Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Section IV: Trauma

General Principles

General Principles

Low Risk Spine Injury WILDERNESS PROTOCOL

High Risk Spine Injury WILDERNESS PROTOCOL

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• Normal mental status; reliable patient • Tolerable pain and tenderness; able to move and bear weight easily • No new tingling, numbness or muscle weakness • Normal motor/sensory exam

• Unreliable patient with significant MOI • New onset of tingling, numbness, or muscle weakness • Abnormal motor/sensory exam • Intolerable pain and tenderness; unable to move and bear weight easily

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Low Risk

High Risk

Low Risk

High Risk

©2018WMA

©2018WMA

Spinal cord injury, however, is an emergency. Persistent neurologic signs or symptoms follow- ing significant trauma may indicate ischemia of the spinal cord that will result in infarction if perfusion is not restored. Early surgical interven- tion may save spinal cord tissue. You will probably choose the helicopter evacuation to the trauma center over the slow carry out to the local hospital, even if the risk in doing so is a bit higher. Evacuating a high risk spine injury usually requires a rugged improvised or commercial litter and a large team to carry it. While awaiting the proper equipment, the patient can be stabilized on a foam pad on the ground with packs or other gear positioned to restrict head motion if necessary. The patient must be monitored for symptoms of any developing pressure sores caused by pro- longed skin ischemia. Helping the patient to move and shift position periodically may be necessary.

In low risk spine injury, pain and tenderness are mild, the patient can move and bear weight easily, and the motor and sensory exam is normal. This is the person who can stand up and sit down without assistance and without screaming in pain. This patient is at low risk for complications if another fall can be prevented. As always, we try to avoid high risk evacuations for low risk problems. Evacuation of the low risk spine injury is non-emergent and usually does not require a carry. However, to reduce the probability of further trauma, the patient probably should not get back on the horse or mountain bike. A walk out may be the safest plan for all concerned. High-Risk Spine Injury The signs and symptoms of high risk spine injury are the same as those for other unstable musculo- skeletal injury: severe pain and tenderness, defor- mity, or the inability to move or bear weight. The pain and disability of serious spinal column injury is usually evident immediately in the patient’s complaint. High risk spinal column injury car- ries the anticipated problem of spinal cord injury in the event of further trauma or rough handling. Fortunately, just like a fractured leg, an unstable spinal column injury may be high risk but is not necessarily an emergency. If the patient is neuro- logically intact, careful handling and protection is more important than speed.

General Principles

High Risk Spine Injury

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Field Treatment

Risk vs Benefit: • Packaging for comfort and protection is ideal when associated risks can be managed • Evacuate; emergent if persistent neurological deficit • Pain control, nursing care, and monitor for changes

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©2018WMA