Spinal immobilisation for trauma patients

The effect of ATLS/PHTLS spinal motion restriction protocol on the incidence of spinal cord injury, a nationwide database study

PURPOSE

To study trends in incidence and outcome of patients with traumatic spinal cord injury (TSCI) in the Netherlands before, during and after implementation of the Advanced Trauma Life Support (ATLS®) and Pre-Hospital Trauma Life Support (PHTLS®)- Spinal Motion Restriction(SMR) protocol.

METHODS

In an observational database we studied national hospital admission and emergency department databases to analyse incidence rates and outcome of traumatic spinal cord injury and spinal fractures in the emergency department and in admittances in The Netherlands between 1986 and 2021.

RESULTS

A significant increase of 39% in TSCI in admitted patients with spinal fractures over the past 35 years (p < 0.001). This increase was especially prevalent in cervical spinal fractures (132%), while thoracic and lumbosacral spinal fractures showed a decrease in accompanied TSCI (64% and 88% respectively). The overall increase in spinal fractures was not significant. The duration of hospital admission decreased for spinal fractures without TSCI and with TSCI (66% and 56% respectively).

CONCLUSION

Since implementation of the SMR-protocol was aiming to limit TSCI in patients who suffered a spinal fracture, the increase in TSCI is an unexpected finding. Exact explanation for this increase is unclear and the contribution of the SMR-protocol is not fully understood due to confounders in the used datasets. Either way, the scientific evidence supporting this costly time- and labor-intensive SMR-protocol remains debated, along with evidence contradicting it. Therefore it stresses the need for clear, evidencebased reasoning for spinal immobilization according to ATLS, as this is currently lacking.

Cervical spine immobilisation following blunt trauma in pre-hospital and emergency care: A systematic review

OBJECTIVES

To assess whether different cervical spine immobilisation strategies (full immobilisation, movement minimisation or no immobilisation), impact neurological and/or other outcomes for patients with suspected cervical spinal injury in the pre-hospital and emergency department setting.

DESIGN

Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Library and two research registers were searched until September 2023.

ELIGIBILITY CRITERIA

All comparative studies (prospective or retrospective) that examined the potential benefits and/or harms of immobilisation practices during pre-hospital and emergency care of patients with a potential cervical spine injury (pre-imaging) following blunt trauma.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected and extracted data. Risk of bias was appraised using the Cochrane ROBINS-I tool for non-randomised studies. Data were synthesised without meta-analysis.

RESULTS

Six observational studies met the inclusion criteria. The methodological quality was variable, with most studies having serious or critical risk of bias. The effect of cervical spine immobilisation practices such as full immobilisation or movement minimisation during pre-hospital and emergency care did not show clear evidence of benefit for the prevention of neurological deterioration, spinal injuries and death compared with no immobilisation. However, increased pain, discomfort and anatomical complications were associated with collar application during immobilisation.

CONCLUSIONS

Despite the limited evidence, weak designs and limited generalisability, the available data suggest that pre-hospital cervical spine immobilisation (full immobilisation or movement minimisation) was of uncertain value due to the lack of demonstrable benefit and may lead to potential complications and adverse outcomes. High-quality randomised comparative studies are required to address this important question.

TRIAL REGISTRATION

PROSPERO REGISTRATION Fiona Lecky, Abdullah Pandor, Munira Essat, Anthea Sutton, Carl Marincowitz, Gordon Fuller, Stuart Reid, Jason Smith. A systematic review of cervical spine immobilisation following blunt trauma in pre-hospital and emergency care. PROSPERO 2022 CRD42022349600 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022349600.

Spinal Backboard-Necessity or Hazard? The IDF Clinical Practice Guidelines and Policy

INTRODUCTION

Prehospital spinal immobilization using a cervical collar and a backboard has been standard practice for suspected spinal cord injuries (SCIs) since the 1960s. Multiple studies have shown that the disadvantages of the spinal backboard outweigh its advantages. This report aims to present a review of the current literature along with the revised IDF protocol regarding patients with suspected SCI.

METHODS

In 2019, the IDF Medical Corps (IDFMC) convened a multidisciplinary expert committee to revise the IDFMC protocols regarding the use of spinal backboards. Prior to convening the committee, a review of the pertinent literature was done by conducting a thorough clinical evaluation in "PubMed" and "Google Scholar" databases to identify recent studies investigating traumatic SCI and the prehospital military use of spinal backboards.

RESULTS

There were no documented studies that have managed to prove the efficacy of spinal backboards to prevent exacerbation of spinal injuries during mobilization. Despite being a good tool for extraction from vehicles and combat arenas, more than 11 studies have shown that backboards may even result in adverse outcomes such as pain due to the contact between board and skin, the formation of decubitus ulcers, hypothermia, and inadequate ventilation.

CONCLUSION

In light of the evidence showing the potential harmful effects of the routine use of spinal backboards, the IDF guidelines have been revised and now recommends avoiding the routine use of spinal backboards and using a standard stretcher for transporting potential SCI patients. Current IDF guidelines recommend using a backboard for the extraction of an entrapped patient and for obtunded or unconscious patients with obvious deformity or mechanism for spinal trauma.

Cervical spine movements during laryngoscopy and orotracheal intubation: a systematic review and meta-analysis

BACKGROUND

Airway management is challenging in trauma patients because of the fear of worsening cervical spinal cord damage. Video-integrated and optic-integrated devices and intubation laryngeal mask airways have been proposed as alternatives to direct laryngoscopy with the Macintosh laryngoscope (MAC). We performed a meta-analysis to clarify which devices cause less cervical movement during airway management.

METHODS

We searched MEDLINE, Cochrane Central, Embase and LILACS from inception to January 2022. We selected randomised controlled trials comparing alternative devices with the MAC for cervical movement from C0 to C5 in adult patients, evaluated by radiological examination. Additionally, cervical spine immobilisation (CSI) techniques were evaluated. We used the Cochrane Risk of Bias Tool to evaluate the risk of bias, and the principles of the Grading of Recommendations, Assessment, Development, and Evaluations system to assess the quality of the body of evidence.

RESULTS

Twenty-one studies (530 patients) were included. Alternative devices caused statistically significantly less cervical movement than MAC during laryngoscopy with mean differences of -3.43 (95% CI -4.93 to -1.92) at C0-C1, -3.19 (-4.04 to -2.35) at C1-C2, -1.35 (-2.19 to -0.51) at C2-C3, and -2.61 (-3.62 to -1.60) at C3-C4; and during intubation: -3.60 (-5.08 to -2.12) at C0-C1, -2.38 (-3.17 to -1.58) at C1-C2, -1.20 (-2.09 to -0.31) at C2-C3. The Airtraq and the Intubation Laryngeal Mask Airway caused statistically significant less movement than MAC restricted to some cervical segments, as well as CSI. Heterogeneity was low to moderate in most results. The quality of the body of evidence was 'low' and 'very low'.

CONCLUSIONS

Compared with the MAC, alternative devices caused less movement during laryngoscopy (C0-C4) and intubation (C0-C3). Due to the high risk of bias and the very low grade of evidence of the studies, further research is necessary to clarify the benefit of each device and to determine the efficacy of cervical immobilisation during airway management.

Immobilization in Emergency Medical Service - Are CSR and NEXUS-Criteria Considered? A Matched-Pairs Analysis Between Trauma Patients Treated by Onsite EMS Physicians and Patients Treated by Tele-EMS Physicians

Background

The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over- as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS- and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device.

Methods

A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter.

Results

Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard.

Conclusion

It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS- and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.

