Disability: Neuro & Spinal Assessment

The 'D' in the primary survey stands for Disability. Your goal is to establish a baseline neurological status and prevent secondary injury to the brain or spinal cord.

Neurological Assessment (AVPU & GCS)

For a rapid primary survey, use the AVPU scale:

• A - Alert: Eyes open, tracking, tracking normally.
• V - Voice: Responds to verbal stimuli (opens eyes or groans when spoken to).
• P - Pain: Responds only to painful stimuli (sternal rub, trapezius squeeze).
• U - Unresponsive: No response to any stimuli.

For a more detailed baseline, calculate the Glasgow Coma Scale (GCS) (Score 3-15). <redflag> A decrease in GCS of 2 or more points during your transport is a critical sign of rising intracranial pressure (ICP) and requires immediate notification to the receiving hospital. </redflag>

Pupillary Assessment

Check pupils for size, equality, and reactivity to light (PEARL).

• Unilateral Dilated Pupil: Suggests increasing ICP on that side of the brain (herniation).
• Pinpoint Pupils: Suggests opiate overdose or pontine hemorrhage.

Spinal Motion Restriction (SMR)

Historically, all trauma patients were placed on hard spine boards. Modern protocols emphasize Spinal Motion Restriction over strict immobilization, as rigid boards cause pain, pressure ulcers, and compromise breathing.

Indications for SMR (NEXUS Criteria)

Apply SMR if the patient has a mechanism of injury AND any of the following:

1. Midline cervical spine tenderness
2. Altered level of consciousness or intoxication
3. Focal neurological deficit (e.g., numbness/tingling in fingers)
4. Distracting painful injury (e.g., a femur fracture might mask neck pain)

Application Techniques

1. Manual In-Line Stabilization (MILS): The first responder holds the head in a neutral, in-line position. Do not release until the patient is fully secured or a collar is cleared.
2. Cervical Collar: Measure accurately using fingers from the top of the shoulder to the bottom of the chin. A poorly fitted collar is worse than no collar, as it can cause airway obstruction or increased ICP.
3. Log-Roll: Requires at least 4 personnel. The person at the head commands the roll. Ensure the spine remains straight during the maneuver to check the back and place the scoop stretcher.

<goldenrule> The cervical collar only restricts 30% of neck movement. True SMR requires the collar PLUS securing the patient's head to the stretcher using head blocks and tape. </goldenrule>

Traumatic Brain Injury (TBI) Management

In suspected severe TBI:

• Avoid hypoxia! A single episode of hypoxia (SpO2 < 90%) significantly increases mortality.
• Avoid hypotension! Keep systolic BP > 90 mmHg (or > 110 mmHg for older adults).
• Elevate the head of the stretcher 30 degrees (if spine is cleared or patient is secured) to help venous drainage and lower ICP.