# Spinal Precautions



## medichopeful (Oct 11, 2009)

I have a quick question,

Is there any harm in putting a person with suspected spine injury onto a backboard _before_ applying a cervical collar?  This is for a trauma assessment, so the steps would go something like this (this only includes relevant parts):

1)  sticky test
2)  roll patient onto side
3)  do rapid assessment of neck, back (during the sticky test, so you can get it done and out of the way)
*4)  place patient on backboard when rolling to supine position(not secured)
5)  apply cervical collar*
6)  secure patient to backboard

We have not gone over backboarding yet, but I would like to know.

Thanks!
Eric


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## Shishkabob (Oct 11, 2009)

One, why would you be able to do the board before the collar?

And two, the properly sized collar helps the neck move even less while doing the roll.


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## Sasha (Oct 11, 2009)

What's the sticky test?


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## Lifeguards For Life (Oct 11, 2009)

why would one want to place a patient on a backboard, before application of a collar?


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## triemal04 (Oct 11, 2009)

Hey look!  An actual answer to the question!

Is there harm?  No.  Is it acceptable in reality?  Yes.  Is putting a collar on first better?  Yes.  Does this mean it's acceptable to your proctor?  Probably; as long as manual stabilization is held then you shouldn't have a problem; ask them if all you are worried about is testing.

There will be situations you come across where you will not initially be able to apply a c-collar right away; often times in that type of situation it's more appropriate to place the person straight onto a backboard.

That what you wanted?


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## Hollywood (Oct 11, 2009)

Is the patient down or ambulatory when you AOS?

If the the Pt id down when you arrive, you immediately assess LOC, Whether they have a pulse and respirations. Then move to your RTA start at the head looking for DCAP-BLS-TIC.
Move to the neck, check for DCAP-BLS-TIC, JVD, and make sure the trachea is midline, also reach back and check for step down or spinal deformity on the back of the neck. Next step put your collar on and continue with the rest of your assessment checking the posterior last as your roll to transfer to a long board. Also some should if at all possible be holding C-Spine until the Pt's head is secured to the board.

DCAP-BLS-TIC= Deformities, Contusions, Abrasions, Penetrations, Burns, Lacerations, Swelling, Tenderness, Instability, Crepitus. Just a handy pneumonic I was taught in case anyone was wondering what it was.


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## Lifeguards For Life (Oct 11, 2009)

triemal04 said:


> Hey look!  An actual answer to the question!
> 
> Is there harm?  No.  Is it acceptable in reality?  Yes.  Is putting a collar on first better?  Yes.  Does this mean it's acceptable to your proctor?  Probably; as long as manual stabilization is held then you shouldn't have a problem; ask them if all you are worried about is testing.
> 
> ...



i disagree. 
can you give me an example of a situation in which you would have ample room and resources to place a patient on a board which would prohibit initial application of a collar?
by placing a collar after boarding a patient, i would say there is an increased potential to further any injuries. Is it acceptable in the field? could be. Is it acceptable to a procotor in a testin situation? best have a darn good reason or else they will believe you forgot, and only remembered to apply a collar too late in the scenario.


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## medichopeful (Oct 11, 2009)

> One, why would you be able to do the board before the collar?
> 
> And two, the properly sized collar helps the neck move even less while doing the roll.



Here is what I was thinking.  If you do the log roll _without_ a collar on, you would be able to actually _look_ at the neck.  Before you rolled the patient back, you would put the backboard underneath so that you wouldn't have to do any unnecessary rolling.  After they were rolled back to a supine position, they would be laying _on_ the spine board, but they would not be secured or have a collar on.  When they were just laying on the backboard, I was thinking that you could put on a cervical collar, and _then_ secure them to the backboard.

*When I say put them on the backboard, I do NOT mean strap them down.  Just lay them there.*



> What's the sticky test?



I'm sure it goes by other names as well.  For us, a sticky test is a VERY rapid assessment looking for leaking bodily fluids (blood, etc).



> why would one want to place a patient on a backboard, before application of a collar?



I should have been more clear in the original post, but they would just be laying on the backboard.  They would not be secured.



