Proper Immobilization With Head Injury

It always seems to happen in 3’s. This time it started as I was doing an interfacility transport. I had a patient with a significant head injury. Her C-spine was cleared and I had strict instructions to keep her head elevated about 30 degrees.

During the transport I considered how we are always taught to take C-spine with a head injury. But what about elevation of the head for the head injury? Yes, I know, I can put a pillow under the long board to elevate it. What if that is not enough? How many pillows can I use to elevate the head of the board and still secure the patient safely?

I ruminated on this for a couple of weeks. I had been thinking could we just KED someone, if they needed C-spine and needed their head up? After all, once the KED is on, manual C-spine is let go and the patient is moved to the long board. Does the patient have to be on a long board?

Then my husband came home to tell me about a tree cutter who fell 60 feet with his chainsaw. There were no chainsaw injuries but the man landed on his face. Now he had C-spine, head injury and facial issues. The patient had bleeding on his face and in his mouth. Airway was a concern, especially with the patient on his back on the long board. So we discussed how to put a supine patient into a KED. We only use it for the seated patient so we talked about the possibility of sliding the patient onto a KED then securing it.

Then the third instance came when I went into the ED to work. An EMT came to me and asked me if I ever heard of putting a patient in a KED but not on a long board. Talk about déjà vu! I chuckled as I related the thoughts I had been having over the past few weeks. We looked at our protocols and they clearly state that once the patient is secured in the KED they are to be positioned on a long board. Yet there may be instances when we need to deviate from protocols. If airway is a major concern and the patient can only breathe if he/she is upright, maybe using a KED without a long board is adequate spinal immobilization. If the patient has significant head trauma, maybe this is another time to deviate from protocols. Check with your medical director. Be sure to document why you deviated from protocol.

What do you think?

Julie Brady, RN, NREMT-P, is an EMS instructor/coordinator at Waukesha County Technical College (WCTC) which is located in southeastern Wisconsin.