Table 2 The final set of recommendations clarified by a rationale with levels of agreement

Pre-rescue section

R1: It is recommended against using spinal motion restriction when the trauma is due to a mechanism unlikely to cause spinal cord injury

Patients are at risk for in-water traumatic spinal cord injury only if they have also sustained a relevant trauma. Spinal motion restriction should not be used solely based on a history of drowning because it is time-demanding and may delay the rescue [30]

95%

R2: It is recommended to always alert the available EMS, but this should not delay the rescue

The mechanism of injury related to in-water traumatic spinal cord injury, such as diving into a shallow body of water or wave-forced impacts, may cause severe intracranial haemorrhage, spinal cord injury, fractures, or bleedings. Early transportation to the hospital and definitive treatment is imperative. Current guidelines on spinal motion restriction of suspected traumatic spinal cord injury recommend calling for an ambulance as one of the top priorities [31]

100%

R3: It is recommended to assess scene safety before attempting a water rescue. This assessment should include the aquatic conditions (such as high surf, fast-moving water, or rocky areas), the level of training and the experience of the lifeguards, the number of lifeguards available and needed, the size of the patient, and the equipment available

The safety of the lifeguard(s) and the patient(s) must always be the top priority

100%

R4: It is recommended against using spinal motion restriction in patients suspected of in-water traumatic spinal cord injury in any circumstance with imminent danger of drowning or injury to the lifeguard

Spinal motion restriction should only apply to situations where the scene is safe. The lifeguard should prioritise a fast rescue of patients suspected of in-water traumatic spinal cord injury who are in imminent danger of drowning or injury (e.g., high surf, fast-moving water, or rocky areas). Spinal motion restriction in these locations will increase the risk to the lifeguard(s) and patient(s)

100%

R5: It is recommended against using spinal motion restriction in patients suspected of in-water traumatic spinal cord injury who are unconscious and not breathing normally (suspected cardiac arrest)

Assessment of consciousness and breathing in the water may be difficult. If the lifeguard is unsure, the patient should be treated as if the patient was in cardiac arrest, requiring resuscitation as soon as possible and urgent transfer to the hospital

95%

Rescue section

R6: It is recommended to turn a face-down patient suspected of in-water traumatic spinal cord injury immediately and carefully into a face-up position

Any patient face-down in the water is in imminent danger of hypoxia or drowning and must be turned face-up immediately to assess the level of consciousness and breathing. Various techniques are currently instructed to turn a face-down patient. Importantly, lifeguards must secure a stable position of the head in relation to the thorax during the turn

90%

R7: It is recommended to use the AVPU scale to identify an altered level of consciousness in patients suspected of in-water traumatic spinal cord injury

The AVPU (Alert, Verbally responsive, Painfully responsive, Unresponsive) scale is a fast and simple way of detecting an altered level of consciousness in patients, even during a rescue. It is feasible in the prehospital setting as a score lower than “A and oriented” should be considered abnormal until proven otherwise [32, 33]

95%

R8: It is recommended to use the symptom of spinal pain to assess the need for spinal motion restriction in alert patients without a critical ABC problem suspected of in-water traumatic spinal cord injury by asking: “Do you feel pain in your neck or back?”

Lifeguards are not trained healthcare professionals, and clinical assessments in the aquatic environment are challenging. Simple and sensitive diagnostic tools should guide clinical decision-making. Current guidelines on spinal motion restriction of trauma patients recommend using spinal pain to assess the need for spinal motion restriction in alert patients suspected of in-water traumatic spinal cord injury [9]

90%

R9: It is recommended to use obvious signs of any neurological deficit to assess the need for spinal motion restriction in alert patients without a critical ABC problem suspected of in-water traumatic spinal cord injury by asking: “Can you move your arms and legs?”