> Hey look! An actual answer to the question!
> 
> Is there harm? No. Is it acceptable in reality? Yes. Is putting a collar on first better? Yes. Does this mean it's acceptable to your proctor? Probably; as long as manual stabilization is held then you shouldn't have a problem; ask them if all you are worried about is testing.
> 
> ...



Yep, that's what I wanted.

However, I am not JUST worried about testing.  I would also like to know so I can do what's best for the patient.



> Is the patient down or ambulatory when you AOS?
> 
> If the the Pt id down when you arrive, you immediately assess LOC, Whether they have a pulse and respirations. Then move to your RTA start at the head looking for DCAP-BLS-TIC.
> Move to the neck, check for DCAP-BLS-TIC, JVD, and make sure the trachea is midline, also reach back and check for step down or spinal deformity on the back of the neck. Next step put your collar on and continue with the rest of your assessment checking the posterior last as your roll to transfer to a long board. Also some should if at all possible be holding C-Spine until the Pt's head is secured to the board.
> ...



For this case, I am thinking that they are laying down.  I know you could just reach back and feel the neck, but I was thinking that it would be better to actually SEE the neck.

As far as DCAP-BLS-TIC, I've never heard that.  I was taught DCAP-BTLS: deformities, contusions, abrasion, pokes/punctures, burns, tenderness, lacerations, swelling.

Thanks for the help everybody.  Any other feedback is appreciated.


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## medichopeful (Oct 11, 2009)

*Clarification*

For this scenario, I am talking about just placing them on the backboard.  I am NOT talking about securing them and THEN putting the collar on.


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## triemal04 (Oct 11, 2009)

Lifeguards For Life said:


> i disagree.
> can you give me an example of a situation in which you would have ample room and resources to place a patient on a board which would prohibit initial application of a collar?
> by placing a collar after boarding a patient, i would say there is an increased potential to further any injuries. Is it acceptable in the field? could be. Is it acceptable to a procotor in a testin situation? best have a darn good reason or else they will believe you forgot, and only remembered to apply a collar too late in the scenario.


Sure.  The pt's prone (facedown)...on their side (not always but depending on the pt's anatomy and specific position)...it's not a common thing, but it does happen.  Far as increased risk of injury...not a whole lot when done correctly, just like a lot of what we do.

Far as testing...depends on the proctor, but technically, according to the national skill sheets, as long as manual stabilization is held it's ok; that "technically" mind you, so it'd be best to ask first.


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## Lifeguards For Life (Oct 11, 2009)

medichopeful said:


> Here is what I was thinking.  If you do the log roll _without_ a collar on, you would be able to actually _look_ at the neck.  Before you rolled the patient back, you would put the backboard underneath so that you wouldn't have to do any unnecessary rolling.  After they were rolled back to a supine position, they would be laying _on_ the spine board, but they would not be secured or have a collar on.  When they were just laying on the backboard, I was thinking that you could put on a cervical.



you don't necessarily need to look. you can feel behind there right before application of the collar. 
It is best to err on the side of the patient. If you felt or saw anything that in your eyes confirmed a c-spine injury, would you treat the patient very differently that a patient who just likely has a cspine injury?


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## medichopeful (Oct 11, 2009)

Lifeguards For Life said:


> you don't necessarily need to look. you can feel behind there right before application of the collar.
> It is best to err on the side of the patient. If you felt or saw anything that in your eyes confirmed a c-spine injury, would you treat the patient very differently that a patient who just likely has a cspine injury?



I would not, but 2 senses are better than one, correct?


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## Sasha (Oct 11, 2009)

Lifeguards For Life said:


> you don't necessarily need to look. you can feel behind there right before application of the collar.
> It is best to err on the side of the patient. If you felt or saw anything that in your eyes confirmed a c-spine injury, would you treat the patient very differently that a patient who just likely has a cspine injury?



It's still worth noting.. You can't feel a bruising, but that would be something worth noting in your report.


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## Lifeguards For Life (Oct 11, 2009)

medichopeful said:


> I would not, but 2 senses are better than one, correct?



you are correct, multiple sources of information are better than one. What it comes down to though, is to you, is gaining that additional piece of information(which will not alter your care of the patient) worth the possibility of aggravating a spinal injury?


