Question 19 from the first paper of 2014 asked about the injuries which require specific positioning or immobilisation techniques, and influence of such techniques on the management of the multi-trauma patient. The examiners complained that the 63% of candidates who failed that question "did not think broadly and gave a limited answer and did not adequately address the issue of competing injuries and risk v benefit." This chapter was constructed in response to such comments. Clearly, the trainees took heed and did the past papers, as the identical Question 29 from the first paper of 2019 was passed by 84.1% of them, even though the examiners again complained of "poor discussion... ...lacked detail... at junior registrar level".
Unfortunately, there is no one specific overview which might serve as a reference here. Even LITFL have no chapter on this. Judson and Hsee, in their chapter for Oh;s Manual ("Severe and multiple trauma", Ch. 74, p. 755) have nothing to say on this subject. The only reference I have found was Robert Christie's 2008 article for the British Journl of Nursing. The summary below was concocted from a combination of this article with the college model answer. Only positioning and physical immobilisation is discussed; the use of sustained neuromuscular junction blockade is explored in detail elsewhere.
Positioning for head injury patients
- 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 patients
- 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:
- Pressure areas under the collar
- Source of sepsis
- Need for skin grafts
- Increased hospital stay
- Increased intracranial pressure
- Airway is made more difficult by in-line stabilisation
- Central venous access is made more difficult (IJ is out of bounds)
- Oral care is made more difficult, increasing the risk of VAP
- Nutrition is affected:
- Gastroparesis and ileus results from prolonged immobility
- Aspiration risk is increased by supine position
- Physiotherapy is delayed or impossible
- A greater risk of DVT/PE results from prolonged immobility
- A minimum of 4 nursing staff are required to turn the patient.
Positioning for thoracolumbar spinal 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
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.