Cervical spine immobilization before admission to the hospital

Prehospital Cervical Spine (C-spine) Stabilization and Airway Management in a Trauma Patient: A Review

Severe traumatic damage to the brain-to-body signaling bundle that results in bruising and a partial or total tear of the spinal cord is known as a spinal cord injury (SCI). SCI may develop at the time of an event or after. It can also develop while handling the patient and can worsen during the transportation of the patient. So prehospital care is crucial to prevent or minimize SCI. Prehospital care involves examining the patient, immobilizing the cervical spine (C-spine), providing cardiovascular support (keeping the mean arterial blood pressure over 85 mmHg), and carefully managing the airway (possibly intubating the patient using manual in-line stabilization (MILS)). Methylprednisolone (MPS) and other pharmacological treatments have not been shown to offer clinically meaningful and essential benefits for people with SCI. The therapeutic use of MPS in patients with SCI in the prehospital context is no longer supported. Additionally, whether or not pharmaceutical drugs will be effective in therapeutic hypothermia is unknown. When performing endotracheal intubation on these patients, the potential for C-spine damage is always considered. During intubation, the MILS approach significantly reduces C-spine movement. The MILS method, however, can potentially restrict mouth opening and result in subpar laryngoscopic vision. These issues can be handled using the recently developed video laryngoscope, such as Airtraq laryngoscope and AirWay Scope (AWS). Compared to a direct laryngoscope, the AWS and Airtraq laryngoscope reduced the improvement of intubation conditions and the acceleration of tracheal intubation through the occiput-C1 and C2-C4 levels of the C-spine extension movement.

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.

Cervical Spinal Immobilization: A Head-to-Head Comparison of a One-Step Spray-on Foam Splint Versus Structural Aluminum Malleable Splint Immobilization

INTRODUCTION

Cervical spine immobilization in a low-resource environment is difficult secondary to limited equipment, prolonged transportation, and secondary complications. A structural aluminum malleable (SAM) splint is commonly utilized because of its availability and multipurpose intention. A one-step spray-on foam immobilization technique (Fast Cast) has been shown to be effective in lower-extremity splinting. The aim of this study was to demonstrate the ability of the Fast Cast to effectively immobilize the cervical spine in a head-to-head comparison against the SAM splint. We hypothesized that there would be no difference in surgeon scoring between Fast Cast and SAM splints for the immobilization of the cervical spine.

METHODS

This was a cadaveric experimental comparative study that compared a SAM splint versus Fast Cast for the immobilization of an unstable cervical spine. Each of the three cadaveric specimens had a corpectomy without fixation performed. A board-certified emergency medicine physician specialized in disaster medicine performed all SAM immobilizations. An orthopedic surgeon performed Fast Cast immobilizations. Each method of immobilization was done on each cadaver. Lateral fluoroscopic imaging was taken before and after immobilization and after log roll/gravity stress. Five board-certified orthopedic surgeons served as graders to independently score each splint. A 5-point Likert scale based on 10 splinting criteria (50 total points possible) was utilized to evaluate cervical spine immobilization. The lead statistical analyst was blinded to the immobilization groups. The statistical significance was assessed via a Wilcoxon signed-rank test and chi-square Fisher's exact test with significance between groups set at α < .05. Inter-rater reliability of the Likert scale results was assessed with the interclass correlation coefficient.

RESULTS

Inter-rater reliability for the current Likert scale in the evaluation of cervical spine stabilization was good (interclass correlation coefficient = 0.76). For the cumulative Likert scale score, Fast Cast (32 [28-34]) exhibited a higher total score than SAM (44 [42-47]; P < .01). Likewise, Fast Cast exhibited a greater likelihood of higher Likert scores within each individual question as compared to SAM (P ≤ 0.04). In 100% of cases, raters indicated that Fast Cast passed the gravity stress examination without intrinsic loss of reduction or splinting material, whereas 33% of SAM passed (P < .01). In 100% of cases, raters indicated that Fast Cast passed the initial radiographic alignment following immobilization, whereas 66% of SAM passed (P = .04). In 100% of cases, raters indicated that Fast Cast passed radiographic alignment after the gravity stress examination, whereas 47% of SAM passed (P < .01).