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## triemal04 (Oct 11, 2009)

Lifeguards For Life said:


> you are correct, multiple sources of information are better than one. What it comes down to though, is to you, is gaining that additional piece of information(which will not alter your care of the patient) worth the possibility of aggravating a spinal injury?


How much extra movement do you think that a c-collar really prevents versus only holding manual stabilization?  Think about HOW a collar prevents movement in the spine, and then HOW manual stabilization is held when rolling a pt.  Really, if it did such a great job, then there would be no need to even hold on once a collar was on; you could just let go.  Don't make this out to be such a danerous thing; it's not.


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## medichopeful (Oct 11, 2009)

Lifeguards For Life said:


> you are correct, multiple sources of information are better than one. What it comes down to though, is to you, is gaining that additional piece of information(which will not alter your care of the patient) worth the possibility of aggravating a spinal injury?



Good points.


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## Lifeguards For Life (Oct 11, 2009)

triemal04 said:


> How much extra movement do you think that a c-collar really prevents versus only holding manual stabilization?  Think about HOW a collar prevents movement in the spine, and then HOW manual stabilization is held when rolling a pt.  Really, if it did such a great job, then there would be no need to even hold on once a collar was on; you could just let go.  Don't make this out to be such a danerous thing; it's not.



sorry. i'm not trying to say that this is definitively dangerous. From my experiences, i would not count on a provider manually holding c-spine alone. I still can not think of a good scenario that would warrant delayed application of a collar, that also allows rapid application of a backboard.


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## triemal04 (Oct 11, 2009)

Lifeguards For Life said:


> sorry. i'm not trying to say that this is definitively dangerous. From my experiences, i would not count on a provider manually holding c-spine alone. I still can not think of a good scenario that would warrant delayed application of a collar, that also allows rapid application of a backboard.





triemal04 said:


> Sure.  The pt's prone (facedown)...on their side (not always but depending on the pt's anatomy and specific position)...it's not a common thing, but it does happen.  Far as increased risk of injury...not a whole lot when done correctly, just like a lot of what we do.


So...how many times have you placed a c-collar on a person who's face down?  People don't end up lying face-up completely straight in a large, open room like happens in the classroom.  It'll happen.  To not bed ready because you can't think of a situation when it'd happen...bad idea.


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## Shishkabob (Oct 11, 2009)

When doing the rapid traime assessment, you should be palpatong the back of the neck for deformities and/or bleeding anyhow, so unless you have a reasonable reason to look, ie it feels weird or there's blood on your glove, or even more so, they complain of pain or tenderness indicitive of bruising or an injury there's probably not much reason to risk a look. 

Most c-collars I've seen have a "window" in the back for inspection anyhow.


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## medichopeful (Oct 28, 2009)

Sorry I abandoned this thread.

I talked to my instructor, and this is what he said.  He said that if it is a significant MOI, apply the collar BEFORE doing the log roll.  If not, you can roll them without a collar.

I think if you're not sure, it would be better to apply the collar.


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## mycrofft (Oct 28, 2009)

*Follow protocols unless in an unequipped situation.*

And by unequipped I mean a richter 7.9.
Part of your head to toe survey ought to be the neck, and that is completed before stopping to immobilize. Establish no exterior wounds, no foreign objects, and if you see angulation, it's either a normal variant or your pt's probably unconscious, dead, screamig in pain or wondering why they can't feel their extremities.
Your ambulance should have the full equipment. Also, how many spinal patients can you safely transport at a time? If you have used up your equip and there are more pt's, you need more units, and they will have the equip...unless as I say there's been a total breakdown of structure. 
If you are not transporting, stop and call for an ambulance. Spinal precautions are for movement and transport to prevent further harm, they are not curative or treatment. Keep the pt still and calm. I've seen numerous pts get wild once they are boarded, it hurts and they get claustrophobic.

Pools have spineboards because of the high potential for spinal injury plus near-drowning; you may be forced to move the pt to safety, or rescuscitate, when spinal injury is very likely.

Ditto trapeze artists over the lion cage!


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## mycrofft (Oct 28, 2009)

*IN fact..*

No, I'll start another thread. "What every EMT should be required to experience before they graduate".


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## Scout (Oct 29, 2009)

I know a number of people who preferance board before collar in a standing takedown.