Cervical immobilization in trauma patients: soft collars better than rigid collars? A systematic review and meta-analysis

INTRODUCTION

Rigid cervical spine following trauma immobilization is recommended to reduce neurological disability and provide spinal stability. Soft collars have been proposed as a good alternative because of the complications related to rigid collars. The purpose of this study was to perform a systematic review on soft and rigid collars in the prehospital management of cervical trauma.

METHOD

A systematic review was performed following the PRISMA guidelines. Search terms were (immobilization) AND (collar) AND ((neck) OR (cervical)) to evaluate the range of motion (ROM) and evidence of clinical outcome for soft and rigid collars.

RESULTS

A total of 18 studies met eligibility criteria including 2 clinical studies and 16 articles investigating the range of motion (ROM). Four hundred and ninety-six patients at a mean age of 32.5 years (SD 16.8) were included. Measurements were performed in a seated position in twelve studies. Eight articles reported the ROM without a collar, 7 with a soft collar, and 15 with a rigid collar. There was no significant difference in flexion/extension, bending and rotation following immobilization with soft collars compared to no collar. Rigid collars provided significantly higher stability compared to no collar (p < 0.005) and to soft collars in flexion/extension and rotation movements (p < 0.05). The retrospective clinical studies showed no significant differences in secondary spinal cord injuries for soft collar (0.5%) and for rigid collar (1.1%). One study, comparing immobilization without a collar compared to that with a rigid collar, found a significant difference in neurologic deficiency and supraclavicular nerve lesion.

CONCLUSION

Although rigid collars provide significant higher stability to no collar and to soft collars in flexion/ extension and rotation movements, clinical studies could not confirm a difference in neurological outcome.

LEVEL OF EVIDENCE

II, Systematic Review.

The Immo Traffic Light System as a Decision-Making Tool for Prehospital Spinal Immobilization

BACKGROUND

Spinal injuries are difficult injuries to assess yet can be associated with significant neurological damage. To avoid secondary damage, immobilization is considered state of the art trauma care. The indication for spinal immobilization must be assessed, however, for potential complications as well as its advantages and disadvantages.

METHODS

This systematic review addressing the question of the correct indication for spinal immobilization in trauma patients was compiled on the basis of our previously published analysis of possible predictors from the Trauma Registry of the German Society for Trauma Surgery. A Delphi procedure was then used to develop suggestions for action regarding immobilization based on the results of this review.

RESULTS

The search of the literature yielded 576 publications. The 24 publications included in the qualitative analysis report of 2 228 076 patients. A decision tool for spinal immobilization in prehospital trauma care was developed (Immo traffic light system) based on the results of the Delphi procedure. According to this system, severely injured patients with blunt trauma, severe traumatic brain injury, peripheral neurological symptoms, or spinal pain requiring treatment should be immobilized. Patients with a statistically increased risk of spinal injury as a result of the four cardinal features (fall >3m, severe trunk injury, supra clavicular injury, seniority [age >65 years]) should only have their spinal motion restricted after weighing up the pros and cons. Isolated penetrating trunk injuries should not be immobilized.

CONCLUSION

High-quality studies demonstrating the benefit of prehospital spinal immobilization are still lacking. Decision tools such as the Immo traffic light system can help weigh up the pros and cons of immobilization.

Soft collar for acute cervical spine injury immobilisation -patient experiences and outcomes: A single centre mixed methods study

BACKGROUND

Cervical collars are used as standard care for neck immobilisation after cervical spine injury. Although evidence for the most effective type of collar is lacking, there is evidence regarding adverse patient outcomes when managed in a semi or rigid collar. In response to the evidence of complications and adverse effects when using a hard collar, a large Australian adult trauma hospital that specializes in spinal care, changed its policy from hard to soft collars when managing acute cervical spine injury.

OBJECTIVE

The aim of this study was to investigate patients' experiences and outcomes when wearing a soft collar for acute cervical spine injury management in hospital.

METHOD

A single centre mixed method sequential study design was used.

RESULTS

Medical records from 136 patients were examined and no adverse events resulting from collar use were recorded. Interviews with 20 patients revealed that they understood the value of wearing a soft collar. The soft collars were considered supportive and well tolerated, with good adherence to recommendations for use.

CONCLUSIONS

Understanding the patients' experiences informs better care management. This study suggests that soft collars are well tolerated, do not result in pressure injuries or other adverse events and are suitable for managing acute cervical spine injury.

Removal of the cervical collar from alpine rescue protocols? A biomechanical non-inferiority trial in real-life mountain conditions

Background

Alpine skiing rescues are challenging because of the mountainous environment and risks of cervical spine motion (CSM) induced during victims’ extrications (EXs) and downhill evacuations (DEs). The benefits of applying a cervical collar (CC) over manual in-line stabilization without CC (MILS) in terms of spinal motion restriction during simulated alpine rescues are undocumented. Our hypothesis was that CSM recorded using MILS alone is non-inferior to CSM recorded with a CC according to a 10 degrees margin.

Methods

A total of 32 alpine extrications and 4 downhill evacuations on different slope conditions were performed using a high fidelity mannequin designed with a motion sensors instrumented cervical spine. The primary outcome was the peak extrication 3D excursion angle (Peak 3D θ_EX,) of the mannequin’s head. The secondary objectives were to describe the time to extrication completion (tEX) and to highlight which extrication manipulation is more likely to induce CSM.

Results

The median Peak 3D θ_EX recorded during flat terrain extrications using CC was 10.77° (95% CI 7.31°–16.45°) compared to 13.06° (95% CI 10.20°–30.36°) using MILS, and 16.09° (95% CI 9.07°–37.43°) for CC versus 16.65° (95% CI 13.80°–23.40°) using MILS on a steep slope. Peak 3D θ_EX with CC or using MILS during extrications were equivalent according to a 10 degrees non-inferiority hypothesis testing (p < 0.05). Time to extrication completion (tEX) was significantly reduced using MILS without CC on a flat terrain with a median duration of 237,3 s (95% CI 197.8 s, 272.2 s) compared to 358.7 s (95% CI 324.1 s, 472.4 s). During downhill evacuations, CSM with and without CC across all terrain conditions were negligible (< 5°). When CC is used; its installation manipulation induces the highest CSM. When EXs are done using MILS without CC, the logroll initiation is the manipulation inducing the highest risk of CSM.

Conclusion

For experienced ski patrollers, the biomechanical benefits of spinal motion restriction provided by CC over MILS during alpine skiing rescues appear to be marginal and CC use negatively affects rescue time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01031-3.

Evaluation of external stabilization of type II odontoid fractures in geriatric patients-An experimental study on a newly developed cadaveric trauma model

Background

Along with the growing geriatric population, the number of odontoid fractures is steadily increasing. However, the effectiveness of immobilizing geriatric odontoid fractures using a cervical collar has been questioned. The aim of the present study is to analyze the physiological and pathological motion in odontoid fractures and to assess limitation of motion in the cervical spine when applying a cervical collar.

Methods

Motion analysis was performed with wireless motion tracker on unfixed geriatric human cadavers. First, a new geriatric type II odontoid fracture model was developed. In this model, the type II odontoid fracture is operated via a transoral approach. The physiological and pathological flexion and lateral bending of the cervical spine resulting from this procedure was measured. The resulting motion after external stabilization using a cervical collar was analyzed.

Results

The new geriatric type II odontoid fracture model was successfully established using seven unfixed human cadavers. The pathological flexion of the cervical spine was significantly increased compared to the physiological flexion (p = 0.027). Furthermore, the flexion was significantly reduced when a cervical collar was applied. In case of flexion the mean remaining motion was significantly reduced (p = 0.0017) from 41° to 14°. For lateral bending the mean remaining motion was significantly reduced (p = 0.0137) from 48° to 18°.

