Background: It has been common practice in trauma to place patients in cervical collars and on long backboards (LBBs) to achieve spinal immobilization. LBBs are used to help prevent spinal movement and facilitate extrication of patients. Cervical collars (C-Collars) are used to help prevent movement of the cervical spine and often are combined with lateral head blocks and straps. The theory behind this is that spine immobilization prevents secondary spinal cord injury during extrication, transport, and evaluation of trauma patients by minimizing movement. Most of this information has been passed on from historical teachings, like the Advanced Trauma Life Support (ATLS) courses, and not from scientific research. To date there has been no high-quality evidence that use of spinal immobilization improves patient outcomes. In this post, we will review the evidence associated with spinal immobilization in trauma patients. Show
Study #1: Spinal Immobilization Does NOT Help Immobilize the Cervical Spine [5]What They Did:
Outcomes:
Inclusion:
Exclusion:
Results:
Strengths:
Limitations:
Discussion:
Author Conclusion: “The stretcher mattress significantly reduced lateral movement during transport.” Clinical Take Home Point: This study confirms that long spine board immobilization does not limit lateral movement, however the clinical correlation to possible spine movement and neurologic outcomes cannot be evaluated based on this trial alone. Study #2: Spinal Immobilization Does NOT Decrease Rates of Spinal Cord Injury[6]What They Did:
Outcomes:
Inclusion:
Exclusion:
Results:
Strengths:
Limitations:
Author Conclusion: “Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.” Clinical Take Home Point: Acute spinal immobilization may not have benefit for the prevention of neurologic deterioration from unstable spinal fractures Study #3: Spinal Immobilization Increases the Difficulty of Airway Management[7]What They Did:
Outcomes:
Inclusion:
Exclusion:
Results:
Strengths:
Limitations:
Author Conclusion: “Tracheal intubation using Airtraq in the presence of rigid cervical collar has equivalent success rate, acceptable difficulty in insertion, and mild increase in IDS.” Clinical Take Home Point: Tracheal intubation is more difficult, takes a longer time, and requires more maneuvers for success when cervical collar is applied. Study #4: Spinal Immobilization Can Cause Pressure Ulcers [1]What They Did:
Outcomes:
Inclusion:
Exclusion:
Results:
Strengths:
Limitations:
Discussion:
Author Conclusion: “The results from this systematic review show that immobilization with devices increases the risk for Pressure Ulcer Development. This risk is demonstrated in nine experimental studies with healthy volunteers and in four clinical studies.” Clinical Take Home Point: Spinal immobilization can cause the development of pressure ulcers. Extrication backboards should be removed as soon as possible to prevent prolonged times on hard surfaces. The time of rigid/semi-rigid C-collar devices should also be minimized by standardizing the procedure for C-collar clearance (i.e. NEXUS or Canadian C-spine rules). If patients require prolonged C-collar time, the rigid/semi-rigid extrication collars should be exchanged out for more comfortable soft collar devices. Study #5: Spinal Immobilization Changes the Physical Exam [2]What They Did:
Outcomes:
Exclusion:
Results:
Strengths:
Limitations:
Discussion:
Author Conclusion: ‘This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. In order to reduce this high false-positive rate for midline vertebral tenderness, the authors recommend that, initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients. Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations.” Clinical Take Home Point: Prolonged spinal immobilization (>30min) can increase the rate of midline spine tenderness, likely resulting in unnecessary health care costs due to radiologic evaluations. Study #6: Spinal Immobilization Worsens Pulmonary Function [3]What They Did:
Outcomes:
Exclusion:
Results:
Strengths:
Limitations:
Discussion:
Author Conclusion: “This study confirmed the previously reported respiratory restriction caused by spinal immobilization. Vacuum mattresses are more comfortable than wooden backboards.” Clinical Take Home Point: When comparing baseline pulmonary function tests to spinal immobilization, there is a significant restrictive decrease in patient’s pulmonary function (average of 17%) when fully immobilized. Study #7: Spinal Immobilization Increases Intracranial Pressure [4]:What They Did:
Outcomes: ICP Inclusion:
Results:
Strengths:
Limitations:
Discussion:
Author Conclusion: “Early assessment of the cervical spine in head-injured patients is recommended to minimize the risk of intracranial hypertension related to prolonged cervical spine immobilization with a hard collar.” Clinical Take Home Point: Although this is a case series, looking at the surrogate outcome of increased ICP, removal of rigid collars at the earliest time should be recommended. Future studies should evaluate the correlation of collar placement and secondary brain injury. Position Statement from National Association of EMS Physicians and American College of Surgeons Committee on Trauma [8]
THE BOTTOM LINE:
References:
For More Thoughts on This Topic Checkout:
Support the Show by Paying & Claiming 0.5hrs of CME/CEH by Clicking on the Logo BelowPost Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami) What is direct carry used for?The direct carry is used to transfer a patient: from a bed to the ambulance stretcher. In most instances, you should move a patient on a wheeled ambulance stretcher by: pushing the head of the stretcher while your partner guides the foot.
Which is the most appropriate method to use when moving a patient?There are quite a few techniques that EMS crews utilize in order to facilitate the appropriate movement of the patient. The most recognized technique is the use of the stretcher. EMS and stretchers go together like peanut butter and jelly.
When lifting a backboard you should use?lift by straightening your knees. Whenever you grasp a stretcher or backboard, your hands should be at least 10 inches (25 cm) apart. Lifting by extending the properly placed flexed legs is the most powerful way to lift and is called an emergency move.
How do you position an unresponsive patient with no suspected spinal injuries?Move them onto their side and tilt their head back.
Putting them in this position with their head back helps keep their airway open. It ensures their tongue falls forward and blood and vomit drain out. It is sometimes called the “recovery position”.
|