MOI for c-spine injury emergencies

Facilitator: Grace + Becca
Medics: Charis + Greg
Patients: C-spine pt
Time: 30 mins; 1055-1125
Actual time:
Learning Objectives:
Materials: Gloves for medics.

Mechanism of Injury

Facilitator says

Remember Lisa? When the scene assessment buddy interviewed her friends, he wanted to know if she had fallen or been hit on the head. The medics decided her lowered level of responsiveness (LOR) was probably because of a diabetic emergency, not injury. The scene assessment buddy was assessing the mechanism of injury (MOI) or nature of illness (NOI).

In this training we've met with MOIs including skipping meals while diabetic, foreign body in the airway, getting riled when that is an asthma trigger, probable heroin overdose, chainsaw injury to the leg, and fall from a height with lateral high-speed impact on pavement.

Skills drill: Stabilizing potential C-spine injury

Why stabilize?

Facilitator says

  • The big concern after a fall from a height is not the badly fractured legs, but the stress transmitted up the spine from the impact -- and the risk of it cracking a cervical vertebra.

  • Moving a cracked cervical vertebra could drive a bone fragment into spinal nerves that control breathing, causing death; or into major motor nerves, causing paraplegia.

  • We also have a triage situation here. To simplify, imagine another buddy pair is taking care of the sitting patient.

Model

Buddies talk to each other, patient, and patient's friends, but not to classroom while they demonstrate:

  • Ground, put on gloves.

  • Scene survey.

  • Approach in her natural sight line so she doesn't have to turn her head1.

Patient care buddy

  • Stabilizes c-spine, introduces pair, is nice, asks consent, explains every touch.

  • Tells standing buddy: "Get us a privacy circle and call 911."

  • Checks LOR (not alert, responds to loud but nice "Open your eyes!" -- responsive to voice).

  • Keeps talking to pt.

Scene assessment buddy

  • Makes privacy circle, delegates 911 call and scene assessment.

  • Crouches down and does head tilt/chin lift and looks, listens, and feels for breathing (it is present).

  • Does bloodsweep.

  • Stands and asks bystander to put phone to his ear. Tells 911 operator, "She fell 30 ft from 3rd Street into the eastbound lane of I-10, lowered level of consciousness, currently breathing," then rejoins buddy.

Patient begins to retch. Patient care buddy

mobilizes bystander. The three execute a log roll to the side and wait for vomit to clear. Then the three execute a log roll back to perfect pt position.

Patient care buddy

  • To scene assessment/comms buddy -- once pt is on her back again -- "Keep that privacy circle tight. Cover her to protect her modesty, expose her legs up to her pelvis to assess the bleeding, and check her abdomen for bruising."

  • To patient: "My buddy is checking your thighs and abdomen for dangerous bleeding."

Both buddies

calm, comfort, and reassure and maintain consent all the way

Debrief

Facilitator asks

What did we find out? Good answers:

  • She fell 30 feet and has MOI for c-spine injury (MOI problem).

  • She's responsive to voice but not alert (LOR+D problems; threat of A problem).

  • Vomiting put her airway at risk (A problem fixed).

  • She's breathing (A+B ok).

  • She's bleeding from her broken lower legs but it's probably not life-threatening (C ok).

Facilitator asks

What did the medics do? Good answers:

  • Had a buddy and clear roles, grounded, BSI, scene survey (made the scene safer for themselves).

  • Patient care buddy introduced the pair to pt, calm, consent/explanation, privacy circle.

  • Witnessed MOI, discovered emergency, activated EMS (stop and fix).

  • Assessed LOR (lowered), A (vomiting), B (currently ok), C (probably ok).

  • Log rolled to maintain airway while vomiting and planned to assess bleeding more thoroughly.

Practice

Count off into groups of 3.

Find C-Spine

Students practice finding cervical spine.

Hang head forward and find C-7 protruding between shoulderblades, then feel the vertebrae up to the base of the skull.

