Prehospital Immobilization

Background

The first widely accepted recommendations for “spinal immobilization” following blunt trauma came from the American Academy of Orthopaedic Surgeons in 1971. These guidelines called for spinal immobilization of patients with symptoms or physical findings suggestive of spinal injuries. Since then, recommendations for spinal immobilization have evolved considerably.

During the 1980s and 1990s, indications for spinal immobilization were based primarily on the mechanism of injury, regardless of the presence or absence of symptoms or physical findings suggestive of a spinal injury. This resulted in routine and often unnecessary prehospital spinal immobilization for all but the most trivial injuries.

In 1998, Hauswald and colleagues published the results of a 5-year retrospective review comparing patients from Malaysia, where cervical spine immobilization was nonexistent, to patients from New Mexico, where cervical spine immobilization based on the mechanism of injury was standard practice. The authors concluded that out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries. This study, and others demonstrating increased complications and significant spinal movement, despite the use of cervical collars (c-collars) and long spine boards, prompted the development and evaluation of prehospital clinical decision rules to selectively immobilize patients after blunt trauma.

A 4-year prospective study in two Michigan counties found that the use of a selective immobilization protocol resulted in spine immobilization for most patients with spinal injury without causing harm to patients in which spine immobilization was withheld. A larger study in Maine demonstrated that selective immobilization based on a statewide protocol resulted in only one nonimmobilized unstable cervical spine fracture in more than 32,000 patient encounters.

Data demonstrating the safe application of selective spinal immobilization protocols by prehospital providers, a lack of scientific evidence demonstrating improved outcomes with the use of long spine boards, and a keen awareness of the complications associated with spinal immobilization has resulted in new recommendations from the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma and the American College of Emergency Physicians. These recommendations include the selective use of long spine boards following blunt trauma and elimination of their use following penetrating trauma in patients with no evidence of spinal injury ( Box 46.1 ).

At the present time, the effects of spinal immobilization on mortality, neurologic injury, spinal stability, and adverse effects in trauma patients remains uncertain. Due to the low incidence of actual spinal cord injury (SCI) and associated neurologic sequelae, prospective trials are difficult to safely design and perform. Nevertheless, available data suggests that we should reduce or eliminate routine prehospital spinal immobilization in favor of using validated clinical rules to determine which patients may have sustained a spinal column injury and applying spinal motion restriction strategies only to these patients. However, these new approaches will take time to promulgate through the EMS community. Until then, emergency physicians must be knowledgeable about prehospital spinal immobilization. Therefore the remainder of this section provides a detailed review of immobilization devices and techniques.

Epidemiology

According to the National Spinal Cord Injury Statistical Center, an estimated 12,500 new, survivable SCIs occur in the Unites States annually, and 276,000 people were living with SCIs in the United States in 2014. Since 2010 the most common cause of SCI is motor vehicle collision, which accounts for almost 40% of cases, followed by falls and acts of violence, primarily gunshot wounds. Sports such as American football, rugby, swimming and diving, gymnastics, ice hockey, track and field (specifically pole vaulting), cheerleading, and baseball all place participants at increased risk for spinal injuries. The cost of care in both the immediate and extended care setting can be exorbitant, especially among the young. The average lifetime cost of medical care for patients with SCI varies depending on the level of injury and age at time of injury, and ranges from $1 million to more than $4.7 million, with annual costs from $42,000 to $1 million.

Pathophysiology

The direction and strength of the injurious force may help predict the type of injury sustained. Generally speaking, the basic forces that can be exerted on the spine are flexion, extension, rotation, lateral bending, distraction (stretching), and compression (axial loading). Of course, complex mechanisms may exert multiple forces. For example, high-speed rollover motor vehicle collisions could easily exert all the aforementioned forces.

