Spinal Immobilization V 2 Feb 2011

Spinal
Immobilisation
Techniques and
Devices.
A GUIDE FOR EDUCATION & COMPETENCY
Compiled by: Wendy Porteous - V 2 - 2011
ACKNOWLEDGEMENTS
Thank you to: Pat Standen, Di Woods for reviewing the document and providing their expert advice; and
Ballarat Health Services and Ambulance Victoria for so generously allowing their clinical practice guidelines
to be used as a guide.
Thanks to Emergency Technologies and Anthony Hann for the use of the resources available in their
publication A Photographic Guide to Prehospital Spinal Care. It can be downloaded from
www.emergencytechnologies.com.au
PURPOSE
The purpose of this guide is to assist educators in the Grampians Region to design their own Health Service
specific package for Registered Nurses Division 1 & 2 required to manage patients with suspected or actual
spinal column injuries in an emergency situation. The aim of this guide is to provide generic information
based on principles of care.
It is the responsibility of each individual practitioner and Health Service to ensure appropriate education for
all equipment and that competency in the use of the equipment is maintained.
For information regarding this Guide contact:

Pat Standen
Trauma, Emergency & Critical Care Coordinator | Service & Workforce Development | Grampians Region
Department of Health
35 Armstrong Street South, Ballarat, Victoria, 3350
Email: Pat.Standen@health.vic.gov.au
Phone: 03 5333 6026
Version
1.0
2.0
Date
December 2009
February 2011
Major Changes
Page No
DISCLAIMER:
Care has been taken to confirm the accuracy of the information presented in this guide, however, the authors, editors and publisher are not responsible
for errors or omissions or for any consequences from application of the information in the guide and make no warranty, express or implied, with
respect to the contents of the publication.
Every effort has been made to ensure the clinical information provided is in accordance with current recommendations and practice. However, in view
of ongoing research, changes in government regulations and the flow of other information, the information is provided on the basis that all persons
undertake responsibility for assessing the relevance and accuracy of its content.
Spinal Immobilisation Techniques and Devices

Version 2/2011
Contents
Introduction
Anatomy & Physiology of the Spine
Aetiology of Spinal Cord Injury
30
Primary Spinal Cord Injury

Hyperextension Injury
Flexion Injury
Compression / Axial Loading
Distraction
Rotation
Penetration
Secondary Spinal Cord Injury

Pathological Changes following Injury
Neurogenic Shock
Post Traumatic Ischaemia
Calcium entry into the cells
Increased Extracellular Potassium
Failure to immobilise unstable fractures
Functional Classifications
Tetraplegia
Tetraparesis
Paraplegia
Paraparesis
Spinal Cord Injuries

Complete Injuries
Incomplete Injuries
Central Cord Syndrome
Brown Sequard Syndrome
Anterior Cord Syndrome
Cauda Equina Syndrome
30
31
32
33
34
35
36
37
37
38
39
39
39
39
40
40
40
40
40
41
41
42
42
43
43
44
Signs & Symptoms of Spinal Cord Injury
45
Mechanisms of spinal Cord Injury
51
Spinal Immobilisation
52
Indications
Cautions
Patient preparation
Procedural steps
Age specific considerations
Spinal Clearance

Version 2/2011
52
52
53
53
55
57
Considerations of Spinal Cord Injury in Paediatrics
58
Manual In-Line Immobilisation
60
Motor Cycle Helmet Removal
64
Log-Rolling
72
Semi-Rigid Extrication Collars
76
Stifneck Collar
Vertebrace Collar
Philadelphia Collar
77
85
90
Spinal Boards / Back Boards
96
Maintenance of Neutral In-Line Position of the Head
97
Immobilisation of the Head to the Device
100
Head Blocks / Head Immobilisers
101
Vacuum Mattresses
103
Extrication Vests
105
Jordon (Donway) Lifting Frame
112
Clinical Practice Guidelines and Competency Assessments
114
Bibliography, References and Further Reading
125

Version 2/2011
INTRODUCTION
Spinal trauma, if not recognised and properly managed can result in irreversible damage
and leave a patient paralysed for life. Some patients sustain immediate spinal cord
damage as a result of trauma. Others sustain an injury to the spinal column that does not
initially damage the cord; cord damage may result later with movement of the spine.
Because the central nervous system is incapable of regeneration, a severed spinal cord
cannot be repaired. The consequences of inappropriately moving a patient with a spinal
column injury, or allowing the patient to move, can be devastating.
Anatomy and Physiology of the Spine

The Nervous System is made up of all the nerve tissue in the body including the brain,
brainstem, spinal cord, nerves and ganglia. It is divided into two parts:
Central Nervous System (CNS).
Peripheral Nervous System (PNS).
Brain and Spinal Cord

Version 2/2011
CENTRAL NERVOUS SYSTEM

The Central Nervous System (CNS) is that part of the nervous system that consists of the
brain and spinal cord.
The average adult human brain weighs 1.3 to 1.4 kg. The brain is thought to contain
approximately 100 billion nerve cells (also known as neurons) and trillions of "support
cells" called glia.
The spinal cord is approximately 43 cm long in the average adult female and 45 cm long in
average adult male. It weighs approximately 35 to 40 gms. The spinal cord is protected by
a series of structures including the vertebral column, muscles, ligaments, cerebral spinal
fluid, and the meninges.
PERIPHERAL NERVOUS SYSTEM
The Peripheral Nervous System (PNS) is the nervous system found outside the spinal
cord. Nerves in the PNS connect the CNS with sensory organs, other body organs,
muscles, blood vessels and glands.
The PNS is divided into two major parts:
Somatic nervous system
Autonomic nervous system
SOMATIC NERVOUS SYSTEM
The somatic nervous system is under voluntary control.
It consists of peripheral nerve fibres that send sensory information to the brain, and motor
nerve fibres that send messages to the skeletal muscles.
AUTONOMIC NERVOUS SYSTEM
The autonomic nervous system looks after those neurons that are not under conscious
control and regulates key functions, including the activity of the heart muscle, smooth
muscles (e.g. abdomen), and the glands.
It is divided into two parts:
Sympathetic nervous system
Parasympathetic nervous system

Version 2/2011
SYMPATHETIC NERVOUS SYSTEM

The Sympathetic Nervous System is the system that involves the fight/flight responses of
the body including accelerating the heart rate, constricting blood vessels, raising blood
pressure, producing sweating, increasing blood supply to the muscles and accelerating
respiration.
The Sympathetic Nervous System fibres come out of cell bodies in the spinal cord from T1
to L2 and secrete adrenaline & nor-adrenaline.

Version 2/2011
PARASYMPATHETIC NERVOUS SYSTEM

The Parasympathetic Nervous System is the system that slows down the body including
slowing the heart rate, dilating the blood vessels, lowering blood pressure and slowing
respiration.
The Parasympathetic Nervous System fibres come out of the cranial nerves 3, 5, 9 & 10,
and from the spinal cord at the sacral levels of S2 to S4.
FLOWCHART OF THE NERVOUS SYSTEM

Version 2/2011
NEURONS
Cells of the nervous system are called nerve cells or neurons. These are the basic
information processing unit of the nervous system, and are responsible for generating and
conducting nerve impulses via an electrochemical process. The human brain has some
100 billion neurons. Neurons come in many different shapes and sizes. Some of the
smallest neurons have cell bodies that are only 4 microns in diameter (1 micron is equal to
one thousandth of a mm). Some of the larger neurons have cell bodies measuring 100
microns in diameter.
Neurons differ from other cells in the body because:
Neurons have specialized extensions called dendrites (bringing information to the cell
body) and axons (which take information away from the cell body).
Neurons communicate with each other via an electrochemical process.

Version 2/2011
Dendrites are thread like extensions of the cell bodys cytoplasm forming a tree like
formation. Unlike axons, dendrites are not surrounded by an outer covering.
Dendrites comprise most of the receptive surfaces of a neuron.
The dendrites main purpose is to conduct nerve impulses towards the neurons cell body.
CELL BODY
The cell body is the main part of the neuron and is composed of substances to keep the
neuron alive.
It consists of nucleus, cytoplasm & endoplasmic reticulum.
Cell bodies are found in the grey matter (H shape) of the spinal cord.
AXON
The axons purpose is to conduct nerve impulses away from the cell body. Most axons are
covered with a myelin sheath for axon protection and to improve conduction of the nerve
impulse down the axon.
Myelinated axons are found in the white matter of the spinal cord.

Version 2/2011
10
OLIGODENDROCYTES
Oligodendrocytes are a form of neuroglial cells (type of connective tissue) found in the
CNS that forms a myelinated wrapping around the CNS axons.
Oligodendrocytes surround neurons, providing both mechanical & physical support, and
electrical insulation between neurons; dramatically increase the speed of conduction
through the axon.
Oligodendrocytes form the white matter of the spinal cord.
SCHWANN CELLS
Schwann cells are a form of neuroglial cells found in the PNS that form a myelinated
sheath wrapping around the PNS neurons axons.
The purpose of this myelinated sheath is to provide an insulating layer surrounding the
axon that dramatically increases the speed of conduction through the axon.
NODES OF RANVIER
Nodes of Ranvier are regions of exposed neuronal plasma membrane on a myelinated
axon that occur every 1 - 2 cm down the axon.
The nodes contain very high concentrations of voltage gated ion channels and are the site
of propagation of action potentials (which reduces the capacitance of the neuron), allowing
much faster transmission of the nerve impulse down the axon.
SYNAPTIC CLEFT
Communication from neuron to neuron, or neuron to muscle & sensory receptor (including
pain, temperature and pressure receptors) occurs at the synaptic cleft, by a process called
the synapse.
The synapse process occurs by:
An impulse moves down the axon to the synaptic knob.
Calcium channels in the synaptic knob are stimulated and open allowing calcium to enter
the synaptic knob.
Calcium stimulates synaptic vesicles which move towards and fuse with the presynaptic
membrane.
Synaptic vesicles release neurotransmitter substances including acetylcholine (between
nerves & skeletal muscle), nor-adrenaline and acetylcholine (between nerves & visceral
organs) and a range of other substances (for neuron to neuron).

Version 2/2011
11
Neurotransmitters pass across the synaptic cleft to the post synaptic membrane.
The neurotransmitters combine with the receptors on the post synaptic membrane and if
strong enough, stimulates an excitatory or inhibitory reaction.

Version 2/2011
12
SPINAL CORD
The spinal cord is a bundle of neurons (approximately 13.5 million) that forms the main
pathway for information connecting the brain and the peripheral nervous system.
The human spinal cord is about 43 to 45 cm long, 9 to 14 mm wide, and weighs
approximately 35 gms. It is a continuation of the brainstem beginning at the foramen
magnum and extending down to the last of the 2nd lumbar vertebra. Nerves that branch
from the spinal cord at the lumbar and sacral levels must run in the vertebral canal for a
distance before they exit the vertebral column. This collection of nerves in the vertebral
canal is called the cauda equina (which means "horse tail").
The central grey matter of the spinal cord is made up of the nerves cell body, dendrites
and unmyelinated axons, with the white matter formed by the myelinated axons.

Version 2/2011
13
Spinal Cord
Extends from foramen magnum to second lumbar vertebra
Segmented
Cervical
Thoracic
Lumbar
Sacral
Gives rise to 31 pairs of spinal nerves
Not uniform in diameter throughout length
http://www.glittra.com/yvonne/neuropics/spinalcross.gif

Version 2/2011
14
SPINAL NERVES
Spinal nerves are collections of axons of the peripheral nervous system.

