Best Practices and Current Care Concepts in Prehospital Care of the Spine-Injured Athlete in American Tackle Football
March 2–3, 2019; Atlanta, GA

When dealing with a potentially life-threatening situation such as an athlete with a spine injury, the injury scene is not the time or place for health care providers to debate appropriate treatment. Proper emergency preparation before the event helps to optimize proper care. Athletic programs should have an emergency action plan (EAP) developed in conjunction with the local emergency medical services (EMS) agency. Spine injuries are unpredictable and can occur at any time during practice or competition. Proper management of emergencies in athletics is critical. The development of the EAP should be a collaborative effort of the sports medicine team, local EMS personnel, and others who might be involved in helping to provide emergency care to the injured athlete. When multiple agencies may be responsible for responding to the emergency, it is always good practice to involve all local EMS agencies in developing and implementing the EAP. Inclusion and concurrent training of various health care providers during EAP creation reduces the likelihood of confrontations among multidisciplinary health care providers and promotes coordinated, efficient delivery of vital lifesaving psychomotor skills to critically injured patients.¹⁷  The EAP should be reviewed and approved by the medical director and by all parties at least annually.

Best practice is to develop a protocol for the spine-injured athlete specific to the sport venue that is reviewed and approved by the medical director. This helps to educate all team members about specific management procedures, including scenario-based training (eg, athlete in prone or supine position; barriers or space restrictions; the combative athlete; emesis; respiratory or cardiac arrest or both; limited number of rescuers onsite) with the entire medical care team and with EMS represented. The EAP and procedures should be reviewed, rehearsed, and documented on a regular basis (at least yearly), and athletic emergency responses should be documented. The sports medicine team is advised to review each emergency response postincident for quality improvement purposes.¹⁸ 

Emergencies should be handled by trained medical personnel. Preparation is essential and should include education and scenario-based training; maintaining emergency equipment and supplies; selecting personnel; and creating, practicing, and implementing an EAP.^19–22  An athletic trainer or other sport-trained medical provider should ideally be present at high-risk activities. If medical personnel are not present, sports administrators should develop procedures for implementing the EAP. The role of the sports medicine team includes the following:

• Establishing and controlling scene safety,

• Activating the EMS system,

• Directing EMS to the scene, and

• Initiating and directing care of the injured athlete.

The primary steps for assessing and managing the spine-injured athlete are scene survey, primary survey, stabilizing the head and spine, immediately deploying life-preserving procedures as necessary, transferring to an SMR device, secondary survey, and transport to an appropriate preselected medical facility.²³  Periodic reassessment should be performed to recognize any change in the athlete's condition and after interventions by the medical staff.

It is essential that a transportation plan and hospital destination be identified as part of the EAP. The hospital choice should be based on the strengths and capabilities of the facility for providing advanced cervical spine injury care as well as on local EMS protocols. When planning the EAP, personnel should give strong consideration to the transport of spine-injured athletes to hospitals with trauma center designations. Level 1 and 2 trauma centers provide acute, urgent care for the most seriously injured and potentially seriously injured patients. The hospital should have a protocol for equipment removal. Options include having individuals at the hospital trained in equipment removal or allowing a team medical representative skilled in equipment removal to accompany the athlete to the hospital and be available to assist with equipment removal. If possible, an on-field medical provider should accompany the athlete to the hospital. That person can directly inform the hospital staff of the history and actions taken on the field, assist with equipment removal as needed, and communicate to the team or opponent the status of the athlete's care at the hospital. If medical personnel travel with the athlete to the hospital, the need for continued coverage of the athletic event must be addressed.

Sports medicine teams should conduct a pre-event medical time out before each athletic event (both practices and competitions). Best practices for the precompetition medical timeout require the presence of medical personnel from both teams, EMS personnel, and game officials. Because miscommunication may lead to potentially catastrophic errors, information sharing and team and skill coordination among the emergency medical providers are critical components of emergency medical care and the obligation of the host institution or organization. The medical time out should include a review of items such as the presence of medically qualified personnel onsite, available equipment, management protocols for patients with suspected catastrophic injuries, the medical professional in charge of the response, signals and communication, contact numbers for local facilities, EMS response routes (primary and secondary), transport procedures, and local hospital trauma-management plans. Additionally, a review of the equipment to be used will prevent the inadvertent use of equipment that may not fit into the transport vehicle. It is incumbent on the host to coordinate with the visiting team and medical personnel to ensure that a coordinated emergency approach is in place for an athlete with a suspected catastrophic injury.²⁴  Advance preparation is crucial, particularly for those events hosted at neutral sites, where neither team is familiar with the venue or local medical facilities.

For best practice, the emergency scene must be controlled, calm, and orderly to facilitate optimal medical care. It has been said that “calm is contagious.”²⁵  Bystanders may be well intentioned but cause distractions and interfere with the delivery of care. As a part of the medical time out before the competition, sports medicine personnel from both teams should review their responsibilities in the event of an injury with the game officials. Maintaining a buffer zone between the athlete and all nonmedical people allows adequate space for the sports medicine team to work and position emergency equipment, carts, and ambulances. If available, coaches and other team personnel (administrators, operations, event management, chaplains, etc) can assist in maintaining the buffer zone (Figures 1 and 2).

