Presence Regional EMS System
July 2014 C.E.
Objectives
 Review spinal anatomy and physiology
 List the mechanisms of injury that cause a high index
of suspicion for the possibility of spine injury.
 Outline the steps of patient assessment of spine injury
Objectives
 Discuss the decision making process regarding Spinal
Motion Restriction (SMR)
•Mechanisms of injury indicating need for SMR
•Emergency Rescue and Rapid Extrication
•History and assessment indicating no need for SMR
•Special situations indicating need for alteration of
SMR
 Demonstrate the process of application of SMR
 Describe potential complications of Spinal Motion
Restriction
Anatomy of the Human Spine
 The human spine consists of 33 vertebrae
 Are divided up into separate regions
 Cervical region consists of 7 vertebrae
 Thoracic region consists of 12 vertebrae
 Lumber region consists of 5 vertebrae
 Sacral region consists of 5 fused vertebrae
 Coccygeal region consists of 4 fused vertebrae
 Can be identified by region and location; i.e. T1 being
the top vertebrae in the Thoracic region and C3 being
the third vertebrae from the top of the Cervical region
Anatomy of the Human Spine
 Cervical, Thoracic, and Lumber vertebrae are
separated by intervertebral discs allowing for
movement independent of other vertebrae
 Sacral and Coccygeal vertebrae are fused and have no
range of movement independent of the other bones of
the structure
Cervical Spine
 Consists of 7 vertebrae separated by intervertebral
discs
 Known as C1 (Superior Cervical Vertebrae) to C7
(Inferior Cervical Vertebrae)
 Top Cervical vertebrae (C1) is known as the Atlas
 This is the vertebrae connecting the head to the spine
 Second vertebrae (C2) is known as the Axis
 Supports the Atlas and allows the Atlas to pivot
 Cervical region allows for movement of the head and
neck
Thoracic Spine
 Consists of 12 vertebrae separated by intervertebral
discs
 Known as T1 (Superior Thoracic Vertebrae) to T12
(Inferior Thoracic Vertebrae
 Have facets on either side of the vertebrae that allow
for interaction with the ribs
 Increase in size gradually from T1 to T12
Lumbar Spine
 Consists of 5 vertebrae separated by intervertebral
discs
 Known as L1 (Superior Lumbar Vertebrae) to L5 (Inferior
Lumbar Vertebrae)
 Largest vertebrae of the spinal column
 Support the weight of the body and allow for
movement
Sacral and Coccygeal Spine
 Consists of 5 fused vertebrae (Sacral) and 4 fused
vertebrae (Coccygeal)
 Sacral region starts are 5 unfused bones that have
fused into the Sacrum by the mid-30s
 Sacral region is the base of the spine and allows for
articulation with the pelvis
 Coccygeal region (Coccyx) is below the Sacral region;
serves a function as an attachment for various tendons,
ligaments, and muscles
 Coccygeal region also allows for support for sitting
Functions of the Spinal Column
 Supports structure for the human body
 Spinal canal of vertebrae is hollow and houses the
primary route of the nervous system to the body,
commonly referred to as the spinal cord
 Provide structure for attachment of
muscles, tendons, and ligament
needed for movement
Types of Injury to the Spinal Column
 Hyperextension – excessive posterior movement of the head
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or neck
Hyperflexion – excessive anterior movement of the head or
neck
Compression – weight of head or pelvis driven into stationary
neck or torso
Rotation – excessive rotation of the torso or head and neck,
moving one side of the spinal column against the next
Lateral stress – direct lateral force on spinal column, typically
shearing one level of cord from another
Distraction – excessive stretching of column and cord
Mechanism of Injury
 The force that causes injury to the spinal column or
cord
 Must be a factor in patient assessment of possible
spinal column injuries
 Common mechanisms are automobile accidents, falls,
and other blunt force traumas
 Err on side of patient; if mechanism is unknown
assume that there was enough force to cause an injury
to the spinal column
Examples of Mechanism of Injury
 A fall where a patient lands on their feet is likely to
cause a compression injury
 Automobile accidents with frontal collision is likely to
cause both hyperextension and hyper-flexion due to
the forces exerted onto the neck and spine
 A hanging is likely to cause a Distraction injury due to
vertebrae being pulled apart by gravity
Law of Conservation of Energy
 States that energy cannot be destroyed, but can only
be transferred or transformed
 Applies to all mechanisms of injury
 Spinal column is prone to injury due to it’s role as a
supporting structure for the rest of the body
 Energy from mechanism of injury can be transferred
to spinal column, producing spinal injury
Assessment of Spinal Column
 Consider Mechanism of Injury
 If unknown and patient is unresponsive use SMR to protect
Patients spinal column
 Assess for DCAPP-BLS-TIC of spinal column
 Look for Deformities, Contusions, Abrasions, Punctures, Penetration,
Burns, Lacerations, Swelling, Tenderness, Instability, and Crepitus.
