The efficacy and comfort of full-body vacuum splints for cervical-spine immobilization

Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update

The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.

Maintaining immobilization devices on trauma patients during chest and pelvic X-ray: a feasibility study

BACKGROUND

Most trauma systems and traumatic spinal injury guidelines mandate spinal stabilization from the site of injury to a radiological confirmation or refutal of spinal injury. Vacuum mattresses have been advocated for patients in need of prehospital spinal stabilization.

PURPOSE

To investigate the effect of different vacuum mattresses on standard resuscitation bay conventional radiography of chest and pelvis, especially regarding artefacts.

MATERIAL AND METHODS

We used a mobile X-ray machine to perform chest and pelvic conventional radiography on an anthropomorphic whole-body phantom with a trauma transfer board, three different vacuum mattresses, and without any stabilization device. The vacuum mattresses were investigated in activated, deactivated, and stretched after deactivated states. Two radiologists assessed the artefacts independently. Agreement was measured using kappa coefficient.

RESULTS

All radiographs were of good technical quality and fully diagnostic. With the exception of one disagreed occurrence, artefacts were seen to hamper clinical judgment exclusively with activated vacuum mattresses. There was substantial agreement on artefact assessment. The observed agreement was 0.82 with a kappa coefficient of 0.71. The first vacuum mattress caused no artefacts hampering with clinical judgment.

CONCLUSION

Our study concludes that it is feasible to maintain some vacuum mattresses through resuscitation bay conventional radiography of chest and pelvis. They do not result in artefacts hampering with clinical judgment. Our vacuum mattress No. 1 is recommendable for this purpose. Together with our previous findings our present results indicate that some vacuum mattresses may be used throughout the initial resuscitation bay assessment and CT examination.

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.

Prehospital Protocols Reducing Long Spinal Board Use Are Not Associated with a Change in Incidence of Spinal Cord Injury

Introduction: Many emergency medical services (EMS) agencies have de-emphasized or eliminated the use of long spinal boards (LSB) for patients with possible spinal injury. We sought to determine if implementation of spinal motion restriction (SMR) protocols, which reduce LSB use, was associated with an increase in spinal cord injury (SCI). Methods: This retrospective observational study includes EMS encounters from January 1, 2013 to December 31, 2015 submitted by SMR-adopting ground-based agencies to a state EMS database with hospital discharge data. Encounters were excluded if SMR implementation date was unknown, occurred during a 3-month run-in period, or were duplicates. Study samples include patients with traumatic injury (TI), possible spinal trauma (P-ST), and verified spinal trauma (V-ST) using hospital discharge ICD-9/10 diagnosis codes. The incidence of SCI before and after implementation of SMR was compared using Chi-squared and logistic regression. Results: From 1,005,978 linked encounters, 104,315 unique encounters with traumatic injury and known SMR implementation date were identified with 51,199 cases of P-ST and 5,178 V-ST cases. The incidence of SCI in the pre-SMR and post-SMR interval for each group was: TI, 0.20% vs. 0.22% (p = 0.390); P-ST, 0.40% vs. 0.45% (p = 0.436); and V-ST, 4.04% vs. 4.37% (p = 0.561). Age and injury severity adjusted odds ratio of SCI in the highest risk cohort of patients with V-ST was 1.097 after SMR implementation (95% CI 0.818-1.472). Conclusion: In this limited study, no change in the incidence of SCI was identified following implementation of SMR protocols. Prospective evaluation of this question is necessary to evaluate the safety of SMR protocols.

Spinal Immobilization in the Trauma Room - a Survey-Based Analysis at German Level I Trauma Centers

BACKGROUND

Spinal immobilization is a standard procedure in daily out-of-hospital emergency care. Homogenous recommendations concerning the immobilization of trauma patients during the first therapy in the emergency department do not exist. The aim of the current study was the analysis of the existing strategies concerning spinal immobilization in German level I trauma centers by an internet-based survey.

MATERIALS AND METHODS

The current study is a survey-based analysis of the current strategies concerning spinal immobilization in all 107 level I trauma centers in Germany. The internet-based survey consists of 6 items asking about immobilization in the emergency department.

RESULTS

The return rate was 47.7%. In 14 (28.6%) level I trauma centers the patients remained immobilized on the immobilization tool used by the professional emergency care providers. In 19 (38.8%) level I trauma centers the patients were transferred to a stretcher with a soft positioning mattress on it. Patient transfer to a spineboard or to a TraumaMattress was performed in 11 (22.4%) and 7 (14.3%) level I trauma centers, respectively. Trauma patients were never transferred to a vacuum mattress. Cervical spine protection was most of the time performed by a cervical collar (n = 48; 98.0%). In general, the survey's participants were mainly satisfied (mean = 84/100) with the current strategy of spinal immobilization. The satisfaction was best if the spineboard is used.

