SPINAL MANAGEMENTSCI = spinal cord injuriesCSF = Cerebrospinal fluid

Spinal cord injuries are classified as: Traumatic – resulting from external causes like motor vehicle accidents, violence, falls and water

or sport related injury. Non-traumatic – caused by medical conditions. Eg: cancer, disc disease and spinal infections.

OR Complete injuries – Total loss of motor function (paralysis) and sensory perception Incomplete injuries – Partial preservation of sensory and/or motor functions

Unless an accident has been witnessed, the motionless and unconscious casualty should be treated as having a spinal injury.

A first aider must balance the aim of minimal movement of the spinal column and the requirement to maintain an open airway.

Central Nervous System (CNS) comprises the brain and spinal cord. Peripheral Nervous System (PNS) comprises all nerves that lie outside the brain and spinal cord. The central nervous system cannot regenerate itself. Only around 50% of casualties show recognised symptoms or signs of spinal damage.

The spine is made up of 33 separate vertebrae. The spine can be divided into five sections;

o the first three sections (Cervical, Thoracic and Lumbar) are flexible and allow movement, twisting and bending of the spine.

o the two lower sections (Sacrum and Coccyx) are fused and provide attachment points for muscles (such as the gluteus maximus).

Flexion = chin to chest

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Damage to the spinal cord can be caused by: Concussion – a sudden violent jolt injures the tissues around the cord. ie surfing or diving injury Contusion – bleeding occurs in the spinal column exerting pressure around or onto the cord. Compression – an object exerts pressure on the spinal cord. ie object falls on the spinal column depressing a vertebra

Tearing or Cutting – the spinal cord is partially or completely severed due to a force.

Mechanisms of Injury (MOI) The mechanism of injury is the exchange of forces that result in an injury. There are five main mechanisms in spinal cord injury:

Hyperextension: spine is arched backwards beyond its normal limits

Hyperflexion: spine is arched forward beyond its normal limit

Compression: spinal cord is compressed following impact

Distraction: overstretching of the spinal cord

Rotation: head and body rotate in opposite directions

Types of InjuryQuadriplegia or Tetraplegia Paralysis of four limbs, usually the result of spinal cord damage between C1 and C7.

Paraplegia or Biplegia Paralysis of both lower extremities (legs) as a result of damage to the cord at T1 and below.

SCI signs and symptoms The signs and symptoms of a spinal cord injury depend on two factors:

the location of the injury the extent of the injury – complete or partial injury.

Signs Loss of consciousness or fading in and out Loss of function in hands, fingers, feet or toes Fluid leaking from the ears Neck or head in abnormal position Breathing difficulties Loss of bladder or bowel control Dilated pupils Abnormal blood pressure Profuse bleeding from the head Abrasions or bruising to the head or forehead Shock Prioprism (erection in males)

Symptoms Back or neck pain (often intense) Tingling, numbness or lack of feeling in lower or upper limbs Headache or dizziness Nausea Increased muscle tone

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Special considerations -- Infants and children compared to adults When treating a casualty younger than 8 years the anatomical differences between the child and adult SCI casualty must be considered.

The younger child or infant has a relatively large head in proportion to their body. In the supine position the enlarged head can be pushed forward into a hyperflexed position narrowing the airway and elongating the cervical section of the spine.

In cases of suspected SCI in children, the placement of padding under the child or infant’s torso (shoulder to hip) will assist in aligning the casualty’s head to the neutral position. Once the head is in the neutral position a paediatric cervical collar should be applied before moving the infant or child.

An infant without padding under torso with head in hyperflexed position (left) and with padding under torso with head in neutral position (right)

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Managing a Suspected Spinal InjuryUnless an accident has been witnessed, or if a neck and/or back injury is highly improbable, motionless and unconscious casualties should always be treated for a suspected spinal injury.

Management: Conduct Primary Survey, Vital signs and Secondary Surveys accordingly Call 000 urgently Keep the patient still and reassure them Maintain normal body temperature Minimise any movement of the head and spinal column

o Manual stabilisation, cervical collar, spine board, strapping Manage any other injuries Provide oxygen Continually monitor vital signs

A clear airway, breathing and circulation take precedence over a spinal injury. However, where a casualty must be moved, minimising movement of the head and spinal column should occur.

It is recommended that a casualty with a suspected head, neck or spinal injury should not be moved. However, if danger exists to the casualty and they must be moved, then spinal immobilisation techniques should be applied.

Step 1 - Manual stabilisation

Even when spinal immobilisation equipment is utilised (ie cervical collar), manual stabilisation should always be maintained.

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Log rollThe log roll is an accepted method to position a casualty on their side, allowing for the placement of a blanket, board or litter against the spine. The casualty can then be rolled back onto the blanket or board.

A log roll is best performed using four to six first aiders, however modified versions drawing on two and three people can still be successfully used.

