After five plus decades, physicians and pre-hospital providers are seriously questioning the benefits of field immobilization, especially in wilderness and austere environments where evacuations can be long, arduous, and put both patients and rescuers at risk.
Current research supports the following statements:
- The vast majority of spine injuries are stable and will not cause or lead to spinal cord damage.
- A very low percentage of awake, alert, and reliable patients have an unstable spine or cord injury.
- Prolonged spinal immobilization increases morbidity and mortality. Problems include: increased ICP (a tenfold increase with head-injured patients may occur when using a hard cervical collar), respiratory compromise, pain, and pressure sores.
- There is less spine movement during an extrication when a cervical collar is applied and alert patients are permitted to extract themselves from the situation than when trained rescuers do the extrication.
- Complex and challenging litter evacuations increase risk to rescuers and patients.
- The effectiveness of spine immobilization in preventing further neurological injury is uncertain. There is some research that indicates that spine immobilization even in the presence of an unstable spine injury may not be necessary.
- The potential for a spine or cord injury decreases with the significance of the MOI.
- Neurologic deficit (motor or sensory impairment not attributable to an extremity injury) indicates a potential spine and/or cord injury and, at this point, is grounds for immobilization.
Practically, from a field perspective, this means:
- Apply a C-collar and assist (rather than lift or carry) awake, alert, and reliable patients found in difficult anatomical positions to extract themselves from the situation.
- Ambulatory, awake, and reliable patients with no neurologic impairment are highly unlikely to have an unstable spine injury even if they fail the CCR or Nexus due to spine pain or tenderness. If there is significant risk to either the patient or a rescuer to fully immobilize and evacuate the patient in a litter and self-evacuation would incur less risk, consider having the patient self-evacuate. If it is more comfortable, consider supporting a painful and/or tender cervical spine with a C-collar and/or the thoracic or lumbar spine with an internal backback frame and hip belt.
- The development of pressure sores can occur on a hard surface within a few hours and can be mitigated during a long evacuation by using thick padding; a vacuum mattress is preferred.
- If a potentially spine-injured patient has a moderate or severe concussion, or increased ICP, avoid using a hard cervical collar when fully immobilizing them in a litter for evacuation. Instead use the Go-beyond principle to immobilize their head and consider using a soft cloth roll (made from an article of clothing) to help prevent flexion.
- Sacrifice immobilization in a potentially spine injured patient when their packaging interferes with respiratory support. Consider immobilizing potentially spine injured patients on their side if vomiting is an issue during evacuation.
Want to learn more about managing spine injuries in the field? Take one of our Wilderness First Responder or Wilderness EMT courses.