CONCLUSION

The Fast Cast exceeded our expectations and was shown to be rated not equivalent but superior to SAM splint immobilization for the cervical spine. This has significant clinical implications as the single-step spray-on foam is easy to transport and has multifaceted applications. It also eliminates pressure points and circumferential wrapping and obstruction to airway/vascular access while immobilizing the cervical spine and allowing for radiographic examination. Further studies are needed for human use and application.

Established and Emerging Therapies in Acute Spinal Cord Injury

Acute spinal cord injury (SCI) is devastating for patients and their caretakers and has an annual incidence of 20–50 per million people. Following initial assessment with appropriate physical examination and imaging, patients who are deemed surgical candidates should undergo decompression with stabilization. Earlier intervention can improve neurological recovery in the post-operative period while allowing earlier mobilization. Optimized medical management is paramount to improve outcomes. Emerging strategies for managing SCI in the acute period stem from an evolving understanding of the pathophysiology of the injury. General areas of focus include ischemia prevention, reduction of secondary injury due to inflammation, modulation of the cytotoxic and immune response, and promotion of cellular regeneration. In this article, we review established, emerging, and novel experimental therapies. Continued translational research on these methods will improve the feasibility of bench-to-bedside innovations in treating patients with acute SCI.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Quantitative Approach Based on Wearable Inertial Sensors to Assess and Identify Motion and Errors in Techniques Used during Training of Transfers of Simulated c-Spine-Injured Patients

Patients with suspected spinal cord injuries undergo numerous transfers throughout treatment and care. Effective c-spine stabilization is crucial to minimize the impacts of the suspected injury. Healthcare professionals are trained to perform those transfers using simulation; however, the feedback on the manoeuvre is subjective. This paper proposes a quantitative approach to measure the efficacy of the c-spine stabilization and provide objective feedback during training. Methods. 3D wearable motion sensors are positioned on a simulated patient to capture the motion of the head and trunk during a training scenario. Spatial and temporal indicators associated with the motion can then be derived from the signals. The approach was developed and tested on data obtained from 21 paramedics performing the log-roll, a transfer technique commonly performed during prehospital and hospital care. Results. In this scenario, 55% of the c-spine motion could be explained by the difficulty of rescuers to maintain head and trunk alignment during the rotation part of the log-roll and their difficulty to initiate specific phases of the motion synchronously. Conclusion. The proposed quantitative approach has the potential to be used for personalized feedback during training sessions and could even be embedded into simulation mannequins to provide an innovative training solution.

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

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

Translating mechanisms of neuroprotection, regeneration, and repair to treatment of spinal cord injury

One of the big challenges in neuroscience that remains to be understood is why the central nervous system is not able to regenerate to the extent that the peripheral nervous system does. This is especially problematic after traumatic injuries, like spinal cord injury (SCI), since the lack of regeneration leads to lifelong deficits and paralysis. Treatment of SCI has improved during the last several decades due to standardized protocols for emergency medical response teams and improved medical, surgical, and rehabilitative treatments. However, SCI continues to result in profound impairments for the individual. There are many processes that lead to the pathophysiology of SCI, such as ischemia, vascular disruption, neuroinflammation, oxidative stress, excitotoxicity, demyelination, and cell death. Current treatments include surgical decompression, hemodynamic control, and methylprednisolone. However, these early treatments are associated with modest functional recovery. Some treatments currently being investigated for use in SCI target neuroprotective (riluzole, minocycline, G-CSF, FGF-2, and polyethylene glycol) or neuroregenerative (chondroitinase ABC, self-assembling peptides, and rho inhibition) strategies, while many cell therapies (embryonic stem cells, neural stem cells, induced pluripotent stem cells, mesenchymal stromal cells, Schwann cells, olfactory ensheathing cells, and macrophages) have also shown promise. However, since SCI has multiple factors that determine the progress of the injury, a combinatorial therapeutic approach will most likely be required for the most effective treatment of SCI.

