When a head neck or back injury is suspected it is best to leave the person in what position?

For years we have been told that the casualty who is in shock needs to lie down with their legs elevated because this will drain blood from the legs into the core to:

Table of Contents Show

First aid when the injured person is conscious
First aid when the injured person is unconscious
Treatment of concussion
Spinal injuries
Spinal injury first aid
Where to get help

Improve cardiac output
Improve systemic vascular resistance
Improved mean arterial pressure
Improved systolic blood pressure

There is limited evidence that elevating the legs may provide a transient (<7 min) improvement in heart rate, mean arterial pressure, cardiac index, or stroke volume; (3-5) for those with no evidence of trauma. However, one study (6) published in 2020, has reported adverse effects due to elevating the legs.

There is no evidence that applies to a hypovolaemic casualty who is already compensating. If you think about it, you know there is no available blood in the legs because the casualty is cold and pale - they are already shunting any available blood to the core by vasoconstriction.

ERC 2020 draft guidelines state:

• Place individuals with shock into the supine (lying-on-back) position

• Where there is no evidence of trauma first aid providers might consider the use of passive leg raising as a temporizing measure while awaiting more advanced emergency medical care.

”Because improvement with Passive Leg Raising is brief and its clinical significance uncertain, it is not recommended as a routine procedure, although it may be appropriate in some first aid settings.”

The sniffing position—only in the absence of cervical spine injury

Position the patient supine on the stretcher.
Align the upper airway for optimal air passage by placing the patient into a proper sniffing position. Proper sniffing position aligns the external auditory canal with the sternal notch. To achieve the sniffing position, folded towels or other materials may need to be placed under the head, neck, or shoulders, so that the neck is flexed on the body and the head is extended on the neck. In obese patients, many folded towels or a commercial ramp device may be needed to sufficiently elevate the shoulders and neck. In children, padding is usually needed behind the shoulders to accommodate the enlarged occiput.

A: The head is flat on the stretcher; the airway is constricted. B: The ear and sternal notch are aligned, with the face parallel to the ceiling (in the sniffing position), opening the airway. Adapted from Levitan RM, Kinkle WC: The airway Cam Pocket Guide to Intubation, ed. 2. Wayne (PA), Airway Cam Technologies, 2007.

If cervical spine injury is a possibility

Position the patient supine or at a slight incline on the stretcher.
Avoid moving the neck and do the jaw-thrust maneuver first (before trying the head tilt–chin lift if needed to open the airway).

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Remind me later

Always call triple zero (000) for an ambulance in an emergency.
The presence or absence of blood isn’t a reliable indicator of the seriousness of the head injury.
Symptoms of serious head injury can include clear fluid leaking from the nose or ears, altered consciousness or a period of unconsciousness, skull deformities, vision changes, bruised eyes and ears, nausea and vomiting.
A person who has sustained a head injury may also have injured their spine.

The brain is a soft and delicate organ. A hard blow to the head can injure the brain or spinal cord even when there are no visible signs of trauma to the scalp or face. That’s why all head injuries are considered serious and should be assessed by your doctor or the nearest hospital emergency department.

Always call triple zero (000) for an ambulance in an emergency.

Head injuries can be classified as:

• open – with bleeding wounds to the face or head
• closed – no visible signs of injury to the face or head.

The soft, jelly-like brain is protected by the skull. The brain doesn’t fill the skull entirely – it floats in a clear, nourishing liquid called cerebrospinal fluid. This fluid acts as a shock absorber, but its protective value is limited.

The kinetic energy of a small knock to the head or face can be absorbed by the cerebrospinal fluid, but a hard impact can bruise the brain or tear blood vessels. If this occurs, it may cause a rise in the intracranial pressure (pressure inside the skull) which may lead to permanent damage.

Being able to see blood is not a reliable indicator of the seriousness of a head injury. Apart from wounds, other symptoms of serious head injury can include:

Altered consciousness – for example, the person may lose consciousness for short or longer periods or may be conscious again, but confused or drowsy. They may even have a brief seizure. They may also change by improving for a while and deteriorating again later.
Skull deformities – compressions or deformities are signs of fracturest.
Clear fluid from the ears or nose – a skull fracture, especially a fracture to the base of the skull, can allow cerebrospinal fluid to leak from the ears or nose.
Black eyes and bruised skin behind the ears – this indicates that the force of the blow was sufficient to rupture blood vessels around the eyes and ears.
Vision changes – the pupils of the eyes may be dilated (enlarged) and be different sizes in a person with a serious head injury. The person may complain of double or blurred vision.
Nausea and vomiting – these are common side effects of serious head injury and should always be considered important if they persist.

In cases where there is a serious head injury, always call triple zero (000) for an ambulance.

First aid when the injured person is conscious

Encourage the injured person to minimise any movement of their head or neck.
Scalp injuries can bleed profusely, so control any significant blood loss from head wounds with direct pressure and a dressing.
While examining the wound, avoid disturbing blood clots forming in the hair.
Reassure the person and try to keep them calm.

First aid when the injured person is unconscious

The person should not be moved unless they are in immediate danger. Any unnecessary movement may cause greater complications to the head injury itself, the spine or other associated injuries. A good rule is that if the head is injured, the neck may be injured too.
Your role is to protect the injured person from any potential dangers at the scene.
You should monitor their airway and breathing until the arrival of an ambulance. If the person’s breathing becomes impaired due to a problem with their airway, you may need to very carefully tilt their head back (and support it) until normal breathing returns.
If the person stops breathing or has no pulse, cardiopulmonary resuscitation (CPR) may be required.

Treatment of concussion

Concussion is a mild traumatic brain injury that follows some trauma to the head. It is a diagnosis made by a doctor when it is certain a more serious head injury has not occurred.

Symptoms of concussion can persist for up to 3 months or longer after trauma. Your doctor or hospital will provide advice for you and your family regarding your ongoing care when being discharged for home.

Most importantly, be alert for symptoms over the first 3 days days, such as repeated vomiting, loss of coordination, bad or worsening headaches, repetitive questions, agitation or drowsiness despite analgesia (pain-relieving medication). Seek medical attention immediately.

Spinal injuries

A person who has sustained a head injury may have also injured their spine. In elderly people, the force required to cause neck injuries is much less than in younger people. It can even occur from a standing height fall in the elderly.

Signs and symptoms of spinal injuries may include:

body lying in an awkward, unnatural position
skin feeling clammy and cool
reporting unusual tingling sensations in the limbs or an absence of any sensation, including pain
incontinence
inability to move limbs.

Spinal injury first aid

In cases where there is a spinal injury, always call triple zero (000) for an ambulance.

It is important to keep the injured person’s head in line with their neck.

Avoid twisting their head or allowing their head to roll to the side.
If you can, roll a t-shirt, towel or similar soft item and place it around their neck to remind them to keep their head straight.

Don’t try to move them unless there is an urgent need to.

Toddlers fall over all the time. Parents should note that:

A fall from the child’s own height usually isn’t enough to cause a serious head injury.
The size of a bump on the head has no connection with the severity of injury.
Minor head injuries, like a bump on the head, can be treated with cuddles and an age-appropriate dose of children’s pain-relieving syrup.

Medical attention should be sought immediately if the child shows any signs of serious head injury, particularly if:

they are unusually drowsy or vomiting
you think the fall was heavy enough to have caused harm
the child appeared to be unconscious or did not immediately cry after the fall.

Examples of a heavy fall are:

falling down multiple stairs
rolling from a normal height change table to a hard floor
falling from a bed to a hard surface
a head strike on bedside furniture.

If in doubt, see your doctor.

Where to get help

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