Conclusions

In case of type II odontoid fracture, flexion and lateral bending of the cervical spine are increased due to spinal instability. Thus, if an odontoid fracture is suspected in geriatric patients, the application of a cervical collar should always be considered since external stabilization can significantly reduce flexion and lateral bending.

Analysis of remaining motion using one innovative upper airway opening cervical collar and two traditional cervical collars

The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered.

Prehospital care for traumatic spinal cord injury by first responders in 8 sub-Saharan African countries and 6 other low- and middle-income countries: A scoping review

INTRODUCTION

Traumatic spinal cord injury (TSCI) constitutes a considerable portion of the global injury burden, disproportionately affecting low- and middle-income countries (LMICs). Prehospital care can address TSCI morbidity and mortality, but emergency medical services are lacking in LMICs. The current standard of prehospital care for TSCI in sub-Saharan Africa and other LMICs is unknown.

METHODS

This review sought to describe the state of training and resources for prehospital TSCI management in sub-Saharan Africa and other LMICs. Articles published between 1 January 1995 and 1 March 2020 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for TSCI. Two reviewers assessed full texts meeting inclusion criteria for quality using the Newcastle-Ottawa Scale and extracted relevant characteristics to assess trends in the state of prehospital TSCI care in sub-Saharan Africa and other LMICs.

RESULTS

Of an initial 482 articles identified, 23 met inclusion criteria, of which ten were set in Africa, representing eight countries. C-spine immobilization precautions for suspected TSCI patients is the most prevalent prehospital TSCI intervention for and is in every LMIC first responder program reviewed, except one. Numerous first responder programs providing TSCI care operate without C-collar access (n = 13) and few teach full spinal immobilization (n = 5). Rapid transport is most frequently reported as the key mortality-reducing factor (n = 11). Despite more studies conducted in the Southeast Asia/Middle East (n = 13), prehospital TSCI studies in Africa are more geographically diverse, but responder courses are shorter, produce fewer professional responders, and have limited C-collar availability.

DISCUSSION

Deficits in training and resources to manage TSCI highlights the need for large prospective trials evaluating alternative C-spine immobilization methods for TCSI that are more readily available across diverse LMIC environments and the importance of understanding resource variability to sustainably improve prehospital TSCI care.

ResQbot 2.0: An Improved Design of a Mobile Rescue Robot with an Inflatable Neck Securing Device for Safe Casualty Extraction

Despite the fact that a large number of research studies have been conducted in the field of search and rescue robotics, significantly little attention has been given to the development of rescue robots capable of performing physical rescue interventions, including loading and transporting victims to a safe zone—i.e., casualty extraction tasks. The aim of this study is to develop a mobile rescue robot that could assist first responders when saving casualties from a dangerous area by performing a casualty extraction procedure whilst ensuring that no additional injury is caused by the operation and no additional lives are put at risk. In this paper, we present a novel design of ResQbot 2.0—a mobile rescue robot designed for performing the casualty extraction task. This robot is a stretcher-type casualty extraction robot, which is a significantly improved version of the initial proof-of-concept prototype, ResQbot (retrospectively referred to as ResQbot 1.0), that has been developed in our previous work. The proposed designs and development of the mechanical system of ResQbot 2.0, as well as the method for safely loading a full-body casualty onto the robot’s ‘stretcher bed’, are described in detail based on the conducted literature review, evaluation of our previous work, and feedback provided by medical professionals. We perform simulation experiments in the Gazebo physics engine simulator to verify the proposed design and the casualty extraction procedure. The simulation results demonstrate the capability of ResQbot 2.0 to carry out safe casualty extractions successfully.

To collar or not to collar. Views of pre-hospital emergency care providers on immobilisation without cervical collars: a focus group study

BACKGROUND

Spinal cord injury (SCI) is a rare event, with high numbers of patients unnecessarily immobilised with no potential benefit based on limited evidence from the 1950s and 1960s. Contemporary opinion now challenges the notion that traditional immobilisation prevents movement and protects the spine. Current literature suggests that these methods which include semi-rigid collars can potentially cause more movement of the spine and harm the patient. The purpose of this study was to explore the views and perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar.

METHODS

Focus groups were used to allow individuals to discuss and comment on a new method of immobilisation which omits the semi-rigid collar and to capture the thoughts, feelings and experiences of participants. Thematic analysis of the coded transcriptions was used to identify emerging themes.

RESULTS

Three focus groups were conducted with 15 participants in each. Participants were all exposed to patients sustaining trauma within their professional roles. Six intertwined themes emerged from the analysis: communication, conflict, education/training, empowerment, risk and the patient. Woven between these themes are the complex interactions that bring together the inter-professional relationships with other emergency services and hospital staff, the patient, the public and pre-hospital care providers.

DISCUSSION

Existing immobilisation practices are being challenged, with clinicians empowered to tailor practice to meet specific patient needs. There is limited empirical evidence to support current immobilisation practices. Contemporary literature suggests current practices may potentially cause harm. New pragmatic immobilisation practices are gradually being adopted by some pre-hospital care providers.

CONCLUSION

This study explored the perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar for potential SCI. The consensus of the participants supports a pragmatic approach to managing potential SCI that provides safe, high-quality patient-centred care.

Vacuum mattress or long spine board: which method of spinal stabilisation in trauma patients is more time consuming? A simulation study

BACKGROUND

Spinal stabilisation is recommended for prehospital trauma treatment. In Germany, vacuum mattresses are traditionally used for spinal stabilisation, whereas in anglo-american countries, long spine boards are preferred. While it is recommended that the on-scene time is as short as possible, even less than 10 minutes for unstable patients, spinal stabilisation is a time-consuming procedure. For this reason, the time needed for spinal stabilisation may prevent the on-scene time from being brief. The aim of this simulation study was to compare the time required for spinal stabilisation between a scoop stretcher in conjunction with a vacuum mattress and a long spine board.

METHODS

Medical personnel of different professions were asked to perform spinal immobilizations with both methods. A total of 172 volunteers were immobilized under ideal conditions as well as under realistic conditions. A vacuum mattress was used for 78 spinal stabilisations, and a long spinal board was used for 94. The duration of the procedures were measured by video analysis.

RESULTS

Under ideal conditions, spinal stabilisation on a vacuum mattress and a spine board required 254.4 s (95 % CI 235.6-273.2 s) and 83.4 s (95 % CI 77.5-89.3 s), respectively (p < 0.01). Under realistic conditions, the vacuum mattress and spine board required 358.3 s (95 % CI 316.0-400.6 s) and 112.6 s (95 % CI 102.6-122.6 s), respectively (p < 0.01).

CONCLUSIONS

Spinal stabilisation for trauma patients is significantly more time consuming on a vacuum mattress than on a long spine board. Considering that the prehospital time of EMS should not exceed 60 minutes and the on-scene time should not exceed 30 minutes or even 10 minutes if the patient is in extremis, based on our results, spinal stabilisation on a vacuum mattress may consume more than 20 % of the recommended on-scene time. In contrast, stabilisation on a spine board requires only one third of the time required for that on a vacuum mattress. We conclude that a long spine board may be feasible for spinal stabilisation for critical trauma patients with timesensitive life threatening ABCDE-problems to ensure the shortest possible on-scene time for prehospital trauma treatment, not least if a patient has to be rescued from an open or inaccessible terrain, especially that with uneven overgrown land.

Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel

Background

Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.

