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OBJECTIVES:
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1. To provide initial manual stabilization to the entire spinal column and head to facilitate a patent airway
2. To restore and maintain normal anatomical alignment of the spinal column and head through application of manual stabilization until appropriate stabilization and immobilization is assumed by a mechanical device
3. To provide total immobilization of the entire spinal column and head through the proper positioning and securing of a spinal injury or suspected spinal injury patient to a mechanical movement/stabilization device
4. To provide stabilization and immobilization of the spinal column and head from the time at which manual stabilization is first initiated and neutral positioning achieved through all patient handling, packaging and transport procedures
5. To determine the presence or absence of circulation, movement and sensation in the patient’s extremities
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IMPORTANT POINTS:
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1. One rescuer is responsible for stabilization of the head, neck and maintenance of the airway
2. Rescuer maintaining manual stabilization directs patient movement.
3. Restoring spinal alignment may be appropriate during the spinal stabilization and immobilization process. However, if resistance to movement of the neck or spine is felt, or the patient experiences an increase in pain, stabilize the patient in the position found
4. In general, a cervical collar should be used during the stabilization/immobilization process. A cervical collar alone is not adequate for protecting the cervical spine
5. Stabilization and immobilization are the only adequate protection for suspected spinal injuries
6. Once immobilization has been completed, the device may be positioned to assist in maintaining a patent airway
7. Patients may be immobilized to a long or short immobilization device using straps, tape, cravats, Velcro closures, commercial devices, etc. Appropriate padding such as blankets, towels, dressings, etc, may be needed to prevent movement of the patient in or on the immobilization device
8. Consider padding board for patient comfort
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SKILLS:
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I. SPINAL INJURIES
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A. KENDRICK EXTRICATION DEVICE (KED)
First rescuer
1. Stabilize and support the head in a neutral position
2. Maintain stabilization until patient’s head is secured to KED
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Second rescuer
1. Check CMS in all four extremities
2. Assist in repositioning the patient’s body to a neutral position, as necessary
3. Select and apply an appropriately sized cervical collar
4. Prepare and position KED behind patient (Request additional help in positioning patient if necessary)
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5. Secure KED with center and bottom chest straps. Assure firm contact of device with lower back and armpits
6. Pad any void between patient’s head and the device to preserve neutral alignment as is necessary
7. Secure head to device; first strap over forehead, second strap over chin
NOTE: The chin strap may be omitted or removed if airway compromise exists
8. First EMT may now release manual stabilization
9. Recheck CMS in all four extremities
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It is permissible for rescuers to exchange positions while providing immobilization
Depending on the style of C-collar in use, the chinstrap may be more appropriately placed on the C-collar below the chin
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Both rescuers
1. Secure groin and top chest straps, if not done previously
2. Tie hands together and lower extremities together, if necessary
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3. Position long immobilization device adjacent to patient
4. Slide and pivot patient; support patient at thighs and with device handles
5. Lower patient to long immobilization device; maintain legs in flexed position
6. Move patient to head of long immobilization device
7. Release groin straps and lower the patient’s legs to the long immobilization device. Loosen top chest strap as necessary to facilitate breathing and patient comfort
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Groin strap must be properly positioned under the mid-line of each buttock to properly secure device to patient
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8. Secure patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as necessary
9. Recheck CMS in all four extremities
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Reassess head, strap placement and tension
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B. SPINAL INJURY – XP-ONE (XP-1) (Optional)
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First rescuer
1. Stabilize and support the head in a neutral position
2. Maintain stabilization until patient’s head is secured to XP-1
Second rescuer
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1. Check CMS in all four extremities
2. Assist in repositioning the patient’s body to a neutral position, as necessary
3. Apply Med-Spec extrication collar
4. Prepare and position XP-1 behind patient (Request additional help in positioning patient if necessary)
5. Secure XP-1 with center and bottom chest straps. Assure firm contact of device with lower back and armpits
6. Secure head to device, choose appropriate tabs and attach them to the Velcro on both sides of the collar. Place forehead pad on patient and attach tabs
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It is permissible for rescuers to exchange positions while providing manual stabilization