Injuries to the upper cervical spine (C1 and C2) ( Fig. 46.1 ) occur more often in older, osteoporotic patients than in younger patients. The spectrum of injuries in the cervicocranium includes occipital condyle fractures, occipitoatlantal dislocations, dislocations and subluxations of the atlantoaxial joint, fractures of the ring of the atlas, odontoid fractures, fractures of the arch of the axis, and fractures of the lateral mass of the axis ( Fig. 46.2 ). Involvement of the spinal cord at this high level can cause devastating neurologic injury, and it is reasonable to believe that many of these injuries are not reported because they result in death. Subaxial cervical spinal injuries involving C3–C7 have broad clinical implications. Approximately two-thirds of cervical injuries causing quadriplegia occur within the lower cervical spine, with fractures occurring most often in C6 and C7 and dislocations most commonly occurring between C5–C6 and C6–C7.

The orientation of the facets in the thoracic spine allows significantly less flexion and extension than in the cervical or lumbar spine. In addition, the free space between the thoracic spinal cord and the borders of the spinal canal is relatively small, and the blood supply is less robust. These factors increase the susceptibility of the spinal cord to injuries at this level. At the thoracolumbar junction there is an acute transition in stability because of the loss of rib restraint, which increases the risk for flexion-extension and rotational injuries. Disk size and shape also change, thus making this section of the spine particularly susceptible to injury. Approximately half of all vertebral body fractures and 40% of all SCIs occur between T11 and L2.

The lumbar spine is protected only by the abdominal and paraspinous musculature, making it subject to distracting and shearing forces, such as those seen with lap belt injuries. There is also a higher prevalence of compression and burst fractures in the lumbar spine. These fractures commonly occur when axial loading forces straighten the natural lordosis at the moment of impact.

The sacrum forms both the terminal portion of the spine and the central portion of the pelvis, which gives it added stability and makes isolated sacral fractures uncommon. Such fractures are usually caused by direct trauma or falls from a height, or occur as a result of sacral insufficiency secondary to osteopenia, chronic steroid use, or previous pelvic irradiation. More often, sacral fractures occur as a result of high-energy mechanisms and are associated with major pelvic disruption.

Indications

Spinal motion restriction should be considered for victims of blunt trauma who sustain an injury with a mechanism that has the potential for causing spinal injury and who have at least one of the following criteria: altered mental status, intoxication, a distracting painful injury (e.g., long-bone fracture), a neurologic deficit, and spinal pain or tenderness (see Box 46.1 ).

Extremes of age and the presence of communication barriers (e.g., language, hearing impairment) may affect the ability to accurately assess the patient's perception and communication of pain and should lower one's threshold for spinal precautions. It is also important to remember that serious cervical cord injuries can occur in the absence of demonstrable fractures. SCI is common in elderly patients with cervical spondylosis, in whom an arthritic osteophyte may sever a portion of the cord as permanently as a fracture or dislocation. In such cases there may be little subjective pain, and the mechanism of injury may appear seemingly minor.

Although data is sparse, patients who have had a seizure in the field are at low risk for spinal injury. Nevertheless, immobilization of postictal patients due to a presumed risk for spinal injury and inability to adequately assess the patient is commonplace. Unfortunately, attempts at immobilization often prompt further patient confusion and agitation, and struggling may exacerbate injuries that do exist ( Fig. 46.3 ). In these situations, when there is concern for a spinal injury based on the mechanism of injury, physical findings (e.g., focal neurologic deficit, facial injuries), or patient complaints, administer sedation rather than, or in addition to, spinal immobilization.

In summary, there is no good evidence that cervical immobilization restricts harmful movement, and the use of c-collars may cause harm. There is evidence that c-collars reduce venous return and hence may cause an increase in intracranial pressure (ICP). Taking a patient out of a comfortable position and placing them in a collar that extends the neck does not make them safer.

Contraindications

Spinal immobilization with a c-collar or a backboard following blunt trauma is not necessary in patients with a normal mental status (Glasgow Coma Scale 15), no spinal tenderness or anatomic abnormality, no neurologic findings or complaints, no distracting injuries, and no intoxication (see Box 46.1 ).

