1. Officer 1 undertakes full assessment of the patient before application of
     the C-Collar & NIEJ. This includes:

• Check safety, scene, and situation.

• Officer 3 brings c-spine into neutral in-line position (unless contra-indicated) and performs manual head stabilisation.
  
  

• Perform Primary Survey

1. Conscious Status Assessment (Glascow Coma)

2. Perfusion Status Assessment (Pulse, BP, Skin) 

3. Respiratory Status Assessment (Rate, Rhythm, Effort,   Sounds, Speech, Tidal Volume)

1. Motor/Sensory x 4

2. Head

3. Spine

4. Chest

5. Abdomen

6. Pelvis

7. Legs

8. Arms

• Check AMPLE:

1. Allergies

2. Medications

3. Past medical history

4. Last oral intake

5. Events leading up to injury

Following the patient assessment (step 1) Officer 3 continues manual head stabilisation and  maintains this during application of NIEJ, even once the C-Collar is applied.   Remember a C-Collar will provide only 50%  immobilisation of the c-spine.

Select and apply a correctly fitting C-Collar as per manufacturers guidelines

If appropriate, remove all bulky items from chest and pelvic pockets to prevent discomfort of NIEJ once in place

Remove the NIEJ from the carry bag.  Do not undo any straps on the jacket, but ensure all straps are firmly held in place for insertion.  Loose or released straps will make insertion & application of the NIEJ more difficult.

Lay the carry bag on the vehicle or ground, and place 1 x yellow lumber support, 2 x blue groin pads, 5 x red head pads and 2 x black head straps on the carry bag for ease of  access and location of items later. 

Slightly rotate seat back or alternatively, lean patient slightly forward of the seat.  This will allow easy insertion of the NIEJ.

Insert NIEJ at 45 degree angle behind patient with buckles facing outwards from the patient.  Once in behind patients back, straighten up the NIEJ and ensure it is correctly  centered behind patient.  

Insert lumber support in curve of lumber spine. This will  assist in maintaining the natural curvature of lumber spine, and help prevent lower back pain following immobilisation.

To insert the lumber support, roll the lumber support in your hand squeezing out all the air.  This will allow for easier insertion if flattened.  The lumber support will then re-inflate once in position.

Alternatively, a folded towel can be used if the lumber support is misplaced.

Lean patient back into NIEJ.

Step 9

Position NIEJ so that top of NIEJ is no higher than the top of the patients head, or if this is not possible, the jacket is firmly in the patients armpits.

Release groin straps from back of NIEJ. Hold both groin straps together ensuring straps are not twisted.  Pull groin straps down between patient and chest flap. 

Slide both groin straps together under one leg, zig zagging straps  under leg and  buttocks until straps are in the gluteal fold.   It is essential that the straps are in the gluteal fold to ensure proper stability of NIEJ and to prevent loosening of straps when leg position changes during the extrication. 

Pull groin straps full forward and leave.  

Raise arms to shoulder height, then position chest flaps against patients chest.   Avoid raising arms higher than shoulders as this may cause upper spinal column      movement.  Again ensure NIEJ is correctly positioned at head level or in the armpits.

Apply green shoulder straps.  These will prevent NIEJ sliding down body.  Select one of the following two methods:

Cross Strapping

This is the preferred method of application as it provides better immobilisation than vertical strapping.

Release green shoulder strap from holder.  Bring left sided green strap over shoulder and connect to green strap female buckle on right side of chest flap.  Place hand between strap & chest, adjust strap using feed & pull until a firm sensation is felt on hand. Bring right sided green strap over shoulder and connect to green strap female buckle on left side of chest flap.  Place hand between strap & chest, adjust strap using feed & pull until a firm sensation is felt on hand.

Vertical Strapping

This vertical strapping method  is preferred when shoulder or chest injuries are present, or  when there is respiratory distress.  Release green shoulder strap from holder.  Bring left sided green strap over shoulder and connect to green strap female buckle on left side of chest flap.  Place hand between strap & chest, adjust strap using feed & pull until a firm sensation is felt on hand. Bring right sided green strap over shoulder and connect to green strap female buckle on right side of chest flap.  Place hand between strap & chest, adjust strap using feed & pull until a firm sensation is felt on hand. 

