Question: I am a recent grad from the PCP program and a new hire at my service. I have a question regarding packaging. We were called code 4 for a patient who had a fall. A call from a wrist alarm company.

Patient was found on floor by superintendent in the patient's building after connect care instructed the super. Upon arrival patient was found still sitting on the floor. The carpet behind the patient had a small pool approx. 200mls. Patient cannot remember event but is LOA x 3, good long term memory. Patient does not know how long she has been on the ground.

Physical assessments - Trauma noted on back of head. Lac (bleeding stopped) + Hematoma approx. 1 inch diameter noted on occipital area. Chest is clear, abdomen soft and non tender, pelvis stable, no trauma otherwise noted.

Equal grip strengths. Pupils PERL. Vitals are all within normal limits. Patient upon assessment has no complaints. No dizziness, no lightheaded. NO c-spine, tenderness, no back pain.

It looked as though the patient fell from height, backwards, struck head on dresser and activated wrist alarm. I decided to package the patient as a precaution. I padded the backboard with a towel before laying patient head on the board.

My question is was it necessary to apply collar and backboard this patient? Patient had no c-spine tenderness, no back pain, LOA x 3, good long term memory only issue is patient cannot remember the fall. Patient had no complaint, except the pain from the hematoma against the board.

 Great question! The issue of when to immobilize a patient using a C-Spine collar and board is a hot topic in EMS currently. Remember, the decision to immobilize a patient is not a delegated act and, as such, it is not a task that Base Hospital Programs are asked to provide oversight or direction. Paramedics are instructed to follow the Basic Life Support Patient Care Standards (BLS-PCS) for this decision which states:

A paramedic will "€¦completely immobilize the neck, spine, pelvis, legs and head when spinal cord injury is obvious, suspect, or cannot be ruled out."

That would be our bottom line answer.

That being said, there are many sources for guidance as to when to consider spinal immobilization. The 2010 American Heart Association Guidelines in Part 17 (Markenson et al Part 17: First Aid S938) state that:

Cervical spine injury should be suspected in traumatic injury if the victim:

• Is ‰¥65 years of age
• Is involved as driver, passenger, or pedestrian in a motor vehicle, motorized cycle, or bicycle crash
• Falls from a greater than standing height
• Has tingling in the extremities
• Complains of pain or tenderness in the neck or back
• Has sensory deficit or muscle weakness involving the torso or upper extremities
• Is not fully alert or is intoxicated
• Has other painful injuries, especially of the head and neck
• Is a child ‰¥2 years of age, has a GCS score < 14, or has a GCS Eye Opening score of 1

A link to these Guidelines can be found here: http://circ.ahajournals.org/content/122/18_suppl_3/S934.full.pdf+html

Finally, based upon research from Ontario EMS systems and emergency departments, the following approach has been utilized with success and is currently in the final phases of validation.

So, while there are many approaches as to when to immobilize a patient, we would suggest that paramedics should completely immobilize the neck, spine, pelvis, legs and head when spinal cord injury is obvious, suspect, or cannot be ruled out as per the BLS Standards.

In the case you have presented above, the fall from height, the head injury, and the amnesia for the event are causes for concern and would prompt spinal immobilization by many as spinal injury cannot be ruled out. Remember, spinal cord injury is thankfully rare. A pit fall however is to not adopt conservative practices regarding immobilization in high risk situations based upon the fact that previous patients wound up not having an injury€¦it is only a matter of time that a patient will have a fracture and the results of an unrecognized spinal injury can have catastrophic results.

BLS,Miscellaneous

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