A total of 31 pairs of spinal nerves emerge from the spinal cord which includes:
Cervical - 8
Thoracic - 12
Lumbar - 5
Sacral - 5
Coccygeal - 1
The motor nerves leave the spinal cord anteriorly whilst the sensory nerves enter the cord
posteriorly.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Version 2/2011
15


Version 2/2011
16
BLOOD SUPPLY TO THE SPINAL CORD

There are 3 arteries running the length of the spinal cord:
One anterior spinal artery supplies the anterior two-thirds of the spinal cord.
Two posterior spinal arteries supply the posterior one-third of the spinal cord.
Additional arteries known as segmental radicular arteries enter the vertebral canal at the
same points that spinal nerves enter and leave the spinal cord.
Veins run parallel with the arteries and are continuous with the venous drainage system of
the brain.
The internal vertebral venous plexus are a group of spinal veins found both anterior and
posterior (usually 3 of each) that drain into numerous radicular veins. These form a
network of thin walled, valveless veins in the extradural (epidural) space draining the
spinal cord.
The external vertebral venous plexus surrounds the vertebral column and communicate
freely with the internal vertebral venous plexus, also draining the spinal cord.
http://www.frca.co.uk/images/spinal-cord5.jpg

Version 2/2011
17
MENINGES
The brain and spinal cord are surrounded by a protective lining known as the meninges
which is designed to keep out infection
There are 3 layers of the meninges:
Dura Mater forms the outer most layer. It is a tough, fibrous, tubular sheath that
extends down to S2 (even thought the spinal cord terminates at L1-L2).
Arachnoid forms the middle layer. It is a delicate membrane sheath that also
extends down to S2.
Pia Mater forms the inner layer. It adheres closely to the surface of the spinal cord,
enclosing a network of blood vessels & gives rise to denticulate ligaments.

Version 2/2011
18
CEREBRAL SPINAL FLUID

Cerebral spinal fluid (CSF) is a clear odourless fluid produced from plasma by a structure
(called the choroid plexus) in the lateral, third and fourth ventricles of the brain. CSF flows
from the ventricles into the subarachnoid space. Approximately 100 mL of CSF flows
around the brain and spinal cord.
The CSF has four functions including:
1. Protection: the CSF protects the brain and spinal cord from damage by acting to
cushion blows to the head and torso (to lessen the impact).
2. Buoyancy: because the brain is immersed in fluid, the net weight of the brain is
reduced from about 1.4 kg to about 50 gm. Therefore, pressure at the base of the
brain is reduced.
3. Excretion of waste products: the one-way flow from the CSF to the blood takes
potentially harmful metabolites, drugs and other substances away from the brain.
4. Endocrine transport throughout the brain: the CSF transports hormones throughout
the brain and spinal cord where they may act.

Version 2/2011
19
DENTICULATE LIGAMENTS
The denticulate ligaments extend from the spinal cord at 21 points between nerve roots, to
suspend the spinal cord within the dural sac.
These ligaments help prevent the spinal cord being knocked against the vertebrae during
motion.
http://www.anatomy.tv/StudyGuides/Images/Denticulateligament.jpg

Version 2/2011
20
SPINAL COLUMN
The individual bones of the spinal column (also referred to as vertebral column) are known
as the vertebrae.
The vertebrae provide significant protection and support to the spinal cord. Vertebrae also
take the majority of the weight placed upon the spinal column.
There are 31 to 33 vertebrae that, when stacked on top of each other, create the spinal
column.
The variation in number of vertebrae is due to the fusing of the sacral and
coccygeal vertebrae which numerous texts classify differently.
The normal spinal column forms an "S" like curve when looking at it from the side. This
allows for an even distribution of weight. The "S" curve helps a healthy spine withstand all
kinds of stress. The cervical section curves slightly inward, the thoracic section curves
outward, and the lumbar section curves inward. Even though the lower portion of the spine
holds most of the body's weight, each section relies upon the strength of the other sections
to function properly.
The body of each vertebra is a large, round portion of bone. The body of each vertebra is
attached to a bony ring. When the vertebrae are stacked one on top of each other, these
rings creates a hollow tube known as the spinal canal, through which the spinal cord
passes.
VERTEBRAE
The vertebrae are the individual bones of the spinal column, and are made of a hard outer
shell called cortical bone, with an internal component being soft and spongy cancellous
bone.
The anatomy of the vertebrae consists of:
The Body is the large round section at the front of the vertebrae and takes most of
the weight placed on the spinal column.
The Spinal Canal also known as the vertebral foramen is where the spinal cord is
located.
The Transverse Processes are where the back muscles attach to the vertebrae.

Version 2/2011
21
The Spinous Process is the bony portion opposite the body of the vertebrae.
The Lamina extends from the body to cover the spinal canal.
The Facets connect each vertebra together and allows the vertebral column to
move.
The Pedicle is a bony projection that connects to both sides of the lamina.
The Neural Foramen is the opening between each pair of vertebrae where the
nerve roots exit the spine.


Version 2/2011
22
SPINAL SECTIONS
The spinal column is made up of 33 vertebrae, although some medical textbooks range
from 27 to 33 due to the fused bones of the sacral and coccygeal sections.
The 5 sections of the spinal column are:
Cervical spine (7)
Thoracic spine (12)
Lumbar spine (5)
Sacral spine (5)
Coccyx spine (4)
http://www.jeffersonhospital.org/images/staywell/125634.GIF

Version 2/2011
23
CERVICAL SPINE
The cervical section (also called cervical spine) consists of the first seven vertebrae of the
vertebral column and is the most mobile of all the sections.
The first two vertebrae in the cervical spine, the atlas and the axis differ from the other
vertebrae as they are designed specifically for significant rotation.
The cervical spine's shape has a lordotic curve. The lordotic shape is like a backward "C".
Think of the spine as having an "S" like shape, and the cervical region being top of the "S".
http://www.spineuniverse.com/anatomy/vertebral-column
THORACIC SPINE
The thoracic section (also called thoracic spine) consists of the next 12 vertebrae of the
spinal column.
Each thoracic vertebra connects to ribs and form part of the posterior wall of the thorax
(the rib cage area between the neck and the diaphragm).
This section of the spine has very narrow, thin intervertebral discs, therefore limiting
movement between vertebrae in comparison to the lumbar or cervical sections of the
spine. There is also less space in the spinal canal for the nerves.
The thoracic spine's curve is called kyphotic because of its shape, which is a regular "C"
shaped curve with the opening of the "C" in the front.

Version 2/2011
24
LUMBAR SPINE
The lumbar section (also called lumbar spine) consists of the next 5 (stubby) vertebrae.
These vertebrae are the largest in the entire spinal column, and need to be as they carry
two thirds of the bodys weight. Thus the larger area of the spinal canal in each of the
lumbar vertebrae allows more space for the spinal cord to move laterally.
The lumbar sections shape is similar to the cervical section in that it has a lordotic curve (a
backward "C"). Remembering that the spinal column is an S shape, the lumbar spine is
the bottom of the "S". This lordotic curve is the result of walking and standing erect.
This group of vertebrae are very mobile and during bending takes 50% of the upper body
weight (the other 50% by the hips). As a result, great pressure is placed onto the lumbar
sections discs, often causing them to rupture in later life.

Version 2/2011
25
SACRAL SPINE
The sacral section (also called sacral spine) consists of the next 5 vertebrae (6 on rare
occasions). These are fused together to form a single bone.
The sacral spine is joined to the pelvic girdle forming the posterior section of the pelvis. It
transmits the weight of the body to the pelvis.
http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19464.jpg
COCCYXL SPINE
The coccygeal section (also called coccygeal spine) consists of the final either 2 or 4
vertebrae. These are also fused together.
http://www.almostzara.com/wp-content/uploads/sacrum-coccyx-250x274.jpg

Version 2/2011
26
VERTEBRAL DISCS
A vertebral disc is found between each of the vertebrae from the cervical to lumbar.
The main purpose of each disc is to act as a shock absorber. Each disc also spreads
stress placed on the spine, assists in movement between vertebrae and provides stability.
Each disc is composed of two parts, a tough outer coating and a softer inner substance. At
birth, the discs are of a watery substance that with age dehydrates to form a more jelly like
substance.
http://www.spineuniverse.com/conditions/spinal-fractures/anatomy-spinal-fractures

Version 2/2011
27
SPINAL LIGAMENTS
Spinal ligaments assist in providing structural stability to the spinal column. Two main
ligament systems exist in the spinal column:
Intrasegmental systems.
Intersegmental systems.
The intrasegmental system which includes the ligamentum flavum, interspinous and
intertransverse ligaments join individual vertebrae together.
The intersegmental system consisting of the anterior longitudinal ligaments, posterior
longitudinal ligaments, and the supraspinous ligaments. These join and stabilise large
sections of the spinal column.
http://static.spineuniverse.com/displaygraphic.php/138/dp_ligaments-BB.gif

Version 2/2011
28
MUSCLES OF THE SPINAL COLUMN

The muscles around the spinal column are referred to as paraspinal muscles. More than
30 muscles and tendons help to provide balance, stability, and mobility to the spinal
column.
There are many minor muscles surrounding the spinal column connecting anywhere from
2 to 9 vertebrae (with each assisting in some movement between all the vertebrae and the
rest of the skeleton). The two main muscles that extend up and down the spinal column
are the trapezius and the latissimus dorsi.

Version 2/2011
29
AETIOLOGY OF SPINAL CORD INJURY

INTRODUCTION
Trauma to the head, neck, shoulders, torso and / or pelvis as a result of motor vehicle
collisions, falls, sporting injuries and other traumatic events may lead to damage of the
spinal vertebrae, the protective supports of the spinal column (muscles, ligaments or discs)
or to the spinal cord itself. Primary and secondary SCI can develop either through
vertebrae lacerating, pinching or compressing the spinal cord, overstretching of the spinal
cord, or cessation of the blood supply to the spinal cord. A progressive tissue destruction
process of the spinal cord can also develop. Primary and secondary SCI or progressive
tissue destruction appear to be caused by both mechanical factors such as blood vessel
compression or laceration, and the chemical factors such as vasodilating endorphins,
which precipitate an ischaemic or hypoxic state following a high impact injury.
PRIMARY SPINAL CORD INJURY
A primary SCI is the mechanical disruption of axons by the initial mechanical injury. This
can be caused by the following types of forces:

Version 2/2011
30
Hyperextension
Hyperextension injuries appear in 19% to 38% of SCI and occur when the spine is arched
backwards beyond normal limits. This type of injury is seen most commonly in the upper
cervical section of the spinal cord as there is nothing to restrain the head until the occiput
hits the lower cervical section. Thoracic and lumbar hyperextension injuries are less
common, but often result in fractures to the lamina or vertebral body, or prolapse of a disc.
Hyperextension injuries are often caused by:
Collisions in motor vehicles without head rests
Rear end collisions in motor vehicles

Version 2/2011
31
Hyperflexion
Hyperflexion injuries appear when the spine is arched forwards beyond normal limits.
Injuries to the cervical segment occur when the head is pushed forward until the chin
makes contact with the chest, fracturing the vertebrae at the front of the cervical spine and
tearing the supporting ligaments at the back.
Hyperflexion injuries are often caused by:
Motor vehicle collisions with lap or lap/sash seatbelts but no SRS airbags.

Version 2/2011
32
Compression / Axial loading

Axial loading can occur in several ways. Most commonly, this compression of the spine
occurs when the head strikes an object and the weight of the still moving body bears
against the stopped head, such as when the head of an unrestrained occupant strikes the
windshield or when the head strikes an object in a shallow water diving incident.
Compression and axial loading also occurs when a patient sustains a fall from a
substantial height and lands in the standing position. This drives the weight of the head
and thorax down against the lumbar spine while the sacral spine remains stationary.
Compression injuries occur when the spinal cord is compressed following impact, often
resulting in injuries at C5-6 and T12-L1. This type of injury often causes a burst vertebral
body.
Compression injuries are often caused by:
Diving injuries.
Impacting windscreens in motor vehicle collisions.

Version 2/2011
33
Distraction
Distraction injuries are an overstretching of the spinal cord.
Distraction injuries are often caused by:
Hanging injuries.
Playground injuries to children.

Version 2/2011
34
Rotation
Rotational injuries occur when head and body rotate in opposite directions resulting in
twisting of the muscle, ligaments, vertebrae and / or spinal cord.
Rotational injuries are often caused by:
Motor vehicle rollovers.
Ejections from a motor vehicle.

