Head-Neck Motion in Prehospital Trauma Patients under Spinal Motion Restriction: A Pilot Study

Development and validation of assessment instruments for cervical collar and spinal board placement in simulated environments for nursing students in the care of polytrauma patients

BACKGROUND

Multiple trauma injuries are the leading cause of death and disability in people under the age of 45 and require prompt and specialised care. However, medical and nursing education programmes do not always include specific training in emergency pre-hospital care, resulting in a lack of basic practical skills in trauma management.

OBJECTIVE

To develop and validate two instruments for assessing nursing students' competence in cervical collar and spinal board application in simulated pre-hospital emergency scenarios.

METHOD

This is an instrumental study that involves the development of two assessment instruments and the evaluation of their psychometric properties in a sample of 392 nursing students. Content validity was assessed using expert judgement, by calculating the content validity ratio (CVR) for each item and the scale level content validity index average (S-CVI/Ave) for the instruments. Exploratory factor analysis using the MINRES extraction method and Promax rotation was performed to analyse the performance of the items and structure of the rubrics. Internal consistency was analysed using the Omega coefficient and inter-rater agreement was assessed using Cohen's Kappa coefficient.

RESULTS

Initially, two rubrics were obtained: one with six items for cervical collar placement (S-CVI/Ave = 0.86) and one with nine items for spinal board placement (S-CVI/Ave = 0.81). Both had a single-factor structure, with all items having factor loadings greater than 0.34 for the cervical collar rubric and 0.56 for the spinal board rubric, except for item 2 of the cervical collar rubric (λ = 0.24), which was subsequently removed. The final cervical collar rubric (five items) had an overall internal consistency of 0.84 and the spinal board rubric had an overall internal consistency of 0.90, calculated using the Omega statistic. The weighted Kappa coefficient for each item ranged from acceptable (0.32) to substantial (0.79). These results show that we have successfully developed two sufficiently valid instruments to assess the immobilisation competencies proposed in the objective of the study.

CONCLUSION

Whilst further research is needed to fully establish their psychometric properties, these instruments offer a valuable starting point for evaluating nursing students' competence in cervical collar and spinal board application in simulated pre-hospital scenarios.

Patterns of change in prehospital spinal motion restriction: A retrospective database review

BACKGROUND

Acute management of trauma patients with potential spine injuries has evolved from uniform spinal immobilization (SI) to spinal motion restriction (SMR). Little research exists describing how these changes have been implemented. This study aims to describe and analyze the practice of SMR in one emergency medical services (EMS) agency over the time frame of SMR adoption.

METHODS

This was a retrospective database review of electronic patient care reports from 2009 to 2020. The effects of key practice changes (revised documentation and a collar-only treatment option) were analyzed in an interrupted time series using the rate of SI/SMR as the primary outcome. Secondary outcomes included patient age, sex, acuity, mechanism of injury, treatment provided, cervical collar size, and positioning. These were assessed for changes from year to year by Poisson regression. Associations between patient and treatment characteristics were investigated with binomial logistic regression.

RESULTS

There were 25,747 instances of SI/SMR included. Among all patients, the median age was 40 (interquartile range 24-56), 58% (14,970) were male, and 20% (5062) were high-acuity. The rate of SI/SMR declined from 31.2 to 12.7 treatments per 100 trauma calls per month. The proportion of high-acuity patients increased by 9.6% per year on average (95% CI 8.7%-10.0%). When first available, collar-only treatment was provided to 47% of patients, rising by 6.3% per year (95% CI 3.2%-9.5%) to 60% in 2020. Collar-only treatment (compared to board-and-collar) was more likely to be applied to low-acuity patients (as compared to high): odds ratio 3.01 (95% CI 2.64-3.43).

CONCLUSIONS

This study shows decreasing SI/SMR treatment and changing patient and practice characteristics. These patterns of care cannot be attributed solely to formal protocol changes. Similar patterns and their possible explanations should be investigated elsewhere.

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.

Paramedic attitudes towards prehospital spinal care: a cross-sectional survey

BACKGROUND

The optimal application of spinal motion restriction (SMR) in the prehospital setting continues to be debated. Few studies have examined how changing guidelines have been received and interpreted by emergency medical services (EMS) personnel. This study surveys paramedics' attitudes, observations, and self-reported practices around the treatment of potential spine injuries in the prehospital setting.