Objective

To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.

Eligibility criteria

All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.

Sources of evidence

PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.

Charting methods

Evidence was searched according to clinically relevant topics and PICO questions.

Results

Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.

Conclusions

Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

The Effects of Positional Change on Hemodynamic Parameters in Spinal Immobilization

INTRODUCTION

The use of a long backboard and cervical collar are commonly recommended by international guidelines for spinal immobilization, but both devices may cause several side effects. In a recent study, it was reported that spinal immobilization at 20° eliminated the decrease in pulmonary function secondary to spinal immobilization performed at 0°. Spinal immobilization at 20° is a new recommendation, but other potential effects need to be explored before it can be implemented in clinical use.

STUDY OBJECTIVE

Hemodynamic observation is important in the management of trauma patients. The aim of this study was to investigate the effect of spinal immobilization at a 20° position instead of 0° on hemodynamic parameters.

METHODS

This study included 53 healthy volunteers who underwent spinal immobilization in the supine position (00) and in an elevated position (200). Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), left ventricular outflow tract velocity time integral (LVOT-VTI), left ventricular stroke volume (LVSV), cardiac output (CO), inferior vena cava diameter inspiration (IVC diameter insp), IVC diameter expiration (IVC diameter exp), and inferior vena cava collapsibility index (IVC-CI) were measured at the 0th and 30th minutes of spinal immobilization in both positions. The data were compared for demonstrating the efficiency of both positions in spinal immobilization.

RESULTS

A statistically significant difference was found in the parameters of the IVC diameter (exp), IVC diameter (insp), LVOT-VTI, LVSV, and CO through the measurements starting in the 0th minute of the transition from 0° to 20° (P <.001). Delta values (∆) of hemodynamic parameters (∆IVC diameter [exp], ∆IVC diameter [insp], ∆LVOT-VTI, ∆SV, ∆CO, ∆IVC-CI, ∆MAP, ∆SAP, ∆DAP, and ∆HR) were similar in spinal immobilization at 0° and 20°.

CONCLUSION

The findings obtained from this study illustrate that spinal immobilization at 20° does not cause clinically significant hemodynamic changes in healthy subjects compared to spinal immobilization at 0°.

Epidemiology and predictors of traumatic spine injury in severely injured patients: implications for emergency procedures

PURPOSE

This study aimed to identify the prevalence and predictors of spinal injuries that are suitable for immobilization.

METHODS

Retrospective cohort study drawing from the multi-center database of the TraumaRegister DGU^®, spinal injury patients ≥ 16 years of age who scored ≥ 3 on the Abbreviated Injury Scale (AIS) between 2009 and 2016 were enrolled.

RESULTS

The mean age of the 145,833 patients enrolled was 52.7 ± 21.1 years. The hospital mortality rate was 13.9%, and the mean injury severity score (ISS) was 21.8 ± 11.8. Seventy percent of patients had no spine injury, 25.9% scored 2-3 on the AIS, and 4.1% scored 4-6 on the AIS. Among patients with isolated traumatic brain injury (TBI), 26.8% had spinal injuries with an AIS score of 4-6. Among patients with multi-system trauma and TBI, 44.7% had spinal injuries that scored 4-6 on the AIS. Regression analysis predicted a serious spine injury (SI; AIS 3-6) with a prevalence of 10.6% and cervical spine injury (CSI; AIS 3-6) with a prevalence of 5.1%. Blunt trauma was a predictor for SI and CSI (OR 4.066 and OR 3.640, respectively; both p < 0.001) and fall > 3 m for SI (OR 2.243; p < 0.001) but not CSI (OR 0.636; p < 0.001). Pre-hospital shock was predictive for SI and CSI (OR 1.87 and OR 2.342, respectively; both p < 0.001), and diminished or absent motor response was also predictive for SI (OR 3.171) and CSI (OR 7.462; both p < 0.001). Patients over 65 years of age were more frequently affected by CSI.

CONCLUSIONS

In addition to the clinical symptoms of pain, we identify '4S' [spill (fall) > 3 m, seniority (age > 65 years), seriously injured, skull/traumatic brain injury] as an indication for increased attention for CSIs or indication for spinal motion restriction.

New clinical guidelines on the spinal stabilisation of adult trauma patients - consensus and evidence based

Traumatic spinal cord injury is a relatively rare injury in Denmark but may result in serious neurological consequences. For decades, prehospital spinal stabilisation with a rigid cervical collar and a hard backboard has been considered to be the most appropriate procedure to prevent secondary spinal cord injuries during patient transportation. However, the procedure has been questioned in recent years, due to the lack of high-quality studies supporting its efficacy. A national interdisciplinary task force was therefore established to provide updated clinical guidelines on prehospital procedures for spinal stabilisation of adult trauma patients in Denmark. The guidelines are based on a systematic review of the literature and grading of the evidence, in addition to a standardised consensus process.This process yielded five main recommendations:A strong recommendation against spinal stabilisation of patients with isolated penetrating trauma; a weak recommendation against the prehospital use of a rigid cervical collar and a hard backboard for ABCDE-stable patients; and a weak recommendation for the use of a vacuum mattress for patient transportation. Finally, our group recommends the use of our clinical algorithm to ensure good clinical practice.

Patient experience of spinal immobilisation after trauma

Background

Spinal immobilisation of blunt trauma victims with potential spinal cord injury is considered standard of care. The traditional management has, however, been increasingly questioned and concerns about harm have been raised. Few studies have described the perspective of the trauma patient regarding the spinal immobilisation.

The objective of this study was therefore to evaluate the patient experience of immobilisation after trauma.

Methods

We prospectively screened adult trauma patients admitted to a level 1 trauma centre for eligibility. We included adult trauma patients who had been, and remembered being, immobilised for spinal protection with a cervical collar and a spine board prehospitally or upon arrival at the trauma centre. A semi-structured interview was conducted 2 to 72 h after admission either in person or by telephone.

Results

One hundred and fourteen patients were eligible for inclusion based on the patient charts. Out of 98 patients assessed for participation, 48 (49%) had no memory of being immobilised.

We thus included 50 patients with a median age of 37 years (IQR: 26–60) of whom 38 (76%) were men. The median injury severity score was 9 (IQR: 3–15) and the median time with a cervical collar from initial application to in-hospital removal or until the interview was given was 91 min (IQR: 72–136).

Nineteen patients (38%) reported discomfort and 12 patients (24%) experienced pain related to the immobilisation. Forty patients (80%) reported a sense of protection related to the immobilisation.

Conclusion

Discomfort related to spinal immobilisation was reported in 38% of trauma patients. However, a sense of protection was a recurring theme in 80% of the trauma patients, who recalled being immobilised. Nearly half of the awake trauma patients had no memory of being immobilised.

Analysis of cervical spine immobilization during patient transport in emergency medical services

PURPOSE

It remains controversial how to immobilize the cervical spine (CS) in trauma patients. Therefore, we analyzed different CS immobilization techniques during prehospital patient transport.

METHODS

In this explorative, biomechanical analysis of immobilization techniques conducted in a standardized setting, we recorded CS motion during patient transport using a wireless human motion tracker on a volunteer. To interpret spinal movement a benchmark called motionscore (MS) was developed based on biomechanics of the injured spine.

RESULTS

We found the best spinal motion restriction using a spine board, head blocks and immobilization straps with and without a cervical collar (CC) (MS 45 vs. 27). Spinal motion restriction on a vacuum mattress with CC and head blocks was superior to no CC or head blocks (MS 103 vs. 152). An inclined vacuum mattress was more effective with head blocks than without (MS 124 vs. 187). Minimal immobilization with an ambulance cot, CC, pillow and tape was slightly superior to a vacuum mattress with CC and head blocks (MS 92 vs. 103). Minimal immobilization without CC showed the lowest spinal motion restriction (MS 517).

