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

[Transport of severely injured trauma patients in an ambulance with and without a rigid neck orthosis: comparative biomechanical measurements]

BACKGROUND

The actual significance of prehospital immobilization of the cervical spine in severely injured trauma patients remains unclear. In view of possible negative implications, such as an increase in intracranial pressure due to the application of a rigid cervical spine orthosis, the long-term use must be critically questioned. Further studies are required to justify the long-term use of a rigid cervical spine orthosis in the prehospital setting.

OBJECTIVE

Comparative measurements of the mobility of the cervical spine during immobilization using a vacuum mattress with or without the additional application of a rigid cervical spine orthosis after positioning on the stretcher were carried out.

MATERIAL AND METHODS

Biomechanical measurements of the movement of the cervical spine were carried out by attaching inertial measurement units to a test person during the loading and unloading process in a modern ambulance and during the journey along a predefined parkour. The test person on whom the measurements were carried out was immobilized on a vacuum mattress with the option of lateral fixation of the head and chin and forehead strap on an electrohydraulic stretcher. The complete standard monitoring was set up to simulate as realistic a transport of a severely injured patient as possible. A total of 30 test runs were realized. In one half of the tests, the cervical spine was additionally immobilized using a rigid orthosis and in the other half a cervical spine orthosis was not used. For each of the 30 tests, the angles, axial rotation, lateral bending and flexion/extension as well as the first and second derivatives were considered for loading, transport and unloading and the parameters mean deviation from the zero position, size of the swept angle range and maximum were calculated for each test run.

RESULTS

Statistically significant differences were only found for some biomechanical parameters in the sagittal plane (flexion and extension). No significant differences were found for the measured parameters in the other directions of movement (axial rotation, lateral flexion). In general, only very small angular deflections were measured both in the tests with the cervical spine orthosis and without the cervical spine orthosis (on average in the range of 1-2° for axial rotation and flexion/extension and up to 3° for lateral flexion).

CONCLUSION

If immobilization is carried out correctly using a vacuum mattress with the option of lateral stabilization of the head and chin and a forehead strap on an electrohydraulic stretcher with a loading system, there are no relevant advantages with respect to the restriction of movement of the cervical spine by the additional use of a rigid cervical spine orthosis for the loading and unloading process or during the transport in a modern ambulance. It could therefore be advantageous to remove the rigid cervical spine orthosis initially applied for the rescue of the patient at the scene after the patient has been positioned on the vacuum mattress and stretcher to avoid potential negative effects of the rigid cervical spine orthosis for the period of transportation to the hospital.

Lack of Association between Cervical Spine Injuries and Prehospital Immobilization: From Tradition to Evidence

Background: Cervical spine (C-spine) trauma usually results from blunt injuries and is traditionally managed by prehospital spinal immobilization using a cervical collar. We sought to examine if prehospital C-spine immobilization is associated with actual C-spine injuries and what factors are associated with the decision to immobilize the C-spine. Methods: We retrospectively analyzed blunt trauma patients treated by Israeli Defense Force (IDF) medical teams from 2015 to 2020. Children, penetrating injuries, and non-threatening injuries were excluded. Demographic data, injury characteristics, and prehospital information were collected from the IDF Trauma Registry's electronic medical records and merged with corresponding hospital data from the Israeli National Trauma Registry. Results: Overall, 220 patients were included, with a mean age of 32 and a predominance of male patients (78%). Most injuries were due to motor vehicle collisions (77%). In total, 40% of the patients received a cervical collar. C-spine injuries were present in 8%, of which 50% were immobilized with a cervical collar. There were no significant differences in the incidences of C-spine injuries or disability outcomes with or without collar immobilization. The use of a collar was significantly associated with backboard immobilization (OR = 14.5, p < 0.001) and oxygen use (OR = 2.5, p = 0.032). Conclusions: Prehospital C-spine immobilization was not associated with C-spine injury or neurological disability incidences. C-spine immobilization by medical providers may be influenced by factors other than the suspected presence of a C-spine injury, such as the use of a backboard. Clear clinical guidelines for inexperienced medical providers are called for.

Pre-hospital emergency medicine: a spectrum of imaging findings

The goal of emergency medical services (EMS) is to provide urgent medical care and stabilization prior to patient transport to a healthcare facility for definitive treatment. The number and variety of interventions performed in the field by EMS providers continues to grow as early management of severe injuries and critical illness in the pre-hospital setting has been shown to improve patient outcomes. The sequela of many field interventions, including those associated with airway management, emergent vascular access, cardiopulmonary resuscitation (CPR), patient immobilization, and hemorrhage control may be appreciated on emergency department admission imaging. Attention to these imaging findings is important for the emergency radiologist, who may be the first to identify a malpositioned device or an iatrogenic complication arising from pre-hospital treatment. Recognition of these findings may allow for earlier corrective action to be taken in the acute care setting. This review describes common EMS interventions and their imaging findings.

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

OBJECTIVES

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

DESIGN

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

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

DATA EXTRACTION AND SYNTHESIS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Where Do We Stand on Cervical Spine Immobilisation? A Questionnaire among Prehospital Staff

Background: Cervical collars (CC) are routinely used in prehospital trauma treatment. However, over the past years, their application was discussed more critically since they increase intravenous pressure due to reduced venous drainage and the possibility of secondary cervical spine injury. Guidelines have been adjusted accordingly. The question is how efficient has this been put into practice, and how good, as well as up to date, is the knowledge of prehospital emergency medicine personnel about indications on cervical spine immobilisation? Methods: A 15-item questionnaire regarding the self-evaluation and result checking of the right indications for the use of a cervical collar in the prehospital setting was sent to paramedics and emergency doctors in Germany. Two hundred and nineteen completed surveys were statistically analysed. Results: Mean age of the participants was 30.45 ± 8.8. 72% were male. Regarding subjective safety, the appropriate indication of CC participants reached 79.8 ± 19.5 on a metric scale from 0 (no safety) to 100 (full safety). Mean right answers were as follows: Ambulance man (RS) 0.78 ± 0.84, paramedic (RA) 0.9 ± 0.74, paramedic (NFS) 1.03 ± 0.83 and emergency doctor (ED) 1.75 ± 1.06 (p = 0.013, Kruskal-Wallis Test). Participants who estimated their knowledge < 85% had 0.83 ± 0.8 right answers, and > 85% had 1.14 ± 0.9 right answers. Conclusions: Rational spine immobilisation is still necessary in severely injured patients. This study highlights the importance of continuing education using ongoing training, lectures or online learning with a questionnaire as a monitor for success to ensure the transfer of evidence-based medicine into daily practice.

Triage tools for detecting cervical spine injury in paediatric trauma patients

BACKGROUND

Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy.

