Downloaded from http://emj.bmj.com/ on October 21, 2015 - Published by group.bmj.com Consensus statement injuries.56Techniques involving place- Minimal patient handling: a faculty of ment on a scoop stretcher and application of spinal immobilisation have been prehospital care consensus statement demonstrated to be equivalent, if not superior, to log-rolling and immobilisation 1 2 3 R Moss, K Porter, I Greaves, On behalf of the consensus group on a long spinal board for spinal column movement. A long spinal board is likely to be less comfortable than a vacuum mat- INTRODUCTION spinal immobilisation. The best practice tress and possibly a scoop stretcher.7 The Safe and effective patient packaging is a described is based on the recommenda- risk of tissue pressure injury is reduced vital step in the safe transport of trauma tions of a consensus meeting held in the when using a vacuum mattress and poten- fi fi patients to de nitive care. A signi cant West Midlands in April 2012, where the tially when using a scoop stretcher due to proportion of patients are treated with opinion of experienced practitioners from the increased surface area of contact. spinal immobilisation precautions based across the prehospital and emergency care on their examination findings or on the community considered the currently avail- 2. The scoop stretcher should be used for mechanism of injury.1 Current UK prac- able evidence and reviewed current clinical patient transfer and to provide spinal tice commonly involves the use of a cer- practice. immobilisation. vical collar and blocks usually secured to a The indications for spinal immobilisa- The scoop stretcher is a piece of transfer rigid spinal board. Alternatively, and tion are not considered in this statement equipment with which the majority of increasingly commonly, immobilisation is as they are addressed in other consensus prehospital practitioners will be familiar. achieved using either a scoop stretcher or statements. Although it currently does not satisfy all a vacuum mattress. the ideals for a prehospital spinal immo- RECOMMENDATIONS bilisation device, it was felt by the consen- sus working group that its routine use has BACKGROUND 1. The long spinal board is an extrication a number of advantages. The main advan- Spinal immobilisation is a common inter- device and should no longer be used for tage of using a scoop stretcher is that only vention for the prehospital patient follow- providing spinal immobilisation during fi a minimal tilt, sufficient to allow insertion ing trauma. Most commonly the patient is transport to de nitive care. fi of the blades under the patient, is needed, log-rolled on to a rigid long spinal board. This recommendation marks a signi - thus satisfying the intention to minimise Once on the long spinal board, the cant change in current practice. It is made patient handling as much as possible. patient, with a cervical collar applied, will in the light of the potential risks to the There is no evidence to recommend one be immobilised using head blocks and patient from log-rolling in the prehospital particular model, but use of a second gen- straps and secured to the board for trans- environment and the risk of harm from eration design compatible with radio- portation to definitive care. immobilisation on the long spinal board, logical imaging is important. Once at definitive care, the patient may also giving consideration to the likelihood Placement on a scoop stretcher is also again be log-rolled to facilitate removal of of repeated transfers during the early easier to achieve where there are a limited the spinal board, removal of clothing and stages of management after arrival in number of practitioners available com- examination of the back and spinal hospital. pared with performing a log-roll. columns. Further movement of the patient Disadvantages of the scoop stretcher will usually occur again during transfer Risks of log-rolling include its suitability for carrying over for CT imaging. Promoting haemostasis in the trauma long distances, its cost, the weight limit of Spinal immobilisation using these tech- patient is a vital step in attempting to min- the device and the lack of a custom- niques is not without negative sequelae.2 imise further deterioration. There is designed system for immobilising the There is the potential for harm to be increasing evidence that movement of the head and neck once the patient has been caused by the log-rolling used to place patient and changes in their positioning placed on the stretcher. Current practice and remove the patient on the spinal and orientation may promote further by clinicians who routinely use the scoop board and by the immobilisation on the internal haemorrhage; for example, the stretcher for immobilisation involves spinal board. Consequently, a number of compression and distraction of a fractured adapting existing blocks either by invert- prehospital clinicians are using alternative pelvic ring when rolling the patient to 90° 3 ing or rotating the blocks and