Acute Management of Head and Spine Injuries

Acute Management ofHead and Spine Injuries

Ron Courson, ATC, PT, NREMT-I, CSCSSenior Associate Athletic Director - Sports Medicine

University of Georgia Athens, GA

Enormous Impact Associated With Catastrophic Cervical Spine Injuries

– Physical: • pain and suffering• permanent disabilities for remainder of life

– Financial: • significant medical costs• other associated costs (i.e. home and auto modifications, attendants,

wheelchair, etc...)• loss of income for parents/guardians

– Emotional:• mental stress and anguish for student-athlete, family, friends,

teammates, coaches

University of Georgia Sports Medicine

Objective

• Provide guidelines for the pre-hospital care of an athlete with a suspected head and/or spine injury


Background

• Variety of healthcare professionals may be involved in on-field management of suspected head and/or spine injury

• Important to develop standard guidelines to be used by all providers of pre-hospital care to ensure safe management


TEAMWORK• When dealing with a

potential life-threatening situation such as a head or c-spine injury, the scene of the injury is not the time nor the place for healthcare professionals to decide on appropriate treatment on such a controversial area


Emergency Preparation

• Healthcare providers for athletic competition (MDs, EMTs, ATCs) should develop emergency plan and protocol for dealing with such injuries when they occur and rehearse on regular basis


Emergency Assessment• organized process to

quickly obtain information vital to care– primary survey

• assess LOC-CAB

– provide immediate basic life support measures as needed

– quickly make decision regarding transportation

– secondary survey (more detailed) performed either on-site or during transport


Emergency Assessment

Neurologic assessment should be performed before and after full-body immobilization ! PMSC

Pulse Motor Sensation Capillary refill


Emergency Assessment

Heightened suspicion of potentially catastrophic spine injury: MOI unconscious or altered

level of consciousness neurological complaints

and/or deficits significant midline spine

pain obvious spinal column

deformity


Emergency Assessment Heightened suspicion

of potentially catastrophic spine injury: priaprism respiratory distress

“tracheal tugging” accessory respiratory

muscles

neurogenic shock decreased blood

pressure increased pulse


Cervical Spine Injury Case Study• Not all c-spine injuries

present in acute distress!

• 22YOBM college football player (DB/kick returner)

• returned kick-off in game

• MOI: helmet to helmet contact

• returned to sideline without apparent injury

• c/o neck pain/stiffness

• no neurologic complaints


Cervical Spine Injury Case Study


Cervical Spine Injury Case Study


Black & White or Gray ?

Every emergency situation and every patient is different

Individual circumstances must dictate appropriate actions

No such thing as “always” and “never”

James R. Andrews, MD



Neutral Alignment

• Current recommendations for the acute treatment of the cervical-spine injured athlete are to immobilize the head and neck in neutral alignment prior to transfer to an emergency facility and to minimize the motion that occurs throughout this process



Sustained Spinal Cord Compression• “Sustained compression of

the spinal cord is a crucially important factor in the secondary injury process”

• “Longer duration of compression is associated with increased pathological changes and decreases in neurologic recovery”

• “Damage to the spinal cord depends strongly on the duration of displacement and timing of treatment”


Cervical Immobilization Device (CID)

Always use cervical collar if feasible

Measure for cervical collar

Adjustable c-collar


Spine Board

Standard fiberglass spine board

Oversize fiberglass spine board with pins for speed clips

Scoop stretcher Miller full-body

splint


Spine Board Accessories

Spine board kit CID HID body immobilization

straps facemask removal

tools wrist straps tape padding


Head Immobilization Device (HID)

• Variety of designs to secure head to spine board; be skilled in use of design you select

• Always secure head last to spine board


Facemask Removal:Combined Tool Approach

• Facemask should be removed prior to transportation, regardless of current respiratory status

• Facemask removal tools should be readily available

• Combined tool approach


Facemask Removal

• Prior to facemask removal, pocket mask may be positioned through facemask for ventilatory assistance


Facemask Removal

• Following facemask removal, bag-valve-mask may be utilized for ventilatory assistance

• Utilize oxygen if available


Facemask Removal

• Do not “flip” mask !

– studies show increased movement from torque involved in rotating facemask

– facemask acts as lever arm with helmet, increasing risk of c-spine movement if moved


Facemask Removal

• Be familiar with all types of equipment utilized by your athletes

• Utilize quick release facemask clips if possible– Riddell– Schutt

Facemask Removal:Quick Release Clips



Spinal Immobilization Techniques

Log roll

Lift and slide


Spinal Immobilization Techniques

Log roll vs. lift and slide research compared

techniques to assess movement in healthy individuals and destabilized c-spines of cadavers


Spinal Immobilization Research

• Del Rossi, Heffernan and Horodyski; Spine J 2004; 29(7); E134-8

Del Rossi, Horodyski and Heffernan; J Ath Tr; 38(3); 204-208

Both techniques created movement; more with log roll


Supine Log Roll


Prone Log Roll

In-line c-spine stabilization

Thumbs toward face If c-spine not in

neutral, gently correct unless resistance met

Airway takes priority over c-spine


Prone Log Roll

• Pull technique


Prone Log Roll

• Push technique


Centering on Spine Board

Position top of board ~ 10-12 inches above athletes’ head to allow for further centering movement when positioned on board



• Various techniques– angled centering– over and up on angle

– avoid straight lateral movements



• Athlete may be straddled by one or multiple rescuers and clothing gripped to facilitate centering


Lift and Slide

• May be lifted from sides or by straddling athlete

• Requires multiple rescuers (6-8)


Straps & Strapping Technique

• Pin and speed clip system– requires customized

spine board– allows for multiple

strapping techniques– rapid fixation to

spine board


Straps & Strapping Technique

• Velcro “Spider” Straps”


Securing to Spine Board

X-strapping technique from top of shoulder under opposite axilla

Minimizes translation on spine board– important with

acceleration/ deceleration of

ambulance


Securing to Spine Board

• Effectiveness of Strapping Techniques in Spinal Immobilization– Annals of Emergency

Med. Mazolewski and Manix. 23:6 June 1994


Securing to Spine Board Head should be last

body segment secured to spine board

Use circumferential taping technique for top of head

Eyebrows as landmark if no helmet

Secure chin Secure wrists together

outside of spine board straps


Athletic Equipment Removal

• Many EMTs in past have advocated removal of helmets or headgear

• Many ATCs in past have advocated leaving athletic helmet or headgear in place

• Both schools of thought provide rationales for that course of treatment

• “All or none” principle ?

Paradigm Shift in Equipment Removal ?

Full Body Immobilization With and

Without Equipment

Transfer to Spine Board

Helmet Removal

Shoulder Pad Removal


Shoulder Pad Removal


Emergency Room Education

• Medical team may choose to remove athletic equipment following transportation to an emergency facility and following the evaluation and diagnostic testing

• Emergency room workers should be trained in athletic equipment removal


Conclusion• Important to develop

standard guidelines• Carefully weigh all

factors and make educated decision on what fits best into individual situation

• Proper planning and preparation

• Sports medicine team concept

• Further research and training needed in spinal immobilization and equipment removal techniques

Documents

Acute Management of Head and Spine Injuries