 Assess PMS of patients extremities
 Assess for Pulse, Movement, and Sensation of all extremities
to rule out neurological or cardiovascular damage
Assessment of Spinal Column
 Maintain manual control of C-spine during
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assessment of patient
Assessment of patient’s neck should take place prior to
placement of a cervical collar
Assessment of patient’s spinal column/back should
take place during log roll to backboard or prior to
placement into a short backboard (KED)
Reassess PMS following placement into full SpinalMotion-Restriction
Priapism (male erection) is an indication of spinal
cord injury
Terms to remember
 SMR: Spinal Motion Restrict – use of a cervical collar
and backboard device to provide cervical-spine
stabilization
 PMS: Pulse, Movement, Sensation – assessed on
extremities to check and recheck neurological and
cardiovascular condition of patient
 C-Spine: Cervical Spine
 C-Collar: Cervical Collar
Consider SMR based on Mechanism
 Suspect Spinal Column Injury with any of the following
mechanisms of injury:
 Motor Vehicle Crashes
 Pedestrian vs vehicle
 Falls
 Blunt Force Trauma
 Penetrating Trauma to the head, neck, or torse
 Motorcycle Crashes
 Hangings
 Diving Accidents
 Recreational accidents; i.e. ATV, waterskiing, snowboarding
Emergency Rescue
 The method of extrication from a scene or vehicle
when there is an immediate life threat to the patient
and/or the EMS Provider
 Attempt to move patient and providers out of harms
way as quickly as possible
 Does not provide much, if any, control of cervicalspine
 Used if cases of fire, hazardous materials, or other
potentially deadly threats
Emergency Rescue
 To perform with one provider, ensure that patients legs
will not become entangled
 Place arms under patient’s armpits and use hands to
grab the wrist of the patient’s opposite arm
 Pull patient free of hazard; if available use second
rescuer to grab patient’s legs
 Attempt to regain control of cervical-spine once
patient/EMS providers are safe
Rapid Extrication
 Used to loosely control cervical-spine movement and
move patient from a seated position in a vehicle to a
backboard rapidly
 Used for the following situations:
 The vehicle or scene is unsafe
 The patient cannot properly be assessed before removal
from the vehicle
 The patient requires immediately interventions
 The patients condition requires immediate transport
 The patient position blocks assess to another critical
patient
Rapid Extrication
 The first rescuer still provides manual cervical-spine
stabilization, often from the back or side of the patient
 The second rescuer serves as the team leader, applies
the cervical collar, and moves the patients body onto
the backboard
 Third rescuer moves the patients lower extremities
during rotation
 Other rescuers can assist in movement and support
Rapid Extrication
 Begin by obtaining manual cervical-spine stabilization
 Place cervical collar onto patient
 Use minimum three rescuers to rotate patient 90
degrees using short movements and keeping patients
spine straight
 Place backboard between the patient’s buttocks and
seat once rotated
 Move patient as a unit back onto backboard and into
proper position; coordinate to maintain cervical-spine
control
Special Situations
 Not all patients will be able to tolerate Spinal Motion
Restriction
 Infants, Pediatric, Bariatric, and Geriatric patients may
require alternative methods of SMR
 Use padding and equipment available to maintain neutral
alignment of cervical-spine
 Spinal Motion Restriction may not be possible with
patients who have impaled objects
Special Situations
 Patients with helmets require special consideration
 Athletic Helmets should be removed when:
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Face mask cannot be removed in a timely fashion
Airway cannot be controlled
It does not hold the head securely
It prevents stabilization
 Shoulder pads should be removed:
 With helmet removal
 When it does not support neutral alignment
 When it impedes securing the patient to a backboard
 When access to the chest is required
Special Situations
 Motorcycle helmets should be removed when:
 The helmet is poorly fitted to patient and allows for
movement of head inside the helmet
 When it causes flexion of the neck
 The patients airway needs to be monitored
ALS Spinal Clearance Protocol
 Region 6 Allows Advanced Providers to perform spinal
clearance in order to deem a patient exempt from
requiring SMR
 Patient must meet criteria:
 Must be over 12 years of age but less than 75 years of age
 Must not have chronic neck pain
 Must have Glascow Coma Scale of 15
 Cannot be complaining of neck or back pain
 Must not complain of tenderness upon palpation of spine
 Cannot have a distracting injury; i.e. injured extremity or burns
 Must be free of drugs or alcohol
 Must be able to move freely without pain or neurological compromise
Application of SMR
 Application of SMR should be based on the
circumstances of the call: patients will be immobilized
differently based upon how they are found.
