Cervical and spinal immobilization techniques: an overview
Cervical and spinal immobilization techniques: emergency medical services (EMS) personnel continue to be the primary caregivers in the management of most out-of-hospital emergencies, including trauma situations
The ATLS (advanced trauma life support) guidelines, developed in the 1980s, continue to be the gold standard for assessing and prioritising the management of life-threatening injuries in a logical and efficient manner, although there has long been a serious debate about the methods of using this aid.
Spinal immobilization has been an essential part of teaching, in addition to pelvic binders and splints for long bone fractures
Different types of medical equipment have been developed to enable effectiveness and ease of application, as well as allowing flexibility and vital access for airway management and other procedures.
The need to immobilise the spine is determined by scene and patient assessment.
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Consider spinal immobilisation when the mechanism of injury creates a high index of suspicion for head, neck or spinal injury
Impaired mental status and neurological deficit are also indicators that spinal immobilisation should be considered.
Traditional ATLS teaching for appropriate spinal immobilisation of a patient in a major trauma situation is a well-fitted rigid collar with blocks and tape to secure the cervical spine, as well as a backboard to protect the rest of the spine.
The Kendrick extrication device allows the spine to be protected with the injured person in a seated position during rapid extrication from a vehicle or in other situations where access is limited to allow the use of a full backboard.
However, this device requires that rescue personnel take care to limit cervical spine movement by using inline mobilisation until assembly .
The 10th edition of the ATLS guidelines and the consensus statement of the American College of Emergency Physicians (ACEP), the American College of Surgeons Committee on Trauma (ACS-COT), and the National Association of EMS Physicians (NAEMSP) state that, in the case of penetrating trauma there is no indication for restriction of spinal movement , in line with a retrospective study from the American Trauma Database that showed a very low number of unstable spinal injuries requiring surgery in the context of penetrating trauma. The study also shows that the number of patients to be treated to obtain a potential benefit is much higher than the number of patients to be treated to obtain an injury, 1032/66.
However, in the case of significant blunt trauma, restrictions continue to be indicated in the following situations:
- Low GCS or evidence of alcohol and drug intoxication
- Midline or posterior cervical spine tenderness
- Obvious spinal deformity
- Presence of other distractive lesions
The recommendation for effective restriction continues to be a cervical collar with full-length spinal protection, which should be removed as soon as possible.
This is due to the risk of multi-layered injuries.
However, in the paediatric population, the risk of multilevel injuries is low and therefore only cervical spine precautions and not full spine precautions are indicated (unless signs or symptoms of other spinal injuries are present).
Cervical immobilization and rigid collar in a paediatric patient
- Neck pain
- Alteration of limb neurology not explained by limb trauma
- Muscle spasm of the neck (torticollis)
- Low GCS
- High-risk trauma (e.g. high-energy car accident, hyperextension injury of the neck and significant upper body injury)
Areas of concern
There is a growing body of evidence and concern that field triage has led to overuse of spinal immobilisation methods and that some patients are potentially at risk.
Potential problems of spinal immobilisation:
- Discomfort and distress for the patient.
- Lengthening of pre-hospital time with potential delay of important investigations and treatments, as well as interfering with other interventions.
- Restriction of breathing by the straps, as well as worse respiratory function in the supine position compared to the upright position. This is particularly important in cases of thoracic trauma, whether blunt or penetrating Difficulty with intubation.
- The case of patients with ankylosing spondylitis or pre-existing spinal deformity, where actual harm could be caused by forcing the patient to conform to the predetermined position of a rigid cervical collar and backboard.
A new review of the Scandinavian literature, conducted to examine the available evidence for the restriction of spinal movement , provides very valuable insights into the comparison of prehospital spinal stabilisation methods with the evaluation of the strength of evidence.
The rigid collar has been used since the mid-1960s as a method of cervical spine stabilisation, with low-quality evidence supporting its positive influence on the neurological outcome of cervical spine injury, with potential negative effects due to a significant increase in intracranial pressure and dysphagia .
The article also suggests that an alert and cooperative patient with muscle spasms caused by the injury is unlikely to have a significant displacement, as has been noted in cadaver studies that have attempted to study the effect of an injury.
The article suggests balancing the risks and benefits of this surgery.
However, the American Association of Neurological Surgeons continues to suggest the rigid collar as a method of stabilising the cervical spine in the pre-hospital scenario.
Rigid board: When is the spinal longboard used?
The original spinal longboard was used together with a rigid collar, blocks and straps to achieve immobilisation of the spine.
Potential damage, in particular pressure sores on the sacrum, have now been demonstrated, especially in the case of spinal injuries without a feeling of protection.
The soft vacuum mattress offers a gentler surface that protects against the effects of pressure sores and at the same time provides sufficient support when extended above head level.
Blocks are part of the inline mobilisation strategy for stabilising the spine and appear to be effective when strapping the patient to a spinal board to achieve a certain degree of immobilisation, without the added benefit of using a rigid collar in combination .
Comparing the vacuum mattress with the rigid board alone, the mattress offers more control and less movement during application and lifting than the rigid board .
Taking into account the risk of pressure sores, the mattress seems to offer a better option for patient transportation.
Freeing the spine: modulation of spinal and cervical immobilization
The NEXUS criteria: an alert, non-intoxicated person without distractive injuries has a very low probability of injury in the absence of midline tension and neurological deficit.
This appears to be a sensitive screening tool with a sensitivity of 99% and a negative predictive value of 99.8%.
However, other observational studies have suggested that an alert patient with a cervical spine injury will try to stabilise the spine and that the presence of distractive lesions (excluding the thorax) does not affect the results of the clinical test of the cervical spine and therefore the spine could be clinically cleared without further imaging. Other studies suggest the same results for the thoracolumbar spine.
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Although pre-hospital spinal immobilisation has been performed for decades, current data indicate that not all patients need to be immobilised.
Now the National Association of Emergency Physicians USA and the American College of Surgeons Committee on Trauma suggest a limited application of spinal immobilisation.
These latest guidelines indicate that the number of patients who can benefit from immobilization is very small
The committee went on to state that the empirical use of spinal restraints during transport should be used with caution, as in some cases their potential risks outweigh their benefits.
Furthermore, in patients who have suffered a penetrating trauma and have no obvious neurological deficits, the use of spinal restraints is not recommended.
In the USA the EMS operator must use clinical acumen before deciding to use the spinal board.
Finally, spinal immobilisation has been associated with back pain, neck pain and makes it very difficult to perform certain procedures, including imaging.
Spinal immobilisation has also been associated with breathing difficulties, especially when large straps are applied to the chest.
Although many EMS organisations in the US have adopted these new guidelines on spinal immobilisation, this is not universal.
Some EMS systems fear litigation if they do not immobilise patients.
Patients who should be immobilised at the spine include the following:
- Blunt trauma
- spinal pain
- patients with an altered level of consciousness
- neurological deficits
- obvious anatomical deformity of the spinal column
- High-intensity trauma in a patient intoxicated by drugs, alcohol.
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