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## downunderwunda (Oct 29, 2009)

I find it interesting that we are debating the use & application of a spinal collar.

Isnt the first thing you do to TALK to the patient. That will give you an idea even before an exam of any spinal injury. Lets be more specific & define what we are talking about here. 

There are spinal injuries & _spinal cord injuries_. 

One can have a spinal injury, including fractures, without spinal cord involvment. The actual incidence of spinal cord injury is nominal & we need to look at the true reason for immobilisation is to prevent an insult to the cord.

Hard collars provide some reduction in movment, about 35%, but that is nowhere near enough. The use of an extrication device will increase that to arount 90%.

The use of a hard back board should only be for extraction, not for transport as the discomfort afforded that patient can actually increase their desire to move, thus increasing their risk of insult to the spinal cord.

What order should we do it?

Collar (it is pard of any extrication device)
Extrication device
Backboard & then, as part of your full exam, roll them on the backbaord for a full spinal exam & remove it.


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## mycrofft (Oct 29, 2009)

*Downunda, that's what we learnt in '78.*

Makes sense to me.
I have to restrain my coworkers from "putting on a backboard" once or twice a quarter. No medical benefit here, best to keep 'em quiet and wait for the squad.


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## EMSLaw (Oct 29, 2009)

downunderwunda said:


> Hard collars provide some reduction in movment, about 35%, but that is nowhere near enough. The use of an extrication device will increase that to arount 90%.
> 
> The use of a hard back board should only be for extraction, not for transport as the discomfort afforded that patient can actually increase their desire to move, thus increasing their risk of insult to the spinal cord.
> 
> ...



That makes sense in a situation where the patient has to be extracted.  I assume you're talking about a KED or something similar?  

But I don't know of any option to transport other than on the long back board.  Unfortunately, for better or worse (mostly worse), they are the standard in the US.  What are you suggesting as an alternative for transport?  Simply putting them on a cot won't be enough.


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## downunderwunda (Oct 29, 2009)

EMSLaw said:


> That makes sense in a situation where the patient has to be extracted.  I assume you're talking about a KED or something similar?
> 
> But I don't know of any option to transport other than on the long back board.  Unfortunately, for better or worse (mostly worse), they are the standard in the US.  What are you suggesting as an alternative for transport?  Simply putting them on a cot won't be enough.



We are fortunate enough that our stretchewrs are rated for spinal. If yours are not, then I would suggest you begin the long arduous process of getting them.

Patient comfort in this situation is better than morphine. 

Yes I refer to a KED. However, no they do not just have to be used for extrication. I have used them in other situations as well very sucessfully. You need to open your mind & think outside the square. If you think they have a spinal injury, that has a chance of spinal cord involvment, put it on (by the way, it is easier to put it on when they are not in a car), what does it matter.

Just because it is called an extrication advice does not mean we can only use it for extrications.


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## medichopeful (Oct 30, 2009)

Scout said:


> I know a number of people who preferance board before collar in a standing takedown.



Really?  Why?  I'm very curious.


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## dragonjbynight (Oct 30, 2009)

Please forgive this question, as I have have read several threads that discuss different points on this topic. I have seen firsthand how patients react to the backboard, more often than not, the backboard makes them more uncomfortable, more in pain than not. I realize, the board is meant to be a stable immobilization platform, but an eldery person with a hip fracture laying on a solid piece of plastic for 40 minutes....ouch! (common here as hospital is generally 30 miles away)

I readily admit that I am a beginning EMT-B student and I don't have much experience or education. I know from FF experience the purpose of spinal immobilization, backboards, KED's C collars and so forth. But, has there been studies done that say a backboard actually helps in that type of injury, or is it more of a case of the 1 in 100, but is done to prevent a suit? Just curious. 

My second question is, is there anyway to improve the backboard, maybe with some inflatable airbags that could give some sort of cushion, support, comfort, yet still maintaining purpose? I am not talking a home rig, something straight from the supplier, built in so forth...


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## Scout (Oct 30, 2009)

dragonjbynight said:


> My second question is, is there anyway to improve the backboard,



Stop using it, Scoop onto a vacuum mattress, Use the board as an aid to extrication.

MedicHope, It is their belief that the gap between the chin and shoulders changes as you lye down. Personally it does for my neck, I go from regular to short.