OBJECTIVES

To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions.

SELECTION CRITERIA

We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

Traditional Spinal Immobilization versus Spinal Motion Restriction in Cervical Spine Movement; a Randomized Crossover Trial

Introduction

Proper cervical spine immobilization is essential to prevent further injury following trauma. This study aimed to compare the cervical range of motion (ROM) and the immobilization time between traditional spinal immobilization (TSI) and spinal motion restriction (SMR).

Methods

This study was a randomized 2x2 crossover design in healthy volunteers. Participants were randomly assigned by Sequential numbered, opaque, sealed envelopes (SNOSE) with permuted block-of-four randomization to TSI or SMR. We used an inertial measurement unit (IMU) sensor to measure the cervical ROM in three dimensions focusing on flexion-extension, rotation, and lateral bending. The immobilization time was recorded by the investigator.

Results

A total of 35 healthy volunteers were enrolled in the study. The SMR method had cervical spine movement lower than the TSI method about 3.18 degrees on ROM in flexion-extension (p < 0.001). The SMR method had cervical spine movement lower than the TSI method about 2.01 degrees on ROM in lateral bending (p = 0.022). The immobilization time for the SMR method was 11.88 seconds longer than for the TSI method (p < 0.001) but not clinically significant.

Conclusion

SMR that used scoop stretcher resulted in significantly less cervical spine movement than immobilization with a TSI that used long spinal board. We recommend implementing the SMR protocol for transporting trauma patients, as minimizing cervical motion may enhance patient outcomes.

Temporal changes in the prehospital management of trauma patients: 2014-2021

INTRODUCTION

Aggressive prehospital interventions (PHI) in trauma may not improve outcomes compared to prioritizing rapid transport. The aim of this study was to quantify temporal changes in the frequency of PHI performed by EMS.

METHODS

Retrospective chart review of adult patients transported by EMS to our trauma center from January 1, 2014 to 12/31/2021. PHI were recorded and annual changes in their frequency were assessed via year-by-year trend analysis and multivariate regression.

RESULTS

Between the first and last year of the study period, the frequency of thoracostomy (6% vs. 9%, p ​= ​0.001), TXA administration (0.3% vs. 33%, p ​< ​0.001), and whole blood administration (0% vs. 20%, p ​< ​0.001) increased. Advanced airway procedures (21% vs. 12%, p ​< ​0.001) and IV fluid administration (57% vs. 36%, p ​< ​0.001) decreased. ED mortality decreased from 8% to 5% (p ​= ​0.001) over the study period. On multivariate regression, no PHI were independently associated with increased or decreased ED mortality.

CONCLUSION

PHI have changed significantly over the past eight years. However, no PHI were independently associated with increased or decreased ED mortality.

Trends in prehospital cervical collar utilization in trauma patients: Closer, but not there yet

OBJECTIVE

This study aims to assess the change in cervical spine (C-spine) immobilization frequency in trauma patients over time. We hypothesize that the frequency of unnecessary C-spine immobilization has decreased.

METHODS

A retrospective chart review of adult trauma patients transported to our American College of Surgeons-verified Level I trauma center from January 1, 2014, to December 31, 2021, was performed. Emergency medical services documentation was manually reviewed to record prehospital physiology and the application of a prehospital cervical collar (c-collar). C-spine injuries were defined as cervical vertebral fractures and/or spinal cord injuries. Univariate and year-by-year trend analyses were used to assess changes in C-spine injury and immobilization frequency.

RESULTS

Among 2906 patients meeting inclusion criteria, 12% sustained C-spine injuries, while 88% did not. Patients with C-spine injuries were more likely to experience blunt trauma (95% vs. 68%, p < 0.001), were older (46 years vs. 41 years, p < 0.001), and had higher Injury Severity Scores (31 vs. 18, p < 0.001). They also exhibited lower initial systolic blood pressures (108 mm Hg vs. 119 mm Hg, p < 0.001), lower heart rates (92 beats/min vs. 97 beats/min, p < 0.05), and lower Glasgow Coma Scale scores (9 vs. 11, p < 0.001). In blunt trauma, c-collars were applied to 83% of patients with C-spine injuries and 75% without; for penetrating trauma, c-collars were applied to 50% of patients with C-spine injuries and only 8% without. Among penetrating trauma patients with C-spine injury, all patients either arrived quadriplegic or did not require emergent neurosurgical intervention. The proportion of patients receiving a c-collar decreased in both blunt and penetrating traumas from 2014 to 2021 (blunt-82% in 2014 to 68% in 2021; penetrating-24% in 2014 to 6% in 2021).

CONCLUSIONS

Unnecessary C-spine stabilization has decreased from 2014 to 2021. However, c-collars are still being applied to patients who do not need them, both in blunt and in penetrating trauma cases, while not being applied to patients who would benefit from them.

Radiographic cervical spine injury patterns in admitted blunt trauma patients with and without prehospital spinal motion restriction

Objectives

Selective prehospital cervical spine motion restriction (C-SMR) following blunt trauma has increasingly been used by emergency medical service (EMS) providers. We determined rates of prehospital C-SMR and concomitant radiographic injury patterns.

Methods

A retrospective trauma registry and chart review was conducted for all adult blunt trauma patients who were transported by EMS and hospitalized with radiographic cervical spine injuries from 2011 to 2019 at a level 1 trauma center.

Results

Of 658 admitted blunt trauma patients with confirmed cervical spine injury by imaging, 117 (17.8%) did not receive prehospital C-SMR. Patients without prehospital C-SMR were significantly older (76 vs 54 years), more often had low fall as mechanism of injury (59.8% vs 15.9%) and had lower Injury Severity Score (10 vs 17). Patients without C-SMR (Non-SMR) experienced the full array of cervical spine injury types and locations. While the non-SMR patients most often had dens fractures,C-SMR patients most often had C7 fractures; frequencies of fractures at the remaining vertebral levels were comparable. On MRI, cervical spinal cord (8.5% vs 19.6%) and ligamentous injuries (5.1% vs 12.6%) occurred less often in non-SMR patients. Approximately 8.5% of non-SMR patients and 20% of C-SMR patients required cervical spine surgery.

Conclusion

Patients without prehospital C-SMR demonstrate a broad array of cervical spine injuries. While the rates of certain cervical injuries are lower in prehospital non-SMR patients, they are not insignificant.

Level of evidence

Level III.

The Effects of Cervical Orthoses on Head and Intervertebral Range of Motion

STUDY DESIGN

Prospective Cohort.

OBJECTIVE

Quantify and compare the effectiveness of cervical orthoses in restricting intervertebral kinematics during multiplanar motions.