DISCUSSION

Patient positioning during initial emergency therapy in the emergency department of German level I trauma centers is highly heterogenous. Besides complete full body immobilization, also the lack of any immobilization was reported by the survey's participants.

Comparative Evaluation of Flexural Strength and Flexural Modulus of Different Periodontal Splint Materials: An In Vitro Study

Splinting of the mobile teeth is a critical part of periodontal management to improve the prognosis and longevity of stable results of periodontally compromised teeth with increased mobility. Different types of splints are used in the dental field based on their mechanical and physical properties.The objective of the current in vitro study was to evaluate the flexure strength and flexural modulus of different types of splinting materials, such as: composite block, ligature wire, Ribbond®, InFibra®, and F-splint-Aid® bonded utilizing Flowable composites resin material. Seventy-five bar specimens were prepared with the dimensions of 25 × 4 × 2 mm, utilizing split metallic mold. Specimens were divided equally (n = 15) into five groups (one control group, four test groups). Different layers of splinting material were placed in between the layers of composite before curing. All the specimens were subjected to a three-point bending test by using a universal testing machine to calculate the flexural strength and flexural modulus. The entire data was subjected to statistical tests to evaluate the significance. Specimens from composite block groups showed the least mean value for flexural strength (89.15 ± 9.70 MPa) and flexural modulus (4.310 ± 0.912 GPa). Whereas, the highest mean value for flexural strength (168.04 ± 45.95 MPa) and flexural modulus (5.861 ± 0.501 GPa) were recorded by Ribbond® specimens. Inter group comparison of flexural strength showed statistically significant differences (P-value < 0.05), whereas comparison of flexural modulus showed non-significant difference among the groups (P-value > 0.05). Within the limitation of the present study, it was concluded that the Ribbond® exhibits maximum flexural strength and flexural modulus, whereas the composite blocks recorded the least values. Still, the decision making depends on the clinical scenario and the unique characteristic of each splint material.

Comparing the Efficacy of Methods for Immobilizing the Cervical Spine

STUDY DESIGN

This was a prospective simulator study with 16 healthy male subjects.

OBJECTIVE

The aim of this study was to compare the relative efficacy of immobilization systems in limiting involuntary movements of the cervical spine using a dynamic simulation model.

SUMMARY OF BACKGROUND DATA

Relatively few studies have tested the efficacy of immobilization methods for limiting involuntary cervical movement, and only one of these studies used a dynamic simulation system to do so.

METHODS

Immobilization configurations tested were cot alone, cot with cervical collar, long spine board (LSB) with cervical collar and head blocks, and vacuum mattress (VM) with cervical collar. A motion platform reproduced shocks and vibrations from ambulance and helicopter field rides, as well as more severe shocks and vibrations that might be encountered on rougher terrain and in inclement weather (designated as an "augmented" ride). Motion capture technology quantitated involuntary cervical rotation, flexion/extension, and lateral bend. The mean and 95% confidence interval of the mean were calculated for the root mean square of angular changes from the starting position and for the maximum range of motion.

RESULTS

All configurations tested decreased cervical rotation and flexion/extension relative to the cot alone. However, the LSB and VM were significantly more effective in decreasing cervical rotation than the cervical collar, and the LSB decreased rotation more than the VM in augmented rides. The LSB and VM, but not the cervical collar, significantly limited cervical lateral bend relative to the cot alone.

CONCLUSION

Under the study conditions, the LSB and the VM were more effective in limiting cervical movement than the cervical collar. Under some conditions, the LSB decreased repetitive and acute movements more than the VM. Further studies using simulation and other approaches will be essential for determining the safest, most effective configuration should providers choose to immobilize patients with suspected spinal injuries.

LEVEL OF EVIDENCE

3.