CONCLUSIONS

We suggest an immobilization procedure customized to the individual situation. A spine board should be used whenever spinal motion restriction is indicated and the utilization is possible. In some cases, CS immobilization by a vacuum mattress with CC and head blocks could be more beneficial. In an unstable status of the patient, minimal immobilization may be performed using an ambulance cot, pillow, CC and tape to minimize time on scene caused by immobilization.

Semirigid cervical spine collar and risk of missing significant soft tissue injuries

We report the case of an initial misdiagnosis of significant scalp soft tissue hidden beneath a semirigid cervical collar. A 16-year-old unrestrained rear seat passenger was involved in an RTA sustaining a subdural haematoma, cervical spine fractures and what was initially diagnosed as a significant degloving scalp injury. The patient was admitted to the intensive care unit intubated sedated, and with a cervical collar. The scalp injury was dressed with a view that potential reconstructive surgery would be needed subsequently.This case demonstrates that while cervical collars remain a fundamental aspect of initial prehospital care in trauma, they have potential drawbacks to their use, which need to be carefully noted. Some of these drawbacks have been reported extensively in the literature. This case outlines the necessity of a thorough secondary survey in the trauma patient as the cervical collar can obscure the assessment of significant head and neck soft tissue injuries.

[Parameters influencing the preclinical application of cervical collars]

BACKGROUND

The application of cervical collars is a standard procedure in emergency care of trauma patients. It is often observed that the application of cervical collars is performed incorrectly, which may lead to reduced immobilization of the cervical spine.

OBJECTIVES

The objective of this study was to analyze the practical skills of professional emergency care providers concerning the application of cervical collars.

MATERIALS AND METHODS

Emergency care professionals (n = 104) were asked to apply a cervical collar to a training doll. Each performance step was assessed separately. Furthermore, personal and occupational data of all study participants were collected using a questionnaire.

RESULTS

The study participants included professional rescue personnel and emergency physicians. The average occupational experience of all study participants in out-of-hospital emergency care was 11.1 ± 8.9 years. Most participants had already received training on trauma care (61 %) and felt "very confident" in handling a cervical collar (84 %). The application of the cervical collar was performed correctly in 11 % of the performances. The most common error was incorrect size adjustment of the cervical collar (66 %). No association was found between the correct application of the cervical collar and possible parameters of influence, such as working experience in emergency care or participation in trauma courses.

CONCLUSIONS

Despite pronounced subjective confidence regarding the application of cervical collars, this study shows that there are general deficits in the practical skills of applying cervical collars. Therefore, a critical assessment of the current training contents on the subject of trauma care must be demanded.

Prehospital care of spinal injuries: a historical quest for reasoning and evidence

PURPOSE

The practice of prehospital immobilization is coming under increasing scrutiny. Unravelling the historical sequence of prehospital immobilization might shed more light on this matter and help resolve the situation. Main purpose of this review is to provide an overview of the development and reasoning behind the implementation of prehospital spine immobilization.

METHODS

An extensive search throughout historical literature and recent evidence based studies was conducted.

RESULTS

The history of treating spinal injuries dates back to prehistoric times. Descriptions of prehospital spinal immobilization are more recent and span two distinct periods. First documentation of its use comes from the early 19th century, when prehospital trauma care was introduced on the battlefields of the Napoleonic wars. The advent of radiology gradually helped to clarify the underlying pathology. In recent decades, adoption of advanced trauma life support has elevated in-hospital trauma-care to an high standard. Practice of in-hospital spine immobilization in case of suspected injury has also been implemented as standard-care in prehospital setting. Evidence for and against prehospital immobilization is equally divided in recent evidence-based studies. In addition, recent studies have shown negative side-effects of immobilisation in penetrating injuries.

CONCLUSION

Although widely implementation of spinal immobilization to prevent spinal cord injury in both penetrating and blunt injury, it cannot be explained historically. Furthermore, there is no high-level scientific evidence to support or reject immobilisation in blunt injury. Since evidence in favour and against prehospital immobilization is equally divided, the present situation appears to have reached something of a deadlock. These slides can be retrieved under Electronic Supplementary Material.

Transportation mode and timing of spinal cord decompression and stabilization in patients with traumatic spinal cord injury in Iran

STUDY DESIGN

Cross-sectional retrospective study.

OBJECTIVE

To describe the transportation mode to hospital and timing of spinal cord decompression and stabilization (D&S), length of hospital stay, frequency of pressure injuries, and sepsis during hospitalization.

SETTING

Brain and Spinal Injury Research Center, Tehran, Iran.

METHODS

Eight hundred and thirty patients with traumatic spinal cord injury (TSCI) were enrolled. Mode of transportation and length of time to reach the first hospital, length of hospital stay (LOS), and the time span between hospital arrival and decompression and stabilization (D&S) were recorded.

RESULTS

Fifty-nine percent of the enrolled individuals were transported to the first hospital by ambulance, while 41% were transferred by vehicles without medical equipment and personnel. Median length of time to reach the first hospital was 1 h for both ambulance and non-equipped car groups, with no statistically significant difference (p = 0.1). Median LOS, frequencies of pressure injuries, and sepsis based on the injury levels were not significantly different between two transportation modalities. One hundred and seventy-seven individuals had early surgery, and 254 had late surgery. Median LOS was 13 days in the early surgery group and 20 days in the late surgery group (p = 0.002). Frequencies of pressure injuries and sepsis were not significantly different between the late and early surgery groups for various injury levels.

CONCLUSION

About 59% of our patients had been transported to a hospital by non-medical personnel. Those with late surgery had significantly longer LOS. Improving TSCI patients' transportation method and early surgical interventions, if possible, may be considered.

Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts

The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords "paediatric cervical spine injuries" or "paediatric cervical spine trauma." Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%-80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.

Value of prehospital assessment of spine fracture by paramedics

BACKGROUND

Current guidelines state that trauma patients at risk of spine injury should undergo prehospital spine immobilization to reduce the risk of neurological deterioration. Although this approach has been accepted and implemented as a standard for decades, there is little scientific evidence to support it. Furthermore, the potential dangers and sequelae of spine immobilization have been extensively reported. The role of the paramedic in this process has not yet been examined. The aim of this study was to evaluate the accuracy of prehospital evaluations for the presence of spine fractures made by paramedics.

METHODS

All patients who presented with prehospital spine immobilization at our level II trauma center between January 2013 and January 2014 were prospectively included in a database. Prior to the diagnosis, paramedics recorded the probability of a spine fracture after a prehospital examination. These predictions were compared with patient outcomes. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated.

RESULTS

One hundred and thirty-nine patients were included that positive predictive value was 22%, negative predictive value was 95%, sensitivity was 92%, specificity was 30%, and accuracy was 41%.

CONCLUSIONS

The results of this study suggest that paramedics cannot accurately predict spinal fractures.

Errors in cervical spine immobilization during pediatric trauma evaluation

BACKGROUND

The purpose of this study was to identify factors during trauma evaluation that increase the likelihood of errors in cervical spine immobilization ('lapses').

MATERIALS AND METHODS

Multivariate analysis was used to identify the associations between patient characteristics, event features, and tasks performed in proximity to the head and neck and the occurrence and duration of a lapse in maintaining cervical spine immobilization during 56 pediatric trauma evaluations.