Version 2/2011
35
Penetration
Penetrating injury represents a special consideration regarding the potential for spinal
trauma. In general, if a patient did not sustain definite neurologic injury at the moment the
trauma occurred, there is little concern for a spinal injury. This is because of the
mechanism of injury and the kinematics associated with the force involved. Penetrating
objects generally do not produce unstable spinal fractures as does blunt force injury
because penetrating trauma produces little risk of unstable ligamentous or bony injury. A
penetrating object causes injury along the path of penetration. If the object did not directly
injure the spinal cord as it penetrated, the patient will not likely develop a spinal cord injury.

Version 2/2011
36
SECONDARY SPINAL CORD INJURY

Secondary SCI is a cascade of ongoing events caused by the initial primary cord injury,
which damages axons secondarily to the initial primary injury, that otherwise should have
survived. If the cause of secondary SCI can be predicted and controlled, further
neurological dysfunction may be limited, reversed or prevented.
Causes of secondary SCI are thought to include but are not limited to:
Pathological changes following injury
Following the initial injury to the spinal cord, petechial bleeding (caused by the leaking of
blood cells from capillaries) occurs in the grey matter of the spinal cord, as well as in the
surrounding white matter.
Between 12-24 hours after the initial injury, the grey and white matter in the central region
of the spinal cord loses its structure and becomes a region of dead tissue. The spinal
cords unique blood supply is the probable cause of these changes, and is thought to assist
in further structural damage to the spinal cord, and ongoing neurological dysfunction.
Microscopically, there is a breakdown of the capillary structure and disruption of the blood /
spinal cord barrier. Significant swelling develops in the surrounding white matter as the
bleeding to the central region of the spinal cord continues.
Swelling also interferes with the transmission impulses at the synaptic cleft.
Changes begin to appear to the axon of the spinal nerve including rupture of the outer
membranous covering of the axon, breakdown of the axons cytoplasm, disruption of the
axons myelin sheath and separation of the myelin sheath from the axon itself. Damage to
the myelin severely compromises transmission of nerve impulses throughout the spinal
cord.
Macrophages (white blood cells that engulf and digest debris) move in to remove any
destroyed spinal cord tissue.
Eventually, a fluid filled cavity (syrinx) surrounded by non conducting glial scar tissue is left
behind within the spinal cord.
The syrinx has now formed a barrier that inhibits the
reconnection of axons.

Version 2/2011
37
Neurogenic shock
Neurogenic shock, also known as vasogenic shock, usually occurs within 30 - 60 minutes
following
suppression
of
the
autonomic
nervous
systems
ability
to
maintain
vasoconstriction below the level of SCI.

The autonomic nervous system, through the sympathetic nervous system, maintains the
muscles of the veins and arteries in a partially contracted state. However, with the loss of
sympathetic stimulus, the vascular muscles cannot maintain this contraction and the arteries and veins dilate, drastically expanding the size of the circulatory system, with a corresponding reduction of blood pressure.
These cardiovascular effects may worsen ischaemic lesions in the injured spinal cord.

Version 2/2011
38
Post traumatic ischaemia

Following a severe injury, blood flow to the spinal cord, especially in the veins and in the
capillaries supplying the grey matter, is reduced. Causes for the reduced blood flow are
unclear, but may include one or more of the following:
Direct mechanical irritation producing vasospasm.
Release of biochemical agents such as noradrenaline or cAMP.
Products of lipid peroxidation and arachidonic acid metabolism which are

vasoactive causing vasoconstriction and tissue infarction.
Calcium entry into the cells

A dramatic fall in extracellular calcium is seen after an acute injury as the calcium moves
into the cells. Calcium moving into the cells causes activation of phopholipases and
phosphatases.
Phospholipases results in breakdown of membrane phospholipids and the release of free
fatty acids. Free fatty acids are converted to eicosanoids such as prostaglandins, which
are potent vasoconstrictors, restricting blood flow to the spinal cord.
Excitatory amino acids are also released after injury (primarily glutamate) which also
increases intracellular calcium by activating NMDA receptors, and further compounds the
problem.
Increased calcium levels also disrupt a range of cellular processes including transport,
secretion, metabolism and ion permeability.
Increased Extracellular Potassium

The transmission of nerve impulses in neurons requires the appropriate levels of sodium
and potassium inside and outside the cells.
An increase in extracellular potassium (produced by damage to a relatively small
percentage of cells in a particular region) depolarizes intact cells and prevents action
potential conduction, which directly affects spinal cord function.
Failure to immobilise unstable fractures
Failure to stabilise and immobilise an unstable fracture has the potential to allow the
movement of fragments of bone towards the spinal cord causing either pressure on the
spinal cord or actually cutting the spinal cord.

Version 2/2011
39
FUNCTIONAL CLASSIFICATIONS
Tetraplegia: Also known as quadriplegia refers to a loss of motor and sensory function in
the cervical section of the spinal cord. Arms and legs are affected.
Tetraparesis: Also known as quadraparesis is a condition where the arms and legs are
not paralysed, but are weakened or have reduced motor or sensory function.
In Australia 54% of SCI are at the tetraplegic level.

Paraplegia: Refers to a loss of motor and sensory function in the thoracic, lumbar or
sacral sections of the spinal cord. The SCI patient will still have arm function.
Paraparesis: Is where the legs are not paralysed, but are weakened or have reduced
motor or sensory function.
The remaining 46% of SCI are at the paraplegic level.

Version 2/2011
40
SPINAL CORD INJURIES
Primary injury occurs at the time of impact or force application and may cause cord
compression, direct cord injury (usually from sharp or unstable bony fragments), and/or
interruption of the cords blood supply. Secondary injury occurs after the initial insult and
can include swelling, ischaemia, or movement of bony fragments. Cord concussion results
from the temporary disruption of the spinal cord functions distal to the injury. Cord
contusion involves bruising or bleeding into the spinal cords tissues, which may also result
in a temporary loss of cord function distal to the injury. Spinal shock is a neurological
phenomenon that occurs for an unpredictable variable period of time after spinal cord
injury, resulting in loss of all sensory and motor function, flaccidity and paralysis, and loss
of reflexes below the level of the spinal cord injury. Cord contusion is usually caused by a
penetrating type of injury or movement of bony fragments. The severity of injury resulting
from the contusion is related to the amount of bleeding into the tissue. Damage to or
disruption of the spinal blood supply can result in cord ischaemia. Cord compression is
pressure on the spinal cord caused by swelling, which may result in tissue ischaemia and
in some cases, may require decompression to prevent a permanent loss of function. Cord
laceration occurs when cord tissue is torn or cut. Neurological deficits may be reversed if
the cord has sustained only slight damage; however, it usually results in permanent
disability if all spinal tracts are disrupted.
INCOMPLETE - COMPLETE CLASSIFICATIONS
SCI is classified as either complete or incomplete injuries:

Complete Injuries:
Complete SCI are a total loss of motor function (paralysis) and sensory perception as a
result of complete interruption of the ascending and descending nerve tracts in the spinal
cord.
In Australia, approximately 43% of SCI are complete. Due to the small diameter of the
spinal canal, 60% of thoracic SCI are often complete, while only 40% of cervical SCI and
14 % of lumbar & sacral SCI are complete.

Version 2/2011
41
Incomplete Injuries:
The majority of SCI in Australia (67%) are incomplete injuries, i.e. there is some function of
either motor and / or sensory function below the level of the SCI.
Poor management of the patient with incomplete SCI can cause progressive worsening of
spinal cord function.
Incomplete SCI are further divided according to the area of SCI and include:
Central Cord Syndrome - is most often seen in hyperextension injuries, with most
damage to the spinal cord being in the centre of the cord itself. In this syndrome, there is
greater loss of function in the upper
extremities, as the nerves to these areas are
concentrated more towards the centre of the spinal cord, whilst lower extremity nerves are
found towards the outside of the spinal cord.
The majority of patients will walk again and have a return of motor and sensory function to
the lower extremities and trunk, but tend to have poor recovery of hand function owing to
irreversible central gray matter destruction.

Version 2/2011
42
Brown-Squard Syndrome - occurs when only one side of the spinal cord is damaged.
Motor function and positional awareness is lost on the body side with the injury, but loss of
touch, pain and temperature perception occurs on the opposite side of the body.
This syndrome has a good prognosis for recovery with more than 90% of patients
regaining bladder & bowel control. Most patients will also regain some strength in their
lower extremities and be able to walk again.
Figure 8. Brown-Squard syndrome.

Anterior Cord Syndrome -occurs most often in flexion injuries which primarily damages
the anterior spinal artery and also the anterior 2/3 of the spinal cord. There is paralysis of
motor function, as well as loss of touch, temperature and pain perception. The ability to
sense the position, location, orientation and movement of the body and its parts remain.
Anterior cord syndrome has the worst prognosis of all spinal cord syndromes with only
10% to 15% of patients showing functional recovery. Prognosis is however good if
recovery is seen to progress during the first 24 hours.

Version 2/2011
43
Figure 6.Anterior cord syndrome.
Cauda Equina Syndrome - involves injury to the peripheral nerves rather than the spinal
cord itself (as the cord ends at L2). While initial injury may result in anything from partial to
complete cessation of motor & sensory function, as the peripheral nerves have the ability
to repair themselves, this injury can often repair itself to some degree.

Version 2/2011
44
SIGNS & SYMPTOMS OF SCI

The use of signs & symptoms alone to determine the presence of SCI has been found in
multiple studies to be ineffective and will miss 40% - 60% of patients with SCI. A multitude
of reasons exist for the these missed injuries including distracting injuries or events,
alcohol consumption, drug usage, unconsciousness or an altered conscious state, and
communication difficulties due to extremes of age, language barriers or intellectual
disabilities.
Attempts to diagnose the actual level of injury should also be discouraged. Reasons for
this include 40% - 60% of patients will have no pain over the damaged area due to a range
of issues as listed above. Various studies show persons suffering traumatic fractures to
the spinal column will have a 20% - 66% occurrence of a secondary fracture elsewhere in
the spinal column.
A range of signs & symptoms may be seen in the potential or actual SCI patient and
include:
Bradycardia
The control centre for the heart rate is found in the medullas vasomotor centre of the
brainstem and is under control of the Autonomic Nervous System.
The Autonomic
Nervous Systems sympathetic nerves (which come from the spinal cord T1 to L2) speed up
the heart rate, whilst the parasympathetic nerves (which are mainly cranial nerves) slow
the heart down.
A bradycardia in SCI occurs due to interruption of the brainstems communication to the
spinal cord resulting in the loss of the sympathetic control.
The parasympathetic system can now act unopposed, without the sympathetic influence,
leading to a slowing of the heart rate.
The bradycardia can be effectively treated in the acute stage with Atropine.