SUMMARY OF BACKGROUND DATA

Previous studies evaluating the efficacy of cervical orthoses measured global head motion and did not evaluate individual cervical motion segment mobility. Prior studies focused only on the flexion/extension motion.

METHODS

Twenty adults without neck pain participated. Vertebral motion from the occiput through T1 was imaged using dynamic biplane radiography. Intervertebral motion was measured using an automated registration process with validated accuracy better than 1 degree. Participants performed independent trials of maximal flexion/extension, axial rotation, and lateral bending in a randomized order of unbraced, soft collar (foam), hard collar (Aspen), and cervical thoracic orthosis (CTO) (Aspen) conditions. Repeated-measures ANOVA was used to identify differences in the range of motion (ROM) among brace conditions for each motion.

RESULTS

Compared with no collar, the soft collar reduced flexion/extension ROM from occiput/C1 through C4/C5, and reduced axial rotation ROM at C1/C2 and from C3/C4 through C5/C6. The soft collar did not reduce motion at any motion segment during lateral bending. Compared with the soft collar, the hard collar reduced intervertebral motion at every motion segment during all motions, except for occiput/C1 during axial rotation and C1/C2 during lateral bending. The CTO reduced motion compared with the hard collar only at C6/C7 during flexion/extension and lateral bending.

CONCLUSIONS

The soft collar was ineffective as a restraint to intervertebral motion during lateral bending, but it did reduce intervertebral motion during flexion/extension and axial rotation. The hard collar reduced intervertebral motion compared with the soft collar across all motion directions. The CTO provided a minimal reduction in intervertebral motion compared with the hard collar. The utility in using a CTO rather than a hard collar is questionable, given the cost and little or no additional motion restriction.

Intensive Care Physician-Led Clearance of the Cervical Spine: A Retrospective Review of the Utility of a Normal Cervical CT Scan for Safe Removal of Hard Collars by Critical Care Physicians

Background: Cervical spine clearance in intubated patients due to blunt trauma remains contentious. Accumulating evidence suggests that a normal computed tomography (CT) cervical spine can be used to clear the cervical spine and remove the collar in unconscious patients presenting to the emergency department. However, whether this strategy can safely be employed by critical care physicians with intubated patients admitted to the trauma intensive care unit (TICU) with cervical collars in situ, has not been definitively studied. Methods: A retrospective review of 730 intubated victims of trauma who presented to the Level 1 Trauma center of a tertiary hospital was conducted. The rates of missed cervical injuries in patients who had their cervical collars removed by intensive care physicians based on a normal CT scan of the cervical spine, were reviewed. Secondary outcomes included rates of collar-related complications. Results: Three hundred and fifty patients had their cervical collars removed by Trauma ICU doctors based on a high-quality, radiologist-interpreted normal CT cervical spine. Seventy percent of patients were sedated and/or comatose at the time of collar removal. Fifty-one percent of patients had concomitant traumatic brain injury. The average GCS at time of collar removal was 9. The incidence of missed neurological injury discerned clinically at time of both ICU and hospital discharge was nil (negative predictive value 100%). The rate of collar-related complications was 2%. Conclusion: Cervical collar removal by intensive care physicians on TICU following normal CT cervical spine, is safe, provided certain quality conditions related to the CT scan are met. Not removing the collar early may be associated with increased complications. An algorithm is suggested to assist critical care decision-making in this patient cohort.

Development of a Machine Learning-Based Model for Accurate Detection and Classification of Cervical Spine Fractures Using CT Imaging

Cervical spine fractures represent a significant healthcare challenge, necessitating accurate detection for appropriate management and improved patient outcomes. This study aims to develop a machine learning-based model utilizing a computed tomography (CT) image dataset to detect and classify cervical spine fractures. Leveraging a large dataset of 4,050 CT images obtained from the Radiological Society of North America (RSNA) Cervical Spine Fracture dataset, we evaluate the potential of machine learning and deep learning algorithms in achieving accurate and reliable cervical spine fracture detection. The model demonstrates outstanding performance, achieving an average precision of 1 and 100% precision, recall, sensitivity, specificity, and accuracy values. These exceptional results highlight the potential of machine learning algorithms to enhance clinical decision-making and facilitate prompt treatment initiation for cervical spine fractures. However, further research and validation efforts are warranted to assess the model's generalizability across diverse populations and real-world clinical settings, ultimately contributing to improved patient outcomes in cervical spine fracture cases.

Patient outcomes before and after implementation of a selective pre-hospital spinal immobilization protocol: A comparative cohort pilot study in a level 2 trauma center

BACKGROUND

A new selective preventive spinal immobilization (PSI) protocol was introduced in the Netherlands. This may have led to an increase in non-immobilized spinal fractures (NISFs) and consequently adverse patient outcomes.

AIM

A pilot study was conducted to describe the adverse patient outcomes in NISF of the PSI protocol change and assess the feasibility of a larger effect study.

METHODS

Retrospective comparative cohort pilot study including records of trauma patients with a presumed spinal injury who were presented at the emergency department of a level 2 trauma center by the emergency medical service (EMS). The pre-period 2013-2014 (strict PSI protocol), was compared to the post-period 2017-2018 (selective PSI protocol). Primary outcomes were the percentage of records with a NISF who had an adverse patient outcome such as neurological injuries and mortality before and after the protocol change. Secondary outcomes were the sample size calculation for a larger study and the feasibility of data collection.

RESULTS

1,147 records were included; 442 pre-period, and 705 post-period. The NISF-prevalence was 10% (95% CI 7-16, n = 19) and 8% (95% CI 6-11, n = 33), respectively. In both periods, no neurological injuries or mortality due to NISF were found, by which calculating a sample size is impossible. Data collection showed to be feasible.

CONCLUSIONS

No neurological injuries or mortality due to NISF were found in a strict and a selective PSI protocol. Therefore, a larger study is discouraged. Future studies should focus on which patients really profit from PSI and which patients do not.

Burn Care in Low-Resource and Austere Settings

More than 95% of the 11 million burns that occur annually happen in low-resource settings, and 70% of those occur among children. Although some low- and middle-income countries have well-organized emergency care systems, many have not prioritized care for the injured and experience unsatisfactory outcomes after burn injury. This chapter outlines key considerations for burn care in low-resource settings.

SOFTLY: Comparison of outcomes of rigid versus soft collar during emergency department investigation for potential cervical spine injury in low-risk blunt trauma patients - A pilot study

OBJECTIVE

Blunt trauma patients with potential cervical spine injury are traditionally immobilised in rigid collars. Recently, this has been challenged. The present study's objective was comparison of the rate of patient-oriented adverse events in stable, alert, low-risk patients with potential cervical spine injuries immobilised in rigid versus soft collars.