Regardless of airway status, airway access should always be achieved before transport (Figure 3) by removing either the face mask (Figure 4) or the helmet (Figure 5).²⁶  Historically, the recommendation for accessing the airway in a football athlete with a suspected spine injury has been to remove the face mask from the helmet while keeping the helmet and shoulder pads in place during transport.^27,28  Rescuers may elect to remove the chinstrap, which can limit manual airway maneuvers such as the modified jaw thrust and prevent an adequate seal of the bag-valve mask to the face. Although previous guidelines³  have worked well clinically, researchers^29–36  suggested that, in certain circumstances, the helmet and shoulder pads may be removed. Control of an athlete's compromised airway may be affected by protective equipment. Health care professionals should be familiar with multiple airway maneuvers and ventilation techniques.³⁶  When deemed necessary by onsite medical personnel, removal of the helmet and shoulder pads may be performed before transport, eliminating the need for separate face mask removal.

The highest priority when considering helmet and shoulder pad removal is maintaining circulation, airway, and breathing (CAB). Traditionally, immediate transport to a designated hospital after on-field face mask removal has been advised for the athlete with a suspected cervical spine injury and remains a reasonable option. A decision to remove equipment before transport should be based on a variety of factors, including the medical status of the injured athlete, type of protective equipment worn (eg, helmet, shoulder pads, neck roll, rib pads), number of onsite rescuers, and training and experience levels of the rescuers in equipment removal. When it is deemed appropriate to remove the helmet and shoulder pads before transport, they should be removed together when possible. To safely remove the helmet and shoulder pads, 2 to 9 trained rescuers (depending on the technique selected) are recommended. Alternate strategies may be necessary based on changes in clinical status, equipment failure, space barriers, etc. The medical team should recognize when it is unnecessary or inappropriate to remove equipment on the field and have a plan for best management of the patient in those situations.²⁶ 

The advantages of on-field removal of the helmet and shoulder pads include improved airway management; access to the chest if cardiopulmonary resuscitation (CPR), use of an automated external defibrillator (AED), or both are necessary (Figure 6); and expedited care of the athlete. The quality of basic life support skills (chest compressions and ventilations) may be compromised in the presence of certain athletic equipment.^29–31,36  Shoulder pads may inhibit consistent chest compressions of adequate depth and full pulmonary expiration.³¹  Trained and experienced personnel may remove helmets faster than face masks.³¹  Shoulder-pad removal may be accomplished safely during the packaging sequence.^32–34  For ventilations, the helmet complicates a jaw-thrust maneuver and pocket or bag-valve mask placement,^29–31,36  whereas the football-helmet chin strap can prevent the mask from creating an adequate ventilatory seal.³¹  Finally, proper placement of AED pads may be complicated if obtaining access to the chest is difficult. With helmets and shoulder pads removed in the prehospital setting, evaluation, treatment, and diagnostic tests may be expedited while in transport and at the receiving emergency facility.

The rationale for prehospital equipment removal is based on the following concepts.³ 

Recent studies and changes to the International Liaison Committee on Resuscitation guidelines (https://www.ilcor.org) prioritize compressions and AED deployment over ventilations. Both procedures require access to the chest, thus necessitating equipment removal. Removal of the shoulder pads may be supported by research²⁹  demonstrating that when the shoulder pads remained on the athlete, the adequacy of chest compressions was compromised. Providers should be familiar with shoulder and chest padding and equipment to determine the most efficient method of gaining access to the chest. Previous authors^{19,26,30,31,34}  advised cutting American football shoulder pads in front. However, some new shoulder-pad designs cannot be removed by cutting through the front area. Shoulder pads of this design prevent access to the chest and must be removed if CPR is needed.

Although less motion occurs during face-mask removal compared with helmet removal, the helmet must be removed at some point. In some instances, helmet removal may be faster than face-mask removal. Using a simulation manikin, researchers³³  demonstrated that certain airway adjuncts may provide adequate ventilation in the helmeted football player. However, the ability to provide proper ventilations with 1- and 2-person bag-valve mask procedures may be impeded when the helmet and chin strap remain on the athlete.

In most cases, athletic trainers have been exposed to more equipment removal training than many other members of the emergency medical team. Compared with hospital ED staff, onsite medical professionals (eg, athletic trainers, emergency medical technicians, physicians) often possess the requisite tools and experience necessary to safely and efficiently remove athletic equipment. However, when removing equipment on field is not appropriate (eg, status of the injured athlete, insufficient personnel, personnel not trained in equipment removal), removal should occur in the hospital setting. Thus, best practice is for EDs identified as receiving facilities in the EAP to train all staff members in equipment removal.

Applying a cervical immobilization device may be difficult while protective equipment is in place because of the lack of space between the helmet and shoulder pads. In some cases, such application may actually be contraindicated due to the motion involved.^28,37 

Certain changes in helmet and shoulder pad design have facilitated equipment removal, which in turn have helped limit spinal motion.