Version 2/2011
45
Hypotension
The control centre for vasoconstriction and vasodilation of the blood vessels is found in the
medullas vasomotor centre of the brainstem and is under control of the Autonomic
Nervous System. The Autonomic Nervous Systems sympathetic nerves (which come
from the spinal cord T1 to L2) constrict the blood vessels, with the parasympathetic nerves
having only a minor effect on dilation of the blood vessels.
Hypotension in SCI occurs due to interruption of the brainstem communication to the
spinal cord resulting in the loss of the sympathetic control thus resulting in dilation of the
peripheral blood vessels and therefore hypotension. Hypotension leads to ischaemic SCI.
SCI induced hypotension (also called neurogenic shock) can be treated in the acute stage
with carefully controlled fluid replacement to avoid pulmonary oedema, or by
vasoconstricting drugs such as Metaraminol or Adrenaline. Both of these drugs have a
short half life, therefore repeated doses or infusions are often required.
Hyperthermia / Hypothermia
The loss of the sympathetic control results in dilation of the peripheral blood vessels
causing peripheral vasodilation below the level of injury. This dilation causes skin to
initially feel warm.
As time progresses, hypothermia develops as the loss of muscle
contraction due to paralysis causes a significant reduction in body heat production. Dilation
of the blood vessels close to the skin also results in heat loss by convection.
Acute treatment of SCI induced hypothermia is aimed at maintaining normal body
temperature by the use of blankets.
Breathing Difficulty
The diaphragm provides 70% of normal inspiration / expiration effort, with the intercostal
muscles accounting for only 30% of respiratory effort.
A sensation of shortness of breath will occur if the SCI is in the thoracic region of the
spinal cord (T1-12) as the intercostal muscles, which allow chest expansion for respiration,

Version 2/2011
46
are now paralysed. The higher the level of injury; the greater the sensation of
breathlessness experienced.
Emergency care of a SCI patient with breathing difficulties should include supplemental
oxygen to cater for up to 30% reduction in respiratory ability, and the removing of any
restrictions placed on the diaphragm to contract.
Diaphragmatic Breathing
SCI injuries above T1 results in a total loss of the intercostal muscles that assist with
respiration, placing total reliance on the diaphragm for breathing.
To assist the patients diaphragmatic respiration, emergency care should include
supplemental oxygen to cater for the 30% reduction in respiration, and the removing of any
restrictions placed on the diaphragm to contract

Version 2/2011
47
Respiratory Arrest
Nerve supply for the diaphragm comes from the phrenic nerve which exits the spinal cord
at C4, with some innervation also from C3 and C5.
Phrenic Nerve
http://www.baileybio.com/plogger/images/anatomy___physiology/08._powerpoint_-_peripheral_nervous_system/phrenic_nerve.jpg
SCI injuries at C1-3 will cause a loss of all muscles for respiration, resulting in the inability of
the patient to breath.
Paralysis and Numbness

Paralysis and / or numbness in the trauma patient may be indicators of significant damage
to the spinal cord itself. Such symptoms may occur in one or more limbs. In a small
number of cases, it may also be a temporary effect caused by a sudden temporary
cessation of the autonomic nervous system that occurs following trauma (spinal shock)
which may last hours to weeks.
Acute care, when paralysis or numbness is present, is to reduce any ongoing ischaemia or
swelling that may be causing the loss of motor or sensory function. This can include

Version 2/2011
48
supplemental oxygen therapy, the use of methylprednisolone to help reduce inflammation,

and maintaining adequate blood flow to the spinal cord by ensuring adequate perfusion
(both pulse and blood pressure).
Immobilisation of the spinal column to prevent further
bone movement damaging the spinal cord is also beneficial.

Heaviness and Tingling
Heaviness and / or tingling sensations in one or more limbs are indicators of possible
pressure being exerted on the spinal cord by either a bone or through swelling, but
suggest that the cord is still intact.
Acute care when heaviness and / or tingling sensations are present is to prevent further
bone movement that may be pressing on the spinal cord by immobilisation of the spinal
column, and to reduce any ongoing ischaemia or swelling that may be causing the sensory
changes by giving supplemental oxygen therapy, and maintaining adequate blood flow to
the cord by ensuring adequate perfusion (both pulse and blood pressure) to reduce
ischaemic injury. The use of methylprednisolone to help reduce inflammation is also an
option.
Pain or Tenderness
Pain or tenderness over any portion of the spinal column is a sufficient indicator to suspect
potential SCI damage. It is however, only stated as being present in 40% - 60% of SCI
patients due to a range of reasons including natural release of endorphins, distracting
injuries, unconscious patient, drug usage, alcohol consumption, neuropathy in the elderly,
communication difficulties due to extremes of age, etc.
Pain management in the emergency setting for SCI should include the use of drugs such
as Penthrane or Morphine to reduce pain to a comfortable and tolerable level.
Deformity
Deformity is a definite indication that significant damage has occurred to the spinal
vertebrae, but it is only seen in 3% of SCI. This is in part due to the anatomy of the spinal
column. At C1 to C5 no vertebra bone can be felt on examination. From C6 to L5 only the

Version 2/2011
49
posterior aspect of the spinous process is palpable. As a result, there exists controversy
as to whether the patient assessment should include palpation of the spinal column to
determine if such deformity exists, especially if the patient needs to be moved to examine
this area.
Priapism
Priapism is a sustained erection of the penis in a male that occurs following the loss of
sympathetic nerve control resulting in dilation of blood vessels in the lower body including
the deep and dorsal arteries of the penis.

Version 2/2011
50
MECHANISMS OF SCI
As stated earlier, only 40% - 60% of spine-injured patients exhibit signs & symptoms of
their injury. Using this as the only criteria for recognition would exclude a large percentage
of patients with potential or actual SCI.
It has been well established that if Mechanisms and Pattern of injury are also included in
the assessment for a potential SCI, then very few patents will be missed.
Mechanisms of Injury: Patterns of Injury:

Occupants of high-speed MVCs.
Pedestrians hit by vehicles travelling > 30 kph.
Patients ejected from motor vehicles.
Patients in a motor vehicle which has rolled over following an MVC.
Patients in a motor vehicle where there is a death of another occupant.
Patients falling greater than 2 times their height.
Patients hit by falling object, falling greater that 2 times their height.
Motorcyclists, cyclists > 30 kph.
Explosions.
Entrapments > 30 mins.
Penetrating injury to the head, chest, abdomen, or pelvis.
Significant blunt trauma to the head, chest, abdomen, or pelvis
This should not be considered a definitive list, but should be used as a guide to the more
common injuries leading to potential SCI. Patients with lesser mechanisms of injury can
also suffer SCI, as seen in falls in which >40% of falls in Australia that resulted in SCI occurred from a height of below 1 metre.

Version 2/2011
51
SPINAL IMMOBILISATION
INDICATIONS
-
To immobilise the spine of a patient with actual or potential spinal injury. The decision
to immobilise the spine is usually based on mechanism of injury and not physical
findings. A high index of suspicion should accompany the following mechanisms and
patient presentations.
o motor vehicle crashes
o falls
o head, neck, or facial trauma
o multiple trauma
o Trauma with a history of loss of consciousness, altered level of consciousness, or
intoxication.
If in doubt, immobilise.
CAUTIONS
1. Evacuation should precede immobilisation in the presence of an environmental
hazard, such as fire or noxious fumes, or risk of drowning.
2. Realignment of the head to a neutral position is recommended and may improve
neurological function. If realignment manoeuvres cause additional pain or muscle
spasm or compromise the airway, the manoeuvres should be stopped immediately
and the patient immobilised in the position found. If the patient holds the head
rigidly angulated or is unable to move the head, realignment is contraindicated, and
the patient should be immobilised in the position found.
3. Pre-existing spinal deformities secondary to conditions such as arthritis or
ankylosing spondylitis may require modification of these procedures to align the
head and neck in a position neutral for that patient.
4. Suction should be immediately available in the event the immobilised or partially
immobilised patient begins to vomit.

Version 2/2011
52
PATIENT PREPARATION
1. Stabilise the head manually in the position found, and, instruct the patient not to
move. Large bore oral suction should be immediately available in case the patient
vomits.
2. Instruct the patient to remain as still as possible and let the carers do all the work.
3. Instruct the patient to alert you immediately if any of the manoeuvres cause
increased neck pain, numbness or tingling of the extremities, or difficulty breathing.
4. Assess and document neurological status, including movement and sensation of all
extremities.
PROCEDURAL STEPS
1. Return the patients head to a neutral position. Place your thumbs along the
mandible and your index and middle fingers on the occipital ridges to avoid soft
tissue compression and secure a firm hold on the patient. This manual stabilisation
should be maintained until the patient is securely immobilised to a spine board with
a cervical collar in place.
2. Apply a semi-rigid cervical collar. If possible, remove jewellery from the ears and
neck before collar placement. A correctly sized collar should extend from the
shoulders to the mandible. Refer to manufacturers instructions for sizing different
brands of collars.
3. Log roll the patient to a supine position on a long back board. The team leader
should maintain alignment of the head and coordinate the teams movements. A
useful landmark for maintaining head position is to keep the nose aligned with the
umbilicus. At least three additional people are preferred for this movement: one to

Version 2/2011
53
roll the shoulders and hips, one to roll the hips and legs, and one to place the back
board under the patient.
4. Place a pad underneath the head if necessary to prevent hyperextension when the
head is lowered to the board.
5. Secure the torso and legs to the board with straps or adhesive tape. Strap under
the armpits at the level of the axillae, across the upper arms, abdomen, hips, distal
thighs, and lower legs.
6. Stabilise the head bilaterally with foam blocks or towel rolls, place adhesive tape
directly on the skin across the patients forehead and onto the board. The use of
sand bags for lateral stabilisation is discouraged because the weight of the
sandbags could increase head movement if the board is tipped to the side.
7. Reassess and document neurological status, including movement and sensation of

all extremities.
8. Discontinue manual stabilisation of the head at this point.
9. Have suction available at all times, and be prepared to turn the patient on the board
should vomiting occur.

Version 2/2011
54
AGE-SPECIFIC CONSIDERATIONS
1. Young children present challenges in the assessment of pain. Take into

consideration the mechanism of injury to aid in the decision to immobilise.
2. If a child is frightened and fighting, attempts at immobilisation may increase
movement.
3. Children who are younger than 7 years of age have a relatively large head
compared with their trunk size. As a result, placement on a standard back board
may cause excess flexion. To achieve neutral alignment, padding should be placed
under the trunk and shoulders, or a back board with a cut-out for the head may be
used. Optimal position results in the external auditory meatus in line with the
shoulders.
4. Paediatric and infant semi-rigid collars are available. If an appropriate sized collar is
not available, a folded towel around the neck may help prevent flexion. Tape across
the forehead and head blocks are crucial in this instance. Care must be taken to
ensure that the towel around the neck is not too tight.
5. Standard head blocks may be too large to be effective with small children. Rolled
towels or small blankets can be substituted.
6. Geriatric patients may be at increased risk for skin breakdown because of thinner
skin, poor peripheral circulation, loss of subcutaneous padding, and concomitant
disease processes.

Version 2/2011
55
COMPLICATIONS
1. Further damage to the spine or the spinal cord as a result of movement.
2. Respiratory compromise secondary to tight straps across the chest, aspiration of
vomitus, an improperly sized or placed cervical collar, or excessive neck flexion in
young children.
3. Increased intracranial pressure and reduced venous drainage from the head as a
result of excessive tightness of the collar.
4. Pain related to backboard and collar. Using a vacuum mattress instead of a
backboard may help eliminate this problem.
5. Tissue breakdown secondary to prolonged contact of bony prominences with the
back board or stiff cervical collar.
6. Supine hypotension in pregnant patients (secondary to the pressure of the gravid
uterus on the inferior vena cava). This can be minimized by tilting the back board to
the patients left by 15-20 degrees.

Version 2/2011
56
SPINAL CLEARANCE
The use of signs & symptoms of SCI in conjunction with mechanisms and patterns of injury
provide an excellent level of diagnosis of potential or actual SCI. But it also leads to many
patients being unnecessarily immobilised. Pain does not appear in 40-60% of patients.
The reasons include:
Altered Conscious State
Any patient with an altered conscious state or a period of unconsciousness may be
confused and not able to answer questions regarding pain or injuries correctly.
Alcohol or Drug Use
Any patient who has ingested alcohol or consumed illicit drugs again may be confused and
not able to answer questions regarding pain or injuries correctly.
Distracting Injuries
Distracting injuries are those injuries which cause sufficient pain to distract the patient from
spinal pain that may be present. Such injuries are long bone fractures, but may also
include amputations, dislocations and other injuries causing significant distracting pain to
the patient.
Distracting Event
Distracting events are situations that cause the patient to be sufficiently distracted from
spinal pain that may be present. Such events include a parent whose child has been
critically injured, and as such is unaware or unwilling to admit to their own pain until the
child is adequately cared for.
Modifying Factors
Modifying factors refer to problems of communication with the patient. Such situations
include:
In young children where communication is limited.
Patients where a language barrier exists.
Patients with intellectual disabilities which makes communication difficult.
The elderly (>65 yrs of age) due to neuropathy and / or other diseases that affect pain
perception.

Version 2/2011
57
CONSIDERATIONS of SCI in PAEDIATRICS
INTRODUCTION
Paediatric spinal care requires a modified approach to immobilisation to that of the adult
patient. The following discusses the essential differences in treating the child patient
versus the adult patient.
HEAD SIZE
Children under the age of 8 years have what is often referred to as the Charlie Brown
Effect, that is the head is larger than the body, with the majority of the enlarged head of
the child posterior to the spinal column. It has been shown that if the child was therefore to
be placed on a flat board, the head would be pushed into a hyperflexed position.
It is essential therefore to place padding under the complete torso from the shoulder down
to the buttocks. Methods where padding is placed only under the shoulders causes
hyperflexion of the thoracic and lumbar spine. To overcome this, always place firm padding
under the childs entire torso. While this will elevate the torso more than required in many
cases, the gap under the head can then be padded out. This technique overcomes the
chances of under judging the amount of padding required under the patients torso and
removes the need for additional log rolls until correct padding is found.