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Both rescuers
1. Secure groin straps
2. Apply top chest strap; draw shoulder straps down, loop Velcro around top on top and middle chest straps and secure in place
3. Position long immobilization device adjacent to patient
4. Slide and pivot patient; support patient at thighs and with device handles
5. Lower patient to long immobilization device; maintain legs in flexed position
6. Move patient to head of long immobilization device
7. Release groin straps and lower the patient’s legs to the long immobilization device. Loosen top chest strap as necessary to facilitate breathing and patient comfort
8. Remove chin strap, if needed, to assure an airway
9. Secure patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as necessary
10. Recheck CMS in all four extremities
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C. LONG SPINEBOARD - Standing Patient
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IMPORTANT POINTS:
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1. A standing patient with a potential spinal injury must be moved to a supine position as soon as possible
2. Manual stabilization of the patient’s head and neck can be maintained from either the front or the back of the patient depending on the rescuer’s height. Shorter rescuers may need to stabilize from the front of the patient
3. While holding manual stabilization from the rear, communicate with team members as your view of the patient will be obstructed by the immobilization device
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SKILL:
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1. Maintain manual stabilization of the patient’s head, neck and spine
2. Check CMS in all four extremities
3. Select and apply a cervical collar
4. Position the long spinal immobilization device behind the patient being certain it is centered directly behind the mid-line of the patient
5. Two rescuers face the patient and stand on either side
6. The two rescuers place their arms that are closest to the patient, under the patient’s arms and grasp the device just above the patient’s armpit
7. The two rescuers, with their free hand, grasp the patient’s arm at the elbow or the board to maintain a secure grip as the device is tilted backward
8. The device is then tilted backward to the ground
9. The patient’s torso and lower extremities are secured to the device, followed by the patient’s head, padding as necessary to maintain neutral alignment
10. Recheck CMS in all four extremities
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D. SLING AND LONG SPINEBOARD
First rescuer
1. Stabilize and support the head in a neutral position
Second rescuer
1. Check CMS in all four extremities
2. Select and apply an appropriately-sized cervical collar
3. Position sling across chest and under armpits of patient and tighten around body
4. Secure patient’s hands together if possible
5. Position long spineboard at slight elevation to patient’s longitudinal axis. Support at this angle while pulling patient
6. On command, pull patient slowly onto board keeping sling close to board at all times as First rescuer guides patient’s body and maintains stabilization of the head
7. As first rescuer approaches head of board, lower board gently and move back as pull is completed
8. Secure patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as necessary
9. Secure patient’s head to long spineboard, padding as necessary
10. First rescuer may then release manual stabilization
11. Recheck CMS in all four extremities
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E. LOG ROLL AND LONG IMMOBILIZATION DEVICE (Patient Supine – 3 Rescuers)
First Rescuer
1. Stabilize and support the head in a neutral position
2. Maintain stabilization until patient’s head is secured to long immobilization device
Second and Third Rescuers
1. Check CMS in all four extremities
2. Select and apply an appropriately-sized cervical
3. Tie patient’s lower extremities together
4. Second rescuer raises patient’s near arm over patient’s head to prevent arm from obstructing roll or places arm along patient’s side with hand against thigh
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6. Second and third rescuer s reach across patient and place their hands along patient’s body evenly spaced between shoulder and knees
7. On signal from first rescuer, second and third rescuer s roll patient toward them, maintaining spinal alignment
8. Second and third rescuer s each use hand closest to patient’s feet to position the long immobilization device on the floor next to the patient’s back
9. On signal from first rescuer, all roll the patient back onto long immobilization device and lower arm to side
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Hand spacing may be adjusted to accommodate patient’s weight and height
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10. If centering of the patient is necessary; on signal from first rescuer, slide patient with gentle even motion while maintaining spinal alignment
11. Third rescuer secures patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as necessary
12. Second rescuer secures patient’s head to long immobilization device, padding as necessary to maintain neutral alignment
13. First rescuer may then release manual stabilization
14. Recheck CMS in all four extremities
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The patient may be centered through the use of either direct lateral movement or the “Z” method, which combines longitudinal and lateral movement
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F. LOG ROLL AND LONG IMMOBILIZATION DEVICE (Patient Prone or on side – 3 Rescuers)
First Rescuer
1. Stabilize head, neck and spine in position found
Second and Third Rescuers
1. Check CMS in all four extremities
2. Secure patient’s lower extremities together
