Prehospital Spinal Care

Prehospital Spinal Care – Are we doing the right thing by our patients?

First stop:  Queensland Ambulance Service is getting rid of hard collars and using only soft collars very soon.  Check out this post from Minhn Le Cong(QAS Royal Flying Doctors):

http://prehospitalmed.com/2014/10/08/soft-neck-collar-to-replace-hard-times-are-a-changin/

So why this change?  Have a quick look at this post for a bit of myth busting:

http://www.scancrit.com/2013/10/10/cervical-collar/

And then this one to find out what ILCOR now recommends for spinal immobilisation!!!:

http://www.scancrit.com/2015/02/12/cervical-collars-slashed-guidelines/#more-7884

And one from the states that is an excellent overview, including a run down on the complications and issues that collars cause such as increased ICP, pressure sores, airway problems and increased movement of unstable cervical fractures:

http://www.jems.com/articles/print/volume-40/issue-2/patient-care/why-ems-should-limit-use-rigid-cervical.html

There has been a recent update to the NSW Ambulance skills manual with a series of spinal precautions and immobilisation skill sheets.  Take this consensus statement on minimal patient handling into consideration in conjunction with the new skill sheets:

24232010_ Minimal patient handling_ a faculty of prehospital care consensus statement

Faculty of Prehospital Care Recommendations:

– Spineboards should be used only for extrication, never for transport

– Scoops are good for spinal injuries(minimal patient movement) and underused, they decrease log rolls and patient movement

– A minimal handling approach should always be used in the setting os suspected spinal injury

 

  

Extrication Techniques:

23811859_ Biomechanical analysis of spinal immobilisation during prehospital extrication_ a proof of concept study

Biomechanical analysis of various spinal immobilisation and extrication techniques, showing the worst in terms of shift of the spine from mid line was to use a NIEJ, strip the B pillar and extricate on a spineboard.  The best technique was instruct the the patient to carefully step out of the vehicle, followed by application of a collar and then instruct to step out of the vehicle.

Distracting Injuries:

Cervical spine fractures in elderly patients with hip fracture after low-level fall_ an opportunity to refine prehospital spinal immobilization guidelines_

Investigates the spinal immobilisation of elderly patients with femoral/pelvic fractures caused by falls from sitting or standing height, finding only 0.4% incidence of spinal fractures out of 2441 patients.  Many of these patients are collared due to their distracting injury.

Collars in penetrating trauma:

PHTLS Recommendations:
– There are no data to support routine spine immobilization
in patients with penetrating trauma to the neck or
torso.
– There are no data to support routine spine immobilization
in patients with isolated penetrating trauma to the
cranium.
– Spine immobilization should never be done at the expense
of accurate physical examination or identification
and correction of life-threatening conditions in patients
with penetrating trauma.
– Spinal immobilization may be performed after penetrating
injury when a focal neurologic deficit is noted on
physical examination although there is little evidence of
benefit even in these cases.

19820585_ Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso

GSW to torso only caused injury via direct penetration of the spinal cord by a bullet, no benefit to be gained from collaring these patients, but a potential increase in scene time by 5.5 minutes on average and a worsening of airway issues which killed 16% of theses patients.

21909006_ Prehospital spine immobilization for penetrating trauma–review and recommendations from the Prehospital Trauma Life Support Executive Committee

“Of particular concern are two studies that suggest an
increase in mortality from spine immobilization in victims of
penetrating injury.20,33 Vanderlan et al.20 reviewed data from
a single trauma center and noted cervical collar placement to
be an independent risk factor for death. An analysis from the
National Trauma Data Bank of 45,284 patients with penetrating
trauma noted a twofold increase in mortality in patients
who were immobilized compared with similar patients who
were not.33 Only 0.01% of patients with an incomplete spinal
cord injury eventually required operative spine fixation, leading
the authors to conclude that spinal cord damage from
penetrating trauma is done at the time of injury, does not
worsen, and does not benefit from immobilization. The increased
mortality found in immobilized patients was attributed
to increased scene times and the potential to miss signs
of immediate life threat, such as tracheal deviation and
subcutaneous emphysema.”

Cadaver studies of the effects of collars:

20093981_ Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury

9 cadavers, collar application effectively “pushed” the head away from the shoulders, causing gross separation of high cervical injury by displacing the verterbral gap at the site of injruy.

21217496_ Motion within the unstable cervical spine during patient maneuvering_ the neck pivot-shift phenomenon

Small sample size of 7 “fresh” cadavers, however found significant movement of the C-spine with collars on during log rolling and other patient movement.  Postulated that a pivot point is caused by the collars plastic.

21397431_ Cervical collars are insufficient for immobilizing an unstable cervical spine injury

5 cadavers(not so fresh this time) with 2 different types of collars or no collar, found very little reduction in movement across the groups.  Suggest that collars provide a visual cue but very little other benefit.(This is in line with the goals of QAS soft collars, almost no reduction in movement of the spine but provide a visual cue and also reduce the negative effects of hard collars).

 Blast Injuries: 

22071997_ Spinal injuries after improvised explosive device incidents_ implications for Tactical Combat Casualty Care

Patients injured in IED blasts had a 10.4% incidence of acute spinal injury(n=212), higher than that from other blunt force mechanisms in the study.  Blast injury patients were also significantly less likely to have spinal precautions in place.

Recent spinal care reviews:

24232010_ Minimal patient handling_ a faculty of prehospital care consensus statement

25624270_ Should suspected cervical spinal cord injury be immobilised__ A systematic review

 

 

 

 

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1 Response to Prehospital Spinal Care

  1. Damien pinchen says:

    Great evidence based information matty, especially the incidence of increased ICP from neck compression in head injuries. Plenty of food for thought 😊.I look forward to your next post mate. I also want to personally thankyou for your time and effort, it is very much appreciated. As clinicians we should all be looking to improve our knowledge and question our current practice.

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