Version 2/2011
58
TYPES OF SCI in Children

Spinal fractures in children are a rare occurrence with the majority of SCI being elongation
of the spinal cord and shearing damage to the nerves in the spinal cord. This is due to the
fact that the muscles and ligaments in the childs spinal column are much weaker in
comparison to the adult. As a result, these muscles and ligaments are unable to resist
tractional forces effectively.
As a result, SCI in children often occur without x-ray findings. Therefore never rule out SCI
in children on x-ray alone.
LOCATIONS OF SCI
SCI in paediatrics totals only 3% of all SCI patients. Location of the cervical spine injury in
children is most commonly in the upper spine C1 - C2, while in adults the most common
injury appears to be C5 - C6. It is well established that no Cervical Collar provided
acceptable immobilisation; therefore Cervical Collars must be used in conjunction with a
Cervical Extrication Device or a Long Spine Board.
SHOULD YOU IMMOBILISE THE PAEDIATRIC PATIENT WITH A POTENTIAL SCI?

There is much controversy as to whether a child should be immobilised. Isolated case
reports of SCI occurring in the child struggling against the procedure have been
documented. There is an opposing view however that young children will often stop fighting
when snugly immobilised.
Full spine immobilisation in paediatrics is still considered to be
appropriate despite rare cases of secondary SCI occurring. It should however be done
with careful consideration to prevent the child from becoming agitated and struggling.

Version 2/2011
59
MANUAL IN-LINE STABILISATION

INTRODUCTION
With the detection of, or suspicion of a potential or actual SCI, the first procedure in spinal
management is to stabilise the cervical section of the spinal column. This can rapidly be
achieved by the use of Manual In-Line Stabilisation of the head.
The aim of Manual In-Line stabilisation is twofold:
To provide immediate temporary stabilisation of the cervical spine.
To join the head to the chest to stabilise the neck.
LIMITATIONS OF MANUAL IN-LINE STABILISATION

There are a number of limitations to Manual In-Line Stabilisation when used in isolation:
Manual In-Line Stabilisation alone, without the support of other immobilisation devices, has
never been proven to be safe. Further splinting will be required before transport or
movement. A semi-rigid Cervical Collar will at best provide only 50% immobilisation.
Therefore, Manual In-Line Stabilisation should be maintained even after a Cervical Collar
has been applied, and until full spinal immobilisation has been applied to adequately
stabilise the cervical spine.
It provides no thoracic / lumbar spinal support to the patient.
It does not take the weight of the patients head off the cervical spine.
It should only be used whilst the patient is not being moved.
DANGERS OF MANUAL IN-LINE STABILISATION

A number of dangers may be associated with Manual In-Line stabilisation:
If the patients teeth are clamped closed when performing Manual In-Line Stabilisation, the
airway may be compromised if the patient vomits.
Neck pressure increases intracranial pressure, therefore the hands must be carefully
positioned.
Do not place traction to the patients head.
The patients head must be immobilised in relation to their chest to prevent neck
movement. Failure to achieve this means the neck becomes the pivoting point.

Version 2/2011
60
STABILITY DURING MANUAL IN-LINE STABILISATION

To gain the greatest amount of stability, the immobiliser fans their fingers to obtain the
greatest amount of contact as possible with the patients head.
The immobiliser should rest their elbows on a stable object such as the ground, seat, bed
or their own torso; this will prevent swaying of the immobilisers arms as they become
tired.
MANUAL IN-LINE STABILISATION: BEHIND
Emergency Technologies 2004
From behind the patient, the immobiliser places their hands over the patients ears.
Then places the thumbs of each hand against the posterior aspect of the patients skull
and at the same time the immobiliser places both of their little fingers just above the
patients angle of the mandible.
The immobiliser now places their index and ring fingers of each hand on either side of the
appropriate cheek bone of the patient.
If the patients head is not in the neutral in-line position, slowly realign it, unless contraindicated.
The immobiliser brings their arms in at the elbows and rests their arms against the seat,
headrest or their own torso.

Version 2/2011
61
MANUAL IN-LINE STABILISATION: SIDE
The immobiliser stands at the side of the patient, then passes one arm (the arm closest to
the patients back) over the patients shoulder, and cups the back of the patients head with
the hand belonging to this arm.
Between where the upper molars insert in the maxilla and the inferior margin of the
zygomatic arch, there is an indentation ideal for grasping. The immobiliser places the
thumb and first finger of their other hand on the patients cheeks so that it grasps the
patient, in the above indentation.
If the patients head is not in the neutral in-line position, slowly realign it, unless contraindicated.
The immobiliser brings their arms in at the elbows and rests their arms against the seat,
headrest or their own torso.

Version 2/2011
62
Manual in line immobilisation from the Front
Manual In line immobilisation for a supine patient

Version 2/2011
63
MOTORCYCLE HELMET REMOVAL
INTRODUCTION
Treatment of the motorcycle trauma patient generally requires removal of the patients
helmet to allow easy access to the patients airway and to allow proper examination of
their face, ears and skull. Despite the need to remove the helmet, personnel are in
general, poor at performing the Helmet Removal Technique safely and correctly.
TYPES OF HELMETS
Four basic motorcycle helmets are currently in use:
http://en.wikipedia.org/wiki/File:White_full-face-helmet.jpg

Version 2/2011
64
http://en.wikipedia.org/wiki/File:Nolan102.jpg
http://en.wikipedia.org/wiki/File:MotoX_Helmet.jpg
http://en.wikipedia.org/wiki/File:Open-face_helmet.JPG

Version 2/2011
65
For the helmet to fit correctly on the motorcycle rider and not fall of in a crash, it must be a
firm fit with the riders skin moving with the helmet. The riders sides & top of head, as well
as their cheeks, should move with the helmet when the rider shakes their head. This
required firm fit will potentially result in movement of the cervical spine during the removal.
REASONS FOR HELMET REMOVAL
Controversy appears to exist in regard to leaving the riders helmet in-situ for transport to
hospital or removing it at the crash scene. In general, leaving a helmet on the rider will:
Interfere with administration of oxygen therapy.
Prevent the application of a Cervical Collar.
Cause an airway compromise if the patient vomits.
Place the head into hyperflexion due to the helmets bulk.
Hyperflexion caused by the helmet may occlude the airway in the unconscious rider.
REASONS FOR NOT REMOVING HELMET

Helmets are generally best left in place when:
A penetrating injury to the head has possibly occurred.
Increasing neurological deficit occurs during the removal of the helmet.

Version 2/2011
66
HELMET AND SPINE ALIGNMENT
Larger style helmets will often place the riders cervical spine into the hyperflexed position
and prevent correct placement of a Cervical Collar.
Therefore, if there is a need to keep the helmet in situ, padding will need to be placed
under the thoracic / lumbar spine.
No padding
Padding under torso with a blanket

Version 2/2011
67
HELMET REMOVAL TECHNIQUE
The following technique is the current teachings from the PHTLS course, approved by the
American College of Surgeons - Committee on Trauma, and offers the best technique for
full face motorcycle helmet removal. Two separate studies undertaken on cadavers using
this technique suggest that some spinal manipulation will occur, and so the procedure
should be carried out with extreme care. If neurological deterioration occurs during the
procedure, cease the removal of the helmet and immobilise the patient with the helmet in
situ.
Procedure
Step 1
Person 1 kneels or lies above the patients head. Person 1 places their hands on either
side of the helmet, and brings the patients head into the neutral in-line position unless
contra-indicated

Version 2/2011
68
Step 2
Person 2 kneels alongside the patients torso, lifts the face shield, removes the patients
glasses, and undoes the helmets chin strap.
Step 3
Person 2 now grasps the patients mandible with one hand so that the thumb is at the
patients angle of the mandible on one side and the first two fingers are at the patients
angle of the mandible on the other side. Person 2 places their other hand under the
patients neck making contact with the occiput of the skull. Person 2 now takes over
Manual In-Line Stabilisation of the patients cervical spine.

Version 2/2011
69
Step 4
Person 1 now releases their hold on the sides of the helmet. Then holding the base of the
helmet by its sides, Person 1 gently spreads the helmets sides slightly apart.
Person 1 now rotates the helmet so that the lower end of the face piece is rotated towards
them, and elevates the helmet - clearing the patients nose.

Version 2/2011
70
Step 5
Person 1 then pulls the helmet off the patients head in a straight line until the patients
head begins to push upwards. The back of the helmet is then rotated vertically upwards at
about 30 following the curvature of the patients head and is removed.
Step 6
Person 1 again takes over Manual In-Line Stabilisation of the cervical spine until Full Spine
Immobilisation is completed.
If the head is not in the neutral in-line position, slowly realign it, unless contra-indicated.

Version 2/2011
71
Procedure for Log-Rolling a patient with a cervical spine injury (or suspected
injury).
Aims:
to prevent further spinal cord injury and/or ascension of injury
to facilitate assessment of the patient's dorsal surface
to facilitate airway management without further spinal cord injury
to minimise manual handling risks
Requirements: Requires a minimum of 4 people

1 person -maintaining the axial alignment of head & neck
3 people -maintaining body alignment
Dont forget the person required to perform the procedure or treatment that necessitated
the log-roll.
Head Holding Person

This person manages cervical spine alignment and is in control of the roll. They must
ensure all members of the team are ready before proceeding and should give clear
instructions. Whilst the head hold person takes their position assistance may be required
to minimize head movement.
Photo 1: Shows 'head hold person' at the head of the bed with their hands alongside the
head gripping the shoulders whilst another person performs a shoulder brace to prevent
head movement.

Version 2/2011
72
Chest person
If possible should be the tallest person in the team who places hands over the patients
shoulder and lower back.
Hip person
This person is responsible for ensuring the lower spine is not twisted during the roll. Places
one hand near the lower hand of the 'chest' person on the patient's lower back and the
other under the patients thigh. A pillow may be inserted between the patients legs to help
maintain alignment.
Leg person
Each patient must be assessed on an individual basis for manual handling risks. A leg
person is required for tall or heavy patients or those in plaster. The weight of the leg
should be supported from underneath.

Version 2/2011
73
The rolling procedure

When the equipment is obtained, the patient is prepared and the personnel
understand their roles the procedure for log-rolling is as follows:
The procedure is explained to the patient and the cervical collar is checked.
The personnel take their positions as described previously.
The head hold person says we will all roll on 'three'. The count is made and all personnel
roll the patient together on 'three'.
The person who is to perform the procedure and is not a log-roll member reassures the
patient and supports the lines and airway until the patient is in a stable position on their
side.
Photo: Shows a patient in a stable position on their side. Note the alignment of the spine
and the position of the head hold person's hands

Version 2/2011
74
Completing the roll.
The head hold person asks if everyone is ready. When ready, the head hold person states
we will roll back on 'three'. The count is made and everyone rolls together.
The procedure person reduces creasing by gently pulling on the sheets as the patient is
lowered.
All personnel stay in place while the head hold person checks alignment.