Efficacy of prehospital spine and limb immobilization in multiple trauma patients

Background:

Injuries are a major cause of mortality and disability worldwide and are estimated to become the third leading cause of death by 2020. Most traffic deaths occur during the prehospital phase; consequently, prehospital trauma care has received considerable attention during the past decade. However, there is no study on the prehospital immobilization of spine and limbs in patients with multiple trauma in Iran.

Objectives:

This study aimed to investigate the epidemiology of trauma and the quality of limb and spine immobilization in patients with multiple trauma transferred to Shahid Beheshti Medical Center via emergency medical services (EMS).

Patients and Methods:

This cross-sectional study was conducted in 2013. The study population consisted of all patients with multiple trauma who had been transferred by EMS to the Central Trauma Department of the Shahid Beheshti Medical Center, Kashan, Iran. The study used a checklist and we recruited a convenience sample of 400 patients with multiple trauma. Data were described by using frequency tables, central tendency measures, and variability indices. Moreover, we analyzed data using SPSS.

Results:

The study sample consisted of 301 (75.2%) males and 99 (24.8%) females. The most common mechanism of trauma was traffic injuries (87.25%). Motorcyclists constituted 52.25% of the road traffic injuries victims. Overall, the quality of immobilization was at an undesirable level in 95.8% of patients with spine and limbs injuries. A significant association was observed between the quality of spine and limbs immobilization and the EMS workers’ education level (P = 0.005).

Conclusions:

The quality of spine and limb immobilizations was undesirable in more than 90% of cases. Due to the importance of good spine and limb immobilization in patients with multiple trauma, prehospital EMS technicians should be retrained for proper immobilization in patients suspected of spine or limb injuries. Developing evidence-based protocols and strengthening the regulatory and supervisory system to improve quality of prehospital emergency care in patients with multiple trauma is recommended.

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

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

A re-conceptualisation of acute spinal care

The emergency care of patients who may have spinal injuries has become highly ritualised. There is little scientific support for many of the recommended interventions and there is evidence that at least some methods now used in the field and emergency department are harmful. Since prospective clinical trials are not likely to resolve these issues I propose a reconceptualisation of spinal trauma to allow a more rational approach to treatment. To do this I analyse the basic physics, biomechanics and physiology involved. I then develop a list of recommended treatment variations that are more in keeping with the actual causes of post impact neurological deterioration than are current methods. Discarding the fundamentally flawed emphasis on decreasing post injury motion and concentrating on efforts to minimise energy deposition to the injured site, while minimising treatment delays, can simplify and streamline care without subjecting patients to procedures that are not useful and potentially harmful. Specific treatments that are irrational and which can be safely discarded include the use of backboards for transportation, cervical collar use except in specific injury types, immobilisation of ambulatory patients on backboards, prolonged attempts to stabilise the spine during extrication, mechanical immobilisation of uncooperative or seizing patients and forceful in line stabilisation during airway management.

