Cervical Collar–Related Pressure Ulcers in Trauma Patients in Intensive Care Unit

A bioengineering investigation of cervical collar design and fit: Implications on skin health

BACKGROUND

Cervical collars restrict cervical spine movement to minimise the risk of spinal cord injury. Collars apply mechanical loading to the skin putting it at risk of skin damage. Indeed, cervical collar-related pressure ulcers are unacceptably prevalent, especially at the occiput, mandibles, and chin. Collar design and fit are often key considerations for prevention.

METHODS

This comprehensive study evaluated four commercial prehospital and acute care cervical collars. Pressure, microclimate, transepidermal water loss and skin hydration were measured at the interface between the device and the skin. Range of motion restriction was measured to evaluate effective immobilisation. Head, neck, and shoulder morphology was evaluated using three-dimensional scans.

FINDINGS

The occiput experienced significantly higher interface pressures than the chin and mandibles for most collar designs. Interface pressure at the occiput was significantly higher for the Stiffneck extrication collar compared to the other collar designs. The Stiffneck collar also provided the most movement restriction, though not significantly more than other designs. Relative humidity at the device skin interface was significantly higher for the Stiffneck and Philadelphia collars corresponding to closed cell foam padding, in contrast to the open cell foams lined with permeable fabric used in the other collars. Collar discomfort correlated with both occipital pressure and skin humidity.

INTERPRETATION

The occiput is at increased risk of cervical collar-related pressure ulcers during supine immobilisation, especially for Stiffneck extrication collars. Lined open-cell foams could be used to minimise skin humidity and increase comfort.

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.

Interventions and strategies to prevent medical device-related pressure injury in adult patients: A systematic review

BACKGROUND

Current evidence shows that medical device-related pressure injury (MDRPI) has a high prevalence (10%) and incidence (12%), and much research has been done to prevent MDRPI in recent years. However, to our knowledge, there is limited systematic review available on interventions and strategies to prevent MDRPI.

AIM

To synthesise research evidence on interventions and strategies used to prevent MDRPI.

METHODS

This systematic review adhered to the PRISMA Guidelines. We searched six databases including Medline, CINAHL, EMBASE, Cochrane library, Web of Science and ProQuest with no restriction to year of publication. Data were extracted and checked by two authors independently. A narrative summary technique was used to describe the findings. Implementation strategies were grouped into six classifications: dissemination/implementation process/integration/capacity building/sustainability/scale-up strategies.

RESULTS

Twenty-four peer-reviewed papers met the inclusion criteria, which comprised of 11 quality improvement projects and 13 original research. Types of devices included respiratory devices (non-invasive ventilation mask, CPAP/BiPAP mask, endotracheal tube), gastrointestinal/urinary devices and other devices. Interventions used included the use of dressing, hyperoxygenated fatty acids, full-face mask, training, and/or multidisciplinary education, use of special securement devices or tube holder, repositioning, application of stockinette, early removal and foam ring use. Common implementation strategies included ongoing staff education, audit and standardising documentation or guideline development.

CONCLUSION

Much work on MDRPI prevention strategies has been undertaken. There were a variety of devices reported, however, it is evident that higher quality research is needed.

RELEVANCE TO CLINICAL PRACTICE

Current evidence shows that interventions including use of dressing or special securement device, repositioning, and training/multidisciplinary education can be beneficial for MDRPI prevention. High-quality research, such as randomised controlled trials are needed to test the effectiveness of the interventions and their implementation strategies. No patient or public contribution.

Telehealth consultation before inter-hospital transfer after falls in a subacute hospital (the PREVENT-2 study)

OBJECTIVE

Inter-hospital transfers are increasingly common due to the regionalisation of healthcare, but are associated with patient discomfort, high costs and adverse events. The aim of the present study was to evaluate the effectiveness of a trauma outreach service for preventing inter-hospital transfers to a major trauma centre.

METHODS

This was an observational pre- and post-intervention study over a 12-month period from 1 October 2020 to 30 September 2021. Eligible patients sustained a fall at Caulfield Hospital, a subacute care hospital specialising in community services, rehabilitation, geriatric medicine and aged mental health. The intervention was delivery of site-specific education at Caulfield Hospital and a trauma outreach service by specialist trauma clinicians at The Alfred Hospital who provided remote assessment, assisted with clinical management decisions and advised on appropriateness of transfer.

