# C-Spine questions I hope you can help answer. .



## ryujinn (May 9, 2010)

Hello EMTlife,

I tried to do a quick search but did not find any posts that answered my questions, so sorry if there is a duplicate :/.

(1) Coming across a conscious patient and once ABC's have been taken care of, how does one apply the cervical collar if he/she is in an awkward position? For example, lying in like a fetal position, sprawled all over the floor, on his side, etc.

We of course don't want to move their neck because of potential damage to their spine or nerves, so do we do a patient roll-over with assistants and someone manually holds the head?

Isn't there at some point where you actually have to move their neck to get them in the correct "anatomical" position to properly board or spine them? Can you do a c-collar on them without them in the anatomical position? (facing forward, lying supine). 

I just feel like if you ever have to "gently rotate" the head towards you to put the collar underneath them, it'd be really dangerous. So what, you put a collar on them with their head at some other angle and transport them as is?

What is the safe way to "adjust a patient's body" into a good position to collar and board without neural compromise? Or, do I just try to transport them as is? 

Sorry just a question my partner and I talked about on yesterday's shift, and wanted to post it up on the forum.

Please excuse me for any confusion, and I look forward to any feedback or advice.

Michael


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## Mountain Res-Q (May 9, 2010)

Why are we taking spinal precautions with this patient?  What is the MOI on this patient?  Is it medically neccissary to board them?  Or is it a protocol based choice?


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## clibb (May 9, 2010)

Doesn't every c-spine (c-collar) have to be put on while the head is in "in-line" position. Which means the the chin lines up with Sternum. If your patient was found with his head all twisted up, I honestly do not think you'll injure him if you put his head into in-line position.


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## Veneficus (May 9, 2010)

ryujinn said:


> Hello EMTlife,
> 
> I tried to do a quick search but did not find any posts that answered my questions, so sorry if there is a duplicate :/.
> 
> ...



This is one of the great challenges of EMS.

One of the great things about primates is they have evolved a protection reflex where the most comfortable position is the position doing the least amount of cell damage.  (pain is caused by damage) 

Another interesting fact is that your major motor neurons are on the opposite column so that if something was trying to eat you, you would be able to defend your wounded side. (Who says biology was useless?)

On to anatomy. I have developed an anatomical rule that the deeper something is in the body, the more important it is. (maybe somebody else thought of it too) The CNS is extremely well protected, which is why with the exception of penetrating trauma you rarely see a cord transection. While technically still a fx of the spine, transverse and spinus processes are more common fx, and often do not require any emergency management. (or any management)

C1 fx is caused by compression, most often C1 is a diving injury. C2 by extension, that is why it is called a hangman’s fx. The rest of the cord usually needs to be subluxed in order to cause transection. (I have most often encountered them in motorcycle accidents and very rarely in the cervical area, probably because those people don’t live long enough to make it to the trauma center.)

Peripheral nerves actually have some intrinsic healing capabilities, (not much but enough to work with.) In the CNS however, the healing process actually causes more damage. 

Once the cord is transected, providers worry about “secondary damage.” Inevitably there will be some level of secondary damage, but that might be beyond EMS control, as the spine is stabilized naturally. Significant primary and secondary injury comes from the ischemia of the cord, particularly the anterior and posterior spinal arteries. The local inflammation from tissue damage shuts off these arteries. Without O2 and metabolites the CNS quickly hibernates as a compensatory response prior to becomming necrotic. The best way I can describe it is a "compartment syndrome" in the spinal compartment that damages the cord. Hypothermia is the only treatment available to EMS.

A c-collar was designed to prevent the skull and contents from compressing lower portions of the cervical vertebrae and cord. It was not meant to “hold the neck in place” or stop any other movement. 

The common spineboard actually creates compression of the body, predisposing compression of spinal arteries no longer protected by intact vertebrae and more likely to cause the “compartment issues.” Then you go one further and realize that blood is toxic to CNS tissue, so you can have direct cell injury secondarily.

What to do with your patient? Since mechanism is a poor predictor of injury, the best answer is to call med control and ask if you can deviate from protocol. Second to that, follow whatever your protocol is. 

