Dr. Adrian Cohen MB., BS (Hons.) UNSW

Director, Immediate Assistants Pty. Ltd

December 1997

INTRODUCTION

Spinal Cord Injury (SCI) is a devastating condition further complicated by a multiplicity of physical and emotional factors.

The general public often "do not want to know about it" on the basis that SCI carries unpalatable imagery and much stigma. Medical and Paramedical personnel have all too infrequent contact with the spinally injured in either the acute, hospitalised, convalescent or rehabilitation phases of the injury.

In Australia each year, there are over 300 SCI’s which are variously classified as Complete or Incomplete depending on the severity of the spinal damage and the degree of sensory or motor functional loss at and below the injury.

The breakdown in terms of causation of traumatic SCI is as follows:

It is the acute management of spinal injuries in the aquatic environment that forms the basis for this paper, and a new technique for these situations has been developed.

The NeckSafe Aquatic Spinal Management Technique is based on a supine "eyes upward" approach and utilises additional spinal stabilisation equipment such as semi-rigid collars, floating rescue stretchers and spinal boards.

It has the advantages of being easy to learn and apply, provides optimum stabilisation of the potential SCI, allows airway maintenance at all times and the patient’s face to be constantly observed.

Over the past 10 years, considerable advances have been made both in prevention and treatment of SCI, with recent research highlighting the potential for a "cure" for both Acute and Chronic SCI^,,,,

This research is very encouraging, and offers great hope for those already injured.

Whilst we continue the search for a cure, preventative strategies are of the utmost importance.

Prevention can be classified as either Primary or Secondary.

Primary Prevention is aimed at preventing the injuries occurring in the first instance, and some impressive steps have been made in Australia in recent years.

These include:

These initiatives should be continued, encouraged and expanded.

Secondary Prevention recognises that even with a high level of Primary Prevention, SCI’s will still occur and deals with the mitigation of further damage after the initial insult.

In a study in Victoria in 1988, Dr. Joe Toscano found that almost 25% of all admissions to a major State Spinal Unit over 18 months suffered an increase in the severity of their SCI after the initial collision, fall or incident and prior to arrival at a Spinal Unit.

These findings alarmed many, particularly those in the paramedical and ambulance fraternities, and spurred the author to publish a booklet specifically designed to address Secondary Prevention.

The "Acute Management of Spinal Injuries" was designed for first responders, be they Basic Life Support (BLS: General Duties Ambulance, Red Cross, Surf Lifesavers, State Emergency Services, St. Johns Ambulance, Sports Trainers and Coaches etc) or trained in Advanced Life Support (ALS: Physicians, Paramedics, Nurses etc).

A video tape called "NeckSafe" was made with the assistance of the NSW Rugby League and disseminated to all major sporting codes in Australia via the National Coaching Council. Based on the NeckSafe Lecture Programme initiated by the author, the video was designed to spread the Primary and Secondary Prevention messages.

Another major step forward came with the widespread adoption of the semi-rigid cervical collar by both BLS and ALS agencies. Collars such as the "Stifneck" were widely in use by the mid-1990’s and associated training programmes, such as NeckSafe, were becoming more common.

During the 1980’s, a new series of principles were adopted by the country’s premier surf rescue organisation, the Surf Life Saving Association of Australia (SLSA).

The new practice utilised a 5-person lift from the water in the prone ("eyes down") position in order to ensure the airway (often compromised by both spinal injury and near-drowning) remained clear.

Whilst an important step forward, the technique is somewhat cumbersome to apply, does not provide optimum spinal stabilisation and does not allow for continuous observation of the patient’s face.

The priorities of resuscitation have always been "ABC": Airway, Breathing and Circulation, and wherever possible these should be supplemented by the words "with adequate cervical spine control".

SCI in the aquatic environment is often associated with beaches in Australia, the most common scenarios being that of the individual being propelled head-first into the sand in shallow water by the force of a wave ("dumped" by the wave), or a mistimed or misjudged head-first plunge into shallow water, a sand-bank or submerged rock, with attendant flexion and rotation of the cervical spine.

Once injured in this fashion, the patient may remain at the shore-line or be swept back out to sea beyond standing depth for rescue personnel.

