Spine Management for Wilderness & Remote Locations

For over four decades and with little or no data to back it up, EMS fully immobilized all patients involved in major traumatic incidents in order to prevent neurological damage from a potential spine injury. The premise underlying this practice was that a major traumatic event could injure the patient's spine and subsequent spinal movement would result in a cord injury, and full external spinal immobilization would prevent said movement. This precept is seen as false and spine management in both urban and wilderness environments has changed—or is in the process of changing—accordingly. Read on to see how and why this transformation has taken place...and what the current spine management guidelines are for wilderness and remote locations.

In 1998, Professor Mark Hauswald (Department of Emergency Medicine, University of New Mexico) released a five-year retrospective study comparing trauma patients in Malaysia with those seen in a US hospital. None of the 120 patients seen at the University of Malaya were immobilized during transport while all 334 patients seen at the University of New Mexico were.

The study showed a significantly higher rate of neurologic injury in the immobilized group. The study brought current spine management guidelines into question and sparked decades of research.

In 2012, Dr. Hauswald released another article on the biomechanics and pathophysiology of spinal injures that challenged existing spinal immobilization theory. In his article Dr. Hauswald asserts that most spinal injuries are biomechanically stable, that the majority of those few patients with unstable spinal injuries will already have spinal cord damage as a result of the forces imparted during the traumatic event, and that pre-hospital immobilization will not affect either patient's outcome. This means that cord and neurological injury can only be caused by a second traumatic event where new force is applied to the injured area, and movement within the patient's normal range of motion is safe.

Increased research over past two decades—primarily due to Hauswald's work—has clearly shown that spinal immobilization:

• in a remote environment requires a litter evacuation and transport often putting both patients and rescuers at risk.
• may cause respiratory compromise in some patients due to positioning, tightness and location of chest straps, or the use of cervical collars.
• causes pain.
• causes potentially devastating pressure sores if the litter is not extremely well-padded.

Here's what else we know:

• The 2000 National Emergency X-Radiography Utilization Study (NEXUS) and the 2001 Canadian Cervical Spine Rule (CCR) produced the two most widely used algorithms used in EDs to identify patients who do not require spinal imaging. Use of the NEXUS and CCR criteria for the field clearance of potentially unstable spine injuries is both safe and effective. Meta-analysis on clearance of the asymptomatic cervical spine showed the NEXUS & CCR negative predictive value is 99.6%, it's positive predictive value is 3.7%; the overwhelming majority (96.3%) of patients who fail the exams do not have an unstable spine injury. The State of Maine uses a Nexus-based protocol includes spine pain and paraspinal tenderness. Most wilderness medicine providers teach a focused spine assessment based on the NEXUS algorithm; the algorithm is modified to include spine pain and applies to the entire spine (the original NEXUS low risk criteria did not include spine pain and was only applied to the cervical spine). If a patient is cleared by either protocol, there is no need to transport or evacuate them for a further spinal assessment. Click here to see the details of the modified NEXUS criteria and read and article comparing each protocol.
• A very low percentage of awake, alert, reliable, and ambulatory patients have an unstable spine or cord injury.
• Neurologic deficit-motor or sensory impairment not attributable to an extremity injury-indicates a potential cord injury.
• The use of a full-body vacuum split offers the best spinal support for non-ambulatory spine-injured patients.
• While the use of rigid cervical collars is still a somewhat controversial within urban EMS, they are no longer used in wilderness and remote locations because they increase ICP even in uninjured subjects, restrict access to the patient's airway and, perhaps most important, spine immobilization is not effective in preventing cord injures. Note that a soft cervical collar may be used if it increases patient comfort and does not restrict access to the patient's airway.

So how should we treat patients in a wilderness or remote locations? The treatment goal is to prevent a spinal cord injury.

To that end:

Assume a patient has a Spine Injury when the MOI is Trauma or Unknown and support all voice-resonsive, pain-responsive, and unresponsive patient’s spines during Basic Life Support. Ask awake patients to remain still as you check and treat for severe bleeding during your primary survey. Do not attempt to hold a patient’s head or restrain them, especially if they are anxious or combative.

Begin the focused spine assessment (FSA) only after you have completed all three triangles of the Patient Assessment System to ensure the patient is reliable.