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## downunderwunda (Oct 30, 2009)

dragonjbynight said:


> Please forgive this question, as I have have read several threads that discuss different points on this topic. I have seen firsthand how patients react to the backboard, more often than not, the backboard makes them more uncomfortable, more in pain than not. I realize, the board is meant to be a stable immobilization platform, but an eldery person with a hip fracture laying on a solid piece of plastic for 40 minutes....ouch! (common here as hospital is generally 30 miles away)
> 
> I readily admit that I am a beginning EMT-B student and I don't have much experience or education. I know from FF experience the purpose of spinal immobilization, backboards, KED's C collars and so forth. But, has there been studies done that say a backboard actually helps in that type of injury, or is it more of a case of the 1 in 100, but is done to prevent a suit? Just curious.
> 
> My second question is, is there anyway to improve the backboard, maybe with some inflatable airbags that could give some sort of cushion, support, comfort, yet still maintaining purpose? I am not talking a home rig, something straight from the supplier, built in so forth...




There is no study that says transport on a spinal board improves outcomes.

The body has many natural hollows & the back board will not mould to suit these. 

The best thing you can use, it provides comfort, support & stability for the spinal area is a vac pack.


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## wyoskibum (Oct 30, 2009)

dragonjbynight said:


> My second question is, is there anyway to improve the backboard, maybe with some inflatable airbags that could give some sort of cushion, support, comfort, yet still maintaining purpose? I am not talking a home rig, something straight from the supplier, built in so forth...



There is a product called  the "BACKRAFT" which is an inflatable pad that sticks to existing long boards.  We used them at my old service out west and they worked pretty well especially since we had some extended transport times.


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## downunderwunda (Oct 30, 2009)

The main thing to remember, regardless, is a long board is used to assist with extrication. It is an extrication device. It is not intended as a transport aid. Transport to your stretcher, but take the patient off it. 

They will thank you & be far more compliant than insisting they suffer with any length of transpord on that hard uncomfortable board.

Most people dont think to take the pt off through sheer laziness cause it is easier to move the pt at the hospital on the board rather than slide & do it properly.


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## karaya (Oct 30, 2009)

downunderwunda said:


> Transport to your stretcher, but take the patient off it.
> 
> ... Most people dont think to take the pt off through sheer laziness cause it is easier to move the pt at the hospital on the board rather than slide & do it properly.


 
Well, maybe that is the Australian way.  But the last dozen or so EMS books that I've worked on do not support your concept; at least at this time they don't.  The issue here in the States is that back-boarding after extrication and leaving the backboard on the patient is the current standard of care that is taught in EMT schools.  Perhaps some services that have C-spine clearing protocols after extrication your concept may be supported.


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## IrishMedic (Oct 31, 2009)

I have to agree with Karaya, I have never heard of protocols in the northern Hemisphere which allow the removal of a Spinal Board after its been applied due to concern for C-Spine In Pre-Hospital setting. Personally I wouldn't feel comfortable removing one, sure they're uncomfortable and yes the pt's don't like them, but once i explain to my pts that i'm worried about the spine due to MOI, and the possible outcomes of damaging the spine without using one in transport.....they're usually content with staying on them.....

not to mention the legal aspect the pt is risking by coming off one....example being.....pt in mva hit by driver on wrong side of road, you extricate on board remove board....pt arrives at hosp and when xray compete it shows pt has Fx, Pt now paralysed...pt takes legal action against driver who caused mva.....when it is checked what tx you provided and that you removed a spinal immobilisation device....and subsequently pt is now paralysed...pts lawsuit goes out window cause the defendant cud claim Ambulance crew paralysed pt.........Simple option.....Leave Pt on Board til ED clear C-Spine by Diagnostic Exams......Cover your own ***!!!!!!!!


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## JPINFV (Oct 31, 2009)

I still find it hilarious that we're debating over the proper use of a device that, to the best of my knowledge, has never been proven to prevent secondary spinal injury.


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## downunderwunda (Oct 31, 2009)

JPINFV said:


> I still find it hilarious that we're debating over the proper use of a device that, to the best of my knowledge, has never been proven to prevent secondary spinal injury.



Here Here.


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