Last update 12/11/23

The Spine

The spine consists of the vertebral column which is made up of 24 vertebrae separated by intervertebral discs, and the pelvis.  Within the spine is the spinal canal, which houses and protects the spinal cord. Individual nerves exit the spinal cord at various levels along the length of the spine, connecting individual parts of the body to the brain.

The spinal cord can be injured by stretching, bruising, pressure, or by sharp objects puncturing or cutting it.  This will interfere with communication between the brain and other parts of the body. The effects may be temporary or permanent.

The higher up the spine an injury occurs, the more serious the consequences. Neurogenic shock (see later) can also occur if the cord damage is at or above the thoracic region (the chest).

Effect of cord damage at different levels

The location of an injury also has an impact on the level of paralysis, and this is shown in the diagram below. The higher the injury, the more serious the potential paralysis.

Like traumatic brain injuries, spinal trauma is categorised into two types:

• Primary injury, which results from the initial trauma at the time of the incident

• Secondary injury, that occurs after the initial trauma due to hypoxia, low blood pressure (hypotension), careless handling, if the casualty attempts to move themselves, etc.

The focus in MR when managing casualties with suspected spinal trauma is the prevention of secondary injury by careful handling, immobilisation and rapid evacuation to definitive care.  Patients with spinal injuries, such as a fracture of a vertebra or ligament disruption, may not have detectable neurological symptoms and may have normal movement and sensation in all four limbs. However, movement and incorrect handling can potentially lead to cord damage. The best example of this is Will Clarke who went over the handlebars of his bike. Initially, he thought he was OK but when he attempted to sit up, he felt his body 'lock up' and he subsequently sustained permanent cord damage. Diagnosis or exclusion of spinal trauma can be extremely difficult and is often only detectable with an MRI scan in hospital. Therefore, on the hills, we often have to proceed as though an injury is present. If there are reasons to suspect a spine injury based upon the mechanism of injury, you should proceed as if one is present until it can be excluded conclusively.

Assessment and management of suspected spinal injuries

In the past, we worked on the principle that any movement of a potentially injured spine could lead to serious neurological consequences. As a result, the advice was that if a potential mechanism of injury exists, all appropriate patients should be fully immobilised 'just in case' as it is not possible to rule out spinal injuries without full clinical evaluation and scans. This meant a rigid collar and putting them on a rigid spine board. Over the last 15 years, substantial research and reviews of large numbers of patients have resulted in two important changes to the way we assess and manage these injuries in MR, and these are outlined below. These changes are advocated by authoritative organisations such as the Faculty of Prehospital Care. In addition, the changes have been embraced by MREW.

Cervical Spine

The current recommended practice is called spinal motion restriction. This reflects the following important facts:

• Complete immobilisation of the spine is not possible

• Complete immobilisation has not been shown to reduce injury

• Immobilisation methods have side effects, some of which are serious e.g. making casualty extraction from a difficult location more difficult and potentially more dangerous, and interfering with airway management

• Potentially spinally-injured patients will usually protect their own spines by muscle spasm, etc.

Understanding cervical spine injury, why protection is important and how best to achieve this in practice

The big worry about damage to the spine is whether it can go on to cause damage to the spinal cord with resultant disability, which can be permanent. It was believed that the principle cause of damage after the initial injury was from movement and therefore, attempting to eliminate all spinal movement became the goal and the standard of care. This was typically achieved using a collar, head blocks and placing the casualty on a spinal board. This method of caring for the potentially spinally-injured casualty evolved through fear of causing further mechanical injury and was not evidence-based.

It is now understood that deterioration after spinal injury can occur for several reasons, of which movement is only one. Studies have shown that the classical methods of immobilisation not only don't fully stop the spine from moving but in some cases, can force the spine into an unnatural position that can actually worsen damage. There are other also complications from this rigid approach, including increasing the complexity of extrication from a difficult location, the effects on airway management and co-existing brain injury and skin damage from lying on a hard board. This understanding has revolutionised the way we manage patients with potential spine injury who are at risk. The modern principle of care is called spinal motion restriction i.e. the use of motion limitation in those casualties who are likely to benefit, rather than apply immobilisation to all trauma casualties, regardless of the risk of damage actually being present. The term ‘immobilisation’ is no longer appropriate.