Treatment Principles for Spine & Spinal Cord Injuries

• Voluntary spinal movement within the patient’s normal range of motion is safe.
• Avoid adding energy to the patient’s vertebral system through external movement or poor handling. Encourage awake patients to extricate themselves from difficult positions, with or without assistance.
• Rigid cervical collars, commercial or improvised, are unnecessary, potentially harmful, and should be avoided. A soft cervical collar may be used if it increases patient comfort and does not restrict access to the patient's airway.
• Patients who pass the focused spine assessment do not need to be evacuated for a potential spine or spinal cord injury.
• Patients who fail the focused spine assessment may have a spine injury and must be evacuated for physician assessment and potential imaging; those who have motor or sensory impairment may also have a spinal cord injury. Gentle handling and voluntary patient movement during their evacuation will not exacerbate the injury. Consider self-evacuation with awake, ambulatory patients.

The Focused Spine Assessment (FSA) is very conservative: It's negative predictive value is roughly 99%. This means there is less than 1% chance a patient who passes the FSA actually has a spine injury. On the other hand, the FSA's positive predictive value is, at most, 4%. This mean that roughly 96% of the patient's who fail the FSA do not have a spine injury. The risk for an actual spine injury increases as spine pain and tenderness increase, and increases significantly further if neurological deficit is present; the exact amount, unfortunately, is unknown.

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​When assessing whether a patient who fails the FSA should be permitted—or encouraged—to self-evacuate, you will need to consider the severity of their S/Sx (above), the difficulty of the evacuation (are they likely to fall and cause further damage), and the hazards of waiting for outside assistance.

​Additional Risk Considerations

• BIG traumatic MOI
• Rough, high-risk evacuation terrain
• Additional patient injuries (simple extremity injuries versus critical system injuries)
• SAR response   
• Immediate or impending environmental hazards

• Package and evacuate non-ambulatory patients who fail the focused spine assessment and all VPU patients in a well-padded litter or stretcher using a vacuum splint. The patient’s actual position within the litter—side or back—depends on the type and severity of any concurrent injuries. If a vacuum splint is unavailable, use thick, soft materials for padding under the patient and around their head, neck, and body to support their spine during the evacuation. Attempting to fully immobilize a potentially spine- or spinal cord-injured patient is unnecessary, potentially harmful, and should be avoided.​

• The level of the evacuation may be independent of the potential cord injury and based on any concurrent injuries or illnesses.
• Consider a Level 2 evacuation for patients who fail the Focused Spine Assessment (FSA) due to motor or sensory impairment. If the patient is awake, ambulatory, and able to safely self-evacuate, exercise caution during the evacuation to avoid additional trauma to the patient's spine. The ideal evacuation would occur within 6-24 hours to correspond with the swelling curve.
• Begin a Level 1 EVAC for all paraplegic and quadriplegic patients. Complete paralysis may mask musculoskeletal injuries and complicate assessment of internal bleeding/volume shock. Spinal (neurogenic) shock is an anticipated problem for pts with complete paralysis and may result in death.

 Lifting & Moving Guidelines for Voice-responsive, Pain-responsive, and U Patients

•  Gentle, supported movements are safe; avoid abrupt movement.
• Use small increments; if possible, avoid large unsupported movement.
• Axial pulling and loading are safe; if possible, avoid horizontal movement.
• Rolling is safe: roll patients onto a board/litter if they present on their stomach.
• Firmly control the patient’s weight centers (head, shoulders, & hips) at all times.  Move and align one weight center at a time while supporting the others.
• Bring the litter as close to the patient as possible; use it to create a working platform. If possible, avoid carrying a spine-injured pt unsupported.

Litter Packaging Guidelines for Non-ambulatory Patients

• Package head-injured patients on their side to help protect their airway.
• Use rolled, tied-off sleeping bags, or clothing-filled day packs to pad the patient’s sides and minimize horizontal sliding. Use shoulder straps to minimize axial sliding towards the top of the backboard or litter. Slightly flex and pad under patient’s knees.
• Position sleeping pad(s) under the patient; if possible, use self-inflating pads (do not overinflate). Extend both the bags & pads beyond the patient’s head to support their head and neck using the “Go-beyond principle.” Leave space between the patient’s head and the top of the litter to avoid cervical compression.
• Secure the patient’s body before their head. Use either individual straps or a rope to build an “X” or “Shoelace” system.
• Consider diapering patients in preparation for waste elimination; urinary catheters are helpful in long evacuations.
• Consider a hypothermia package. Build prior to lifting VPU patients.
• To help avoid bed sores, venous clots, and pulmonary embolisms, periodically release patient and massage their back and limbs; gently flex and extend uninjured extremities.

Click on image to enlarge.

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