Acute Injury Management




INTRODUCTION



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Acute management of injuries in the field is one of the key components of routine emergency medical response. Although many controversies exist and will continue to arise concerning the indications for these interventions, when the decision is made to employ a procedure the technique should be performed properly. EMS physicians and medical directors must consider the impact of providers observing their technique and should always employ, and expect their providers to utilize, good technique. A step-by-step description of these interventions is included in this chapter.




PROCEDURES



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  • Spinal immobilization




    • From the ground



    • Standing takedown



    • Extrication device to long spine board



    • In-the-water immobilization




  • Tourniquets



  • Hemostatic bandages





GENERAL CONSIDERATIONS



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The indications and need for spinal immobilization are highly controversial. 1 For instance, the NAEMSP/ACS-COT combined position paper questions the utility of long spine boards beyond initial extrication and some studies suggest that routine spinal immobilization of penetrating trauma patients who do not exhibit evidence of neurologic injury is unnecessary and potentially exposes the patient to unnecessary adverse effects. 2 Potential adverse effects include airway compromise, pain, pressure ulcers, and unnecessary radiographic imaging. This section will not address areas of controversy but will instead assume that spinal immobilization is necessary and indicated and that multiple techniques are potentially safe and acceptable when performing each skill and procedure (ie, log roll vs lift and slide). Of note, some EMS systems have replaced immobilization on a long spine board with spinal precautions on a firm mattress and utilize the long spine board primarily as a means of extrication. A recent study even showed better restriction in spinal movement when patients self-extricated wearing only a cervical collar. 3



Indications Spinal immobilization may be performed in patients in whom there is significant concern for potential spinal cord injury. Concern for spinal cord injury may stem from mechanism, comorbid conditions, physical examination findings, or a combination of these factors. Some examples of patients who should be considered for spinal immobilization include patients with a high-energy mechanism of injury such as vehicle or motorcycle accidents, falls, and swimming/diving injuries in which prehospital clearance is impossible or impractical. Some examples of historical and physical examination findings that raise concern for spinal cord injury are complaints of neck pain, paresthesias, paralysis, and findings of midline tenderness or step-offs.



FROM-THE-GROUND SPINAL IMMOBILIZATION TECHNIQUE



When victims are found down and/or are instructed to remain on the ground, spinal immobilization should take place from where there are found unless hazards prevent this approach.



Indication This technique may be considered when a patient requiring spinal immobilization is found lying supine or prone by EMS providers.



    Essential Equipment

  • Long spine board (LSB)



  • Head immobilization device/tape/sandbags/towel rolls/ etc



  • Semirigid cervical collar



  • Straps/other devices to secure to LSB



  • Sufficient manpower



  • PPE




    Technique

  • Step 1: First assume and maintain inline cervical spine alignment manually (Figure 60-1).



  • Step 2: Place semirigid cervical collar (Figure 60-2).



  • Step 3: The rescuer holding C-spine directs synchronous log roll of the patient w/ LSB placed (Figure 60-3).



  • Step 4: The patient and LSB rolled back as single unit (Figure 60-4).



  • Step 5: Patient’s torso/pelvis/legs secured to LSB with straps first (Figure 60-5).



  • Step 6: Patient head immobilized w/ device to LSB last (Figure 60-6).





FIGURE 60-1.


Manual immobilization of the C-spine.






FIGURE 60-2.


Placement of the C-collar.






FIGURE 60-3.


Log roll for inspection.






FIGURE 60-4.


Log roll onto a long spine board.






FIGURE 60-5.


Strapping to the long spine board.






FIGURE 60-6.


Head immobilized to the long spine board.





    Pitfalls

  • Failure to recognize spinal injury



  • Failure to keep an awake patient informed of rescuer procedures and expectations



  • Failure to maintain manual cervical spine control



  • Failure to work as a team with all movements coordinated by the provider at the head of the patient



  • Insufficient personnel to safely and effectively stabilize the patient



  • Airway compromise



  • Pain and discomfort



  • Pressure ulcers from prolonged immobilization




STANDING TAKEDOWN SPINAL IMMOBILIZATION TECHNIQUE



While this remains a common technique in prehospital provider education, there is limited evidence beyond anecdotal accounts to support its use. In actual practice, ambulatory patients are often assisted to an LSB or mattress. Cervical spine immobilization can occur while the patient is standing, as illustrated below, prior to assisting the patient the a LSB or mattress.



Indication The standing takedown technique may be considered when a patient requiring spinal immobilization is found ambulatory or standing by EMS providers.



    Essential Equipment

  • Long spine board



  • Head immobilization device/tape/sandbags/towel rolls/ etc



  • Semirigid cervical collar



  • Straps/other devices to secure to LSB



  • Sufficient manpower



  • PPE




    Technique

  • Step 1: First assume and maintain inline cervical spine alignment manually from posterior approach to the standing patient (Figure 60-7).



  • Step 2: Place semirigid cervical collar (Figure 60-8).



  • Step 3: Place LSB upright between rescuer holding C-spine and patient’s back (Figure 60-9).



  • Step 4: Additional rescuers grasp hand holds on LSB at level of patient’s axilla to support the patient (Figure 60-10).




  • Step 5: C-spine rescuer directs backward lowering of the patient and LSB to ground surface (Figure 60-11).



