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Norwegian paper suggests stop routine prehospital cervical collar use

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(picture attribution HERE)

Hi! Here is the recent Norwegian article in Journal of Neurotrauma
PREHOSPITAL USE OF CERVICAL COLLARS IN TRAUMA PATIENTS : A CRITICAL REVIEW

Basically after a comprehensive literature review in their paper, these Norwegian authors suggest the cessation to all routine prehospital application of cervical collars for trauma patients unless there is a temporary need during extrication. They further suggest the best way to immobilise the neck if needed is using spinal board, head straps and head blocks and ideally spinal vacuum mattress.

This contrasts to an American paper in Neurosurgery here
PREHOSPITAL CERVICAL SPINE IMMOBILIZATION AFTER TRAUMA

This 2013 review paper recommends using cervical collar , spinal board, head blocks and straps as the best method still of neck immobilisation.

Both papers have the advice and cite the literature that in general we dont need to immobilise cervical spines of many trauma patients routinely. In particular awake patients can generally protect their own cervical spines better than any splint!

In my own prehospital care provision I have tended over time too adopt the position of the Norwegians! But then again I have luxury of placing patient into a comfy vacuum mattress!

When you think of it, it does seem ludicrous we place awake, cooperative patients in these cervical collars as a routine! Both papers strongly suggest using clinical decision rules to clear cervical spines in low risk trauma patients.

It can be a big deal this issue of what to do with trauma patients in remote locations who need to get “their C spine cleared” before removing neck collar. Traditionally this meant Xrays. Still does in many cases but is probably quite a waste of resources and patient morbidity for very little gain.

For example recently I flew a patient out of a remote hospital for this exact reason : need to clear the C Spine with xrays that could not be done at local hospital after a car rollover.

Patient was in cervical collar, supine for over 4hrs, even with a bladder catheter in to remove need to situp! They had a clavicle fracture but no other obvious injuries..and neck pain..well everyone gets neck pain after being in cervical collar for >2hrs! It was difficult to tell after so many hours! They certainly had an occipital headache from lying supine for so long!

No neurological signs at all.
I was tempted to remove the collar and advise she get driven to nearest hospital with form to have her “clearance” xrays! They were alert, awake, cooperative and could do better job at protecting own neck than any piece of plastic/foam!

It seemed excessive to transport but I did as the wheels were in motion and patient certainly expected such after so many hours in that painful cervical collar!

Which brings me onto another point! We should be using the more comfortable cervical collars like the ASpen or Philadelphia if we are going to still use cervical collars at all!

So go the Norwegians I say!

5 Comments Post a comment
  1. Plain X-ray to “clear” C-spine?

    Maybe I have got this all wrong, but my rural/remote patients tend to fall into one of three groups

    (i) low risk – aim to clear this clinically. No imaging
    (ii) failed clinical clearing (for whatever reason, intoxication most common) but low risk mechanism/gestalt – plain film? Sensitivity not that great….may need to transfer for CT anyhow as films often sub-optimal
    (iii) high risk – usually the major trauma – these’ll get transferred, vac-mat and usu CT at receiving institution. No problems there.

    Casey Parker blogged on this a year ago, which seems to offer practical advice for the rural doctor at least (but maybe not for the retrieval service whose workload may increase..)

    http://wacdocs.csp.uwa.edu.au/2012/03/c-spine-trauma-in-a-town-with-no-ct/

    I freely admit that as a rural doctor taking own X-rays(no radiographer), I will often get suboptimal views, so much so that if ANY concern I will seek transfer. Is resource intensive, but consequences of missed injury outweigh this.

    Perfectly happy to transfer in vac-mat w/o C-collar.

    September 7, 2013
    • thanks TIm. we agree!

      I think though as rural docs we need to think of ways we can minimise overIx! Much like the blog from Casey and Anand regarding PE OverIx! LOL!

      If intoxicated patient but otherwise well and just needing that ” cleared C Spine” then why not leave collar off, let them nurse themselves in position of comfort, and wait for them to sober up to be cleared clinically without xrays!

      I have no papers or biostats to support that suggestion but makes common sense to me as a rural doctor as well as a retrievalist!

      September 7, 2013
      • Yep, agree on the intoxicated, providing no high risk mechanism (sadly the history is often elusive).

        Quick Q – you (or rather the Norwegian’s) mention C collar for extrication. I must admit I tend to encourage patients to maintain own neck immobilisation (assuming conscious, alert) rather than collar whilst we get them out (or better still, self-extricate).

        Every now and then you hear of some over-enthusiastic fire crew being directed to peel open a vehicle because of A&O patient c/o neck pain (including, famously, a pt who’d self-extricated then sat in another vehicle to await emergency services – who then cut A/B/C pillars to extricate from undamaged, uninvolved car!)

        Agree?

        The hard bit (and I have no answer) is between finding a balance between the competing demands of clinical condition, resource limitation and of course the off-chance of having to defend ones actions to m’learned friends in a medicolegal challenge…

        September 7, 2013
      • great prehospital question Tim!

        LOL funny example you give!

        Extrication situations are difficult, sometimes impossible to adequately assess a patient with suspected C spine injury

        thats why Norwegians and I would still recommend use of cervical collar in those situations.

        but if patient can self extricate..thats good too!

        September 7, 2013
  2. Mark Le bois #

    This article piqued my interest in the latest products available on the market, and I found a great resource here: http://www.medicalexpo.com/medical-manufacturer/cervical-collar-2912.html. Hope this is a useful resource for you other readers.

    May 8, 2014

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