr.edu.au/documents-download/3838-print-version-paediatric-cervical-spine

Connor, D., Porter, K., Bloch, M., & Greaves, I. (2013, December). Pre-hospital Spinal Immobilisation: An Initial Consensus Statement. Emergency Medicine, 30(12), 1067-1069.

Deasy, C., & Cameron, P. (2011). Routine application of cervical collars – What is the evidence? Injury, 841-842. doi:10.1016/j.injury.2011.06.191

Engsberg, J., J., S., Shurtleff, T., Eggars, J., Shafer, J., & Naunheim, R. (2013). Cervical Spine Motion During Extrication. The Journal of Emergency Medicine, 44, 122-127. doi:10.1016/j.jemermed.2012.02.082

Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. New England Journal of Medicine. 2000; 343(2): 94-9

Hood, N., & Considine, J. (2015). Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature. Australasian Emergency Nursing Journal, 18, 118-137. doi:10.1016/j.aenj.2015.03.003

Kornhall DK, Jorgensen JJ, Brommeland T, et al. The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury. Scandinavian Journal of Trauma and Resuscitation Emergency Medicine. 2017;25:2.

Lee, M., McPhee, R., & Stringer, M. (2008). An evidence-based approach to human dermatomes. Clinical Anatomy, 21(5), 363-373. doi: 10.1002/ca.20636

Nikolić, S. & Živković, V.  Cervical spine injuries in suicidal hanging without a long-drop—patterns and possible underlying mechanisms of injury: an autopsy study. Forensic Science, Medicine and Pathology (2014) 10: 193. doi:10.1007/s12024-014-9550-y

Oteir, A., Smith, K., Stoelwinder, J., Middleton, J., & Jennings, P. (2015). Should suspected cervical spinal cord injury be immobilised? :A systematic review. Injury, 46, 528-535. doi:10.1016/j.injury.2014.12.032

Paykin, G., O'Reilly, G., Ackland, H., & Mitra, B. (2017). The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients. Injury, 48, 1020-1024. doi:10.1016/j.injury.2017.02.013

Stanton, D., Hardcastle, T., Muhlbauer, D., & van Zyl, D. (2017). Cervical collars and immobilisation: A South African best practice recommendation. African Journal of Emergency Medicine, 4-8. doi:10.1016/j.afjem.2017.01.007

Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al.  The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA. 2001; 286(15): 1841-8.

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