RESULTS

The present study included 160 patients in the pre-intervention phase and 203 after the intervention. The primary outcome of transfer occurred in 19 (11.9%) patients in the pre-intervention phase and 4 (2.0%) in the post-intervention phase (P < 0.001). In the subgroup of patients without pelvis or long bone fractures, pre-intervention transfer occurred for 17 (10.9%) patients and post-intervention transfer occurred for 4 (2.0%) patients (P < 0.001). CT imaging was performed for 54 (33.8%) patients in the pre-intervention and 45 (22.2%) patients in the post-intervention group (P = 0.014).

CONCLUSIONS

Telehealth consultation with a trauma specialist was associated with significant reduction of inter-hospital transfers, and significant reduction of CT imaging. This supports continuation of the service with scope for expansion and evaluation of patient-centred outcomes.

Near Hanging: Evaluation and Management

Prior to the COVID-19 pandemic, the incidence of self-harm was already on the rise. Hanging/suffocation accounted for 50% of the increase in suicide attempts and remains the second leading cause of death from self-harm in the United States. Studies on the management of near-hanging patients are lacking, and most published literature is retrospective. Following airway and circulation assessment, clinical examination and imaging, namely CT angiography, remain the standard for identifying the injuries associated with near hanging: cervical spine fracture, blunt cerebrovascular injury, laryngeal injury, and injury to the trachea and oropharynx. These injuries, however, are uncommon, and each occur in < 5% of patients in most series. In a large series of critically ill near-hanging patients, > 50% survived to hospital discharge; however, cardiac arrest predicted a poor outcome. The management of asphyxia-related arrest remains controversial. Targeted temperature management has only been studied in a single large multicenter trial, which was retrospective. Given the significant selection bias of targeted temperature management in the treatment of the most ill patients, no firm recommendations can be made. Finally, for survivors, the underlying mental health issues must be addressed to avoid recurrent suicide attempts. Thirty percent of patients in a large near-hanging series were admitted for their second suicide attempt.

Adverse Events Relating to Prolonged Hard Collar Immobilisation: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To evaluate systematically the complications of prolonged cervical immobilisation in a hard collar.

METHODS

Following registration with PROSPERO, a systematic search of electronic databases (MEDLINE, EMBASE) was conducted. Two reviewers independently screened the search results according to pre-determined search criteria. Data was extracted and tabulated. Joanna Briggs Institute checklists were used for assessing the quality of included studies.

RESULTS

The search identified 773 articles. A total of 25 studies were selected for final inclusion. The results largely comprised a mixture of case reports/series, cohort studies and reviews. The most commonly reported complications were pressure ulcers, dysphagia and increased intracranial pressure. A pressure ulcer pooled prevalence of 7% was calculated. There was insufficient data for quantitative analysis of any other complication.

CONCLUSIONS

There is significant morbidity from prolonged hard collar immobilisation, even amongst younger patients. Whilst based upon limited and low-quality evidence, these findings, combined with the low-quality evidence for the efficacy of hard collars, highlights a knowledge gap for future research.

Risk factors for deep surgical site infection after posterior cervical spine surgery in adults: a multicentre observational cohort study

Surgical site infection (SSI) is a serious complication following spine surgery and is correlated with significant morbidities, poor clinical outcomes, and increased healthcare costs. Accurately identifying risk factors can help develop strategies to reduce this devastating consequence; however, few multicentre studies have investigated risk factors for SSI following posterior cervical spine surgeries. Between July 2010 and June 2015, we performed an observational cohort study on deep SSI in adult patients who underwent posterior cervical spine surgery at 10 research hospitals. Detailed patient- and procedure-specific potential risk variables were prospectively recorded using a standardised data collection chart and were reviewed retrospectively. Among the 2184 consecutive adult patients enrolled, 28 (1.3%) developed postoperative deep SSI. Multivariable regression analysis revealed 2 statistically significant independent risk factors: occipitocervical surgery (P < 0.001) and male sex (P = 0.024). Subgroup analysis demonstrated that occipitocervical surgery (P = 0.001) was the sole independent risk factor for deep SSI in patients with instrumented fusion. Occipitocervical surgery is a relatively rare procedure; therefore, our findings were based on a large cohort acquired using a multicentre study. To the best of our knowledge, this is the first study to identify occipitocervical procedure as an independent risk variable for deep SSI after spinal surgery.