METHODS

Unblinded, prospective quasi-randomised clinical trial of neurologically intact, adult, blunt trauma patients assessed as having potential cervical spine injury. Patients were randomised to collar type. All other aspects of care were unchanged. Primary outcome was patient-reported discomfort related to neck immobilisation by collar type. Secondary outcomes included adverse neurological events, agitation and clinically important cervical spine injuries (clinical trial registration number: ACTRN12621000286842).

RESULTS

A total of 137 patients were enrolled: 59 patients allocated to a rigid collar and 78 to a soft collar. Most injuries were from a fall <1 m (54%) or a motor vehicle crash (21.9%). Median neck pain score of collar immobilisation was lower in the soft collar group (3.0 [interquartile range 0-6.1] vs 6.0 [interquartile range 3-8.8], P < 0.001). The proportion of patients with clinician-identified agitation was lower in the soft collar group (5% vs 17%, P = 0.04). There were four clinically important cervical spine injuries (two in each group). All were treated conservatively. There were no adverse neurological events.

CONCLUSIONS

Use of soft rather than rigid collar immobilisation for low-risk blunt trauma patients with potential cervical spine injury is significantly less painful for patients and results in less agitation. A larger study is needed to determine the safety of this approach or whether collars are required at all.

Spine Bracing: When to Utilize-A Narrative Review

Spinal bracing is a common non-surgical technique that allows clinicians to prevent and correct malformations or injuries of a patient's spinal column. This review will explore the current standards of practice on spinal brace utilization. Specifically, it will highlight bracing usage in traumatic injuries, pregnancy, pediatrics, osteoporosis, and hyperkyphosis; address radiological findings concurrent with brace usage; and provide an overview of the braces currently available and advancements in the field. In doing so, we aim to improve clinicians' understanding and knowledge of bracing in common spinal pathologies to promote their appropriate use and improve patient outcomes.

Implementation of the Modified Canadian C-Spine Rule by Paramedics

STUDY OBJECTIVE

The Canadian C-spine rule was modified and validated for use by the paramedics in a multicenter study where patients were assessed with the Canadian C-spine rule yet all transported with immobilization. This study evaluated the clinical impact of the modified Canadian C-spine rule when implemented by paramedics.

METHODS

This single-center prospective cohort implementation study took place in Ottawa, Canada (from 2011 to 2015). Advanced and primary care paramedics were trained to use the modified Canadian C-spine rule, collect data on a standardized study form, and selectively transport eligible patients without immobilization. We evaluated all consecutive low-risk adult patients (Glasgow Coma Scale [GCS] 15, stable vital signs) at risk for a neck injury. We followed all patients without initial radiologic evaluation for 30 days. Analyses included descriptive statistics with 95% confidence intervals (CI), sensitivity, specificity, and kappa coefficients.

RESULTS

The 4,034 enrolled patients had a mean age of 43 (range 16 to 99), and 53.4% were female. Motor vehicle collisions were the most common mechanism of injury (55.1%), followed by falls (23.9%). There were 11 clinically important injuries. The paramedics classified these injuries with a sensitivity of 90.9% (95% CI, 58.7 to 99.8) and specificity of 66.5% (95% CI, 65.1 to 68.0). There was no adverse event or resulting spinal cord injury. The kappa agreement between paramedics and investigators was 0.94. A total of 2,583 (64.0%) immobilizations were avoided using the modified Canadian C-spine rule.

CONCLUSION

Paramedics could accurately apply the modified Canadian C-spine rule to low-risk trauma patients and significantly reduce the need for spinal immobilization during transport. This resulted in no adverse event or any spinal cord injury.

Critical Care Flight Nurses' role within secondary aeromedical services and the inter-hospital transfer of patients with acute spinal cord impairment

Aim: To highlight the role of secondary aeromedical services and required knowledge of Critical Care Flight Nurses (CCFN), in facilitating the safe inter-hospital transfer of patients with acute Spinal Cord Impairment (SCI) from a Major Trauma Centre (MTC) to a specialist SCI centre. Method: Literature search. Results: There is significant demand for secondary aeromedical services in order for patients with acute SCI to be transferred to a SCI centre within 24 h of injury. CCFN play an important role in triaging patients, coordinating patient care, arranging logistics of transport as well as providing direct clinical care inflight. CCFN must have knowledge regarding the pathophysiology of acute SCI, altitude physiology and interventions to manage stressors of flight in the aeromedical environment. Specific clinical challenges encountered by CCFN include the prevention of hypobaric hypoxic hypoxia and achieving appropriate immobilisation of the spine. Conclusion: Mitigating the increased risk associated with transporting critically unwell patients with SCI in the aeromedical environment, relies on aeromedical clinicians with education and training within the clinical specialty of aeromedical retrieval. The availability of secondary aeromedical services to undertake urgent inter-hospital retrieval of patients with acute SCI will be promoted by the continued development of Retrieval Nurse Practitioner (RNP) roles.

Investigating the Rate and Affecting Factors of Unnecessary Cervical Collar Use in Trauma Patients

Objective

This study aimed to investigate the necessity of cervical collars in patients with neck problems.

Methods

This cross-sectional study was conducted on 114 patients who were admitted to the Haft Tir and Rasoul Akram Hospitals (Tehran, Iran) from August to September 2022. The Nexus protocol was used to select the patients with cervical collars. According to the protocol, a cervical collar was required for individuals who had at least one symptom. If none of these symptoms existed, the cervical collar was deemed unnecessary. The data were analyzed using the Chi-square test and Fisher's exact test.

Results

Of the 114 trauma patients, the cervical collar was used unnecessarily by 49 (43%) patients. Tenderness was the most common complication in 62 patients (54.4%). The prevalence of unnecessary cervical collar use was 37.5% in female trauma patients and 43.88% in male trauma patients, which was not statistically significant (p=0.63). The prevalence of unnecessary cervical collar use in trauma patients with multiple trauma was 39.42% and 80% in patients without multiple trauma, which was statistically significant (p=0.018). Patients with a medical history had a higher rate of unnecessary use of the cervical collar (47.96%) than those without a history (12.5%), and this difference was statistically significant (p=0.008).

Conclusion

The guidelines for using cervical collars need to be updated by the EMS. Due to the large number of trauma patients in Iran, cervical collars for necessary conditions can help to reduce the healthcare expenses and injuries caused by unnecessary cervical collars.

Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: A scoping review

·

There is a need for a patient-centred approach to the prehospital spinal management approach, which considers the associated risks, available personnel and limited resources.

·

There is limited evidence supporting the use of the NEXUS and CCR decision tools in the prehospital setting.