How does spinal cord injury occur?

Spinal cord injury can occur if something presses on the cord, it becomes stretched or misshapen, or it loses adequate blood and oxygen supplies. There are several ways these can occur in addition to the original mechanical force of the injury. Care for the injured casualty should address all these issues and not focus on mechanical movement. Like the brain, secondary cord injury can occur. This is damage occurring due to events happening subsequently: 

• Swelling due to tissue damage

• Hypoxia due to injured casualty having impaired breathing

• Interruption in the blood supply e.g. as can occur with low blood pressure due to major bleeding

• Blood clot around the cord and pressing on it, as can occur when a damaged spinal vertebra bleeds

• Mechanical injury

Spinal injury types

There is a range of spinal injuries possible.

The term ‘unstable’ means that the bony integrity of the spine has been lost, thereby increasing the likelihood of cord injury occurring.

• Uninjured spine i.e. bony pain in the spine but no loss of integrity. There is no risk of cord damage in this case.

• Stable bony injury i.e. there is a fracture in a spinal vertebra, but it is not unstable and there is no potential for cord damage to occur.

• Unstable bony injury or potentially unstable, but there is currently no cord damage. One or more vertebrae have been damaged in such a way that cord damage is possible, but it hasn't happened yet.

• Unstable bony injury with neurological compromise i.e. the envelope of protection for the spinal cord that is provided by the vertebrae has been lost and the cord has been damaged. This will be evident on clinical examination (discussed in the section on Spinal Trauma).

• Severely injured casualty with unknown spinal status because they cannot be assessed clinically e.g. examined to check for weakness or abnormal sensation

The important thing is that each of these groups needs different management and it is wrong to treat them all as though they were the worst possible scenario. 

Reading the Wreckage

The assessment and management of potential spinal injuries begins prior to reaching the casualty.  Through reading the wreckage as you approach and considering information provided in the rescue alert message or made available on route, you can begin to assess whether the mechanism of injury suggests the possibility of a spinal cord injury. Based upon what you can see, consider whether any of the following are present:

• Fall from height of greater than 1 metre or five stairs

• Axial load to head (compression of the spine from the head)

• Tumbling fall

• Fall from height onto the feet causing damage to the heels, ankles, but also potentially, the spine

• High speed impact (mainly falls in our environment)

• Bicycle collision

• High speed vehicle collision

• Vehicle roll-over or thrown from vehicle

• Non-ambulatory since incident (not walked in the absence of any injury that could prevent them from doing so)

• Significant distracting injury

• Intoxicated

• Reduced conscious level following trauma

• Head or facial injury

If any of the above are present, there is a risk of spinal injury. 
Be careful how you approach the casualty and start manual in-line stabilisation as soon as you arrive.

Maintain manual in-line stabilisation whilst you assess the casualty using the Primary Survey. 
Then assess for spinal injury and decide whether immobilisation is necessary.

Approaching the Casualty

Four scenarios when you arrive:

• The casualty is lying down in a position where they cannot see you. Approach by walking around behind them and place your hand on their forehead to immobilise them as you introduce yourself. Then begin manual in-line stabilisation.

• The casualty is looking at you as you approach. Ask them to keep their head still. Explain that you are going to support their head in case they have injured their spine, and ask them to try not to nod or shake their head when answering questions (they will need reminding!). Then sit behind them and place you hands on either side of the head.

• The casualty is unconscious. They will not move their head voluntarily, but it should still be stabilised in the normal anatomical position.

• The casualty is combative, following a head injury. Do your best to get them not to move their head but under no circumstances should you forcibly try to immobilise the C-Spine. If you make them more agitated, you risk creating the very thing you are trying to prevent.

If you can't easily reach the casualty to examine them fully, for example on Jack's Rake, you can ask them to walk to a place of safety for a fuller assessment IF they fulfil the NEXUS criteria set out below.