What is the incidence of medical device-related pressure injuries in adults within the acute hospital setting? A systematic review

Medical devices provide effective therapeutic care for patients. However, medical device-related pressure injuries (MDRPI) are caused by prolonged pressure or shear from a medical device on any location on the body, including mucosal cavities. The primary outcome of this quantitative systematic review was to identify the incidence of MDRPIs in adults within the acute hospital setting. Secondary outcomes include grading, anatomical location and devices that caused such injuries. Electronic databases (CINAHL Plus with Full Text, MEDLINE, EBSCO Host, Health Business Elite Web of Science, PsychINFO, Google Scholar, and Research Gate) were searched for all potential primary studies between November 2019-January 2020. Studies were refined to the English language only, had no time limit from publication, and had to include participants over the age of 18 years with an MDRPI in the acute hospital setting and 720 potential primary studies were identified. Fourteen articles were identified that matched the predefined criteria and were included in the review. All included studies were critically appraised using the evidence-based librarianship critical appraisal tool and data analysis and narrative synthesis were completed. The incidence of MDRPIs in adults within the acute care setting was 28.1% (SD: 29.1%, min: 1.14%, max: 100%). 71.3% of studies documented anatomical locations of MDRPIs, 36.2% included grading of MDRIs, and 71.4% studies documented the offending medical devices. The mean quality appraisal percentage of all included studies was 76.67% (SD: 4.61%; min: 66.6%, max: 83.3%). Despite the heterogeneity of the studies, the review has identified that MDRPIs are prevalent among individuals cared for within the acute hospital setting. Thus, given the morbidity associated with these wounds, it is important to develop strategies to reduce the scope of this problem.

Cervical Spine Clearance in Trauma Patients with an Unreliable Physical Examination

BACKGROUND

The objective of this study was to describe and compare the timing of cervical spine clearance in trauma patients with an unreliable physical examination.

METHODS

We prospectively included adult trauma patients admitted with a cervical collar and an unreliable clinical examination (as defined by the NEXUS criteria) at two level 1 trauma centers: one in the USA (US) and one in Denmark (DK). We excluded patients with cervical spine injuries requiring a collar or surgery as treatment and patients with a collar placed after hospital arrival. The primary outcome was time from emergency department (ED) arrival to collar removal. Secondary outcomes included time to CT of the cervical spine (CTCS). At the US trauma center, an institutional protocol allowing cervical spine clearance exclusively by CTCS was in place. At the Danish trauma center, cervical spine clearance was based on a clinical evaluation by an orthopedic surgeon, usually after CTCS.

RESULTS

A total of 113 patients were included (US: n = 56; DK: n = 57). The median age was 47 years, and 68% were males. The main reasons for an unreliable physical examination were a Glasgow Coma Scale score below 14 (35%), distracting injuries (26%), cervical spine tenderness (13%) and intoxication (13%). The injury severity score at the US trauma center was higher than at the DK trauma center (median: 17 vs. 11, p = 0.03). Both time to CTCS (median: 41 vs. 18 min, p < 0.0001) and time to collar removal (median: 1042 vs. 49 min, p < 0.0001) were significantly greater at the US trauma center.

CONCLUSIONS

Time to collar removal was significantly greater in a trauma center utilizing a cervical spine clearance protocol based on CTCS. As patients may develop complications related to the collar, future studies should clarify how early removal can be implemented without increasing the risk of morbidity.

Preventative interventions, protocols or guidelines for trauma patients at risk of cervical collar-related pressure ulcers: a scoping review

OBJECTIVE

The objective of this scoping review was to explore the existing literature related to preventative interventions, protocols or guidelines for trauma patients at risk of cervical collar-related pressure ulcers to examine and conceptually map the evidence, and to identify any gaps in the literature.

INTRODUCTION

Cervical collars are necessary to stabilize cervical spine injuries in trauma patients; however, pressure ulcers are a major complication of prolonged cervical collar use. The longer a patient wears a cervical collar, the more likely the patient will develop a pressure ulcer that will worsen as wear time increases.