  • Step 6: Patient torso/pelvis/legs secured to LSB w/ straps first (Figure 60-12).



  • Step 7: Patient head immobilized w/ device to LSB last (Figure 60-13).





FIGURE 60-7.


Standing takedown: inline cervical spine alignment.






FIGURE 60-8.


Standing takedown: placement of the C-collar.






FIGURE 60-9.


Standing takedown: placing the long spine board.






FIGURE 60-10.


Standing takedown: support the patient.






FIGURE 60-11.


Standing takedown: backboard lowering.






FIGURE 60-12.


Standing takedown: securing to the long spine board.






FIGURE 60-13.


Standing takedown: head immobilization.





    Pitfalls

  • Failure to recognize potential spinal injury



  • Failure to keep the patient informed of rescuer procedures and expectations



  • Failure to maintain manual cervical spine control



  • Failure to work as a team with all movements coordinated by the provider at the head of the patient



  • Insufficient personnel to safely and effectively stabilize the patient




EXTRICATION DEVICE TO LONG SPINE BOARD SPINAL IMMOBILIZATION TECHNIQUE



A number of extrication devices designed to immobilize a patient from a closed space (usually seated in a motor vehicle) and aid in their extrication from that space and onto a long spine board. The most commonly references device is the Kendrick Extrication Device (K.E.D.).



Indication Used when a stable patient requiring spinal immobilization is found entrapped (ie, in a vehicle) with reduced access or within a confined space.



    Essential Equipment

  • Extrication device (K.E.D. is shown here) (Figure 60-14)



  • Long spine board



  • Head immobilization device/tape/sandbags/towel rolls/ etc



  • Semirigid cervical collar



  • Straps/other devices to secure to LSB



  • Sufficient manpower



  • PPE





FIGURE 60-14.


Kendrick Extrication Device (K.E.D.). (Reprinted with permission from Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study, 7th ed. New York, NY: McGraw-Hill; 2011.)





    Technique

  • Step 1: First assume and maintain inline cervical spine alignment manually from easiest approach to the injured patient (Figure 60-15).



  • Step 2: Place semirigid cervical collar (Figure 60-16).



  • Step 3: Additional rescuers place K.E.D upright behind the patient (Figure 60-17).



  • Step 4: Secure the patient firmly in K.E.D. utilizing color-coded strapping system (Figure 60-18).



  • Step 5: Secure head, chin, and leg straps (Figure 60-19).



  • Step 6: Extricate the patient utilizing K.E.D. haul straps and place on LSB (Figure 60-20).



  • Step 7: Disconnect the leg straps, allowing the patient’s legs to lay flat on the long spine board.



  • Step 8: Secure the patient in K.E.D. to LSB utilizing available patient restraint devices (Figure 60-21).





FIGURE 60-15.


Extrication: inline C-spine immobilization.






FIGURE 60-16.


Extrication: placement of the C-collar.






FIGURE 60-17.


Extrication: K.E.D. being placed.






FIGURE 60-18.


Extrication: securing torso.






FIGURE 60-19.


Extrication: securing the head, chin, and legs.






FIGURE 60-20.


Extrication: extricating on the K.E.D.






FIGURE 60-21.


Extrication: securing to the long spine board.





    Pitfalls

  • In unstable patients, in whom prolonged extrication time could be potentially fatal, the risks and benefits of expeditious extrication must be weighed. If expeditious extrication is performed, the cervical spine should not be ignored. Extrication even when performed quickly should still make every attempt to reduce spinal manipulation whenever possible.



  • Forgetting to loosen or disconnect the leg straps when laying the patient on the LSB.




IN-THE-WATER SPINAL IMMOBILIZATION TECHNIQUE



Water rescue can take the form of different levels of technical rescue. The initial consideration of operational safety for rescuers should remain the primary concern in these situations. Presuming technical rescue is not required, or that the rescuers have the correct type and level of training, spinal immobilization may occur in otherwise safe conditions. Although deepwater backboard is possible, it may be impractical in most rescue operations and overall safety and maintaining the victim’s airway above the water is the priority.



Indication For use when a patient requiring spinal immobilization is found in an aquatic environment. 4



    Essential Equipment

  • Long spine board



  • Head immobilization device/tape/sandbags/towel rolls/etc



  • Semirigid cervical collar



  • Straps/other devices to secure to LSB



  • Sufficient manpower



  • PPE




    Technique

  • Step 1: Move the patient to a safe area to affect in-water immobilization—shallow, easiest to access—while maintaining cervical inline stabilization (Figure 60-22).



  • Step 2: Additional rescuers submerge LSB and move it under the patient, allowing it to rise up under the patient (Figure 60-23).



  • Step 3: The rescuer supporting the head holds the backboard and the patient while others secure the patient to LSB (Figure 60-24).



  • Step 4: Move head end of LSB toward egress point—shore, pool edge, boat transom (Figure 60-25).



  • Step 5: Place head end of LSB on surface and slowly slide out of water (Figure 60-26).



  • Step 6: Ensure that the patient once removed from the water is moved an adequate distance from the water’s edge to ensure the patient does not slide back into the water.





FIGURE 60-22.


Water: move to a shallow, safe place.






FIGURE 60-23.


Water: submerging long spine board to move under the patient.

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Jan 22, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on Acute Injury Management
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