(2011). 2010;68(1):115121. The term "cervical collar" (cervical collar or neck brace) is used in medicine to indicate a medical device that is worn to prevent movement of the patient's cervical vertebrae when physical trauma to the head-neck-trunk axis is suspected or confirmed. (2008). 2 prehospital care by ems personnel is part of the larger spectrum of care that sci. This resulted in no adverse event or any spinal cord injury. The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects. Using 10 healthy volunteersa smaller sample size than Houghton and Driscoll (1999)Holla (2012) determined that increasing the number of participants in this study would not affect the outcome as the best cervical immobiliser can be identified through the ROM it allows. and transmitted securely. C-collars interfere with airway management: There are a considerable number of studies that have shown C-spine immobilization practices can interfere with airway management. Common sites of skin breakdown specifically associated with c-collars include the occiput, mandible, ears, chin, laryngeal prominence, shoulders and sternum (Hewitt, 1994). 2014 Mar 15; 31(6): 531540. The acute management of potential spinal injuries in trauma patients is undergoing radical reassessment, and patients at high risk for spinal instability should be removed from the hard surface to avoid tissue ischemia. Cadavers limit the study by negating the natural ability of an alert patient to splint their neck with muscle tone (Horodyski et al, 2011), so ROM had to be induced by a third party. This was the principal reason this issue came to the forefront. 2 CPAP and BiPAP have been available on Advanced Life Support units for some time, but CPAP is now being included on Basic Life Support and First Responder units. Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: Historical review and current questions. 5Helicopter Emergency Medical Services, Bergen, Norway. 1. We dont want to throw the baby out with the bathwater; we just want to provide the best possible evidence-based care for our patients. Sparke A, Voss S, Benger J. Jeanneret B., Magerl F., and Ward J.C. (1991). Out-of-hospital spinal immobilization: its effect on neurologic injury. Conclusion: Chin K.R., Auerbach J.D., Adams S.B., Sodl J.F., and Riew K.D. Spine immobilization in penetrating trauma: more harm than good? The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway. Incorrect use may give a false sense of security and the patient should still be fully immobilised. Its repeatedly been argued that spinal immobilization is a relatively harmless procedure and the perceived benefits certainly outweigh any perceived risks. Kwan I., Bunn F., and Roberts I.; WHO Pre-Hospital Trauma Care Steering Committee (2001). Why do we put cervical collars on conscious trauma patients? (See Figure 1 above.) This led the authors to remark, Cervical spinal immobilization is a myth.18 Common prehospital 12. Life expectancy after spinal cord injury: a 50-year study. The results of this study suggest that paramedics cannot accurately predict spinal fractures. 1999;24(17):18391844. Barkana Y., Stein M., Scope A., Maor R., Abramovich Y., Friedman Z., and Knoller N. (2000). Results of literature search (continued overleaf). Like other studies, a repeated-measures design was used, with all movements repeated twice on each cadaver. The second step is acceptance. Are you aware of these in your practice and how would you address them? Hauswald M., Hsu M., and Stockoff C. (2000). Themes of adverse effects and range of movement were identified in this review. (2010). Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. It is assumed that pressure causing severe pain results in distress, necessitating movement to relieve pain, so high pain scores resulting from pressure potentially impede the main purpose of the cervical collar (Ham et al, 2016). The meta-analysis was performed using random-effects model. Spine (Phila Pa 1976). Motion in the unstable cervical spine during hospital bed transfers. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association, African journal of emergency medicine : Revue africaine de la medecine d'urgence, JPMA. However, despite prehospital trauma life support (PHTLS) (National Association of Emergency Medical Technicians (NAEMT), 2018) guideline recommendations, the rigid cervical spine collar was not removed (Oosterwold et at. 3Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway. The aim of this systematic review was to determine whether the use of spinal collars in the pre-hospital trauma patient was recommended by published literature. Injured patients may have an unstable injury of the cervical spine. -, Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J. A new external upper airway opening device combined with a cervical collar, Airway management in the patient with potential cervical spine instability: continuing professional development. In this study, Fred and colleagues found a strong association between cervical fractures and traumatic brain injuries (TBIs), with 11% of patients having a moderate to severe TBI and 78% having a minimal to mild TBI. Hske D, Lefering R, Stock JP, Kreinest M; TraumaRegister DGU. Increased risk of death with cervical spine immobilisation in penetrating cervical trauma. Why EMS Should Limit the Use of Rigid Cervical Collars, Pro Bono: Preventing Theft and Embezzlement, MI Governor Permits EMS Providers to Carry Emergency Contraception, Report Criticizes Rialto (CA) Firefighters for Failing to Enter Facility to Treat Dying Patient, Denver Firefighters Suspended for Getting Living Woman Pronounced Dead, Gunshot Victims Seek Help at Pittsburgh Hospital, EMS Headquarters, FDA Advisers Meet On Racial Disparities in Pulse Oximeters, International Prehospital Medicine Institute Literature Review, November 2022, Buprenorphine May Guide Overdose Patients into Treatment, Rogue Nurse Gave Lethal Insulin Doses to Patients in NC, Travis County (TX) ESD No. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. Generating an ePub file may take a long time, please be patient. 22. Dietrich A.M., Ginn-Pease M.E., Bartkowski H.M., and King D.R. Overdistraction: a hazard of skull traction in the management of acute injuries of the cervical spine, Emergency transportation in the event of acute spinal cord lesion. (1998). Prehospital use of cervical collars in trauma patients: a critical review. However, if a cervical collar is used this should be correctly sized and fitted. 2002;6(4):421424. The EBSCOhost Health Science Research database was searched. Ryken T.C., Hadley M.N., Aarabi B., Dhall S.S., Gelb D.E., Hurlbert R.J., Rozzelle C.J., Theodore N., and Walters B.C. 2014;31(6):531540. At least one severe indentation mark was observed in 28.1% of patients. Blackham J, Benger J. Gunn B.D., Eizenberg N., Silberstein M., McMeeken J.M., Tully E.A., Stillman B.C., Brown D.J., and Gutteridge G.A. 3 Now, spinal precautions are much simpler and much more comfortable for the patient. Doesimmobilisation cause physical changes? Davis D.P., Hoyt D.B., Ochs M., Fortlage D., Holbrook T., Marshall L.K., and Rosen P. (2003). Clipboard, Search History, and several other advanced features are temporarily unavailable. EBSCHOhost was searched in June and July 2017 to obtain the literature (Table 1) and five key search terms were identified. Powers J., Daniels D., McGuire C., and Hilbish C. (2006). However, this model of maximum exertion could represent conditions experienced through involuntary motions leading to secondary injury (Bell et al, 2009). The soft C-collar doesnt immobilize the C-spine, but it serves as a reminder to the patient to limit movement of their neck. It was often said, When in doubt, immobilize the spine. Much of this came from the 1984 U.S. Department of Transportation Emergency Medical TechnicianAmbulance: National Standard Curriculum. Goldberg W., Mueller C., Panacek E., Tigges S., Hoffman J.R., and Mower W.R.; NEXUS Group (2001). Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. There has never been any evidence that suggests that the C-collar benefits our patients in any way. Hasler R.M., Exadaktylos A.K., Bouamra O., Benneker L.M., Clancy M., Sieber R., Zimmermann H., and Lecky F. (2011). Transportation of patients with acute traumatic cervical spine injuries, Airway management in adults after cervical spine trauma. Patients without inclusion criteria . Because of this, a major goal in the ED and trauma center is to get the patient off of a backboard and out of a C-collar as fast as possible. Both the NEXUS criteria and Canadian C-spine rules are partially based upon the presence or absence of midline C-spine tenderness. 