With protective athletic equipment such as helmets and shoulder pads removed in the prehospital setting, evaluation, treatment, and diagnostic tests may be expedited during transport and on acceptance by the receiving emergency facility. When deciding to remove equipment, considerations should include the status of the athlete and where the highest number of appropriately trained personnel are located.

The typical patient with a suspected SCI presents without equipment, and many EMS and ED personnel are not familiar with procedures for removing sporting equipment. Yet the removal of equipment by untrained individuals or trained individuals with minimal practice or experience is not ideal. The Supplemental Table, “Rationale for Medical Personnel to Remove Equipment Before Transport” https://www.nata.org/practice-patient-care/health-issues/spine-injury provides an overview.

Furthermore, limitations to helmet and shoulder-pad removal in the prehospital setting exist. Removing the face mask alone may provide adequate access to the airway for certain airway adjuncts (eg, laryngeal mask airway, other supraglottic airways, endotracheal tube) with less cervical motion than from helmet removal.³⁵  Removing the face mask and leaving the helmet and shoulder pads in place requires fewer trained and experienced personnel and may result in less cervical spine motion while the athlete receives care on the field. The ED is better equipped to manage complications (eg, worsening neurologic status; cardiac or respiratory arrest or both) that may arise during the early stages of care of a spine-injured athlete. In some situations, removal of the helmet and shoulder pads may extend the time until the athlete is transported for definitive care.

Sports medicine, EMS system, and ED personnel providing care for equipment-specific sports should be familiar with athletic equipment as well as a variety of safe sport-specific equipment-removal techniques.

A wide variety of face masks and helmets exist. It is important for rescuers to be aware of the different face-mask and helmet types on the market and their features (eg, quick-release clips for a face mask) and knowledgeable about removal options. A combined-tool approach was reported to be 98% to 100% successful for removing face masks from football helmets. Thus, immediate access to a cordless screwdriver and a cutting device is optimal for face-mask removal.^38,39  Helmets with quick-release clips result in faster face-mask removal and comparable success rates.^40,41  The helmet and face-mask attachments should ideally be maintained throughout the season and, at a minimum, before the start of each season. If the facemask cannot be removed in a timely manner, helmet removal may be necessary to access the airway in the event of respiratory distress or arrest. If the helmet is removed in this scenario, either the shoulder pads should also be removed or padding should be placed in the space created by the helmet removal beneath the head to prevent cervical spine extension.

In a life-threatening situation, it is important to have chest access.^29,31  Therefore, onsite medical personnel should be familiar with shoulder-pad construction, accessories (eg, string ties, coated webbing, high-impact plastic, cervical rolls, rib pads), and removal techniques.

As complete immobilization of the cervical spine is not possible, the term SMR is used to designate various procedures for stabilizing the cervical spine. The premise of SMR is to reduce spinal motion and prevent further harm to the spinal cord.²³ 

• Blunt trauma and altered level of consciousness,

• Spinal pain or tenderness,

• Loss of cervical range of motion,

• Neurologic complaint or findings (eg, numbness or motor weakness in more than 1 limb), or

• Anatomic deformity of the spine

Spinal-motion restriction is not necessary when the athlete has a normal level of consciousness, no spine tenderness or anatomic abnormality, and no neurologic findings or complaints.^42,43 

The first step in SMR is in-line stabilization provided by the first on-scene rescuer once a spine injury is suspected, using either the head squeeze or the trap squeeze, both of which are accepted stabilization techniques for the cervical spine. The rescuer stabilizing the cervical spine should stabilize the head using his or her hands with the thumbs pointing toward the face (Figure 7), regardless of whether the athlete is supine or prone.⁴⁴ 

If possible, the cervical spine should be immobilized in a neutral position or in normal axial alignment. This facilitates airway management and application of immobilization devices and reduces the spinal cord morbidity that would otherwise result from compromised local circulation.²⁷  Once the spine is in a neutral position, spine alignment may involve packing and filling the space with foam padding or towels; for example, an athlete with kyphosis may have a space between the occiput and SMR device.

In an athlete with a suspected cervical spine injury, the highest priority is maintaining CAB while minimizing cervical spine motion so as to minimize further neurologic impairment. Alignment should be sufficient to maintain a patent airway. In an awake, responsive, and cooperative athlete, trained medical personnel should use their clinical judgment and discretion before working with the patient to gently, either actively or passively, attain in-line cervical spine stabilization before transport. If the athlete's consciousness is impaired, active manipulation of the spine should be avoided unless it is deemed necessary by trained medical personnel to maintain CAB. Cervical spine realignment procedures should be abandoned and the neck stabilized in the current position if pain increases, neurologic signs or symptoms deteriorate, or resistance to movement is present.

