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Brannigan JF, Dohle E, Critchley GR, Trivedi R, Laing RJ, Davies BM. Adverse Events Relating to Prolonged Hard Collar Immobilisation: A Systematic Review and Meta-Analysis. Global Spine J 2022; 12:1968-1978. [PMID: 35333123 PMCID: PMC9609519 DOI: 10.1177/21925682221087194] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To evaluate systematically the complications of prolonged cervical immobilisation in a hard collar. METHODS Following registration with PROSPERO, a systematic search of electronic databases (MEDLINE, EMBASE) was conducted. Two reviewers independently screened the search results according to pre-determined search criteria. Data was extracted and tabulated. Joanna Briggs Institute checklists were used for assessing the quality of included studies. RESULTS The search identified 773 articles. A total of 25 studies were selected for final inclusion. The results largely comprised a mixture of case reports/series, cohort studies and reviews. The most commonly reported complications were pressure ulcers, dysphagia and increased intracranial pressure. A pressure ulcer pooled prevalence of 7% was calculated. There was insufficient data for quantitative analysis of any other complication. CONCLUSIONS There is significant morbidity from prolonged hard collar immobilisation, even amongst younger patients. Whilst based upon limited and low-quality evidence, these findings, combined with the low-quality evidence for the efficacy of hard collars, highlights a knowledge gap for future research.
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Affiliation(s)
- Jamie F.M. Brannigan
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,School of Clinical Medicine, University of Cambridge, Cambridge, UK,Jamie F.M. Brannigan BA, Division of
Neurosurgery, Department of Clinical Neurosciences, University of Cambridge,
Jesus College, Cambridge CB5 8BL, UK.
| | - Esmee Dohle
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Giles R. Critchley
- Department of Neurosurgery, Brighton and Sussex University
Hospitals National Health Service Trust, Brighton, UK
| | - Rikin Trivedi
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Rodney J. Laing
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Benjamin M. Davies
- Division of Neurosurgery,
Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Myelopathy.org, University of Cambridge, UK
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Randall MM, Egbert J, Ito BM, Yalung JE, Brown L. Outcomes of Patients With Negative Cervical Imaging but Persistent Neck Tenderness Discharged With a Rigid Collar After Trauma. Cureus 2022; 14:e24170. [PMID: 35592211 PMCID: PMC9110094 DOI: 10.7759/cureus.24170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction It is not uncommon for patients with persistent neck pain after trauma despite negative cervical imaging to be discharged with a rigid collar. Protocols for these patients vary widely. Few studies have evaluated clinical outcomes after discharge. No studies have evaluated the patient’s experience in a cervical collar after discharge. Methods We evaluated adults with blunt trauma and negative cervical spine imaging who were discharged in a rigid cervical collar. Over a 19-month period, 45 patients were available for analyses. The primary outcome was any identified missed injuries after discharge. Secondary outcomes were the incidence of patients self-clearing from their collars and complications related to wearing a collar. Results There were no missed traumatic injuries on follow-up imaging. Twenty of 45 patients cleared themselves from the collar without a physician order. Twenty-four patients had their collars removed by a provider in the clinic between 1-84 days after injury. One patient removed the collar after being advised by a chiropractor. More than half of patients reported one or more complications from wearing the cervical collar including pain, skin irritation, problems sleeping, difficulty talking or swallowing. Conclusions Collar complications are frequent. Follow-up imaging did not change outpatient management. Our data suggests against the practice of discharging trauma patients home in a cervical collar with negative imaging and no focal neurologic deficit.