INCLUSION CRITERIA

This review considered both experimental and quasi-experimental study designs, analytical observational studies, case-control studies, analytical cross-sectional studies, descriptive observational studies, qualitative studies, and text and opinion papers. Trauma patients of all ages who presented to the emergency department or intensive care unit with an extrication or field collar in place were included in this study. Extrication collars included but were not limited to Stifneck, Philadelphia and Miami J.

METHODS

The JBI scoping review methodology was used for this review. The database searches included MEDLINE (PubMed), CINAHL, Embase, Scopus, JBI Database of Systematic Reviews and Implementation Reports, NHS Research Register, National Institute of Health Clinical Trial Databases, Cochrane Database of Sytematic Reviews, MedNar, WorldWideScience, PsycEXTRA, OAIster, OpenGrey, and ProQuest Dissertations and Theses. The data were extracted using a charting table, which was developed to record key information from sources relevant to the review questions. The findings were descriptively presented, with tables and figures to support the data, when appropriate. Only studies in English from 1965 to December 2018 were included.

RESULTS

Preventative interventions found in the seven studies included in the review were: removal of the extrication collar, cervical spine clearance, nursing education, routine nursing care, use of products such as air mattresses, and a multidisciplinary approach to care. Additionally, six of the seven studies identified 28 risk factors associated with the development of cervical collar-related pressure ulcers. Two studies reported elimination of cervical collar-related pressure ulcers while three studies reported reduced incidence in cervical collar-related pressure ulcers. Another study reported a reduction in cervical collar wear time from 14 days to 7.7 days.

CONCLUSIONS

Protocols with a multidisciplinary approach are available in the literature to serve as guidance for proper treatment and care of trauma patients' wearing of cervical collars. Standardized cervical collar protocols should highlight the importance of early identification of trauma patients who may be at risk. Risk factors identified in this review should be assessed and addressed to halt cervical collar-related pressure ulcers from ever developing in trauma patients who are immediately identified as at risk. Preventative interventions identified in the protocols in this scoping review can be used to create a standardized approach to care for patients in cervical collars.

Pressure injury development in critically ill patients with a cervical collar in situ: A retrospective longitudinal study

Trauma patients with a serious injury to the head or neck can remain immobilised with a cervical collar (C-collar) device in situ and are subsequently exposed to device-related skin integrity threats. This study aimed to determine the incidence and risk factors associated with the development of C-collar-related pressure injures (CRPIs) in an intensive care unit. This retrospective longitudinal cohort study was conducted in an Australian metropolitan intensive care unit. Following ethical approval, data from patients over 18 years, who received a C-collar were retrieved over a 9-year period. Chi square and t-tests were used to identify variables associated with CRPI development. A logistic regression model was employed to analyse the risk factors. Data from 906 patients were analysed. Nine-year pressure injury incidence was 16.9% (n = 154/906). Pressure injury development directly associated with a C-collar increased by 33% with each repositioning episode (odds ratio 1.328, 95% confidence interval 1.024-1.723, P = .033). Time in the C-collar (10.4 to 2.5 days, P = .002) and length of stay in intensive care unit (ICU) (20.1 to 16.1 days, P < .001) were associated with pressure injury development. Patients with C-collar devices are a vulnerable group at risk for pressure injury development because of their immobility and length of ICU stay.

MEDICAL-DEVICE-RELATED PRESSURE INJURY ON ADULTS: AN INTEGRATIVE REVIEW

ABSTRACT Objective: to identify factors associated with medical-device-related pressure injury. Method: an integrative review of published articles on the subject related to the adult population in the databases of PUBMED, Scopus, MEDLINE, Latin American and Caribbean Health Sciences Literature (Literatura Latino-Americana e do Caribe em Ciências da Saúde, LILACS), Web of Science and Nursing Database (Banco de Dados em Enfermagem, BDENF), between 2013 and 2018. Results: medical-device-related pressure injuries were common in adults, especially in the elderly, due to capillary fragility, among other changes. Other observed factors were length of stay, critically ill patients or those requiring any type of medical device. Numerous medical devices have been associated with skin lesions; among the most frequent were breathing, feeding, and orthopedic devices, tubes, oximeters, neck collars, patches and nasogastric tubes. Conclusion: the first step towards prevention is exploration in terms of identifying the types of injury-causing devices and evidence-based interventions, and disseminating information to the entire multidisciplinary team.

