Spinal immobilisation, cervical collars and extrication from cars: More harm than good. Time for a change.

MJ Slabbert HEMS

Dr. Marietjie “MJ” Slabbert

I recently heard of a complaint made by a patient to the ambulance service. This patient complained that after she was involved in a car accident, the air ambulance paramedics asked her a couple of questions, felt her neck and limbs, asked her if she could move and would like to try and get herself out of the car herself.

Although she was able to comply with this request and able to walk to the ambulance stretcher AND was discharge from hospital the same day (having suffered only a couple of bruises), she felt that, on reflection she had to write a complaint to let the ambulance service. She thought she should have been immobilised (just in case) for extrication and “wanted to make sure that the next patient doesn’t come to harm by these negligent ambulance practices”.

I could hardly believe what I heard, until (upon my own reflection), I realised where this discrepancy between “patient expectation” and safe practice stem from. It also made me realise that there are several of my clinician colleagues who might also have felt the desire to question this “gung-ho” “cowboy-ish” approach by the particular ambulance crew, of allowing a patient to self-extricate.

Having recently been asked to provide something on spinal care for a blog, I thought this would be a good starting point.
As most of us are aware, the overarching principle in medical care has always been: “first do no harm”. Our good intentions to prevent any further harm from happening to our trauma patients, has led to the use of spinal precautions that, in itself is not risk free and often not indicated.

Up until quite recently, trauma patients, almost universally would be transported to the Emergency Department on a “spinal board” – a hard (often cold) wooden slab surface. This was in an attempt to prevent any spinal movement and limit the risk of worsening any spinal injury sustained during the trauma. A patient would be “strapped down” with no padding, and often a poorly fitting cervical collar. Our intensions were good, but questions started to be asked when we noticed that patients (often the elderly or young) sustained clinically significant pressure sores lying on these hard surfaces for as short as 30-60minutes. For anyone who has ever spent any time strapped to a spinal board would agree, it is incredibly uncomfortable and hardy encourage a natural spinal posture.

Over the past few years, the universal application of spinal immobilisation for all patients who suffered trauma has therefore been questioned. With social media making its appearance international debates have started to appear questioning whether what we do is actually to the benefit of patients or is harming them. Change is often slow, but it helps when the leaders in prehospital care get involved in the debate and put their heads together to drive change forward. Because of the buy-in of many of these trendsetters, the UK has largely moved away from using wooden flat spinal boards to transport patients to hospital. This device is now mainly used to assist in the extrication of a trauma patient from a vehicle involved in a collision. In most of the United Kingdom trauma patients are now generally transported to hospital on a scoop stretcher or a vacuum mattress by many services.

Here are some of the things you need to be aware of:

“SAFE” EXTRICATION FROM A VEHICLE AFTER A COLLISION: ROOF-OFF AND FULL IMMOBILISATION
versus SELF-EXTRICATION:

Getting patients safely out of a bent mess of metal is not an easy feat. Over the years a practice has developed whereby the belief is that taking the roof off and bringing a patient out fully immobilised is definitely the safest thing to do. Too often I have seen a car with minimal damage from likely a low impact collision being slowly taken apart by the fire brigade because the patient experienced some discomfort when the first ambulance personal pressed firmly over the back of the neck. While the roof gets taken off and metal and glass debris gets slowly distributed in small particle forms across in incident site, the patient is physically restrained by both a cervical collar and a fireman or junior member of the ambulance team with their hands firmly around the patient’s neck. At the same time the oxygen cylinders slowly run out, the sun set and the patient rapidly become hypothermic. Subsequently the conscious (now cold and still) patient gets “man-handled” in a coordinated fashion onto a hard board and lifted or slid (sometimes vertically) out of the vehicle to spend the next 20-60 minutes in the back of an ambulance restrained. Quite often to be released from all these precautions within 5-minutes of arriving in the Emergency Department.

The preliminary results of a recent study by the University of Limerick looking into the BIOMECHANICS OF EXTRICATION AND SPINAL IMMOBILISATION revealed that the motion and movement required to extricate a patient on a spinal board is far more than the movement experienced when a conscious patient is able to extricate themselves.