In general, spinal immobilization with a c-collar and a backboard is contraindicated (or may require modification) when its use could harm the patient, when it is logistically impossible, or when the scene is unsafe ( Box 46.2 ). Good clinical judgment, not blind application of protocols, is essential. For example, if application of a c-collar will cause or mask airway compromise secondary to swelling, an expanding hematoma, or other process, it should not be used. Obviously, if a patient requires a surgical airway, the EMS provider will need immediate, unencumbered access to the anterior aspect of the neck. Sometimes preexisting airways (e.g., tracheotomy tube) and associated equipment prohibit proper application of a c-collar. These situations can often be managed with an improvised cervical immobilizer, such as a collar fashioned from a towel roll or prolonged manual stabilization without traction.

Other conditions that may prevent spinal immobilization or require modification of standard techniques and equipment (e.g., towel roll and manual in-line stabilization) include obesity, impaled objects, underlying respiratory problems or acute respiratory distress, altered mental status (e.g., combative patients due to intoxication or psychiatric illness), and cervical dislocation with fixed angulation or anatomic limitations from preexisting conditions such as ankylosing spondylitis and kyphosis.

There are also scenarios when spinal motion restriction is logistically difficult or impossible. In a mass-casualty incident or wilderness accident, maintaining spinal motion restriction may be impractical or impossible ( Fig. 46.4 ). Moreover, spinal motion restriction may need to be delayed or modified when the scene poses a significant threat to the patient or providers (see Box 46.2 ). In these situations, the prehospital provider may opt for rapid extrication of the patient from the scene without immobilization of the spine ( Fig. 46.5 ).

In general, victims of penetrating trauma to the head, neck, or torso, such as gunshot wounds, with no evidence of spinal injury should not be immobilized. No study has demonstrated worsening neurologic outcomes related to a lack of prehospital spinal immobilization, whereas delays to definitive care for life-threatening hemorrhage or airway obstruction can lead to increased morbidity and mortality in these patients ( Fig. 46.6 ). In hemodynamically stable patients with focal neurologic deficits following a penetrating injury, it may be reasonable to restrict spinal motion; however it is prudent to err on the side of expediting care at the expense of immobilization.

Equipment

C-Collars

Traditionally, c-collars have used a four-point support structure at the bottom of the collar: at the two trapezius muscles posteriorly and at the two clavicles anteriorly. Most modern collars are modified rigid head-cervical-thoracic devices that use the sternum as a fifth support structure. Current collar designs support the head with winglike flaps on the collar's upper posterior edges. Anteriorly, the collar supports the mandible. The collar's flaring design generally prevents compression of the thyroid cartilage and cervical vessels, even when applied firmly. Some collars come as single units that conform to the neck once a chin support has been assembled, whereas others come in two parts, with a front and a back that are secured with Velcro ( Fig. 46.7 ). Some manufacturers have developed collars that have adjustable heights to account for different neck lengths. Soft collars, though comfortable, have no role in spinal immobilization because they provide minimal support and do not reduce cervical motion to any significant degree.

Investigators have attempted to evaluate c-collars in an objective fashion. The accepted “gold standard” for comparison is the halo brace, which restricts motion to 4% flexion-extension, 1% rotation, and 4% lateral bending. Unfortunately, even the best c-collars (when used independently) restrict flexion and extension by only 70% to 75% and overall neck movement by 50% or less. A number of studies have evaluated neck motion in volunteers immobilized supine on a backboard with various collars in place. Although these studies demonstrated small differences among some of the collars, overall they merely confirm the fact that c-collars do not completely prevent motion of the cervical spine. Interestingly, some cadaver studies have shown the potential for c-collars to actually increase motion and force in the unstable cervical spine. Despite these limitations, c-collars remain a widely used component of most spinal motion restriction strategies ( Video 46.1 ).

