Can-SCIP Coach App
  1. Can-SCIP
  2. Recommendations
  3. Guidelines
  4. Section 1 - COMPONENTS OF IDEAL SCI CARE SYSTEM

A - PREHOSPITAL AND EMERGENCY




A.1.1
When there is an immediate threat to an individual’s life and rapid extrication is needed, make all efforts to limit spinal movement while not delaying treatment. (Adapted from NICE 2016, p.8; Level B)
A.1.2
Expeditious and careful transport of patients with acute SCI is recommended from the site of injury by the most appropriate mode of transportation available to the nearest capable definitive care medical facility. Whenever possible, transport to a specialized acute SCI treatment centre is recommended. (CNS-TRANSPORT 2013, p.35; Level C)
A.1.3
First emergency responders on scene should explain to an individual who is planning to self-extricate that if they develop spinal pain, numbness, tingling or weakness, they should stop moving and wait for assistance. (Adapted from NICE 2016, p.9; Level B)
A.1.4
When an individual has self-extricated, support the individual to lay in a recovery position at a safe area from the vehicle or incident. (Adapted from NICE 2016, p.9; Level B)
A.1.5

When an individual is self-extricated, they should be assessed for:

  1. catastrophic hemorrhage
  2. airway with in-line spinal immobilization (for guidance on airway management, refer to the NICE guideline on major trauma)
  3. breathing
  4. circulation
  5. disability (neurological)
  6. exposure and environment
(Adapted from NICE 2016, p.9; Level B)
A.1.6
Do not transport individuals with suspected SCI on a rigid spine board/“longboard.” Laying on such rigid boards for long periods of transport can cause pressure injury, particularly in individuals with a SCI who do not have protective sensation. (Adapted from NICE 2016, p.9; Level B)
A.1.7
Time spent at the scene should be limited to lifesaving interventions only. (Adapted from NICE 2016, p.10; Level B)
A.1.8
The optimal first destination for a patient with a SCI is a major trauma centre with specialized SCI care. Hence, emergency transport personnel who have a patient with a suspected SCI should go directly to such a facility if possible. However, if the patient needs an immediate lifesaving intervention, such as rapid sequence induction of anesthesia and intubation that cannot be delivered by the prehospital teams, the emergency transport personnel should take the patient to the nearest hospital emergency room where such interventions are possible. (Adapted from NICE 2016, p.10; Level B)
A.1.9
Emergency transport personnel should go directly to the nearest trauma unit if a patient has: a suspected acute traumatic SCI (with or without spinal column injury), full in-line spinal immobilization, and needs an immediate lifesaving intervention (such as rapid sequence induction of anesthesia and intubation) that cannot be delivered by the prehospital teams. (NICE 2016, p.10; Level B)


A.2.1

On arrival at the scene of the incident, use a prioritizing sequence to assess individuals with suspected trauma, for example ABCDE:

  1. catastrophic hemorrhage
  2. airway with in-line spinal immobilization (for guidance on airway management, refer to the NICE guideline on major trauma)
  3. breathing
  4. circulation
  5. disability (neurological)
  6. exposure and environment

At all stages of the assessment:

  1. protect the individual's cervical spine with manual in-line spinal immobilization, particularly during any airway intervention and
  2. avoid moving the remainder of the spine.

(NICE 2016, p.8; Level C)

A.2.2

Assess the individual for spinal injury, initially taking into account the factors listed below. Check if the individual:

  1. has any significant distracting injuries
  2. is under the influence of drugs or alcohol
  3. is confused or uncooperative
  4. has a reduced level of consciousness
  5. has any spinal pain
  6. has any hand or foot weakness (motor assessment)
  7. has altered or absent sensation in the hands or feet (sensory assessment)
  8. has priapism (unconscious or exposed male)
  9. has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.
(Adapted from NICE 2016, p.5; Level C)


A.3.1

Assess the individual with suspected thoracic or lumbosacral spine injury using these factors:

  1. age 65 years or older and reported pain in the thoracic or lumbosacral spine
  2. dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
  3. pre-existing spinal pathology (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis), or known or at risk of osteoporosis – for example, steroid use
  4. suspected spinal fracture in another region of the spine
  5. abnormal neurological symptoms (paraesthesia or weakness or numbness)
  6. on examination:
    1. abnormal neurological signs (motor or sensory deficit)
    2. new deformity or bony midline tenderness (on palpation)
    3. bony midline tenderness (on percussion)
    4. midline or spinal pain (on coughing)
  7. on mobilization (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs)
(Adapted from NICE 2016, p.6; Level C)


A.4.1

Emergency personnel or first responders should carry out or maintain full in-line spinal immobilization if:

  1. a high-risk factor for cervical spine injury is identified and indicated by the Canadian C spine rule, or,
  2. a low-risk factor for cervical spine injury is identified and indicated by the Canadian C spine rule, and the individual is unable to actively rotate their neck 45 degrees left and right, or,
  3. indicated by one or more of the factors:
    1. age 65 years or older and reported pain in the thoracic or lumbosacral spine
    2. dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
    3. pre-existing spinal pathology (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis), or known or at risk of osteoporosis – for example, steroid use
    4. suspected spinal fracture in another region of the spine
    5. abnormal neurological symptoms (paraesthesia or weakness or numbness)
    6. on examination:
      1. abnormal neurological signs (motor or sensory deficit)
      2. new deformity or bony midline tenderness (on palpation)
      3. bony midline tenderness (on percussion)
      4. midline or spinal pain (on coughing)
    7. on mobilization (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs)
(Adapted from NICE 2016, p.7; Level C)
A.4.2

Do not carry out or maintain full in-line spinal immobilization if:

  1. they have low-risk factors for cervical spine injury as identified and indicated by the Canadian C spine rule
  2. they do not have any of the following factors:
    1. age 65 years or older and reported pain in the thoracic or lumbosacral spine
    2. dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
    3. pre-existing spinal pathology (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis), or known or at risk of osteoporosis – for example, steroid use
    4. suspected spinal fracture in another region of the spine
    5. abnormal neurological symptoms (paraesthesia or weakness or numbness)
    6. on examination:
      1. abnormal neurological signs (motor or sensory deficit)
      2. new deformity or bony midline tenderness (on palpation)
      3. bony midline tenderness (on percussion)
      4. midline or spinal pain (on coughing)
    7. on mobilization (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs)
(Adapted from NICE 2016, p.7; Level C)


A.5.1

When immobilizing the spine, tailor the approach to the individual's specific circumstances. Specific attention should be paid to patients in whom there is an obvious pre-injury deformity of the spine (e.g., in patients with ankylosing spondylitis) where comfortable positioning in the patient’s pre-injury alignment should be a priority.

The use of spinal immobilization devices may be difficult (for example, in individuals with short or wide necks or individuals with a pre-existing deformity) and could be counterproductive (for example, increasing pain, worsening neurological signs and symptoms). In uncooperative, agitated, or distressed individuals, think about letting them find a position where they are comfortable with manual in-line spinal immobilization. (Adapted from NICE 2016, p.8; Level B)

A.5.2

When carrying out full in-line spinal immobilization in adults, manually stabilize the head with the spine in-line using the following stepwise approach:

  1. fit an appropriately sized semi-rigid collar unless contraindicated by:
    1. a compromised airway
    2. known spinal deformities, such as ankylosing spondylitis (in these cases, keep the spine in the individual's current position).
  2. reassess the airway after applying the collar
  3. place and secure the individual on a scoop stretcher
  4. secure the individual with head blocks and tape, ideally in a vacuum mattress.

(NICE 2016, p.8; Level C)



A.6.1
We recommend that first responsders be aware of who to contact at the trauma center. The trauma team leader should be identified prior to the handover, and the trauma team should be ready to receive the information. (Adapted from NICE 2016, p.19; Level C)
A.6.2
The prehospital documentation, including the recorded pre-alert information, should be available to the trauma team and immediately placed in the patient's hospital notes. (Adapted from NICE 2016, p.19; Level C)


A.7.1

On arrival at the emergency department, use a prioritizing sequence protocol for assessing individuals with suspected trauma:

  1. catastrophic hemorrhage
  2. airway with in-line spinal immobilization (for guidance on airway management, refer to the NICE guideline on major trauma)
  3. breathing
  4. circulation
  5. disability (neurological)
  6. exposure and environment

At all stages of the assessment:

  1. protect the individual's cervical spine with manual in-line spinal immobilization, particularly during any airway intervention, and
  2. avoid moving the remainder of the spine.