A New Craniothoracic Mattress for Immobilization of the Cervical Spine in Critical Care Patients

Current immobilization techniques of the cervical spine are associated with complications including pressure ulcers, discomfort, and elevated intracranial pressures with limited access to the thorax and airway. In this study, a newly developed craniothoracic immobilizer (Pharaoh mattress) for critical care patients with cervical injury was tested for its restriction of cervical movement, peak interface pressures, comfort, and radiolucency, and compared with headblocks strapped to a spineboard. Cervical movement was measured by roentgen stereophotogrammetric analysis in 5 fresh frozen cadavers. Peak interface and discomfort pressures were measured in 10 healthy volunteers. Radiographic absorption was calculated by measuring the total emission radiation with and without immobilizer. The Pharaoh mattress caused a mean restriction of 59% (SD: 15) flexion-extension, 77% (SD: 14) lateral bending, and 93% (SD: 3) rotation, compared with the unrestricted situation. No significant differences in restriction of cervical movement were found between headblocks strapped to a spineboard and the Pharaoh mattress. The mean peak pressures on the Pharaoh mattress were significantly lower than on the spineboard. Healthy volunteers gave significantly lower numeric discomfort scores on the Pharaoh mattress than on the spineboard. The Pharaoh mattress absorbed more x-rays than the spineboard. The Pharaoh mattress provides similar restriction of cervical movement compared with headblocks strapped to a spineboard but with lower interface pressures and increased comfort. This new mattress could be useful for immobilization of the cervical spine in critical care patients with mechanically instable spinal fractures.

Comparing the Efficacy of Methods for Immobilizing the Thoracic-Lumbar Spine

OBJECTIVE

The purpose of this study was to compare the relative efficacy of immobilization systems in limiting thoracic-lumbar movements.

METHODS

A dynamic simulation system was used to reproduce transport-related shocks and vibration, and involuntary movements of the thoracic-lumbar region were measured using 3 immobilization configurations.

RESULTS

The vacuum mattress and the long spine board were generally more effective than the cot alone in reducing thoracic-lumbar rotation and flexion/extension. However, the vacuum mattress reduced these thoracic-lumbar movements to a greater extent than the long spine board. In addition, the vacuum mattress significantly decreased thoracic-lumbar lateral movement relative to the cot alone under all simulated transport conditions. In contrast, the long spine board allowed greater lateral movement than the cot alone in a number of the simulated transport rides.

CONCLUSION

Under the study conditions, the vacuum mattress was more effective for limiting involuntary movements of the thoracic-lumbar region than the long spine board. Moreover, the increased lateral bend observed with the long spine board under some conditions suggests it may be inadequate for immobilizing this anatomic region as presently designed. Should emergency medical service providers choose to immobilize patients with suspected injuries of the thoracic-lumbar spine, study results support the use of the vacuum mattress.

A Comparison of Cervical Spine Motion After Immobilization With a Traditional Spine Board and Full-Body Vacuum-Mattress Splint

Background:

The National Athletic Trainers’ Association (NATA) advocates for cervical spine immobilization on a rigid board or vacuum splint and for removal of athletic equipment before transfer to an emergency medical facility.

Purpose:

To (1) compare triplanar cervical spine motion using motion capture between a traditional rigid spine board and a full-body vacuum splint in equipped and unequipped athletes, (2) assess cervical spine motion during the removal of a football helmet and shoulder pads, and (3) evaluate the effect of body mass on cervical spine motion.

Study Design:

Controlled laboratory study.

Methods:

Twenty healthy male participants volunteered for this study to examine the influence of immobilization type and presence of equipment on triplanar angular cervical spine motion. Three-dimensional cervical spine kinematics was measured using an electromagnetic motion analysis system. Independent variables included testing condition (static lift and hold, 30° tilt, transfer, equipment removal), immobilization type (rigid, vacuum-mattress), and equipment (on, off). Peak sagittal-, frontal-, and transverse-plane angular motions were the primary outcome measures of interest.

Results:

Subjective ratings of comfort and security did not differ between immobilization types (P > .05). Motion between the rigid board and vacuum splint did not differ by more than 2° under any testing condition, either with or without equipment. In removing equipment, the mean peak motion ranged from 12.5° to 14.0° for the rigid spine board and from 11.4° to 15.4° for the vacuum-mattress splint, and more transverse-plane motion occurred when using the vacuum-mattress splint compared with the rigid spine board (mean difference, 0.14 deg/s [95% CI, 0.05-0.23 deg/s]; P = .002). In patients weighing more than 250 lb, the rigid board provided less motion in the frontal plane (P = .027) and sagittal plane (P = .030) during the tilt condition and transfer condition, respectively.

Conclusion:

The current study confirms similar motion in the vacuum-mattress splint compared with the rigid backboard in varying sized equipped or nonequipped athletes. Cervical spine motion occurs when removing a football helmet and shoulder pads, at an unknown risk to the injured athlete. In athletes who weighed more than 250 lb, immobilization with the rigid board helped to reduce cervical spine motion.

Clinical Relevance:

Athletic trainers and team physicians should consider immobilization of athletes who weigh more than 250 lb with a rigid board.