Time in Collars and Collar-Related Complications in Older Patients

BACKGROUND

Cervical spine immobilization, including cervical collars, has been recommended in most trauma guidelines. However, cervical spine immobilization can be associated with harm, and an increasing body of evidence has demonstrated associated complications. We hypothesized that older trauma patients placed in cervical collars for >24 hours were at greater risk of developing collar-related complications compared with those placed in cervical collars for ≤24 hours.

METHODS

We conducted a retrospective cohort study of injured patients without a fracture of the cervical vertebrae, aged ≥65 years, who had been placed in a cervical collar during the period from January 1, 2015 to December 31, 2015. The primary outcome was the composite of the in-hospital development of nosocomial pneumonia and collar-related pressure ulcers.

RESULTS

A total of 1154 patients had been treated with cervical collars during the study period, and 61 (5.1%) had developed collar-related complications. Male sex, a lower initial Glasgow Coma Scale score, a history of congestive heart failure, a history of chronic obstructive pulmonary disease or asthma, operative management, and longer hospital and intensive care unit lengths of stay demonstrated a univariable association with collar-related complications (P < 0.10), in addition to a duration in the collar for >24 hours. An independent association was found between collar duration >24 hours and the outcome of interest (adjusted odds ratio, 2.50; 95% confidence interval, 1.16-5.39; P = 0.02).

CONCLUSIONS

Among older patients without a cervical vertebral fracture, duration of cervical collar use for >24 hours was associated with the development of collar-related complications. We recommend attention to early collar clearance for older trauma patients.

Evaluation of a fluidised positioner to reduce occipital pressure injuries in intensive care patients: A pilot study

This pilot study aimed to evaluate the clinical efficacy and feasibility of a fluidised positioning device to reduce occipital pressure injuries (PIs). A post-test design with a historical control group was used in a 54-bed intensive care unit between September 2017 and August 2018. Patients who were receiving either extracorporeal membrane oxygenation, were mechanically ventilated, or had raised intracranial pressure (≥20) were recruited. The intervention consisted of a fluidised positioning device under the patient's head, and a skin assessment every 8 h. Outcome measures included the occurrence of occipital PIs and registered nurses (RNs)' perspectives of the intervention. Data collected from patients in the intervention group were compared with data obtained from the historical control group between May 2016 and April 2017. Sixty-four patients were recruited in the intervention phase and 63 were in the historical control group. Results showed a statistically significant reduction in occipital PIs by 87.7% (16/63; 25.4% historical control vs 2/64; 3.13% interventional group). Bedside RNs provided positive evaluation of the fluidised positioning device. The findings demonstrate that the fluidised positioning device is a feasible and effective intervention in reducing the risk of occipital PIs in intensive care patients, which merits the continuation of use and further evaluation through a larger-scale study.

The effects of spinal immobilization at 20° on intracranial pressure

OBJECTIVE

In this study, it was aimed to evaluate whether spinal immobilization at 20°, instead of the traditional 0°, affects intracranial pressure (ICP) via the ultrasonographic (USG) measurement of optic nerve sheath diameter (ONSD).

METHODS

140 healthy, adult, non-smoking volunteers who had no acute or chronic diseases were included this study. Volunteers were randomly divided into two groups; performed spinal immobilization at 0° (Group 1) and at 20° (Group 2). After spinal immobilization (at 0 or 20°), measurements of ONSD were performed at 0, 30, and 60 min in an immobilized position.

RESULTS

When evaluating the change in ONSD over time (at 30 and 60 min) as compared to basal measurements at 0 min, it was found that the ONSD values of both sides (the right and left eyes) were significantly increased in Group 1 and Group 2. For Groups 1 and 2, these differences existed both between 0 and 30 min and between 30 and 60 min. In addition, in this study, the amounts of increase in the ONSD measurements from 0 to 30 min and from 30 to 60 min (ΔONSD0-30 min and ΔONSD30-60 min) in both groups were compared. The results showed that there was no significant difference between Group 1 and Group 2 in terms of ΔONSD measurements.

CONCLUSIONS

Spinal immobilization at 0° as a part of routine trauma management increased ONSD and thus ICP. Secondly, we found that similar to immobilization at 0°, spinal immobilization at 20° increased ONSD.