Cervical Extrication Splints

A large variety of short spine boards and intermediate-stage extrication devices are available for prehospital use ( Fig. 46.8 ). Generally, these devices are manufactured from rigid lightweight material. They have a narrow board design that permits easy application in automobiles or confined spaces and are constructed with multiple openings along the edges to allow for a variety of strapping options. Ideally, these devices should also be translucent so that radiographs can be readily obtained in the emergency department (ED), and they should allow repeated use and easy cleanup.

Application of a cervical extrication splint ( Video 46.2 ) should not produce unnecessary movement or change the position of the head, neck, shoulders, or torso. In conjunction with a good c-collar, a properly applied cervical extrication splint should effectively limit flexion, extension, lateral motion, and rotational motion of the head, neck, and torso.

One commonly used device that meets all these criteria is the Kendrick Extrication Device (KED) (see Fig. 46.8 B ). This device consists of two layers of nylon mesh impregnated with plastic and sewn over plywood slats to provide rigidity. It has a nylon loop behind the patient's head that is continuous with the pelvic support straps for additional strength. Part of its anterior thoracic panels can be folded backward to fit obese, pregnant, or pediatric patients. When properly applied, the KED is a snug-fitting, highly adaptable immobilizer that can be used in even the most adverse circumstances.

When patients require immobilization or extrication (or both) in more difficult or treacherous environments, many EMS providers prefer the LSP half-back (Allied Healthcare Products, Inc., St. Louis, MO), which resembles a KED, but is more rugged and durable. In addition to providing spinal motion restriction, it also acts as a harness and can be used for hauling patients over flat surfaces and for vertical lifts ( Fig. 46.9 ).

Mosesso and coworkers compared six prehospital cervical immobilization devices and concluded that the devices were similar in their ability to limit motion of the cervical spine.

Full-Body Spinal Restriction

Long Spine Boards (Backboards)

Backboards are made of wood or plastic composites and can be either rectangular or tapered in shape ( Fig. 46.10 A ). Most rescuers prefer the tapered type because it takes up less horizontal room when angled into a narrow opening or doorway. In addition, the slight narrowing of these boards on either end enhances the effectiveness of strapping.

Most backboards ( Video 46.3 ) have strategically placed openings along the edges that can be used to secure head-stabilizing devices, strap the patient to the board, or lift the patient. Many also feature runners, usually approximately 2.5 cm thick, on their undersides that serve both as stiffeners and as spacers. They raise the board slightly off the ground so that rescuers can get their fingers under the board during lifting. The runners, however, may make it more difficult to slide a patient onto the board.

Advantages of backboards over full-body splints include their ease of storage, low cost, and extreme versatility. The backboard can be used to slide a victim out of an automobile or to protect a victim during removal of a windshield.

Board splints, as a class, are the least comfortable of all immobilizers. Studies have demonstrated that spinal immobilization on a hard backboard causes head, back, and jaw pain. Pain in these areas may become severe if patients are left immobilized on these boards for extended periods. In addition, the pain caused by application of a backboard may be difficult to separate from other sources of pain in a trauma patient and might lead to costly radiographs and unnecessary radiation exposure to the patient. Discomfort may be minimized by using padding at points of contact between a bony prominence and the board. This concept was reaffirmed by Hauswald and colleagues, who found that increasing the amount of padding on a backboard decreases the amount of ischemic pain caused by immobilization. In some cases, tissue ischemia can lead to frank pressure ulcers, particularly in the elderly or nutritional deficient populations. Other concerning, well-described risks of long spine board immobilization include respiratory compromise, aspiration in the event of vomiting, delay to care for management of emergency injuries, and restraint-related “combativeness.”

Scoop Stretchers

In many cases, a litter that separates longitudinally into two halves, commonly called a scoop stretcher, is an ideal field immobilizer (see Fig. 46.10 B ). In fact, one study found that using the scoop stretcher caused less spinal motion than did a traditional long backboard and logroll technique.

