Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 1 of 14

District Procedure

MLHD Spinal Immobilisation and Log Rolling

Relates to MLHD-GLNE348

Cervical Spine Immobilisation and Management – Adult and Paediatric

PROCEDURE: All major trauma patients are considered to have potentially sustained spinal trauma and are immobilised as a precaution to prevent possible further spinal injury. Indications: Patients with suspected cervical spine injury must have their cervical spine properly immobilised until formal assessment occurs. Patients presenting to the Emergency department with altered level of consciousness and a history or evidence of traumatic injury that has the potential to cause spinal injuries.

Complaining of neck pain or tenderness or limitation of movement

Using Hands to support their neck

Has a neurological deficit, significant head or facial injuries Any patient with a mechanism of injury which may indicate spinal injuries

Patients that have spinal precautions recorded in their medical care and notes

Fall from elevation ≥ 3m

Axial load to head

Diving injury, near drowning

Motor vehicle collision (MVC) at high speed

MVC with rollover or patient ejection or backed over by car

Motorised recreational vehicles, Quadbike, motorised all-terrain vehicles

Bicycle struck or collision

Thrown over handle bars of bicycle

Kicked by or thrown from horse

Severe Electric Shock

> 65 years of age and cervical spine pain post traumatic injury

Patients presenting with paraesthesia’s in extremities post traumatic incident

Patients presenting with post traumatic amnesia or suspected closed head injury General Information: The clinician holding the head during collar application/change should be appropriately trained and competent in the application of Rigid and Semi Rigid cervical spine collars. If this is not available, the head holder should be a Registrar/Consultant.

The clinician holding the patient’s head is the team leader who informs the assistants of their roles and verbally directs the procedure.

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 2 of 14

N.B. If children are less than 8 years they should support under their shoulders. "A suitable folded pad allows for a child's large occiput and keeps spine in a neutral position." Fig. 1.

Fig.1.

A. Head Holding without collar insitu:

Perform hand hygiene in accordance with the Hand Hygiene Policy Directive

PD2010_058

Don appropriate Personal Protective Equipment (PPE) in accordance with the

Infection Control Policy Directive PD2007_036

The clinician holding the head takes position at the head of the of the patient and

positions hands on each side of the head, with thumbs along the mandible and

fingers behind the head on the occipital ridge. (Fig 2 & Fig 3)

Maintain gentle but firm stabilisation on the neck throughout the procedure (e.g.

application of cervical collar or log roll) and where applicable a cervical collar is

applied.

Explain to the patient what to expect and not to move their head

Fig.2. Fig. 3. Philadelphia collar In MLHD the Adjustable Philadelphia cervical collar replaces the semi rigid (“Stiffneck”) collar applied at the trauma scene if the neck cannot be cleared within 4 hours from the time the rigid collar was applied.(note Fig. 4) B. Fitting an Adjustable Philadelphia collar

Proper sizing is important for patient immobilisation and comfort. Always maintain the patient’s head in neutral alignment when fitting or removing a cervical spine collar. A two person procedure must be adhered to, in order to ensure alignment and fitting of the cervical spine collar. Perform hand hygiene and don appropriate PPE

With the patient supine or sitting have a trained staff member hold the patient

head in neutral alignment. Maintain the alignment until the collar is secured.

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 3 of 14

Place the chin cup of the front to the patients chin and slid the lower front down to

the patients sternum. Fig.4

Lift the front away from the patient, remove the plastic covering the sizing holes

and push the two tabs to lock the size. Fig.5

Fig.4. Fig.5

Identify the patient’s profile type according to the chart. Adjust the circumference by tearing away sections of the back piece foam to change to a smaller circumference Fig.6

Fig. 6 After adjusting the size of the collar, apply the back piece of the collar to the

back of the neck by direct application or by sliding the collar under the neck when the patient is in the supine position. Centre the collar. The back arrow should point upward.

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 4 of 14

Fig. 6 Fig. 7. Apply the front piece of the collar with the chin secured in the recess. Centre

the collar to secure neutral alignment. The front piece overlaps the back piece to ensure effective immobilisation and comfort. The front arrow should point upward. Fig.7.

With the Velcro fasteners, tighten the collar with bilateral adjustment, this will secure the patient’s cervical region in neutral alignment. Fig.8

.

