C-Spine Clearance - A Real Pain in the Neck

C-spine Clearance—A Real Pain in the Neck.

AWLS Students assess a pediatric trauma patient in a field scenario.

AWLS Students assess a pediatric trauma patient in a field scenario.

I’ve seen quite a change in the use of spinal immobilization in my career.  When I began practice the universal application of a C-collar and long spine board to all trauma patients was the standard of practice.  Practitioners felt that was the safest intervention to protect the patient from devastating neurologic injury.  As medicine has evolved to more evidence-based practice we’ve learned that is universal spinal immobilization is not indicated in all patients and in certain cases may be causing harm.  

It is challenging to change what has been accepted as the standard of care for such a long time but hopefully we can provide some resources to help make your decisions rationale, reasonable, and clinically responsible.  

In my practice I prefer to use the Canadian C-Spine Rule.  This is an evidence based algorithm that will guide you through the steps necessary to clear a patient’s neck or to confirm that they need immobilization and imaging.  There are many online resources with both calculators and algorithm images.  A quick Google search led me to this image at:      https://canadiem.org/tiny-tip-canadian-c-spine-rule/

Photo credit to  https://canadiem.org/tiny-tip-canadian-c-spine-rule/

Photo credit to https://canadiem.org/tiny-tip-canadian-c-spine-rule/

As you can see it all starts with the mechanism and then progresses through a quick history and physical exam.  Then an assessment of whether or not you can clear their c-spine without imaging.  One caveat to this algorithm is the impaired patient.  I like to use “impaired” to cover a broad range of mental and/or physical factors that make the patient unreliable.  That may include physical issues like a traumatic brain injury, a major distracting injury, or mental status changes from hypothermia.  A very common impairment in trauma is having some drug or toxin onboard.  Substances like alcohol, marijuana, and methamphetamine can all render the Canadian C-Spine rule useless.  

So that’s all well and good if you have a 64 slice CT scanner down the hall to help evaluate the C-spine but what if you’re 10 miles into the backcountry?  What trekking in a 3rd world country and the nearest access to any imaging is days away?  Therein lies some of the challenges of wilderness medicine.  If your patient rules out by the criteria above you can feel very confident that they have an extremely low risk of a catastrophic C-spine injury.  If they don’t rule out then it is time to protect the C-spine.  

I’ve been focusing on the C-spine but what about the rest of the spine?  There are 17 more vertebrae in the thoracic and lumbar spine that have the potential to be damaged as well.  C-Spine injuries, arguably, have the risk for greatest morbidity and mortality so let’s approach that first.  If there is any question of injury then immobilize the C-spine.  How?  Well, what do you have with you or around you?  Ideally you have a commercially made, size adjustable, dedicated C-collar with you.  That may be an option if your medical kit has no limits on space, size, or weight.  Most of us don’t carry one in the backcountry but that’s OK.   SAM splints, backpack Lumbar support, and self-fashioned horse collars can all be used.  Courses such as AWLS teach these techniques.  Once the C-spine is immobilized it is time to work on an extrication plan to get them to a higher level of care for further evaluation and management.  

If the patient has additional spinal injury, which is common, further immobilization may be needed for transport and/or extrication.  In austere conditions patients may have to self extricate/evacuate and if they can that is allowable.  Research is showing that patients can self-immobilize very well when they’re awake, alert, and cooperative.  The same body of research has shown that patients that are immobilized on long spine boards can still have movement in multiple different planes.  In cases where they are unable to extricate or ambulate then protection of the thoracic and lumbar spine may also be necessary and that is when we must use a long spine board.  A key point with immobilization on any type of spine board is that it is for transport and/or extrication only.  Let’s say you have successfully extricated a skier from avalanche debris onto a long spine board, evacuated to a hut, but now it’s dark and a storm has rolled in for the night.  In a case such as this it is imperative that he patient be off of a rigid board as much as possible.  This is essential for patient comfort as well as prevention of skin breakdown and subsequent ulcer formation.  

Backboard immobilization for transport.

Backboard immobilization for transport.


