TRAIL FIRST AID – PART TWO

ARTICLE TWO: SAVING HUMPTY: HEADS, NECKS AND OTHER THINGS THAT BREAK

What’s your action plan for head or spinal injuries or broken bones on the trail? Paramedic and rad mountain biker Anna Beck provides her tips.

For those of us who live to ride, it’s no surprise that orthopaedic injuries are the most common ailment affecting mountain bikers presenting to emergency departments, with upper limb fractures being the most common region injured. In this article we are going to unpack some injury patterns common to mountain biking, including head injury, spinal injury and extremity fractures, and what to do if you come across these in the trail.

DONKED NOGGINS

Head injuries, the type referred to as Traumatic Brain Injuries (TBI) by medical personnel, are a very real risk factor for any cyclist. The combination of speed, airtime, and tiny ice-cream buckets as the mainstay of safety equipment means that many cyclists will at some time be diagnosed with a TBI; be it mild, moderate or severe. In fact, one study found that 12% of offroad injuries presenting to emergency included a head injury of some severity, which considering what mountain biking entails is quite a low percentage and can be attributed to high levels of compliance with wearing a helmet.

In a trailside situation, acute things to look out for in the case of a crash include: • witnessed blow to head • evidence of impact on helmet • any damage/lacerations/injuries to face • loss of consciousness, or acting inappropriately at any stage (confusion, answering inappropriately, moaning or any other state of semi-consciousness) • nausea or vomiting • dizziness, extreme headache

Your action plan:

1. Golden rule: stop the bleeding. 2. In the case that someone is presenting with the above symptoms, they may have a head injury. In the case of any loss of consciousness or confusion, it’s time to call an ambulance.

It’s also important to have a high index of suspicion for spinal trauma in this case, as any mechanism causing an injury to the head impacts the spine by virtue of the rapid acceleration/deceleration causing the injury. 3. Keep the patient calm and treat symptomatically: this patient requires transport to a tertiary hospital, and assessment and treatment depends on the diagnosis. If the patient is unconscious, ensure the airway is clear: and if snoring or occluded, remember that airway management takes precedence over spinal precautions and move the patient gently to ensure the airway is clear (see below).

SPICY SPINAL PRECAUTIONS

A spinal injury—in non-technical terms—is when any part of the 33 vertebrae of the spinal column is injured. Fractures and dislocations of the spinal column can result in spinal cord injury (SCI) due to severance or compression of the spinal cord, which runs through the centre of the vertebrae. Management of a spinal injury is based upon trying to reduce the likelihood of secondary injury, including bleeding into the cord and worsening swelling at the site of injury. Like head injuries, spinal injuries also account for 12% of injuries from mountain biking, and sporting injuries are a major cause of spinal injuries globally.

The most common mechanisms of injury include motor vehicle collisions, falls, sporting/ recreational pursuits and assaults. Injury to the spine is a result of hyperflexion (ie: landing chin to chest), hyperextension (ie:landing head extended backwards, ‘’scorpion”), axial loading (ie: “swan dive” fall) or rotational forces (any crash that has a sudden rotation of head/ neck involved). Higher velocity or greater force magnitude equates with a greater risk of injury, so it’s unlikely (though not impossible) that lower speed crashes result in extensive spinal injuries. Keep this in mind if you witness an accident; speed and mechanism are key.

If you do happen to witness or encounter an inured rider on the trail, spinal injury symptoms and signs to look out for include: • Pain in the spine/back • tingling and numbness in the limbs below the injury site/site of pain • weakness or paralysis of limbs • nausea, headache or dizziness • head or neck in abnormal position • evidence of a head injury or • altered conscious state (this includes unconsciousness) • breathing difficulties • altered sensation on skin, change in muscle tone (flaccid or stiff) • loss of function of limbs, bowel or bladder • priapism (erection in males)

Your action plan:

In the case of any of these call an ambulance and manage airway, breathing and any external haemorrhage, remembering to keep the spine in a neutral position. If conscious, tell the patient to remain still but don’t restrain. If the patient does require to be moved into the recovery position (in the case of managing or clearing an airway in the setting of gurgling or snoring or inadequate breathing or unconsciousness), it should be done by those with first aid training in order to maintain spinal alignment. In the worst case scenario, keep the neck straight and in line with the torso, and avoid any unnecessary movement, gently moving patient onto their side to clear their away passively.

KNEES BENDING BACKWARDS AND S-SHAPED ARMS

In a study of mountain biking injuries presenting to emergency, it’s not surprising that orthopaedic injuries were the most common presentation, comprising 46.5% of all presentations. The mechanism? The simple OTB (over the bars), which is often accompanied by the outstretched hand, leading to the creation of the snazzy acronym FOOSH (fell on outstretched hand). As a result, of all orthopaedic injuries accounted for, upper limb injuries are the most common, comprising predominantly of clavicle (collarbone), radius and ulna (forearm), and greater tuberosity (humeral) fractures.

In the case that something looks not quite right in the upper or lower extremeties, splinting is a good option to realign the limb, and provide support regardless of fracture, dislocation or sprain; after all, often an injured extremity requires imaging to be diagnosed. Unless there are obvious bony protrusions or deformities/ tenting of the skin, then you can be reasonably certain there’s a bone where it shouldn’t be.

To make a splint in the wild, you need to channel your inner Bear Grylls. Follow the steps below for splinting success! 1. Check blood flow by searching for a distal pulse (in wrist or foot). If it’s a bit tricky, you can check that the blood is still meeting its target tissues by giving a fingertip or toe a squeeze, it should return to red from white in <2 sec. Longer than this then alert the medics! Who you have definitely already called if something is at the wrong angle or there is bone sticking out. 2. Check if they can wiggle their toes/fingers and feel you touching them (this checks sensory nerves, on the affected limb). 3. For upper arm injuries, making a broad-arm sling out of a regular triangular bandage is often the position of most comfort, but a cuff-and-collar sling is often the most comfortable for clavicular injuries. Get comfortable making these slings before you get to a trailside emergency! 3. For lower arm and leg/ankle injuries, splinting in-line is often the most comfortable option. To make a splint, you need a long stiff object. A straight branch, a bit of a broom handle, anything that provides rigidity without being overly bulky: just a little larger than the limb to be splinted to immobilise adjacent joints. You want to return the limb to a neutral ‘normal’ looking position if possible. Do not handle any exposed bone unless you have saline available to rinse out. 5. Wrap the injured part with a bandage and pad if possible, align the splint, and then secure with more bandage, remembering to reassess the pulse or circulation frequently to ensure nil loss of circulation.

And that’s about it for the basics for heads, necks and troublesome bony and soft-tissue extremity injuries. Stay tuned for the next instalment of trailside first aid, where we will unpack the many ways that Australian Flora and Fauna want to kill you!