Fig. 8

Assessment of correct fit: -

The patient’s chin should be sitting in the moulded chin support of the anterior section of the collar

The posterior section of the collar should be centred so that it is symmetrical, not rotated and the Velcro straps are even. The centre of the posterior section should be aligned with the patient’s spine.

The bottom of the anterior of the collar should sit on the patient’s chest and the anterior section must overlap the posterior section of the collar.

Causes of collar related pressure ulceration: -

Collar related pressure ulcers are formed when unrelieved pressure on poorly oxygenated tissue results in tissue ischaemia.

Supine patients are particularly at risk of pressure ulcers over bony prominences, particularly the occiput. Other susceptible sites include the chin, mandible, ears, laryngeal prominence, sternum, clavicles and shoulders.

The presence of moisture e.g. sweat, blood etc. may soften the skin resulting in predisposition to ulceration.

The recommended time frame for the use of the Philadelphia Collar is up to 48 hours post application in trauma patients.

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 5 of 14

Neck & Collar Care: -

Every 4 hours the collar should be removed to inspect the neck for signs of

pressure. The head and neck must be held in anatomical alignment by another

staff member until the collar and neck care has been attended and the cervical

collar is replaced (refer to head holding Fig 2)

The close cell foam does not absorb water so the neck becomes hot and sweaty

under the collar.

The collar should be washed in warm soapy water and dried with a towel

The patient’s skin must be washed and dried thoroughly and inspected for signs

of pressure. The collar must be replaced prior to log rolling for removal of the

posterior sect and inspection of the occiput

B. For head holding from the top of the bed (trapezius hold): This hold can be used

for log rolling (NOT for collar application)

With the forearms in the supinated position and with thumbs extended slide the

fingers along the trapezius bilaterally with thumbs resting over the clavicles snugging

the collar at the same time (Fig.9). In this hold, the forearms are used to maintain

traction/support of the patient’s head during the logroll (Fig.10). This is the preferred

method of head holding for log rolling or extrication once the cervical collar has been

applied.

Fig. 9 Fig. 10.

C. Head holding for intubated patient:

One hand is placed around the patient’s jaw with fingers spread (for a ventilated patient, the endotracheal tube may be stabilised with the thumb and index finger). The forearm is used to stabilise the lateral aspect of the head. The other hand is positioned under the patient’s neck with fingers spread. Firm pressure must be applied to restrict the possibility of flexion, extension and lateral tilting (Fig. 11).

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 6 of 14

Fig. 11

D. Log Rolling

The person who takes the head of the patient is the team leader for this procedure

and verbally directs the team for the log roll.

The log rolling procedure is implemented prior to thoracolumbar spinal clearance for

examination of the patient’s back, cervical collar care, pressure care, to facilitate

chest physiotherapy etc. The main principles underlying the log rolling procedure are

the strict adherence to correct anatomical alignment in order to prevent the possibility

of further, catastrophic neurologic injury and the prevention of pressure sores.

Four to five staff members are required to assist in this procedure:

▬ 1 person to hold the patient’s head and direct the procedure ▬ 2 or 3 people to support the chest, abdomen and lower limbs, and ▬ 1 person to carry out the planned activity i.e. pressure care etc.

In some cases, (e.g. morbidly obese patients or patients with lower limb traction) three assistants may be required to support the chest, abdomen and lower limbs).

Explain the procedure to the patient regardless of conscious state and ask the patient to lie still and to refrain from assisting.

Ensure that the collar is well fitting prior to commencement.

If applicable, ensure that devices such as indwelling catheters, intercostal

catheters, ventilator tubing etc. are repositioned to prevent overextension and

possible dislodgement during repositioning.

If the patient is intubated or has a tracheostomy tube, suction the airway prior to

log rolling is suggested, to prevent coughing which may cause possible

anatomical malalignment during the log rolling procedure.

The bed must be positioned at a suitable height for the head holder and

assistants.

The patient must be supine and anatomically aligned prior to commencement of

log rolling procedure.

The patient’s arm closest to the team must be bent slightly to avoid rolling onto

monitoring devices e.g. arterial or peripheral intravenous lines. The patient’s

opposite arm should be extended in alignment with the thorax and abdomen (Fig

12), or bent over the patient’s chest if appropriate i.e. if the arm is uninjured.