Lifeguards are not trained healthcare professionals, and clinical assessments in the aquatic environment are challenging. Hence, simple and sensitive diagnostic tools should guide clinical decision-making. Current guidelines on spinal motion restriction of trauma patients recommend using neurological deficits to assess the need for spinal motion restriction in alert patients suspected of in-water traumatic spinal cord injury [9]

90%

R10: It is recommended to use spinal motion restriction for extrication in alert and oriented patients without a critical ABC problem suspected of in-water traumatic spinal cord injury where self-extrication is impossible

If the patient is alert, oriented, and suspected of in-water traumatic spinal cord injury, the lifeguard should ask, “Can you stand up?". Current guidelines on spinal motion restriction of trauma patients recommend spinal motion restriction for extrication of alert and oriented trauma patients where self-extrication is impossible [9]

90%

R11: It is recommended against using a rigid cervical collar in all patients suspected of in-water traumatic spinal cord injury

Based on recent research, current guidelines on spinal motion restriction of trauma patients recommend against using a rigid cervical collar as there are no proven benefits on neurological outcomes or mortality [10, 34,35,36,37,38,39,40], and the effect on the range of motion in the cervical spine is very limited [37, 41,42,43,44]. Furthermore, using a rigid cervical collar is correlated to a series of harmful effects such as impeded airway management [10], worsening of existing cervical injury [10], increased spinal movement due to pain or discomfort [10], elevation of intracranial pressure due to impeded venous drainage through the neck [45, 46], and prolonged stay in the emergency room [47]

95%

R12: It is recommended to in-line stabilise the head in relation to the thorax with two hands during the extrication if in-water traumatic spinal cord injury is suspected

If the patient cannot perform self-extrication, lifeguards must perform spinal motion restriction and extrication from the water. Various techniques are currently instructed to manually stabilise the patient’s head during the extrication. Importantly, lifeguards must be trained in a technique that secures a stable position of the head in relation to the thorax during the extrication and is suitable for the specific circumstance

86%

R13: It is recommended to use a floatable, lightweight device that drains water and is appropriate to water conditions to perform spinal motion restriction for extrication of alert patients suspected of in-water traumatic spinal cord injury who cannot perform self-extrication

Various boards and stretchers have been approved for handling a patient suspected of in-water traumatic spinal cord injury, and these may be an appropriate solution for the given situation

95%

R14: It is recommended against using straps in water unless required for safe extrication

Using straps in the water can be dangerous as it may cause situations in which water aspiration, submersion, or permanent loss can occur. The in-water use of straps is often time-consuming and inefficient. However, in some circumstances (e.g., related to pool designs), extrication requires straps to prevent the patient from being dropped or sliding off the board

90%

R15: It is recommended that one lifeguard trained in spinal motion restriction acts as the team leader and is responsible for the stabilisation of the patient's head, the team's safety, supervision, instructions, and coordination

Lifeguards performing spinal motion restriction need to be sure that they maintain spinal alignment during extrication and transportation without risks to the rescuers or the patient. Therefore, a team leader responsible for the team’s safety, supervision, instructions, and coordination should be appointed. The team leader is responsible for the stabilisation of the patient's head

100%

R16: It is recommended to use at least three persons to perform spinal motion restriction to extricate a patient suspected of in-water traumatic spinal cord injury. At least one person should be specifically trained. If the necessary number of persons is not available, do not further delay extrication

Various extrication techniques are currently instructed. All these techniques require a minimum of three persons to be performed successfully with minimal risk to the patient. At least one of the lifeguards should be trained in spinal motion restriction

81%

R17: It is recommended to integrate untrained bystanders under the leadership of the lifeguard(s) if there are not enough trained lifeguards available for spinal motion restriction and extrication

Untrained bystanders can be asked to support the lifeguard if the required number of lifeguards are not available to perform spinal motion restriction. This may improve the quality of spinal motion restriction and lower the risks to the lifeguard(s) and the patient(s)

90%

R18: It is recommended against using spinal motion restriction in patients suspected of in-water traumatic spinal cord injury who have NO relevant symptoms

