First Aid Management of Spinal Injuries in the Outdoors
How to Manage a Casualty with a Suspected Spinal Injury
Twice in the past year I have had to manage a casualty with a suspected spinal injury, and the second time the casualty in question was me.
Suspected spinal injuries have got to be among the most challenging (and scary) emergencies faced by walkers, climbers, mountain bikers and the equine sports. Traditional first aid advice has long been to keep the casualty completely still, but current thinking is changing how professionals assess and can manage spinal injuries in remote environments. This guide explains the latest evidence and what it means for outdoor first aiders.
Case #1: Kent Scouts
I was running an outdoor first aid course with Kent Scouts and whilst the weather was dry and sunny, it was also bitterly cold. The caretaker came running up the stairs and asked me to come out to the car park where my help was needed.
What I was faced with was a male casualty who had collapsed out of his car’s passenger door onto the floor and against the adjacent car. His feet were still in the footwell. He was lying on his left arm, with his head squashed up against the car upon which he had fallen.
Just as I teach, I went through my ABCs. He was conscious, but only talking when asked questions and not fully with it. His breath smelled of the previous night’s excesses. Clearly he was breathing and the mechanism of injury suggested there would be no reason for blood loss, though I did a quick check for this nevertheless.
When I asked him about pain or how he felt he told me he had pins and needles (or paraesthesia as the medics say). For me this, combined with how he had fallen was a clear signal for a possible neck injury.
An easy decision to make
Here I was in a car park, not far from the nearest hospital, on a Sunday morning. The ambulance was already on its way. Apart from the risk of hypothermia, there was no real risk to keeping this casualty still. But I was intrigued as to how the ambulance technicians would manage him …
When the paramedics arrived they simply said to the guy “can you sit yourself up? Can you stand up? Can you lie yourself on this trolley?” It was that simple!
Case #2: Let’s go mountain biking in Wharny …
(What could possibly go wrong?)
As always, a mountain bike is to blame. Mike and I pedalled up the hill along an easy fire-break and arrived at our first descent: a route I was familiar with and was happy to start the day with.
The small rise in front of us gave way to a steep, double step which led down onto a rocky, rooty single-track. Hindsight is a smug teacher, and in hindsight maybe I should have warmed up on some of the easier trails first.
Within moments of dropping through the first two steps I was no longer in control of the bike and instead, I ploughed headfirst into a tree. Perversely my last thought was one of celebration that at least it wasn’t my shoulder taking the brunt of the collision (which was still healing from another incident).
I felt my spine compress into my helmet and my back immediately went into a spasm of intense pain between my shoulder blades.
Knees, palms and head down, kneeling on the floor, I was bent over, exhaling heavy sighs of pained breath. I mentally went through my ABCs. I was fully conscious and aware of my circumstances. I had an airway and I was breathing. I knew there was no blood loss. My back hurt. It hurt a lot.
Could I have had a spinal injury?
Spine checks. I was conscious. I could hear sounds all around me, and I could move my eyes left and right, though actually focusing on the mud just inches from my face was never going to happen. Neurologically this was all positive news. I could feel my fingers and toes, both sides. Gingerly, I picked my head up off the floor and turned my head left and then right without any difficulty. But my back was in pain.
What do the (old) guidelines say?
The guidelines typically say “For a suspected spinal injury, do not move the person unless they are in immediate danger”. I wasn’t in immediate danger, but I would need to get off this hill somehow. The choice facing me was either to call mountain rescue, and wait in-situ, (for an age), or just extricate myself. I would get cold. I took a moment to think about this, and something told me, self-rescue would be my best bet.
With some help from Mike, I got myself up onto my feet, and walked to the top of the hill, and then lay myself down in the recovery position. (I felt I might be sick). One by one, Mike brought up the bikes and the discarded kit. And then, I got up and we walked back to my car. Mike got my bike into the car. I drove home, showered and dosed up on paracetamol plus ibuprofen.