In the situation you described if it were up to me and I suspected spinal damage, I would stabilize the pt with towel rolls, lift them with a scoop stretcher to the cot, and gently transport. If they lost their airway or it was in question, then they get gently moved supine and the airway is taken care of appropriately. (because the pt will die without it and that causes loss of function from the spine  ) However, if I didn’t think there was cause for spinal injury, which can also be tested for, I wouldn’t just randomly start putting people on in spinal precautions because “what if…”

Unfortunately though I don’t write everyone’s protocols and this question will probably go on long after any of us.

If you really are hell bent on anatomical position, I would proceed gently, and if there was any resistance to movement, I would stabilize in position and transport as it is unless there are compromised ABCs. I have seen providers advocate quite extensive manipulation techniques, but I figure if you are going to use those, the patient isn't really that bad.


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## EMSLaw (May 9, 2010)

Mountain Res-Q said:


> Why are we taking spinal precautions with this patient?  What is the MOI on this patient?  Is it medically neccissary to board them?  Or is it a protocol based choice?



I can't speak for the OP's protocols, but ours are that any unresponsive patient with an unknown MOI/NOI requires spinal precautions.  I think this is pretty standard, at least in my area.  So, per our protocols, at least, this patient would technically be immobilized. 



ryujinn said:


> Coming across a conscious patient and once ABC's have been taken care of, how does one apply the cervical collar if he/she is in an awkward position? For example, lying in like a fetal position, sprawled all over the floor, on his side, etc.
> 
> We of course don't want to move their neck because of potential damage to their spine or nerves, so do we do a patient roll-over with assistants and someone manually holds the head?
> 
> ...



A conscious patient or an UNconscious patient.  The conscious patient, I would first inquire to discover their MOI - and determine whether spinal precautions were even indicated.  

You're going to hold manual stabilization and, with assistance, gently move the patient into an anatomical position.  If you feel any crepitus, or the patient cannot be moved, then you would secure them at the angle/in the position they were found.  That usually means towel rolls and tape.  

I have been told that to reposition the head, you should also apply gentle traction.  That was not covered in my EMT-B class, but has come up in other classes I've taken.  

The question of whether we SHOULD be backboarding as much as we do is a matter of some dispute, and Veneficus has summed up the reasons why we should probably be using LBBs less (Basically, they aren't terribly helpful, and may be harmful, especially with long transport times.  With conscious patients, they are also very uncomfortable, and may compromise respiration in certain patients, especially the elderly).  

That being said, there is no particular reason you can't pad and immobilize the patient on his or her side, though again, that's not taught in EMT-B courses.  Put the head block under the patient's head to maintain an in-line position and tape the head in place.  Also, something like a vacuum mattress would work great in this situation.  

To sum up my very long-winded meanderings - you do need help.  Move the patient slowly and gently, and stop if you feel any crepitus or meet resistance.  Someone should be holding manual stabilization until the patient is secured to the board.


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## Mountain Res-Q (May 9, 2010)

EMSLaw said:


> I can't speak for the OP's protocols, but ours are that any unresponsive patient with an unknown MOI/NOI requires spinal precautions.  I think this is pretty standard, at least in my area.  So, per our protocols, at least, this patient would technically be immobilized.



Treat the Patient... NOT the MOI.  Do do otherwise is bad medicine.  That is why I want to know more about the patient.  Risk versus benifit.  Does the patient medically need (in your educated clinical judgement) to be boarded and therefore or are we so fixated on "BOARD THEM ALL!!!  THEY MIGHT HAVE A SPINAL INJURY!!!" that we risk causing injury?

In the end, however, remeber the purpose of the c-collar and board...  to help the patient maintain some type of spinal restriction in case further injury might result (a very rare thing since most damage occured as a result of the accident and not as a result of anything we do or do not do).  So, the question is, if you feel that this is medically called for in this case:  How do I achieve the end result to the best of my ability without casuing harm?  And only the EMT/Medic with that patient can determine that based on the situation, the assessment, and the cooperation fo the patient.  Sometimes the best way to "immobilize" the spine can be achieved without a backboard...