Traumatic spinal cord injury will cause symptoms. These symptoms must guide the spinal motion restriction. If the patient has NO relevant symptoms (no spinal pain and normal movement in arms and legs), in-water traumatic spinal cord injury should not be suspected, and spinal motion restriction should not be performed. Current guidelines on spinal motion restriction of trauma patients recommend no spinal motion restriction in asymptomatic trauma patients because (1) Significant spinal injury is unlikely to occur without causing any symptoms [9], and (2) Numerous studies have demonstrated possible hazardous effects of spinal stabilisation including pain [36, 40, 48, 49], development of pressure ulcers [48,49,50], difficult clinical examination [36], and prolonged prehospital on-scene time [48]

95%

R19: It is recommended to use self-extrication and self-stabilisation in alert patients suspected of in-water traumatic spinal cord injury who can perform self-extrication and self-stabilisation

The risk of an unstable spinal injury in alert patients is rare [34]. Additionally, alert patients will automatically stabilise their spine in the most comfortable position [9, 34, 51]. Current guidelines on spinal motion restriction of trauma patients recommend encouraging an alert trauma patient to self-stabilise the spine and perform self-extrication [32]. Lifeguards should always help the patient perform self-stabilisation (e.g., support the patient so that the risk of falling or stumbling is reduced as much as possible, protect from waves, remove stones and other submerged objects)

95%

Post-rescue section

R20: It is recommended to allow an alert patient to place him/herself in the most comfortable position during spinal motion restriction on land

Alert patients will automatically stabilise their spine in the most comfortable position [9, 34, 51]. Current guidelines on spinal motion restriction of trauma patients recommend encouraging an alert trauma patient to self-stabilise the spine and focusing on optimising patient comfort [32]. Alert patients should be allowed to sit or lay down comfortably until EMS professionals arrive

95%

R21: It is recommended to use the jaw thrust manoeuvre with the head in a neutral position to open the airway in patients suspected of in-water traumatic spinal cord injury who cannot maintain an open airway

Airway management should always be a top priority for all patients with suspected spinal injuries. Various techniques for airway management exist. If a neutral head position does not open the airway, use the jaw thrust manoeuvre before the head tilt [52]

95%

Patient selection section

R22: It is recommended to treat potentially intoxicated patients in the same way as non-intoxicated patients suspected of in-water traumatic spinal cord injury

It is often not possible to rule out or diagnose intoxication clinically since it is difficult to differentiate, for example, between intoxication symptoms, concussions, or critical neurological injuries (e.g., intracranial haemorrhage [53]). Current guidelines on spinal motion restriction of trauma patients recommend that trauma patients being affected by alcohol or drugs be treated in the same way as all other non-intoxicated trauma patients [9]

86%

R23: It is recommended to treat patients with distracting injuries in the same way as patients without distracting injuries suspected of in-water traumatic spinal cord injury

Distracting injuries do not disturb the sensitivity of a spine examination [54,55,56] Current guidelines on spinal motion restriction of trauma patients recommend treating trauma patients with distracting injuries in the same way as all other trauma patients [9]

86%

R24: It is recommended to treat patients with language barriers in the same way as patients without language barriers suspected of in-water traumatic spinal cord injury

Language barriers will challenge history taking, but current guidelines on spinal motion restriction of trauma patients recommend treating trauma patients with language barriers in the same way as all other alert trauma patients [57]. The lifeguard may assess spinal pain by interpreting the patient's facial expressions and neurological deficits by observing the patient's spontaneous movements in arms and legs

90%

R25: It is recommended to treat children in the same way as adults suspected of in-water traumatic spinal cord injury

Children with suspected in-water traumatic spinal cord injury should be treated in the same way as adults, including stabilisation with two hands (bimanual stabilisation) [52]. Children under eight may require an additional 2.5 cm back elevation under their shoulders to achieve a better neutral head position in the supine position [58]

90%