Assessment and Management

All injured players should be assessed, and their treatment priorities established based on the primary survey.

As previously, this consists of the SABCDE of immediate care and identifies life-threatening conditions by using the following sequence.

1. Safe approach
2. Airway maintenance with C-spine protection
3. Breathing with adequate ventilation
4. Circulation with haemorrhage control
5. Disability: neurological status
6. Exposure & environment control

As with any other injury, in suspected spinal injuries, during the primary survey life-threatening conditions should be identified and management commenced immediately after. If there are a number of care providers present the steps can accomplished simultaneously

Airway maintenance with C- spine protection

In a suspected spinal injury, the cervical spine should be stabilised by in-line immobilisation while the primary survey is performed. The caveat is that airway assessment takes priority; if it is not possible to maintain optimal spinal immobilisation in order to secure an adequate airway then management of the airway takes priority.

Caution is required when performing airway interventions in patients with potential spinal cord injuries where there may be damage to the sympathetic nervous system. This results in unopposed parasympathetic activity, which may be exaggerated by hypoxia or hypovolaemia, as a result, airway manoeuvres can result in profound bradycardia or cardiac arrest.

Airway interventions should be kept to the minimum which provides a satisfactory airway. If suction or airway adjuncts are planned, vascular access should be obtained while maintaining the airway with a jaw thrust, in order to enable the administration of atropine to treat any bradycardia.. If the players airway is compromised, it should be opened using a manual method while cervical spine stabilisation is maintained.

Manual In-line Stabilisation

All players with a mechanism of injury that suggests the likelihood of spinal injury must have manual in-line stabilisation commenced at the earliest possible opportunity.

The player’s head should be supported as shown below.

An alternative technique may be used to take control initially or used when transferring control. This is known as an anterior hold, shown below.

Manual in-line stabilisation must be maintained at all times until full mechanical immobilisation has been achieved, or assessment identifies that there is no need to continue this (see Clearing the Spine).

If the head is not in a neutral position, it should be carefully moved into that position unless any of the following contraindications occur during the movement:

• Increased pain
• Increased muscle spasm
• Resistance to movement
• Onset or worsening of neurological deficit
• Crepitus

If neutral alignment cannot be achieved, the head must be immobilised in the position it is found.

Breathing

The next priority is the assessment of the player’s breathing. Life-threatening conditions should be identified and appropriate immediate treatment delivered.

All players with a suspected spinal injury should be provided with oxygen in the pre-hospital environment via a non-rebreathe (trauma) mask with high flow oxygen.

An injury to the upper thoracic or lower cervical spinal cord may result in paralysis of the intercostal muscles, resulting in respiratory distress and diaphragmatic breathing.

In high cervical spinal cord injuries, the diaphragm (innervated by C3/4/5) may be paralysed, causing severe respiratory impairment. Assisted ventilation may be required.

Circulation

Neurogenic Shock - Damage to the sympathetic nervous system causes a loss of vascular tone. This results in the pooling of blood in the peripheral circulation, leading to hypotension, usually with warm extremities. The body would normally compensate by increasing the heart rate, but because this would normally be mediated via the sympathetic nervous system, this does not occur. Patients with neurogenic shock therefore have a low blood pressure with a low pulse rate.

In patients with multiple injuries, shock must never be attributed solely to a spinal cord injury, and hypovolaemic shock must be excluded. External haemorrhage should be managed and areas of potential occult bleeding must be assessed (the chest, abdomen, retroperitoneum, pelvis and long bones).

When managing neurogenic shock, fluid replacement should be kept to the minimum sufficient to maintain the radial pulse. This will provide adequate perfusion of the vital organs without the risk of pulmonary oedema. When handling the patient, care must also be taken not to tip them feet down as this may exacerbate the peripheral pooling of their circulating volume and cause a rapid circulatory decompensation.

Disability: neurological status

The on-pitch baseline observation of the neurological status of the player involves the use of the ACVPU system and a check of the player’s peripheral neurology should be undertaken.

On the pitch, this should consist of:

• Spinal pain or tenderness. This is midline pain/tenderness. Tenderness isolated to the paravertebral muscles is not spinal.
• Sensory: ask about loss of sensation, or paraesthesia. Check sensation to light touch in selected dermatomes i.e. C5, C8, T4, T10, L2, and L5.
• Motor: check selected myotomes that do not cause movement of the trunk i.e. elbow flexion, hand and finger movements, and ankle movement.

This is a limited assessment but is sufficient to confirm the need for immobilisation and give a feel for the level of injury. If taken to the medical room a more detailed neurological examination can be undertaken there.

Exposure & environment control

For the initial on-pitch assessment there should be limited exposure and the player protected from the environment.