·

Prehospital spinal motion restriction decision tools should focus on reducing unnecessary spinal motion restriction and its associated adverse effects

·

Developing a decision tool with more context-specific prehospital instructions for selective spinal motion restriction is of value.

Introduction

The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners.

Method

We performed a focused scoping review of published literature on the prehospital use of clinical c-spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis.

Results

Following screening, forty-two articles were included in this scoping review. No studies conducted specifically in low resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting.

Conclusion

This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety, and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation, and a lack of context-specific evidence. These may provide important considerations for future guideline development.

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.

Recommendation for changes to the guidelines of trauma patients with potential spinal injury within a regional UK ambulance trust

BACKGROUND

Spinal assessment and immobilisation has been a topic of debate for many years where, despite an emerging evidence base and the delivery of new guidance overseas, little has changed within UK pre-hospital practice. Since 2018, South East Coast Ambulance Service NHS Foundation Trust has spent time working with local trauma networks and expertise from within the region and international colleagues to develop a set of C-spine assessment and immobilisation guidelines that reflect the current best available international evidence and significant changes in international pre-hospital practice from settings such as Scandinavia and Australasia.

METHODS

A specialist group was commissioned to review the topic of pre-hospital spinal immobilisation and explore potential for evidence-based improvement. In conjunction with local trauma networks, subject matter experts and a thorough review of recent literature, a series of recommendations were made in order to improve spinal care within the authoring trust.

RESULTS

Seven recommendations were made, and an updated set of guidelines produced. These included the removal of semi-rigid collars from pre-hospital spinal immobilisation; the creation of two tiers of patients to ensure that the high-risk and low-risk populations are considered separately and an accompanying decision tool to safeguard both cohorts; an increased emphasis on the risk of spinal injury in the frail and older patient; an emphasis on spinal motion restriction rather than rigid immobilisation; an increased emphasis on self-extrication; and the use of a marker for emergency departments.

SUMMARY

An updated set of guidance has been produced using a combination of specialist and expert opinion alongside a literature review with close involvement of key stakeholders, both public and professional. The new guidance helps to ensure a patient-centred approach where each person is considered an individual with their risk of injury and management measures tailored to their specific needs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHOD

A single centre mixed method sequential study design was used.

RESULTS

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

CONCLUSIONS

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

A Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision

BACKGROUND

Approximately 1.3 million people die each year globally as a direct result of motor vehicle collisions (MVCs). Following an MVC some patients will remain trapped in their vehicle; these patients have worse outcomes and may require extrication. Following new evidence, updated multidisciplinary guidance for extrication is needed.

METHODS

This Delphi study has been developed, conducted and reported to CREDES standards. A literature review identified areas of expertise and appropriate individuals were recruited to a Steering Group. The Steering Group formulated initial statements for consideration. Stakeholder organisations were invited to identify subject matter experts (SMEs) from a rescue and clinical background (total 60). SMEs participated over three rounds via an online platform. Consensus for agreement / disagreement was set at 70%. At each stage SMEs could offer feedback on, or modification to the statements considered which was reviewed and incorporated into new statements or new supporting information for the following rounds. Stakeholders agreed a set of principles based on the consensus statements on which future guidance should be based.

RESULTS

Sixty SMEs completed Round 1, 53 Round 2 (88%) and 49 Round 3 (82%). Consensus was reached on 91 statements (89 agree, 2 disagree) covering a broad range of domains related to: extrication terminology, extrication goals and approach, self-extrication, disentanglement, clinical care, immobilisation, patient-focused extrication, emergency services call and triage, and audit and research standards. Thirty-three statements did not reach consensus.

CONCLUSION

This study has demonstrated consensus across a large panel of multidisciplinary SMEs on many key areas of extrication and related practice that will provide a key foundation in the development of evidence-based guidance for this subject area.

The Impact of Prehospital Spinal Immobilization in Patients with Penetrating Spinal Injuries: A Systematic Review and Meta-Analysis

Penetrating injuries, such as gunshot or stab wounds, may cause spinal cord injuries and require prehospital spinal immobilization (PHSI) to stabilize the spine. However, the use of PHSI in penetrating spinal injuries remains controversial. This systematic review aimed to investigate the efficacy of prehospital PHSI in patients with penetrating trauma. We systematically searched Google Scholar, Medline (PubMed), The Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE between January 2000 and July 2021. All studies in English that assessed PHSI in patients (>16 years) with penetrating spinal injuries were included. Quality and risk of bias assessments were performed using the modified Newcastle-Ottawa scale. A narrative synthesis and a meta-analysis was conducted. Our search identified 928 studies but only 6 met our inclusion and exclusion criteria. All of the included studies were conducted in the US and the number of patients ranged from 156–75,567 over 3–9 study years. The majority of patients were gunshot or stab wounds. Three studies demonstrated an increased risk of mortality with spinal collars whilst the remaining three studies failed to show any benefits or the benefits remained unproven. All studies were retrospective studies with some risks of bias. This review highlights that the evidence from the literature on PHSI in penetrating trauma outweigh its benefits; thus, its use is discouraged in penetrating spinal trauma. However, further high-quality research is necessary to reach definitive conclusions and to possibly identify suitable alternatives to PHSI for penetrating spinal trauma.

A multicenter cohort study on the association between prehospital immobilization and functional outcome of patients following spinal injury in Asia

Prehospital spinal immobilization is a widely used procedure in the emergency medical service (EMS) system worldwide, while the incidence of patients with spinal injury (SI) is relatively low, and unnecessary prehospital spinal immobilization is associated with patient complications. This study aimed to determine the association between prehospital spine immobilization and favorable functional outcomes at hospital discharge among trauma patients with SI. We conducted a retrospective cohort study using the Pan-Asia Trauma Outcomes Study (PATOS) registry data from January 1, 2016, to November 30, 2018. A total of 759 patients with SI were enrolled from 43,752 trauma patients in the PATOS registry during the study period. The subjects had a median age of 58 years (Q1-Q3, 41-72), and 438 (57.7%) patients had prehospital spine immobilization. Overall, prehospital spinal immobilization was not associated with favorable functional outcomes at discharge in multivariable logistic regression (aOR 1.06; 95% CI 0.62-1.81, p = 0.826). However, in the subgroup of cervical SI, prehospital spinal immobilization was associated with favorable functional outcomes at discharge (aOR 3.14; 95% CI 1.04-9.50; p = 0.043). Therefore, we suggest that paramedics should be more careful when determining the presence of a cervical SI and should apply full spine immobilization if possible.

