Spinal Injury
 
Status
Potential or suspected Spinal Injury
   
Assess
Assess Spinal Cord Injury using Spinal Cord Injury Card (below, added by editor)
   
Assess
Major Trauma Criteria
   
Meets Major Trauma Criteria
Manage airway as appropriate (Adult) (Paed)
Provide spinal immobilisation
Administer pain relief as required (Adult) (Paed)
Manage hypovolaemia (Adult) (Paed)
Transport without delay to an appropriate receiving hospital in accordance with Trauma Triage Guidelines (Adult) (Paed)
 
   
Does Not Meet Major Trauma Criteria
Stop
The clearance criteria below, is not to be used for paediatric patients. No paediatric patient should be spinally cleared pre-hospital after major trauma. Apply all spinal care

If any of the following present provide spinal immobilisation

Increased Injury Risk: 
• Age > 55 years 
• History of bone disease (e.g. osetoporosis, osteoarthritis, rheumatoid arthritis or muscular weakness disease (e.g. muscular dystrophy)

Difficult patient assessment:
• Unconsciousness or any acute or chronic altered conscious state (GCS<15) or period of loss of consciousness
• Drug or alcohol affected
• Significant distracting injury e.g. extremity fracture or dislocation

Actual evidence of structural injury:
 • Spinal column pain/bony tenderness

Actual evidence of spinal cord injury
• Neurological deficit or changes
  - Manage as per emergent time critical trauma criteria
If none of the above present in the adult Pt then spinal immobilisation/cervical collar not necessary
Stop
If any doubt exists as to history or the above assessment, or if there is inability to adequately assess the Pt, provide spinal immobilisation
 
Special Notes
A cervical collar alone does not immobilise the cervical spine. If the neck needs immobilising then the whole spine needs immobilising. This may include the use of 'head rolls' or other approved proprietary devices and the whole body immobilised on a spine board or ambulance stretcher in a manner that is appropriate for the presenting problem. A spine board must be restrained to the ambulance stretcher during transpor.
The head should not be independently restrained.
In Pts with a diseased vertebral column, al lesser mechanism of injury may result in SCI and should be managed accordingly.
Spinal immobilisation with neutral alignment may not be possible in a PT with a diseased vertebral column with associated anatomical deformity and should be modified accordingly e.g. position of comfort
Spinal immobilisation is not without risk. Complications may include head and neck pain, detrimental effects on pulmonary function and subsequent neurological deficit (particularly in the elderly).
 
Special Notes
If a cervical collar is applied then it must be properly fitted and applied directly to the skin, not over clothing and not placing any pressure on the neck veins
Where there is no immediate risk to life and extrication is required than an extrication device (e.g. KED) should be considered
Pts with a SCI may develop pressure areas within as little as 30 min. Following placement on a spine board and the duration on a spine board must be noted on the PCR. Effective padding should be provided to protect pressure areas and a Pt can remain on a spine board for 60mins if properly padded
For transport times in excess of 60 minutes consideration should be given to removing the patient from a spine board and appropriately securing them to the ambulance stretcher
Pts with isolated neurogenic shock should be given a small fluid bolus (up to 500ml Normal Saline IV) to correct hypotension. No further fluid should be given if SCI is the sole injury
The Pt with multi trauma and SCI may not mount a sympathetic response to hypovolaemia. Fluid should be given based on estimated blood loss.
 
Spinal Cord Injury Card
To rule out spinal cord injury, a complete spinal cord examination must be completed by the paramedic.
The following examination must be thoroughly carried out:
See side two See notes

See side one See notes
 
Spinal Card Notes
Ruling out Spinal Cord Injury in the field;
• Patient is fully conscious, alert and has a GCS of 15
• Has passed all the examination criteria set out on the Spinal Cord Injury Card;
• Does not have any problems described in the next two sections below;
• Meet above three points, no spinal immobilisation required.
Spinal cord injury cannot be ruled out if the patient has;
• Fails any of the assessments on the spinal cord injury card
• Has an altered conscious state
• Has consumed alcohol
• Has a painful distracting injury (eg fractured femur etc).
Golden Rules of Spinal Cord Injury;
• Any unconscious person is a spinal cord injury unless proven otherwise;
• Any male trauma patient with an erection has a spinal cord injury;
• Any trauma patient with a bradycardia and a low blood pressure is a spinal cord injury until proven otherwise.
If in doubt, treat for the worst (ie pay off principle) – Immobilise the patient