# C-spine immobilization on a pt. with increased pain upon manual stabilization?



## IcantThinkofAname (Jan 11, 2009)

Sorry for the long title of the post, I couldn't think of a better way to word it.

Anyway, question...

If a pt.'s neck is not in neutral position but breathing is inadequate and the pt. has increased difficulty breathing when you try to move the c-spine into neutral position, do you just immobilize the pt. to a long board without trying further to align the c-spine or do you try to get the c-spine into neutral position, thinking that when it's finally there, the pt's breathing will be better?


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## rogersam5 (Jan 11, 2009)

Well If I start to move things and it causes the pt. more pain I am inclined to think that there is something happening that I am not seeing. Especially with the neck, if it is not in a neutral position but moving it to one causes more pain and a decline in Recuperation for the pt. I would be inclined to keep it as is and bag them until ALS shows up and takes over.


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## BossyCow (Jan 12, 2009)

Are we talking "ouch" or screaming?


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## Veneficus (Jan 12, 2009)

BossyCow said:


> Are we talking "ouch" or screaming?



may not matter, if you have a patient out of neutral position, and you force the head back into place, you may may not sever a cord, but you might decrease blood supply to a cord, which will cause necrosis. In both selective spinal and clinical clearing any pain on movement has to be investigated. (Usually radiographically by CT or MRI)


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## traumateam1 (Jan 12, 2009)

Veneficus said:


> may not matter, if you have a patient out of neutral position, and you force the head back into place, you may may not sever a cord, but you might decrease blood supply to a cord, which will cause necrosis. In both selective spinal and clinical clearing any pain on movement has to be investigated. (Usually radiographically by CT or MRI)



So then leave in the position of comfort / better resps. ?


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## Scout (Jan 12, 2009)

Leave it alone.

Just wrap and pad to limit movement.


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## BossyCow (Jan 12, 2009)

Veneficus said:


> may not matter, if you have a patient out of neutral position, and you force the head back into place, you may may not sever a cord, but you might decrease blood supply to a cord, which will cause necrosis. In both selective spinal and clinical clearing any pain on movement has to be investigated. (Usually radiographically by CT or MRI)



What I was getting at was I've had a lot of pts complain about a c-collar, generally expressing mild annoyance at the collar being uncomfortable. And who 'forces' anything on a scene especially when the spine is involved?


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## mikeylikesit (Jan 12, 2009)

well unless you have x-ray vision you should stabilize and transport. If however you need the airway then it come to decision time, pain or breathing, which will kill him fastest?


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## Veneficus (Jan 12, 2009)

BossyCow said:


> What I was getting at was I've had a lot of pts complain about a c-collar, generally expressing mild annoyance at the collar being uncomfortable. And who 'forces' anything on a scene especially when the spine is involved?



I have noticed there are a good number of people who always "follow the rules" instead of exercising good judgement, particularly in the more paramilitary cultured organizations.

Unfortunate, but still true.


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## Scout (Jan 12, 2009)

Wait i read it as adaquate breathing my bad.


Can i get a feeling for rate and quality, are they on O2 yet, what else could you do to improve brathing without moving the neck.

 how "stiff" are we talking about,


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## Veneficus (Jan 12, 2009)

mikeylikesit said:


> well unless you have x-ray vision you should stabilize and transport. If however you need the airway then it come to decision time, pain or breathing, which will kill him fastest?



vent dependant is not breathing.

There are several things I would consider. As bossy inquired, are we talking about an uncomfortable c-collar or actual neck pain with movement?

in the former, might be better to pad/adjust the collar, or go with the old towel roll. since the collar is only there to limit vertical compression. 

if the latter, you are taking some risks in forcing movement. perhaps an alternative in immobilization may be reached to preserve a little of both. You may have to reduce restriction to the chest wall to allow better expansion to aid in breathing.(aka ditch the spine board, it won't immobilize the neck without further movement anyway, if the patient is that sick lower spine precautions might have to be forgone for the airway.) Perhaps assist breathing with a BVM in the current position. If there is a growing hematoma or other restiction in the compartment, that would require some stainless steel and it may be time to start moving, repositioning of the airway is unlikely to make a difference at that point.

Use good judgment with the overall condition (not stipulated in the scenario here) in mind, when in doubt contact med control.


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## IcantThinkofAname (Jan 12, 2009)

Sorry, I should be more specific...