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Lacey L, Palokas M, Walker J. Preventative interventions, protocols or guidelines for trauma patients at risk of cervical collar-related pressure ulcers: a scoping review. ACTA ACUST UNITED AC 2020; 17:2452-2475. [PMID: 31464850 DOI: 10.11124/jbisrir-2017-003872] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this scoping review was to explore the existing literature related to preventative interventions, protocols or guidelines for trauma patients at risk of cervical collar-related pressure ulcers to examine and conceptually map the evidence, and to identify any gaps in the literature. INTRODUCTION Cervical collars are necessary to stabilize cervical spine injuries in trauma patients; however, pressure ulcers are a major complication of prolonged cervical collar use. The longer a patient wears a cervical collar, the more likely the patient will develop a pressure ulcer that will worsen as wear time increases. INCLUSION CRITERIA This review considered both experimental and quasi-experimental study designs, analytical observational studies, case-control studies, analytical cross-sectional studies, descriptive observational studies, qualitative studies, and text and opinion papers. Trauma patients of all ages who presented to the emergency department or intensive care unit with an extrication or field collar in place were included in this study. Extrication collars included but were not limited to Stifneck, Philadelphia and Miami J. METHODS The JBI scoping review methodology was used for this review. The database searches included MEDLINE (PubMed), CINAHL, Embase, Scopus, JBI Database of Systematic Reviews and Implementation Reports, NHS Research Register, National Institute of Health Clinical Trial Databases, Cochrane Database of Sytematic Reviews, MedNar, WorldWideScience, PsycEXTRA, OAIster, OpenGrey, and ProQuest Dissertations and Theses. The data were extracted using a charting table, which was developed to record key information from sources relevant to the review questions. The findings were descriptively presented, with tables and figures to support the data, when appropriate. Only studies in English from 1965 to December 2018 were included. RESULTS Preventative interventions found in the seven studies included in the review were: removal of the extrication collar, cervical spine clearance, nursing education, routine nursing care, use of products such as air mattresses, and a multidisciplinary approach to care. Additionally, six of the seven studies identified 28 risk factors associated with the development of cervical collar-related pressure ulcers. Two studies reported elimination of cervical collar-related pressure ulcers while three studies reported reduced incidence in cervical collar-related pressure ulcers. Another study reported a reduction in cervical collar wear time from 14 days to 7.7 days. CONCLUSIONS Protocols with a multidisciplinary approach are available in the literature to serve as guidance for proper treatment and care of trauma patients' wearing of cervical collars. Standardized cervical collar protocols should highlight the importance of early identification of trauma patients who may be at risk. Risk factors identified in this review should be assessed and addressed to halt cervical collar-related pressure ulcers from ever developing in trauma patients who are immediately identified as at risk. Preventative interventions identified in the protocols in this scoping review can be used to create a standardized approach to care for patients in cervical collars.
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Affiliation(s)
- Lanise Lacey
- School of Nursing, University of Mississippi Medical Center, Jackson, United States.,Mississippi Centre for Evidence Based Practice: a Joanna Briggs Institute Centre of Excellence
| | - Michelle Palokas
- Mississippi Centre for Evidence Based Practice: a Joanna Briggs Institute Centre of Excellence
| | - Jean Walker
- Mississippi Centre for Evidence Based Practice: a Joanna Briggs Institute Centre of Excellence
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Wang HRN, Campbell J, Doubrovsky A, Singh V, Collins J, Coyer F. Pressure injury development in critically ill patients with a cervical collar in situ: A retrospective longitudinal study. Int Wound J 2020; 17:944-956. [PMID: 32239663 DOI: 10.1111/iwj.13363] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 11/27/2022] Open
Abstract
Trauma patients with a serious injury to the head or neck can remain immobilised with a cervical collar (C-collar) device in situ and are subsequently exposed to device-related skin integrity threats. This study aimed to determine the incidence and risk factors associated with the development of C-collar-related pressure injures (CRPIs) in an intensive care unit. This retrospective longitudinal cohort study was conducted in an Australian metropolitan intensive care unit. Following ethical approval, data from patients over 18 years, who received a C-collar were retrieved over a 9-year period. Chi square and t-tests were used to identify variables associated with CRPI development. A logistic regression model was employed to analyse the risk factors. Data from 906 patients were analysed. Nine-year pressure injury incidence was 16.9% (n = 154/906). Pressure injury development directly associated with a C-collar increased by 33% with each repositioning episode (odds ratio 1.328, 95% confidence interval 1.024-1.723, P = .033). Time in the C-collar (10.4 to 2.5 days, P = .002) and length of stay in intensive care unit (ICU) (20.1 to 16.1 days, P < .001) were associated with pressure injury development. Patients with C-collar devices are a vulnerable group at risk for pressure injury development because of their immobility and length of ICU stay.
