CHAPTER 60: Acute Injury Management

INTRODUCTION

Acute management of injuries in the field is one of the key components of routine emergency medical response. Although many controversies exist and will continue to arise concerning the indications for these interventions, when the decision is made to employ a procedure the technique should be performed properly. EMS physicians and medical directors must consider the impact of providers observing their technique and should always employ, and expect their providers to utilize, good technique. A step-by-step description of these interventions is included in this chapter.

PROCEDURES

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  Spinal immobilization

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    From the ground

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    Standing takedown

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    Extrication device to long spine board

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    In-the-water immobilization

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  Tourniquets

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  Hemostatic bandages

GENERAL CONSIDERATIONS

The indications and need for spinal immobilization are highly controversial. ¹ For instance, the NAEMSP/ACS-COT combined position paper questions the utility of long spine boards beyond initial extrication and some studies suggest that routine spinal immobilization of penetrating trauma patients who do not exhibit evidence of neurologic injury is unnecessary and potentially exposes the patient to unnecessary adverse effects. ² Potential adverse effects include airway compromise, pain, pressure ulcers, and unnecessary radiographic imaging. This section will not address areas of controversy but will instead assume that spinal immobilization is necessary and indicated and that multiple techniques are potentially safe and acceptable when performing each skill and procedure (ie, log roll vs lift and slide). Of note, some EMS systems have replaced immobilization on a long spine board with spinal precautions on a firm mattress and utilize the long spine board primarily as a means of extrication. A recent study even showed better restriction in spinal movement when patients self-extricated wearing only a cervical collar. ³

Indications Spinal immobilization may be performed in patients in whom there is significant concern for potential spinal cord injury. Concern for spinal cord injury may stem from mechanism, comorbid conditions, physical examination findings, or a combination of these factors. Some examples of patients who should be considered for spinal immobilization include patients with a high-energy mechanism of injury such as vehicle or motorcycle accidents, falls, and swimming/diving injuries in which prehospital clearance is impossible or impractical. Some examples of historical and physical examination findings that raise concern for spinal cord injury are complaints of neck pain, paresthesias, paralysis, and findings of midline tenderness or step-offs.

FROM-THE-GROUND SPINAL IMMOBILIZATION TECHNIQUE

When victims are found down and/or are instructed to remain on the ground, spinal immobilization should take place from where there are found unless hazards prevent this approach.

Indication This technique may be considered when a patient requiring spinal immobilization is found lying supine or prone by EMS providers.

Essential Equipment

• Long spine board (LSB)

• Head immobilization device/tape/sandbags/towel rolls/ etc

• Semirigid cervical collar

• Straps/other devices to secure to LSB

• Sufficient manpower

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