 Log roll technique should be used for patient found
laying supine or prone
 Patients found seated should first be immobilized to a
short backboard in order to maintain control of cervicalspine
 Standing patients should be stood against a backboard
with a rescuer holding manual c-spine, then lowered to
a supine position
Log Roll Technique
 First rescuer takes manual inline stabilization at the
head; this rescuer directs movement of colleagues
 Second rescuer applies c-collar after checking the back
of the neck while a third rescuer places a backboard
beside the patient
 Keeping the cervical-spine inline, the patient is rolled
onto an uninjured side, their back is palpated to assess
for spinal column injuries, and the backboard is
brought into place in the position the patient was
formerly in
Log Roll Technique
 Keeping the Cervical-Spine inline, the patient is
rotated back onto their back, this time in position on a
backboard
 They are secured to the backboard first by the torso
then legs; the head is secured last
 Patient pulses, movement, and
sensations are reassessed
SMR for the Seated Patient
 The first rescuer will gain access to patient and take
manual cervical stabilization
 A second rescuer will apply a cervical collar after
assessment of the neck
 Next a short spine board will be placed between the
patient’s back and the seat; palpate the spine for
injuries at this time
 Secure the patient to a short spine board; first use the
torso straps, then the leg stirrups, and finally pad
behind and secure the head
SMR for the Seated Patient
 Moving the patient as a unit, rotate and move the
patient onto a long backboard
 Secure patient to backboard as you would normally do
 DO NOT attempt to remove the short backboard from
the patient
SMR for the Standing Patient
 First rescuer comes behind the patient and obtains
manual inline stabilization
 Second rescuer applies C-Collar following assessment
of neck
 Third rescuer places patient against board following
palpation of patient’s spine
 The second and third rescuer place their arms under
the armpits of the patient and grab onto the
backboard
SMR for the Standing Patient
 Moving as a unit, the patient is lowered to the supine
position
 Patient should now be secured to the backboard
following standard procedures
 Reassess PMS
Potential Complications of SMR
 SMR may cause airway compromise due to the head
and neck being in a fixed position
 SMR can cause head and back pain due to position on
the hard spine board
 Obese patients and patients with certain illnesses may
not tolerate backboards: Assess for hypoxia
 Application of SMR may increase amount of time on
scene; ensure that SMR will benefit your patient
 Poor application of SMR may be detrimental to
patient; reassess PMS prior to and following SMR
Review
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If doing this CE individually, please e-mail your
answers to: Shelley.Peelman@presencehealth.org
Use “July 2014 CE” in subject box.
IDPH site code: 06-7100-E-1214
You will receive an e-mail confirmation. Print
this confirmation for your records and document
in your PREMSS CE record book.
Determine the Mechanism of Injury and decide
whether or not SMR is needed
25 y/o male found unresponsive
55 y/o driver c/o neck pain
35 y/o complaining of chronic back pain
43 y/o male hanging
Restrained driver unconscious
GSW to chest with no exit wound
76 y/o female c/o right hip pain
Water-skier struck by speedboat
Skateboarder c/o right shoulder pain
Answers
 25 y/o male should have full spinal motion restriction
due to unknown MOI
 55 y/o driver should have full spinal motion restriction
based on damage to care and chief complaint
 35 y/o does not require SMR due to no MOI
 43 y/o hanging victim requires full SMR
 Driver requires Emergency Rescue then SMR when in
a safe area
Answers
 GSW victim does not require SMR per ITLS standards
 76 y/o female requires SMR due to possible injuries
sustained in fall; hip pain can be viewed as a
distracting injury
 Water-skier requires SMR due to blunt force trauma to
back
 Skateboarder does not require SMR due to isolated
injury