Aquatic SCI’s also occur in still water, in pools, rivers and dams with the sufferer diving head-first into water of untested or underestimated depth.

Whilst working on a new International Surf Sports circuit, "Oceanman", the author developed a new technique for the acute management of spinal injuries in the aquatic environment, the NeckSafe Aquatic Spinal Management Technique. The NeckSafe technique is based on a supine "eyes upward" approach and utilising additional spinal stabilisation equipment such as semi-rigid collars, floating rescue stretchers and spinal boards.

This technique can be applied to both the surf and still water scenarios mentioned above, and in the former case is appropriate for the patient at the shore-line or in deeper water.

It is also appropriate for both conscious and unconscious patients, and makes provision for the airway to be maintained at all times with safety and the patient’s face to be continuously observed.

Anticipation of an aquatic spinal injury is usually the result of direct observation of the incident or an observed patient in environmental conditions and circumstances which alert to the possibility of such an injury (big waves, children running around a swimming pool etc)

Assessment should occur in the water: the first rescuer must enter the water and talk to the patient, providing initial reassurance and eliciting both the history of the injury and the current physical status. An exact neurological diagnosis is not required, simply identifying the possibility of spinal damage is sufficient.

In both the conscious and unconscious patient, the NeckSafe Aquatic Spinal Management Technique should be utilised if spinal injury is suspected.

In the case of an unconscious patient, it is also necessary to rule out the possibility of a related (or causal) spinal injury based on the associated water/sea conditions and any corroborating evidence.

The first rescuer (having already entered the water) is responsible for immobilising the neck of the patient in the neutral position using Manual Inline Support (MIS).

By positioning him/herself at the patient’s head, a "modified Full Nelson" wresting hold is applied, by placing both arms simultaneously under the armpits of the patient from below, extending them backwards and alongside the neck on each side with the fingers pointing towards the top of the patient’s head.

If the patient is face down when found, then an assessment of the breathing and circulation should be made. If CPR is not immediately required, the hold is applied from above and the patient can then be rolled onto his/her back with the head, neck and torso remaining in alignment.

The rescuer should now have control of the patient’s neck, and should be able to maintain it in the neutral position and provide MIS.

The patient should now be manoevred so that his/her head is seawards to minimise the effects of further waves.

A second rescuer enters the water and now sizes and positions the semi-rigid collar according to the manufacturer’s instructions.

Once this is accomplished, the first rescuer removes his/her arms and repositions them alongside the patient’s neck with the fingers pointing towards the patients feet.

In the absence of additional rescuers, the second rescuer can then position the appropriate spinal splinting device (additional rescuers can both stabilise the patient and simplify this task).

Either a floating full-length spine board or a Stokes Litter with floatation collar can be utilised, the principles being the presence of adequate floatation and the ability to secure the collared patient securely to the device.

The board or stretcher is submerged by the second rescuer and positioned below the patient.

A standard fiberglass surf rescue board is not suitable for this task, as it has too much flotation to be sunk below the patient and lacks straps for securing the patient to it.

All straps are then tightened, with the exception of any cutting across the head or neck or the semi-rigid collar itself.

The Patient-Collar-Stretcher unit is now secure, and can be carried from the water by a minimum of four (4) personnel if at the shore-line or loaded into a rescue boat (inflatable "Zodiac" type or rigid hull) or onto a Rescue Surf Mat attached to the back of a Surf Rescue Jet Bike.

When loading into a rescue boat, the stretcher is passed "head first" to ensure the patient’s face remains clear of the water.

If at any stage the patient’s airway becomes compromised, usually in this situation by the tongue falling backward into the pharynx or by vomiting, the entire Patient-Collar-Stretcher unit can be turned towards the side for the airway to be cleared, and the patient returned to the supine position.

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Cohen, A 1990
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  CIG Press Sydney June 1990

NeckSafe, A Focus on Safety 1990
  NSW Rugby League
  Video footage from the NeckSafe Sydney Football Stadium lecture series

NeckSafe Spinal Injury Programme 1990-present
  Copyright Immediate Assistants Pty Ltd, 1990

Trademark Laerdal Pty Ltd

Laerdal Pty Ltd. Model "HDx" or "Stabilizer" Spine Boards

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