This page is STILL under CONSTRUCTION!
Until this "blurb" is REMOVED, this page remains a "rough draft" version, and its contents should NOT NECESSARILY be implemented as currently written. However! Protocol-writers with a strong understanding of the information contained within the articles, "All Tied Up & No Place To Go" and "Restraint Asphyxia – Silent Killer," should be able to use this "ROUGH" information to build their own protocol. If you have "time" to delay your protocol writing, PLZ check back here periodically, to see if MY version of this protocol has been completed!

The Following Text Was "PLUGGED IN HERE" From the article, "All Tied Up & No Place To Go."

Section IV: Spinal Immobilization Of Combative Patients:

Combative patients who require spinal immobilization present a special challenge to emergency care providers. As a matter of fact, they require a Spinal-Immobilization-Protocol all of their own! Unfortunately, to date, NO ONE has researched and substantiated a protocol for the safe and medically appropriate method of spinally immobilizing a combative patient. What follows are my personal opinions and observations about this subject. I do not have any medical research to base these upon! They are developed solely from my personal experience, and my understanding of the kinetic forces involved with combative patients.

To a great extent, patients are responsible for assisting with - cooperating with - their own care. This basic assumption underlies the vast majority of emergency care protocols. However, when altered levels of consciousness (secondary to trauma or acute medical causes) impede a patient's ability to cooperate with appropriate, "standard," care procedures, altered protocol procedures must be employed. Patients are people. Their individual needs don't always follow "standard" protocols. As emergency care providers, our basic, universal goal is to provide the best, most appropriate, care and protection for each individual patient, without further injuring the patient or endangering others.

My Protocol For Spinal Immobilization of Combative Patients is based upon the following:

  1. standard, historical spinal immobilization protocols (designed for cooperative patients)
  2. common sense anticipation of stresses involved with combativeness and the application of standard spinal immobilization protocols
  3. altered spinal immobilization protocol approaches anticipated to provide the best possible patient care and protection when the patient is combative and resistant to treatment.

Before any care or control can be safely initiated, enough providers must be present. At least FIVE or more people are required to safely control and treat any combative patient - especially one requiring spinal immobilization. That's one provider per limb/major-body-section, and one provider to obtain and apply restraints/immobilization devices. (Prior to the accumulation of such a "small army" of providers, keep care providers and third parties away from the combative, probably spine-injured patient, to ensure their safety.)

RULE #1: GO TO GROUND AND STAY THERE! Providers must act simultaneously, as a team, and control the "take-down" of the patient so that a minimum of additional injury is risked. Get the patient on the ground and keep him there. As soon as possible, make sure that the patient is placed supine (see positional asphyxia information in SECTION II).

RULE #2: AVOID WRESTLING WITH THE PATIENT'S HEAD! If the mechanism of injury suggests potential cervical spine (C-spine) injury, you must assume that C-spine injury exists. In my opinion, following the "standard" spinal immobilization protocol of immediately controlling (immobilizing/restraining) the patient's head and C-spine when the patient is physically resistive to immobilization increases the risk of neurologic compromise should C-spine injury actually exist. Attempts to manually restrain a patient's head against his will - wrestling with the patient's head - significantly increases the stresses upon the patient's C-spine. I suggest that, leaving the combative patient's head alone causes less cervical spine stress and less risk of increased injury.

As soon as a patient evidences strong (combative) physical resistance to C-spine control, such control should be discontinued. Then, immediately employ these three simple, specific verbal cues:

  1. "Please stop moving your head."
  2. "You probably have a neck injury from the force of that accident."
  3. "If you keep moving your head you may become paralyzed or even die."

Continue repeating these three verbal cues throughout the remaining steps of immobilization. No, these verbal cues probably won't work - remember, these patients have an altered level of consciousness and are unlikely to understand or follow cues. But these cues sound a lot better on video tape than yelling, "Stop moving your head!" and the like (or worse). Avoid arguing with the patient. Simply keep repeating the three magic cues, and carry on with patient care.

If head-banging ensues, provide padding around the patient's head. A blanket or "head bed" will eventually be needed for spinal immobilization anyway.

If the patient attempts to bite or injure others with her/his head, then you will be forced to restrain the patient's head to prevent injury of others. Although in-line cervical spine "traction" was discontinued years ago, it is probably the best, most effective way to restrain a combative patient's head and still protect her/his C-spine. Anchor your fingers around the patient's jaws and apply slight in-line, axial traction. Avoid hyperextension and apply only enough in-line traction to prevent biting and head-butting. Once this sort of in-line traction is applied, however, it must be manually continued, without pause, until the patient is completely immobilized and no longer combative!

Likewise, do not attempt to wrestle a cervical collar onto a combative patient. Since any cervical collar (C-collar) provides little (true) immobilization, one may or may not be applied after the patient is better controlled.

