Changes in cervical spine immobilisation protocols

There is a need to rethink the traditionally held belief that all trauma patients should automatically receive full spinal immobilisation. Earlier studies had attributed pre-hospital neurological deterioration to a failure to immobilise the spine. More recent studies have however failed to support this link. This doesn’t mean that the earlier studies were incorrect, but rather that more extensive research is needed before a decisive protocol can be developed for the patient immobilisation. Until such time, full body immobilisation must still be considered as an important treatment protocol, and the use of cervical collars under certain conditions is still advised.

Cervical collars present additional challenges in using the optimal protocol for a patient. We find that they are often not an ideal fit for all patients, and that even when they do fit a patient favourably they still allow for an undesirable amount of cervical spine movement, and as such are not a complete cervical spine immobilisation tool. Also, if cervical collars are applied too tightly to a patient, they can compress the jugular veins, which can lead to substantially increased intracranial pressure – a serious concern in patients with confirmed or suspected head injuries.

As part of the overall patient assessment, the following factors should be considered when deciding on the immobilisation methods to be used:

  • In an unstable patient with blunt trauma, time is of the essence and rapid transportation to hospital should be the priority. In such instances, the use of a cervical collar only, while limiting movement on a stretcher, can be considered.
  • In a patient with a penetrating traumatic wound and unstable circulation there is very little evidence to suggest that use of spinal immobilization is of any benefit, and rapid transportation without the application of immobilisation techniques can be considered.

It needs to be highlighted that reduced immobilisation techniques should only be applied to patients that are in a critical condition.

In patients that are stable, the following considerations should be taken:

  • Patients who show signs of head injuries or increased intracranial pressure should not be immobilised with the use of a cervical collar. Full body immobilisation using a device like a vacuum mattress should still be applied. A spine board and head blocks can also be used for short immobilisation periods, but the use of a vacuum mattress is preferred.
  • In stable patients who show no signs of a head injury or increased intracranial pressure, the use of a proper fitting cervical collar is still recommended as part of a full body immobilisation protocol that also includes the use of a vacuum mattress or spine board and head blocks.

We strongly recommend that the reader familiarises themselves with the attached article in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine on The Development of a New Emergency Medicine Spinal Immobilization Protocol, as well as any further literature available to this effect before deciding to apply any new cervical spine treatment methods in their regular patient care procedures.

 

10 thoughts on “Changes in cervical spine immobilisation protocols

  1. Finally a start to some commonsense.

    Cervical collars can be very uncomfortable. Many manufacturers produce uncomfortable collars, poorly designed and often selected by Services based on cost rather than fucnction and comfort, thus often producing unwanted dangers. Time to rethink about what you buy. Buy cheap, you get rubbish and the studies show this. Studies rarely however review descently designed and properly applied collars, very apparent when you get past the abstract.

    Board immobilisation. Multiple studies show proper torso padding , occipital padding and lumber padding significantly resolves board discomfort, pressure sores, etc, but these studies rarely if ever appear in the studies on boards due to bias research and publications. Why include a study that may contradict what the research want s to prove. Don’t tell the full story is the current policy of many research papers. Further, flat board design is outdated. A number of States in Australia used curved boards with a 20 to 25 degree side curve, further improving comfort and significantly improving function. Most have since been removed, not due to problems with the Board, but poor training and the option to by cheaper items at the sacrifice of patient care and equipment function. Again outdated designs and cheap equipment purchased by many services, and withholding the studies proving that a curved padded board improves almost all issues re withheld from the research papers, thus distorting the truth and denying the medical community of treating patients descently. But why reference studies that go against what you are trying to falsely prove.

    Studies in extrication. Two major studies in the USA looked at spinal movement removing patients from vehicles, Both studies used the outdated techniques of sidedoor extrication that we already know causes massive twisting of the spine. Both studies failed to follow very two basic principles in removal, that is. 1. Maintain spine alignment, and 2. Minimal body twisting. If you fail to follow basis rules of extrication and use poor standards of care then the results will be poor. And yet again, these two studies are considered land mark papers. All these studies prove is that outdated techniques do what we already know .. they cause spinal twisting.

