And so the rigid cervical collar is laid to rest in the Emergency Medical Service (EMS) of Bergen, Norway. Bergen is the second largest city in Norway, and has an active HEMS department at Bergen University Hospital. Particularly, HEMS doc Helge Asbjørnsen has been a strong advocate against the cervical collar, providing the basis for our “Curse of the Cervical Collar” post. Now, the latest EMS SOP is – for all practical purposes – getting rid of the cervical collar in Bergen’s ambulance service.
If DeBacker is the Dopamine killer, Asbjørnsen seems to be the c-collar killer. The SOP is based on the increasing sceptisism to immobilisation in general and against the rigid cervical collar in particular. Despite long standing use, there has not been any proven benefit from the use of cervical collars in trauma patients, but instead some increasing (although not very strong) evidence of possible harm and unwanted effects.
1. The cervical collar can lead to increased movement in the upper parts of the neck compared to no collar.
2. In patients with trauma affecting the spine, available evidence points to larger neurological deficits in areas where the cervical collar is routine vs areas where they are not in use.
3. The cervical collar increases ICP because of decreased venous return due venous compression of the neck
4. The cervical collar hampers airway management
5. Cervical collars leads to increased risk of aspiration.
This is what you get for using c-collars
The SOP then lists handling of the awake and the unconscious trauma patient:
The awake patient can and will stabilise his/her own neck and do not need a cervical collar. They can also stabilise their own neck for extrication from a vehicle. Let the patient control the extrication and movements.
Unconscious, non-intubated patients are to be transported in the lateral trauma position, focusing on keeping the spine straight, using blankets under the head, between the legs and – depending on habitus – under the abdominal area.
If intubated and lying on their backs, a simple, standard pillow will be used to lightly stabilise the neck and keep it in a more natural position. For handling/moving the patient, the team will have to keep the spine stabilised – just as we’ve always done with a c-collar in place.
Other things of interest
This SOP also focuses on getting rid of the backboard, and using it only for transfers to the gurney – not putting the backboard itself on the gurney. But the scoop stretcher is preferred to the backboard for scooping up and transporting trauma patients.
The only indications left in this SOP for the cervical collar, is difficult extrication of unconscious patients where the EMS personnel can’t get in position to stabilise the patient’s head. The second one is for stabilising the neck during stretcher carrying in difficult terrain. The SOP advices on using a cervical collar for extrication/difficult terrain, then removing it for transport.
For the circulatory or respiratory unstable patient, expedite transport gets priority over any immobilising measures.
Due to the c-collar use being cemented by ATLS and introduced to the trauma patient with the A in ABC, this is sure to spark some controversy.
However, when there is no good evidence supporting the use of cervical collars, but some (although weak) evidence against its use, the only rationale is to abandon it.
Here’s a list of all references from the SOP for any readers to dive into if you want to read more on the subject. The main article is the one Dr. Asbjørnsen co-authored: Prehospital use of cervical collars in trauma patients: a critical review, the first reference below. Then lots more for anyone interested:
- Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K.Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. Jour of Neurotrauma. Epub ahead of print.
- Kwan, I., Bunn, F., and Roberts, I.; WHO Pre-Hospital Trauma CareSteering Committee. (2001). Spinal immobilisation for trauma patients.Cochrane Database Syst. Rev. Issue 2. Art. No.: CD002803.
- Abram, S., and Bulstrode, C. (2010). Routine spinal immobilization in trauma patients: what are the advantages and disadvantages? Surgeon 8, 218–222.
- Benger, J., and Blackham, J. (2009). Why do we put cervical collars on conscious trauma patients? Scand. J. Trauma Resusc. Emerg.Med. 17, 44.
- Chin, K.R., Auerbach, J.D., Adams, S.B., Sodl, J.F., and Riew, K.D. (2006). Mastication causing segmental spinal motion in common cervical orthoses. Spine (Phila Pa 1976) 31, 430–434.
- Thumbikat, P., Hariharan, R.P., Ravichandran, G., McClelland, M.R., and Mathew, K.M. (2007). Spinal cord injury in patients with ankylosing spondylitis: a 10-year review. Spine (Phila Pa 1976) 32, 2989–2995.