2001;286:18418. Changes in physical examination caused by use of spinal immobilization. As a result, these changes have caused considerable angst among both prehospital providers and hospital-based personnel. Of the 24 participants recruited from a hospital, 15 were men, which is a representative sample of the general population as 81% of those with SCI are men (Casey, 2017). Stone M.B., Tubridy C.M., and Curran R. (2010). An important adverse effect of cervical collars application is the increase in intracranial pressure (ICP) values. C-collars allow even more movement than the Aspen collar.19,20Harmless? Results indicated that collars alone restrict movement by 3040%; head blocks increase restriction by 2030%; and collars alone restrict movement but do not achieve total immobilisation (Houghton and Driscoll, 1999). Acad Emerg Med. "First do no harm" It is said 3-25% of spinal cord injuries are secondary to "inappropriate management" at prehospital care [6]. If the patient doesnt require imaging, then they dont require immobilization. MeSH Stiell IG, Wells GA, Vandemheen KL, et al. Subjects were immobilised on a long spinal board in addition to the cervical collar, and asked to actively move their head as far as possible in flexion, extension, left and right lateral flexion, and both left and right rotation (Houghton and Driscoll, 1999). Validation of the Canadian c-spine rule in the UK emergency department setting. (2001). Basically after a comprehensive literature review in their paper, these Norwegian authors suggest the cessation to all routine prehospital application of cervical collars for trauma patients unless there is a temporary need during extrication. The prognosis of acute blunt cervical spinal cord injury, Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. However, recent evidence suggests that cervical collars can do more harm than good, contradicting current UK ambulance guidelines for spinal immobilisation. Increase in intracranial pressure by application of a rigid cervical collar: a pilot study in healthy volunteers. However, the hard collars used in this study are still being used, which demonstrates its relevance to current practice. Coffey F., Hewitt S., Stiell I., Howarth N., Miller P., Clement C., Emberton P., and Jabbar A. The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. There are a couple of reasons for this. Several studies have shown that early institution of CPAP in the prehospital environment has decreased the need for intubation by up to 60%, thereby reducing associated complications. Fr Autoren; ePaper; Service; Shop; Anzeigen; Mein D Suche; For authors; Suche Vanderlan WB, Tew BE, McSwain NE. A spinal cord injury (SCI) is damage to the spinal cord; half of the fractures that cause SCI involve the cervical spine (Spinal Injuries Association, 2009) (Figure 1). (2006). They were based on the following assumptions: Stone MB, Tubridy CM, Curran R. The effect of rigid cervical collars on internal jugular vein dimensions. Aoi Y., Inagawa G., Nakamura K., Sato H., Kariya T., and Goto T. (2010). Reid D.C., Henderson R., Saboe L., and Miller J.D. 23. Even the post-operative halo frames used by neurosurgeons still allow 4 degrees of motion when properly placed.17 1998;2(2):112116. Mortality is highest during the first year after the injury and is correlated with injury site and severity (World Health Organization, 2013). PMC The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury.. Prehospital rapid sequence intubation improves functional outcome for. 2015 & Beyond Spinal immobilisation for unconscious patients with multiple injuries. Mobbs R.J., Stoodley M.A., and Fuller J. Stein D.M., Roddy V., Marx J., Smith W.S., and Weingart S.D. However, they included the need to identify worsening signs and symptoms when a cervical collar is in place. Hussmann B., Lefering R., Waydhas C., Ruchholtz S., Wafaisade A., Kauther M.D., and Lendemans S. (2011). Two themes were identified regarding cervical collars: adverse effects and range of movement. Kokoska E.R., Keller M.S., Rallo M.C., and Weber T.R. Most of these result from motor vehicle collisions. Fears of worsening a spinal injury, fears of missing a spinal injury and fears of litigation have long driven this process instead of scientific evidence. ICP values before and after cervical collar application were not statistically significant (WMD = 0.49; 95%CI - 1.61, 2.59; P = 0.65), meaning no ICP change. As with previous studies, a repeated-measures design was used, with a correctly sized collar applied, as well as one size too big and one size too small. 