    Further. Spinal immobilisation is only one part of the use of Board. Strapping someone to a well padded curved Board provides lateral support, for comfort and reduction in lateral movement, and reduces movement on the majority of the damaged body during transport, that if used well in competent hands, significantly reducing painful movement to the multi trauma patient during the drive to hospital. They are not needed for hospital care as vehicle movement is no longer so hospital use has limited value so stop using hospital studies for prehospital care. This simple fact is often overlooked. Again by the researchers. It’s just not the spine. It’s about providing proper standards by well trained operators, and ausing a device that limits movement. In the prehospital setting.

    Finally, many studies quote only the abstracts to support their questionable finding, hoping the reader will not read the full article and find the multiple flaws in basic patient care and equipment useage failures, where proper use of the equipment or commonsense are not even followed in the studies.

    So in summary, stop buying cheap poorly designed equipment, pad your boards, buy a comfortable collar ( they do exist but are few and far betweeen), think about basic patient care and the results of immobilisation for spinal care and for multiple fractures will be of great comfort to the patient. Or continue with the purchasing and use of cheap substandard equipment and procedures and in the long term, the descent equipment will be lost and our patients will be the ones who suffer..

    And remember the equipment is not just used for spinal care. That less than 20% of its use. So start undertaking studies of the equipment for it’s multiple uses rather than just one area.

    Anthony Hann
    MICA – Paramedic

  2. So you don’t publish articles that question the research you publish and find fault with your articles. This is the problem with alot of medical literature. It is selective and when holes are found in the research, if websites such as yourself don’t like it, you just do publish it. This destroys your credibilty, only showing one side of the argument. Very dissappointing.

  3. So the Stifneck Select Cervical Collar and flat Long Spine boards (esp with no padding are the most uncomfortable devices on the market. Yet you sell them. Why. You publish research that shows Collars (such as the Stifneck Select which are cheap and poorly designed are dangerous, and are extremely uncomfortable, yet you sell them. I don’t get it. And you won’t publish comments relating to flaws in articles you present. Bizzare really. But you want to be credible. You can’t have it both ways.

    So if you don’t want to publish oppsing points of view that is fine. I’ll expose your website, the articles you publish, and what you sell, and then everyone can see the hypocrisy of your website and the lack of credability you have.

    1. Good day Anthony

      Thank you for your input.

      In brief response to some of your queries:

      1) The recommendations that have been published in the AFEM Journal are excellent. These recommendations were published in the March 2017 issue of the journal. The SAPAESA article on the subject was published in July 2016, and as a result the AFEM recommendations were not available at the time that our article was published. The Scandinavian recommendations were some of the most balanced recommendations available at the time of the SAPAESA article and as such these recommendations were referenced.

      2) SAPAESA does sell both Spine Boards as well as Cervical Collars. The reason for this is simple. The Board of Healthcare Funders of South Africa accreditation criteria for the minimum norms and standards for private ambulance services makes it mandatory for every ambulance service to carry this equipment on an ambulance. SAPAESA does not set these accreditation standards and until they are updated we need to support our members by providing equipment that is reliable and affordable in order to assist our members to maintain ongoing compliance with accreditation standards.

      3) The use of padded spine boards is a practice that is a relatively new one which was not mentioned in main stream publications at the time that the SAPAESA article was written. We continue to monitor the developments within the use of the padded spine boards and any potential risks and benefits that may be attributed to their use.

      4) Please be mindful that the contents of our article are not a clinical guideline recommendation. The clinical guidelines for EMS staff in South Africa are published by the Health Professions Council of South Africa (HPCSA). SAPAESA strives to provide a conservative and balanced view on various opinions regarding the use of spinal immobilization practices, however until such time as the HPCSA makes changes to the local protocol, SAPAESA must be cautious about making any clinical recommendations in order to avoid liability to both ourselves and to local EMS practitioners.

      Kind Regards

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