You come upon the scene and the neck is bent to the side and the patient is having trouble breathing.  However, upon trying to move the neck into neutral position to apply a c-collar, the patient experiences INCREASED breathing difficulty, not necessarily pain.  So the question becomes...pad and go or try to move the neck to neutral even if doing so causes the patient to experience increased breathing difficulty with the attempt?

Specifically, would it be worth moving the neck through the point where the breathing difficulty increased, thinking that once the neck is in neutral position, the patient's breathing would improve?  Or is it more likely that the patient's breathing would continue to deteriorate and it'd be better to pad and go?


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## MSDeltaFlt (Jan 12, 2009)

IcantThinkofAname said:


> Sorry, I should be more specific...
> 
> You come upon the scene and the neck is bent to the side and the patient is having trouble breathing.  However, upon trying to move the neck into neutral position to apply a c-collar, the patient experiences INCREASED breathing difficulty, not necessarily pain.  So the question becomes...pad and go or try to move the neck to neutral even if doing so causes the patient to experience increased breathing difficulty with the attempt?
> 
> Specifically, would it be worth moving the neck through the point where the breathing difficulty increased, thinking that once the neck is in neutral position, the patient's breathing would improve?  Or is it more likely that the patient's breathing would continue to deteriorate and it'd be better to pad and go?



This is where pt assessment comes into place.  You have to actually *assess* your pt.  What is their LOC?  Define "increased breathing difficulty".  How's the pt's PMS?  What's the big picture here?  

Bear in mind that C-spine control goes hand in hand with "Airway".  Breathing difficultly is "Breathing".  Let's not confuse the two.  You have to maintain your airway and never lose it.  If you have a patent airway and your manual stabilization begins to compromise your breathing, you might want to hold off on doing any more.  Pad the pt in position found and assist breathing as needed.  However, if you are unable to assist breathing in position found, then you might need to move C-spine to neutral and assist that way.

This is also a judgement call.  Because if there is any question in which way to go, that is why God created Med Control.  They get paid the big bucks for a reason.


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## A140160 (Jan 19, 2009)

Depending on the amount of difficulty breathing, my response would be different.  If it's only a little difficulty, keep head in position you found it and pad it as best you can, just like treating an elderly patient with a deformed spine.  I'd pad, put pt. on O2 via NRB, or if need be BVM him with O2 connected.


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## wehttam (Feb 4, 2009)

BossyCow said:


> What I was getting at was I've had a lot of pts complain about a c-collar, generally expressing mild annoyance at the collar being uncomfortable. And who 'forces' anything on a scene especially when the spine is involved?




i was taught as a guide if the pts says the collar is uncomfortable its a good thing.If u have ever had your co-workers place a collar of *correct size *on your neck its not a comfortable feeling.a collar that is to slack will be a very comfortable collar and would not serve any purpose. so in that case annoynace is serving its purpose


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## frogtat2 (Feb 19, 2009)

You present an interesting scenario.  In this situation, I would maintain manual c-spine control, pad where possible, put the pt on O2, and if needed assist with ventilations.  Like the others have said, though, when you are in a tough situation and don't know what to do, call medical control!


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## DevilDuckie (Feb 19, 2009)

We carry some two piece collars, in case a situation were to arise where the one piece would be too painful to apply. In such case, the application of the two piece would be minimal movement, quick, comfortable, and last but not least - Better than nothing. I would immobilize the patient to death, well, not really, but pad the voids, make it so there is no way in hell for that person to move. Not only to cover my posterior, but if the patient has that level of neck pain, I don't want the tissue or muscles around the spine moving. All they need is to adjust, and have a bone fragment tear into their spinal cord.


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## Aidey (Feb 19, 2009)

The situation is a bit vague, so what I would do would probably depend on exactaly what I see. 

Personally I would immobilize in place, and not try and move the neck into a neutral position. With the neck not in a neutral position that means anatomically their airway is more likely to be compromised, so someone would be assigned to hold it open and I would probably place a NPA. Depending on exactaly what is going on with their breathing they would get high flow O2 and possibly override/assistance bagging.

I've had to immobilize in place a couple of times, without a C-Collar, just using rolled up blankets/sheets and kerlex. As long as I documented very very clearly exactaly what was done, and why I had to do it that way my MD sponsor was ok with it. 

One example I can think of is a 9yo F with head trauma second to a large animal vs car. She was rapidly deteriorating on scene, and when they tried to do a standing c-spine immobilization and take down she gave the EMT holding C-spine behind her a black eye. (She was swinging her hands up and behind her). Anyway, it was obvious she was moving more fighting him off than if we just let her lay down on her own, so we did and just packed her in blankets and pillows and documented it well.


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