2012;29(2):104107. Oosterwold et al (2016) added that clearance needs to be a priority to minimise time in the collar in order to prevent adverse effects. All rights reserved. The NEXUS criteria and the Canadian C-spine rules have been applied in the pre-hospital setting; those who will require imaging are placed in a cervical collar for c-spine stabilization. Characteristics of pediatric cervical spine injuries. 15. Request PDF | On Oct 26, 2022, David Hske and others published Entscheidungshilfe zur prhospitalen Wirbelsulenimmobilisation (Immo-Ampel) | Find, read and cite all the research you need on . (2009). Spine immobilization in penetrating trauma: More harm than good? However, its been said that the first step toward change is awareness. 'Clearing' the cervical spine in conscious trauma patients. (2010). Being placed on a hard backboard also causes discomfort. 9. Study level characteristics and ICP values before, during and after cervical collar application, were extracted. Possible explanations for this discrepancy were that on-scene times were less than 30 minutes (Oosterwold et al 2016), despite the mean total time from initial contact to hospital arrival being 49.13 minutes. (1995). For instance, studies have shown that collars can be placed and removed without large displacements,66 a rigid collar can increase movement in the upper cervical spine,67 there is similar restriction in cervical range of motion using soft and rigid collars,68 there is less motion with a collar in place than without a collar,69 using a collar does not effectively reduce motion in an unstable spine,70,71 there is no extra motion control by adding a collar to a spine board with head blocks,72 a collar and spine board provide more immobilization than a collar alone,73,74 a collar and a vacuum mattress offer greater stability and comfort than a collar and a spine board,75,76 immobilization provided by the short board is superior to collars and not augmented by adding collars,77,78 sandbags, collar, and tape is the most effective measure for motion control (the use of sandbags is limited though because of practical concerns),55 a board, collar, and towels/foam wedges is the most stable immobilization,79,80 and allowing an individual to exit a car under his own volition with a collar in place may result in the least amount of movement of the cervical spine.81 Altogether, whereas any form of immobilization is superior to no immobilization, no available method is optimal, and there is no solid evidence to support the commonly accepted treatment standards of today.6,42,8285, In the recent AANS/CNS guidelines, Theodore and colleagues reviewed different methods of prehospital spinal immobilization and cautiously concluded that the most effective immobilization method seemed to be a combination of a rigid collar with supportive blocks on a rigid spine board with straps.42 To our knowledge, there are no studies showing a clinical benefit of using the double immobilization strategy with rigid collars and head blocks.72, Studying the natural course of overlooked or missed fractures is another way of looking into the efficacy of cervical immobilization. Multicenter prospective validation of prehospital clinical spinal clearance criteria. Neurologic complications following immobilization of cervical spine fracture in a patient with ankylosing spondylitis. (2011). (1988). Padded vs unpadded spine board for cervical spine immobilization. 2009;1(3):247252. Priorities for pediatric prehospital research. The .gov means its official. Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review Terje Sundstrom, Helge Asbjornsen et al. 2000;85(4):665. A limitation in some of the studies is a weakness of evidence in documentation, which is highlighted throughout. Prehospital use of cervical collars in trauma patients: A critical review. Stiell I.G., Clement C.M., O'Connor A., Davies B., Leclair C., Sheehan P., Clavet T., Beland C., MacKenzie T., and Wells G.A. Background: It has been common practice in trauma to place patients in cervical collars and on long backboards (LBBs) to achieve spinal immobilization. Holla (2012), using modern accurate testing, supports Poldolsky's (1983) study and quashes the assumption that using a combination of head blocks and cervical collars results in the best immobilisation. Bochicchio G.V., Ilahi O., Joshi M., Bochicchio K., and Scalea T.M. The https:// ensures that you are connecting to the Wang H.E., Peitzman A.B., Cassidy L.D., Adelson P.D., and Yealy D.M. Few of the recent advancements in EMS have been this significant. Sandler A.J., Dvorak J., Humke T., Grob D., and Daniels W. (1996). The position of the spine in the recovery positionan experimental comparison between the lateral recovery position and the modified HAINES position. How could a clinician ensure a patient is not affected by adverse effects from cervical collars? 