At present the safest techniques, based on current research, is for the patient’s arms to be fully extended and placed by the patient’s side with the palms facing inwards. While some sagging will occur, it is minimal and less that other methods currently use. Techniques which elevate the arms above the head or place the arms across the chest result in thoracic / lumbar spine sagging, and should therefore be avoided whenever possible.

LOG ROLL - 4 PERSON SUPINE

Step 1 Officer 1 maintains manual In-Line Stabilisation of casualty’s head with both hands (by placing one hand on either side of the casualty’s head), positioned behind.

Step 2 Officer 2 applies a Cervical Collar and places the spine board alongside Officer 1.o The Manual In-Line Stabilisation is maintained until full spine immobilisation is achieved as a Cervical Collar

will at best provide only 50% immobilisation.

Step 3 Officer 2 kneels at the patient’s mid-torso, straightens the patient’s arms with the patient’s palms facing in next to the torso.o Palm-out may result in elbow joint damage during the roll.

Step 4 Officer 2 positions themselves on the same side of the injured person and reaches across the injured person, securely grasping the upper arm and hip.

Step 5 Officer 3 kneels next to Officer 2, reaches across the injured person and grasps the hip. Officer 3’s lower hand grasps both trouser cuffs at the ankles.

Step 6 Officer 4 kneels on the opposite side of the patient at the patient’s pelvic level. Officer 4’s upper hand is placed on the patient’s upper arm and Officer 4’s lower hand is placed on the patient’s upper leg.

Step 7 A coordinated roll (patient towards the first aiders) is performed, ensuring head and spine stability is maintained.

Officer 1 at the head watches the patient’s torso turn and maintains manual support of the head, rotating it exactly with the torso.

The first aider at the head is in charge of coordinating the movement.Step 8 Officer 4 slides the board in against the patient’s back and elevates the side of the board

furthest from the patient at a 45º angle towards the patient’s back.o Align the patient’s shoulders level with the shoulder markings on the board.

Step 9 Lower the casualty and elevated side of the spinal board down onto the ground, the board maintains body alignment with the casualty.

Check first aider’s body position supports casualty’s body from sliding off or away from spinal board

Step 10 Keeping the patient in the neutral in-line position, gently adjust the patient’s position sideways so that the patient is centred on the board.

Step 11 Apply appropriate padding under the patient’s head and lumbar spine to maintain proper alignment of the spinal column and for comfort.

Step 12 Immobilise the patient onto the board for transport.

The first aider on the head is in charge of the operation and the casualty should be rolled on their word.

Note:Blanket or Litter Board can be used in place of spine board.

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The log roll can be performed if a casualty presents in a face down position.

LOG ROLL - 5 PERSON PRONE 180ºWhen the patient presents in a semi-prone position (as shown), the Officers may wish to carry out the following manoeuvre which rolls the patient onto their back. It incorporates the same initial alignment of the patient’s limbs as other log rolls - arms by the patient’s side

Points To Remember:1. The patient is log rolled away from the direction in which the patient’s face initially points.2. A Cervical Collar is not applied until the patient is in the supine position on the Spine Board.3. Remaining in the prone position will limit the patient’s ability to breath due to pressure on the rib

cage.4. Arching of the spine will occur with each of the patient’s breath whilst in the prone position.

Officer 1 positioned at the patient’s head, positions their arms in anticipation of the full rotation that will occur. Officer 1 positions at a 45º angle to the patient, with arms placed so that the elbow to the side the patient will be rolled onto is in line with the patient’s inner shoulder to roll. Manual In-Line Stabilisation is achieved Officer 1 placing their distal hand under the patient’s head and their proximal hand on top of the patient’s head.

Officer 2 kneels at the patient’s mid-torso, on the other side to which the patient is to be rolled, and extends the patient’s arms down the patients torso. Officer 2 places their upper hand under the patient’s shoulder and the lower hand under the patient’s abdominal region level with lower ribs.

Officer 3 kneels on the same side as Officer 2 at the patient’s thigh, slides their upper hand under the patient’s pelvic region, and lower hand under patient’s upper leg.

Officer 4 kneels at the patient’s mid torso grasping the patient’s opposite side shoulders and opposite lower chest. Officer 5 kneels at the patient’s thigh grasping the patient’s opposite pelvis and opposite mid femur.

A LSB is rested on the knees of Officer 4 & 5. The LSB’s shoulder marking is aligned with the patient’s shoulders.

The patient is carefully log rolled until the patient’s back is placed on the LSB. Officer 1 at the patient’s head watches the patient’s torso turn and maintains the current position of the head, rotating it exactly with the patient’s torso. Whilst rotating the patient, Officer’s 4 & 5 steadily shuffle backwards until the LSB and patient are flat on the ground.

Keeping the patient in the neutral in-line position, gently adjust the patient’s position sideways until centred on the LSB.A Cervical Collar is now applied, and the patient immobilised to the LSB for transport

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