Pressure Ulcer in Trauma Patients: A Higher Spinal Cord Injury Level Leads to Higher Risk

Background

In a systematic review, the level of spinal cord injury (SCI) was not associated with risk for pressure ulcer (PU). We hypothesized that in the acute trauma population, upper-SCI (cervical/thoracic) has greater risk for PU when compared to lower-SCI (lumbar/sacral). We additionally sought to identify risk factors for development of PUs in trauma.

Methods

A retrospective analysis of the NTDB (2007-2015) was performed. Covariates were included in a multivariable logistic regression analysis to determine risk for PU.

Results

Of 62,929 patients (0.9%) with SCI, most had an upper-SCI (83%). The overall rate of PUs in patients with SCI was 5.1%. More patients with upper-SCI developed PUs compared to lower-SCI (5.8% vs. 2.2%, p < 0.001). SCI was the strongest predictor for PU (OR = 13.77, CI = 13.25-14.31, p < 0.001). Upper-SCI demonstrated greater risk compared to lower-SCI (OR = 2.81, CI = 2.45-3.22, p < 0.001).

Conclusions

Contrary to previous reports, a higher SCI level is associated with a three-fold greater risk for PU compared to lower SCI.

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

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

Investigating the effects of cervical collar design and fit on the biomechanical and biomarker reaction at the skin

Background

Research has shown that up to 33% of pressure ulcers (PUs) acquired in hospitals result from the application of a medical device. Cervical collars (C-collars) have been implicated in causing PUs, due to the mechanical force they apply to the skin. In order to improve our understanding of collar-related PUs, the present study aimed to assess the biomechanical, biochemical, and microclimate effects of C-collar design and fitting tension.

Methods

A cohort of 15 healthy volunteers was fit with two different C-collars according to the manufacturer guidelines. Two further collar tensions were also defined as loose and tight for each device. Each collar condition was applied for 15 minutes, with a 10 minute refractory period. Measurements at the device–skin interface included interface pressures, inflammatory biomarkers, microclimate, range of cervical motion, and comfort scores.

Results

The interface pressures at each tissue site increased monotonically with greater collar tension (p<0.01), irrespective of collar design. Biomarker analysis revealed that inflammatory cytokines (IL-1a) were elevated during collar application, with the highest increase during the tight fit condition, representing over a fourfold increase from unloaded conditions. Regardless of collar tension or type, there was an increase in temperature 1.5°C ±0.8°C compared to baseline values. Range of motion significantly decreased with greater strap tension (p<0.05), with an associated increase in discomfort.

Conclusion

The present findings revealed that increasing C-collar tensions caused elevated contact pressures at the device–skin interface, with a corresponding inflammatory response at the skin. These peak contact pressures were highest at the occiput, corresponding with reported PU locations. Devices should be designed to uniformly distribute pressures, and appropriate guidance is needed for their application.

Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey

BACKGROUND

Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice.

METHODS

A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered.

RESULTS

Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data.

CONCLUSION

For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers.

LEVEL OF EVIDENCE

Diagnostic tests or criteria, level II.

Validation of two case definitions to identify pressure ulcers using hospital administrative data

OBJECTIVE

Pressure ulcer development is a quality of care indicator, as pressure ulcers are potentially preventable. Yet pressure ulcer is a leading cause of morbidity, discomfort and additional healthcare costs for inpatients. Methods are lacking for accurate surveillance of pressure ulcer in hospitals to track occurrences and evaluate care improvement strategies. The main study aim was to validate hospital discharge abstract database (DAD) in recording pressure ulcers against nursing consult reports, and to calculate prevalence of pressure ulcers in Alberta, Canada in DAD. We hypothesised that a more inclusive case definition for pressure ulcers would enhance validity of cases identified in administrative data for research and quality improvement purposes.

SETTING

A cohort of patients with pressure ulcers were identified from enterostomal (ET) nursing consult documents at a large university hospital in 2011.

PARTICIPANTS

There were 1217 patients with pressure ulcers in ET nursing documentation that were linked to a corresponding record in DAD to validate DAD for correct and accurate identification of pressure ulcer occurrence, using two case definitions for pressure ulcer.

