Moving an Injured Patient with a Head Injury

[caregiver222]

A common situation in a disaster will be to encounter injured fellow citizens or family members. It is not possible to provide a first aid course in a few posts on the internet. My recommendatiom is for a lay person to enroll to take a basic Emergency Medical Technician (EMT) course. The Red Cross offers first aid training, however it is not as thorough and up-to-date.

That being said I am going to address a common type of injury that even today, is not properly addressed. An injury that one is likely to encounter in a disaster situation.

If a person strikes their head, or recieves a blow that causes SUDDEN neck flexure, it must be assumed they have a cervical injury (fracture) until this is ruled out by imaging. Moving such a patient inappropriately can cause them to suffer spinal damage and become a paraplegic or a quadraplegic.

The decision to stabilize should NEVER rest upon whether or not they have lost consciousness or their current neurological state or deficit.

(1) A history of sudden cervical flexure alone warrants immobilization.
(2) Re-read (1)
(3) Re-read (2)

Question: "The patient is moving his/her hands and has full sensation. Is it still necessary to stabilize the head?"

I have never been more frustrated that to see a properly stabilized patient with a neck brace come into an emergency room and a doctor determine they have full sensation in all limbs and can wiggle their toes, and then rips off the cervical collar.

And yet this continues to happen in every emergency room. Not all the time, but often enough.

The fact the person has not suffered neurological damage is only because the spinal cord has not been cut or transected. If there are broken bones, the fragments can cut the cord at any time.

Proper stabilization is best taught by a physician or at an EMT course. The general idea is to prevent all movement. The drill is to provide gentle axial traction with the hands of the first-responder while a rigid cervical collar is emplaced and the patient is secured to a back-board or a special stabilizing apparatus. Axial traction is upward pressure along the vertical axis of the spine. Imagine you are standing upright and place a meter ruler against your sline extending up above your head. Draw an imaginary line along this ruler upwards. Gentle pressure along this arrow is called "axial traction".

EMT's are taught to place the palms of both hands against the side of the head to apply this pressure. Often they get in the seat behind an automobile accident victim to accomplish this. They practice in drills with various techniques to arrange a patient who is in various positions so as immobilize him/her with a minimum of potential danger.

This type of injury is common when a person's head hits a windshield. It could also occur from a slip on the sidewalk or a blow to the head by a baseball.

IN ALL SUCH CASES, the patient should be not moved or walked to an ambulace, but remain in place until stabilized.

Now I going to give you a suggestion that is not generally taught to first responders.

(1) Talk to the patient.

(2) EXPLAIN that is is CRITICAL they do not move or flex their head or atttempt to move. Explain that a bone may be broken in the cervical area that will sever nerves controlling their ability to walk and breathe and that this can only be definitively determines at a hospital with imaging facilities!

You will find that even youngsters can understand such instructions.

Question: "But what if the patient is in danger?"

Answer: This is a judgemental call. Obviously if a car is on fire it is wise to remove the occupants. In such a case as little movement as possible should be tolerated and the patient moved only to a safe distance before they are immobilized. Further discussion is a "how many angels are on the head of a pin" question. Use common sense.

More often then not, a patient is improperly prematurely moved. Decades ago I was in a parking facility when a man slipped in front of my car, fell backwards, and hit his head. I went over, examined him, and told him not to move and went off around the corner to use a pay phone to call an ambulance.  He could move his arms and legs and had sensation in his feet, which I determined by poking him with a ball-point pen. I removed his shoes and he could wiggle his toes. At the time there were no cell phones and this was a rural area. Meanwhile a number of cars had backed up seeking to leave the facility. The parking lot attendant decided to move the man out of the way. They did not stabilize him. They brought him fifty feet to a nearby office and sat him down upright..

When I returned to examine the man he could no longer move his legs. They had turned him into a paraplegic for the convenience of a few people trying to get their cars out of a lot.

[caregiver222]

The decision to remove someone quickly from a danger area without proper stabilization or by untrained first responders is a difficult one, and not addressed well in scenarios.

In the first place, lay people don't attend these training sessions.

In general, it is best not to move someone unless you are trained and to wait for trained first responders. The exception, of course, is when the patient is in imminent extreme danger. Wait for the ambulance.

If you suspect neck flexure and a possible "broken neck", and don't feel confident to move the patient (or don't have the equipment), stay with the patient and:

(1) Tell them NOT to move their head.

