Emergency medical services (EMS) personnel continue to be the first-line responders in dealing with the majority out of hospital emergencies including trauma situations. The ATLS guidelines ( advanced trauma life support) which have been developed in the eighties continue to be the gold standards in assessing and setting priorities in the management of life-threatening injuries in a time-efficient and logical manner. Immobilization of the spine has been an essential part of the teaching in addition to pelvic binders and splinting of long bone fractures. Different medical types of equipment have been developed to allow effectiveness and ease of application in addition to allowing flexibility and vital access for the management of airway and other procedures.
The need for spinal immobilization is determined when assessing the scene and patient. Consider spinal immobilization when the mechanism of injury creates a high index of suspicion for head or spinal injury. Altered mental status and neurologic deficit are also indicators that spinal immobilization should be considered.
The traditional ATLS teaching for adequate spinal immobilization of a patient in a major trauma situation is a well fitted hard collar with blocks and tape to secure the cervical spine in addition to a backboard to protect the rest of the spine. other devices currently in use are scoop stretcher and vacuum splint. The Kendrick extrication device allows the protection of the spine with the casualty in a seated position while being rapidly extricated from a vehicle or other situations with limited access to allow a full backboard. This however still requires the EMS to pay attention to limiting the movement of the cervical spine by using in-line mobilization until fitted .
The 10 edition of the ATLS guidelines and the consensus statement of the American College of Emergency Physicians (ACEP), American College of Surgeons Committee on Trauma (ACS-COT), National Association of EMS Physicians (NAEMSP) states that in the situation of penetrating trauma, there is no indication for spinal movement restriction this in keeping with a retrospective study of the American trauma data bank showed a very low number of unstable spinal injuries needing surgery in the context of penetrating trauma. The study further shows that the number needed to treat achieve potential benefit was much higher than the number needed to harm 1032/66. However, in the case of significant blunt trauma the restrictions continue to be indicated in the following situations:
- Low GCS or evidence of alcohol and drug intoxication
- Midline tenderness either in the back of the cervical spine
- Obvious spinal deformity.
- The presence of other distracting injuries
The advice for effective restriction continues to be a cervical collar with full-length protection of the spine which is to be removed as soon as possible. This is due to the risk of multilevel injury. However, in the pediatric population, the risk of multi-level injury is low and therefore only cervical spine and not full spinal precautions are indicated ( unless signs or symptoms of other spinal injuries is present)
Rigid collar in a pediatric patient
- Neck pain
- Altered limb neurology not explained by limb trauma
- Muscle spasm of the neck (torticollis)
- Low GCS
- High-risk trauma (e.g., high energy motor vehicle accident, hyperextension neck injury, and significant upper-body injury).