NPLQ Spinal Cord Injury Management 2 — Questions and Answers
Question 1: What mechanism of injury most commonly causes cervical spinal injury in an aquatic setting?
- Slipping on a wet poolside surface
- Diving into shallow water — hyperflexion or axial loading of the cervical spine (Correct answer)
- Cramp causing a fall while swimming
- Wave machine turbulence
Correct answer: Diving into shallow water — hyperflexion or axial loading of the cervical spine
Diving into shallow water is the leading cause of aquatic spinal injury, causing axial compression and/or hyperflexion of the cervical spine as the head strikes the pool floor.
When a diver enters shallow water, the head decelerates abruptly on contact with the pool floor while the body continues moving forward. This transmits massive axial compressive force through the cervical spine. The result is typically a fracture-dislocation at the C4–C6 level. RLSS NPLQ emphasises the prohibition of diving in shallow water and the importance of clear depth markings and 'no diving' signage in any pool section shallower than 1.5 metres.
Question 2: What is the RLSS recommended method for managing a face-up casualty in the water with suspected spinal injury?
- Remove them from the water immediately using the fastest available method
- Maintain in-water spinal stabilisation using head hold and gentle horizontal support until a spine board is brought to the casualty (Correct answer)
- Turn them face down and support their back
- Leave them floating freely to avoid disturbing the spine
Correct answer: Maintain in-water spinal stabilisation using head hold and gentle horizontal support until a spine board is brought to the casualty
The priority is in-water spinal stabilisation: the lifeguard supports the casualty in a horizontal supine position with the head and neck in neutral alignment, maintaining this hold until a spine board and backup rescuers are ready.
The RLSS NPLQ in-water spinal management sequence: (1) approach from behind or the side, (2) apply a head hold, (3) ensure the face is above water, (4) keep the body horizontal and spine in neutral alignment, (5) call for the spine board and backup, (6) float the spine board under the casualty, (7) secure with head blocks and straps, (8) team-lift to the pool deck.
Question 3: Which signs and symptoms may indicate a cervical spinal injury in a retrieved pool casualty?
- Tachycardia and hypertension only
- Neck pain, reduced or absent limb sensation/movement, numbness, tingling, or priapism (in males) (Correct answer)
- Abdominal pain and nausea only
- Chest pain and shortness of breath only
Correct answer: Neck pain, reduced or absent limb sensation/movement, numbness, tingling, or priapism (in males)
Cervical cord injury presents with neck pain, weakness or paralysis of limbs, loss of sensation (numbness or tingling), and in males, priapism — all indicating cord involvement.
Cervical spinal cord injury symptoms depend on the level and completeness of the injury. Common presentations include: localised neck pain or tenderness, inability to move arms or legs, altered or absent sensation below the injury level, hypotension and bradycardia (neurogenic shock), loss of bladder/bowel control, and in males, priapism. Any of these findings in a casualty retrieved from the water after a potential mechanism should prompt full spinal precautions.
Question 4: Why should spinal injury be suspected in any near-drowning casualty, even without a witnessed diving incident?
- It should not — spinal injury requires a clear diving mechanism
- Because the mechanism may not be known, and cervical injury can occur from wave/flume forces or unwitnessed falls into the water (Correct answer)
- Because CPR causes spinal injury
- Because all drowning casualties are assumed to have fallen from a height
Correct answer: Because the mechanism may not be known, and cervical injury can occur from wave/flume forces or unwitnessed falls into the water
When the mechanism is unknown, the lifeguard cannot rule out spinal injury. RLSS NPLQ advocates maintaining spinal precautions for all casualties where the mechanism is unclear until clinical assessment rules it out.
RLSS NPLQ guidance states that spinal injury should be suspected whenever: the mechanism is unknown, there is a history or suspicion of diving, there are signs or symptoms of cord injury, or the casualty cannot provide a reliable history. For any unconscious pool casualty, spinal precautions are applied by default during extraction using the spine board protocol.
Question 5: What does 'neutral alignment' mean when managing a suspected spinal injury casualty?
- Placing the head in the flexed (chin-to-chest) position
- Maintaining the head, neck, and spine in a straight line, as if the person were standing naturally (Correct answer)
- Tilting the head fully back as in CPR airway opening
- Rotating the head to one side to check breathing
Correct answer: Maintaining the head, neck, and spine in a straight line, as if the person were standing naturally
Neutral alignment means keeping the spine in its natural, unstressed position — head in line with the body, not flexed, extended, or rotated — to avoid additional cord compression.
Neutral spinal alignment avoids the three dangerous movements: flexion (chin to chest), extension (head back), and rotation (head turning). In CPR situations where a casualty is not breathing and spinal injury is suspected, a jaw thrust (rather than head-tilt chin-lift) is used to open the airway without extending the neck.
Question 6: At what point in the spine board extraction process should head blocks and straps be applied?
- Before the spine board enters the water
- After the casualty has been positioned on the board in the water, before the board is lifted clear of the water (Correct answer)
- After the board is out of the water and on the pool deck
- Head blocks are not used — manual head hold is maintained until hospital
Correct answer: After the casualty has been positioned on the board in the water, before the board is lifted clear of the water
Head blocks and straps are applied while the casualty is still in the water, after positioning on the board, so that the head and body are secured before the board is lifted — reducing movement during the lift phase.
RLSS NPLQ spine board protocol: position rescuers, float board alongside casualty, slide board under casualty, centre casualty on board, apply head blocks while a dedicated rescuer maintains manual head hold, apply forehead/chin straps and body straps, confirm all secure, then on command perform team vertical lift, place board on pool deck, and continue manual head stabilisation until paramedics apply a cervical collar.
NPLQ Spinal Cord Injury Management 2
What mechanism of injury most commonly causes cervical spinal injury in an aquatic setting?