Comparison of the Vacuum Mattress versus the Spine Board Alone for Immobilization of the Cervical Spine Injured Patient: A Biomechanical Cadaveric Study

STUDY DESIGN

A biomechanical cadaveric study.

OBJECTIVE

We sought to determine the amount of motion generated in an unstable cervical spine fracture with use of the vacuum mattress versus the spine board alone. Our hypothesis is that the vacuum mattress will better immobilize an unstable cervical fracture.

SUMMARY OF BACKGROUND DATA

Trauma patients in the United States are immobilized on a rigid spine board, whereas in many other places, vacuum mattresses are used with the proposed advantages of improved comfort and better immobilization of the spine.

METHODS

Unstable subaxial cervical injuries were surgically created in five fresh whole human cadavers. The amount of motion at the injured motion segment during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc.). The measurements recorded in this investigation included maximum displacements during application and removal of the device, while tilting to 90°, during a bed transfer, and a lift onto a gurney. Linear and angular displacements were compared using the Generalized Linear Model analysis of variance for repeated measures for each of the six dependent variables (three planes of angulations and three axes of displacement).

RESULTS

There was more motion in all six planes of motion during the application process with use of the spine board alone, and this was statistically significant for axial rotation (P = 0.011), axial distraction (P = 0.035), medial-lateral translation (P = 0.027), and anteroposterior translation (P = 0.026). During tilting, there was more motion with just the spine board, but this was only statistically significant for anteroposterior translation (P = 0.033). With lifting onto the gurney, there was more motion with the spine board in all planes with statistical significance, except lateral bending. During the removal process, there was more motion with the spine board alone, and this was statistically significant for axial rotation (P = 0.035), lateral bending (P = 0.044), and axial distraction (P = 0.023).

CONCLUSION

There was more motion when using a spine board alone during typical maneuvers performed during early management of the spine injured patient than the vacuum mattress. There may be benefit of use of the vacuum mattress versus the spine board alone in preventing motion at an unstable, subaxial cervical spine injury.

LEVEL OF EVIDENCE

2.

Maintaining immobilisation devices on trauma patients during CT: a feasibility study

BACKGROUND

To reduce the possibility of secondary deterioration of spinal injuries, it is desirable to maintain the spinal immobilisation that is applied in the prehospital setting throughout computed tomography (CT) scanning. A previous study found that metallic components within the inflation valve of the vacuum mattresses caused CT artefacts. The aim of our study was to investigate the effect of vacuum mattresses with plastic valves on CT artefacts, the radiation dose, and noise compared to a trauma transfer board and the spine boards currently used in our trauma system.

METHODS

We scanned an anthropomorphic whole body phantom with different immobilisation devices on a 128-slice CT scanner using the standard polytrauma CT-protocol at our institution. The phantom was scanned without any immobilisation device and with three different vacuum mattresses, two spine boards, and one trauma transfer board. Two radiologists independently assessed the artefacts. Agreement between the two radiologists was measured using the kappa coefficient. The radiation dose and noise were assessed.

RESULTS

One spine board produced major artefacts due to its metal components. One of the vacuum mattresses resulted in artefacts that impaired clinical judgement. Otherwise, the artefacts predominantly did not impede clinical judgement and were mainly subtle. One of the vacuum mattresses resulted in no artefacts that affected clinical judgement. The overall inter-rater agreement was substantial (0.86, kappa 0.77). We did not observe any artefacts due to plastic valves. The mean CT radiation dose was slightly higher for two of the devices in the head series than that for the trauma transfer board, used as the standard in our system. Only marginal differences were noted for the other devices and series. Small differences in image noise were found between the devices.

CONCLUSIONS

Our results indicate that it is feasible to maintain some vacuum mattresses with plastic valves on trauma patients during CT scanning. The tested mattresses did not result in a considerably increased radiation dose or artefacts that hampered clinical judgement. One of the tested vacuum mattresses produced no artefacts that hampered clinical judgement whatsoever.

The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury

The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.