Stabilize C-Spine

Trainer buddy pair slowly demonstrates initiating and holding c-spine stabilization (facilitator narrates).

Approach in the patient's natural sight line so he doesn't have to move head to see you. Explain exactly what you are doing, and why, get consent. Some people do c-spine before consent, others will not touch the person without consent.

  • Hold head in the position you find it.

  • Place one hand on the forehead if necessary for initial control of head movement. Fingers on bony things, not mushy things. Don't cover ears. Gentle traction feels good.

  • If person has glasses on, have your buddy remove them if it's okay with injured person. Put glasses in the person's hand or pocket.

  • How comfortable and stable is your position?

Students practice

holding c-spine immobilization in their groups of 3.

Facilitator asks:

Any questions? Comments? Feedback for students from trainers?

Transfer stabilization

T rainer buddy pair slowly demonstrates transferring c-spine stabilization (facilitator narrates).

Only transfer to a person of equal or higher training. In this demo, medic 2 relieves medic 1.

  • Medic 2 slides her hands in under medic 1's hands:

  • Medic 1 slowly removes one hand and places it on forehead of injured person to increase stability.

  • Medic 1 removes other hand.

  • While medic 1 holds forehead, and medic 2 maintains hands on either side of patient's head, medic 2 moves into a comfortable, stable position.

Students practice

transferring c-spine stabilization in groups of 3.

Facilitator asks:

Any questions? Comments? Feedback for students from trainers?

Log roll

Trainer buddy pair asks for a volunteer to help and slowly demonstrates log roll (facilitator narrates).

The only purpose of log roll is to keep the airway clear by allowing vomit or other fluids to drain from the mouth. When the mouth is clear, roll back.

  • The medic holding head gives all directions and makes all decisions.

  • If possible, recruit a bystander to help. There should be one medic on the head and two people on the body.

  • The medic and bystander on the body kneel. They will roll the patient towards them. One has a hand grasping the shoulder and a hand grasping the hip. The other has a hand grasping the hip and a hand grasping the knee. Their arms cross at the pt's hip for added stability.

  • The medic holding head head clarifies how they will count. This avoids the problem of some people starting movement on "3" others on "roll." "We are going to roll on 'roll.' I will say '1-2-3-roll.' " The medic holding head asks, "Is anyone not ready?"

  • Roll person slowly, following instructions of person at head. Wait for vomit to drain.

  • Roll person back when directed by medic at head ("Is anyone not ready? Okay, 1-2-3-roll.")

Students practice

log roll in groups of 3 -- trainers can play patient or bystander.

Facilitator asks:

Any questions? Comments? Feedback for students from trainers?

Sitting C-Spine\

Trainer buddy pair demonstrates holding c-spine stabilization on pt sitting in chair

and reinforces the principles:

  • Hold head in position you find it.

  • Fingers on bony things, not mushy things. Don't cover ears. Gentle traction feels good.

  • Get in a position that will be comfortable and stable for the long haul.

All together now

Students practice the whole shebang.

Still in groups of 3, 3s and 2s are a buddy pair that approaches 1s (patient who fell from banner hang) and run through the whole shebang.

MOI for C-spine Injury

Facilitator says

Think "bowling ball on a broomstick" -- average adult human head weighs 9 lbs. Four major mechanisms for cervical spine injury:

  • Fall from a height -- 2X person's height (Some say 20 feet, 10 for kids. We say 2X person's standing height). Falling hard on feet compresses spine.

  • Blunt trauma to back of neck.

  • Injury where the head snapped back fast (whiplash, from car accident; serious fall on head; serious blunt trauma to head).

  • Crush from top of head, compressing spine.

If the cervical vertebra is damaged, a splinter of bone can cut or scratch the spinal cord when the head moves. Damage to the spinal cord at any level cuts off messages passing through that level. Messages about breathing and heart beating pass through the cervical spine.

C-spine stabilization is an intervention to prevent potential injury -- like recovery position (which prevents airway obstruction).

  1. Patient should be in perfect patient position. If she is not, do not take her down; hold her in position.↩