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## EMSLaw (May 9, 2010)

Mountain Res-Q said:


> Treat the Patient... NOT the MOI.  Do do otherwise is bad medicine.  That is why I want to know more about the patient.  Risk versus benifit.  Does the patient medically need (in your educated clinical judgement) to be boarded and therefore or are we so fixated on "BOARD THEM ALL!!!  THEY MIGHT HAVE A SPINAL INJURY!!!" that we risk causing injury



You don't have to tell me that - tell the guys who write the protocols.   But being at the bottom of the EMS food chain, I have to follow the protocols that I get from my medical direction.

I will say that I'm gathering the articles on backboarding, of which there are many, to see if I can at least broach the subject of changing protocol.


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## Mountain Res-Q (May 9, 2010)

EMSLaw said:


> You don't have to tell me that - tell the guys who write the protocols.   But being at the bottom of the EMS food chain, I have to follow the protocols that I get from my medical direction.
> 
> I will say that I'm gathering the articles on backboarding, of which there are many, to see if I can at least broach the subject of changing protocol.



Good Luck...  B)


You'll Need It...


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## EMSLaw (May 9, 2010)

Mountain Res-Q said:


> Good Luck...  B)
> 
> You'll Need It...



Hey, we all tilt at our windmills now and again.  Maybe I'll just have to go to medical school.  EMSLaw, JD, MD? ;p


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## farmallm (May 27, 2010)

We had a call ike that and we ended up mannually stablizing the head and getting them on the board in the position they were in they had an airway they were breathing and blood flow was good. It was hard to get them on the board and then to the strecher in the position they were in but we still thought leaving them in the position that they were in was better and making sure their C-Spine was in the same position till we knwe that there wasn't any injuries.


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## Scout (May 28, 2010)

Veneficus said:


> On to anatomy. I have developed an anatomical rule that the deeper something is in the body, the more important it is




Can I be childish?


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## MSDeltaFlt (May 28, 2010)

ryujinn said:


> Hello EMTlife,
> 
> I tried to do a quick search but did not find any posts that answered my questions, so sorry if there is a duplicate :/.
> 
> ...


 


Veneficus said:


> Once the cord is transected, providers worry about “secondary damage.” Inevitably there will be some level of secondary damage, but that might be beyond EMS control, as the spine is stabilized naturally. Significant primary and secondary injury comes from the ischemia of the cord, particularly the anterior and posterior spinal arteries. The local inflammation from tissue damage shuts off these arteries. Without O2 and metabolites the CNS quickly hibernates as a compensatory response prior to becomming necrotic. The best way I can describe it is a "compartment syndrome" in the spinal compartment that damages the cord. Hypothermia is the only treatment available to EMS.
> 
> A c-collar was designed to prevent the skull and contents from compressing lower portions of the cervical vertebrae and cord. It was not meant to “hold the neck in place” or stop any other movement.
> 
> ...


 
The above paragraph states it nicely here.  I would add to start by getting your partner to gently hold manual C-spine and then follow the above paragraph.  Should go without saying, but I'm just covering all bases here.

Speaking as someone who has had a C2 vertebral body Fx maybe I can shed some light on this for you.  Veneficus and Mountain Res-Q are right on a lot of things here.  

I would like to find out *why* you are considering C-Spine precautions in the first place.  The "why" is so much more important.  Following protocol regardless of what the scenario is requires the clinician to do one thing first and foremost.  You have to assess your patient.  Because eventually you will find yourself in a situation and/or a pt where you will fall outside of protocol.  This is when you will need to use some critical thinking.  

I have come across a pt(s) in a fetal position where I needed to package them, but was unable to gently move them out of that position.  So I padded them generously with blankets and towels as best I could and transported them that way.  

There is no such beast as C-spine *immobilization* in the prehospital setting.  *Restrictions* yes.  *Immobilization* no.  The only way you can get C-spine immobilization is by having the pt placed in a HALO where they drill rods that come into contact with the pt's skull.  It's done by neurosurgeons and they use a torque wrench to do it.  They use conscious sedation; more conscious than sedation I might add.  If this sounds barbaric to you, it should because it is.

Basically assess your patient.  Are C-spine precautions needed?  Are they feasible?  Go from there.  Never say never.  Never say alsways.


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## Veneficus (May 29, 2010)

Scout said:


> Can I be childish?



Sure, but the rule still holds true, 

at least I find it important.


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## usafmedic45 (May 29, 2010)

> The CNS is extremely well protected, which is why with the exception of penetrating trauma you rarely see a cord transection.