3. Place long spinal immobilization device parallel to the patient so the back of the patient’s head is next to the board
4. Both rescuers kneel on board facing the patient with second rescuer at the patient’s chest and third rescuer at the patient’s thighs
5. Second rescuer raises patient’s arm nearest the device and positions it over the patient’s head or along side the patient’s body with the hand against the thigh
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6. Second and third rescuer s reach across patient and place their hands along patient’s body evenly spaced between shoulder and knees
7. On signal from first rescuer, second and third rescuer s roll patient toward them onto long immobilization device
8. As patient is rolled, first rescuer brings head into neutral position, if possible, achieving spinal alignment (If resistance is felt, head is stabilized at that point)
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Hand spacing may be adjusted to accommodate patient’s weight and height
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9. If centering of the patient is necessary; on signal from first rescuer, slide patient with gentle even motion while maintaining spinal alignment
10. Third rescuer secures patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as necessary
11. Second rescuer selects and applies an appropriately-sized cervical collar, then secures patient’s head to long immobilization device, padding as necessary to maintain neutral alignment
12. First rescuer may then release manual stabilization
13. Recheck CMS in all four extremities
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The patient may be centered through the use of either direct lateral movement or the “Z” method, which combines longitudinal and lateral movement
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G. ORTHOPEDIC STRETCHER (Two Rescuers – Patient Supine)
First Rescuer
1. Stabilize head and neck in neutral position
Second EMT
1. Check CMS in all four extremities
2. Select and apply cervical collar
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3. Adjust stretcher to height of patient
4. Place one half of stretcher on each side of patient
5. Slide stretcher halves under patient and latch head end together
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Stretcher should remain closed when length is adjusted
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6. Close foot end of stretcher being careful not to pinch patient
7. Secure patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as necessary
8. Secure patient’s head to orthopedic stretcher, padding as necessary to maintain neutral alignment
9. First EMT may then release manual stabilization
10. Recheck CMS in all four extremities
11. Place and secure patient to a long board
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A bystander may be used to gently lift patient to help avoid pinching when closing stretcher halves
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H. STRADDLE SLIDE (4 Rescuer minimum)
First Rescuer
1. Stabilize head, neck and spine in neutral position
Second, Third and Fourth Rescuer s
1. Check CMS in all four extremities
2. Select and apply an appropriately-sized cervical collar
3. Second and third rescuer s straddle patient facing first rescuer
a. Second rescuer bends and places hands under patient’s chest below the shoulders
b. Third rescuer bends and places hands under patient’s pelvis
4. Fourth rescuer positions long spineboard lengthwise at the patient’s head or feet
5. At signal from the first rescuer, second and third rescuers lift patient just enough to allow the long spineboard to pass under the patient’s body
6. Fourth rescuer slides long spineboard under patient in one smooth, unbroken movement
7. On signal from first rescuer, second and third rescuers lower patient on the long spineboard
8. If centering of the patient is necessary; on signal from first rescuer, slide patient with gentle even motion while maintaining spinal alignment
9. Third rescuer secures patient to long immobilization device at chest, pelvis, thighs, and below knees, padding as necessary
10. Second rescuer secures patient’s head to long spineboard, padding as necessary to maintain neutral alignment
11. First rescuer may then release manual stabilization
12. Recheck CMS in all four extremities
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J. HELMET REMOVAL
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IMPORTANT POINTS:
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1. The ability to maintain an airway is of ultimate importance when managing helmeted patients
2. Stabilization and immobilization are the only adequate protection for suspected spinal injuries
3. Consideration should be given to leaving a well fitting helmet, which allows ready access to perform all necessary airway maneuvers, in place
4. Proper immobilization of patients wearing helmets and other protective equipment often requires the patient’s body or head to be padded to maintain appropriate neutral position
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SKILL:
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1. Open faced helmets/half helmets
a. From the cephalic position, first EMT provides manual stabilization by placing one hand on each side of the helmet with the fingers on the mandible
b. Second EMT removes the face shield, then and unfastens the restraining strap
c. Second EMT places one hand on each side of the patient’s neck with thumbs resting against the angle of the jaw and the fingers extending behind the occiput to support the patient’s head and maintain manual stabilization
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d. First EMT then removes the helmet by grasping the straps or edges of the helmet to spread it as it is gently pulled along the long axis of the body and tilted slightly forward