"In the conscious patient with no overt alcohol or drugs on board and with no major distracting injuries, the patient, unless physically trapped should be invited to self-extricate and lie on the trolley cot. Likewise, for the non-trapped patient who has self-extricated, they can be walked to the vehicle and then laid supine, examined and then if necessary immobilised" Faculty of Prehospital Care, April 2015

The casualty who has been moving around

It is a good sign (for you) if you notice, as you approach the casualty, that they are turning their head in each direction with a good range of movement or you find that they have moved from the place where the accident occurred. In the past, it was common practice to immobilise people purely on the basis of mechanism of injury, even if they had been moving around freely after the incident, in case further movement caused harm. In some cases this resulted in some slightly silly situations, as the video below parodies. Recent evidence suggests that if the casualty has already moved themselves significantly e.g. they've got up and walked or crawled some distance from the incident site, they are very unlikely to have a significant spinal injury or to suffer from being allowed to continue to move. If they have been moving around, get them to gently sit down and just assess them. Unless that turns up something completely unexpected on when you examine them, immobilisation is unnecessary. 

 Self-splinting 

When the cervical spine is injured, the patient's own muscle spasm provides excellent support for the neck. The result will be that they will be holding their neck stiffly and they will have limited range of movements. You may notice this as you approach as these features will be very apparent in conscious patients. A neck that is stiff indicates trouble, and caution is indicated. Even if the casualty says that their neck is always stiff, evaluate it carefully. 

Manual In-line Stabilisation

Manual in-line stabilisation involves simply kneeling or lying behind the casualty and placing a hand on either side of the head as shown below to protect the region from movement or accidental contact.

How to apply Manual Inline Stabilisation

Place your hands on either side of the head as shown below and hold it still.

An alternative method is called the 'Trap Squeeze' (trapezius muscle squeeze). You grip the muscle between the neck and shoulder on each side, holding the head still between your forearms. You should use this method if the casualty is restless or needs to be moved.

A third very useful method is to place the head between your knees. This is very useful when you are on your own as it leaves your hands free e.g. to support the airway (with a jaw thrust) or assess the casualty. This method can be used when the casualty is lying on their back or face down.

Two things must be remembered at all times

• The person undertaking the manual in-line stabilisation is in charge of the head and co-ordinates all movements.

• Manual in-line stabilisation should be continued until the spine has been cleared or the casualty has been fully packaged.

Once manual in-line stabilisation has been initiated you should proceed to assess the casualty using the Primary and Secondary Survey approach with C-Spine control in place.  

Only reassess the need for C-Spine immobilisation during the Secondary Survey
using NEXUS, after life threatening Primary Survey injuries have been excluded or treated

History

First take a history to determine if a dangerous mechanism of injury has taken place. As mentioned above these include:

• Fall from height of greater than 1 metre or five stairs

• Axial load to head (compression of the spine from the head)

• Tumbling fall

• Fall from height onto the feet causing damage to the heels, ankles, but also potentially, the spine

• High speed impact (mainly falls in our environment)

• Bicycle collision

• High speed vehicle collision

• Vehicle roll-over or thrown from vehicle

• Non-ambulatory since incident (not walked in the absence of any injury that could prevent them from doing so)

• Significant distracting injury

• Intoxicated (drugs and/or alcohol)

• Reduced conscious level following trauma

• Head or facial injury

Other features that indicate a possible spinal injury at any level (not just C-Spine) are:

• Immediate onset of neck pain

• Loss or change of sensation anywhere (enquire about the limbs)

• Paraesthesia (a sensation of tickling, tingling, burning, pricking, or numbness of a person's skin) or numbness in the extremities

• Patient unable to turn their head through 45 degrees to the left and right. Do NOT ask them to attempt this.

• Incontinence

If a dangerous mechanism or indicator is present, assess using the NEXUS criteria. If not (e.g. casualty with an ankle injury), then further assessment is not necessary.

Two useful signs that indicate that a significant C-Spine injury is unlikely are:

• The patient is spontaneously turning their head when talking to you, especially if they are turning 45 degrees left and right.