The Impact of a Cervical Collar on Intracranial Pressure in Traumatic Brain Injury Patients: A Systematic Review and Meta-Analysis

Purpose: Although the use of a cervical collar in the prehospital setting is recommended to prevent secondary spinal cord injuries and ensure spinal immobilization, it is not known what effects this has on raising intracranial pressure (ICP) in traumatic brain injury (TBI) patients. In the absence of studies measuring ICP in the prehospital setting, the aim of this study was to systematically review the data related to ICP changes measured after presentation at the hospital in patients who had arrived wearing cervical collars. Methods: We searched Medline (PubMed), Embase, CINAHL, and Google Scholar for studies that investigated in-hospital ICP changes in TBI patients arriving at the hospital wearing collars. Titles, abstracts, and full texts were then searched for inclusion in the study. A narrative synthesis, as well as a meta-analysis, was performed. Results: Of the 1006 studies identified, only three met the inclusion/exclusion criteria. The quality of the three included studies was moderate and the risk of bias was low. All three studies used the Laerdal Stifneck collar, but all studies showed an increase in ICP after application of the collar. A further three studies that measured ICP but did not fit the systematic search were also included due to low patient numbers. A meta-analysis of the pooled data confirmed a significant increase in ICP, although between the four studies, only 77 patients were included. The meta-analysis also confirmed that after removal of the collar, there was a significant decrease in ICP. Conclusions: Our study suggests that the use of a cervical collar increases ICP in TBI and head injury patients, which may have detrimental effects. However, due to the extremely low sample size from all six studies, caution must be exercised when interpreting these data. Thus, further high-quality research is necessary to unequivocally clarify whether cervical collars should be used in patients with TBI.

Extrication techniques of entrapped car crash victims: a scoping review

OBJECTIVE

to summarize the extrication techniques of entrapped car crash victims with potential spinal injury.

METHOD

a literature review study, of scoping review type, using the MEDLINE/PubMed, CINAHL, Scopus, Science Direct, Web of Science, Cochrane Library and gray literature data sources, without time frame, with studies that addressed extricating techniques extrication of entrapped car crash victims.

RESULTS

a total of 33 studies were included that enabled identifying and summarizing the different types of extrication and respective devices for extrication of entrapped car crash victims, indicated according to injury assessment and the victim's clinical condition. All pointed to the need for techniques to maintain neutral alignment and prevent spine twists.

CONCLUSION

this study indicated that injury assessment with an emphasis on the victim's clinical condition provides a coherent decision-making regarding the technique and device to be used. However, carrying out other comparative studies between existing techniques may help in the decision-making process more assertively.

Accuracy of after-hours trauma cervical spine CT reporting by radiology trainees: Experiences from two Australian teaching hospitals

INTRODUCTION

Like many teaching hospitals in Australia, after-hours computed tomography (CT) reporting at our institution is undertaken by the on-call radiology registrar. The accuracy of these reports is important as management is often initiated based on the interim findings, prior to review by the consultant radiologist. A common exception to this approach is cervical CT (CCT), as many hospital protocols recommend patients to remain in spinal precautions until the report is finalised by a consultant, although there are very few studies to support this practice.

METHODS

The interim registrar reports for all CCTs performed after-hours over a 12-month period were retrospectively reviewed. The final consultant report was used as the gold standard to establish accuracy of the registrar report. The primary outcome was discrepancy between the provisional and final reports. Any discrepancy was classified as either an 'overcall' or 'miss'. Discrepancies were graded by the RADPEER scoring system.

RESULTS

A total of 1084 after-hours CCT studies were reviewed. The number of cases positive for injury was 37 (3.4%). The total number of discrepancies was 14 (discrepancy rate 1.3%), including 4 overcalls (0.3%) and 10 misses (0.9%). The discrepancy rates for junior and senior registrars were 1.7% and 0.7% respectively. Only 5 misses (0.5%) were considered clinically significant.

CONCLUSION

Registrars reporting after-hours CCT have low rates of discrepancy with very few clinically significant misses. However, the reduced registrar sensitivity for detection of cervical injury highlights the ongoing importance of consultant review in the process of cervical spine clearance pathways.

Projected paediatric cervical spine imaging rates with application of NEXUS, Canadian C-Spine and PECARN clinical decision rules in a prospective Australian cohort

BACKGROUND

Clinical decision rules (CDRs) are commonly used to guide imaging decisions in cervical spine injury (CSI) assessment despite limited evidence for their use in paediatric populations. We set out to determine CSI incidence, imaging rates and the frequency of previously identified CSI risk factors, and thus assess the projected impact on imaging rates if CDRs were strictly applied as a rule in our population.

METHODS

A single-centre prospective observational study on all aged under 16 years presenting for assessment of possible CSI to a tertiary paediatric emergency department over a year, commencing September 2015. CDR variables from the National Emergency X-Radiography Utilization Study (NEXUS) rule, Canadian C-Spine rule (CCR) and proposed Paediatric Emergency Care Applied Research Network (PECARN) rule were collected prospectively and applied post hoc.

RESULTS

1010 children were enrolled; 973 had not received prior imaging. Of these, 40.7% received cervical spine imaging; 32.4% X-rays, 13.4% CT scan and 3% MRI. All three CDRs identified the five children (0.5%) with CSI who had not received prior imaging. If CDRs were strictly applied as a rule for imaging, projected imaging rates in our setting would be as follows: NEXUS-44% (95% CI 41% to 47.4%), CCR-at least 48.4% (95% CI 45.3% to 51.7%) and PECARN-68% (95% CI 65.1% to 71.1%).

CONCLUSION

CSIs were rare (0.5% of our cohort), however, 40% of children received imaging. CDRs have been designed to guide imaging decisions; if strictly applied as a rule for imaging, the CDRs assessed in this study would increase imaging rates. Projected rates differ considerably depending on the CDR applied. These findings highlight the need for a validated paediatric-specific cervical spine imaging CDR.

Emergency management of older people with cervical spine injuries: an expert practice review

Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.

The role of cervical collars and verbal instructions in minimising spinal movement during self-extrication following a motor vehicle collision - a biomechanical study using healthy volunteers

Background

Motor vehicle collisions account for 1.3 million deaths and 50 million serious injuries worldwide each year. However, the majority of people involved in such incidents are uninjured or have injuries which do not prevent them exiting the vehicle. Self-extrication is the process by which a casualty is instructed to leave their vehicle and completes this with minimal or no assistance. Self-extrication may offer a number of patient and system-wide benefits. The efficacy of routine cervical collar application for this group is unclear and previous studies have demonstrated inconsistent results. It is unknown whether scripted instructions given to casualties on how to exit the vehicle would offer any additional utility.

The aim of this study was to evaluate the effect of cervical collars and instructions on spinal movements during self-extrication from a vehicle, using novel motion tracking technology.