I shrugged it off as a soft-tissue injury and thought the painkillers were all I needed. By the next morning, my wife (who is a doctor) had other ideas …
In hospital …
And so it is, I’m sat here writing this from Chesterman 3 ward in the Northern General Hospital, with ribs 1, 7, 8 and 9 broken, a sternal fracture and contusion. Plus, for good measure spinous process T3 and 4 and a tiny one on 2. (This means those spiky bits of my vertebrae between the shoulder blades are broken).
Two casualties – but the same action
Here I have outlined two very different situations, where the calculus for making the decision was very different, but each time the conscious casualty was able to move themselves. And this is very much the message echoed through the latest research and guidelines:
How to check for a spinal injury – NEXUS criteria
First aid decisions rarely boil down to “always” or “never”. First aiders will never be able to “clear a C-Spine”, but a considered, informed decision will always be the best way forward for anyone. For me on each of the occasions above I began by asking myself how damaged might the casualty be?
A good rule of thumb is to assume all trauma casualties have a spinal injury, until a medical professional has ruled it out. The NEXUS (National Emergency X-Radiography Utilization Study) criteria are a validated clinical decision tool used to safely rule out cervical spine injuries without imaging in alert, stable trauma patients. These criteria were not created for first-aiders managing a casualty out on a hill, or in a car park, but they can guide us in gaining valuable information. The information we discover can help us make decisions. Or, better, with this information, it can enable a call handler (the ambulance service or mountain rescue) to make better decisions for us.
What is the mechanism of injury?
My first point of reference is what’s happened? Consider what forces have been applied to your casualty, where, how and how much. Anyone that has fallen further than their body length (down a hillside or off a climbing wall or crag), any crashed cyclists or fallen horse-riders; any injured skate-boarders: these are all prime suspects for a spinal injury.
Is my casualty a reliable witness?
There is no point trusting anything my casualty tells me if they don’t have the capacity to do so. This means that if they are concussed (a sign of a spinal injury in itself) or intoxicated, or in pain due to a distracting injury, what they say can’t be relied upon. Eg If someone has broken their ankle will they necessarily know if their back is in pain as well? But also severe impact forces that cause a traumatic brain injury (lowering the levels of consciousness) frequently co-occur with cervical or spinal column damage.
The ‘low hanging fruit’ tests …
Ok so let’s say our casualty has a GCS of 15 (ie properly and definitely conscious) and they have no distracting injury; the easiest thing now is to test for any neurological deficits. Can they see left, and right? Can they hear sounds in both ears and tell you where the sound is coming from? Can they feel sensation in the extremities in all four limbs and tell you which limb is being touched? If so, these are all promising signs. You can achieve this information at zero risk to your casualty.
The big one …
Can your casualty rotate their head 45 degrees right and left without any difficulty or pain? Asking someone to do this is effectively you deciding that you are happy for this person to move themselves. It is extremely important to follow the casualty’s lead here: if they don’t want to move their head, don’t ask them to. If they feel their neck is tender in any way, don’t ask them to move it. Only if they feel absolutely happy to do this and have the capacity to make this decision, should you consider this final test.
Why not just leave the casualty still?
We’re asking here, why would we ask a conscious casualty with a suspected neck or cervical spine injury maybe, to move themselves?
- Firstly it is what any professional rescuers or medics will likely do anyway: ask the casualty to move themselves. So you may as well do it sooner than later. Studies suggest the longer a casualty stays in situ the worse will be their outcomes. Further, the decades-old practice of using spine boards and collars to immobilise a casualty lack any scientific data to say these methods work. Increasingly the evidence suggests these age-old practices could actually be harmful to our casualty. (As well as extreme discomfort, spinal boards come with an increased risk of pressure sores, asphyxiation caused by aspirating vomit and require the casualty to be log-rolled onto them. Cervical collars are proven to raise intercranial pressure and hinder advanced airway management. They’re also uncomfortable for the casualty).