On-scene treatment of spinal injuries in motor sports

Because spinal cord injuries can have fatal consequences for injured race car drivers, prehospital treatment of spinal injuries is a major concern in motor sports. A structured procedure for assessing trauma patients and their treatment should follow established ABCDE principles. Only then, a stable patient could be further examined and appropriate measures can be undertaken. For patients in an acute life-threatening condition, rapid transport must be initiated and should not be delayed by measures that are not indicated. If a competitor must first be extricated from the racing vehicle, the correct method of extrication must be chosen. To avoid secondary injury to the spine after a racing accident, in-line extrication from the vehicle and immobilization of the patient are standard procedures in motor sports and have been used for decades. Since immobilization can be associated with disadvantages and complications, the need for immobilization of trauma patients outside of motor sports medicine has become the subject of an increasing number of reports in the scientific literature. Even in motor sports, where specific safety systems that offer spinal protection are present, the indications for spinal immobilization need to be carefully considered rather than being blindly adopted as a matter of course. The aim of this article is to use recent literature to present an overview about the treatment of spinal injuries in motor sports. Further, we present a new protocol for indications for immobilizing the spine in motor sports that is based on the ABCDE principles and takes into account the condition of the patient.

Comparison of tissue-interface pressure in healthy subjects lying on two trauma splinting devices: The vacuum mattress splint and long spine board

BACKGROUND

Most emergency transport protocols in the United States currently call for the use of a spine board (SB) to help immobilize the trauma patient. However, there are concerns that their use is associated with a risk of pressure ulcer development. An alternative device, the vacuum mattress splint (VMS) has been shown by previous investigations to be a viable alternative to the SB, but no single study has explicated the tissue-interface pressure in depth.

METHODS

To determine if the VMS will exert less pressure on areas of the body susceptible to pressure ulcers than a SB we enrolled healthy subjects to lie on the devices in random order while pressure measurements were recorded. Sensors were placed underneath the occiput, scapulae, sacrum, and heels of each subject lying on each device. Three parameters were used to analyze differences between the two devices: 1) mean pressure of all active cells, 2) number of cells exceeding 9.3kPa, and 3) maximal pressure (Pmax).

RESULTS

In all regions, there was significant reduction in the mean pressure of all active cells in the VMS. In the number of cells exceeding 9.3kPa, we saw a significant reduction in the sacrum and scapulae in the VMS, no difference in the occiput, and significantly more cells above this value in the heels of subjects on the VMS. Pmax was significantly reduced in all regions, and was less than half when examining the sacrum (104.3 vs. 41.8kPa, p<0.001).

CONCLUSION

This study does not exclude the possibility of pressure ulcer development in the VMS although there was a significant reduction in pressure in the parameters we measured in most areas. These results indicate that the VMS may reduce the incidence and severity of pressure ulcer development compared to the SB. Further prospective trials are needed to determine if these results will translate into better clinical outcomes.

Open-Design Collar vs. Conventional Philadelphia Collar Regarding User Satisfaction and Cervical Range of Motion in Asymptomatic Adults

OBJECTIVE

The current study aimed to compare the Philadelphia collar and an open-design cervical collar with regard to user satisfaction and cervical range of motion in asymptomatic adults.

DESIGN

Seventy-two healthy subjects (36 women, 36 men) aged 18 to 29 yrs were recruited for this study. Neck movements, including active flexion, extension, right/left lateral flexion, and right/left axial rotation, were assessed in each subject under three conditions--without wearing a collar and while wearing two different cervical collars--using a dual digital inclinometer. Subject satisfaction was assessed using a five-item self-administered questionnaire.

RESULTS

Both Philadelphia and open-design collars significantly reduced cervical motions (P < 0.05). Compared with the Philadelphia collar, the open-design collar more greatly reduced cervical motions in three planes and the differences were statistically significant except for limiting flexion. Satisfaction scores for Philadelphia and open-design collars were 15.89 (3.87) and 19.94 (3.11), respectively.

CONCLUSION

Based on the data of the 72 subjects presented in this study, the open-design collar adequately immobilized the cervical spine as a semirigid collar and was considered cosmetically acceptable, at least for subjects aged younger than 30 yrs.

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.