Apply yellow chest strap. This yellow strap is designed to help prevent rotation of the NIEJ.  To apply, release yellow strap from holder.  Connect yellow strap buckles & place hand between strap and patients chest.  Place hand between yellow strap & chest, adjust strap using feed & pull until a firm sensation is felt on hand.   Beware of over tightening as it may result in respiratory compromise.

Apply red chest strap.  This  red strap along with yellow strap is designed to help prevent rotation of the NIEJ. To apply, release red strap from holder.  Connect red strap buckles & place hand between strap and patients chest.  Adjust strap using feed & pull  until a firm sensation is felt on hand.   Beware of over tightening strap as it may result in pressure on the abdominal organs.

Groin Straps are designed to prevent upward sliding of the NIEJ.  Connect groin straps by:

Slide blue groin pads onto each black groin strap

Slide into sub pubic groin area. Pads will improve comfort for when lifting the patient.

Connect black groin strap buckles. Place hand between strap and patients abdomen.  Adjust straps using feed & pull until a firm sensation is felt on hand. 

·       If the NIEJ is to be used for c-spine immobilisation,    immobilise the head (as per steps 20 & 21), but DO NOT lift using the NIEJ as c-spine movement or stretching may occur, with potentially disastrous results. 

Begin application of the head section by initially ensuring head is still positioned in the neutral in-line position.  In general, adults  require between 4 cm to 7 cm of padding at the occipital skull to prevent hyperextension of the c-spine.  Padding at the neck region when using semi-rigid c-collars is not required and may place unwanted pressure on the c-spine.

Officer 1 selects and velcros together a sufficient number of red head pads needed to completely fill the space between the patient’s occiput and the NIEJ.   Carefully slide and velcro the padding onto the NIEJ, avoiding movement of the head.   This will prevent hyperextension of the cervical spine. Alternatively, a folded towel can be used if head pads are misplaced (Use a small towel folded to the correct thickness).

Whilst Officer 3 continues to maintain manual in-line immobilisation, Officer 1 folds the head flaps inwards placing them alongside the flat lateral planes of the head. Once the head flaps are in place, Officer 3 maintains manual in-line support with their hands now on the outside of the head flaps.

Apply 25mm Collar Strap by attaching side hook velcro tabs to head flaps with sliders level with front of head flaps. Tighten strap by ensuring foam pad is centred on c-collar (away from chin support), placing thumbs on centre of strap, and pulling both ends with equal pressure. Place only enough pressure to prevent movement, but not to deform collar or place pressure on the jaw line.  Velcro into place. Under no circumstances is pressure to be placed on the patients jaw line as this may clamp the mouth shut, compromising the patients airway.

If no C-Collar can be applied, tighten strap by ensuring pad centered on maxilla just under nostrils, placing thumbs on center of strap, and pulling both ends with equal pressure.  Velcro into place.

Step 21

Apply 50mm Forehead Head Strap by attaching side hook  velcro tabs to head flaps with sliders level with front of head flaps, ensuring forehead head strap bottom aligns with bottom of patients eyebrows.  Tighten strap ensuring foam pad centered on forehead, placing thumbs on center of forehead, and pulling both ends with equal pressure.  Velcro into place.

Alternatively, if head straps are not available, crepe bandages or Coban^TM can be used.

DO NOT USE NIEJ FOR LIFTING UNLESS ABSOLUTELY SURE ALL STRAPS 
ARE PROPERLY SECURE

Extricate patient from position by sliding, lifting and/or maneuvering the patient onto a long spine board or  vacuum mattress.

Once the patient is lying supine on the long spine board, carefully straighten to patient’s knees.  If the groin straps are correctly in position,  no tightening in the groin area should be felt.  Straps can be loosened, but not removed, if increasing tension is however felt.

Immobilise patient still wearing NIEJ to Long Spine Board or Vacuum Mattress.

Provide necessary additional treatment.