Depending on your level of training at the least maintain a hand on their shoulder or hold their wrist. If you don't feel confident applying slight axial traction, place your hands on each side of his/her head and prevent it from moving. If the head is bent downward, it should only be straightened and moved by someone who is prepared to exert axial traction and continue to do so until a cervical collar is applied.

In general, I am opposed to starting an IV on a patient who is scrunched and not yet extricated and prefer to wait until they are on a backboard in the absence of extenuating circumstances. For example, excessive blood loss.  This is an opinion of one. The IV interferes with the extrication. Don't tell me it doesn't.

If there is the possibility of internal bleeding, my advice is to "pack and run". My understanding is that when Princess Diana had her accident she was lucid, tyalking and able to walk, and the ambulance crew kept her on the scen for one hour and fifty five minutes while they "stabilized" her. She died from internal bleeding.

Straightening a "crunched up" patient is always dangerous, even when accomplished by trained first responders. There is a danger that damage can be done to the spinal cord even when taking the greatest of care.

My own observations are, in general, the extrication and straightening is unnecessarily rushed. "Slowing things down" , even a little bit is helpful.

It is not possible to make up a zillion rules to cover every eventuality, as some emergency services have attemted to do.

If you have a head injury with neck flexure, you are likely to have, in addition to the possibility of a cervical fracture, the problem of concussion and internal bleeding (a subdural hematoma).

There is a "window of opportunity" in treating head injuries, and clearly expeditious removal to an adequate facility should be at the top of the priority list.

On the other hand, an extra fifteen to twenty minutes spent in properly extricating a patient and insuring his head does not move and bone fragments do not transect his spinal cord, is time well spent.

[caregiver222]

A medical professional knows enough not to flex the neck of a patient who has a head injury, but I am giving advice to lay people who may not know any better. I see time, and time again, that someone who has been struck by an automobile, and lying in the street, has someone roll mup a jacket to put under his/her head as a pillow until "help arrives".

This is absolutely, positively the wrong thing to do.

The neck should not be flexed forward.

If not qualified or confident enough to provide axial traction, simply stabilize the head by kneeling above the patient and placing one hand on each cheek, while telling them not to move.

There are exceptions to this drill if there is airway compromise, but in general this will not be the case.

[caregiver222]

This brings us to the issue of removing clothing.

(1) In the event of an injury involving sudden cervical (neck) flexure, the clothing should not be removed unless it is CUT OFF prior to imaging to rule out fracture.

(2) Re-read rule # 1

Many times the clothing need not be removed. Protocol dictates that a patient's upper extremities be evaluated without clothing. Particuliarly if someone decides it is necessary to ausculate the lung fields, anterior and posterior, four quadrants.

In no case should the patient be permitted to remove his jacket/shirt/sweatshirt normally and especially not by raising the arms and pulling it over his/her head.

If is is deemed necessary for comfort or for examination purposes to remove clothing CUT IT OFF with a paramedic bandage scissors.

This includes expensive leather jackets.

This rule is ocasionally violated with tragic results.

The best course of action is imply to start cutting and ask questions later. Then you can tell the patient "I'm sorry, but the clothing seems to be ruined anyway, so I might as well continue cutting..."

Let's take a case in point. A very pretty 22 year old female bumps her head on the windshield in a relatively minor accident, but does not lose consciousness. The glass is broken, which should givem them some idea that there was a hard impact.

"I'm fine," she says.

She reluctantly goes to the hospital (after some convincing) with Mother Jugs and Speed, the local ambulance "attendants". She insists she is alright and they walk her to the "amalance" and sit her on the seat for the trip to the hospital. Why mess up the white sheet on the cot? She sits on the red-upholstered bench.

Speed does put a collar on her. But no backboard. I know this is incorrect procedure, but this is a true story.

They enter the emergency ward, which is busy and Nancy nurse, the triage God, decides she wants a look-see. Nancy says "wiggle your toes" and the young lady complies.

"Everythings fine," thinks Nancy. No apparent spinal compromise.

Off goes the cervical collar. BEFORE an x-ray. The young lady has on a sweatshirt and the nurse helps her remove the sweatshirt by having our patient raise her arms and pulls it up over her head.

The young lady screams.

She has transected her spinal cord.

She will never walk again.