34. Even if the C-spine were firmly immobilized, movement of the body below the neck would also cause movement of the neck. Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome. Secondary conditions, such as respiratory dysfunction and pulmonary infections, as well as suicide, can result from SCI in the long term (Hagen et al, 2010). Field intubation of trauma patients: complications, indications, and outcomes, The airway: problems and predictions in 18.500 patients. (2006). Even over a short period of time, patients in spinal immobilization will develop pain and tenderness in their C-spine.30,31 The rationale behind this study was that the optimal testing conditions seen in other studies do not offer a realistic representation in the emergency clinical setting (Bell et al, 2009). Using a retrospective study design over 5 years where spinal immobilisation was applied to 96.3% of 1082 patients, Oosterwold et al (2016) researched the incidence of possible adverse effects of spinal immobilisation in the prehospital setting. LISTA (Library, Information Science and Technology Abstracts), Psychology and Behavoural Sciences Collection, Clear, focused question to investigate the immobilising effects of collars with and without head blocks, Immobilisation with and without head blocks, Clear, focused question to determine whether spinal immobilization causes changes in physical examination findings over time. 2005;95(3):344348. This site needs JavaScript to work properly. The influence of time, injury severity and patientcharacteristics on thedevelopment of pressure ulcers, indentation marks and pain were explored, Influence of time, injury severity and patientcharacteristics on adverse effects, 623 patients with suspected SCI were admitted. Aktuelle Traumatol. Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit. Marshall L.F., Knowlton S., Garfin S.R., Klauber M.R., Eisenberg H.M., Kopaniky D., Miner M.E., Tabbador K., and Clifton G.L. Moreover, as a systematic literature review was not undertaken, evidence may have been omitted; for example, that on more severe adverse effects such as aspiration and respiratory compromise. Cervical collar; Intracranial hypertension; Intracranial pressure; Meta-analysis; Traumatic brain injury. (2003). Acad Emer Med 1998;5:214-21. (2001). C-collars are uncomfortable: Its no secret that rigid C-collars are uncomfortable. Placing the patient in a simple C-collar isnt going to stop all axes of movement. In this chapter, we review in detail the anesthetic . Articles published over the last 1015 years were prioritized. 2009;17:44. Georgoff P., Meghan S., Mirza K., and Stein S.C. (2010). However, the studies can be questioned because inaccuracies and the use of outdated practice potentially skew the results. Specific objectives To describe the effects of immobilizing a multiple trauma patient when the spine is unstable. Ann Emerg Med. FOIA (2009). C-collars are often tight enough on the neck to restrict venous drainage of the head through the jugular veins. Potential adverse effects of spinal immobilization in children. Meschino A., Devitt J.H., Koch J.P., Szalai J.P., and Schwartz M.L. The impact of aeromedical response to patients with moderate to severe traumatic brain injury, Endotracheal intubation in the field improves survival in patients with severe head injury. Snooks H., Evans A., Wells B., Peconi J., Thomas M., Woollard M., Guly H., Jenkinson E., Turner J., andHartley-Sharpe C.; 999 EMS Research Forum Board (2009). Background: In the UK, around 500-600 people a year sustain traumatic injuries to the spinal cord, half of which involve the cervical spine. A statewide, prehospital emergency medical service selective patient spine immobilization protocol, Comparison of flight nurses' prehospital assessments and emergency physicians' ED assessments of trauma patients. (2012). Cervical collars are an accepted form of cervical immobilisation, and are prominent in the prehospital management of suspected SCI in the UK. Sunde, GA, Wester, K. Prehospital use of cervical collars in trauma patients: a critical review. Brown R.L., Brunn M.A., and Garcia V.F. Lemyze M., Palud A., Favory R., and Mathieu D. 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