securing techniques to provide spinal immobilisa- perpendicular to the ground. with straps or tape. It was felt that this tion and to package patients either using a Log-rolling the patient with multiple practice is acceptable in the interim while scoop stretcher or a vacuum mattress. long bone and rib fractures is often a waiting for the widespread use of custom- This consensus statement will outline painful process for the patient despite anal- designed devices that are soon to be emerging best practice when packaging the gesia. This pain is not only avoidable but released on to the market. prehospital trauma patient and providing may also lead to an increase in sympathetic drive and an associated increase in BP. 1Department of Anaesthetics, University Hospital of North Staffordshire, Stoke on Trent, UK; 2Trauma, Evidence base Management at definitive care Queen Elizabeth Hospital Birmingham, Birmingham, The evidence base for spinal immobilisa- Management of the trauma patient at 3 UK; Department of Emergency Medicine, James Cook tion techniques and the equipment used is definitive care increasingly involves CT University Hospital Middlesborough, Middlesborough, not extensive.4 Log-rolling a patient to imaging of injuries soon after arrival UK 90° in order to facilitate placement of a in the emergency department. If the Correspondence to Professor K Porter, Trauma, Queen Elizabeth Hospital Birmingham, Mindelsohn long spinal board under the patient may patient has been packaged on a scoop Way, Edgbaston, Birmingham B15 2WB, UK; not maintain alignment of the spinal stretcher, this will enable easy transfer on [email protected] column in the patient with spinal and off the scanner, avoiding further Moss R, et al. Emerg Med J December 2013 Vol 30 No 12 1065 Downloaded from http://emj.bmj.com/ on October 21, 2015 - Published by group.bmj.com Consensus statement potentially detrimental changes in patient consideration should be given to using a needed include identifying frequency of positioning. vacuum mattress. use of immobilisation, spinal column sta- Vacuum mattresses provide the most com- bility and movement with the various 3. Patients should be managed according fortable method of immobilising the devices, the incidence of tissue pressure to a package of minimal handling trauma patient with the lowest incidence complications and heat loss and mainten- considerations of pressure tissue injury. They are, ance associated with the devices. In order to promote haemostasis, and however, not routinely used in many areas with the aim of avoiding any unnecessary of the UK, are expensive and require care movement that may interfere with this and maintenance to avoid device failure. goal, patients should be managed with a The recommendation that the total dur- Summary number of minimal handling considera- ation spent on the scoop stretcher should This consensus statement seeks to change tions. The principle of a single movement not exceed 45 min is not based on any the spinal immobilisation practices for early on in the patient’s care should be robust evidence; indeed, tissue pressure prehospital trauma patients. Following the adopted with the intention of restoring injury can occur after a very short time principles of minimal handling with one the patient to the anatomical position. frame in some frail patients. However, single early movement, the consensus no Due consideration should be given to this time frame was felt to be a balance longer supports the routine use of the adequate analgesia to avoid further sym- between the benefits of immobilising on a long spinal board for spinal immobilisa- pathetic stimulation. A single episode of vacuum mattress and the added length of tion and patient transportation. In its patient movement early in the timeline of on-scene time and additional patient place the scoop stretcher should be the the patient’s care will avoid unnecessary transfers that would be needed if a preferred device for transfer, immobilisa- patient movement and handling later vacuum mattress were used. tion and transportation to definitive care. during the patient’s care, at a point where In recommending that the total time Consideration should be given to using a coagulation and clinical condition may spent on a scoop stretcher should not vacuum mattress when the time spent on have deteriorated. exceed 45 min, it is felt that it would be the scoop stretcher would be expected to Under this single movement principle, advantageous to include the time when exceed 45 min. all necessary interventions and procedures immobilisation was initiated in the patient should be carried out contiguously to Contributors The literature search and programme handover and on patient documentation. prepare the patient for transportation to presentation was produced by RM. The consensus paper was written by all three contributors. The delivery definitive care and to facilitate ongoing Special circumstances of the consensus process was coordinated by Professor care in the emergency department.