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Affiliation(s)
- Harn-Rong N Wang
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Jill Campbell
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Skin Integrity Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Anna Doubrovsky
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | | | | | - Fiona Coyer
- Joint appointment Intensive Care Services, Royal Brisbane and Women's Hospital and School of Nursing, Queensland University of Technology, Herston, Queensland, Australia.,Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield, UK
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Ham WH, Schoonhoven L, Schuurmans MJ, Leenen LP. Pressure ulcers in trauma patients with suspected spine injury: a prospective cohort study with emphasis on device-related pressure ulcers. Int Wound J 2016; 14:104-111. [PMID: 26767917 DOI: 10.1111/iwj.12568] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 11/25/2015] [Accepted: 12/01/2015] [Indexed: 11/26/2022] Open
Abstract
Of all patients in a hospital environment, trauma patients may be particularly at risk for developing (device-related) pressure ulcers (PUs), because of their traumatic injuries, immobility, and exposure to immobilizing and medical devices. Studies on device-related PUs are scarce. With this study, the incidence and characteristics of PUs and the proportion of PUs that are related to devices in adult trauma patients with suspected spinal injury were described. From January-December 2013, 254 trauma patients were visited every 2 days for skin assessment. The overall incidence of PUs was 28·3% (n = 72/254 patients). The incidence of device-related PUs was 20·1% (n = 51), and 13% (n = 33) developed solely device-related PUs. We observed 145 PUs in total of which 60·7% were related to devices (88/145). Device-related PUs were detected 16 different locations on the front and back of the body. These results show that the incidence of PUs and the proportion of device-related PUs is very high in trauma patients.
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Affiliation(s)
- Wietske Hw Ham
- Emergency Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette Schoonhoven
- Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom.,Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
| | | | - Luke Ph Leenen
- Department of Traumatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Sparke A, Voss S, Benger J. The measurement of tissue interface pressures and changes in jugular venous parameters associated with cervical immobilisation devices: a systematic review. Scand J Trauma Resusc Emerg Med 2013; 21:81. [PMID: 24299024 PMCID: PMC4222127 DOI: 10.1186/1757-7241-21-81] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 11/20/2013] [Indexed: 12/30/2022] Open
Abstract
Cervical immobilisation is commonly applied following trauma, particularly blunt head injury, but current methods of immobilisation are associated with significant complications. Semi-rigid disposable cervical collars are known to cause pressure ulcers, and impede effective airway management. These collars may also exacerbate a head injury by increasing intracranial pressure as a result of external compression of the jugular veins. There is a clear imperative to find ways of effectively immobilising the cervical spine whilst minimising complications, and any assessment of existing or new devices should include a standardized approach to the measurement of tissue interface pressures and their effect on jugular venous drainage from the brain. This systematic review summarises the research methods and technologies that have been used to measure tissue interface pressure and assess the jugular vein in the context of cervical immobilisation devices. 27 papers were included and assessed for quality. Laboratory investigations and biomechanical studies have gradually given way to methods that more accurately reflect clinical care. There are numerous accounts of skin ulceration associated with cervical collars, but no standardised approach to measuring tissue interface pressure. It is therefore difficult to compare studies and devices, but a pressure of less than 30 mmHg appears desirable. Cervical collars have been shown to have a compressive effect on the jugular veins, but it is not yet certain that this is the cause of the increased intracranial pressure observed in association with cervical collar use. This is the first review of its type. It will help guide further research in this area of trauma care, and the development and testing of new cervical immobilisation devices.
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Affiliation(s)
| | - Sarah Voss
- Research Fellow in Emergency Care, Faculty of Health and Life Sciences, University of the West of England, Bristol, UK.
