# Unwitnessed fall



## eprex (Jan 31, 2013)

Patient has slipped and fallen in the bathroom and now has significant deformity to the neck. The head is extremely angulated and you suspect significant trauma to the cervical spine. The PT is alert and talking.

This is not a homework question and I haven't heard of a scenario such as this. Regardless of this patient's likely outcome, how do you transport them?

Common sense tells me you do not attempt to readjust their neck in an attempt to collar, otherwise you may sever cervical nerves or exacerbate any fractures, tissue damage, etc. Can you collar them in their current deformed position? This presents a problem if the airway is lost.

Thanks


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## NomadicMedic (Jan 31, 2013)

I would just pad them in position using blankets or pillows and some tape and move them on a board to the hospital.  I certainly wouldn't attempt to manipulate their cervical spine to make it fit a collar. That's counterproductive, don't you think? If you're in the kind of system that gets medics jammed up over not following protocols explicitly, I would guess a call to medical control on the radio or phone, painting a clear picture on why you need to do what you need to do would certainly give you clearance to not collar the patient.


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## medichopeful (Jan 31, 2013)

n7lxi said:


> I certainly wouldn't attempt to manipulate their cervical spine to make it fit a collar.



I think the only time manipulation would be appropriate in this situation would be an airway/breathing issue.  I agree with you that it wouldn't be appropriate to try to readjust the head/neck for fitting a collar


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## Rykielz (Jan 31, 2013)

Call ALS! 

In all seriousness, I'd just pad around the head and be as careful as possible. I would not move the patients head under any circumstances. Call as many people as you need and get transporting. The ride should be very slow and controlled.


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## Household6 (Jan 31, 2013)

medichopeful said:


> I think the only time manipulation would be appropriate in this situation would be an airway/breathing issue.  I agree with you that it wouldn't be appropriate to try to readjust the head/neck for fitting a collar



That makes sense to me. I see two choices *if* there are airway issues: a patient dead from suffocation or an aggravated spinal injury. I'd choose the latter.


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## Rykielz (Jan 31, 2013)

There's no way I'm moving that patients neck. There are other ways to ventilate if worst comes to worst. Cricothyrotomy?


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## NomadicMedic (Jan 31, 2013)

Rykielz said:


> There's no way I'm moving that patients neck. There are other ways to ventilate if worst comes to worst. Thoracostomy?



Ehhh... You mean a cricothyrotomy?


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## Medic Tim (Jan 31, 2013)

Rykielz said:


> There's no way I'm moving that patients neck. There are other ways to ventilate if worst comes to worst. Thoracostomy?


Huh?


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## Rykielz (Jan 31, 2013)

Don't mock me! Ya cricothyrotomy. Sorry brain fart right there. I'm just saying if you move that patients neck and cut C1 in the process they're pretty much brain dead. I'll take an airway issue over a dead body any day of the week.


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## Melclin (Feb 4, 2013)

Don't move them.

Pain relief.

Position of comfort, with towels/pillows etc for support. No collar.


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## Handsome Robb (Feb 4, 2013)

But...but...but, they did it on Trauma!!!! Then they did a single med RSI to manage her airway to top it off!!! 



Rykielz said:


> Don't mock me! Ya cricothyrotomy. Sorry brain fart right there. I'm just saying if you move that patients neck and cut C1 in the process they're pretty much brain dead. I'll take an airway issue over a dead body any day of the week.



I don't think anyone was mocking you...there's a big difference between a thoracostomy and a crichothyrotomy...that's all they were saying. 

I wouldn't jump right to them being brain dead because of a spinal cord injury at C1 either. Whether it be complete or incomplete SCI you're looking at serious neurological deficits if not complete quadriplegia/ventilator dependency though, I'll absolutely agree with that. Is brain damage/death a risk? Absolutely, but a SCI at the C1 level =/= brain death. 

I sustained a C2-4 spinal injury playing football 6 years ago. A lot of rehab later (no surgery thank goodness, I count my blessings every day for that) and I'm a fully functioning 23 year old with no deficits or brain damage. Albeit I didn't sustain an injury like the one described here and didn't have any permanent spinal cord injury (again, I count my blessings every day for that as well) but I still had a high cervical spinal injury. Is everyone as lucky as me? Absolutely not, but you can still have a positive outcome with a high spinal injury, that's the point I'm trying to get across. 

With that said, airway comes first, they can't live without an airway, they can live without neurological function below the injury site. If you can't manage their airway you're going to have a dead body on your hands pretty quickly anyways. Do you think CPR with an unstable spinal injury is going to end well? If that life is enjoyable is a whole different argument and it's not a decision we or even a physician is allowed to make. 

A surgical airway is an option but you're adding a huge degree of difficulty to establishing that airway if not making it impossible to establish without having them midline before you start cutting. I guess if you're really stuck a needle crichothyrotomy could be an option with OLMD but at that point you're in a REALLY bad situation and it probably isn't going to make a huge difference. You can't really ventilate through a "coffee straw". In a situation like that I'd agree, you've probably got a brain dead patient on your hands. Not from the spinal injury but from the anoxic brain injury they're sustaining right in front of your eyes. 

Life > limb. 

