Spinals @ MX

[Timmy]

Having attended many motocross events I have come across some quiet unique and unusual situations that they haven’t covered in our training. On many occasions I’ve had riders go flying 5 meters in the air landing on the ground head first only to have another 20 or so bikes ride over the top of them. When we arrive the patient is staggering around swearing at everything and kicking the ground, he’s C/O of server cervical pain with numbness in figures and feet. Now my question is how do you immobilize such a patient? I tend to leave the helmet on or its already off cause they’ve cracked it and thrown it at their bike, get them to stand up in a nice straight anatomical position, place the spine board against their back and strap them on then lower them to the ground while someone is maintaining spinal alignment, remove the helmet if its not already off collar and tape their head to the board.

Also had heaps of patients who have sustained quiet serious collar bone/clavicle injuries were we couldn’t actually apply a collar as the base of the collar would have rested on the bone that was almost a compound fracture.

With patients that have cervical pain with collar bone/clavicle injuries do you have problems with laying them supine? I can only give Penthrane which doesn’t really dull the pain for injuries that server. So the pt refuses to lay flat which chucks all your spinal precautions out the window…

We also had another patient who got flipped up into the air; upon landing he got pinned between the back tyre and the metal support rods, he also had cervical pain but he was in such a position that we couldn’t actually take any spinal precautions until rescue arrived 45mins later.

Does anyone have any advice/tips on how you spinally immobilize those tricky patients?

[scottish emt]

We also cover lots of motocross. Have you tried using a vacuum mattress and rolling a blanket then placing the rolled blanket around the head then tape the head to the blanket and mattress. Give this a practice on your colleages and see what you think

[Eyegor]

I'll 2nd the vacuum mattress. I'll add vacuum splints, SAM splints, blanket rolls, and head blocks. Of course don't forget that if the helmet comes off, the chest armor does too. One last trick that will make almost everyone cringe:

We had a MXer c/o severe shoulder/neck pain who was adamantly refusing a C-collar. No deformity, pulses and neuros normal all around. We also found he refused to lay supine due to pain/pressure it placed on the scapular area of his back. We wound securing him into a KED (no collar) with the head straps replaced by cravats. We transported him sitting up to maintain in-line as much as possible and to minimize pain. We got some strange looks at the ER but upon explanation the doc agreed.

[emsbrian]

First off, SAM splints are more then useful for a number of things, along with vacuum spints. As the others have said!! Remember the c-collar is very limited in its helpfulness, so the lack of the ability to apply one is minimally a problem if you can secure with head blocks (rolled, towels etc...) properly once the rest of the body has been immobilized, as this is the only true final cervical immobilization. A KED is good if you have posterior surface mutilation (not just abrasions or lacerations) preventing normal immobilization, but remember most people will get over the pain. While I'm not going to torture a patient, if a little pain is for there better its the way to go. I find a lot of patients begin to ignore the fact or deal with the pain of damaged tissue on there back when facing spinal injury. If the patient has numbness or pain you really have no choice. As far as body plates and clothing, and helmets. Everything but the helmet comes off, I don't care how much it costs. I don't deal with Mx'ers sept on rear occasion when the local track ties up both its standbys. But I do deal with ALOT of pro soccer and football players. Don't pussy foot around, you have to do a head to toe with one exception. HEAD. Cut off everything to check it. There is never an excuse to miss any injury, you have to be able to see and feel. I wont go into that any more assuming you can make a good head to toe. The reason the head is an exception is the helmet. Helmets are the only piece of protective equipment that can support/splint and injury that may be made worse. If the patient does not have a major bleed and has a patent airway leave the helmet on. Let them remove it in the controlled environment of the ED. There is no reason to risk more injury from removing it. Unless they have the water bladder designed to remove the helmet without risk to the spine. If the helmet has a need to be removed though, such as airway control, bleeding etc. do it carefully, but I stress leaving it. Your description of a standing takedown is the best way to immoblize them, no probs there. If you can make your question a little more precise (had a lot of different topics there) maybe could help a little better. Hope the advice helps.

[iMac]

It all depends on whether or not the patient is still supine on the track or standing up. Im not familiar with the kind of helmets they use when they do motorcross but unless Im really worried about the airway or think there is a chance Im going to be concerned about the airway I wont even bother to get take it off but boarding someone with a helmet on is a pain in the ars.