RESULTS

Using pressure ulcer definition 1 (7 codes), prevalence was 1.4%, and using definition 2 (29 codes), prevalence was 4.2% after adjusting for misclassifications. The results were lower than expected. Definition 1 sensitivity was 27.7% and specificity was 98.8%, while definition 2 sensitivity was 32.8% and specificity was 95.9%. Pressure ulcer in both DAD and ET consultation increased with age, number of comorbidities and length of stay.

CONCLUSION

DAD underestimate pressure ulcer prevalence. Since various codes are used to record pressure ulcers in DAD, the case definition with more codes captures more pressure ulcer cases, and may be useful for monitoring facility trends. However, low sensitivity suggests that this data source may not be accurate for determining overall prevalence, and should be cautiously compared with other prevalence studies.

Risk Factors for Failure of Nonoperative Treatment for Unilateral Cervical Facet Fractures

Study Design

Retrospective clinical study.

Purpose

The purpose of this study was to determine what percentage of patients who underwent nonoperative management of unilateral non-displaced or minimally displaced facet fractures progressed radiographically and to determine what percentage of patients required surgical intervention and to identify risk factors for failure of conservative management.

Overview of Literature

According to most commonly used classification systems, unilateral, non-and minimally displaced facet fractures are be amendable to nonoperative management.

Methods

A retrospective review of the Trauma Registry of a Level I trauma center was performed to identify all patients diagnosed with a non- or minimally displaced unilateral facet fracture which was managed nonoperatively. Several demographic variables and clinical outcomes were recorded. Using computed tomography scanning and plain radiographs, fracture pattern, listhesis, displacement, angle and percentage of the facet that included the fracture were determined. Radiographic progression was defined as the occurrence of listhesis of more than 10% of the anterior-posterior dimensions of the inferior vertebral body during radiographic follow-up. Failure of conservative management was defined as a patient requiring surgical intervention after initially being managed nonoperatively.

Results

Seventy-four patients were included. Fifteen patients (20%) progressed radiographically. However, only 2 developed radicular symptoms and none developed myelopathy or other catastrophic cord related symptoms. Seven patients (9%) underwent surgery. Indications for surgery included significant radiographic progression and/or radicular symptoms. Risk factors for failure of conservative management included presence of radiculopathy at the time of presentation, a higher body mass index, increased Injury Severity Score, greater initial fracture displacement and more than 2 mm of listhesis.

Conclusions

Patients with non-displaced or minimally displaced facet fractures who do not have neurological symptoms at the time of presentation can safely be managed conservatively with careful observation and follow-up.

Pressure ulcers, indentation marks and pain from cervical spine immobilization with extrication collars and headblocks: An observational study

OBJECTIVES

To describe the occurrence and severity of pressure ulcers, indentation marks and pain from the extrication collar combined with headblocks. Furthermore, the influence of time, injury severity and patient characteristics on the development of pressure ulcers, indentation marks and pain was explored.

DESIGN

Observational.

STUDY SETTING

Level one trauma centre in the Netherlands.

PARTICIPANTS

Adult trauma patients admitted to the Emergency Department in an extrication collar combined with headblocks.

METHODS

Between January and December 2013, 342 patients were included. Study outcomes were incidence and severity of pressure ulcers, indentation marks and pain. The following dependent variables were collected: time in the cervical collar and headblocks, Glasgow Coma Scale, Mean Arterial Pressure, haemoglobin, Injury Severity Score, gender, age, and Body Mass Index.

RESULTS

75.4% of the patients developed a category 1 and 2.9% a category 2 pressure ulcer. Indentation marks were observed in 221 (64.6%) patients; 96 (28.1%) had severe indentation marks. Pressure ulcers and indentation marks were observed most frequently at the back, shoulders and chest. 63.2% experienced pain, of which, 38.5% experienced severe pain. Pain was mainly located at the occiput. Female patients experienced significantly more pain (NRS>3) compared to male patients (OR=2.14, 95% CI 1.21-3.80) None of the investigated variables significantly increased the probability of developing PUs or indentation marks.

CONCLUSIONS

The high incidence of category 1 pressure ulcers and severe indentation marks indicate an increased risk for pressure ulcer development and may well lead to more severe PU lesions. Pain due to the application of the extrication collar and headblocks may lead to undesirable movement (in order to relieve the pressure) or to bias clinical examination of the cervical spine. It is necessary to revise the current practice of cervical spine immobilization.