Question 19 from the first paper of 2014 asked about the injuries which require specific positioning or immobilisation techniques, and influence of such techniques on the management of the multi-trauma patient. The examiners complained that the 63% of candidates who faile that question "did not think broadly and gave a limited answer and did not adequately address the issue of competing injuries and risk v benefit."This chapter is a response to such comments.

Unfortunately, there is no one specific overview which might serve as a reference here. Even LITFL have no chapter on this. Judson and Hsee, in their chapter for Oh;s Manual ("Severe and multiple trauma", Ch. 74, p. 755) have nothing to say on this subject. The only reference I have found was Robert Christie's 2008 article for the British Journl of Nursing. The summary below was concocted from a combination of this article with the college model answer. Only positioning and physical immobilisation is discussed; the use of sustained neuromuscular junction blockade is explored in detail elsewhere.

Positioning for head injury patients

  • Ideally, head up 45 degrees. At least angle the bed.
  • It seems to position the patient at least 30° head up decreases the ICP but does not decrease the CPP.
  • At least in the pediatric population, the angle of the bed is directly related to intracranial pressure.
  • Ideally, the C-spine collar should be removed. A good study of intracranial pressure with and without the rigid collar found that one can decrease the intracranial pressure of a TBI patient by about 4-5mmHg simply by removing the rigid collar and using something like sandbags to stabilise the neck.
  • The risk of head-up positioning may be haemodynamic instability, particularly if the sympathetic nervous system is not working (eg. severe diabetes, Parkinson disease or spinal injury)

Positioning for C-spine injury patients

  • Hard collar is required if an injury is confirmed or suspected.
  • The patient must lie flat, and be log-rolled.
  • Clearance of the C-spine should occur as soon as it is practical
  • There are many problems with wearing a collar for a prolonged period:
    • Pressure areas under the collar
      • Source of sepsis
      • Need for skin grafts
      • Increased hospital stay
    • Increased intracranial pressure
    • Airway is made more difficult by in-line stabilisation
    • Central venous access is made more difficult (IJ is out of bounds)
    • Oral care is made more difficult, increasing the risk of VAP
    • Nutrition is affected:
      • Gastroparesis and ileus results from prolonged immobility
      • Aspiration risk is increased by supine position
    • Physiotherapy is delayed or impossible
    • A greater risk of DVT/PE results from prolonged immobility
    • A minimum of 4 nursing staff are required to turn the patient.

Positioning for thoracolumbar spinal injuries

  • The patient must lie flat, and be log-rolled.
  • No bending is permitted
  • The risk of such flatness is an increased incidence of VAP

Positioning for severe chest injuries

  • Sit them up at least 30° if the head permits
  • Do not lie them with the flail segment down. That lung has probably had a contusion anyway. Lie them "good lung down" - oxygenation will improve.
  • Gentle lateral rotation may be appropriate
  • Low-air-loss technology: specialist beds which turn the patient by inflating and deflating air cushions; a turning arc of 40-90° is possible.
  • These are soft beds, unsuited for unstable spinal or pelvic injuries

Positioning in pelvic fractures

  • The unstable pelvis must be in a binder
  • Overmuch manipulation will result in haemodynamic instability
  • Predictably, the solution is to fix the pelvis; angioembolisation may not be possible because the bleeding is frequently venous.
  • While unfixed, the patient must lie flat
  • Nurse patient on a firm mattress to ensure consistent pelvic support
  • Ensure appropriate fitting of specialist equipment (e.g. pelvic binder belt)
  • Maintain flat, straight alignment of whole body at all times.
  • Log-roll patients
  • Use spinal boards and flat-surface hoist
  • If the patient is expected to have an unfixed pelvis for a prolonged period (eg. if they have no private health insurance and were not the victim of a work-related injury), to ameliorate the effects of prolonged immobility one may use continuous lateral rotation therapy using RotoRest or similar specialist beds
  • Low-air-loss pressure mattresses are contraindicated in spinal or pelvic instability.

Positioning in long bone fractures

  • Traction is indicated for the reduction of long bone lower limb fractures which are awaiting repair.
  • This is a significant limitation on positioning
  • The patient in traction is also difficult to transport
  • Traction must come down for transfer fom bed to bed

Competing interest

Airway vs. C-spine collar:

  • Airway wins; the collar can be removed and inline stablisation attempted for intubation

Head injury vs. C-spine injury:

  • Head injury wins, even if the C-spine is unstable the ICP must be managed properly. Remove the collar and sandbag the neck. Paralyse and sedate the patient.
  • If they must remain flat, then angle the bed so the head is still up.





Christie, Robert James. "Therapeutic positioning of the multiply-injured trauma patient in ICU." British Journal of Nursing 17.10 (2008): 638-642.