Version 2/2011
75
SEMI-RIGID EXTRICATION COLLARS
The primary purpose of a cervical collar is to provide a high degree of

immobilisation for a patients cervical spine, while maintaining the cervical spine in neutral
alignment.
No collar can offer adequate immobilisation of the cervical spine when used in
isolation. It should be used with a spine board, head immobilisation devices, and strapping
appropriate for securing the patients body to the board.
Cervical collars do not immobilise. Because they only limit the range of flexion by
about 75 percent at best and the range of motion by 50 percent (or less), they do not in
themselves provide immobilisation of the head and neck. A cervical collar is an important
adjunct.
The unique primary purpose of a cervical collar is to rigidly maintain a minimum
distance between the head and neck so that any significant movement of one towards the
other, and the resulting intermittent compression of the cervical spine it would produce, are
eliminated. The upper margin of the cervical collar purchases the head anteriorly where it
is inserted under the angle and lateral portion of the mandible, and posteriorly where the
back section is inserted and secured below the posterior bulge of the occiput. The lower
edge of the collar, when properly secured, sits firmly on the shoulder girdle and portions of
the upper rib cage. Due to its rigidity and the minimum thickness between its outer edges
and the underlying bone, the collar transfers any unavoidable loading from the head
through the collar to the torso (or from the torso through the collar to the head), instead of
the neck. By maintaining the previous unloaded length between the shoulder girdle and
the head, the rigid cervical collar prevents the movement and cervical compression that
cannot be eliminated by manual or other mechanical devices. Therefore, to eliminate the
possibility of increased pressure being referred to the neck, a properly fitting cervical collar
must be included with other immobilization provided. The collar does not eliminate
movement of the head beyond its upper edge or of C6, and T1 at its lower edge. Although
it helps to limit movement, it must always be used in conjunction with another method or
device to provide adequate immobilisation.

Version 2/2011
76
The Stifneck Extrication Collar
http://www.laerdal.com/doc/7160026/Stifneck-Extrication.html#
The Stifneck Extrication Collar is a one piece, rigid cervical collar. Stifneck collars come in
a range of sizes:
Baby No-Neck
Paediatric
No-Neck
Short
Regular
Tall
Stifneck Select which is adjustable to the equivalent of the No-Neck to Tall sizes.
Stifneck Select - Pediatric

Version 2/2011
77
They all use a simple sizing method. If properly fitted the low angle chin piece ensures
stable support, does not push the patient into extension or limit airway access due to
clenched teeth. The extra large tracheal hole gives exceptional access to the neck for
pulse checking and advanced airway techniques. The rear panel vents increase air flow for
improved comfort and allow early detection of blood and other fluids.
1. Proper sizing is critical for good patient care. Too short a collar may not provide
enough support, while too tall a collar may hyperextend. The key dimension on a
patient is the distance between an imaginary line drawn across the top shoulders,
where the collar will sit and the bottom plane of the patients chin.
2. Measure the patient.
You can easily size a patient using your fingers to measure the key dimension. The
key dimension is the distance between the trapezius, where the collar will sit, and
the bottom of the patients chin. On the collar, because the chin piece is aligned
with the sizing post; you can determine the key dimension by measuring the
distance between the sizing post and the lower edge of the rigid plastic on the
encircling band.

Version 2/2011
78
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5167
The Key Dimension on the collar is the distance between the sizing post (back
fastener) and the lower edge of the rigid plastic encircling band (not the foam
padding).

Version 2/2011
79
3. Match the collar size to the patient
When the patient is being held in a neutral position, use your fingers to measure the
distance from the shoulder to the chin (Key Dimension.) You can then use your
fingers to select the size Stifneck Extrication Collar that most closely matches the
key dimensions of the patient.

Version 2/2011
80
4. Assembly and Pre-forming

Insert Fastener into Hole
The collar is assembled by moving the black fastener (sizing post) at the end of the
chin piece up the inside wall of the collar and then pushing the black fastener all the
way into the small hole. Press firmly
Before applying the Stifneck collar, hold it as shown.
Flex Collar
Flex the collar sharply inward until you can touch your thumb to your fingers. This
will pre-form the collar into a cylinder to simplify application.

Version 2/2011
81
5. Correct Application
With the patient's head held in neutral alignment, position the chin piece by sliding
the collar up the chest wall. Be sure that the chin is well supported by the chin piece
and that the chin extends far enough onto the chin piece to at least cover the
central fastener. Difficulty in positioning the chin piece may indicate the need for a
shorter collar.
6. Attaching the Velcro
Re-check the position of the patient's head and collar for proper alignment. MAKE
SURE THAT THE PATIENT'S CHIN AT LEAST COVERS THE CENTRAL
FASTENER IN THE CHIN PIECE. If it doesn't, tighten the collar further until proper
support is obtained. Select the next smaller size if you think further tightening of the
collar may cause the patient to become extended.

Version 2/2011
82
7. Supine Application
If the patient is supine, begin by sliding the back portion of the collar behind the
patient's neck. Be sure to fold the loop Velcro inward on the top of the foam padding
to prevent it from collecting debris that could limit its gripping ability. Once the loop
Velcro is visible, turn all of your attention to positioning the chin piece and attaching
the Velcro as described in two preceding steps.
8. Final Adjustment
Once positioned, hold the collar in place by using the tracheal hole (as shown above) You
can avoid torquing the neck by using the tracheal hole as an anchor point while first pulling
laterally to tighten and then attaching the loop Velcro to the front so that it mates with, and
is parallel to, the hook Velcro. BE SURE TO MAINTAIN NEUTRAL ALIGNMENT
THROUGHOUT THIS PROCEDURE.

Version 2/2011
83
ADDITIONAL CONSIDERATIONS
1. Do not rely on any cervical collar by itself to adequately motion restrict a patient's
cervical spine. Collars are tools to aid in motion restriction. No collar by itself provides
sufficient motion restriction.
2. Do not use an improperly sized collar. Too large a collar may hyperextend a patient's
cervical spine; too small a collar may not provide appropriate stability. Special sizes of
Stifneck collars are available for children and other individuals with small frames.
DO NOT ADJUST THE SELECT COLLAR ON THE PATIENT
DO NOT RELY ON A COLLAR ALONE TO PROPERLY RESTRICT THE MOTION

OF A PATIENTS CERVICAL SPINE
DO NOT USE AN IMPROPERLY SIZED COLLAR. TOO LARGE A COLLAR MAY

HYPEREXTEND A PATIENTS CERVICAL SPINE; TOO SMALL A COLLAR MAY
NOT PROVIDE APPROPRIATE STABILITY.

Version 2/2011
84
The Vertebrace Extrication Collar

The Vertebrace Extrication Collar has a one piece construction, requiring no
assembly. From a flattened stored position the chin support flips up into place as the collar
is formed to fit the patient. A large anterior opening permits access to the neck for
cricothyrotomy or tracheostomy.
http://www1.mooremedical.com/gen_info/image.cfm?limage=31544_9-05.jpg
http://wound.smith-nephew.com/AU/node.asp?NodeId=3799
The Vertebrace is available in 6 sizes

Pedi-Short
Paediatric
X-Short
Short
Regular
Tall

Version 2/2011
85
A sizing guide/sizing post is needed to correctly fit the patient.

Version 2/2011
86
Instructions for Using the Sizing Guide

1. For suspected C-Spine injury requiring a collar the guide can be used in almost any
position the patient is found.
2. Position the guide alongside the patients head, resting the bottom edge on the
uppermost surface of the shoulder (trapezius muscle). Align the coloured end with
the front of the ear.
3. Read the colour area, with its letter size, that falls in line with the centre of the ear
opening (concha).
4. Each colour area, with its letter designation corresponds to one of the six sizes of
the Vertebrace.
Anatomically the concha falls in the same plane as the occiput. For maximum
support and extension resistance, each Vertebrace collar is sized to fit up against
this bony protuberance.

Version 2/2011
87
Application
1. Holding the collar out in front, grasp it in each hand on either side of the tracheal
opening. With your fingers on the inner surface, push towards yourself while
rotating yours wrists outward. The chin support will flip up over the walls of the
base.
2. Hold the collar as shown. Flex the plastic inward upon itself by touching your thumb
to your fingers
3. Preforming shapes the collar, simplifying application

Version 2/2011
88
4. Establish in line cervical immobilisation manually. Slide the back portion of the collar
with the contact closure strap behind the patients neck. Do not fasten closure yet.
5. Position the chin support beneath the patients chin, while maintaining manual
immobilisation. Avoid excessive movement of the patients head.
6. Secure the collar by firmly pulling on the contact closure and pressing the loop
portion against the mating hook portion.

Version 2/2011
89
The Philadelphia Collar
The Philadelphia Collar is a two piece cervical collar. It is made of non-toxic,

hypoallergenic Plastazote foam. It is said to offer total cervical arch support. The moulded
foam body has rigid plastic occipital and mandible posts. The Philadelphia collar is shaped
to fit chin and shoulder contours.
The Philadelphia collar is used more in a definitive care role rather than as an
extrication collar.
http://www.alphamedical.com/_borders/Cervic3.jpg
Remaining in the standard semi-rigid cervical extrication collar for long periods of time will
produce pressure areas and skin irritation. Therefore, any patient who requires continued
cervical spine immobilisation for prolonged periods (longer than 4 to 6 hours), will require
the collar to be changed to a Philadelphia collar.
Philadelphia Collar Sizes

Neck Circumference
Height
Small
10 12
Medium
13 15
Large
16 19
X-Large
19 +
Sizing

Version 2/2011
90
1. Measure the neck circumference in inches. This determines the size of the collar.
(Measurement B)
2. Measure the distance from the inferior border of the mandible (the chin) to the
sternal notch. ( Measurement A) This determines the height of the collar.
Important Points
1. The neck should be in a neutral position.
2. The collar may need readjustment with position changes.
3. Corners of the collar may be trimmed/cut to relieve pressure areas, or to fit around
ears.
Pressure/Skin Checks
1. Monitor the skin condition particularly around the ears, occiput, chin and clavicles.
2. The Philadelphia Collar should be removed and skin checked at least once every 810 hours.
3. Only one piece of the collar should be removed at a time.
ANTERIORLY one person holds the head and maintains in line immobilisation,
the other removes the front piece.
POSTERIORLY log roll the patient maintaining in line immobilisation. Remove the
back piece to check for pressure areas and to wash the skin.

Version 2/2011
91
PHILADELPHIA COLLAR FITTING INSTRUCTIONS
Sizing
Consider the height and width of the patients neck
Width sizes are small, medium and large
Height sizes are measured in inches from the patients chin to the sternum.
Start with a 3 inch collar and compare with the patients neck in a neutral
position to see if they require a larger or smaller collar in comparison.
Remember that most patients lie with some degree of extension and the
height will need to be reassessed when the patient is sitting up.
Have the next size up and down handy when fitting the collar in case you
need to make adjustments.
Application of the Philadelphia collar
STEP 1.
Have the patient lying in a supine position, instruct the patient not to move their head until
the collar is fitted. Maintain manual in-line spinal immobilisation.
STEP 2.
Remove the extrication collar
STEP 3.
The front piece of the Philadelphia collar is placed on the anterior neck

Version 2/2011
92
STEP 4.
Make sure the chin fits snugly but is not pushing on the collar
Check that you cannot place more than one finger under the sternal portion (if so use next
size up)
STEP 5.
Flatten the back piece and slide under the back of the patients neck (without causing
flexion)

Version 2/2011
93
STEP 6.
Check the front piece is over the top of the back
Secure the Velcro straps over the top
STEP 7.
Check there is no pressure on the patients shoulders or ears
You may trim soft edges of the collar with scissors to remove pressure on bony
prominence (e.g. clavicles) or ears (DO NOT cut while on the patient)

Version 2/2011
94
STEP 8. Check for correct fit

Version 2/2011
95
SPINAL BOARDS / BACKBOARDS
Spine boards or back boards are many and varied in their composition, shape,
design and weight. The ideal spine board should be comfortable for the patient, rigid and
lightweight. Other desirable features are:
-
Contoured design to allow the board to nest compactly.
Impervious to fluids, and have no seams to allow for easy cleaning and
decontamination.
Raised hand holds making it easy to pick up.
Strap connection points.
Radiolucent, MRI and CT compatible.
http://firstresponder.com.au/cart/images/lsb.jpg

Version 2/2011
96
MAINTENANCE OF NEUTRAL IN-LINE POSITION OF THE HEAD

It is essential that the neutral in-line position in which the head has been placed
(and manually immobilised) be maintained when the manual immobilisation is superseded
by mechanical means. The neutral in-line position is defined as the position in which the
head is normally held while walking; or the position in which the head is placed so that with
the eyes centred exactly in their orbital range (neither rotated up, down, left nor right) a line
between the pupils and the point the eyes are focused on would be perpendicular to the
bodys centreline (an imaginary midpoint which would extend in a straight plumbline from
the centre of the skull to a point between the ankles).
In greater than 98% of the adult population, when the head is placed in a neutral inline position, the outermost measure of the occipital region at the back of the head is
between and 3 inches anterior to the plane of the posterior torso. Therefore, in most
adults, when their head is in the neutral in-line position a significant space occurs between
the back of the head and the device (the spine board). Suitable padding must be added
prior to securing the head or the head will move to hyperextension. Firm semi-rigid pads or
folded towels can be used. The amount of padding needed must be evaluated, and varies
from patient to patient. A few individuals require none. If too little padding is provided, or if
the padding is of an unsuitable spongy material, the head will be hyperextended when the
head straps are applied. If too much padding is inserted, the head will be moved into a
flexed position. It must be noted that the padding should be placed directly posterior to the
occipital area, not the neck.
In small children (under eight years old) the size of the head in relationship to the
rest of the body is much larger than in adults. The majority of the enlargement is of the part
of the head which lies posterior to the spinal column. Further, the muscles of a childs back
are less developed than in adults. Therefore, when a small childs head is in the neutral inline position the back of the head usually extends on to two inches beyond the posterior
plane of their back. If a small child is placed directly on a rigid surface, their head will
usually be moved into a position of flexion. As well as the danger of compromising the
spine that this presents in a child, such extreme flexion can kink the immature trachea and
produce airway compromise. The spine board needs to be modified, either by creating a

Version 2/2011
97
recess for the head in the board or by inserting padding under the torso to elevate it, in
order to be able to maintain the childs head in a neutral position.
www.emergencytechnologies.com.au

Version 2/2011
98
No under torso padding
With under torso padding
Padding placed under the torso should be of the appropriate thickness so that the head
can lie on the board in a neutral position: too much will result in extension, too little in
flexion.