• The casualty has uneventfully moved themselves from the position they were immediately after the accident.

NEXUS

The NEXUS criteria provide a way of checking suitable casualties to see if it is likely that a C-Spine injury is present. By using this approach, we can either flag the casualty as potential C-Spine damage, or effectively rule this out on the hill and avoid the need for unnecessary immobilisation, which can occur if we treat based principally on the mechanism of injury. In a Mountain Rescue situation, the current advice is to use this rule.  

When a significant mechanism of injury is present, the NEXUS criteria indicate a very low risk of cervical spine injury following blunt trauma if none of the five conditions listed below are present. These are explained in detail further down.

• Neurological deficit (a fancy way of saying absence or change in feeling or sensation, or inability to move any part of the body)

• Spinal tenderness (midline i.e. pressing on the bones of the neck, not the muscles at the sides)

• Altered mental status/level of consciousness

• Intoxication (drugs or alcohol)

• Distracting injury (an injury that is so painful that it prevents the casualty from focusing on their neck and accurately ascertaining whether or not it is tender)

NOTE - It doesn't matter which order you do the tests, so long as you do all five. However, if ANY of the five elements are present, the C-Spine cannot be considered stable and the casualty should be managed appropriately. So if you start to run down the list and the casualty fails the first one, they have failed the lot and you don't have to proceed any further. 

If the answer to all of these is ‘No’ (they aren’t present), the casualty is NEXUS negative.

If the answer to just of these is ‘Yes’ (i.e. at least one is present), the casualty is NEXUS positive.

Practical tip - A useful way to remember the elements of the NEXUS criteria is the acronym NSAID

Although there are five elements to the criteria, it really has three components:

1. Can they reliably report on their own condition? (Altered level of consciousness, intoxication and Distracting Injury)

2. Can they feel everything and do they have normal movement in the limbs? (Focal neurological deficit)

3. Does their neck hurt? (Spinal tenderness)

THE  NEXUS CRITERIA IN MORE DETAIL

Altered Mental State

This means the level of consciousness when you assess them. It doesn't matter if they were unconscious briefly immediately after the accident. An altered mental state can include any of the following:

• C, V, P, or U on the ACVPU scale

• GCS of 14 or lower

• New onset confusion or aggression (C)

• Disorientation to person, place, time or events

• Delayed or inappropriate response to external stimuli

Intoxication

Casualties should be considered intoxicated if they have had:

• Alcohol

• Drugs which cause intoxication

• Strong analgesia given prior to your arrival

Distracting Injury

When there is potential for a C-Spine injury along with other painful injuries, there is a concern that the casualty will be distracted from the pain in their neck by the other injury and fail to accurately report a neck injury. A number of studies have attempted to define where in the body, and how severe, another pain must be in order to be bad enough to distract the casualty from pain in their neck. The current evidence is that isolated painful lower torso or lower limb injuries are not usually sufficiently distracting to prevent a reliable cervical spine examination, unless the pain is so severe that the casualty is clearly focusing only on that injury. By contrast, upper torso injuries such as fractured clavicle, dislocated shoulder, fractured ribs, etc. may be sufficiently painful to be a distraction. If in doubt, consider other injuries as being a distraction and treat the casualty as NEXUS positive.

Neurological Deficit

This relates to a problem with the nerves or spinal cord. It may just affect one location, such as one arm, or a bigger part of the body e.g. both legs or everything below the waist. To assess for focal neurological deficit, ask about changes in sensation or problems with movement anywhere.  

Assess the limbs for motor function and sensation, noting any abnormalities.

• Motor - test for movement e.g. can they move their hands, feet, fingers or toes normally? Does the limb feel weak?

• Sensation - apply a light touch. Can they feel it; does it feel normal to them; does it feel like the other limb? Is there any numbness or an unusual sensation of tickling, tingling, burning, pricking, or numbness in their skin?

IMPORTANT - check for changes in pain and sensation before AND after moving the casualty.