RESULTS

Lapses in cervical spine immobilization occurred in 71.4% of patients (n = 40), with an average of 1.2 ± 1.3 lapses per patient. Head and neck tasks classified as oxygen manipulation occurred an average of 12.2 ± 9.7 times per patient, whereas those related to neck examination and cervical collar manipulation occurred an average of 2.7 ± 1.7 and 2.1 ± 1.2 times per patient, respectively. More oxygen-related tasks were performed among patients who had than those who did not have a lapse (27.3 ± 16.5 versus 11.5 ± 8.0 tasks, P = 0.001). Patients who had cervical collar placement or manipulation had a two-fold higher risk of a lapse than those who did not have these tasks performed (OR 1.92, 95% CI 0.56, 3.28, P = 0.006). More lapses occurred during evaluations on the weekend (P = 0.01), when more tasks related to supplemental oxygen manipulation were performed (P = 0.02) and when more tasks associated with cervical collar management were performed (P < 0.001).

CONCLUSIONS

Errors in cervical spine immobilization were frequently observed during the initial evaluation of injured children. Strategies to reduce these errors should target approaches to head and neck management during the primary and secondary phases of trauma evaluation.

Major Trauma Outside a Trauma Center: Prehospital, Emergency Department, and Retrieval Considerations

Care of the critically injured begins well before the patient arrives at a large academic trauma center. It is important to understand the continuum of care from the point of injury in the prehospital environment, through the local hospital and retrieval, until arrival at a trauma center capable of definitive care. This article highlights the important aspects of trauma assessment and management outside of tertiary or quaternary care hospitals. Key elements of each phase of care are reviewed, including management pearls and institutional strategies to facilitate effective and efficient treatment of trauma patients from the point of injury forward.

The characteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study

BACKGROUND

Pre-hospital spinal immobilisation by emergency medical services (EMS) staff is currently the standard of care in cases of suspected spinal column injuries. There is, however, a lack of data on the characteristics of patients who received spinal immobilisation during the pre-hospital phase and on the adverse effects of immobilisation. The objectives of this study were threefold. First, we determined the pre-hospital characteristics of blunt trauma patients with suspected spinal column injuries who were immobilised by EMS staff. Second, we assessed the choices made by EMS staff regarding spinal immobilisation techniques and reasons for immobilisation. Third, we researched the possible adverse effects of immobilisation.

DESIGN

A retrospective observational study in a cohort of blunt trauma patients.

STUDY METHOD

Data of blunt trauma patients with suspected spinal column injuries were collected from one EMS organisation between January 2008 and January 2013. Coded data and free text notes were analysed.

RESULTS

A total of 1082 patients were included in this study. Spinal immobilisation was applied in 96.3 % of the patients based on valid pre-hospital criteria. In 2.1 % of the patients immobilisation was not based on valid criteria. Data of 1.6 % patients were missing. Main reasons for spinal immobilisation were posterior midline spinal tenderness (37.2 % of patients) and painful distracting injuries (13.5 % of patients). Spinal cord injury (SCI) was suspected in 5.7 % of the patients with posterior midline spinal tenderness. A total of 15.8 % patients were immobilised using non-standard methods. The reason for departure from the standard method was explained for 3 % of these patients. Reported adverse effects included pain (n = 10, 0.9 %,); shortness of breath (n = 3, 0.3 %); combativeness or anxiety (n = 6, 0.6 %); and worsening of pain when supine (n = 1, 0.1 %).

CONCLUSION/RECOMMENDATION

Spinal immobilisation was applied in 96.3 % of all included patients based on pre-hospital criteria. We found that consensus among EMS staff on how to interpret the criterion 'distracting injury' was lacking. Furthermore, the adverse effects of spinal immobilisation were incompletely documented in pre-hospital care reports. To provide validated information on potential symptoms of SCI, a uniform EMS scoring system for motoric assessment should be developed.

The Burden of Spine Fractures in India: A Prospective Multicenter Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The objectives of this study were (1) to determine the characteristics of patients sustaining spinal trauma in India and (2) to explore the association between patient or injury characteristics and outcomes after spinal trauma.

METHODS

In affiliation with the ongoing INternational ORthopaedic MUlticentre Study (INORMUS), 192 patients with spinal injuries were recruited during an 8-week period (November 2011 to June 2012) from 14 hospitals in India and followed for 30-days. The primary outcome was a composite of mortality, complications, and reoperation. This was regressed on a set of 13 predictors in a multiple logistic regression model.

RESULTS

Most patients were middle-aged (mean age = 51.0 years; median age = 55.5 years; range = 18.0 to 72.0 years), male (60.4%), injured from falls (72.4%), and treated in a private setting (59.9%). Fractures in the lumbar region (51.0%) were most common, followed by thoracic (30.7%) and cervical (18.2%). More than 1 in 5 (21.6%) patients experienced a treatment delay greater than 24 hours, and 36.5% arrived by ambulance. Thirty-day mortality and complication rates were 2.6% and 10.0%, respectively. Care in the public hospital system (odds ratio [OR] = 6.7, 95% CI = 1.1-41.6), chest injury (OR = 11.1, 95% CI = 1.8-66.9), and surgical intervention (OR = 4.8, 95% CI = 1.2-19.6) were independent predictors of major complications.

CONCLUSIONS

Treatment in the public health care system, increased severity of injury, and surgical intervention were associated with increased risk of major complications following spinal trauma. The need for a large-scale, prospective, multicenter study taking into account spinal stability and neurologic status is feasible and warranted.

Effect of Neck Collar Fixation on Ventilation in Multiple Trauma Patients

BACKGROUND

According to the guidelines for treatment of multiple trauma patients, immobilization of the neck and neck collar fixation are essential. However, following neck collar fixation patients usually experience dyspnea. Some studies have found that neck collar fixation can lead to decreased pulmonary volumes, yet there have been no studies on the effect of neck collar fixation on patient ventilation.

OBJECTIVES

The purpose of this study was to determine the effect of neck collar fixation on ventilation in multiple trauma patients.

METHODS

This study was a descriptive-analytical study, which was performed in the emergency department of Tabriz University of Medical Sciences on multiple trauma patients with a Glasgow Coma Score (GCS) of 15. The effect of neck collar fixation on ventilation in the study participants was examined with the use of capnography.

RESULTS

This study involved 163 multiple trauma patients. Of these, 65% were male. The mean of end tidal carbon dioxide (ETCO₂) of the patients without neck collars was 34.62 ± 4.46 and the mean ETCO₂ of the patients with neck collars was 34.21 ± 2.31. There was no significant difference between the means of ETCO₂, before and after removing the neck collar, among the studied patients (P = 0.196).

CONCLUSIONS

According to the results of our study, neck collar fixation has no effect on ventilation in multiple trauma patients.

The definite risks and questionable benefits of liberal pre-hospital spinal immobilisation

INTRODUCTION

The routine practice of pre-hospital spinal immobilisation (phSI) for patients with suspected spinal injury has existed for decades. However, the controversy surrounding it resulted in the 2013 publication of a Consensus document by the Faculty of Pre-Hospital Care. The question remains as to whether the quality of evidence in the literature is sufficient to support the Consensus guidelines. This critical review aims to determine the validity of current recommendations by balancing the potential benefits and side effects of phSI.

METHOD

A review of the literature was carried out by two independent assessors using Medline, PubMed, EMBASE and the Cochrane Library databases. Manual searches of related journals and reference lists were also completed. The selected body of evidence was subsequently appraised using a checklist derived from SIGN and CASP guidelines, as well as Crombie's guide to critical appraisal.