The scoop stretcher is designed to split into two or four pieces. It is comfortable, rigid, and adaptable to patients of various lengths and provides unobstructed radiographic transparency of the entire spine. If necessary, it can be applied almost instantly or removed without disturbing the position of the victim. The scoop stretcher also provides good lateral stability because of the troughlike shape of its top surface, and it is stable enough to be used for carrying. When cervical motion restriction is desired, a c-collar can be used with the scoop stretcher. In keeping with current recommendations regarding rigid long boards (see Box 46.1 ), the scoop should be removed once the patient is transferred to the ambulance cot and the practice of placing a long spine board under the scoop or transferring a patient to a spine board for transport should be abandoned. If the patient must be transported to the hospital on a scoop stretcher, removal is achieved by unfastening the latches at the top and the bottom of the device (see the section on Procedure later in this chapter).

One limitation of the scoop stretcher is the potential for trapping clothes, skin, or other objects between interlocking parts. It also interferes slightly with the ischial section of a half-ring traction splint, but works well with Sager-type devices. The Ferno-Washington model 65 scoop (Ferno-Washington, Inc., Wilmington, OH) is the most widely used stretcher of this type. Other devices such as the CombiCarrier (Hartwell Medical, Carlsbad, CA) and the Scoop EXL (Ferno-Washington, Inc.) offer lightweight polymer construction and additional spinal support (see Fig. 46.10 C and D ).

Full-Body Splints

A variety of full-body splints are available and may be used by some prehospital providers. One popular device is the Miller body splint, which consists of a polyethylene shell injected with closed-cell foam that is radiographically translucent and provides buoyancy in water (see Fig. 46.10 E ). This full-body splint has a removable head harness and a thoracic harness, as well as pelvic and lower extremity belts. The space between the lower extremities facilitates wrapping with bandage material in the event of fractures. In addition, it is shaped so that it can easily fit into a basket-type rescue stretcher. Similar spine immobilization systems are available for pediatric patients (e.g., Pedi-Pac, Ferno-Washington, Inc.).

Another full-body splint designed to reduce the pain associated with many of the immobilization devices described previously is the vacuum mattress splint (e.g., EVAC-U-SPLINT, Hartwell Medical, and Immobile-Vac, MDI, Gurnee, IL) (see Fig. 46.10 F ). It consists of a vinyl-coated polyester envelope filled with thousands of 1.1-mm-diameter polyester foam spheres. A manual or electric vacuum pump is used to evacuate the interior to a pressure of approximately 0.25 atm. The reduction in internal pressure causes the mattress to conform to the contours of the patient's body. Vacuum splints have been shown to produce lower sacral interface pressure and lower mean pain scores than traditional hard backboards and may provide better immobilization in patients with known SCI. It should also be pointed out, however, that vacuum splints are larger and more cumbersome than backboards, thus making ambulance storage more difficult.

Lateral Neck Stabilizers

Lightweight objects such as blocks (10 × 10 × 15 cm) made of medium-density foam rubber are commonly used to provide additional lateral stabilization of the head and neck. Foam blocks are inexpensive and disposable and do not slip on the backboard. Disposable cardboard devices that have the same advantages as foam blocks are also available ( Fig. 46.11 A ).

Another commercial device is the Universal Head Immobilizer (Ferno-Washington, Inc.). It is a lateral neck stabilizer designed to quickly and easily fasten the patient's head to a scoop stretcher or spine board (see Fig. 46.11 B ). The Universal Head Immobilizer is made of a Herculite nylon and a polyethylene foam platform that fastens to the stretcher with Velcro straps. The lateral pillows are then attached to the nylon platform by means of large Velcro interfaces.