“Of course, trauma patients may have an unstable cervical spine injury”. State the writers of Scancrit.com in their blog on “The curse of the cervical collar.” But the incidence seems to be low. “In two studies on trauma patients who were considered at high risk of head and neck trauma, they found an incidence of 0.7% for significant cervical spine injury.”

This small percentage of patients who do suffer a spinal cord injury in a trauma do require careful spinal handling, but there is a far greater proportion of patients we might actually be harming by this practice.

So the most recent recommendations are:

  • Patients should not spend a protracted time in vehicles involved in collisions. The risks of hypothermia and not addressing sustained injuries in a timely fashion and transport to hospital far outweigh the benefit of prolonged extrications with roof-off options.
  • The awake patient can stabilise / support their own neck and do not need a cervical collar. If a patient is conscious and not physically trapped, the patient can be invited to self-extricate under his/her own strength and then be placed on an ambulance stretcher and further examined. They can also look after their own necks on extrication from a vehicle. Let these patients control their own movement during extrication.
  • Manual inline stabilisation is an acceptable alternative to a hard cervical collar when there is an indication to immobilise the patient’s spine.

CONSENSUS GUIDELINES ON PREHOSPITAL SPINAL IMMOBILISATION:

Emerg Med J 2013;30:1067-1069 doi:10.1136/emermed-2013-203207

Not only has the universal use of spinal boards for transport of trauma patients changed, more major changes are on the horizon. In 2013 the Faculty of Prehospital Care, a subgroup at the Royal College of Surgeons Edinburgh, published consensus guidelines on Prehospital Spinal immobilisation. The details of these consensus guidelines are freely available on the internet and the key points are summarised below: These guidelines are UK specific.

  1. The long spinal board is an extrication device solely. Manual-in-line stabilisation is a suitable alternative to a cervical collar: Per implication, no patient should be transported to hospital on a spinal board anymore.
  2. An immobilisation algorithm may be adopted although the content of this remains undefined: This will allow clinicians to immobilise only those who meet pre-defined criteria. The guidelines are not prescriptive about which criteria should be used, but mention the NEXUS and Canadian C-Spine Rules for “clearing the c-spine”.
  3. There may be potential to vary the immobilisation algorithm based on the conscious level of the patient: It may be that in the cooperative patient immobilisation can be deferred until after the primary survey by advising the casualty to refrain from movement.
  4. Penetrating trauma with no neurological signs does not require immobilisation.
  5. ‘Standing take down’ practice should be avoided: This refers to the quite unsafe practice of manually lowering a walking patient down onto an immobilisation device from a standing position. (A blow to some of the motorsport rescue crews who seem to so love their “standing takedowns” for racers who have self-extricated and are wondering around in a dazed state. In the past the “theory” was that these patients are so “high” on adrenaline that they might not “notice” that they have fractured their spine until later and therefore should be lowered to the ground and strapped to a board. This is dogma).

The consensus group was absolutely clear that a change is needed from a policy of immobilizing necks as much for the protection of the clinician as for that of the patient, to a system of selective immobilization designed to reduce the risks to the trauma victim.

DEATH OF THE CERVICAL COLLAR:

When I started working in the United Kingdom in Emergency Medicine in 2004, we would occasionally provide a soft cervical collar for patients who attended then Emergency Department complaining of neck pain after a low-speed car accident a day or two ago. This practice of providing soft collars for “whiplash” injuries seized a couple of years later and left many a patient leaving the Emergency Department feeling somewhat “short changed”. It was a well held belief amongst us emergency docs back then that lawyers and potential claims and court appearances might have been driving these frequent requests for collars, where the reality was more likely to be patient expectation.

When it comes to the use of a hard cervical collar for trauma patients in the prehospital field, there has always been strong opinions on both sides of the fence. On the one end of the spectrum, there are the practitioners who religiously get out of their emergency vehicle with one piece of equipment in hand – a hard cervical collar. It is often the first piece of equipment that gets applied to the trauma patient and in many of clinicians mind, late application is negligent. This to is dogma!