I agree with what everyone else has said. My protocols say that I have to attempt to get the patient to a neutral, midline position unless resistance is met during realignment. With that said, it's very easy to chart around and/or call and get OLMD to not do it. In this scenario I wouldn't be fumbling around with this patient's neck. Applying whatever methods are needed to get appropriate spinal motion restriction in their current position, provide analgesia, scoop them and transport calmly and smoothly to a facility capable of neurosurgery.


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## Anjel (Feb 4, 2013)

Robb said:


> I'm a fully functioning 23 year old with no deficits or brain damage. ,



Uh huh. That explains it. 

To the OP. you would just do the best you could to stabilize. Improvise, adapt, overcome. 

Figure out a game plan, take a deep breath, and get to work. It might not look pretty, but support the head, get them on the board, and off you go to the nearest trauma center.


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## EpiEMS (Feb 4, 2013)

This is a protocol monkey's worst nightmare.


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## eprex (Feb 5, 2013)

EpiEMS said:


> This is a protocol monkey's worst nightmare.



Agreed.


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## VFlutter (Feb 5, 2013)

Screw Thoracostomies go right for the Thoracotomy after a Tracheotomy but before the Fasciotomy. There are too many otomies to keep track of.


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## DrankTheKoolaid (Feb 6, 2013)

*re*

This just happened in recent years to some pro sports figure if memory serves.  He walked into a ED holding his head upright and said i think i broke my neck.  They ask why he thought that and his head imedietely began falling to the side when he let go.  

He had whats called a hangmans fracture.  And this is one of those calls where you really have to question yourself and your training especially if your a new pup in the field. 

Treatment in my eyes is simple, secure it as it lies as we do not have xray vision with the exception of airway complications, then simple reallignment with axial traction applied and maintained post relocation back to an anatomical position. Transport to approprite facility.. chart rinse repeat


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## eprex (Feb 6, 2013)

Corky said:


> This just happened in recent years to some pro sports figure if memory serves.  He walked into a ED holding his head upright and said i think i broke my neck.  They ask why he thought that and his head imedietely began falling to the side when he let go.
> 
> He had whats called a hangmans fracture.  And this is one of those calls where you really have to question yourself and your training especially if your a new pup in the field.
> 
> Treatment in my eyes is simple, secure it as it lies as we do not have xray vision with the exception of airway complications, *then simple reallignment with axial traction applied and maintained post relocation back to an anatomical position.* Transport to approprite facility.. chart rinse repeat



This is where everyone else disagrees if I'm reading correctly.


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## Shishkabob (Feb 6, 2013)

eprex said:


> Common sense tells me you do not attempt to readjust their neck in an attempt to collar




Common sense is wrong because the common person isn't medically educated.   In general, you can attempt to move the neck so long as the patient doesn't have any pain, discomfort, etc.  If the patient experiences any during movement, stop and leave in the position currently in, using what you can find if need be, such as towels, blankets, etc.  As far as this specific one... I'd have to see it to judge it.


Airway go bad?  Well, screw the neck.  Who cares if you're paralyzed if you're dead?  If normal ways can't fix it, you'll have to go a bit more extreme.



(Except me, I'd rather be dead than paralyzed)


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## eprex (Feb 6, 2013)

It doesn't make sense to realign such an incredibly complex area of the body. Isn't realignment used to prevent further damage and relieve the patient? It seems in this case that any realignment without a physician would be high risk, low reward.


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## Shishkabob (Feb 6, 2013)

The joy about medicine, and medicine in the real world, is that nearly everything is a gray area.


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## eprex (Feb 6, 2013)

Linuss said:


> The joy about medicine, and medicine in the real world, is that nearly everything is a gray area.



Do you have a justification for why you'd attempt to realign? What's the gain?


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## usalsfyre (Feb 6, 2013)

Ummm I hate to be a buzz kill, but....if you had a "significantly angulated neck injury" you'd take out the cord. Period. Look at the way it's structured.


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## eprex (Feb 6, 2013)

usalsfyre said:


> Ummm I hate to be a buzz kill, but....if you had a "significantly angulated neck injury" you'd take out the cord. Period. Look at the way it's structured.



I'm unsure if what you mean. Can you reiterate?


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## Chris07 (Feb 6, 2013)

He's saying that because of the way the spinal cord runs through the vertebrae, a person with an angulated neck, as described by the OP, would definitely have a severed spinal cord....implying that no matter what you do for this guy, he's going to be paralyzed.


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## VFlutter (Feb 6, 2013)

usalsfyre said:


> Ummm I hate to be a buzz kill, but....if you had a "significantly angulated neck injury" you'd take out the cord. Period. Look at the way it's structured.



Ya pretty much. However reducing the neck back to a neutral position *may* blunt the progressive inflammation which *could* potentially save some function. Not very likely


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## eprex (Feb 6, 2013)

Or it could kill them, no?

Which still convinces me not to attempt to realign.


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## Handsome Robb (Feb 6, 2013)

eprex said:


> Do you have a justification for why you'd attempt to realign? What's the gain?



Easier airway management is a big one. Guidelines also so to attempt realignment unless met by resistance or exacerbation of pain but I'm not going to get into a protocol argument.

A SCI at that level is, more than likely, going to compromise the patients ability to control their diaphragm and thus their ability to breathe so you're probably going to have to do it for them. 

Phrenic nerve exits at C3-4 level if I'm no mistaken.


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