It should be noted that, although sandbags are effective devices for lateral immobilization, they may cause significant movement of the neck if the board is suddenly tilted (e.g., to decrease the risk for aspiration in a vomiting patient). Therefore their use is no longer recommended. Additionally, tightly securing the head to any device without similarly securing the body has the potential to increase forces on the cervical spine during transportation and transfer. Because any manner of strapping is unlikely to completely prevent movement of the torso, the head should always be able to shift axially as a unit with the body.

Foam Padding

Padding increases comfort and can help prevent further injury. It can also help support an injured extremity or impaled object or allow an obese or kyphotic patient to lie supine on a long backboard or stretcher ( Fig. 46.12 ). Pregnant women may benefit from padding under the right hip to help shift the gravid uterus off the inferior vena cava and increase venous return. Padding applied under the neck and shoulders prevents hyperflexion in children with large occiputs ( Fig. 46.13 ) or in individuals wearing certain types of helmets (e.g., bicycle, motorcycle, rock climbing) that cannot be removed in the field.

Procedure

Cervical Spinal Motion Restriction

The first priority in cervical spinal motion restriction is maintaining the head and spine in the neutral position. If patients are able to cooperate, instruct them to keep their head and neck in the neutral position and remain still. Next, place both hands on the sides of the patient's head to manually stabilize the cervical spine and minimize flexion, rotation, or bending. Be sure to avoid cervical traction as it can theoretically increase the risk for SCI. Once the cervical spine has been manually stabilized, examine the neck for swelling, ecchymosis, deformity, bony tenderness, or penetrating wounds. Application of a c-collar follows and is generally a straightforward procedure ( Fig. 46.14 ). The rescuer's intentions should be thoroughly explained to the patient throughout the procedure.

Once the collar is in place, caution conscious patients against movement of the head. Investigate any persistent complaints of pain or dyspnea by removal and possible replacement of the collar while manual stabilization is maintained. The size of collar should be determined from the manufacturer's suggested guidelines. For example, the Stifneck collar (Laerdal Medical Corporation, Wappingers Falls, NY) is available in various sizes and uses the distance from the top of the shoulder to the chin to determine the appropriate size. Use the tallest collar that does not cause hyperextension. For extremely short necks, a special c-collar such as the No-Neck (Laerdal Medical Corporation) is recommended. In cases in which a c-collar of the proper size is not available, construct an improvised device from available materials ( Fig. 46.15 ).

It should also be remembered that application of a c-collar should not be attempted until the patient's head has been brought into a neutral position and manual in-line stabilization has been applied. If the patient experiences cervical muscle spasm, increased pain, neurologic complaints (e.g., paresthesias, weakness), or airway compromise, immediately halt any further movement of the head and neck. In these situations, immobilize the head and neck in the position they are found or in the position of comfort by using an alternative technique (e.g., blanket, towel roll, manual in-line stabilization).

Thoracolumbar Spinal Motion Restriction

Studies have shown that healthy individuals are able to self-extricate from a vehicle with less spinal motion than when extricated by emergency medical technicians. Consequently, ambulatory patients or those who are able to self-extricate without undue pain should have a c-collar applied and be allowed to move themselves to an EMS cot. If used, backboards should be removed as soon as possible and patients should not be unnecessarily placed on rigid boards during interfacility transfer (see Box 46.1 ).

Sitting Position

To immobilize patients who require extrication and are found in a sitting position, providers can use a short backboard or commercially available cervical extrication device (e.g., KED) or perform rapid extrication using manual in-line stabilization, a c-collar, and a long spine board.

At least two rescuers should be present to apply an extrication splint to a sitting patient.

Open the device butterfly style and gently slide it behind the victim via a rocking motion ( Fig. 46.16 , step 1 ). If necessary, carefully rock the patient forward a few degrees to facilitate placement of the splint. Once behind the victim, free the splint's pelvic support straps from their retainers and allow them to dangle at the patient's sides. Next, bring the lateral thoracic panels around the chest just beneath the patient's shoulders. Grasp these panels and slide the splint upward until the top edges of the panels firmly engage the patient's axillae. Now use the thoracic straps to secure the splint, beginning with the middle strap, then the bottom strap, and finally the top strap (see Fig. 46.16 , step 2 ). The straps should be snug, but not so tight that they interfere with respiration.