Athletes with spine injuries should be secured to an SMR device before transport. However, prolonged time (ie, transport time, wait time in the ED, expected time for patient evaluation and removal of the SMR) on a rigid spine board should be assessed. If the transport time is expected to be short, it may be better to transport the athlete on the device and remove it on arrival at the hospital. If the decision is made to remove the extrication device in the field, SMR should be maintained by ensuring that the patient remains securely positioned on the ambulance stretcher with a cervical collar in place.⁴³  Wide national variability exists regarding SMR devices. Devices for SMR may include an EMS stretcher, long spine board, rigid cervical collar, scoop stretcher, vacuum mattress, and vest-type immobilizer (eg, Kendrick extrication device; Figure 8). When selecting an SMR device, it is important to be aware of local and state EMS protocols. Transport of the spine-injured athlete requires special considerations that may include but are not limited to the injury mechanism, athlete's size, equipment worn, and the number and skill levels of the sports medical team members.

Many EMS systems have changed their guidelines to limit the use of long spine boards for prehospital spine injury management and transport.^42,45–48  This underscores the need to be familiar with local EMS system policy. The changes were based in part on epidemiologic studies^49–52  that were not specific to the athletic population and included patients with SCIs from a variety of mechanisms. These changes suggest that the athlete with a suspected spine injury should be extricated using an SMR device and then removed from the device and placed on a nonrigid EMS stretcher (Table). Historically, the use of the rigid immobilization device for an athlete with a cervical spine injury has been successful clinically.³  Thus, in the case of a spine-injured athlete, a rigid immobilization device (ie, long spine board, scoop stretcher, vacuum mattress) is still recommended for SMR and during transport whenever possible. However, every effort should be made to minimize the time an athlete lies on the long spine board.^43,46  The ED medical team is encouraged to assess the athlete on arrival with transfer to an appropriate hospital bed as soon as safely possible.^53–56  Rescuers can help mitigate discomfort from the rigid long spine board by using a commercial padded spine board, applying adhesive foam padding to a standard spine board,^43,57  or using a vacuum pad on top of a spine board that may be molded to the athlete's body.

Because every emergency and every patient is different, health care professionals should review and rehearse a variety of transfer techniques.²⁶  Effective communication should be delivered with clear and concise commands during the motion restriction and transfer. Commands for transfer techniques should be given by the rescuer stabilizing the head and cervical spine. This avoids any confusion as to who is in charge, and all rescuers should focus on this individual for direction. The log-roll technique is used for prone athletes⁵⁶  and may be used for supine athletes as well (Figure 9). The scoop stretcher⁵⁸  may also be used to lift the supine athlete from the field.⁵⁹  The multiperson lift (previously described in the literature as the 6-plus lift)⁶⁰  has been associated with less cervical motion in cadavers with unstable spines (Figure 10). The number of people and transfer technique selected to move a spine-injured athlete should be determined by the medical professional in charge at the scene and the resources available. Note that variations of transfer techniques exist (eg, verbal commands, hand positions, board angles, centering techniques).

The multiperson lift (previously called the 6-plus lift or lift and slide) is used to move a suspected spine-injured athlete from the injury scene to a rigid SMR device (often a long spine board), which can then be lifted onto a stretcher and placed in the transport vehicle.

• Rescuer 1 (positioned at the head) provides manual in-line stabilization of the head and cervical spine (Figure 11).

• Rescuers 2 through 4 and 5 through 7 position themselves on each side, kneeling at the chest, pelvis, and legs to assist with the lift (Figure 12).

• Rescuer 1 gives the commands directing the others to lift the athlete in unison approximately 6 in (15 cm) off the ground.

• Rescuer 8 slides the long spine board into place beneath the athlete from the foot end.

• Once the SMR device is in position, the athlete is lowered carefully following the commands of Rescuer 1.^28,59–63 

• Rescuer 1 (positioned at the head) provides manual in-line stabilization of the head and cervical spine (Figure 13).

• Rescuers 2 through 4 assist in rolling the athlete.

• On command from Rescuer 1, the athlete is rolled 90° to the side-lying position. Rescuer 5 then wedges the long spine board under the athlete at a 45° angle to the ground.^62,64 

• On command, the athlete is carefully rolled back to the supine position onto the rigid SMR device.

• If the athlete is not centered on the long spine board, additional adjustments may be needed to shift the patient to the center.

• In some instances, the log roll may be completed with fewer rescuers.²³ 

• Rescuer 1 (positioned at the head) provides in-line stabilization of the head and cervical spine using a crossed-hands position (Figure 14).

• Rescuers 2 through 4 are positioned along the athlete's body on the same side the athlete's head is facing. The positions of these rescuers are at the athlete's shoulders and chest, hips, and legs.

• Rescuer 5 prepares the long spine board.

• On command from Rescuer 1, the athlete is slowly rolled away from Rescuers 2 through 4 (ie, pushing) toward the rigid SMR device, which is positioned by Rescuer 5 under the athlete at a 45° angle to the ground.

• Once the rigid SMR device is in place, the rescuers readjust their hand positions, and the athlete is slowly lowered to the rigid SMR device on command of Rescuer 1.^28,56 

• If available, additional rescuers may be positioned on both sides for a hybrid prone log-roll pull-push technique.