Vertebral trauma is not unheard of in the wilderness where high risk injury from skiing, climbing, and horse wrecks can cause catastrophic injuries with significant morbidity and mortality.  The accurate and appropriate assessment and management of these injuries is imperative to improve patient outcomes.  If the management of spinal trauma is not part of your daily routine I think you would benefit from further education through an outdoor life support course.  Remember, when the time comes we don’t rise to the occasion, we fall back to our highest level of training.

Wilderness Medical 10 Essentials

The Wilderness Medical “10 Essentials”

 

Those of us who spend time outside have certainly heard of the 10 essentials of outdoor recreating.  The classic list is:

 

1.        Map

2.       Compass

3.       Sun protection

4.       Extra clothing

5.       Headlamp/flashlight

6.       First aid supplies

7.       Firestarter

8.       Matches

9.       Knife

10.   Extra Food

 

These are great; however I feel that “first aid supplies” are often overlooked and inadequate.  HMC has made a “Wilderness Medical 10 Essentials” to help you pack right for your next trip into the backcountry.

 

1:  Airway/Breathing

Take my word for it when I say managing an airway deep in the backcountry without proper equipment is “heady” at best.  Airway supplies are small and cheap.  Pack a Nasopharyngeal airway for your patients that need some airway support but still have a gag reflex.  I would also pack an Oropharyngeal airway for your truly obtunded patients without a gag reflex.    There are also “pocket BVM” devices that are small and effective for giving breaths, but a rescue mask would work as well.

 

2:  Hemostasis

Hemostatic agents like Quikclot or Celox are unmatched in the wilderness for big bleeds.  It is also vital to have a tourniquet; however, these can be improvised easily with a belt or ski strap.  Remember, all bleeding stops eventually, but you should probably stop it first.

 

3:  Allergy/Anaphylaxis

You never know when your body will decide to have a severe anaphylactic reaction.  If you spend significant time in the backcountry, you should carry an EpiPen, preferably two.  Additionally, have Benadryl, an H2 blocker (ranitidine), and some steroids. Don’t forget: a person who has had an anaphylactic reaction should be seen immediately in an ED to ensure a secondary reaction does not occur.

 

4:  Large Bore Needle

In trauma situations, tension pneumothoraces are not uncommon.  Large bore decompression needles are small, burly and easy to carry.  Decompressing a chest may be your only key to bringing back a traumatic arrest.  Personally, I carry 2 or 3 in case the chest needs to be decompressed multiple times, or bilaterally.

 

5:  Chest Seal

Open chest wounds are less common in the civilian setting, but certainly not unheard of (read: sharp branches jutting out into trail).  Chest seals are low profile and easy to slip into a medical kit.  Remember to bring 2 in case there is an entrance and exit wound.  These seals can also be improvised by making a 3-sided occlusive dressing, but these are likely to fail.

 

6:  Duct tape

Because, well, #ducttape.  Wrap it around a pencil or flask*.  Use tape for almost anything, but especially blister prevention.  Keep *whiskey on hand for when you take the tape off.

 

7:  Simple Sugars/Hydration

You are of no use if you are on a one-way-trip to bonktown.  Carry glucose, or better yet, one of the many commercially available caffeinated gels on the market.  Eat it yourself, or give to your diabetic friend who is hypoglycemic.

Also pack some iodine tabs, or something similar for when you need emergency hydration.

 

8:  Wound Care

At HMC we are not necessarily band-aid guys.  In my experience, big bulky dressings take up space and are the first things to get wrecked in a pack.  I like to carry steri-strips, glue, and a couple non-stick dressings.  I also carry one ABD pad for big bleeds.  A tampon may prove useful for epistaxis or a surprise period.

 

9:  Waterproof Kit

Your kit is no-good if it is soaking wet and covered in Nutella (or heaven-forbid a "fluffer-nutter").  Pack the aforementioned supplies into a waterproof kit that is small and durable.  In my experience, the bigger the kit is, the less likely you are to bring it along.  Continually change out expired or ruined gear.

 

10:  Your Dome

All the things mentioned here are useless if you don’t have the education to use them properly.  A well vetted wilderness medical course like Advanced Wilderness Life Support (AWLS) could very likely help you save your buddy’s bacon someday.  Spots are still available for our July 28-30 AWLS Course in Red Lodge, Montana.  Participate in realistic wilderness medicine scenarios and interactive lectures all while earning 20.5 hours on Category 1 CME in the beautiful Beartooth Mountains!   Sign up here.

