Question 19

College Answer

Patients with "unstable" injuries may be at risk of secondary injury if passive or active movements are not limited.
Brain- Traumatic Brain Injury:
 Head up (venous drainage)
 May be at odds with spinal precautions
 Priority given to greatest identified injury
 Can nurse flat in bed, with entire bed angled head up
 Avoid venous obstruction if TBI (collar and jugular CVC)
C-Spine injury
 Collar (which type not esp evidence based- Philadelphia/Aspen/hard collar)
 Particular attention to head hold in movement including airway manipulation
 Lie flat (but can tilt bed if head elevation dictated by underlying TBI)
 Log roll acceptable but recommended to use 4 people
 Can side lie with wedge to minimise pressure injury
 Should aim to remove collar as early as possible, and many trauma hospitals institute a Radiological clearance protocol using CT or MRI.
 If injury is identified then collar should not be removed until definitive treatment is defined (fixation/hard collar/conservative mx)
 Prolonged collar placement may lead to pressure injuries
 C-spine collar may make airway access more difficult
Thoraco-lumbar spine injury
 Lie flat (no bending) or side lie with a wedge.
 Log roll (4 person).
 Radiologic clearance protocols used commonly.
Pelvic fractures
 Haemodynamic instability may be related to pelvic injury
 Mechanically unstable pelvic fractures may be worsened by rolling/side lie/ sitting
 Pelvic binders may be required if haemodynamically unstable
 Additional fixation once injury identified- or removed if not.

Long bone fractures
 No universal position restrictions
 In event of clinical suspicion long bones should be immobilised to prevent embolic and haemorrhagic complications and pain
Other points
Competing injuries- precautions should relate to the most serious identified injury - e.g. a cleared spine may mean a patient can be sat up, but not in the setting of a co-existing mechanically unstable pelvis.
Likewise:
 Management of ICP in TBI takes precedence over use of cervical collars.
 Chest injuries/hypoxia takes precedence over spinal precautions
 Intubation and securing the airway takes precedence over cervical collars/head holds
Urgency exists in identifying injuries at the earliest possible time (secondary and tertiary survey) in order to remove or increase position restrictions for the individual patient.
Emphasis should be on own practice, no single "right way" but sensible risk/benefit based approach including clinical and radiologic findings to guide practice.

Examiners' comments: Candidates who did not pass this question did not think broadly and gave a limited answer and did not adequately address the issue of competing injuries and risk v benefit.

Discussion

Positioning for head injury

• Ideally, head up 45 degrees. At least angle the bed.
• It seems to position the patient at least 30° head up decreases the ICP but does not decrease the CPP.
• At least in the pediatric population, the angle of the bed is directly related to intracranial pressure.
• Ideally, the C-spine collar should be removed. A good study of intracranial pressure with and without the rigid collar found that one can decrease the intracranial pressure of a TBI patient by about 4-5mmHg simply by removing the rigid collar and using something like sandbags to stabilise the neck.
• The risk of head-up positioning may be haemodynamic instability, particularly if the sympathetic nervous system is not working (eg. severe diabetes, Parkinson disease or spinal injury)

Positioning for C-spine injury

• Hard collar is required if an injury is confirmed or suspected.
• The patient must lie flat, and be log-rolled.
• Clearance of the C-spine should occur as soon as it is practical
• There are many problems with wearing a collar for a prolonged period (eg. pressure areas, increased ICP, and so forth)

Positioning for T/L spine injuries

• The patient must lie flat, and be log-rolled.
• No bending is permitted
• The risk of such flatness is an increased incidence of VAP

Positioning for severe chest injuries

• Sit them up at least 30° if the head permits
• Do not lie them with the flail segment down. That lung has probably had a contusion anyway. Lie them "good lung down" - oxygenation will improve.
• Gentle lateral rotation may be appropriate
• Low-air-loss technology: specialist beds which turn the patient by inflating and deflating air cushions; a turning arc of 40-90° is possible.
• These are soft beds, unsuited for unstable spinal or pelvic injuries

Positioning in pelvic fractures

• The unstable pelvis must be in a binder
• Overmuch manipulation will result in haemodynamic instability
• Predictably, the solution is to fix the pelvis; angioembolisation may not be possible because the bleeding is frequently venous.
• While unfixed, the patient must lie flat
• Nurse patient on a firm mattress to ensure consistent pelvic support
• Ensure appropriate fitting of specialist equipment (e.g. pelvic binder belt)
• Maintain flat, straight alignment of whole body at all times.
• Log-roll patients
• Use spinal boards and flat-surface hoist
• If the patient is expected to have an unfixed pelvis for a prolonged period (eg. if they have no private health insurance and were not the victim of a work-related injury), to ameliorate the effects of prolonged immobility one may use continuous lateral rotation therapy using RotoRest or similar specialist beds
• Low-air-loss pressure mattresses are contraindicated in spinal or pelvic instability.

Positioning in long bone fractures

• Traction is indicated for the reduction of long bone lower limb fractures which are awaiting repair.
• This is a significant limitation on positioning
• The patient in traction is also difficult to transport
• Traction must come down for transfer fom bed to bed

Positioning for the pregnant trauma patient

• Gravid uterus restricts the use of pelvic fixators and pelvic binders
• A tilt may be required to improve haemodynamics, but it may be counterproductive for long bone traction  or spinal immobilisation
• Supine flat position may be required for spinal immobilisation, which will decrease FRC and compromise respiratory function

Competing interest

• Airway vs. C-spine collar:
  • Airway wins; the collar can be removed and inline stablisation attempted for intubation
• Head injury vs. C-spine injury:
  • Head injury wins, even if the C-spine is unstable the ICP must be managed properly. Remove the collar and sandbag the neck. Paralyse and sedate the patient.
  • If they must remain flat, then angle the bed so the head is still up.

Christie, Robert James. "Therapeutic positioning of the multiply-injured trauma patient in ICU." British Journal of Nursing 17.10 (2008): 638-642.