Methods

Biomechanical data on extrications were collected using Inertial Measurement Units on 10 healthy volunteers. The different extrication types examined were: i) No instructions and no cervical collar, ii) No instructions, with cervical collar, iii) With instructions and no collar, and iv) With instructions and with collar. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LAT) planes. Total movement, mean, standard deviation and confidence intervals are reported for each extrication type.

Results

Data were recorded for 392 extrications. The smallest cervical spine movements were recorded when a collar was applied and no instructions were given: mean 6.9 mm AP and 4.4 mm LAT. This also produced the smallest movements at the lumbar spine with a mean of 122 mm AP and 72.5 mm LAT.

The largest overall movements were seen in the cervical spine AP when no instructions and no collar were used (28.3 mm). For cervical spine lateral movements, no collar but with instructions produced the greatest movement (18.5 mm). For the lumbar spine, the greatest movement was recorded when instructions were given and no collar was used (153.5 mm AP, 101.1 mm LAT).

Conclusions

Across all participants, the most frequently occurring extrication method associated with the least movement was no instructions, with a cervical collar in situ.

European Resuscitation Council Guidelines 2021: First aid

The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.

Evaluating the paramedic application of the prehospital Canadian C-Spine Rule in sport-related injuries

OBJECTIVES

We sought to compare the ability of the prehospital Canadian C-Spine Rule to selectively recommend immobilization in sport-related versus non-sport-related injuries and describe sport-related mechanisms of injury.

METHODS

We reviewed data from the prospective paramedic Canadian C-Spine Rule validation and implementation studies in 7 Canadian cities. A trained reviewer further categorized sport-related mechanisms of injury collaboratively with a sport medicine physician using a pilot-tested standardized form. We compared the Canadian C-Spine Rule's recommendation to immobilize sport-related versus non-sport-related patients using Chi-square and relative risk statistics with 95% confidence intervals.

RESULTS

There were 201 sport-related patients among the 5,978 included. Sport-related injured patients were younger (mean age 36.2 vs. 42.4) and more predominantly male (60.5% vs. 46.8%) than non-sport-related patients. Paramedics did not miss any C-Spine injury when using the Canadian C-Spine Rule. C-Spine injury rates were similar between sport (2/201; 1.0%) and non-sport-injured patients (47/5,777; 0.8%). The Canadian C-Spine Rule recommended immobilization equally between groups (46.4% vs. 42.5%; RR 1.09 95%CI 0.93-1.28), most commonly resulting from a dangerous mechanism among sport-injured (68.7% vs. 54.5%; RR 1.26 95%CI 1.08-1.47). The most common dangerous mechanism responsible for immobilization in sport was axial load.

CONCLUSION

Although equal proportions of sport and non-sport-related injuries were immobilized, a dangerous mechanism was most often responsible for immobilization in sport-related cases. These findings do not address the potential impact of using the Canadian C-Spine Rule to evaluate collegiate or pro athletes assessed by sport medicine physicians. It does support using the Canadian C-Spine Rule as a tool in sport-injured patients assessed by paramedics.

Sequential traumatic cervical fractures after paragliding accidents - A case report and literature review

Background

Sports related cervical spine trauma may range from minor injuries to severe life-threatening fractures with spinal cord injuries as following paragliding accidents.

Case Description

A 52-year-old male sustained C4-C5 and C6-C7 fracture-dislocations (American Spinal Injury Association-D) attributed to a paragliding accident. He underwent a C5 corpectomy with C4-C6 anterior fusion. Three years later, he again sustained a paragliding accident, now resulting in a C6-C7 fracture-dislocation that required a C6-C7 anterior discectomy fusion. However, when this latter fusion "failed" 1 month later, he subsequently required a 360° fusion performed as a two-stage procedure. Further, 2 years later, he was involved in a motor vehicle accident resulting in an odontoid fracture.

Conclusion

Unstable spinal fractures require surgical fixation to prevent neurological injury. Long cervical fusions create lever arms that increase the stress to adjacent levels, rendering them prone to future injury.

Hangings attended by emergency medical services: a scoping review

Background

In the United Kingdom (UK) there were 6507 deaths by suicide in 2018, with hanging being the most common method. Hanging will normally result in emergency medical services (EMS) being called and may result in resuscitation being attempted. Trauma audits conducted by North East Ambulance Service NHS Foundation Trust have identified an increased trend in hanging cases, which were also reported in national data. The aim of this scoping review was to explore the literature around EMS attendance at hangings to inform further research and clinical practice.

Methods

A five-stage scoping review method was used. Relevant studies were identified by searching MEDLINE, CINAHL, EMBASE and EMCARE with the help of the Library and Knowledge Service for NHS Ambulance Services in England. Grey literature and reference lists were also searched. Studies were included based on relevance to hangings attended by EMS. Data were tabulated and narratively synthesised.

Results

Sixteen papers were included in the review. Australia was the most frequent source of studies (n = 5, 31%). Most studies (n = 11, 69%) were published in the past 10 years. The median sample size was 53 (IQR 41-988, range 10-3981). All papers included varying levels of patient characteristics, EMS input and patient outcomes.

Conclusion

Hanging is a highly lethal method of suicide that is increasingly used in the UK. This scoping review found that there is scarce literature focused on hangings attended by EMS. Treatment of the hanging patient in cardiac arrest is described in many of the papers included. Hanging patients may benefit from the presence of specialist resources who can deliver interventions such as sedation and advanced airway management. The psychological impact of attending, or witnessing, hanging patients is an area that needs further consideration. Further research is needed to describe and improve EMS treatment of hangings.

Fifteen-minute consultation: Severe traumatic brain injury in paediatrics

Paediatric traumatic brain injury (TBI) is a non-degenerative, acquired brain insult. Following a blow or penetrating trauma to the head, normal brain function is disrupted. If it occurs during the early stages of development, deficits may not immediately become apparent but unfold and evolve over time. We address the difficulties that arise when treating a child with severe TBI.

Early Management of Cervical Spine Trauma: WFNS Spine Committee Recommendations

Epidemiology, prevention, early management of cervical spine trauma and it's reduction are the objectives of this review paper. A PubMed and MEDLINE search between 2009 and 2019 were conducted using keywords. Case reports, experimental studies, papers other than English language and and unrelated studies were excluded. Up-to-date information on epidemiology of spine trauma, prevention, early emergency management, transportation, and closed reduction were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Global incidence of traumatic spinal injury is higher in low- and middle-income countries. The most frequent reasons are road traffic accidents and falls. The incidence from low falls in the elderly are increasing in high-income countries due to ageing populations. Prevention needs legislative, engineering, educational, and social efforts that need common efforts of all society. Emergency care of the trauma patient, transportation, and in-hospital acute management should be planned by implementing detailed protocols to prevent further damage to the spinal cord. This review summarizes the WFNS Spine Committee recommendations on epidemiology, prevention, and early management of cervical spine injuries.