Version 2/2011
99
IMMOBILISATION OF THE HEAD TO THE DEVICE

Once the rigid spine board has been immobilised to the torso and appropriate
padding has been inserted as needed, the head should be secured to the device. Due to
the rounded shape of the head, it cannot be stabilised on a flat surface with only straps or
tape. Use of these alone will still allow the head to rotate and move laterally. The head is
ovoid, being longer than it is wide and having almost completely flat lateral sides.
Adequate external immobilisation of the head, regardless of the method or device, can
only be readily achieved by placing pads or rolled towels on these flat sides and securing
them with straps or tape.
The side pieces, whether they are preshaped foam blocks or homemade rolled
towels, are placed firmly against the flat lateral planes of the head. Two straps or pieces of
tape surrounding these head pieces draw the sides together and mould their inner sides to
the exact shape of the head preventing further movement. When packaged between the
blocks or towels, the head now has a flat posterior surface which can be realistically fixed
to a flat board. The upper head strap is placed tightly across the front of the lower
forehead (across the supra orbital ridge), and helps prevent anterior movement of the
head. The device holding the head regardless of the type also requires a lower strap to
help keep the side pieces firmly against the lower sides of the head and to further anchor
the device and prevent anterior movement of the lower head and neck. The lower strap
passes around the side pieces and across the rigid portion of the cervical collar.
The use of a commercial head immobiliser is the fastest and easiest way to secure
the head. However, if these are not available, a blanket or towel rolled into a bolster and
placed at each side of the head is as effective.
Using sandbags or IV bags secured to the spine board alongside the head and
neck represents dangerous practice. Regardless of how well secured, these heavy objects
can shift and move. The combined weight of the sandbags can produce localised lateral
pressure against the cervical spine. Sandbags as adjuncts to cervical spinal immobilisation
require more attention from care providers rather than less. Sandbags are heavy and if the
extrication board / spinal board/ patient trolley is tipped or bumped side to side during
evacuation and transport, the sandbags can slide, resulting in lateral displacement of the
victims head and neck with respect to their torso.

Version 2/2011
100
HEAD BLOCKS / HEAD IMMOBILISERS

Head blocks or immobilisers are any device which can aid in the firm control of
head movement and help to maintain proper cervical spine alignment.
There are many devices available commercially, but rolled towels or blankets used
in conjunction with adequate taping will also suffice.
http://www.laerdal.info/images/s/AEJBHVQJ.jpg

Version 2/2011
101
http://www.reepl.ru/img/other/StifneckPed.jpg
http://www.laerdal.com.au/images/l/AAKDTGIV.jpg

Version 2/2011
102
VACUUM MATTRESS
The vacuum mattress is a substitute to a back board. It provides fast, effective and
comfortable immobilisation by moulding to the specific contours of the patients body,
reducing pressure point tenderness. It is x-ray, MRI and CT compatible. The manual pump
can evacuate the mattress in 25 seconds and it weighs about 5 kg.
http://www.savelives.com/images_full/em9000_full.jpg
Vacuum mattresses contain numerous polystyrene beads encased in a flexible

outer shell. They are initially soft and malleable, but when the air is removed they become
rigid and conform to the shape of the patient.

Version 2/2011
103
Technique.
After the splint has been flattened and smoothed out, the air is removed to make it rigid
in order to allow the patient to be log rolled onto the device.
The air intake valve is then opened to allow air back into the system to soften it.
The torso is secured using the supplied straps.
Air is then removed from the mattress by one person using the pump.
As air is evacuated, a second person should mould the mattress to the head and neck,
while a third person maintains inline, manual stabilisation of the head.
The head is then secured with tape.

Version 2/2011
104
EXTRICATION VESTS
Kendrick Extraction Device / Medical Extraction Device
Extrication vests are unitized pre-assembled variations of a half backboard. Most of the
straps are pre-positioned as an integral part of the units structure, avoiding a multitude of
loose parts and the time needed to position and secure each to the main unit. The vest
contains internals slats or rigid sections which, although allowing adjustment of the
circumference of the torso and head sections, make the back of the device longitudinally
rigid from the coccyx to the top of the head. This allows them to be flexible enough to form
exactly around the body of differently sized and proportioned patients while providing
adequate rigid in-line immobilisation of the head, neck, and torso for removing the patient
onto a long board. Since they are flexible around their circumference they can easily be
installed regardless of how confined the seat may be and, since they are form fitting and
do not extend significantly beyond the patients anatomical outline once applied, make
removal of the patient through a limited opening easier than with a completely rigid flat
device.
A variety of models are available and , although each has some differences in the
detail of their specific design and exact strapping method at the upper torso and buckles,
their primary design and use is dictated by the general anatomical factors common to all

Version 2/2011
105
patients and is therefore almost the same. Each model has a rigid posterior centre section
with a flap at each side to surround the lateral torso and a second flap superior to these on
each side to surround and secure the flat lateral sides of the head. The vests generally
include several straps to immobilise it to the patients upper torso, several to secure the
flaps and immobilise the mid-torso, and a pair of groin loops. The head flaps are secured
against the lateral sides of the head (and the head is prevented from anterior movement)
by a strap which is placed on the upper part of the head flaps around the forehead. A
second strap across the anterior portion of the cervical collar also connects the head flaps.

Version 2/2011
106
http://upload.wikimedia.org/wikipedia/commons/0/07/KED.jpg
Application of the KED

Ideally a minimum of three people are required to apply the KED
After preliminary stabilisation and application of a rigid cervical collar, one person
should continue to maintain manual in-line immobilisation throughout the entire
procedure.
With an attendant on either side of the patient, slide the KED into place behind the
patients back with a minimum of movement. The restraints should face away from
the patient.

Version 2/2011
107
Centre the KED with the patients spine.
Once the KED is centred, pull the leg restraints (having the white buckles) from
behind the patient and lay them out of the way.
Wrap the chest flaps around the patient and move the KED up the patients trunk
and adjust so the chest flaps fit snugly under the patients arm pits.

Version 2/2011
108
Wrap the central waist strap (yellow) around the patient and secure firmly without
causing discomfort or restrict breathing, then repeat with the lower (red) strap.
Release leg straps, (black) pass one at a time under thigh to mid-thigh, using seesawing motion, work straps under patients legs and buttocks to crotch. Cross the
straps at the crotch, coupling to the receiver on the opposite side of the KED.
Secure the straps (white buckles) and adjust to firm fit.

Ensure the bottom of the KED is in contact with the lower back.
Fill any gap between the KED and the patients neck with a folded towel or other
padding.
Whilst the patients head remains manually immobilised wrap the head flaps
forward around the patients head.
Centre a forehead strap on the patients forehead, just above the eyebrows, pull
straight back and fasten to the KED head support Velcro.

Version 2/2011
109
Centre the chin strap on the patients chin and chin support of the collar, pull
straight back and fasten to the KED head support Velcro.
Take care not to hyperextend patients head and neck.
Finally, couple and tighten the upper chest restraint (green strap).
Firm (tighten) all straps from top to bottom.
i.e. thigh
- Red
- Yellow
- Green
Other Uses of the KED
Pregnant Patient:
The chest flaps may be folded inward, leaving the patients abdomen exposed. Exercise
care in placement and tightening of restraints.

Version 2/2011
110
Small or Paediatric Patient:

Adjustments may be made by placing blankets or towels on the patients chest and
securing the KED.
Splinting:
The KED can be used to splint a fractured hip, invert the KED, allowing equal space above
and below the hip. Use the existing restraints to affix the KED to body and leg.
Use the KED in a similar manner for a fractured pelvis, except place the chest flaps over
the pelvic bone area.

Version 2/2011
111
JORDAN (DONWAY) LIFTING FRAME
http://www.ilcaustralia.org/images/NSW/4450002.jpg
The Jordan Lifting Frame offers a simple system for easy, safe lifting of patients
with suspected neck or spinal injuries. It is designed to be fitted around the patient with the
minimum of disturbance. The principle of the Jordan Lifting Frame recognises the need to
lift and transport patients as they lie without moving them so minimizing further spinal
flexion, rotation or extension.
In the Jordan system the frame is readily built around and under the person
irrespective of the persons position on the ground. After the main aluminium frame has
been positioned around the injured patient, a series of specially designed gliders are slid
under the body of six or seven strategic non-pressure points, tensioned according to the
patents weight and conveniently attached to the studs by a push fitment. Simple restraint
straps are employed where required to firmly hold and prevent the patient from moving
within the frame.

Version 2/2011
112
http://www.necksafe.com.au/equipment.htm
http://www.ilcaustralia.org/images/WA/4441003.JPG
https://spservices.co.uk/images/st191.jpg

Version 2/2011
113
Clinical Practice Guidelines and Competency

Assessments

Version 2/2011
114

Version 2/2011
115

Version 2/2011
116

Version 2/2011
117

Version 2/2011
118

Version 2/2011
119

Version 2/2011
120

Version 2/2011
121

Version 2/2011
122

Version 2/2011
123

Version 2/2011
124
Bibliography, References and further reading

Ackland, HM. (2006).The Alfred Spinal Clearance Management Protocol. The Alfred
Hospital, Melbourne, Australia.
Ajani AE, Cooper DJ, Scheinkestrel CD, Laidlaw J, Tuxen DV. (1998).Optimal assessment
of cervical spine trauma in critical ill patients: A prospective evaluation. Anaesthesia and.
Intensive Care; 26:487-491.
Albrecht RM, Kingsley D, Schermer CR et al. (2001). Evaluation of cervical spine in
Intensive care patients following blunt trauma. World Journal of Surgery.;25:10891096
Albrecht RM, Malik S, Kingsley DD et al. (2003).Severity of cervical spine ligamentous
injury correlates with mechanism of injury, not with severity of blunt head trauma.
American Surgeon. 69:261-265.
Bache, J., Armitt, C., & Gadd, C. Practical Procedures in the Emergency Department.
Mosby London 1998.
Bledsoe BE, Porter RS, Cherry RA. Trauma Emergencies. Paramedic Care: Principles and
Practice, Volume 4. Upper Saddle River, NJ: Prentice Hall, 2001.
British Trauma Society. Guidelines for the initial management and assessment of spinal
injury. Injury 34(6)(2003):405-425.
Brooks RA, Willett KM, (2001). Evaluation of the Oxford Protocol for total spinal clearance
in the unconscious trauma patient. Journal of Trauma.;50:862-867.
Butman, A., Martin, S., Vomacka, R. & McSwain, N. Comprehensive Guide to Prehospital
Skills: A skills manual for EMT-Basic, EMT-Intermediate, EMT-Paramedic. Mosby-Yearbook,
St Louis. 1996.
Chendrasekhar A, Moorman DW, Timberlake GA. (1998). An evaluation of the effects of
semi rigid cervical collars in patients with severe closed head injury. American Surgeon;
64(7):604-606.
Clancy M. (1999). Clearing the cervical spine of adult victims of trauma. Journal Accident
& Emergency Medicine;16:208-214.
Cline, J.R., Scheidel, E. & Bigsby, E.F. (1985). A Comparison of Methods of Cervical Spine
Immobilisation Used In Patient Extrication and Transport. Journal of Trauma
25 (7):649-653.
Cohen, B.J. (2005) Memmlers Structure and Function of the Human Body. 8th Edition.
Lippincott Williams & Wilkins. Philadelphia.