At least clinically....  



> Speaking as someone who has had a C2 vertebral body Fx



Not to sound like a smartass, but that's something you don't hear said very often.  Pay attention folks, you'll learn a lot. 



> C1 fx is caused by compression, most often C1 is a diving injury.



Normally....you can also get it in extreme cases of rotational injury with lateral and rearward neck flexion.  Basically the mechanism that gives you a atlantooccipital dislocation, but with a fracture instead of solely a dislocation.  Also keep in mind that in extreme cases (aircraft crashes for example) you can get the "diving injury" in reverse.  That is the force is applied from the the distal end of the spine, upward to the cervical spine and it is finally expended when the vertebrae and the base of the skull meet.  This is usually instantaneously lethal as a result of a high impingement of the cervical cord above the level of the phrenic nerves (at C3, C4 and C5 in most individuals; hence the nifty little rhyme: "1, 2, the injury you never knew, 3, 4, 5, keep you alive")



> C2 by extension, that is why it is called a hangman’s fx. The rest of the cord usually needs to be subluxed in order to cause transection. (I have most often encountered them in motorcycle accidents and very rarely in the cervical area, probably because those people don’t live long enough to make it to the trauma center.)



True hangman's fracture (with fractures of both pedicles) is quite rare, even- ironically enough- in judicial hangings [1].  Normally you get a fracture of one pedicle or the other because the force is seldom ever truely equally distributed.  It's also not usually instantaneously lethal.  The reason for this is the same force that causes the fracture (compression of the pedicles while they are being levered) also tends to spread the fragments away from the cord itself.  As you said, only in cases where you have a combined C2/C3 subluxation in addition to the C2 fracture are you normally going to get a quick death (assuming the commonly associated head trauma, an A/O dislocation, etc does not get the patient). 

I've personally had someone WALK into the ER with a complete hangman's fracture (he crashed his car on the curve next to the hospital).  It wasn't until his cord started to swell (producing the problems that go along with that) several minutes after his arrival that we realized there was a serious problem.  He actually told us he hit his face on the dashboard.  This was later verified by a police officer who reported finding what appeared to be a bitemark on the dash of the car.  

[1]  James R, Nasmyth-Jones R., The occurrence of cervical fractures in victims of judicial hanging, Forensic Science International, 1992 Apr;54(1):81-91.


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## mgr22 (May 29, 2010)

Just to build on the excellent posts here, the prophylactic use of c-collars, log-rolls, and backboards is being reconsidered because:

- C-collars can worsen injuries (particularly to C1-C2, based on my reading).
- Lifting might be safer than log-rolling patients onto boards.
- Discomfort, soft-tissue damage, airway compromise, resp distress, increased ICP, and distributive shock in pregnant patients can all be consequences of supine immobilization on rigid boards.


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## sdadam (Jun 5, 2010)

*Backboard Shmackboard*

To answer your original question, manually manipulate the head into a neutral inline position. You will not cause further damage doing this, and it is necessary to continue immobilization of the spine.

The reason we demand an inline and neutral position prior to immobilization has little to do with the spine and everything to do with being prepared to manage the patients airway. (And a little to do with the fact that c-collars only face one way, so what else are you going to do?)

Some really great posts about back boarding on this thread, the knowledge of its NEAR complete uselessness is becoming more and more prevalent. There was a good thread where some of us got in to those issues a while back:

http://www.emtlife.com/showthread.php?t=15864

Check that out for both good discussion and links to good resources on back boarding.


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## mcdonl (Jun 5, 2010)

Thank God for protocols.


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## DrParasite (Jun 5, 2010)

EMSLaw said:


> I can't speak for the OP's protocols, but ours are that any unresponsive patient with an unknown MOI/NOI requires spinal precautions.  I think this is pretty standard, at least in my area.  So, per our protocols, at least, this patient would technically be immobilized.


umm, no it's not.  You and I both have the same protocols, and I can assure you that it is not the case.  otherwise, every cardiac arrest would need to be boarded and collared, and we both know that doesn't happen.

Now, if you have an unresponsive patient with signs of trauma (bruising, open wounds, head/facial/neck injuries, even falls with suspected ETOH involvement), then you need to apply spinal precautions.

but def not any unresponsive patient with an unknown MOI.


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