• Rescuer 1 provides in-line stabilization of the head and cervical spine using a crossed-hands position (thumbs toward the face; Figure 15).

• Rescuers 2 through 4 are positioned at the athlete's shoulders and chest, hips, and legs, opposite the direction in which the athlete's head is facing.

• On command from Rescuer 1, the athlete is slowly pulled toward Rescuers 2 through 4 while the long spine board is positioned against the thighs of the rescuers.

• The athlete is slowly lowered to the rigid SMR device following the commands of Rescuer 1.²⁸ 

• The log-roll pull may be used in confined spaces where it is not feasible to position rescuers on both sides of the athlete. If available, additional rescuers may assist.

Once transferred onto the spine board, the athlete may need to be centered before being secured to the device. Centering methods that have been used include the horizontal slide, diagonal slide, and V-adjustment method. When these methods were compared in cadavers,⁶⁵  the horizontal slide best limited cervical spine motion, so it may be the most helpful for minimizing secondary injury.

The scoop stretcher may be used to lift and transfer a supine athlete (Figure 16).

• The scoop stretcher should first be adjusted to the length of the athlete.

• Then it is separated into 2 parts at the hinged interlocking device at each end.

• Each half is wedged under the athlete.

• Rescuer 1 (positioned at the head) stabilizes the head and cervical spine while Rescuers 2 and 3 push the scoop-stretcher halves under the athlete until the hinges are latched and in the locked position.⁵⁹ 

• Care must be taken to avoid touching the arms of the rescuer immobilizing the head and cervical spine.

Vacuum immobilization is used more frequently in Europe than in the United States. The athlete is placed on the vacuum mattress, and then air is removed with a pump while the mattress is molded to the athlete (Figure 17). It has been shown to be more comfortable than the long spine board; however, the long spine board is rigid and cannot experience catastrophic failure, such as loss of the vacuum. If available, vacuum immobilization provides an excellent option for SMR. Full rigid spine board and full-body vacuum immobilization are equivalent in the degree of cervical spine immobilization.^66,67  Vacuum immobilization may be used with football equipment either on or off.

Placing an athlete on an immobilization device in preparation for transportation requires sound strapping techniques. The traditional 3-strap technique for the chest, pelvis, and thighs may allow cephalocaudal movement on the SMR device. Incorporating an X-strap technique⁶⁸  (shoulders, axillae, hips) minimizes cephalocaudal movement on the immobilization device. This may be accomplished by use of a hook-and-loop spider or X-straps (Figure 18) or a speed clip-and-pin system (Figures 19 and 20). The athlete should be centered on the SMR device with the body secured, making sure to keep the arms free. The torso is more secure with the strapping system applied directly to the body. Having the arms free facilitates intravenous access and neurovascular reassessment in the ambulance. If needed, the wrists can be secured together with hook-and-loop straps or tape (Figure 21). The body should always be secured to the SMR device first, followed by the head. This is important in the event that the athlete requires log rolling during preparation to clear the airway of vomitus or blood. If the body is secured to the SMR device, the rescuer can stabilize the head and cervical spine manually during the movement.

A variety of head-immobilization devices are available (Figure 22). The head should be stabilized with a lightweight block or roll. Weighted blocks such as sandbags are now contraindicated as they can move the head laterally if the athlete vomits and must be turned to clear the airway. Tape should be applied to secure the head at 2 points of contact: (1) eyebrows as landmarks for the forehead and (2) chin.

If the helmet and shoulder pads are removed before transport, a properly fitted rigid cervical stabilization device should be applied to any athlete suspected of having a cervical spine injury (Figure 23). With practice, rescuers can place and remove a cervical collar with minimal risk while maintaining manual in-line stabilization of the head and neck.⁶⁹  The type of rigid cervical collar should be selected in advance. Many different types of cervical motion restriction devices are available. The device should be adjustable or available in various sizes to fit all athletes. In-line stabilization should be maintained even after application of the device until the athlete is secured properly to an SMR device.²³ 

Because researchers^50–52,70  have demonstrated that rigid cervical collars cannot limit cervical spine motion in all planes of movement, manual in-line stabilization should be maintained until the athlete has been stabilized on a full-body SMR device (eg, long spine board, vacuum mattress, EMS stretcher) and a head-stabilization device has been applied. Despite these limitations, cervical collars may reduce cervical motion in patients with potentially unstable spines, thereby outweighing their possible disadvantages. The “Spinal Motion Restriction in the Trauma Patient—A Joint Position Statement” stated, “An appropriately sized cervical collar is a critical component of SMR and should be used to limit movement of the cervical spine whenever SMR is employed.”^43(p660)

When the decision is made for transport with the equipment in place, the face mask should be removed first, regardless of the athlete's current respiratory status. Tools for face-mask removal should be readily accessible, and a combined-tool approach is optimal. Quick-release facemask clips facilitate face-mask removal. Rescuers should be aware that, in some instances (ie, certain brands of youth football helmets), the face mask cannot be removed.