Version 2/2011
125
Cooper DJ. (2001). Cervical Spine Management Protocol: The Alfred Intensive Care Unit..
Melbourne.
Cooper DJ, Ackland HM. (2005). Clearing the cervical spine in unconscious head injured
patients: The evidence. Critical Care Resuscitation.;7:181-184.
Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, et al. (1995). Pain and tissueinterface pressures during spine-board immobilization. Annals of Emergency
Medicine, 26(1): 31-36,
Cross DA, Baskerville J. (2001) Comparison of perceived pain with different
immobilization techniques. Prehospital Emergency Care. Jul-Sep;5(3):270-4
Curtis, K., Ramsden, C.,& Friendship, J. eds. Emergency & Trauma Nursing. MosbyElsevier, Sydney 2007.
Davis JW, Phreaner DL, Hoyt DB. (1993). The aetiology of missed cervical spine injuries.
Journal of Trauma.;34:342-346.
Demetriades D, Charalambides BS, Chahwan S et al. (2000);Non-skeletal cervical spine
injuries: Epidemiology and diagnostic pitfalls. Journal of Trauma. 48:724-727.
Freedman I, Van Gelderen D, Cooper DJ, Fitzgerald M, Malham GM, Rosenfeld JV, Varma
D, Kossmann T. (2005). Cervical spine assessment in the unconscious trauma patient.
Journal of Trauma.;58:1183-1188.
Gunby, I. (1981): New Focus on Spinal Cord Injury. Journal American Medical Association
245(12)( 1201-1206.
Hamilton RS and Pons PT. The efficacy and comfort of full-body vacuum splints for
cervical-spine immobilization. Journal of Emergency Medicine, 14(5): 553-559.
Hann, A. (2004). A photographic guide to prehospital spinal care. 5th Edition.
www.emergencytechnologies.com.au/psm.htm
Hauswald M, McNally T. (2000)Confusing extrication with immobilization: the
inappropriate use of hard spine boards for interhospital transfers. Air Med J. OctDec;19(4):126-7
Hedger, A. (2002). Clearance of cervical spines in adult trauma patients. J. Neurosci.
Nurs.;34:331-336.
Hendy GW, Wolfson AB, Mower WR et al. (2002). Spinal cord injury without radiographic
abnormality: Results of the National Emergency X-Radiography Utilisation study in blunt
cervical trauma. J.Trauma. ;53:1-4.

Version 2/2011
126
Hills MM, Deane SA. (1993). Head injury and facial injury: Is there an increased risk of
cervical spine injury? J Trauma.;34:549-554.
Hoffman JR, Mower WR, Wolfson AB et al. (2000). Validity of a set of clinical criteria to
rule out injury to the cervical spine in patients with blunt trauma. N. Engl. J. Med.;343:9499.
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). Ann. Emerg. Med.
32:461-469.
Hogan BJ, Blaylock B, Tobian TL. (1997). Trauma multidisciplinary Q.I. project: Evaluation
of cervical spine clearance, collar selection and skin care. J. Trauma Nurs.;4:60-67.
Huether SE, McCance KL. Understanding Pathophysiology, 3rd Edition. St Louis, MO:
Mosby, 2004.
Hunt K, Hallworth S, Smith M. (2001) The effects of rigid collar placement on
intracranial and cerebral perfusion pressures. Anaesthesia. Jun;56(6):511-3
Iida H, Tachibana S, Kitahara T et al. (1999). Association of head trauma with cervical
spine injury, spinal cord injury or both. J Trauma.;46:450-452.
Ireland, C., Zeitz, K. & Bridgewater, F. Acquiring and maintaining competence in the
application of extrication cervical collars by a group of first responders. Prehospital and
Disaster Medicine. Vol 23, NO 6 , Nov-Dec 2008.
James, C., Reimann, B., Munkasy, B., & Joyner, A. Comparison of cervical spine motion
during application among 4 rigid immobilization collars. Journal of Athletic Trainers. 2004.
39(2): 138-145.
Kenneally A. (1995). The Philadelphia Collar Clinical Education Module.. The Alfred,
Melbourne.
Kilburn MPB, Smith DP, Hadley MN. ,( 2001) The Initial Evaluation and Treatment of the
Patient with Spinal Trauma. In: Batjer HH and Loftus CL (eds.)Textbook of Neurological
Surgery. Lippincott/Williams & Wilkins, Philadelphia, PA.
Kolb JC, Summers RL, Galli RL. (1999) Cervical collar-induced changes in
intracranial pressure. Am J Emerg Med. Mar;17(2):135-7
Kwan, I.,& Bunn, F. Effects of Prehospital spinal immobilization: A systematic review of
randomized trials on healthy subjects. Prehospital Disaster Medicine. 2005; 20(1):47-53.

Version 2/2011
127
Kwan I, Bunn F, Roberts I. (2001) Spinal immobilisation for trauma patients.

Cochrane Database of Systematic Reviews.;(2):CD002803
Mader, S.S. (2005) Understanding Human Anatomy and Physiology. McGraw Hill, Boston
Marieb, E.N. & Hoehn, K. (2007) Anatomy and Physiology. 7th Edition. Benjamin
Cummings, San Francisco
Marion D, Domeier R, Dunham CM et al.(2000). Determination of cervical spine instability
in trauma patients: Update of the 1997 EAST Cervical Spine Clearance Document.
Available at: http:/www.east.org. Accessed June 20, 2004.
Marion D, Domeier R, Dunham CM, et al. (1997). Practice Management Guidelines for
Identifying Cervical Spine Injuries Following Trauma.. Available at: http:/www.east.org.
Accessed April 6, 2005.
Martini FH, Bartholomew EF, Bledsoe BE. Anatomy and Physiology for Emergency Care.
Upper Saddle River, NJ: Pearson Education, 2002.
Mazolewski, P., & Manix, T. The effectiveness of strapping techniques in spinal
immobilization. Annals of Emergency Medicine 1994; 23(6): 1290-1295.
McConnell T, McCann J. (2001). Nursing guidelines for care of patients wearing a cervical
collar: The Alfred Intensive Care Unit.. Melbourne.
McLeod, A. (2004). Traumatic injuries to the head and spine 1: Mechanisms of injury.
British Journal of Nursing. Vol 13. No 16.
Mobbs RJ, Stoodley MA, Fuller J. (2002). Effect of cervical hard collar on intracranial
pressure after head injury. Aust. N.Z.J. Surg.;72:389-391.
Oakley P, Brohi K, Wilson A et al. (2002). Guidelines for initial management and
assessment of spinal injury: British Trauma Society,. Injury. 2003;34:405-425.
Pasquale M, Fabian TC. (1998). Practice management guidelines for trauma: EAST ad hoc
committee on guideline development- identifying cervical spine instability after trauma. J.
Trauma.;44:941-956.
Pimentel, L & Diegelmann, L. (2010) Evaluation and management of acute cervical
trauma. Emerg.Med.Clin.N Am. 28, 719-783.
Plaisier B, Gabram SGA, Schwartz RJ, Jacobs LM. (1994). Prospective evaluation of
craniofacial pressure in four different cervical orthoses. J. Trauma. ;37:714-720.

Version 2/2011
128
Podolsky S, Baraff LJ, et al: (1983).Efficacy of cervical spine immobilization methods.

JTrauma-Injury Infection & Critical Care 23:461-465,
Reid DC, Henderson R, Saboe L et al. (1987). Etiology and clinical course of missed spine
fractures. J. Trauma.;27:980-986.
Richards PJ. (2005). Cervical spine clearance: A review. Injury.;36:248-269.
Roberts: Clinical Procedures in Emergency Medicine. 4th Edition , 2004 Saunders.
Semonin-Holleran, R. ed. Air and Surface Patient Transport Principles and Practice. 3rd
edition. Mosby Inc., St Louis 2003. Chapt 18 pp. 305-319.
Stiell IG, Wells GA, Vandemheen KL et al. (2001). The Canadian C-Spine Rule for
radiography in alert and stable trauma patients. JAMA. 286:1841-1848.
Toscano, J. (1988). Prevention Of Neurological deterioration before admission to a spinal
cord injury unit. Paraplegia 26(3143-150.
Vickery, D. The use of the spinal board after the prehospital phase of trauma
management. Emergency Medicine Journal. 18(1)(2001) 51-54.
Webber-Jones JE, Thomas CA, Bordeaux RE Jnr. (2002). The management and prevention
of rigid cervical collar complications. Orthop.Nurs. ;21:19-28.

Version 2/2011
129

Spinal Immobilization V 2 Feb 2011

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Spinal Immobilization V 2 Feb 2011

Загружено:

Авторское право:

Доступные форматы

Spinal

Compiled by: Wendy Porteous - V 2 - 2011

For information regarding this Guide contact:

Spinal Immobilisation Techniques and Devices

Anatomy & Physiology of the Spine

Aetiology of Spinal Cord Injury

Primary Spinal Cord Injury

Secondary Spinal Cord Injury

Spinal Cord Injuries

Signs & Symptoms of Spinal Cord Injury

Mechanisms of spinal Cord Injury

Spinal Immobilisation Techniques and Devices

Considerations of Spinal Cord Injury in Paediatrics

Manual In-Line Immobilisation

Motor Cycle Helmet Removal

Semi-Rigid Extrication Collars

Spinal Boards / Back Boards

Maintenance of Neutral In-Line Position of the Head

Immobilisation of the Head to the Device

Head Blocks / Head Immobilisers

Jordon (Donway) Lifting Frame

Clinical Practice Guidelines and Competency Assessments

Bibliography, References and Further Reading

Spinal Immobilisation Techniques and Devices

Anatomy and Physiology of the Spine

Brain and Spinal Cord

Spinal Immobilisation Techniques and Devices

CENTRAL NERVOUS SYSTEM

Spinal Immobilisation Techniques and Devices

SYMPATHETIC NERVOUS SYSTEM

Spinal Immobilisation Techniques and Devices

PARASYMPATHETIC NERVOUS SYSTEM

Spinal Immobilisation Techniques and Devices

Spinal Immobilisation Techniques and Devices

Spinal Immobilisation Techniques and Devices

Spinal Immobilisation Techniques and Devices

Spinal Immobilisation Techniques and Devices

Spinal Immobilisation Techniques and Devices

Extends from foramen magnum to second lumbar vertebra

Gives rise to 31 pairs of spinal nerves

Not uniform in diameter throughout length

Spinal Immobilisation Techniques and Devices

Spinal nerves are collections of axons of the peripheral nervous system.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

Spinal Immobilisation Techniques and Devices

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

Spinal Immobilisation Techniques and Devices

BLOOD SUPPLY TO THE SPINAL CORD

Spinal Immobilisation Techniques and Devices

Spinal Immobilisation Techniques and Devices

CEREBRAL SPINAL FLUID

Spinal Immobilisation Techniques and Devices

Spinal Immobilisation Techniques and Devices

coccygeal vertebrae which numerous texts classify differently.

Spinal Immobilisation Techniques and Devices

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma

Spinal Immobilisation Techniques and Devices

Cervical spine (7)

Thoracic spine (12)

Lumbar spine (5)

Sacral spine (5)

Coccyx spine (4)

Spinal Immobilisation Techniques and Devices