- Allowing a casualty to self-extricate from a location is not only safer for them, but safer for the rescuers too. If the casualty is strapped down to a spine-board they then need carrying out. Carrying a casualty in a wilderness environment is not without its own risks for the rescuers.
- Keeping the casualty in-situ, while you wait for help means that you will unlikely be in a position to identify or treat any other injuries. Additionally, the casualty will be far more susceptible to hypothermia. (And thinking about any possible internal injuries, a warm casualty is able to form blood clots more easily than when cold).
- Muscles will spasm and a casualty will experience more pain as time passes.
So, if a casualty can move themselves, and they’re happy to move themselves, you don’t need to tell them to keep still.
How should we consider managing a casualty with a spinal injury?
With regard to casualties who have been in a motor vehicle collision, the FPHC guidelines, Extrication following a Motor Vehicle Collision November, 2024, recommend “Non-clinicians should be empowered to decide on the extrication mode and deliver this before the arrival of the clinical team.” (It is noted however that these guidelines are aimed at non-medical emergency services such the police and fire-service).
These guidelines from the FPHC suggest a USTEP approach. In essence, for a casualty to move themselves, they must understand what they are being asked to do and why, and what will happen next.
- Make a plan. How will the casualty move? Where do you want them to move to? What do you want them to do once there? In exposed remote locations at height is it safe to move the casualty? (Rethink the plan?)
- Communicate and agree your plan with them and confirm that they understand it.
- Check they can move both legs.
- Make the path for them as clear of obstacles as possible.
- Ask the casualty if they need any help or support with the move. Follow their lead: do not pull or drag your casualty.
If the casualty wants their neck supporting, the FPHC guidelines say to use a collar. In this situation, as a first-aider, I would be revisiting my decision to allow the casualty to move. If the casualty is so injured that they feel they need a collar, do you still want them to move themselves? If the position they are presently in, is life threatening, either due to the environment or because as a first-aider you need to access them to treat them, they will need to move.
If the casualty needs a collar, look at what you have available with which you can improvise one from, be it the use of clothing or a roll mat or maybe a SAM splint. (This paper published by the Wilderness Medical Society asserts that an improvised collar utilising a SAM splint is as effective as the Philadelphia collar). Build it around your own neck first and see how well it works. Show this to the casualty, and if possible, allow them to attach it to themselves for best support and fit.
Neck and Spine Injuries – Conclusion
If you find yourself in a position where you are managing a casualty with a potential neck or spine injury you must remember there is no perfect solution to this problem.
In an urban context with good and swift access to the emergency services all I will likely do is encourage the casualty to keep still: especially where hypothermia is no threat to the casualty’s condition. I will try and keep them warm and offer reassurance. Getting out my casualty monitoring card while I wait, checking and recording their vital signs, would also be good first aid and great practice. (Read: One Item of First Aid Kit: Always Needed but the Least Appreciated)
Outdoors, in the wilderness context however, time and environmental factors are not necessarily on your casualty’s side. Here you may well need to think about allowing your casualty to move themselves to a safer, warmer and more comfortable location.
What I encourage you to do in all cases, is to take the time to make an informed decision one way or another. Weigh up the pros and cons of possible decisions, and remember, the casualty is probably always going to be the best person to extract themselves from any given location. They are the best person to support their own neck, and the evidence suggests that allowing the casualty to move to a more comfortable location or position is best done sooner than later.
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Will Legon (of Will4AdventureFirstAid.com) works professionally in the outdoors leading groups walking and instructing single pitch rock climbing, and mountain biking. Since 2009 Will has been delivering first aid training specialising in outdoor first aid courses. He is an ITC (Immediate Temporary Care) trainer, offering a range of courses accredited by Ofqual and Qualifications Scotland. In a former life, Will was a maths teacher and an infantry officer in the Territorial Army.
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