The Human Factor

The Human Factor

 

“Everyone has a plan ‘til they get punched in the mouth.”

Mike Tyson

 

Spending time in the wilderness presents both daunting challenges and immeasurable rewards.  There can be a fine line between adventure and disaster and it is the human factor that helps influence the outcome.  In order to have long term success in austere conditions one must be brutally honest with oneself about their abilities—both physical and mental.  

I believe the most important factor in being successful, not only in the backcountry but also in life, is mental toughness.  Developing an indomitable spirit will allow you to overcome overwhelming challenges and continue on in the face of adversity.  Whether you call it grit, Sisu, or fortitude it all means the same thing—pushing past pain, suffering, and fear to achieve your goal or survive an accident.  This toughness must be trained over time just like muscle.  Pushing yourself further and harder through physical and mental exercises will develop a confidence that will allow you to succeed when you’re cold, tired, and scared.  When the going gets tough mental durability beats physical durability—every time.

 

“Bran thought about it. 'Can a man still be brave if he's afraid?'' That is the only time a man can be brave,' his father told him.”

George R.R. Martin

 

It is common practice for all of us to believe that we’ll be ready when “the time” comes.  The reality is that none of us know if and when that challenge will arise, what form it will take, and what resources we may or may not have at our disposal.  The best way to truly be ready is to have rehearsed that scenario, or a similar one, beforehand.  A dress rehearsal so to speak.  Reality based training is one of the most successful ways to accomplish this.  In the medical world we do this on a regular basis.  Life support courses like ACLS, PALS, and ATLS attempt to accomplish this goal through case based scenarios.  Advanced Wilderness Life Support is a wilderness based life support course that helps to prepare providers with a medical framework based on the austere environment.  In addition to building a strong foundation of medical training it is useful to use mental exercises to work through the “what ifs.”

“We don't rise to the level of our expectations, we fall to the level of our training.”

Archilochus

 

Physical training for the backcountry is not only a useful tool to develop  grit-- it also strengthens the body.  Many of our wilderness activities are physically intensive.  Backcountry recreation is not only dramatically more enjoyable, but also carries less risk when we have more endurance and power.  As discussed previously, we don’t know when we may have to unexpectedly climb higher, carry a partner, or bivy out in a snow cave.  If you’re just getting by on a razor’s edge of fitness any unexpected physical exertion may lead to exhaustion and failure.  

These human factors can, and should, be developed over time.  There is no final destination in this journey.  Development of an unbreakable mind, physical fitness, and a toolbox of medical skills for austere conditions will make your backcountry adventures more enjoyable.   Hellroaring Medical wants to help you be prepared for whatever comes next.  

 

“Character is not defined by the mistakes we make when taking chances.  It is defined by what we do when facing adversity, and when things don’t go as planned.”

SISU  - www.facebook.com/InspireSisu

Mt. Rainier Case Study

Hello and welcome to the first episode of HellCast, a Wilderness Medicine blog and case review.  We have been discussing the best way to organize our blog posts, and decided to start with an in-depth case review, followed by posts dissecting it.

 

To start, My name is Patrick Erley, I am an Emergency Medicine Physician Assistant, and one of the founders of Hellroaring Medical Consultants.  I have a background in Mountain Rescue and high-altitude mountain guiding.  Below, you will find a case review from a mountain rescue mission.  Some details may be changed for anonymity, however, the case will remain as close to actual events as possible.  Later, we will go refer back to this case, and discuss what was done well, and what could be improved upon.  

 

This case is from 2008 on Mt Rainier.  

 

Pre-Mission:

Early summer on Mt Rainier can be beautiful, but anyone who has spent time on the Mountain knows she can be fickle.  We were leading clients up the Muir Snowfield, a large permanent snowfield sweeping up to Camp Muir.  Weather was initially breezy, with a forecast for snow.  Around 9,000 ft, we entered into a cloud, with snow, graupel, and heavy wind.  We advanced past this point, and conditions continued to deteriorate.  Winds were steady at 40 knots, gusting to 70.  Due to the adverse weather conditions navigation was only possible by GPS.  Despite having experienced guides and proper navigational tools, our group struggled to make it to Camp Muir.  