Spinal Tenderness

Spinal tenderness is pain in the neck bones, not the adjacent muscles. Palpate the back of the neck and ask if there is any midline tenderness. At the same time, check the neck bones for distortion such as stepping, bruising or swelling. If the casualty experiences pain from any of these tests, consider the neck potentially unstable and immobilise. 

Other considerations when using NEXUS

Extremes of age

Children
Cervical spine damage is rare in children, particularly the little ones. NEXUS can be used, certainly down to 8 years old, and possibly lower. However, it becomes more difficult in toddlers, particularly if they haven't acquired good language. As described below, forcibly restraining any patient, particularly a distressed child, in a collar and vac mattress could potentially do more harm than allowing them to rest quietly in their mother's arms. 

Elderly
The likelihood of a cervical spine injury is greater in the elderly, probably because the neck becomes stiffer and the bones become softer (osteoporosis) as we get older. A recent review has concluded that NEXUS can safely be applied in those over 65 years. However, some studies have indicated that NEXUS is potentially less reliable in this age group. This may be because as we get older, the most vulnerable part of the cervical spine changes from the middle to the upper cervical spine, where it may be harder to check for spinal tenderness. One problem with these studies is that they include 'old' elderly patients (>75y), who have low energy falls e.g. in a care home. These sustain a different pattern of injury from 'young' elderly patients (65-75y) who are fit enough to walk the hills and have higher energy falls. A useful additional sign in these cases is, if in spite of a negative NEXUS, it is uncomfortable for them to turn their head or you notice they are holding their head stiffly.

FOUR CATEGORIES OF C-SPINE CASUALTIES:-

GROUP 1 - AWAKE: NO PAIN OR NEUROLOGY

GROUP 2 - AWAKE: NECK PAIN AND/OR NEUROLOGY (= NEXUS POSITIVE)

GROUP 3 - AGITATED: COMBATIVE (CANNOT ASSESS AS UNCOOPERATIVE)

GROUP 4 - UNCONSCIOUS

A summary of the management of each category is described in the ‘MR guidelines for assessing the casualty with a possible cervical spine injury’ in the Casualty Care book. ‘

Assessment of the Thoracic and Lumbar Spine

Clinical examination of the thoracic and lumbar spines is less reliable, so there isn't a NEXUS equivalent. If they have a suitable mechanism of injury, manage as though there is an injury present, particularly if they are complaining of spinal pain.

Using special scanning techniques, the log roll technique has been shown not to be as effective in maintaining spinal stability as used to be thought, so it is now recommended that we use an alternative technique called the ‘6+ Lift-and-Slide’ where practicable (see below). This is particularly so in casualties who also have an actual or suspected fractured pelvis. Log rolling has been shown to increase the amount of internal bleeding in these cases. 

Never log roll just to check for spinal tenderness. Clinical examination of the spine below the neck is not very reliable, and the risks of moving the casualty if an injury is present outweigh any potential advantages of confirming the presence of a spinal injury. You can quickly check the spine when undertaking the lift for the ‘Lift and Slide’.  Feel for distortion or spinal tenderness.

Note: it is possible that a casualty can have a thoracic or lumbar spinal injury but no C-Spine injury, depending on how the injury occurred. 

The management is summarised below in this MREW slide.

Management

Beyond manual inline stabilisation (MILS), the definitive management on the hill of possible spinal injuries is undertaken via motion restriction using a Vacuum Mattress (in the Major Fracture sac). Make sure the whole spine well supported and splinted by the Vacuum Mattress (affectionally know as the Vac Matt !). Immobilisation should be started via manual inline stabilisation either at the outset of your assessment, if indicated by the available information and by your reading of the wreckage, or as soon as a spine injury is suspected during the assessment.  The components of immobilisation are:

• Initial manual in-line stabilisation

• Minimal movement

• Extremely careful handling

• Full motion restriction in the vacuum mattress using the Lift-and-Slide technique to move the casualty. Make sure the vacuum matress is well moulded around the casualty

• Improvised head blocks taped in place. The tape across the forehead also reminds the casualty not to move their head.

• Careful handling during evacuation, preferably via helicopter

Remember - Only when fully immobilised in the vacuum mattress can manual in-line stabilisation be discontinued.