Cervical Spine Motion during Transfer and Stabilization Techniques

Abstract Objectives. To compare paramedics' ability to minimize cervical spine motion during patient transfer onto a vacuum mattress with two stabilization techniques (head squeeze vs. trap squeeze) and two transfer methods (log roll with one assistant (LR₂) vs. 3 assistants (LR₄)). Methods. We used a crossover design to minimize bias. Each lead paramedic performed 10 LR₂ transfers and 10 LR₄ transfers_. For each of the 10 LR₂ and 10 LR₄ transfers, the lead paramedic stabilized the cervical spine using the head squeeze technique five times and the trap squeeze technique five times. We randomized the order of the stabilization techniques and LR₂/LR₄ across lead paramedics to avoid a practice or fatigue effect with repeated trials. We measured relative cervical spine motion between the head and trunk using inertial measurement units placed on the forehead and sternum. Results. On average, total motion was 3.9° less with three assistants compared to one assistant (p = 0.0002), and 2.8° less with the trap squeeze compared to the head squeeze (p = 0.002). There was no interaction between the transfer method and stabilization technique. When examining specific motions in the six directions, the trap squeeze generally produced less lateral flexion and rotation motion but allowed more extension. Examining within paramedic differences, some paramedics were clearly more proficient with the trap squeeze technique and others were clearly more proficient with the head squeeze technique. Conclusion. Paramedics performing a log roll with three assistants created less motion compared to a log roll with only one assistant, and using the trap squeeze stabilization technique resulted in less motion than the head squeeze technique but the clinical relevance of the magnitude remains unclear. However, large individual differences suggest future paramedic training should incorporate both best evidence practice as well as recognition that there may be individual differences between paramedics.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Effect of vacuum spine board immobilization on incidence of pressure ulcers during evacuation of military casualties from theater

BACKGROUND CONTEXT

In the summer of 2009, the vacuum spine board (VSB) was designated by the US Air Force as the preferred method of external spinal immobilization during aeromedical transport of patients with suspected unstable thoracolumbar spine fractures. One purported advantage of the VSB is that, by distributing weight over a larger surface area, it decreases the risk of skin pressure ulceration.

PURPOSE

To examine whether the rate of pressure ulcers has changed since the introduction of the VSB.

STUDY DESIGN

Retrospective cohorts.

PATIENT SAMPLE

Injured US service members undergoing spinal immobilization during evacuation from the Iraq and Afghanistan theaters to Landstuhl, Germany.

OUTCOME MEASURES

Presence and stage of pressure ulceration, and deterioration in neurologic status.

METHODS

Records of the initial 60 patients medically evacuated on the VSB to Landstuhl Regional Medical Center were retrospectively analyzed for patient demographics, injury characteristics, and incidence of pressure injury. The incidence of pressure ulcers after the use of VSB was compared with that in a historical control consisting of 30 patients with unstable spinal injuries evacuated before the introduction of the VSB. No sources of external funding were used for this investigation.

RESULTS

The combined cohort had a mean age of 28.8 years and mean Injury Severity Score (ISS) of 20.63 and comprised 96% men. Most injury mechanisms were blunt (58%). The rate of neurological injury was 19%. There were no cases of progressive neurological deficit or deformity in either cohort. In the VSB group, using a broad definition of pressure ulcer, incidence was 13 of 60 patients (22%). Using a strict definition, incidence was eight of 60 (13%): five Stage I and three Stage II. In the non-VSB group, incidence of pressure ulcers was three of 30 (10%), using either definition, all Stage II. Difference in incidence between the groups was not statistically significant. Intubated patients had a significantly higher incidence of pressure ulcers.

CONCLUSION

Both the VSB and historic means (non-VSB) of spinal immobilization appear to be safe and produce only transient morbidity despite an average of 9 to 10 hours of transport. Intubated status was identified as the most important risk factor for the development of a pressure ulcer.

Wilderness Medical Society practice guidelines for spine immobilization in the austere environment

In an effort to produce best-practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several factors related to spinal immobilization. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each factor according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented.

Long backboard versus vacuum mattress splint to immobilize whole spine in trauma victims in the field: a randomized clinical trial

INTRODUCTION

Patients with possible spinal injury must be immobilized properly during transport to medical facilities. The aim of this research was comparing spinal immobilization using a long backboard (LBB) with using a vacuum mattress splint (VMS) in trauma victims transported by an Emergency Medical Services (EMS) system.

METHODS

In this randomized clinical trial, 60 trauma victims with possible spinal trauma were divided to two groups, each group immobilized with one of the two instruments. Speed and ease of application, immobilization rate, and the patients' comfort were recorded.

RESULTS

In this survey, LBB was faster to apply: 211.66 (SD = 28.53) seconds vs 654.00 (SD = 16.61) seconds. Various measures of immobilization were better by LBB. Also, LBB offered a significant improvement in comfort over a VMS for the patient with possible spinal injury. All of the results were statistically significant.

CONCLUSION

The results of this study showed that immobilization using LBB was easier, faster, and more comfortable for the patient, and provided additional decrease in spinal movement when compared with a VMS.

Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines

An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.

National athletic trainers' association position statement: acute management of the cervical spine-injured athlete

OBJECTIVE

To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete.

BACKGROUND

The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment.

RECOMMENDATIONS

Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.