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 7 of 14

A pillow should be placed between the patient’s legs. (if a 3rd assistant is

unavailable)

Assistant 1, the assistant supporting the patient’s upper body, places one hand

over the patient’s shoulder to support the posterior chest area, and the otherhand

around the patient’s hips (Fig 12).

Assistant 2, the assistant supporting the patient’s abdomen and lower limbs,

overlaps with assistant 1 to place one hand under the patient’s back, and the

other hand over the patient’s thighs (Fig 12).

Fig. 12 Fig. 12 Log Rolling with 2 people to support the chest, abdomen and a pillow between the patient’s legs

Fig. 13

(Note: spinal and neck alignment as indicated by red lines) On direction from the Team Leader (head holder), the patient is turned in

anatomical alignment in one smooth action (Fig 13).

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 8 of 14

On completion of the planned activity, the head holder will direct the assistants to either return the patient to the supine position or to support the patient in a lateral position with wedge pillows. The patient must be left in correct anatomical alignment.

Consider suction post log roll to clear any mobilised secretions.

Log rolling is no longer required if the thoracolumbar plain films are clear, but must be clearly documented by Medical Staff that log rolling is no longer required.

Lateral positioning (side lying)

The patient may be positioned laterally prior to spinal clearance to assist with chest physiotherapy and reduction of collar-related occipital pressure. Exceptions to this rule may include unstable thoracic, lumbar or pelvic fractures.

The patient must be well supported in the lateral position using wedges. The patient’s head and body must be kept in anatomical alignment at all times. Padding may be required between the cervical collar and the bed to prevent lateral tilting of the patient’s head.

Equipment & Materials

Standard bed & mattress ( x-ray board optional )

Cardiac Monitored bed within direct sight of staff

Immediate access for log roll with call notification system in reach

Minimum of 3 accredited staff members

Cervical Spine immobilisation device - Philadelphia collar

Suction unit in reach of head of patient

Personal protection equipment

Hand hygiene material and access

Alerts/Risks Traumatic injuries can be sustained over several body regions. Consideration needs to be in the immobilisation and stabilisation for the entire spine in patients that meet a mechanism of injury that has the high suspicion of a spinal injury. Care should be executed in the management of the patient of suspected spinal injured patients.

Aim: To provide a standard for the spinal immobilisation process and log rolling of patients with potential / actual spinal injuries across Murrumbidgee Local Health District (MLHD).

NB: Suspected spinal injury in patients <16 years should be assessed according to the Royal Children’s Hospital Melbourne Cervical Spine Assessment Guideline. Health services should contact NETS on 1300 362 500 and their referral hospital; Sydney Children’s Hospital (Westmead or Randwick) for further advice on the management of the paediatric patient with a potential cervical spine injury. (http://www.rch.org.au/clinicalguide/guideline_index/Cervical_Spine_Injury/)

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 9 of 14

Indication criteria: Patients presenting to the Emergency department with altered level of consciousness and a history or evidence of traumatic injury / fall that has the potential to cause spinal injuries. High risk mechanism of injury is:

Fall from elevation >3m

Axial load to head

Motor vehicle collision (MVC) at high speed

Motorised recreational vehicles

MVC with rollover or patient ejection

Bicycle struck or collision

> 65 years of age and cervical spine pain post traumatic injury

Patients presenting with paraesthesia’s in extremities post traumatic incident

Aims of Care: The main aims of care for trauma patients with potential spinal injuries are:

Prevention of possible further spinal injury

Application of cervical collar Instigation of protocol spinal position restrictions

Prevention of complications of immobilisation

Strict collar care Frequent turning Upright positioning as soon as possible (i.e. based on imaging)

Appropriate and timely documentation

National Standard/Criteria: 1.7 Clinical Practice

3.1 Governance and systems for infection prevention, control and surveillance

8.1 & 8.3 Governance and systems for the prevention and management of pressure injuries

Scope: Medical Officers, Nursing and Midwifery, Allied Health Care Workers, Wards Person, Radiology Staff (For actions A, B C, and D, staff must be able to correctly fit cervical collar and assume team leader role) Sequence of Actions

A. Head holding without collar insitu

B. Fitting an Adjustable Philadelphia collar

C. Head holding with collar insitu

D. Head holding for intubated patient

E. Log Rolling

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 10 of 14

Patient Education

Explain the procedure to the patient regardless of the patient’s conscious state and ask the patient to lie still and to refrain from assisting.

Documentation

Documentation of the collar size and application time should be recorded in the patient’s medical record.