NB: Occasionally, it is very difficult to stop the casualty from moving around, particularly children when they are distressed and/or in pain. In these cases it is essential not to try to restrain them.  Some people can become more agitated by being restrained and increasingly determined to move. The extra muscular effort exerted to overcome being restrained could completely destabilise the spine.  In these cases it's best to try to comfort them in the hope they calm down.

If possible, check and record the findings listed below on the Cas Card before AND after the casualty has been immobilised, including whether or not there have been any changes after immobilisation has been applied:

• Pain

• GCS

• Sensation anywhere (enquire about the limbs)

• Ability to move their hands or feet

• Focal neurological deficit

NB: Although uncommon, if there has been any deterioration since motion restriction has been applied e.g. the casualty says that their legs feel numb, you must release some of the restriction immediately to see if that improves things. If it does, you will have to accept partial restriction. 

IMPORTANT: SPINAL SPLINTING MUST BE MOULDED TO THE CASUALTY, NOT THE CASUALTY SHOE-HORNED INTO OUR CONCEPT OF HOW THEY SHOULD BE LYING

Keep the casualty warm to minimise shivering and oxygen demand. A heat blanket can be used inside the vacuum mattress and a casualty bag wrapped around the outside by placing it on the stretcher prior to moving the casualty onto it in the mattress.

Remember - keeping the casualty warm is particularly important if neurogenic shock is present as the casualty will cool rapidly (see below).

For isolated spinal injury, oxygen can be used as is felt appropriate. There is no research.

Appropriate analgesia for spinal injuries are: morphine, entonox, fentanyl, paracetamol and ibuprofen.

Whether you decide to apply a collar or not, always monitor the patient for comfort and signs of neurological deterioration during the evacuation. 

How to apply a rigid collar

Rigid collars, in particular, do not completely immobilise the neck, and they have several important potential clinical complications: 

• Make airway management more difficult

• Increased risk of inhaling any vomit

• Can force the neck into a poor anatomical position and even exacerbate a C-Spine injury, especially if a poorly-sized and fitted collar is used or in people with some pre-existing disease of the cervical spine e.g. ankylosing spondylitis.

• Impairment of blood flow into and out of the brain causing a rise in intracranial pressure, particularly in the presence of a head injury or in suicide attempt by hanging

• Increase in the incidence of pressure sores, in part because immobilising the C-Spine also involves immobilising the rest of the patient

The way a rigid collar can force the neck into a bad position is shown below. The x-ray on the left is a normal neck. In particular, notice that it has a gentle curve. By contrast, the x-ray on the right is a neck in a rigid collar. The cervical spine is absolutely straight, which is most certainly not a normal anatomical position.

Nowadays, we will rarely apply a collar, but here is a description of how to do it.

First select the correct size collar. We carry two sizes; a yellow paediatric version for children and small adults, and a white adult version.

Then adjust the collar to the size of the casualty's neck as demonstrated in the video below. 

Once sized, pass the collar under the neck and secure in place with the Velcro strap.  

Make sure the collar is comfortable, isn't too tight and the neck has not been hyperextended.

Important rules when applying a collar

• Measure from the black line to the bottom of the plastic, not the foam.

• A collar does not replace manual in-line support by itself.

• Do not force a patient's neck into a hard collar if it won't go easily. If the neck is in an unusual position e.g. due to pre-existing disease or because the injury has caused a misalignment of the spine, forcing the neck to adopt the shape of the collar will cause significant problems.

How To Use The Vacuum Mattress

Whilst spineboards are used by the Ambulance Service, in MR evacuations can be unusually prolonged. With spine injuries, the casualty may be incapable of feeling pressure or moving. Therefore, sores can easily develop and could go undetected. The use of a vacuum mattress reduces the risk of pressure sores as well giving good support. This is considered the gold standard of spine care and should be preferred to spine boards.

Moving The Casualty

In order to minimise the risk of secondary injury, we need to minimise the amount of movement through carefully coordinated handling. There are two techniques for moving the casualty onto the vacuum mattress.