Methodology of systematic reviews and recommendations

Although research in the field of spinal cord injury (SCI) is a relatively new endeavor, a remarkable number of papers focused on this subspecialty have been published in a broad variety of journals over the last two decades. A multidisciplinary group of experts, including clinical epidemiologists, neurosurgical and orthopedic spine surgeons, basic scientists, rehabilitation specialists, intensivists, and allied health professionals (nursing and physical therapy) was assembled through the Spinal Cord Injury Solutions Network to summarize the existing literature focusing on 12 key topics related to acute traumatic SCI, which have not been recently reviewed. The objective was to develop evidence-based recommendations to help translate current science into clinical practice and to identify new directions for research. For each topic one to three specific questions were formulated by consensus through the expert panel. A systematic review of the literature was performed to determine the current evidence for the specific questions. A primary literature search was performed using MEDLINE, CINAHL, EMBASE, and Cochrane databases. A secondary search strategy incorporated additional articles referenced in significant publications (i.e., meta-analysis, systematic and nonsystematic review articles). Two reviewers independently reviewed the titles and abstracts yielded by this comprehensive search and subsequently selected articles based on the predetermined inclusion and inclusion criteria. Data were extracted for population into evidentiary tables. Selected articles were rated for level of evidence and methodological quality, information that was also included in evidentiary tables. Disagreements were resolved by a third reviewer or consensus-based discussion. Based on the evidence compiled, answers to the targeted questions were formulated and recommendations generated by consensus-based discussion and anonymized voting using Delphi methodology. A level of consensus of 80% or higher was considered to represent strong agreement.

Helmet fit and cervical spine motion in collegiate men's lacrosse athletes secured to a spine board

CONTEXT

Proper management of cervical spine injuries in men's lacrosse players depends in part upon the ability of the helmet to immobilize the head.

OBJECTIVE

To determine if properly and improperly fitted lacrosse helmets provide adequate stabilization of the head in the spine-boarded athlete.

DESIGN

Crossover study.

SETTING

Sports medicine research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Eighteen healthy collegiate men's lacrosse players.

INTERVENTION(S)

Participants were asked to move their heads through 3 planes of motion after being secured to a spine board under 3 helmet conditions.

MAIN OUTCOME MEASURE(S)

Change in range of motion in the cervical spine was calculated for the sagittal, frontal, and transverse planes for both head-to-thorax and helmet-to-thorax range of motion in all 3 helmet conditions (properly fitted, improperly fitted, and no helmet).

RESULTS

Head-to-thorax range of motion with the properly fitted and improperly fitted helmets was greater than in the no-helmet condition (P < .0001). In the sagittal plane, range of motion was greater with the improperly fitted helmet than with the properly fitted helmet. No difference was observed in helmet-to-thorax range of motion between properly and improperly fitted helmet conditions. Head-to-thorax range of motion was greater than helmet-to-thorax range of motion in all 3 planes (P < .0001).

CONCLUSIONS

Cervical spine motion was minimized the most in the no-helmet condition, indicating that in lacrosse players, unlike football players, the helmet may need to be removed before stabilization.

The acute respiratory management of cervical spinal cord injury in the first 6 weeks after injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

Identify, evaluate, and synthesize evidence regarding the effectiveness of various treatment strategies for the respiratory management of acute tetraplegia.

SETTING

Melbourne, Australia.

METHODS

A search of multiple electronic databases (Medline, Cinahl, EMBASE, Cochrane Library, Web of Science, http://www.guideline.gov and http://www.icord.org/scire) was undertaken accompanied by the reference lists of all relevant articles identified. Methodological quality was assessed using the Newcastle-Ottawa Scale and the PEDro Scale. Descriptive analysis was performed.

RESULTS

Twenty-one studies including 1263 patients were identified. The majority of the studies were case series (n = 13). A variety of interventions were used for the management of respiratory complications. Mortality (ARR = 0.4, 95% confidence interval (CI) 0.18, 0.61), the incidence of respiratory complications (ARR = 0.36, 95% CI (0.08, 0.58)), and requirement for a tracheostomy (ARR = 0.18, 95% CI (-0.05, 0.4)) were significantly reduced by using a respiratory protocol. A clinical pathway reduced duration of mechanical ventilation by 6 days 95% CI (-0.56, 12.56), intensive care unit length of stay by 6.8 days 95% CI (0.17-13.77) and costs. Intubation, mechanical ventilation, and tracheostomy are the mainstay of respiratory management for complete injuries above the level of C5.