Cervical immobilisation and spinal precautions are to be documented clearly in treatment plan in the patient’s medical record.

Pressure area care and Log roll are to be documented clearly in the patient’s eMR or medical record.

Safety Considerations Back Care Hand Hygiene Clinical Competency Patient Education Standard Precautions

Outcomes

Patient and staff are educated, understand and are deemed competent to perform tasks outlined in this procedure. 100% compliance with this guideline. Suspected cervical spine injuries are immobilised with a semi rigid cervical collar. Patients at risk of or have spinal injuries are immobilised and log rolled in accordance with this procedure. Demonstrated decreased risk of secondary injury to the patient from management. Demonstrated decreased risk of complication from cervical spine immobilisation.

Contra Indications Use in non-trauma patients Application of Philadelphia Cervical Collar for greater than 48 hours post application

Terminology:

Semi Rigid “Stiffneck” Collar: The hard or “Stiffneck” collar is a one piece polyethylene ridged collar available in multiple sizes stocked by Ambulance Service NSW and MLHD facilities This collar is now being replaced in MLHD facilities by the Philadelphia Semi Rigid Collar

Semi Rigid Philadelphia Collar: The Philadelphia collar is a two piece, closed cell foam hypoallergenic collar available a variety of sizes. One adjustable size (that fits 95% adults) a small adult and 2 paediatric size collars currently being stocked by the MLHD.

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 11 of 14

Spinal Injury: Major trauma patients are considered to have sustained a spinal cord injury until proven otherwise and must therefore have appropriate immobilisation procedures applied as a precaution. This ensures that further catastrophic neurological insult is prevented. Trauma to the vertebral column may result in: Skeletal fractures, Subluxation or dislocation injuries including locked facet joints, Disc injuries, Ligamentous injuries, Spinal cord injuries. Spinal Clearance: Spinal clearance is said to have occurred when relevant clinicians have examined the patient physically and/or as well as radio-graphically, and have determined that no significant injury exists, and immobilisation procedures are no longer required. The process of spinal clearance is the application of an assessment framework for the evaluation of spinal status in those patients considered to be at risk for spinal injury. This assessment process is concluded with either a validation that excludes spinal cord injury and potential injury from unstable fractures, via mechanism of injury history, examination and investigation, or the diagnosis and subsequent management of an injury.

Immobilisation: Involves the fitting of a cervical collar as a means of minimising the risk of cervical spinal cord compromise, nursing the patient in a supine or lateral position with wedge support, and log rolling during transfer and pressure area care to minimise the risk to the thoracic and lumbar cord. Failure however to achieve prompt clearance, i.e. within 72 hours of injury, may result in increased mortality and morbidity. Hand Hygiene: The term “Hand Hygiene” includes both hand washing with running water and either plain or antimicrobial-containing liquid and either plain or antimicrobial-containing liquid soap or the use of water-free skin cleansers or antimicrobials such as alcohol-based products. The 5 Moments for Hand Hygiene are: Moment 1: Before touching a patient Moment 2: Before a procedure (immediately before) Moment 3: After a procedure or body fluid exposure risk (immediately after) Moment 4: After touching a patient Moment 5: After touching a patient’s surroundings

Acknowledgements: Canberra Hospital – Standard operating procedure – Spinal precautions and Care of Adult Patients with Potential Spinal Injuries St George Hospital – Practice Guideline – Care and Fitting of Cervical Collars. Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 2012 The Alfred Spinal Clearance Management Protocol November 2009

References: 1. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for

identification of cervical spine injuries following trauma: update from the Eastern

Association for the Surgery of Trauma Practice Management Guidelines

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 12 of 14

Committee. J Trauma 2009;67:651-9.

2. An update on spinal cord injury: Epidemiology, diagnosis, and treatment for the

emergency physician. Trauma Reports. 2013.

3. Hendy GW, Wolfson AB, Mower WR et al. Spinal cord injury without radiographic abnormality: Results of the National Emergency X-Radiography Utilisation study in blunt cervical trauma. J.Trauma. 2002;53:1-4.

4. Hoffman JR, Wolfson AB, Todd K & Mower WR (1998) Selective cervical spine radiography in blunt trauma: Methodology of the National Emergency X-Radiography Utilisation Study (NEXUS), Annuals of Emergency Medicine, 32:461-469

5. James CY, Riemann BL, Munkasy BA, Joyner AB. Comparison of cervical spine motion during application among 4 rigid immobilization collars. Journal of Athletic Training. 2004;39(2):138-145.