Whether before transport or at the ED, the helmet and shoulder pads should be considered a unit and removed. Once the equipment-removal process begins, the helmet is removed first, followed by the shoulder pads. If the decision is made to remove the helmet, it may not be necessary to remove the face mask first, as helmet removal will allow airway access. Commands for helmet and shoulder-pad removal should be given by the rescuer stabilizing the head and cervical spine.

To remove the helmet, the jersey and then the front of the shoulder pads must first be cut, exposing the chest. This allows 1 of the rescuers to access and secure the cervical spine from the front so that the rescuer positioned at the head can remove the helmet. Rescuers should then fit and apply a cervical collar. The athlete should be secured to a rigid SMR device (ie, EMS stretcher, full-body vacuum mattress, scoop stretcher, long spine board, or vest-type immobilizer).

• Rescuer 1 (positioned at the head) stabilizes the head and cervical spine.

• Rescuer 2 (positioned at the side of the athlete) cuts the helmet chin strap (note that the chin strap should not be unsnapped to avoid any inadvertent head movement). With newer helmet models' ear channels, it may not be necessary to remove the cheek pads.

• Rescuer 2 cuts the jersey and shoulder pads in front with a T-cut: sleeve to sleeve and collar to waist (Figures 24 and 25).

• Rescuer 2 assumes cervical spine control from the front (Figure 26), allowing Rescuer 1 to release: “I have C-spine control; you can release.”

• Rescuer 2 secures the cervical spine using an anterior-posterior stabilization technique (Figure 27). The bottom hand carefully cradles the cervical spine and occiput while the top hand grips the chin and jaw, controlling rotation. The top forearm may rest on the athlete's chest, providing additional control. This technique provides a secure hold for stabilizing the cervical spine. Previous medial-lateral stabilization techniques in which the rescuer gripped the side of the athlete's head were limited by the cheek pads inside the helmet (Figures 28 and 29). The weight of the head may cause the cervical spine to extend when the helmet is removed. The anterior-posterior stabilization technique provides additional security to limit cervical extension. However, the medial-lateral stabilization technique may be needed if the posterior hand-placement technique increases pain. Placing the posterior hand inside the shoulder pads and on the occiput may result in contact with the injured area, especially if a deformity is present. Thus, the medial-lateral stabilization technique is still a viable option in some situations. The SMR team should practice both anterior-posterior and medial-lateral stabilization and be comfortable with both techniques.

• Rescuer 1 removes the helmet and then again assumes cervical spine control, allowing Rescuer 2 to release: “I have C-spine control; you can release.”

Several techniques are used to remove shoulder pads (after helmet removal). Rescuers should select the techniques that best fit the individual circumstances of each athlete. With the supine athlete, options for shoulder-pad removal include the following:

• As described previously, the helmet has already been removed.

• Rescuer 1 (positioned at the head) stabilizes the head and cervical spine.

• Before lifting, the rescuers should cut all shoulder-pad straps as well as chest straps and any other straps securing the pads to the body (eg, rib pads, spider pads, cervical collars), allowing the pads to be removed.

• On command of Rescuer 1, Rescuers 2 through 7 (3 on each side) lift the athlete approximately 12 in (30.5 cm) off the ground in unison (the lift must be higher than in the standard multiperson lift to allow shoulder-pad clearance during removal).

• Rescuer 8 slides the board beneath the athlete.

• Rescuer 9 carefully removes the shoulder pads without interfering with Rescuer 1's control of the head and cervical spine.

• Once Rescuer 9 verbalizes, “Shoulder pads are clear,” the athlete is lowered to the board on the command of Rescuer 1.

• Rescuer 1 maintains cervical spine control while a cervical collar is measured and placed on the athlete.

• As described previously, the helmet has already been removed.

• Rescuer 1 (positioned at the head) stabilizes the head and cervical spine (Figure 30).

• Rescuer 2 (positioned at the side of the athlete) assumes cervical spine control from the front, allowing Rescuer 1 to say, “I have C-spine control; you can release.”

• Before lifting, the rescuers should cut all shoulder-pad straps as well as chest straps and any other straps securing the pads to the body (eg, rib pads, spider pads, cervical collars), allowing the pads to be removed.

• On command of Rescuer 2, Rescuers 3 and 4 carefully lift the athlete up, tilting the athlete to 30° at the waist, similar to the motion of a sit-up. An alternate method involves 1 rescuer straddling the athlete to tilt the torso for shoulder-pad removal.

• Rescuer 1 removes the shoulder pads from over the top of the head.

• Rescuer 1 then grasps both sides of the head and assists Rescuer 2 with cervical spine stabilization as the athlete is lowered on command of Rescuer 2.

• Rescuer 1 again assumes cervical spine control and states, “I have C-spine control; you can release.”

• Rescuer 1 maintains cervical spine control while a cervical collar is measured and placed on the athlete.

• Note that the tilt should not be used to remove the shoulder pads when a concomitant thoracic or lumbar injury may be present.⁶⁸ 

• As described previously, the helmet has already been removed.

• Rescuer 1 (positioned at the head) stabilizes the head and cervical spine (Figure 31).