RESULTS

No reliable sources were found proving the benefit for patient immobilisation. In contrast there is strong evidence to show that pre-hospital spinal immobilisation is not benign with recognised complications ranging from discomfort to significant physiological compromise. The published literature supports the Consensus guideline recommendations for safely reducing the impact of these side effects without compromising the patient.

CONCLUSION

The literature supports the Consensus Guidelines but raises the question as to whether they go far enough as there is strong evidence to suggest phSI is an inherently harmful procedure without having any proven benefit. These results demonstrate an urgent need for further studies to determine its treatment effect.

The epidemiology of pre-hospital potential spinal cord injuries in Victoria, Australia: a six year retrospective cohort study

BACKGROUND

Traumatic Spinal Cord Injury (TSCI) is relatively uncommon, yet a devastating and costly condition. Despite the human and social impacts, studies describing patients with potential TSCI in the pre-hospital setting are scarce. This paper aims to describe the epidemiology of patients potentially at risk of or suspected to have a TSCI by paramedics, with a view to providing a better understanding of factors associated with potential TSCI.

METHODS

This is a retrospective cohort study of all adult patients managed and transported by Ambulance Victoria (AV) between 01 January 2007 and 31 December 2012 who, based on meeting pre-hospital triage protocols and criteria for spinal clearance, paramedic suspicion or spinal immobilisation, were classified to be at risk of or suspected to have a TSCI. Data was extracted from the AV data warehouse, including demographic details, trauma aetiology, paramedic assessment, management and other event characteristics.

RESULTS

A total of 106,059cases were included in the study, representing 2.3 % of all emergency transports by AV. Subjects had a median age of 51 years (interquartile range; 29-78) and 52.4 % were males (95 % CI 52-52.7). Males were significantly younger than females (M: 43 years [26-65] vs. F: 64 years [36-84], p =0.001). Falls and traffic accidents were the leading causes of injuries, comprising 46.9 and 39.4 % of cases, respectively. Other causes included accidents due to sport, animals, industrial work and diving, as well as violence and hanging. 29.9 % of patients were transported to a Major Trauma Service (MTS). A proportion of 48.8 % of the study population met the Pre-hospital Major Trauma criteria.

CONCLUSION

This is the first study to describe the epidemiology of potential TSCI in Australia and is based on a large, state-wide sample. It provides background knowledge and a baseline for future research, as well as a reference point for future in policy. Falling and traffic related injuries were the leading causes of potential SCI. Future research is required to identify the proportion of confirmed TSCI among the potentials and factors associated with TSCI in prehospital settings.

Cervical spine immobilization in the elderly population

BACKGROUND

Immobilization of the cervical spine is a cornerstone of spinal injury management. In the context of suspected cervical spine injury, patients are immobilized in a 'neutral position' based on the head and trunk resting on a flat surface. It is hypothesized that the increased thoracic kyphosis and loss of cervical lordosis seen in elderly patients may require alternative cervical immobilization, compared with the 'neutral position'.

METHODS

To investigate this, an audit of pan-scan CT performed on consecutive major trauma patients aged over 65 years was carried out over a 6-month period. Utilizing the pan-CT's localizing scout film, a novel measurement, the 'chin-brow horizontal' angle was independently measured by a senior spine surgeon (RJM) and a neurosurgeon (PJR) with the gantry used as a horizontal zero- degree reference. The benefit of the 'chin-brow horizontal' angle in the trauma setting is it can be assessed from the bedside whilst the patient is immobilized against a flat surface.

RESULTS

During the 6-month study period, 58 patients were identified (30 male, 28 female), with an average age of 77.6 years (minimum 65, maximum 97). Results showed that 'chin-brow horizontal' angles varied widely, between +15.8 degrees in flexion to -30.5 degrees in extension (mean -12.4 degrees in extension, standard deviation 9.31 degrees. The interobserver correlation was 0.997 (95% CI: 0.995-0.998).

CONCLUSIONS

These findings suggest that, due to degenerative changes commonly seen in elderly patients, the routine use of the 'neutral position' adopted for cervical spine immobilization may not be appropriate in this population. We suggest that consideration be taken in cervical spine immobilization, with patients assessed on an individual basis including the fracture morphology, to minimize the risk of fracture displacement and worsened neurological deficit.

[Spinaltrauma : Clinical diagnosis and initial care]

DIAGNOSTIC WORK-UP

The rescue, treatment and transport of patients with an injured spine require a systematic scheme with the subsequent rating of the findings and suspected diagnoses. In addition to the assessment of temporal urgency, the available resources and personnel, the duration and complexity of any possible technical measures that might be anticipated, the rational selection of immobilisation tools also plays a significant role. The most important medical rescue aids are the scoop stretcher and the spine board; the spine board, vacuum mattress and cervical collar are used to immobilise the patient.

PRACTICAL RECOMMENDATIONS

This article is focused on the diagnosis and initial treatment of isolated spinal injuries. The prehospital care of polytraumatised patients and/or those with multiple injuries differs significantly and has different priorities.

Management of maxillofacial trauma in emergency: An update of challenges and controversies

Trauma management has evolved significantly in the past few decades thereby reducing mortality in the golden hour. However, challenges remain, and one such area is maxillofacial injuries in a polytrauma patient. Severe injuries to the maxillofacial region can complicate the early management of a trauma patient owing to the regions proximity to the brain, cervical spine, and airway. The usual techniques of airway breathing and circulation (ABC) management are often modified or supplemented with other methods in case of maxillofacial injuries. Such modifications have their own challenges and pitfalls in an already difficult situation.

Effect of spinal immobilisation devices on radiation exposure in conventional radiography and computed tomography

Trauma patients at risk for, or suspected of, spinal injury are frequently transported to hospital using full spinal immobilisation. At the emergency department, immobilisation is often maintained until radiological work-up is completed. In this study, we examined how these devices influence radiation exposure and noise, as a proxy for objective image quality. Conventional radiographs (CR) and computer tomography (CT) scans were made using a phantom immobilised on two types of spineboard and a vacuum mattress and using two types of headblocks. Images were compared for radiation transmission and quantitative image noise. In CR, up to 23 % and, in CT, up to 11 % of radiation were blocked by the devices. Without compensation for the decreased transmission, noise increased by up to 16 % in CT, depending on the device used. Removing the headblocks led to a statistically significant improvement in transmission with automatic exposure control (AEC) enabled. Physicians should make an informed decision whether the increased radiation exposure outweighs the risk of missing a clinically significant injury by not making a CR or CT scan. Manufacturers of immobilisation devices should take radiological properties of their devices into account in the development and production process.

Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature

OBJECTIVES

The objectives were to review published reports of secondary neurologic deterioration in the early stages of care after blunt spinal trauma and describe its nature, context, and associated risk factors.

METHODS

The authors searched the MEDLINE, EMBASE, and CINAHL databases for English-language studies. Cases were included meeting the criteria age 16 years or older, nonpenetrating trauma, and experiencing neurologic deterioration during prehospital or emergency department (ED) care prior to definitive management (e.g., discharge, spinal clearance by computed tomography, admission to an inpatient service, or surgical intervention). Results were qualitatively analyzed for characteristics and themes.

RESULTS

Forty-one qualifying cases were identified from 12 papers. In 30 cases, the new deficits were apparently spontaneous and were not detected until routine reassessment. In 12 cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, "unintentional manipulation," falling in or near the ED, and forced collar application in patients with ankylosing spondylitis. Thirteen cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study.

CONCLUSIONS

Published reports of early secondary neurologic deterioration after blunt spinal trauma are exceptionally rare and generally poorly documented. High-risk features may include altered mental status and ankylosing spondylitis. It is unclear how often events are linked with spontaneous patient movement and whether such events are preventable.