CONCLUSION

This review showed a clinical pathway with a structured respiratory protocol that includes a combination of treatment techniques provided regularly is effective in reducing respiratory complications and cost. The overall study quality was moderate and further studies using specific interventions that target respiratory complications are associated with specific regions of the cervical spine using more methodologically rigorous designs are required.

Cervical spine motion generated with manual versus jackson table turning methods in a cadaveric c1-c2 global instability model

STUDY DESIGN.: Cadaveric biomechanical study. OBJECTIVE.: To quantify spinal motion created by transfer methods from supine to prone position in a cadaveric C1-C2 global instability model. SUMMARY OF BACKGROUND DATA.: Patients who have sustained a spinal cord injury remain at high risk for further secondary injury until their spine is adequately stabilized. To date, no study has evaluated the effect of patient transfer methods from supine to prone position in the operating room, on atlantoaxial cervical spine motion. METHODS.: A global instability was surgically created at the C1-C2 level in 4 fresh cadavers. Two transfer protocols were tested on each cadaver. The log-roll technique entailed performing a standard 180 degrees log-roll rotation of the supine patient from a stretcher to the prone position onto the operating room Jackson table (OSI, Union City, CA). The "Jackson technique" involved sliding the supine patient to the Jackson table, securing them to the table, and then rotating them into a prone position. An electromagnetic tracking device registered motion between the C1 and C2 vertebral segments. Three different head holding devices (Mayfield, Prone view, and blue foam pillow) were also compared for their ability to restrict C1-C2 motion. Six motion parameters were tracked. Repeated measures statistical analysis was performed to evaluate angular and translational motion. RESULTS.: For 6 of 6 measures of angulation and translation, manual log-roll prone positioning generated significantly more C1-C2 motion than the Jackson table turning technique. Out of 6 motion parameters, 5 were statistically significant (P < 0.001-0.005). There was minimal difference in C1-C2 motion generated when comparing all 3 head holding devices. CONCLUSION.: The data demonstrate that manual log-roll technique generated significantly more C1-C2 motion compared to the Jackson table technique. Choice of headrest has a minimal effect on the amount of motion generated during patient transfer, except that the Mayfield device demonstrates a slight trend toward increased C1-C2 motion.

Acute spinal cord injury

Acute spinal cord injury is a devastating disease with enormous repercussions, not only for the victims and their families but for society as a whole. Despite the advent of novel medical therapies for the treatment of these injuries, many patients with spinal cord injury remain severely incapacitated and dependent on their families and/or specialized nursing care. Much of the controversy in the treatment of these injuries stems from insufficient knowledge about the pathophysiology of the disease as well as the timing of certain treatments such as surgery. We discuss the diagnosis and management of these injuries as well as novel therapies on the horizon. The recent emphasis on evidence-based medicine has resulted in the creation of guidelines from the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, which will hopefully result in some standardization of care. It is our opinion that early recognition of spinal cord injury and careful management in an intensive care setting can prevent many of the medical complications that are the major source of morbidity and mortality in these patients.

Prehospital spinal immobilization and the backboard quality assessment study

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Approach to the comatose patient

BACKGROUND

Coma is a medical emergency and may constitute a diagnostic and therapeutic challenge for the intensivist.

OBJECTIVE

To review currently available data on the etiology, diagnosis, and outcome of coma. To propose an evidence-based approach for the clinical management of the comatose patient.

DATA SOURCE

Search of Medline and Cochrane databases; manual review of bibliographies from selected articles and monographs.

DATA SYNTHESIS AND CONCLUSIONS

Coma and other states of impaired consciousness are signs of extensive dysfunction or injury involving the brainstem, diencephalon, or cerebral cortex and are associated with a substantial risk of death and disability. Management of impaired consciousness includes prompt stabilization of vital physiologic functions to prevent secondary neurologic injury, etiological diagnosis, and the institution of brain-directed therapeutic or preventive measures. Neurologic prognosis is determined by the underlying etiology and may be predicted by the combination of clinical signs and electrophysiological tests.