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Black J, Alves P, Brindle CT, Dealey C, Santamaria N, Call E, Clark M. Use of wound dressings to enhance prevention of pressure ulcers caused by medical devices. Int Wound J 2013; 12:322-7. [PMID: 23809279 DOI: 10.1111/iwj.12111] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 05/06/2013] [Indexed: 11/28/2022] Open
Abstract
Medical device related pressure ulcers (MDR PUs) are defined as pressure injuries associated with the use of devices applied for diagnostic or therapeutic purposes wherein the PU that develops has the same configuration as the device. Many institutions have reduced the incidence of traditional PUs (sacral, buttock and heel) and therefore the significance of MDR PU has become more apparent. The highest risk of MDR PU has been reported to be patients with impaired sensory perception, such as neuropathy, and an impaired ability for the patient to communicate discomfort, for example, oral intubation, language barriers, unconsciousness or non-verbal state. Patients in critical care units typify the high-risk patient and they often require more devices for monitoring and therapeutic purposes. An expert panel met to review the evidence on the prevention of MDR PUs and arrived at these conclusions: (i) consider applying dressings that demonstrate pressure redistribution and absorb moisture from body areas in contact with medical devices, tubing and fixators, (ii) in addition to dressings applied beneath medical devices, continue to lift and/or move the medical device to examine the skin beneath it and reposition for pressure relief and (iii) when simple repositioning does not relieve pressure, it is important not to create more pressure by placing dressings beneath tight devices.
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Affiliation(s)
- Joyce Black
- Nursing, University of Nebraska Medical Center, Omaha, NE, USA
| | - Paulo Alves
- Catholic University of Portugal - Institute of Health Sciences, Porto, Portugal
| | | | - Carol Dealey
- Tissue Viability, University of Birmingham and University Hospital, Birmingham NHSFT, UK
| | - Nick Santamaria
- Nursing Research, Translational Research, University of Melbourne & Royal Melbourne Hospital AU, Melbourne, Australia
| | - Evan Call
- Weber State University, Salt Lake City, UT, USA
| | - Michael Clark
- Tissue Viability, Birmingham City University, Birmingham, UK
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Cervical spine injuries and collar complications in severely injured paediatric trauma patients. Spinal Cord 2013; 51:360-4. [PMID: 23459123 DOI: 10.1038/sc.2013.6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A retrospective registry review. OBJECTIVES To determine the incidence of cervical spine (CS) injuries and collar complications in severely injured paediatric trauma patients. SETTING Regional Trauma Centre, Children's Hospital. METHODS A retrospective review of 365 paediatric severe trauma patients (0-17 years), defined as an Injury Severity Score (ISS)≥12, admitted to the paediatric intensive care unit (PICU). RESULTS Clinically significant CS injuries occurred in 5% (n=18/365) of trauma patients, in 9% (n=13/149) of traumatic brain injury (TBI) patients and in 11% (n=6/56) of in-hospital trauma deaths. CS injuries were suspected before imaging in 33% (n=6/18) of patients based on either motor/sensory impairment or shock. CS injuries were deemed unstable in 61% (n=11/18) of patients. Patients with CS injuries had higher ISS, and longer PICU and hospital stays (P<0.05). CS collar complications occurred in 10% of patients, mainly identified by day 6 and consisting of either erythema or ulcers. Patients with CS collar complications were older and more likely to have TBI, lower Glasgow Coma Scale (GCS) scores, longer PICU and hospital stays, and increased days to CS clearance (P<0.05). Three CS X-rays, together with flexion/extension views, were used most frequently for CS clearance. CONCLUSION CS injuries were prevalent in severely injured paediatric trauma patients, particularly in those with TBI and in nonsurvivors. CS collar complications were associated with a lower GCS and longer CS clearance times. Attention to CS collar management protocols and earlier CS clearance with computed tomography/magnetic resonance imaging in obtunded patients might reduce CS collar complications.
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Walker J. Pressure ulcers in cervical spine immobilisation: a retrospective analysis. J Wound Care 2012; 21:323-6. [DOI: 10.12968/jowc.2012.21.7.323] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J. Walker
- Division of Orthopaedic and Accident Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, UK
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