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

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Wilderness and Rescue Medicine

General Principles

General Principles

Spine Packaging Risk vs Benefit Stabilization can increase other risks: • Increased time and complexity of evacuation

High Risk Spine Injury

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Field Treatment

• Delay in treatment of other problems

• Impair airway control, thermoregulation, and survival efforts

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• Cause skin and soft tissue ischemia

©2018WMA

©2018WMA

During transport, soft stabilization in the lat- eral or recovery position in a well-padded litter or vacuummattress is ideal. Rigid cervical collars and unpadded backboards are not recommended for field use. Acceptable cervical spine stability can be accomplished with clothing and other pad- ding. The old ski patrol horse collar technique that uses a blanket, sleeping bag, or jacket is effective, comfortable, and warm. The use of analgesics and anxiolytics to help an uncomfortable patient tolerate a long carry is appropriate and humane. The dose should be titrated to provide some relief without putting the patient to sleep. If something is going wrong inside the package you will want your patient to tell you. Be aware that opioids and other medica- tions can inhibit shivering or interfere with tem- perature control. Risk Versus Benefit There are many rescue situations in which the risk of full body stabilization exceeds the presumed benefit. Examples include patients or rescuers threatened by wildfire, avalanche, hypothermia, or a difficult technical rescue. In a high-risk environment, the best patient and spine protec- tion may include crawling, walking, running, or swimming. When you have no choice but to move immediately, or to walk rather than carry a patient out, you can take comfort in the knowledge that an unstable spine injury is rare and the probability of further injury is remote.

One of the most common challenges to spine protection is an unsecured airway in a vomiting patient. In a rescue scenario it can be extremely difficult to prevent aspiration of vomit, secretions, or blood into the lungs of a patient stabilized supine on a backboard or litter. It is sobering to realize that aspiration of vomit carries a mortality rate of 20% to 60% depending on which studies are cited. It may be necessary to defer ideal spine protection until you can reduce this high level of risk. Whenever airway problems are anticipated, it is best to package the patient on his or her side, in the recovery position, or sitting up with his or her head turned to keep the airway clear. Another vexing problem for rescuers is the com- bative patient with TBI where there is a positive mechanism, you must assume spine injury, and the patient will not tolerate spine stabilization. Wrestling a patient like this into a litter is a high- risk treatment. The best spine protection may be to allow the patient to assume whatever position is most comfortable or, if necessary, to apply soft extremity restraints only.

General Principles

Spine Packaging Ideal to Real

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Consider: • Assisted walking, crawling, swimming

• Package in sitting or recovery position

• No packaging or splinting if mobility is needed for survival

* “There are situations in wilderness and rescue medicine where the risks of spine stabilization exceed the presumed benefit.”

©2018WMA