Whilst the log roll has long been the most common method for moving a casualty with a suspected spine injury, the evidence indicates that an alternative method call the ‘6 + Lift and Slide’ causes significantly less movement of the spine and is preferred where personnel, location and casualty position allow.

Lift and Slide

Eight rescuers are required during the 6 + lift and slide manoeuvre.

• The vacuum mattress is prepared for insertion by rolling in the sides then deflating.

• If a pelvic binder is to be applied, place this in the correct position on the vacuum mattress for application at the same time as immobilising them.

• One rescuer maintains manual inline stabilisation of the head and coordinates the lift, while another one is responsible for positioning the vacuum mattress underneath the casualty once they have been lifted.

• Six rescuers are placed in pairs across from one another at the chest, pelvis, and legs to perform the lift.

• The person coordinating the lift checks everyone is ready and has a good hold. Then after the instruction, the casualty is lifted 10–20 cm off the ground and the vacuum mattress is slid beneath the patient from the feet toward the head.

• The casualty is then carefully lowered onto the mattress.

• Air is allowed back into the mattress and then it is formed around the casualty before being deflated again.

• To provide extra support and comfort a hand can be used under the curve of the back and knees to mould the mattress as it is deflated.

• The buckles are then clipped and tightened.

The Log Roll Technique

The log roll technique should only be used where it is not practical to use the lift and slide. This technique requires a minimum of five people, but six are preferable.

• One rescuer maintains manual inline stabilisation of the head and controls all movement of the casualty, while another one is responsible for positioning the vacuum mattress.

• At least three people are positioned on the same side of the casualty to perform the roll. Team members reach across the casualty crossing arms with the person next to them before taking hold of the casualty.

• The casualty is then rotated axially to an angle between approximately 30°–90°, at which point the vacuum mattress is placed beneath the casualty.

• Once the vacuum mattress is in place, the casualty is rolled back onto the mattress.

• The casualty is then centred in the middle of the mattress.

• The mattress is formed around the casualty before being deflated.

• To provide extra support and comfort a hand can be used under the curve of the back and knees to mould the mattress as it is deflated.

Head Blocks

Once moved to the stretcher, improvised head blocks taped in place can be used to give additional support.  The team does not currently carry head blocks, the vacuum mattress shaped around the casualties head,  jackets from the cas bag and the group shelter stuffed tightly into there sacks or the casualty's boots can be used as improvised blocks.

 Neurogenic Shock

The most important type of shock is due to disruption of the circulation causing a low blood pressure, because this is a cause of death if untreated (see p13 in Casualty Care Revision in Mountain Rescue):

• Hypovolaemic or haemorrhagic shock (low BP and high pulse rate due to excessive bleeding)

• Anaphylactic shock (very low BP following a severe allergic reaction)

• Cardiogenic shock (low BP because the heart cannot pump strongly enough)

• Neurogenic shock (low BP because of interruption to the nerves that control the heart rate and blood vessel calibre)

IMPORTANT: When dealing with a head or spine injury, one must always initially assume that any low blood pressure is due to ongoing blood loss. Only after other injuries have been identified and treated or excluded can the diagnosis of neurogenic shock be made safely. If you don't do this, you could miss an important source of bleeding.

Beware - casualties with neurogenic shock will cool quickly, leading to hypothermia. Remember to check their temperature and use active methods to keep them warm (heat pads and lots of insulation). 

Management
In addition to everything else we would normally do in a major trauma patient, do the following:

• Clinical assessment (position of the spine; ability to move and feel the extremities; pulse; BP)

• Record the findings before AND after movement (very important)

• Immobilise in a vacuum mattress. NB as the casualty will not be able to feel anything below the level of the cord injury, make sure that nothing sharp is sticking in them or a limb is in an unnatural position.

• Keep warm (heat blankets will be needed)

• Cannulate + IV fluids, if you are qualified to do so, to reduce the severity of the low blood pressure. This is particularly valuable if there is also accompanying trauma causing blood loss

• Oxygen (if oxygen supplies are limited, use the pulse oximeter reading to guide oxygen flow setting)