• Rescuer 2 (positioned at the side of the athlete) assumes cervical spine control from the front and says, “I have C-spine control; you can release.”

• The jersey and shoulder pads were previously cut in the front during helmet removal. Rescuers should cut all shoulder-pad straps as well as chest straps and any other straps securing the pads to the body (eg, rib pads, spider pads, cervical collars), allowing the pads to be removed.

• On command of Rescuer 2, Rescuers 1 and 3 grasp the shoulder pads from either side of the athlete and carefully slide the pads out in an axial direction while Rescuer 2 maintains cervical spine control; this technique may also be executed by 1 trained rescuer (positioned at the head) who carefully slides the pads out while the other rescuer (positioned at the side of the athlete) stabilizes the head and cervical spine.

• Rescuer 1 then again assumes cervical spine control and states, “I have C-spine control; you can release.”

• Rescuer 1 maintains cervical spine control while a cervical collar is measured and placed on the athlete.

• As described previously, the helmet has already been removed.

• A standard log-roll technique is used. Rescuer 1 stabilizes the head and cervical spine.

• On command of Rescuer 1, Rescuers 2 through 4 perform a supine log roll, pausing at the top of the roll.

• Rescuer 5 cuts the jersey and shoulder pads in the back and positions the long spine board. The athlete is lowered onto the board on command of Rescuer 1.

• The jersey and shoulder pads were previously cut in the front during helmet removal. Rescuers should cut all shoulder-pad straps as well as chest straps and any other straps securing the pads to the body (eg, rib pads, spider pads, cervical collars), allowing the pads to be removed.

• The shoulder pads, now separated in both the front and back, are removed from each side by Rescuers 2 and 3 on command of Rescuer 1.

• Rescuer 1 maintains cervical spine control while a cervical collar is measured and placed on the athlete.

• Some shoulder pads are designed with a quick-release mechanism for emergency removal. This involves pulling a cable, which separates the shoulder pads in the back.

• As described previously, the helmet has already been removed.

• Rescuer 1 (positioned at the head) stabilizes the head and cervical spine.

• Rescuer 2 (positioned at the side of the athlete) cuts the emergency quick-release tab and pulls a cable, releasing the shoulder pads in back.

• Rescuers should cut all shoulder-pad straps as well as chest straps and any other straps securing the pads to the body (eg, rib pads, spider pads, cervical collars), allowing the pads to be removed.

• The shoulder pads, now separated in both the front and back, are removed from each side by Rescuers 2 and 3 on command of Rescuer 1.

• Rescuer 1 maintains cervical spine control while a cervical collar is measured and placed on the athlete.

• This technique may be used when it is not possible to cut the shoulder pads in front for any of the techniques discussed earlier.

• As described previously, the helmet has already been removed.

• Rescuer 1 (positioned at the head) stabilizes the head and cervical spine.

• Before lifting, rescuers should cut all shoulder-pad straps as well as chest straps and any other straps securing the pads to the body (eg, rib pads, spider pads, cervical collars), allowing the pads to be removed.

• Rescuer 2 (positioned at the side of the athlete) reaches up under the shoulder pads and takes control of head and cervical spine stabilization from Rescuer 1.

• On command of Rescuer 2, the elevated-torso or tilt technique is executed while Rescuer 2 stabilizes the head and cervical spine from the front.

• Rescuers 3 and 4 carefully lift and tilt the athlete to 30° at the waist, similar to the motion of a sit-up.

• Rescuer 1 removes the shoulder pads over the top of the head.

• Rescuer 1 grasps both sides of the head and assists Rescuer 2 with cervical spine stabilization as the athlete is lowered on command of Rescuer 2.

• Rescuer 1 again assumes cervical spine control and says, “I have C-spine control; you can release.”

• Rescuer 1 maintains cervical spine control while a cervical collar is measured and placed on the athlete.

• Note that the tilt should not be used to remove the shoulder pads when a concomitant thoracic or lumbar injury may be present.⁶⁸ 

To remove shoulder pads from the prone athlete, a log roll is necessary as the multirescuer lift-and-slide and scoop-stretcher techniques can only be used on supine athletes.^56,71  Rescuers should select either the log-roll–push or log-roll–pull technique based on the circumstances of each athlete.

• Rescuer 1 (positioned at the head) stabilizes the head and cervical spine.

• Before initiating the log roll, Rescuer 2 (positioned at the side of the athlete) cuts the jersey and shoulder pads in the back and positions the long spine board.

• On command of Rescuer 1, the log-roll procedure is performed by Rescuers 2 through 5 as described earlier.

• Once the athlete is rolled to the supine position, the jersey and shoulder pads are cut in the front by Rescuer 2, and the helmet is then removed as explained previously.

• Rescuers should cut all shoulder-pad straps as well as chest straps and any other straps securing the pads to the body (eg, rib pads, spider pads, cervical collars), allowing the pads to be removed.

• The shoulder pads, now separated in both the front and back, are removed from each side by Rescuers 2 and 3 on command of Rescuer 1.