(NICE 2016, p.11; Level B)

A.7.2
We recommend protecting the individual's cervical spine with manual in-line spinal immobilization, particularly during any airway intervention and avoid moving the remainder of the spine or maintain full in-line spinal immobilization. (Adapted from NICE 2016, p.11; Level B)
A.7.3

Emergency personnel and Emergency physicians should assess the individual for spinal injury if the individual:

  1. has any significant distracting injuries
  2. is under the influence of drugs or alcohol
  3. is confused or uncooperative
  4. has a reduced level of consciousness
  5. has any spinal pain
  6. has any hand or foot weakness (motor assessment)
  7. has altered or absent sensation in the hands or feet (sensory assessment)
  8. has priapism (unconscious or exposed male)
  9. has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.
(Adapted from NICE 2016, p.11; Level B)
A.7.4

Carry out or maintain full in-line spinal immobilization in the emergency department if any of the factors below are present or if the assessment cannot be done:

  1. significant distracting injuries
  2. under the influence of drugs or alcohol
  3. confused or uncooperative
  4. has a reduced level of consciousness
  5. has any spinal pain
  6. has any hand or foot weakness (motor assessment)
  7. has altered or absent sensation in the hands or feet (sensory assessment)
  8. has priapism (unconscious or exposed male)
  9. has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.
(Adapted from NICE 2016, p.11; Level B)
A.7.5

Suspected cervical spine injury: Assess the individual with suspected cervical spine injury using the Canadian C spine rule:

  1. the individual is at high risk if they have at least one of the following high-risk factors:
    1. age 65 years or older
    2. dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example, diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
    3. paraesthesia in the upper or lower limbs
  2. the individual is at low risk if they have at least one of the following low-risk factors:
    1. involved in a minor rear-end motor vehicle collision
    2. comfortable in a sitting position
    3. ambulatory at any time since the injury
    4. no midline cervical spine tenderness
    5. delayed onset of neck pain
  3. the individual remains at low risk if they are:
    1. unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the individual is at low risk and there are no high-risk factors).
  4. the individual has no risk if they:
    1. have one of the above low-risk factors and
    2. are able to actively rotate their neck 45 degrees to the left and right.
(NICE 2016, p.11; Level B)
A.7.6

Carry out or maintain full in-line spinal immobilization and request imaging if:

  1. a high-risk factor for cervical spine injury is identified and indicated by the Canadian C-spine rule or
  2. a low-risk factor for cervical spine injury is identified and indicated by the Canadian C spine rule, and the individual is unable to actively rotate their neck 45 degrees left and right or
  3. indicated by one or more of the factors are present in those suspected in those with thoracolumbar or cervical spinal injury:
    1. age 65 years or older and reported pain in the thoracic or lumbosacral spine
    2. dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, an accident involving motorized recreational vehicles, bicycle collision, horse riding accidents)
    3. pre-existing spinal pathology (i.e., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis), or known or at risk of osteoporosis – for example, steroid use
    4. suspected spinal fracture in another region of the spine
    5. abnormal neurological symptoms (paraesthesia or weakness or numbness)
    6. on examination:
      1. abnormal neurological signs (motor or sensory deficit)
      2. new deformity or bony midline tenderness (on palpation)
      3. bony midline tenderness (on percussion)
      4. midline or spinal pain (on coughing)
      5. on mobilization (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs).
(Adapted from NICE 2016, p.11; Level B)
A.7.7

Do not carry out or maintain full in-line spinal immobilization or request imaging if:

  1. they have low-risk factors for cervical spine injury as identified and indicated by the Canadian C spine rule, are pain-free and are able to actively rotate their neck 45 degrees left and right
  2. they do not have any of the factors noted above as risk factors for thoracolumbar fracture
(NICE 2016, p.12; Level B)
A.7.8
Radiographic evaluation is not recommended in individuals who are awake, asymptomatic without neck pain or tenderness, who do not have an injury detracting from an accurate evaluation, and who are able to complete a functional range of motion examination. (CNS-RADIO 2013, p.54; Level A)
A.7.9
Emergency physicians who have assessed the individual may discontinue cervical immobilization for awake, asymptomatic patients without cervical spinal imaging. (CNS-RADIO 2013, p.54; Level A)
A.7.10

When carrying out or maintaining full in-line immobilization:

  1. Tailor the approach to the individual's specific circumstances.
  2. The use of spinal immobilization devices may be difficult (for example, in individuals with short or wide necks or individuals with a pre-existing deformity) and could be counterproductive (for example, increasing pain, worsening neurological signs and symptoms). In uncooperative, agitated, or distressed individuals, think about letting them find a position where they are comfortable with manual in-line spinal immobilization.
  3. When carrying out full in-line spinal immobilization in adults, manually stabilize the head with the spine in-line using the following stepwise approach:
    1. Fit an appropriately sized semi-rigid collar unless contraindicated by:
      1. a compromised airway
      2. known spinal deformities, such as ankylosing spondylitis (in these cases, keep the spine in the individual's current position)
    2. Reassess the airway after applying the collar
    3. Place and secure the individual on a scoop stretcher
    4. Secure the individual with head blocks and tape, ideally in a vacuum mattress
(Adapted from NICE 2016, p.12; Level B)
A.7.11
We suggest clinicians transfer the individual off a spinal board and onto a firm padded surface immediately after extraction where possible in consultation with a qualified healthcare professional. (Adapted from NPUAP 2014. p.9; Level C)
A.7.12
All trauma networks should have network-wide written guidelines for the immediate management of an individual with a spinal injury, and these should be agreed with the linked SCI centre. The written guidelines should be updated every two years. (Adapted from NICE 2016, p.15; Level C)


A.8.1
We recommend clinicians routinely use the International Standards for Neurological of Spinal Cord Injury (ISNCSCI) exam as the neurological assessment standard in the care of acute SCI patients. The ISNCSCI should be completed 24 hours post-injury and before and after surgery. (Adapted from CNS-ASSESS 2013, p.40; Level B)
(https://asia-spinalinjury.org/international-standards-neurological-classification-sci-isncsci-worksheet/)


A.9.1
If SCI is suspected, clinicians should complete an Injury Severity Score (ISS), record vital capacity and ability to cough as soon as possible in the emergency department. If the individual has reduced consciousness or if suspicion of brain injury, also a a Glasgow Coma Scale/Score (GCS) should be performed (Adapted from NICE 2016, p.19; Level C)


A.10.1
Early surgery should be offered as an option for acute SCI patients with all levels of injury, including those with acute central cord syndrome, within 24 hours as long as the patient is stable. (Adapted from DECOM 2017, p.198S; Level C)
A.10.2
Early reduction of fracture-dislocation injuries is recommended. (CNS-ATCCS 2013, p.195; Level C)
A.10.3
In patients with acute traumatic SCI, surgical decompression of the compressed spinal cord is recommended. (Adapted from CNS-ATCCS 2013, p.195; Level C)


A.11.1

For patients who are being transferred from an emergency department to another centre, provide verbal and written information that includes:

  1. reason for the transfer
  2. location of the receiving centre and the patient's destination within the receiving centre.
  3. provide information on the linked SCI centre (in the case of cord injury) or the unit the patient will be transferred to (in the case of column injury or other injuries needing more immediate attention)
  4. the name and contact details of the individual who was responsible for the patient's care at the receiving centre
  5. results of ISCNCI examination, vitals, imaging examinations and risk for pressure injury development
  6. the name and contact details of the individual responsible for the patient's care at the initial hospital.
(Adapted from NICE 2016, p.17; Level C)


A.12.1
The trauma team leader must immediately contact the spinal surgeon on-call when someone arrives in the trauma centre with a confirmed or suspected SCI. (Adapted from NICE 2016, p.14; Level C)