Immobilization and splinting in mountain rescue. Official Recommendations of the International Commission for Mountain Emergency Medicine, ICAR MEDCOM, Intended for Mountain Rescue First Responders, Physicians, and Rescue Organizations

Immobilization and splinting of fractures are essential to reduce morbidity and mortality in mountain rescue. Therefore, members of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) debated the results of a literature review carried out by the authors. Focusing on common immobilization and splinting techniques relevant to mountain rescue, a consensus document was formulated. Pain relief of appropriate speed of onset and strength should be available on scene. Spinal immobilization is recommended for all casualties that have sustained head or spine injury. The preferred method is a vacuum mattress with an appropriately sized rigid cervical collar. In such casualties, only those in an unsafe environment or with time-critical injuries should be evacuated before spinal immobilization is performed. In some casualties, the cervical spine may be cleared and a cervical collar may be omitted. In the presence of hemodynamic instability and where there is a suspicion of a fractured pelvis, an external compression splint should be applied. Splinting of a femoral shaft fracture is important to limit pain and life-threatening blood loss. If time allows, extremity fractures should be adequately splinted and, if the practitioner is skilled, a displaced fracture or joint dislocation should be reduced on scene with the use of appropriate analgesia.

Summary of the National Athletic Trainers' Association position statement on the acute management of the cervical spine-injured athlete

The incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment. The objective of the National Athletic Trainers' Association (NATA) position statement on the acute care of the cervical spine-injured athlete is to provide the certified athletic trainer, team physician, emergency responder, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in an athlete. Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport such as football, hockey, or lacrosse; and imaging considerations in the emergency department.

Current status of medical training in mountain rescue in America and Europe

Limited medical training of mountain rescuers may adversely affect the outcome of casualties. Thus, this study evaluated medical training of mountain rescuers in countries associated with the International Commission of Mountain Emergency Medicine. A questionnaire was completed by 33 mountain rescue services from 18 countries in America and Europe. First-aid topics taught most often are (absolute values, percentage): chest compression, hypothermia, cold injuries (32 of 33 organization 97%); avalanche rescue, first-aid kit of rescuer, cervical collar (31, 94%); hemorrhagic shock, automated blood pressure measurement, wound dressing (30, 91%); and heat injuries and SAM SPLINT (29, 88%). Cardiopulmonary resuscitation manikins are used in 32 (97%) organizations, and in 17 (52%) organizations manikins have feedback functionality. After training, exams are compulsory in 27 (83%) organizations. Yearly retraining is done in 12 (36%) organizations; 22 (67%) organizations would like to increase medical training. The study shows high variability in the medical training programs among the surveyed organizations and the need to improve medical education. The authors recommend standardization of medical training and examinations on an international level. Additional topics tailored to the typical injury and illness patterns of a particular area should supplement this core training. Training should be performed by highly qualified instructors on a yearly basis.

Prehospital spinal immobilization and the backboard quality assessment study

INTRODUCTION

Prehospital spinal immobilization (PSI) for patients with suspected spinal injury has been the universal standard of practice for emergency medical services (EMS) in the United States since the early 1970s. PSI research has faced numerous methodological difficulties, including an inability to evaluate whether the immobilizations being studied were carried out appropriately. The purpose of this study was to assess the quality of spinal immobilization to a long spine board in patients presenting via EMS to an emergency department (ED).

METHODS

All noncritically ill patients presenting to a tertiary care academic trauma center who had been immobilized on a long spine board for EMS transport were approached for enrollment. Each subject was evaluated for the number and location of restraining straps and their degree of tightness.

RESULTS

Of 50 consenting subjects, 15 (30%) had at least one unattached strap or piece of tape that should have attached their head to the board. Of 50 subjects, 44 (88%) were found to have greater than 2 cm of slack between their body and at least one strap. Among those with any straps looser than 2 cm, the average number of loose straps was 3.4.

CONCLUSIONS

This study suggests that many patients are not well immobilized on arrival at the Emergency department.

Comparison of the Ferno Scoop Stretcher with the long backboard for spinal immobilization

OBJECTIVES

Spinal immobilization is essential in reducing risk of further spinal injuries in trauma patients. The authors compared the traditional long backboard (LBB) with the Ferno Scoop Stretcher (FSS) (Model 65-EXL). They hypothesized no difference in movement during application and immobilization between the FSS and the LBB.

METHODS

Thirty-one adult subjects had electromagnetic sensors secured over the nasion (forehead) and the C3 and T12 spinous processes and were placed in a rigid cervical collar, with movement recorded by a goniometer (a motion analysis system). Subjects were tested on both the FSS and the LBB. The sagittal flexion, lateral flexion, and axial rotation were recorded during each of four phases: 1) baseline, 2) application (logroll onto the LBB or placement of the FSS around the patient), 3) secured logroll, and 4) lifting. Comfort and perceived security also were assessed on a visual analog scale.