6. Kwan I, Bunn F & Roberts I (2001) Spinal immobilisation for trauma patients (Review), The Cochrane Collaboration, 4:1-15

7. Pimentel L., Diegelmann L., ‘Evaluation and Management of Acute Cervical Spine Trauma’, Emergency Medicine Clinics of North America, no. 28 (2010) pp. 719-738.

8. Stiell, Ian G,M.D., M.Sc, Clement, C. M., R.N., McKnight, R. D., Brison, Robert,M.D., M.P.H., Schull, Michael J,M.D., M.Sc, Rowe, Brian H,M.D., M.Sc, . . . Wells, G. A., PhD. (2003). The canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. The New England Journal of Medicine, 349(26), 2510-8.

9. Tescher A.N., Rindflesch A.B., Youdas J.W., Jacobson T.M., Downer L.L., Miers A.G., Basford J.R., Cullinane D.C., Stevens S.R., Pankratz S., Decker P.A., 2007 ‘Range-of-Motion restriction and craniofacial tissue-interface pressure from four cervical collars’, Journal of Trauma, 2007 no.63, pp. 1120-1126

10. Webber-Jones JE, Thomas CA, Bordeaux RE Jnr. The management and prevention of rigid cervical collar complications. Orthop.Nurs. 2002;21:19-28.

11. Department of Health NSW 2007 Policy Directive PD2007_036 Infection Control

Policy 12. Department of Health NSW 2010 Policy Directive PD2010_058 Hand Hygiene

Policy 13. Ackland.H, 2006 The Alfred spinal clearance management protocol. Melbourne

Implementation & Communication Plan:

Risk Rating (refer to MoH Risk Matrix)

EXTREME

☐

HIGH

☐

MEDIUM

☐

LOW

☐

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 13 of 14

Timeframe for Implementation from release date: 24 hours

14 days

8 weeks 3 months

Implementation Stages & Communication List outcome measure/KPI

Who is responsible?

Timeframe Review/Evidence

Staff read document

Trauma CNC

Emergency & Critical Care Services CNC

3 months All staff providing care to trauma patients with the potential for spinal injury have signed to indicate they have read and understood the procedure

Managers Facility Managers

Ensure staff are educated and accredited in the compliance of this procedure

Training requirements (e.g., in-service, orientation, workshops)

CNC Emergency Services

CNE’s – ED, ICU, Surgical, Trauma

6 months Attain education and accreditation with this procedure

Ensure compliance with this document

Resource requirements (e.g. promotional material, signage,)

Facility Managers

Facilities to have adult and paediatric single use Philadelphia collars in stock to replace the Semi-Rigid “Stiffneck” (Laerdal) collars

System requirements (e.g. IT support, supervision,)

Andrea Clark

District policy officer-

Procedure to be ratified and uploaded onto staffnet policy and procedure page

PART 2: Key Performance Indicators:

1. n/a

Spinal Immobilisation and Log Rolling National Standard 1, 3 & 8 January 2015 Page 14 of 14

Consultation Process / List:

Title / Position Response received –

Yes/No

Executive Director of Medical Services

Dr Bruce Warton

No

Executive Director of Nursing and Midwifery Karen Cairney No

Director of Critical Care Dr Trish Saccasan Whelan Yes

Director of Operations – Ken Hampson

Director of Clinical Governance – Jill Reyment Yes

Director of Trauma Services – Oran Rigby Yes

Director of Emergency Department WWBH - Shane Curran No

Director of Emergency Department GBH - Emmanuel Jeyarajah No

Rural Group Manager (Riverina) - Maria Roche No

Rural Group Manager (Border) - Rosemary Garthwaite No

Rural Group Manager (MIA) - Ken Hampson

MLHD CNC – Emergency & Critical Care Services - Audas Grant No

MLHD CNC – Intensive Care – Kylie Pleming Yes

MLHD CNC Paediatrics – Lesley Jeffries Yes

MLHD Infection Prevention & Control Consultant – Sharon Maher Yes

NUM ICU Griffith Base – Julie Henderson Yes

Created By:

Anne. Hawkins MLHD CNC Emergency & Critical Care Services

(Benjamin Hall CNC Trauma Services)