Managment of Suspected Spinal Injury In TCCC

A large discrepancy between civilian and military medicine exists with respect to the importance placed upon spinal injury management. In the past, most combat injuries have been secondary to penetrating trauma. Therefore, during the initial phases of treatment, moving the casualty to cover would be the only concern, without taking the time to immobilize c-spine as a civilian medic would. However, new injury patterns are emerging. As Dr. Keith Gates noted in the Spring 2010 issue of The Journal of Special Operations Medicine (JSOM), blunt trauma is emerging more often as an mechanism of injury secondary to the increase in number of IED attacks. According unpublished data, 39% of casualties had mechanism of injuries secondary to blunt trauma. Additionally, according to JSOM, between June and December 2009, of the 119 casualties with blunt force trauma spinal fractures, 14 had spinal cord injuries. Thus, an increasing number of casualties are presenting with thoracic and cervical injuries on the modern battlefield.

This trend has not gone unnoticed. A working group was commissioned to address this issue, out of which a new technique for spinal protection emerged, called Spinal Motion Restriction (SMR). Essentially, the rescuer would use the casualty’s IBA to protect the thoracic spine, while taking care to not unnecessarily manipulating the c-spine during movement. The suggested changes to the TCCC protocol are as follows:

Care Under Fire:
3. Direct casualty to move to cover and apply self-aid if able. If casualty requires assistance, move him to cover. If mechanism of injury included blunt trauma (such as riding in a vehicle which was struck by and Improvised Explosive Device), minimize spinal movement while extracting him from the vehicle and moving him to cover. The casualty should be moved along his long spinal axis if at all possible while attempting to stabilize the head and neck.

Tactical Field Care and TACEVAC Care Insert new #2:
Use Spinal Motion Restriction techniques as defined below for casualties whose mechanism of injury included blunt trauma IF: a) they are unconscious; b) they are conscious and have mid-line cervical spine tenderness or mid-line back pain; or c) they are conscious but demonstrate neurological injury such as inability to move their arms and/or legs, sensory deficits, or parenthesis. For these casualties, leave the IBA in place and secure to protect the thoracic spine. The cervical spine may be protected by using a cervical stabilization device in conjunction with the casualty’s IBA or by an additional first responder holding the casualty’s head to maintain alignment with the back. Long or short spine boards should be used in addition to these measures when available (JSOM, Spring 10, pg. 60).

Unfortunately, initial findings from a pilot study conducted at USAISR found that if one keeps the IBA in place, in a supine position, without the helmet, the c-spine is put in extension. More problems surfaced during later discussions: 1) pouches commonly worn on the IBA could further injuries in the supine position; 2) IBAs obstruct evaluation and treatment, thus they are often removed; 3) SMR may not be protective.

In the end, more research needs to be done in light of the recent trends in wounds. As more soldiers and LEO officers are exposed to blunt trauma, medics need to be conscious of the potentiality injuries secondary to it. While Spinal Motion Restriction is unsatisfactory, it continues the conversation regarding treatment.

What are your thoughts and experiences?

2 replies
  1. starlight_cdn
    starlight_cdn says:

    Not sure about a cas being in a non-permissive environment, being evaced, with bits o’ metal flying around in the air at high velocities without a helmet!!!

    Tactical situation must be the overriding factor in a Spinal Motion Restriction tmt. During CUF or if your TFC Bubble gets popped (that never happens), SMR will take a backseat, to react to en contact or protections of the casualties life over limbs.

    MoI will, also, be a deciding factor. Ottawa C-Spine Rule as an example, do not include blast injury. It does take into account age, civilian MoI and is a proven protocol to clear C-Spine in the feild. http://www.ohri.ca/emerg/cdr/docs/cdr_cspine_card.pdf

    At work, we have been instructed to include Spinal Motion Restriction, within our TCCC instruction mandate. The scenarios have be set up so they promote the tactical decision (black and white) as that will support the needs of the mission and casualties (needs of the many).

    It does warrant further research. IEDs will be a threat as long as the GWOT continues.

    Reply
  2. tems_wildmed
    tems_wildmed says:

    Goals of all patient care, whether it be tactical, rescue, or civilian EMS-oriented is about taking care of the whole patient, not just the spine. The presumed benefit of routine spine immobilization has to always be weighed against the situational risk; in civilian EMS that risk is generally assumed to be low. In technical rescue, a wilderness setting, or tactical medicine the risk to the whole patient and rescuers can be significantly higher; good judgement should always be used. It’s comforting to know that significant spine injuries are exceedingly rare, and occur mainly from high-speed motor vehicle accidents; additionally, there is no published research that indicates that routine spine immobilization significantly reduces the risk of significant spine injury (however, there is a published study showing that penetrating trauma victims who are immobilized at the scene have a higher mortality rate). In high-risk environments, partial spine stabilization or even having the patient walk/run to safety might be indicated until the risk can be managed, and then SMR applied as appropriate.

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