Fasten the pelvic support straps next. They can be slipped one at a time beneath the patient's lower extremities and brought directly beneath the pelvis with a back-and-forth motion. If the pelvic straps are not applied properly, considerable slippage may occur when the patient is lifted. Connect the free end of each pelvic strap to buckles located at the patient's hip on the outside of the splint. Once a strap is ready to be buckled, it can be either attached to the buckle on its own side or moved across the patient's lap and engaged with the opposite buckle. Many prehospital care providers prefer the latter method because it allows the patient's knees to remain together without discomfort. It is also a good idea to pad the groin area when placing the pelvic support straps because these straps may cause the patient considerable discomfort.

This procedure may need to be modified for certain injuries and preexisting conditions. For example, patients with pelvic fractures may not tolerate placement of the pelvic support and bottom straps, and the gravid abdomen of a pregnant patient may prevent placement of the middle strap.

Next, secure the head to the device (see Fig. 46.16 , step 3 ). When using the KED, wrap the head panels snugly around the head and neck while another rescuer applies the diagonal head straps. It may be necessary to place padding behind the head to maintain a neutral position. Use the forehead as a point of engagement for one strap and the c-collar for the other.

As a final step, tighten all buckles until the entire splint is firmly in place. The patient can now be moved. If the patient is to be lifted from a vehicle, bring the ambulance cot (with a spine board if needed to facilitate extrication) as close to the patient as possible (see Fig. 46.16 , step 4 ). While one rescuer supports the patient's knees, the other rescuer uses the handholds on the splint to lift the patient. The patient should be rotated and laid in a supine position onto a backboard or cot as needed. Loosen the pelvic straps to allow the legs to be lowered onto the backboard. The legs can then be extended and secured or left in the flexed position with a pillow placed under the knees for support.

If needed, apply a lateral immobilizer to help prevent movement of the head and neck and secure the body with straps. Once the patient is on the stretcher, the thoracic straps may need to be readjusted. The device should be removed as soon as possible, with care to avoid unnecessary movement of the spine until significant injuries are ruled out.

Recumbent Position

A patient who is found in a recumbent position should be placed in a supine position, if not already in one. If repositioning is necessary, examine the back during the process. Physical examination, spinal immobilization, airway management, and transport are easier to accomplish with the patient in the supine position.

Patients who are found supine do not require the use of a cervical extrication splint. They should, however, receive initial manual in-line cervical stabilization and a c-collar. The patient can then be secured to a full-body spinal immobilizer, such as a scoop stretcher, backboard, or full-body splint if indicated (see Box 46.1 ).

Scoop Stretcher.

A patient who is in a supine position can be moved by means of a scoop stretcher. In a conscious patient, rescuers should explain that they are about to apply a scoop-type stretcher beneath the patient's body. Prior to beginning, apply a c-collar and maintain manual in-line cervical stabilization until the patient is completely secured to the stretcher.

Place the scoop on the ground next to the patient and open the latches that regulate its length. Adjust the length to fit the full length of the patient's body and reengage (lock) the latches. Next, release the latches at each end and separate the stretcher into two halves. Place each half next to the patient. One rescuer then gently pushes half the stretcher under one side of the patient. In some cases it may be necessary to have another rescuer rock the patient to allow proper positioning. Repeat the procedure with the opposite half of the scoop until both halves are aligned beneath the patient. Engage the latch at the head of the device first. Then bring the lower ends together and engage the foot latch to complete the integrity of the stretcher. Strap the patient's torso into place and immobilize the head with a suitable lateral neck stabilizer. The patient can then be lifted onto another device for transport, such as a stokes basket or ambulance litter. After placement on another device (e.g., ambulance cot), the scoop stretcher can be removed without disturbing the patient's position.

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