[OzMedic]

Backboards are extrication devices only and should not be utilised to transport spinal patients on! Taping/strapping the head only potentiates the problem and increases the risk of injury exacerbation and aspiration. Studies utilising CT imaging have demonstrated the inappropriateness of this approach not matter how much the patient is trussed to the board (this goes for KED type devices as well). The most efficient method of immobilisation is the full vacuum mattress, if this is not available then scoop/back board the patient onto your stretcher mattress and place 1 towel rolled from both sides under the patients head to minimise lateral movement. Do not tape the patients head in any circumstance!! Again these methods have been shown to be the most spinal friendly by the utilisation of CT imaging. Helmet removal should not be a problem when adequately trained and prepared for and I disagree totally with leaving them on for transport. The added mass of the helmet will add to the mass of the persons head and increase lateral movement. In addition a helmet will not allow a supine patient to lie in a position that does not hyperextend the spine. Airways can also turn from good to bad in an instant and you do not want to have to rip off the helmet in a hurry by yourself while in the back (when was the last motorcross event you attended that was in town and a short distance from hospital?). These patients require a slow/smooth transport (preferably helicopter) so you could be with them for a prolonged period of time. Remember cervical collars are not always going to be an option (try putting one on a rugby front rower) or for reasons previously mentioned, a poorly fitted collar is a bigger risk factor than no collar so if it's not an option then manage as I previously mentioned and use extra care and utilise manual support as practical.

[Timmy]

Thanks for the advice everyone!

Just a few little things I would like to point out, my service doesn’t use KED or anything like that, we only have scoops and spineboards.

Do not tape the patients head in any circumstance!!

RAV still tape patients head to the bed. Vic Aeromed and the westpack chopper guys did the same. This was the way we were taught how to transports spinals by a traurma nurse from the Royal Melborune Hospital as well as a local ED Doc and I think MAS still do the same?? This is either really new or a QAS thing?

I find towels either side of the head then taping their forehead and the middle part of the collar to the spineboard works great... We put gauze strips over the exposed skin so the tape doesn’t cause to much damage and a small face washer under their head for added comfort.

As far as transport goes, the patient is either stretched by foot back to the first aid room or in the vehicle. While were driving over the bumps and jumps someone is always holding their head as well as the tape...

[OzMedic]

Timmy, As I said before backboards have been shown to provide an abnormal surface for spinal support, patients on back boards are supporting their spines with the muscles in their back (if conscious) by both voluntary and involuntary spasm along the spine and around the injury site(this is a protective mechanism and the most effective form of spinal immobilisation). This will only last for so long until fatigue and especially morphine allow the muscles to relax and if on a hard flat backboard the spine conforms in an unnatural manner to the board. Also, as I said before, It has been shown with the help of CT imaging that strapping patients heads increases unnatural movement due to the fact that it is impossible to fully immobilise the body. This is if you are strapping it to a backboard which is wrong anyway but strapping it to a bed is even more wrong because you cannot logroll the patient at short notice if there is a problem with the airway eg: vomiting. A vaccum mattress is the solution to both of these problems because it does immobilise the patient in a manner that conforms to the individual patients anatomical peculiarities and allows 1 person at a pinch to safely logroll the patient. Anything less is substandard and strapping the head to a bed or board is just plain wrong!

Timmy as you gather more experience throughout your EMS career you will realise that a lot of things are done for the wrong reasons, the main one being that it is past accepted practice and that is the only reason I can offer as to why things are done the way they are in VIC as you say. The best argument you can make if you disagree with me is to dig up some evidence that supports spinal immobilisation in the way you propose. Saying that so and so does it that way carries no more weight than if you show the guys down there my posts to demonstrate why you should do it my way. Bushy would be a good place to start if you are chasing the relevant studies but I can tell you now they are all pretty poor. The one factor that is becoming apparent from recent research is that is does not really matter what we do as long as we are not silly as the initial insult usually does the damage or not! Good luck with it mate :wink:

[emsbrian]

his is if you are strapping it to a backboard which is wrong anyway

NO

strapping it to a bed is even more wrong

YES- Not even an option, if I caught this at my service their would be some serious problems.

The reason I post in such an extreme manners is that you advocate vacuum mattress as the ONLY form of immobilization. FOR NEWBIES do no take this to mean don't do it. Obviously alot of services run with only backboards there. BACKBOARDS ARE THE STANDARD OF CARE. It is cavalier to claim they are either useless or affective. One hundred times more studies show positive outcome increase do to immobilization over no spinal precautions.

THE IMPORTANT PART: Muscle twitches are cause by unsupported parts (mind you our body normally twitches muscles in the same manner the study I read stated as a problem on a daily basis even sitting on a couch.) Padding the voids and proper webbing MUST be done. If you don't, then you haven't back boarded your patient. Spider straps and duck tape are crap, use them only for dangerous rescues where you need a high speed extrication because of further harm to Patient your you. But in every case possible you should web them. If you pad the voids you SIGNIFICANTLY reduce spinal movement and twitching. As far as the head. I like disposable cardboard blocks and tape, this prevents as much movement as possible. As a note from a NREMT examiner, most people pass backboarding, but they do it wrong. PAD THE VOIDS. If it was up to me their would be a lot more voids across the wall in NR, SKILL UP people, do it right its not hard I never failed ONE)

Summed up: Backboard, BUT DO IT RIGHT!!!

On that note......... Vacuums better all around, splints and mattresses, they conform to injury and provide the best rigidity for a conforming splint.

[Timmy]

Ok, just to save confusion... This is how I would and do package a spinal patient:

(we use rolled up hand towels for head blocks)

Right or Wrong??