A - PREHOSPITAL AND EMERGENCY

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)

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.

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.

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.

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).

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

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