SPECIAL NOTE: Once the patient is manually restrained, if you have the ability to administer a chemical restraint, you may consider doing so. Unfortunately, you'll have to inject it intramuscularly (IM), because you don't have an IV established and are unlikely to establish one until after the patient is completely restrained and immobilized. Thus, the amount of time before onset of IM injected chemical restraint will be lengthy in most cases. Additionally, I do not advocate the use of chemical restraint prior to complete examination and thorough evaluation of the patient's injuries and medical condition (especially when the patient's problem may be related to toxic or poisonous chemicals already present in his system). Thus, I prefer to wait until the patient is restrained, immobilized, examined, and evaluated before introducing any EMS chemicals.

RULE #3: BRING THE BACK BOARD TO THE PATIENT! Remember RULE #1? "Go To Ground And Stay There." That means that the back board must come to the patient. If you attempt to lift and move a combative patient - even when manually restrained by a provider holding each limb and major body part - you risk dropping the struggling patient, risking further injury to both patient and providers.

In a lovely, level, and clear environment (such as clear streets and highways), it shouldn't be a problem to slide a long back board under a manually restrained patient. Rather than sliding the board in from the side, however (where two or more providers are positioned, restraining the patient), slide the board under the patient from the head-down (or the feet-up).

Unfortunately, uneven terrain or piles of debris will interfere with sliding a board under the patient. In that case, get the board as close to and as level with the patient as possible. Working as a team, all providers must minimally lift and slide the patient onto the board.

Scoop stretchers are rarely helpful in any combative-patient restraint or immobilization situation. First, there's too many bodies on and about the patient to allow for efficient "scooping." Additionally, if attempting to "scoop" a patient who is on uneven or debris-filled terrain, you invariably meet with problems. Either you unevenly scoop-and-stress the patient's spine, or you scoop-up a bunch of debris along with your patient. Use a long back board. It's a good thing.

RULE #4: SILVER DUCT TAPE IS YOUR FRIEND! If applied in correct order and utilizing a specific manner of body-part restraint/immobilization application, silver duct tape can be a very effective, rapid method of securing the combative patient to a spine board. If you don't have silver duct tape, strong (double-folded) versions of Kerlix(r) or Kling(r) roller gauze are your next-best friends.

Whatever you use - duct tape or roller gauze - apply the restraint/immobilization material in the following order and manners:

  1. Immediately above the patient's knees: Attach one end to one side - above the knee - draw it tightly across the patient's legs, and attach the other end to a corresponding site on the other side. By attaching/immobilizing the patient's knees first, you immediately "free" two providers (the ones holding each leg) to assist with rapid application of the remaining restraint/immobilization devices.
  2. "Cross" ("X") the patient's shoulders: Attach one restraint end to the board immediately above one shoulder, then run it diagonally across the very top of the patient's chest to the opposite side, pulling it tightly, and attach it to the board immediately below the opposite armpit. Repeat on the other side. This technique successfully immobilizes the patient's chest to the board by means of an "X" over the shoulders. This technique is specifically designed to avoid interference with chest expansion (respiration).
  3. "Cross" ("X") the patient's hips: As with the shoulder restraint, begin by attaching the restraining material to one side of the board, at a site above one hip. Then run the restraint diagonally across the pelvis, pulling it tightly before attaching it to the opposite side of the board, about where the femur joins the pelvis. Repeat on the other side.
  4. Immobilize each wrist: If the patient is persistently combative, attempting to defeat the shoulder restraints, consider restraining one wrist above the head, the other below the hips. Remember to apply gentle traction of the extended wrist, anchoring the restraint at a point distal to the hand/wrist, so that this limb is "restrained" in an extended position and truly immobilized - not simply "tied up."
  5. Next, wrap a restraint around the ankles and attach it from side to side over the ankles.
  6. Now you must decide whether to immobilize the combative patient's head, or to obtain IV access and initiate chemical restraint. If IV chemical restraint is at your disposal, it may be a better choice at this point (thus minimizing the amount of patient resistance to head immobilization, and minimizing the stresses placed upon the patient's unprotected, unsupported C-spine). However, remember that you haven't performed a full examination or evaluation of the patient's injuries or medical condition as yet. Thus, chemical restraint may be equally as deleterious as head immobilization while the patient is still resistive and combative for unknown reasons.
  7. Whatever you do, when you are ready to immobilize the patient's head, use TAPE (silver duct tape or white-cloth) and apply it across the patient's forehead, from side to side, placing it DIRECTLY OVER THE PATIENT'S EYEBROWS! The eyebrows (the patient's superior orbits) will provide a substantial anchor for keeping the resistant patient's head from moving. This is not a cruel or depilatory manner of immobilization! As long as the tape is torn down the middle and removed by pulling it from the center out (in the direction of eyebrow hair growth), only a very few eyebrow hairs will be removed with the tape.
  8. And, now you may attempt to slide a C-collar into place - as long as it doesn't require struggle and manipulation of the C-spine to apply it! If any struggle or cervical spine manipulation is required to apply a C-collar, you are risking further injury to a patient who is already (for all intents and purposes) fully immobilized.
At this point, your combative, spine-injured patient has been completely immobilized in a manner that has minimized potential for care-provider-caused ("iatrogenic") aggravation of injuries! You may now cut away the patient's clothing, conduct a thorough and unimpeded exam, and perform all necessary care measures.


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Email Charly at: c-d-miller@neb.rr.com
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