Transporting Patients with Spinal Injuries

KEY RECOMMENDATIONS

1. Use a cervical spine immobilization for transport of patients with cervical spine injuries that have not been previously cleared. (Level II)
2. Consider the use of a vacuum spine board when available for the transport of unstable thoracolumbar fractures. (Level III)

The recommendations below apply to fixed wing transport of patients, with the following exception being applicable to all mechanisms of transport: The majority of patients with cervical spine injuries should be transported using semi-rigid orthotic such as an Aspen or Miami-J collar (if available).

Clinical scenarios may arise wherein halo immobilization may be suitable. Halo fixation is the most rigid and stable form of external cervical spine fixation.26 Prior to approving the patient for transport, the team leader must ensure halo removal tools are secured to vest in case there is a need for emergent removal to obtain airway or perform CPR. Additionally, the sending team should educate the transport team how to properly remove the halo if needed. It is not recommended that patients be transported via air or ground in cervical traction as the risk of excessive traction weight transfer associated with vehicular movement, G-forces during takeoff and landing, as well as turbulence can result in further injury.

If the patient has a thoracolumbar fracture that is unstable, then he/she should be transported by the Critical Care Air Transport Team (CCATT) using either a vacuum spine board (VSB) or a standard NATO litter preferably with a memory foam pad to help mitigate pressure sores from Role 2 to Role 3 and beyond if available. Depending on the injury, either of these options can provide sufficient stability to patients with thoracolumbar fractures.27-29 One small study suggested that pressure ulcer development might be decreased with use of VSB when compared to traditional long spine board.30

A thoracolumbosacral orthosis (TLSO) should not be worn during the transport process. This is unnecessary and increases the risk of pressure sores. Prior to transport, the spine surgeon and transportation team should agree upon suitability of VSB versus standard NATO litter. The VSB protocol requires that the VSB be deflated and re-inflated periodically to reduce the risk of pressure sores during the transport process. Logrolling in a VSB without “release of vacuum” does not significantly reduce skin pressure. Additionally, pre-transported skin integrity should be documented and care must be given to padding and pressure reduction maneuvers of the occiput and heels. Once cruising in smooth flight is accomplished, it would be reasonable to release the vacuum until either descent or turbulence is encountered. At a minimum, the VSB pressure should be checked every half hour, smoothed, and re-pressurized every hour, and every two hours the team should release straps and logroll patient (holding patient in appropriate alignment) and provide adequate time for relief of pressure points as part of their normal turning schedule. If the patient is on “spine precautions” due to an unstable cervical or thoracolumbar fracture, the bed should be placed in 30 degree of reverse Trendelenburg if possible. If not on “spine precautions,” then the head of bed should be elevated 30 degrees. During transport, all patients should use the sequential compression devices, which are approved for flight.