Evidence for the use of spinal collars in stabilising spinal injuries in the pre-hospital setting in trauma patients: a systematic review

Purpose

Spinal collars were introduced in 1967 into the management of spinal trauma care as it was thought that this technique of immobilisation would prevent any further neurological or spinal damage in high-risk patients. The aim of this systematic review was to determine whether the use of spinal collars in the pre-hospital trauma patient was recommended by published literature.

Methods

A systematic search of the literature was conducted between 1990 and 2020, screening PubMed, Medline, Science Direct and Google Scholar. The consequent findings were then qualitatively synthesised with the aim of effectively evaluating the evidence to resolve the discrepancy between current practice and literature.

Results

Of the nine eligible studies, six deemed that spinal collars should not be used in pre-hospital trauma patients with the remaining three reporting uncertainty if spinal collars were best practice. Our results suggest that there is a discrepancy between current guidance and practice in that although the guidelines recommend the use of spinal collars in the pre-hospital setting the majority of the studies were against the use of spinal collars. Importantly, none of the studies reported any benefits of spinal collars.

Conclusion

Our study shows a disparity between current guidelines and the published literature and warrants further direct research to obtain a more comprehensive view of the use of spinal collars in a pre-hospital setting.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

How the Implementation of a Battlefield Clinical Practice Guideline Affects Documentation Practice and Informs Future Research Initiatives: Spinal Injuries and Cervical Collars

INTRODUCTION

In 2010, the Joint Trauma System published a clinical practice guideline (CPG) for providing care to patients with suspicion of spinal cord injury. The CPG advocated for liberal use of cervical collars and adequate documentation of the practice. This performance improvement project examined C-spine CPG adherence in both the prehospital and military treatment facility (MTF) settings. Understanding challenges in CPG adherence facilitates evaluation of future CPGs and their success at implantation of the clinical guidance.

MATERIALS AND METHODS

The Department of Defense Trauma Registry was used to identify US Military casualties meeting the criteria for cervical collar placement between January 1, 2007 and December 31, 2018. Criteria for cervical collar placement were defined as any patient who experienced a mechanism of injury relating to an explosion, fall, or motor-vehicle-related injury. Any patients with an AIS severity score greater than 1 to the head or having any ICD injury codes related to either upper spinal cord or head injury were also considered for inclusion. Adherence of cervical collar placement was defined by documented ICD codes or prehospital documentation of cervical collar placement as captured in the registry.

RESULTS

A total of 14,837 patients were identified for possible cervical collar placement and 3,317 had verifiable documentation of having a C-collar placed. Documented C-collar placement was higher after the publication of the clinical practice guideline in 2010 (29% vs. 15%, p < 0.0001). CPG publication was associated with cervical collar application (odds ratio: 2.50, 95% CI: 2.29-2.72).

CONCLUSION

Application of cervical collars has increased significantly, since the initial publication of the spine injury CPG. Current gaps include valid and reliable identification of patients warranting specific clinical interventions and documentation of patient care. Currently, lack of documentation is reported as nonadherence, but it remains unknown if these missing clinical data accurately portray nonadherence or adherence with lack of documentation. Future research and resources would benefit and expand the results collected in this paper, and cement the importance of CPG publication and adherence.

A T2 Translational Science Modified Delphi Study: Spinal Motion Restriction in a Resource-Scarce Environment

INTRODUCTION

Emerging evidence is guiding changes in prehospital management of potential spinal injuries. The majority of settings related to current recommendations are in resource-rich environments (RREs), whereas there is a lack of guidance on the provision of spinal motion restriction (SMR) in resource-scarce environments (RSEs), such as: mass-casualty incidents (MCIs); low-middle income countries; complex humanitarian emergencies; conflict zones; and prolonged transport times. The application of Translational Science (TS) in the Disaster Medicine (DM) context was used to develop this study, leading to statements that can be used in the creation of evidence-based clinical guidelines (CGs).

OBJECTIVE

What is appropriate SMR in RSEs?

METHODS

The first round of this modified Delphi (mD) study was a structured focus group conducted at the World Association for Disaster and Emergency Medicine (WADEM) Congress in Brisbane Australia on May 9, 2019. The result of the focus group discussion of open-ended questions produced ten statements that were added to ten statements derived from Fischer (2018) to create the second mD round questionnaire.Academic researchers and educators, operational first responders, or first receivers of patients with suspected spinal injuries were identified to be mD experts. Experts rated their agreement with each statement on a seven-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤1.0. Statements that were in agreement reaching consensus were included in the final report; those that were not in agreement but reached consensus were removed from further consideration. Those not reaching consensus advanced to the third mD round.For subsequent rounds, experts were shown the mean response and their own response for each of the remaining statements and asked to reconsider their rating. As above, those that did not reach consensus advanced to the next round until consensus was reached for each statement.

RESULTS

Twenty-two experts agreed to participate with 19 completing the second mD round and 16 completing the third mD round. Eleven statements reached consensus. Nine statements did not reach consensus.

CONCLUSIONS

Experts reached consensus offering 11 statements to be incorporated into the creation of SMR CGs in RSEs. The nine statements that did not reach consensus can be further studied and potentially modified to determine if these can be considered in SMR CGs in RSEs.

Indentation marks, skin temperature and comfort of two cervical collars: A single-blinded randomized controlled trial in healthy volunteers

BACKGROUND

Collar-related pressure ulcers (CRPU) are a problem in trauma patients with a suspicion of cervical cord injury patients. Indentation marks (IM), skin temperature (T_sk) and comfort could play a role in the development of CRPU. Two comparable cervical collars are the Stifneck® and Philadelphia®. However, the differences between them remain unclear.

AIM

To determine and compare occurrence and severity of IM, T_sk and comfort of the Stifneck® and Philadelphia® in immobilized healthy adults.

METHODS

This single-blinded randomized controlled trial compared two groups of immobilized participants in supine position for 20 min.

RESULTS

All participants (n = 60) generated IM in at least one location in the observed area. Total occurrence was higher in the Stifneck®-group (n = 95 versus n = 69; p = .002). T_sk increased significantly with 1.0  °C in the Stifneck®-group and 1.3 °C in the Philadelphia®-group (p = .024). Comfort was rated 3 on a scale of 5 (p = .506).

CONCLUSION

The occurrence of IM in both groups was high. In comparison to the Stifneck®, fewer and less severe IM were observed from the Philadelphia®. The T_sk increased significantly with both collars; however, no clinical difference in increase of T_sk between them was found. The results emphasize the need for a better design of cervical collars regarding CRPU.