Management of Trauma Patient on Backboard Awaiting Imaging
Remove the patient from the backboard while maintaining spinal restrictions (Option D). Prolonged immobilization on a backboard beyond 2 hours causes significant morbidity that may exceed the risks of a missed cervical spine injury, and the patient should be transferred to a padded surface while maintaining cervical collar and spinal precautions until imaging is complete. 1, 2
Rationale for Immediate Backboard Removal
The complications of prolonged backboard immobilization escalate rapidly after 48-72 hours, but tissue damage begins much earlier. The serious complications include:
- Pressure sores (each costing approximately $30,000 to treat) 2
- Increased intracranial pressure (worsened by cervical collars raising ICP by 4.69 mm Hg) 2
- Ventilator-associated pneumonia with attributable mortality approaching 6% 1
- Airway complications and failed enteral nutrition 2
- Thromboembolic events 3
These risks are poorly appreciated but exceed those of a serious missed cervical spine injury in most cases. 1, 2
Proper Technique While Awaiting Imaging
The patient should be logrolled off the backboard onto a padded surface using spinal precautions:
- Maintain cervical collar in place 4
- Use logroll technique with multiple personnel maintaining spinal alignment 5
- Transfer to a padded bed or stretcher 1
- Continue spinal restrictions (no flexion, extension, or rotation) 4
The backboard is a transport device only, not intended for prolonged immobilization. 5 Studies demonstrate that backboards provide adequate immobilization for initial stabilization and transport, but prolonged use causes more harm than benefit. 1
Why Other Options Are Incorrect
Option B (keeping patient on backboard) is explicitly contraindicated:
- The patient has already been on the backboard for 2 hours 1
- Prolonged immobilization produces secondary morbidity and mortality that could potentially rival the rates of complications due to missed injuries 1
- There is no good quality evidence showing clinical benefit of prolonged backboard use 2
Option C (removing cervical collar) is premature and dangerous:
- The cervical spine has not been cleared radiologically 1, 3
- Imaging results are still pending 4
- The collar must remain until high-quality CT demonstrates no injury 3
Option A (applying TLSO brace) is premature:
- No thoracolumbar injury has been diagnosed yet 1
- This would be considered only after imaging confirms a specific injury requiring bracing 6
Critical Clinical Pearls
The key distinction is between the backboard (transport device) and the cervical collar (immobilization device):
- Backboards should be removed as soon as the patient reaches the emergency department 5
- Cervical collars remain until the spine is cleared by appropriate imaging 1, 3
- Spinal precautions (maintaining neutral alignment) continue throughout 4
For obtunded or high-risk patients, modern multidetector CT with <3mm slice thickness is the primary screening modality. 1, 3 The sensitivity and negative predictive value approach 99.6% and 99.9% respectively when properly performed. 1