On the other side of the spectrum we now have strong worded blogs published by very renowned prehospital clinicians who call for the “death of the cervical collar” and talk/blog about the “curse of the cervical collar”.

Why this bone of contention?

Well, cervical collars were introduced into emergency practice with very little evidence. Again, it was our attempt as medical community to try and prevent further harm. However since then several cadaver studies have shown that cervical collars might actually lead to more distraction in an injured spine, increase intracranial pressure, lead to pressure sores, impair ventilation and does not prevent spinal movement in the vertical plane. So, not only does it have the potential to do harm, it also doesn’t really do what it says on the tin.

For several years now physicians involved in prehospital care in the UK has had the option of “clearing a c-spine” on scene and recommend that spinal immobilisation does not need to be enforced for all patients. The most common criteria used for clearing c-spines on scene is the NEXUS criteria. Several ambulance services in the UK have also introduced a protocol whereby ambulance crews can follow a criteria for clearing a cervical spine in an attempt to identify patients who are unlikely to have suffered a neck injury and who do not require spinal immobilisation. See NEXUS criteria below as well as an example of an Ambulance protocol used to “clear a c-spine” on scene.

All credit to my colleagues in Scandinavia who wrote a fantastic blog called “the curse of the cervical collar” in 2013 in an attempt to bust some of these myths related to the prehospital use of cervical collars. Since this blog appeared on the web, the use/application of hard collars has been discontinued by the emergency medical services in Bergen Austria and in some parts of Queensland Australia the ambulance service is moving over to using soft cervical collars – not in an attempt to ensure cervical spine immobilisation, but as “visual clue” to the hospital Emergency Department to remind them to evaluate the spine.

So what does this mean for the future and is there any implication for General Practitioners?

Well, in my opinion these are the most sensible recommendations made in a long time in the emergency management of patients. It will not change practice overnight and will take even longer to change expectations and strong opinions amongst the believers of “just put a collar on anyway, just to be on the safe side…”

I am not a General Practitioner or Family Physician and can therefore not speak with any authority on what practices would be recommended for patients presenting to GP practices complaining of neck pain / whiplash after a collision. All I would say is it is unlikely that in the absence of any neurological abnormalities that these patients require any cervical immobilisation device, or a trip to the Emergency Department for an X-ray. Dealing with patient expectation…well, now that is a different kettle of fish.

The bottom line is just because we have always done something a certain way, doesn’t mean it was exceptionally stupid. Change should be based on sound reasoning and where it exist, sound evidence. Not all trauma patients require spinal immobilisation or passive extrication and if you have any shares in the cervical collar industry, I’d suggest selling them now.

But don’t take my word for it…

Blogs you should try and read (regularly…)

Scancrit.com

Sydneyhems.com

Ambofoam.wordpress.com

Interesting articles on the topic of spinal care, spinal assessment tools and more:

Overview and comparison of Nexus and Canadian C-spine Rules (AJCM pdf)

Benger et al. Why do we put cervical collars on conscious trauma patients? SJTREM, 2009. Full text.

Prehospital use of cervical collars in trauma patients – a critical review, J Neurotrauma, 2013. Co-written by Helge Asbjørnsen.

Stone et al. The Effect of Rigid Cervical Collar on Internal Jugular Vein Dimensions, Acad Emerg Med, 2010.

Mobbs et al. Effect of cervical hard collar on intracranial pressure after head injury, ANZ J Surg, 2002.

Hauswald et al. Out-of-hospital Spinal Immobilization: Its Effect on Neurologic Injury, Acad Emerg Med, 1998. Full text.

Peleg et al. Extrication Collars Can Result in Abnormal Separation Between Vertebrae in the Presence of a Dissociative Injury, J Trauma, 2010.

Lador et al. Motion Within the Unstable Cervical Spine During Patient Maneuvering: The Neck Pivot-Shift Phenomen, J Trauma, 2011.