 

After re-warming our clients and checking for cold weather injuries we received word that a party of three climbers that were past due.  They had started up that morning with a plan to visit Camp Muir then turned around in the inclement weather.  We knew that a rescue mission was impossible in the weather conditions, so we waited until the morning to conduct a search.  During the night, one of the missing male subjects was able to contact his wife and confirmed they were in dire straits.

 

Search:

The sun came up simultaneously as the clouds started to lift.  About 500 meters down the snowfield, we saw a figure staggering up toward us.  A couple guides and a park ranger went to check on the subject.  He (subject 1) was a middle-aged man, with ¼ inch of rime ice covering his face.  He was wearing a russian-style fur parka.  He said that his friends were down lower, and that he was late for work.  Altered, but able to ambulate, he was led up to the shelters and was re-warmed.  He insisted his friends were alive, but was perseverating and moderately hypothermic.

 

Expecting the worst, we followed his tracks to just below Anvil Rocks.  Two other subjects were quickly located.  A man (subject 3), on the snow surface, was pulseless, apneic, cyanotic, and rigid.  His wife (subject 2) was lying on top of him, off the snow, obtunded, combative and severely hypothermic.     

 

Recovery:

Attention was quickly directed to the female subject.  Further resources were called down to the scene.  She was placed on high-flow oxygen via non-rebreather and then placed in a hypothermia wrap.  We gently loaded her into a rescue sled, and evacuated up to Camp Muir which was approximately 1000 meters away.  A separate team loaded and evacuated the pulseless subject to the same location.  The evacuation was a relatively easy sled pull up a gently sloping snowfield, which is not crevassed.  All subjects were at Camp Muir in approximately  one hour.  

 

Medical Care:

 

Subject 1:  

This male subject was able to ambulate to Muir on his own.  After being undressed, he was rapidly rewarmed with warm bottles and sleeping bags.  His mentation slowly improved over the course of 60-90 minutes.  He had a waxy appearance to his nose, cheeks and the tips of his fingers and toes.  He experienced intense pain throughout the rewarming, and no narcotics were available for pain relief.  

Final Diagnoses:  Full thickness frostbite of fingers, toes and nose.  Moderate hypothermia

 

Subject 2:  

This was the female subject.  She began to rewarm during her evacuation to Muir and enroute began to scream in pain and complain of shortness of breath.  Again, no narcotic pain medications were available.  She was GCS 10 with relatively stable VS, considering her exposure, although I can’t remember exactly what they were.  No core temperature was able to be taken.  At Muir, she was rewarmed in the same fashion as subject 1.  Care was taken not to jostle her too much.  Her mentation slowly improved, and she became hysterical in light of the recent events.  She also had a waxy appearance to her fingers and toes.

Final Diagnoses:  Full thickness frostbite to fingers and toes.  Moderate to severe hypothermia.

 

Subject 3:

This patient was pulled from a make-shift “snow cave” that the trio had hastily built.  Unfortunately, it was more like a drifted in hole than a shelter.  As previously described, he was unresponsive, pulseless and apneic at discovery.  He was evacuated to Camp Muir and no CPR was done en route.  At Muir, he was undressed, and about 20 water bottles were filled with warm water and placed around his body.  His temperature was raised to approximately 80 degrees fahrenheit, and despite continued efforts we were unable to raise it any higher.  He remained unresponsive and pulseless throughout these efforts.  The rewarming efforts were continued for 2 hours.  After exhausting all available resources further resuscitation was deemed futile and he was pronounced dead.

 

Evacuation off the Mountain:

 

The weather did not clear that day.  The next day, a CH-47 Chinook from an Air Force base launched to our location.  The patients were packaged, with care taken so as not to refreeze their injuries.  Subjects one and two were hoisted, with the ship hovering about 60 ft above.  They were ultimately transported to Harborview Medical Center for definitive care.

 

Subject 3 was evacuated by a private airship the next day.  This smaller rotor wing was able to land at an LZ right at Muir.  The deceased subject was loaded and transferred to the coroner.

______________________________________

 

With limited resources, do you feel that a severely hypothermic patient should be rewarmed before they are declared deceased?

 

Have you had any experience with frostbite?  How do you prefer to manage these patients?

 

Stay tuned for the next HellCast episode in two weeks, where we will discuss the “Human Factor.”