With respect to the management of a multi-trauma patient requiring mechanical ventilation:
Describe the injuries that require specific positioning or immobilisation of the patient and the strategies used in this context.
Include in your answer how these strategies impact upon the care of the patient.
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)
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.
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
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.
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.
Positioning for head injury
Positioning for C-spine injury
Positioning for T/L spine injuries
Positioning for severe chest injuries
Positioning in pelvic fractures
Positioning in long bone fractures
Positioning for the pregnant trauma patient
Christie, Robert James. "Therapeutic positioning of the multiply-injured trauma patient in ICU." British Journal of Nursing 17.10 (2008): 638-642.