• Rescuer 1 maintains cervical spine control while a cervical collar is measured and placed on the athlete.

Other considerations in shoulder-pad removal include any attached accessories, such as cervical collars, rib pads, or back pads, and difficulty in cutting or being unable to cut the pads.

If feasible, an athlete with a spine injury should be transported to a medical facility that can deliver immediate and definitive care if a significant cervical spine injury has occurred. This includes a cervical spine fracture with or without SCI.^1,3 

Immediate and definitive care for the spine-injured athlete includes the following:

• Emergency department staffed with board-certified or -eligible emergency medicine physicians;

• Personnel trained in equipment removal, with a protocol in place to allow team medical personnel to assist with equipment removal;

• Advanced imaging services such as computed tomography and magnetic resonance imaging scanning available within 30 minutes;

• Spine surgeon consultation in house or available within 30 minutes;

• 24/7 operating room access;

• Critical care physiological and neurologic monitoring; and

• Rehabilitation services or a preexisting referral system.

In most cases, spine-injured athletes should be transported to a predetermined trauma center or a large community hospital with the ability to deliver immediate and definitive care. If such comprehensive care is not readily available, the patient should be transported to the closest appropriate hospital for stabilization and possible air medical evacuation to the nearest trauma center. However, attempts should be made to avoid this additional delay in definitive care as the patient may have a better outcome with expeditious definitive management.⁷²  The risk of complications increases when a patient remains on the long spine board for an extended period of time after arrival at the ED. Increased tissue-interface pressures at the occiput, sacrum, and heel have been reported with prolonged immobilization.^73,74  Furthermore, the risk of further neurologic compromise increases every time a patient with spinal instability is moved.⁵⁰  For this reason, transfers within the ED should also be kept to a minimum and appropriate transfer devices used whenever possible.^{53–55,75,76} 

When an athletic trainer or team physician is involved in the transport of a spine-injured athlete, he or she should offer to assist the ED staff with the athlete's care. Establishing the role of the athletic trainer or other medical provider who accompanies the athlete to the ED before the season starts is a valuable part of the EAP.

The highest priority is for all onsite personnel to be adequately trained and to have rehearsed the techniques necessary to protect the spine of the spine-injured athlete. Sports medicine teams should review and rehearse emergency procedures, spine management, and equipment-removal techniques on a regular basis. Training improves the ability to care for an athlete with a suspected spine injury. Training should be scenario based and practical, simulate emergency conditions, and encompass all members of the interdisciplinary health care team. Venue-specific training and rehearsal (including at practice facilities and game sites) should occur at least annually.^1,3 

Sports medicine professionals should continue to investigate the roles of equipment, airway devices, and SMR in caring for athletes with suspected spine injuries. The sports medical team should keep abreast of evidence-based treatment options for the spine-injured athlete.^1,3  As outlined in this document, it is important for medical teams be knowledgeable about procedures and recommended changes for SMR.¹⁷  Future researchers should focus on improving assessment and management strategies to optimize outcomes.

The most important factors in providing optimal care to the athlete with a cervical spine injury are communication among and collaboration of the health care professionals involved in providing care, preparation and practicing of an EAP, review of the EAP at a medical time out before the start of a competition, review of procedures for equipment removal in sports with equipment-laden athletes, procedures for providing SMR, and transport to the appropriate medical facility. Didactic teaching as well as hands-on, practical, scenario-based training improves the ability to care for an athlete with a possible spine injury.^1,3 

The National Athletic Trainers' Association (NATA) and the Spine Injury in Sports Group (SISG) advise individuals, schools, athletic training facilities, associations, and institutions to carefully and independently consider these recommendations. The information contained in the document is neither exhaustive nor exclusive to all circumstances or individuals. Variables such as institutional human resource guidelines, state or federal statutes, rules, or regulations, and regional environmental conditions may affect the relevance and implementation of these recommendations. The NATA and the SISG advise constituents and others to carefully and independently consider each recommendation (including its applicability to any particular circumstance or individual). The foregoing statement should not be relied upon as an independent basis for care but rather as a resource. Moreover, no opinion is expressed herein regarding the quality of care that adheres to or differs from any of the NATA's other statements. The NATA and the SISG reserve the right to rescind or modify their statements at any time.

The following resources are available to provide additional information regarding spine injury and emergency procedures.

Link to Supplementary Table and Video: https://www.nata.org/practice-patient-care/health-issues/spine-injury:

• Supplemental Table. Rationale for Medical Personnel to Remove Equipment Before Transport.

• Spine Injuries in Sports-Managing On-Field Cervical Spine Injuries Produced by the Sports Institute at UW Medicine

Link for Supplementary Figures: http://dx.doi.org/10.4085/1062-6050-430-19.S1

• Supplemental Figure 1. Sample spine injury protocol.

• Supplemental Figure 2. Sample emergency action plans.

• Supplemental Figure 3. Hospital emergency department equipment removal information.

• Supplemental Figure 4. Spine and trauma bag equipment checklists.

• Supplemental Figure 5. Medical time out.