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Spinal Immobilization: What Is The Best Tool?

Issue 9 and Volume 11.

Ambu makes a device for immobilizing the head that is adjustable.
Ambu makes a device for immobilizing the head that is adjustable. Pulling on the white handle draws the sides of the splint towards the patient’s head. Straps are provided for securing the head to the board.
Prepared towel rolls are easy to use and can provide padding to the back and sides of the head.
Prepared towel rolls are easy to use and can provide padding to the back and sides of the head. Usually returned to the laundry at the hospital and exchanged for replacements, they are economical and accommodating to a variety of sizes of patients.

When teaching spinal immobilization I’m often asked, “What’s the best tool”? The short answer is the one you have and know how to use.

The longer answer is that there are a number of devices specifically designed to assist in cervical spine immobilization. Some, as with cervical collars, must be used on all patients unless the specific condition doesn’t allow for it to be placed. Others, like head blocks, are useful but they can be replaced by using readily available materials when they aren’t available or don’t fit.

This month, I’ll discuss what’s available for use in cervical spine immobilization – old and new techniques, devices, and how they can be used effectively.

Different Collars

The types of cervical collars used are often not a matter of choice. The EMS system, or the hospital exchange supply, determines the brand used. The collars are available in a variety of styles and sizes. As for style or type of collar, the major differences are whether they are one or two pieces or adjustable.

Two-piece collars have to be applied in proper sequence and adjustable collars should be sized and adjusted before application.

The most important principle in cervical collar application is selecting the proper size. A collar that is too small for the patient can compress the large blood vessels and the trachea in the neck, impairing circulation and breathing.

If the collar is too large, it won’t provide the stabilization needed. Manufacturers provide instructions with their collars to assist in selecting the proper size. Even with the variety of sizes, some patients won’t fit into the available collars because of their anatomy or the position they need to be placed in to protect the spinal injury or to keep the airway open. These patients will need to be adequately manually immobilized or immobilized with padding and/or splints.

To say that cervical collars provide immobilization is a misnomer. While the collar can assist in stabilizing the cervical spine, it limits motion but does not prevent it entirely.

The only way to ensure cervical spine immobilization is to manually immobilize the head and neck until the patient is completely secured to the spine board. As mentioned earlier, some patients, due to the nature of their injury or the condition of their airway, will require manual protection of the cervical spine throughout transport if adequate splinting cannot be applied on the spine board.

Securing Patients’ Heads

Over the years, a variety of methods and devices have been developed and adapted for securing the head and spine to backboards. From simple placement of towels and blankets to ratcheting plates that can be adjusted to fit the patient.

Certainly one of the oldest methods, using blankets and towels, is still favored by many providers for a variety of reasons. First, it’s cost effective. Blankets and towels are often replaced and laundered by the hospital and return to service after use.

Blankets and towels can be rolled and folded to fill the gaps between the patient and the board to fit any configuration. Many providers store blankets in their vehicles in pre-assembled blanket rolls that fill the void between the back of the patient’s head and the board and roll up to the sides of the head to secure it. It’s also easy to apply additional blankets or towels if necessary.

Another inexpensive method is to use paper towel rolls. Large paper towel rolls – the soft absorbent type used to wipe up kitchen spills – can be placed on either side of the patient’s head to secure it. They can be disposed of once they are removed from the patient. It’s important to note that a towel may have to be used under the patient’s head to prevent neck hyperextension.

Commercially available head blocks usually consist of a device that is strapped to the board, providing padding to the back of the head and Velcro on either side of the head to attach pads to secure.

Straps then are placed to secure the head between the blocks and the board. The blocks are usually plastic or vinyl covered so that they can be cleaned for re-use.

Disposable Devices

There are also cardboard and plastic devices that can be used. These are disposable devices and generally resemble a cradle that the head fits into. Straps secure the head in place. Ambu makes a version that is drawn to the patient’s head by pulling on a handle. Others are cardboard cradles that can be adjusted to fit the patient.

The standard is that whenever possible, the head and neck are placed in a neutral, inline position. In doing so, accommodation will have to be made for the unique anatomy of the patient.

The shoulder size or head shape will dictate the amount and placement of padding. Most people, if lying on their backs, will hyper extend their necks. Try this as a test. Stand with your back to the wall. If you rest your head against the wall you will probably hyper extend your neck. Most of us do. In order to secure in a neutral inline position then, the back of the head will have to be padded. Children, on the other hand, may need padding at the shoulders to maintain inline positioning.

There are a variety of straps available for spinal immobilization. The principle is that they must be used in a way to secure the patient to the board and be strong enough to support their weight as the patient is moved.

Straps should be applied in sequence beginning with securing the trunk, the legs and lastly, the head. This ensures that the patient’s head and neck are secured manually until the patient is completely secured to the board.

Much has been made about how uncomfortable it is for patients immobilized to a backboard and that patients can even sustain injury, like pressure sores, from spending any significant time on the board. This can be more of a hazard in elderly patients, particularly if they have kyphoses or pronounced curving of the spine. This can be mitigated by making sure that padding, like blankets, towels or pads, is used to fill all of the voids between the patient and the board.

Once secured to the board, the patient will rely on constant monitoring his condition. If the airway becomes occluded or if the patient begins to vomit, there will be a need to turn the board and or suction the airway to prevent aspiration. Once bound, these patients will be unable to protect their own airway adequately, so monitoring is important.

Whatever used, either by preference or by necessity, remember it’s the principles of immobilization that are important rather than the devices.

Inline positioning, padding voids, secure strapping and a properly sized collar are the principles. Any device or method should be used as an application of those principles. Use what is comfortable and adhere to the principles.

On a personal note, I am a proud father as my son, Alex, joins my brother Joe and I as a firefighter paramedic on Chicago Heights Fire Department. Welcome son.

That’s it for this month. Remember, if there is anything you’d like me to look into and write about in future columns, drop me a note in care of the magazine at [email protected] and I’ll look into it for you.

Till next time then, stay safe.

Editor’s Note: Will Chapleau, who has 30 years of EMS experience, is chief of the Chicago Heights (Ill.) Fire Department. He has served as the chairperson for the Prehospital Trauma Life Support (PHTLS) program since 1996 and has been a member of its international faculty since 1984 and is a board member of the National Association of EMS Educators.

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