Biomechanics of Extrication and Spinal Immobalisation (pdf)

By Dr. Marietjie “MJ” Slabbert

About Dr. MJ Slabbert

Dr. Marietjie “MJ” Slabbert is a specialist anaesthetist and Intensive Care Medicine doctor with a decade of experience in prehospital emergency medical care. South African trained, she has worked as a physician in prehospital emergency medical field in South Africa, Australia and the UK and is currently working in Trauma Anaesthetics and Critical Care in Toronto Canada. MJ also recently featured on the BBC’s “Hour to save your life” series when working on the HEMS service in the UK. She is an avid tweeter. @mjslabbert

Comments

  1. Harry Stevens says:

    The cervical collar has never been a c-spine immobilisation device. It has only ever been a warning device that there may be a cervical spine injury, practice has always been collar on= c-spine not cleared, collar off c-spine cleared, we need a system to identify this if collars are not used, something sple such as a label would be as protective S any collar!

    Spinal boards have always been extrication devices ONLY, scoop stretchers are what they say they are devices for scooping. Patient onto a stretcher, vacuum mattresses have always been the best option when C-spine injury is suspected!

    Please encourage some form of mechanism to ensure those attending the trauma patients can clearly identify cleared or not yet cleared c-spines!!
    By the way in my early days of clinical practice we used newspapers folded to size placed in women’s stockings, they were very effective as a RED FLAG

    As the son of a tetraplegic patient who did suffer a c 5 fracture, who had full neurological function from a fall from 4 feet high until his neck was manipulated by a Doctor, I do have some passion here! But do fully support this new practice but we must have a RED FLAG system until this practice has been passed to all involved in trauma care!

  2. Andrew haag says:

    Great read. The last paragraph is a great statement.
    Good change can sometimes be so difficult.

  3. Sharing with TLAER peeps that do both large animal and human rescue / extrication work.
    So many lay horse people ask me about this for horses in overturned trailers, etc. because they don’t realize how much muscle and bone is involved in those animals. Totally irrelevant for what we do.
    Anyway – Thank you for giving a great overview of the issues and references as well.

  4. Les Pringle says:

    After thirty years of manning front-line ambulances I couldn’t be in more agreement with the above. When I watched the nonsense going on at RTC’s in the latter years of my career I didn’t know whether to laugh or cry. There is one huge problem though. When you talk about ‘evidence based’ treatment the public has all the ‘evidence’ it needs based purely on what they see on T.V. (I would imagine that’s why the complaint came in that you mention.) Fictional programmes like ‘Casualty’, and ‘fly on the wall’ documentaries where every patient is over-treated in case litigation lawyers are watching, have more clout that a hundred studies.

  5. could not agree more, over immobilisation for minor injuries is definitely detrimental to patient care. Most (not all) of the current research indicates that any initial cord damage will happen in the initial impact, however secondary damage cannot be totally ruled out. Although there is a school of thought that the application of a collar can provide a pivot point and actually cause more damage. The evidence based approach seems to advocate far less immobilisation with the simple question does your neck hurt when you move it? If yes then don’t move it as you get out of the car.

  6. Simon says:

    May I just say, it’s a fire service and fire fighters not fire men!
    The process of space creation it not prolonged the time ticks by generally because of the delay in permission to start the process by the on site medical crews.

    Immobilisation for extrication is not only for spinal injuries let’s not forget pelvic trauma and the associated internal bleeding.

    Both agency’s need to train and discuss the best way forward at incidents so we have a great understanding of capabilities and practices. Unfortunately this rarely happens.

  7. Tom Blyth says:

    I fully agree immobilisation is not necessary in the vast majority of these patients and in the ED most of the intoxicated patients take them off and sit up anyway. However, there is still a cohort of patients with unstable c-spine fractures from low force injuries with few signs or symptoms such as the elderly fall from standing patient with no neck pain but painful hands. Obviously a collar/immobilisation will be highly unlikely to fit and do more harm than good in most cases but we need to find a way of identifying these trickier patients pre-hospitally and in the ED and work out which should be imaged and how they should be treated.

  8. Hi!
    Nicke article!
    Here in Sweden radiology refuses to X-ray cspines if the patient isn’t wearing a collar! Stupid in my eyes.
    Btw Bergen is in NORWAY not Austria.