e. Throughout the removal process, the second EMT maintains manual stabilization of the patient’s head and neck
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Glasses, microphones, head-sets or other obstructions must be removed before attempting to remove the helmet
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f. First EMT resumes control of manual stabilization
g. The second EMT selects and applies an appropriately-sized cervical collar in preparation for moving the patient to a long immobilization device
h. EMTs move patient to long immobilization device using appropriate technique as previously described in this section
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If the patient is wearing other protective equipment, once the helmet is removed, care must be taken to pad between the occiput and the immobilization device to maintain the head in a neutral alignment
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2. Closed face (full face) helmet - (Minimum of three rescuers) Assumes a well fitted helmet and no immediate life-threat due to airway obstruction or respiratory arrest
a. Patient is positioned on long spineboard using appropriate technique as described previously in this section
b. While maintaining manual stabilization, the head end of the long immobilization device is elevated approximately three inches from the horizontal and firmly blocked in that position
c. While the First EMT maintains manual stabilization from the cephalic position, the Second and Third EMTs straddle the patient and the long spineboard
d. Second EMT grasps the patient under the armpits while Third EMT grasps patient at the pelvis
e. On signal from the First EMT, the patient is moved up the long spineboard until the lower rim of the helmet is just beyond the top edge of the board
f. While the Third EMT continues to stabilize the patient’s body, the Second EMT places one hand on each side of the patient’s neck with thumbs resting against the angle of the jaw and the fingers extending behind the occiput to support the patient’s head and maintain manual stabilization
g. Second EMT assumes manual stabilization of patient’s head and cervical spine
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h. When advised by Second EMT that s/he has assumed manual stabilization, First EMT slowly releases manual stabilization
i. First EMT insures that any objects which could obstruct helmet removal (glasses, microphones, headset, etc) have been removed from the patient and/or helmet, then loosens and unfastens the helmet restraining strap
j. First EMT then removes the helmet by grasping the straps or edges of the helmet to spread it as it is gently pulled along the long axis of the body and tilted slightly rearward to clear the patient’s nose
k. Once the lower edge of the helmet has cleared the patient’s nose, the helmet is tilted slightly forward and removed
l. First EMT resumes manual stabilization of the patient’s head and cervical spine
m. Second EMT grasps patient under armpits
n. On signal from First EMT, all EMTs slide the patient down the long spineboard until s/he is properly positioned
o. C-collar is applied and patient is secured to long spineboard using appropriate technique as previously described in this section
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Second EMT may continue to straddle the patient or may move off to one side when assuming C-spine stabilization
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3. Football Helmet (Patient supine)
a. First EMT provides manual stabilization by placing one hand on each side of the helmet with the fingers on the mandible
b. Second EMT removes the face shield by using paramedic shears to cut the nylon straps holding the shield in position
c. Second EMT then unfastens chin strap(s) at the side snaps, removing it completely
d. Using the closed trauma shears as a lever, the second EMT pries the lower lateral interior pads from the helmet and removes them
e. If the helmet is equipped with an air bladder, the second EMT releases the air valve of the helmet and deflates the bladder
f. Second EMT places one hand on each side of the patient’s neck with the thumbs resting against the angle of the jaw and the fingers extending behind the occiput to support the patient’s head and maintain neutral alignment
g. First EMT then removes the helmet by grasping it’s edges to spread it as it is gently pulled along the long axis of the body and tilted slightly forward
h. Throughout the removal process the second EMT maintains manual stabilization of the patient’s head and neck
i. First EMT resumes control of manual stabilization
j. Second EMT selects and applies an appropriately sized cervical collar in preparation for moving the patient to a long immobilization device
k. EMTs move the patient to a long immobilization device using appropriate technique as previously described in this section
l. The second EMT pads as necessary under the patient’s head to maintain neutral alignment
m. Patient is secured to long immobilization device using appropriate technique as previously described in this section
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Depending on the style of helmet being worn, it may be necessary to use a closed face helmet procedure to remove the helmet
Coaching or trainer staff may be able to assist with equipment removal
Shoulder pads may elevate the patient’s body to an extent that traditional immobilization devices will no longer provide adequate immobilization
If the patient is wearing other protective equipment, extreme care must be taken to insure spinal alignment is maintained both during the log roll and once the helmet is removed
Additional care must be taken to pad between the occiput and the immobilization device to maintain the head in a neutral position
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