In the early days of our major trauma centre, when the network was in its relative infancy there was a noticeable lack of standardisation. Patients would be brought to us from distance as close as a few hundred yards, or over a hundred miles on ‘spinal boards’, with occasional use of scoop stretchers.
With time, effort, communication and education things have changed for the better. I would like to write this article to help provide some evidence to others who are passionate about getting the word out.
In the trauma setting, it has become dogma that patients must be immobilised to within a inch of their lives, strapped to some sort of board, and made to be as still as possible as they are transported to hospital, then onwards through radiology and on again to theatre, intensive care or the ward.
These immobilisation devices are necessarily hard, inflexible and impossible to have shaped to fit all sizes of patient, so are usually flat. The weight of one’s body onto a hard surface will promote the formation of pressure sores and are devilishly uncomfortable. Try lying on a ‘spinal board’ for 20 minutes and see what I mean.
For many years it has been known that pressures as high as 200mmHg or more are delivered to at risk skin areas whilst immobilised on a spinal board. It has been recommended that a maximum of 20 minutes on one of these boards should be experienced in order to reduce the incidence of pressure sores, and the Faculty of Prehospital Care of the Royal College of Surgeons of Edinburgh (UK) has gone further stating:
“The long spinal board is an extrication device and should no longer be used for providing spinal immobilisation during transport to definitive care.”
The log roll…
The concept of minimal patient handling is becoming a key message within major trauma care. “The first clot is the best clot”, and disruption of a pelvic/long bone/visceral injury will lead to further bleeding, and less chance of definitive haemostasis.
A patient who is found face down at the road side could be rolled:
- 180 degrees onto his/her back.
- 90 degrees during a log roll and placement of a board, then 90 degrees back onto it
- 90 degrees for ED log roll then 90 degrees back
- Approx 30 degrees for ‘pat sliding’ to CT scanner and back
- Another 30+30 degrees to come off the scanner
Equalling 660 degrees of rotation without trying too hard.
Conversely, with a change of equipment:
- 180 degrees onto his/her back
- 20 degrees each way to introduce a scoop stretcher
- Lift onto ED trolley with a sliding mattress
- Transfer to and from CT without rolling
Equals a maximum of 220 degrees, a reduction of two-thirds.
The scoop stretcher:
A device which splits down the middle so can be introduced from either side and scoops the patient. It has handles and strap attachment clips, and has been found to exert lower pressures on key pressure areas (though not as good as a vacuum mattress, see below).
The sliding mattress:
A padded mattress, like the one manufactured by Wolverson medical has a more comfortable surface, lower pressures and importantly a rigid board beneath the padding, and webbing straps on both sides, which can be slid between ED trolley and CT scanner. It has been designed to be radiolucent and does not degrade CT image quality, nor plain films you might take in the resus room.
Good eh? We have been using sliding mattresses in our resus room for over a year now, and have found it to have simplified the transfer of unstable trauma patients incredibly. (Note – no conflict of interest, just impressed)
How about longer journeys?
In the same study (see pressure sores above) the mean pressures when using a vacuum mattress was significantly lower (in the region of 45mmHg). They were also found to be much more comfortable. This tallies well with our experience, having had many patients transferred in from the North of Wales with transfer times of a couple of hours or more.
These devices conform to the patients body shape, so support all areas of it – notably the lumber spine which is suspended in the air with the other devices. The patient’s weight is evenly distributed along the whole device. It can also be used to immobilise the cervical spine without the need for backboard and blocks.
When a patient arrives in a vacuum mattress they need to be safely extricated from it to facilitate further patient assessment. The first time you do it, it can be frustratingly complicated! Here’s how we do it:
In the example above, the patient (who consented for the pictures to be shared for educational purposes) had already had his cervical spine cleared at the trauma unit, so during the devac stage we did not need to institute MILS.
It is also possible to ‘de-vac’ the mattress on the ambulance stretcher and lift over on scoops, but this has proved problematic sometimes. Residually attached straps, monitor cables, oxygen tubing, ventilator tubing etc have all gotten tangled during this complex manoeuvre, so we transfer to one trolley first.
- Extrication boards (spinal boards) should be used for extrication only, not transfer
- Scoop stretchers should be used for transfers less than 45 mins (ideally 20-30)
- Vacuum mattresses for transfers over 45 mins
- Intra-hospital trauma transfers can easily be facilitated using radiolucent sliding mattresses