The effectiveness of extrication collars tested during the execution of spine-board transfer techniques

BACKGROUND CONTEXT

In the prehospital stages of emergency care, cervical collars are (supposedly) used to aid rescuers in maintaining in-line stabilization of the spinal column as patients with potential or actual injuries are shifted onto a spine board to achieve full spinal immobilization. Unfortunately, not a single study has examined the effectiveness of cervical collars to control motion during the execution of spine-board transfer techniques.

PURPOSE

To evaluate the controlling effect of three cervical collars during the execution of spine-board transfer techniques.

STUDY DESIGN

This was a repeated measures investigation in which a cadaveric model was used to test the effectiveness of the Ambu (Ambu, Inc., Linthicum, MD), Aspen (Aspen Medical Products, Inc., Long Beach, CA) and Miami J (Jerome Medical, Moorestown, NJ) collars during the execution of the log-roll (LR) maneuver and the lift-and-slide (LS) technique.

METHODS

Six medical professionals executed the LR and the LS on five cadavers. An electromagnetic tracking device was used to capture angular movements generated at the C5-C6 vertebral segment during the execution of both transfer techniques. The types of motion that were analyzed in this study were flexion-extension, lateral flexion and axial rotation motion. To test the three cervical collars, an experimental lesion (ie, a complete segmental instability) was created at the aforementioned spinal level of the cadavers and sensors from the electromagnetic tracking device were affixed to the specified vertebrae to record the motion generated at the site of the lesion.

RESULTS

Statistical tests did not reveal a significant interaction between the independent variables of this study (ie, transfer technique and collar type), lending no support to the notion that there may be a combination of collar and transfer technique that could theoretically offer added protection to the patient. Although there was a decrease in the amount of motion generated in every one of the planes of motion as a result of wearing each of the three collars, none of the changes that emerged proved to be significantly different. A significant difference was noted between the LR and LS techniques when the amount of lateral flexion and axial rotation motion generated with each of the procedures were compared. In both cases, execution of the LR maneuver resulted in significantly more motion.

CONCLUSIONS

The data presented here suggest that the collars tested in this study are functionally similar. It is recommended that this study be repeated with a larger sample size.

Critical care and perioperative management in traumatic spinal cord injury

Traumatic spinal cord injury is frequently associated with brain injury and with alterations in respiratory and cardiovascular function that require critical care management. Complications include respiratory failure, atelectasis, pneumonia, neurogenic shock, autonomic dysreflexia, venous thromboembolism, and sepsis. While complications may be managed with supportive care, the goal of ameliorating neurologic outcome has proved elusive. Methylprednisolone, when instituted <8 hours after traumatic spinal cord injury, was associated in two clinical trials with statistically significant improvements in motor scores at 6 months and 1 year; however, critical reappraisal of these data raises questions about their validity and clinical relevance. Until more evidence of clinically effective therapies is available, acute management must be driven by pathophysiologic principles, with emphasis on interventions that attenuate secondary neurologic injury; these include the rational use of immobilization, cautious airway management, and promotion of cord perfusion and oxygenation with the appropriate level of hemodynamic and respiratory support. Clinical trials of pharmacologic neuroprotection have yielded disappointing results, but the ongoing elucidation of spinal cord repair and regenerative mechanisms suggests new therapeutic prospects.

Critical decision making in severe head injury management

The management of severe head injury (SHI) remains a major challenge not only for neurosurgeons but also for all other health professionals involved in the care of trauma patients. Any trauma patient with SHI is at risk of further neurological deterioration if appropriate measures are not instituted from the start of his or her treatment. Secondary insults due to ischaemic, hypotensive, and metabolic or other causes are still common, even in the most advanced neurocritical care settings. Management controversies are widespread and few decision options can be supported by Class I evidence. This article attempts to provide an up-to-date review of the published recommendations that could help health professionals in their management of SHI.