METHODS

This was a cross-sectional survey of a North American EMS agency. After development and piloting, the final version of the survey contained four sections covering attitudes towards 1) general practice, 2) specific techniques, 3) assessment protocols, and 4) mechanisms of injury (MOI). Questions used Likert-scale, multiple-choice, yes/no, and free-text responses. Exploratory factor analysis (EFA) was used to identify latent constructs within responses, and factor scores were analyzed by ordinal logistic regression for associations with demographic characteristics (including qualification level, gender, and years of experience). MOI evaluations were assessed for inter-rater reliability (Fleiss' kappa). Inductive qualitative content analysis, following Elo & Kyngäs (2008), was used to examine free-text responses.

RESULTS

Two hundred twenty responses were received (36% of staff). Raw results indicated that respondents felt that SMR was seen as less important than in the past, that they were treating fewer patients than previously, and that they follow protocol in most situations. The EFA identified two factors: one (Judging MOIs) captured paramedics' estimation that the presented MOI could potentially cause a spine injury, and another (Treatment Value) reflected respondents' composite view of the effectiveness, importance, and applicability of SMR. Respondents with advanced life support (ALS) qualification were more likely to be skeptical of the value of SMR compared to those at the basic life support (BLS) level (OR: 2.40, 95%CI: 1.21-4.76, p = 0.01). Overall, respondents showed fair agreement in the evaluation of MOIs (k = 0.31, 95%CI: 0.09-0.49). Content analysis identified tension expressed by respondents between SMR-as-directed and SMR-as-applied.

CONCLUSION

Results of this survey show that EMS personnel are skeptical of many elements of SMR but use various strategies to balance protocol adherence with optimizing patient care. While identifying several areas for future research, these findings argue for incorporating provider feedback and judgement into future guideline revision.

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.

Effect of a cervical collar on head and neck acceleration profiles during emergency spinal immobilisation and extrication procedures in elite football (soccer) players: protocol for a randomised, controlled cross-over trial

When immobilisation after a cervical spine or head injury is required, the role of the rigid cervical collar is unclear and controversial. There is a need for further studies investigating the use of a rigid cervical collar when head and neck trauma occurs in sport. This study will compare present practice (immobilisation with a cervical collar) to the same procedure without a collar during a simulated spinal immobilisation and extraction scenario from the field of play to the side-line in football (soccer). It will use a prospective cohort within-subjects cross over randomised, controlled trial design. Healthy participants will assume the role of players with a head or neck injury. Clinical practitioners will perform the immobilisation and extrication procedure according to current clinical guidelines. Three dimensional linear and angular acceleration profiles of the head and torso will be measured and the time taken to complete the procedure. The interventions will be a ‘cervical collar’ or ‘no collar’ in random order. Data from the IMUs will be transferred wirelessly to a computer for analysis. Accordingly, within-subject differences between each condition (collar vs no collar) will be assessed with parametric or non-parametric inferential statistics. Statistical significance will be set at p<0.05.

Trial registration number:ISRCTN16515969

A Change from a Spinal Immobilization to a Spinal Motion Restriction Protocol was Not Associated with an Increase in Disabling Spinal Cord Injuries

BACKGROUND

Over the past decade, Emergency Medical Service (EMS) systems decreased backboard use as they transition from spinal immobilization (SI) protocols to spinal motion restriction (SMR) protocols. Since this change, no study has examined its effect on the neurologic outcomes of patients with spine injuries.

OBJECTIVES

The object of this study is to determine if a state-wide protocol change from an SI to an SMR protocol had an effect on the incidence of disabling spinal cord injuries.

METHODS

This was a retrospective review of patients in a single Level I trauma center before and after a change in spinal injury protocols. A two-step review of the record was used to classify spinal cord injuries as disabling or not disabling. A binary logistic regression was used to determine the effects of protocol, gender, age, level of injury, and mechanism of injury (MOI) on the incidence of significant disability from a spinal cord injury.

RESULTS

A total of 549 patients in the SI period and 623 patients in the SMR period were included in the analysis. In the logistic regression, the change from an SI protocol to an SMR protocol did not demonstrate a significant effect on the incidence of disabling spinal injuries (OR: 0.78; 95% CI, 0.44 - 1.36).

CONCLUSION

This study did not demonstrate an increase in disabling spinal cord injuries after a shift from an SI protocol to an SMR protocol. This finding, in addition to existing literature, supports the introduction of SMR protocols and the decreased use of the backboard.