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Wilderness Medical Society - snowmass 2005 (Page 190)

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Wilderness Medical Society - snowmass 2005
Chapter 5
Recommendations are considered Category 1B, except where indicated 1A, by the WMS
Panel of Expert Reviewers.

In an urban environment, many patients placed in full spinal immobilization will prove to
be free of unstable spine injuries. The inconvenience to patients and rescuers is worth the
extra effort to protect the few with unstable spine injuries. In wilderness situations, spinal
immobilization is difficult and can drastically alter the logistics of an evacuation.
Immobilize all patients with signs or symptoms as indicated in the assessment section
below. Patients with no signs or symptoms need not be immobilized despite significant
mechanisms of injury, unless they have an altered level of responsiveness.

In the wilderness a number of steps are involved in ruling out a spinal injury in a patient
with a significant mechanism of injury. Treatment consists of full immobilization on a
backboard or in a rigid litter, or immobilization on the most level ground available with a
cervical collar until a rigid litter can be improvised or brought in. In the case of a patient
with potential spinal injury whose ventilation is inadequate, the jaw thrust (rather than the
head-tilt, chi lift) is the maneuver of choice to provide rescue breathing.
Before deciding to clear the spine, finish a full secondary assessment first 1) to
gain assurance the patient has no obvious signs and symptoms of spine injury and 2) to
assess the patient for distracting injuries. Distracting injuries are any conditions that
cause pain or which might affect the patient's mental alertness. Conditions such as
significant blood loss, alcohol use, fractures, or disturbed psychological status are a few
examples. It is recommended that the rescuer perform a second and specific assessment
relative to the spine before making the decision to clear the spine. The cervical spine can
be clinically cleared if ALL of the following are met and documented (Category 1A)
(Reference: Hoffman JR, Schriger DL, Mower W, et al. Low-risk criteria for cervical-
spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992;21:1454­
The patient must be fully awake and alert, with no alcohol or medications that
might alter his level of consciousness.
The patient has no distracting injuries
The patient has a completely normal motor and sensory neurological examination.
There is no pain or tenderness to palpation of the posterior cervical are, no
palpable step-off deformity, and no other areas of pain to palpation over the
thoracic or lumbar vertebra.

Spinal clearance is a continuous process. Re-evaluation will be required and the
patient immobilized with cervical or full spinal splinting if any of the signs, symptoms, or
conditions listed in 1 to 5 develop during the evacuation.

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