RESULTS

There was approximately 6-8 degrees greater motion in the sagittal, lateral, and axial planes during the application of the LBB compared with the FSS (both p < 0.001). No difference was found during a secured logroll maneuver. The FSS induced more sagittal flexion during the lift than the LBB (p < 0.001). The FSS demonstrated superior comfort and perceived security.

CONCLUSION

The FSS caused significantly less movement on application and increased comfort levels. Decreased movement using the FSS may reduce the risk of further spinal cord injury.

Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects

OBJECTIVE

To evaluate the effects of spinal immobilization on healthy participants.

METHODS

A systematic review of randomized, controlled trials of spinal immobilization on healthy participants.

RESULTS

Seventeen randomized, controlled trials compared different types of immobilization devices, including collars, backboards, splints, and body strapping. For immobilization efficacy, collars, spine boards, vacuum splints, and abdominal/torso strapping provided a significant reduction in spinal movement. Adverse effects of spinal immobilization included a significant increase in respiratory effort, skin ischemia, pain, and discomfort.

CONCLUSIONS

Data from this review provide the best available evidence to support the well-recognized efficacy and potential adverse effects of spinal immobilization. However, comparisons of different immobilization strategies on trauma victims must be considered in order to establish an evidence base for this practice.

Comparison of a long spinal board and vacuum mattress for spinal immobilisation

OBJECTIVES

This study was designed to compare the stability and comfort afforded by the long spinal board (backboard) and the vacuum mattress.

METHODS

Nine volunteers wearing standardised clothing and rigid neck collars were secured on to a backboard and vacuum mattress using a standard strapping arrangement. An operating department table was used to tilt the volunteers from 45 degrees head up to 45 degrees head down, and additionally 45 degrees laterally. Movements of the head, sternum, and pubic symphysis (pelvis) from a fixed position were then recorded. The comfort level during the procedure was assessed using a 10 point numerical rating scale (NRS) where 1=no pain and 10=worst pain imaginable.

RESULTS

The mean body movements in the head up position (23.3 v 6.66 mm), head down (40.89 v 8.33mm), and lateral tilt (18.33 v 4.26mm) were significantly greater on the backboard than on the vacuum mattress (p<0.01 for all planes of movement). Using the NRS the vacuum mattress (mean score=1.88) was significantly more comfortable than the backboard (mean score=5.22) (p<0.01).

CONCLUSIONS

In the measured planes the vacuum mattress provides significantly superior stability and comfort than a backboard.

Cervical spine immobilization before admission to the hospital

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

All trauma patients with a cervical spinal column injury or with a mechanism of injury having the potential to cause cervical spine injury should be immobilized at the scene and during transport by using one of several available methods. A combination of a rigid cervical collar and supportive blocks on a backboard with straps is effective in limiting motion of the cervical spine and is recommended. The long-standing practice of attempted cervical spine immobilization using sandbags and tape alone is not recommended.

Spinal immobilisation for trauma patients

BACKGROUND

Spinal immobilisation involves the use of a number of devices and strategies to stabilise the spinal column after injury and thus prevent spinal cord damage. The practice is widely recommended and widely used in trauma patients with suspected spinal cord injury in the pre-hospital setting.

OBJECTIVES

To quantify the effect of different methods of spinal immobilisation (including immobilisation versus no immobilisation) on mortality, neurological disability, spinal stability and adverse effects in trauma patients.

SEARCH STRATEGY

We searched the Cochrane Controlled Trial Register (CCTR), the specialised register of the Cochrane Injuries Group, MEDLINE, EMBASE, CINAHL, PubMed and the National Research Register. We checked reference lists of all articles and contacted experts in the field to identify eligible trials. Manufacturers of spinal immobilisation devices were also contacted for information.

SELECTION CRITERIA

Randomised controlled trials comparing spinal immobilisation strategies in trauma patients with suspected spinal cord injury. Trials in healthy volunteers were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied eligibility criteria to trial reports and extracted data.

MAIN RESULTS

We found no randomised controlled trials of spinal immobilisation strategies in trauma patients.

REVIEWER'S CONCLUSIONS

We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded. Large prospective studies are needed to validate the decision criteria for spinal immobilisation in trauma patients with high risk of spinal injury. Randomised controlled trials in trauma patients are required to establish the relative effectiveness of alternative strategies for spinal immobilisation.