Does turning trauma patients with an unstable spinal injury from the supine to a lateral position increase the risk of neurological deterioration?--A systematic review

Background

Airway protection and spinal precautions are competing concerns in the treatment of unconscious trauma patients. The placement of such patients in a lateral position may facilitate the acquisition of an adequate airway. However, trauma dogma dictates that patients should be transported in the supine position to minimize spinal movement. In this systematic review, we sought to answer the following question: Given an existing spinal injury, will changing a patient’s position from supine to lateral increase the risk of neurological deterioration?

Methods

The review protocol was published in the PROSPERO database (Reg. no. CRD42012001190). We performed literature searches in PubMed, Medline, EMBASE, the Cochrane Library, CINAHL and the British Nursing Index and included studies of traumatic spinal injury, lateral positioning and neurological deterioration. The search was updated prior to submission. Two researchers independently completed each step in the review process.

Results

We identified 1,164 publications. However, none of these publications reported mortality or neurological deterioration with lateral positioning as an outcome measure. Twelve studies used movement of the injured spine with lateral positioning as an outcome measure; eleven of these investigations were cadaver studies. All of these cadaver studies reported spinal movement during lateral positioning. The only identified human study included eighteen patients with thoracic or lumbar spinal fractures; according to the study authors, the logrolling technique did not result in any neurological deterioration among these patients.

Conclusions

We identified no clinical studies demonstrating that rotating trauma patients from the supine position to a lateral position affects mortality or causes neurological deterioration. However, in various cadaver models, this type of rotation did produce statistically significant displacements of the injured spine. The clinical significance of these cadaver-based observations remains unclear. The present evidence for harm in rotating trauma patients from the supine position to a lateral position, including the logroll maneuver, is inconclusive.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-015-0143-x) contains supplementary material, which is available to authorized users.

Confirmation of suboptimal protocols in spinal immobilisation?

Background

Spinal immobilisation during extrication of patients in road traffic collisions is routinely used despite the lack of evidence for this practice. In a previous proof of concept study (n=1), we recorded up to four times more cervical spine movement during extrication using conventional techniques than self-controlled extrication.

Objective

The objective of this study was to establish, using biomechanical analysis which technique provides the minimal deviation of the cervical spine from the neutral in-line position during extrication from a vehicle in a larger sample of variable age, height and mass.

Methods

A crew of two paramedics and four fire-fighters extricated 16 immobilised participants from a vehicle using six techniques for each participant. Participants were marked with biomechanical sensors and relative movement between the sensors was captured via high-speed infrared motion analysis cameras. A three-dimensional mathematical model was developed and a repeated-measures analysis of variance was used to compare movement across extrication techniques.

Results

Controlled self-extrication without a collar resulted in a mean movement of 13.33° from the neutral in-line position of the cervical spine compared to a mean movement of 18.84° during one of the equipment-aided extrications. Two equipment-aided techniques had significantly higher movement (p<0.05) than other techniques. Both height (p=0.003) and mass (p=0.02) of the participants were significant independent predictors of movement.

Conclusions

These data support the findings of the proof of concept study, for haemodynamically stable patients controlled self-extrication causes less movement of the cervical spine than extrications performed using traditional prehospital rescue equipment.

Cervical spine injury in dismounted improvised explosive device trauma

BACKGROUND

The injury pattern from improvised explosive device (IED) trauma is different if the target is in a vehicle (mounted) or on foot (dismounted). Combat and civilian first response protocols require the placement of a cervical collar on all victims of a blast injury.

METHODS

We searched the Joint Theatre Trauma Registry (JTTR) and the Role 3 Hospital, Kandahar Airfield (KAF) database from Mar. 1, 2008, to May 31, 2011. We collected data on cervical fracture; head injury; traumatic amputation; initial blood pressure, pulse, injury severity score (ISS), Glasgow Coma Scale (GCS) score and base excess; and patient demographic information.

RESULTS

The concordance rate between JTTR and KAF databases was 98%. Of the 15 693 admissions in JTTR, 326 patients with dismounted IED injuries were located. The rate of cervical collar prehospital placement was 7.6%. Cervical fractures were found in 19 (5.8%) dismounted IED victims, but only 4 (1.2%) were considered radiographically unstable. None of these 19 patients had prehospital placement of a collar. Patients with cervical spine fractures were more severely injured than those without (ISS 18.2 v. 13.4; GCS 10.1 v. 12.5). Patients with head injuries had significantly higher risk of cervical spine injury than those with no head injury recorded (13.6% v. 3.9%). No differences in frequency of cervical spine injury were found between patients who had associated traumatic amputations and those who did not (5.4% v. 6.0%).

CONCLUSION

Dismounted IED is a mechanism of injury associated with a low risk for cervical spine trauma. A selective protocol for cervical collar placement on victims of dismounted IED blasts is possible and may be more amenable to combat situations.

Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature

BACKGROUND

Spinal immobilisation has been a mainstay of trauma care for decades and is based on the premise that immobilisation will prevent further neurological compromise in patients with a spinal column injury. The aim of this systematic review was to examine the evidence related to spinal immobilisation in pre-hospital and emergency care settings.

METHODS

In February 2015, we performed a systematic literature review of English language publications from 1966 to January 2015 indexed in MEDLINE and Cochrane library using the following search terms: 'spinal injuries' OR 'spinal cord injuries' AND 'emergency treatment' OR 'emergency care' OR 'first aid' AND immobilisation. EMBASE was searched for keywords 'spinal injury OR 'spinal cord injury' OR 'spine fracture AND 'emergency care' OR 'prehospital care'.

RESULTS

There were 47 studies meeting inclusion criteria for further review. Ten studies were case series (level of evidence IV) and there were 37 studies from which data were extrapolated from healthy volunteers, cadavers or multiple trauma patients. There were 15 studies that were supportive, 13 studies that were neutral, and 19 studies opposing spinal immobilisation.

CONCLUSION

There are no published high-level studies that assess the efficacy of spinal immobilisation in pre-hospital and emergency care settings. Almost all of the current evidence is related to spinal immobilisation is extrapolated data, mostly from healthy volunteers.

Clinical evaluation and airway management for adults with cervical spine instability

Airway management of patients with cervical spine instability may be difficult as a result of immobilization, and may be associated with secondary neurologic injury related to cervical spine motion. Spinal cord instability is most common in patients with trauma, but there are additional congenital and acquired conditions that predispose to subacute cervical spine instability. Patients with suspected instability should receive immobilization during airway management with manual in-line stabilization. The best strategy for airway management is one that applies the technique with the highest likelihood of success on the first attempt and the lowest biomechanical influence on a potentially unstable spine.

Spinal trauma

The practice of spinal immobilization has existed since the 1960s under the premise that trauma victims with cervical spine injuries may suffer neurologic injury if moved without stabilization consisting of a rigid cervical collar and long spine board. Because of this assumption, it is of particular importance to assess for movement of the cervical spine with and without spinal immobilization. Over time, the on-field management of athletes with a mechanism consistent with spinal cord injury (SCI) has evolved and produced protocols that can be considered standard of care. Attempts to find evidencebased research to verify the necessity of a rigid collar and long spine board as the only option in athletic medicine for suspected SCI is difficult. As changes occur in the Emergency Medical Services standards, there will be opportunities to see how their processes relate to athletes and the rationale for immobilization on the field of play. Going forward, there could very well be a significant change in the approach to and management of the athlete down on the field of play with a suspected spinal cord injury.