- Clarke, A., James, S., and Ahuja, S. (2010). Ankylosing spondylitis: inadvertent application of a rigid collar after cervical fracture, leading to neurological complications and death. Acta. Orthop. Belg. 76, 413–415
- Deasy, C., and Cameron, P. (2011). Routine application of cervical collars—what is the evidence? Injury 42, 841–842.
- Hauswald, M., and Braude, D. (2002). Spinal immobilization in trauma patients: is it really necessary? Curr. Opin. Crit. Care 8,566–570.
- Sporer, K.A. (2012). Why we need to rethink C-spine immobilization: we need to reevaluate current practices and develop a saner cervical policy. EMS World 41, 74–76.
- Hauswald, M., Ong, G., Tandberg, D., and Omar, Z. (1998). Out-ofhospital spinal immobilization: its effect on neurologic injury. Acad. Emerg. Med. 5, 214–219.
- Craig, G.R., and Nielsen, M.S. (1991). Rigid cervical collars and intracranial pressure. Intensive Care Med. 17, 504–505.
- Davies, G., Deakin, C., and Wilson, A. (1996). The effect of a rigid collar on intracranial pressure. Injury 27, 647–649.
- Hunt, K., Hallworth, S., and Smith, M. (2001). The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia 56, 511–513.
- Kolb, J.C., Summers, R.L., and Galli, R.L. (1999). Cervical collarinduced changes in intracranial pressure. Am. J. Emerg. Med. 17. 135–137.
- Mobbs, R.J., Stoodley, M.A., and Fuller, J. (2002). Effect of cervical hard collar on intracranial pressure after head injury. ANZ J. Surg.72, 389–391.
- Stone, M.B., Tubridy, C.M., and Curran, R. (2010). The effect of rigid cervical collars on internal jugular vein dimensions. Acad. Emerg. Med. 17, 100–102.
- Holla, M. (2012). Value of a rigid collar in addition to head blocks: aproof of principle study. Emerg. Med. J. 29, 104–107.
- Aoi, Y., Inagawa, G., Nakamura, K., Sato, H., Kariya, T., and Goto,T. (2010). Airway scope versus macintosh laryngoscope in patients with simulated limitation of neck movements. J. Trauma 69, 838–842.
- Criswell, J.C., Parr, M.J., and Nolan, J.P. (1994). Emergency airway management in patients with cervical spine injuries. Anaesthesia 49, 900–903.
- Doran, J.V., Tortella, B.J., Drivet, W.J., and Lavery, R.F. (1995). Factors influencing successful intubation in the prehospital setting. Prehosp. Disaster Med. 10, 259–264.
- Ghafoor, A.U., Martin, T.W., Gopalakrishnan, S., and Viswamitra, S. (2005). Caring for the patients with cervical spine injuries: what have we learned? J. Clin. Anesth. 17, 640–649.
- Goutcher, C.M., and Lochhead, V. (2005). Reduction in mouth opening with semi-rigid cervical collars. Br. J. Anaesth. 95, 344–348.
- Heath, K.J. (1994). The effect of laryngoscopy of different cervical spine immobilisation techniques. Anaesthesia 49, 843–845.
- LeGrand, S.A., Hindman, B.J., Dexter, F., Weeks, J.B., and Todd, M.M. (2007). Craniocervical motion during direct laryngoscopy and orotracheal intubation with the Macintosh and Miller blades: an in vivo cinefluoroscopic study. Anesthesiology 107, 884–891.
- Lubovsky, O., Liebergall, M., Weissman, C., and Yuval, M. (2010). A new external upper airway opening device combined with a cervical collar. Resuscitation 81, 817–821.
- Robitaille, A. (2011). Airway management in the patient with potential cervical spine instability: continuing professional development. Can. J. Anaesth. 58, 1125–1139.
- Rodriguez-Nunez, A., Oulego-Erroz, I., Perez-Gay, L., and Cortinas- Diaz, J. (2010). Comparison of the GlideScope Videolaryngoscope to the standard Macintosh for intubation by pediatric residents in simulated child airway scenarios. Pediatr. Emerg. Care 26, 726–729.
- Santoni, B.G., Hindman, B.J., Puttlitz, C.M., Weeks, J.B., Johnson, N., Maktabi, M.A., and Todd, M.M. (2009). Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology 110, 24–31.
- Thiboutot, F., Nicole, P.C., Tre´panier, C.A., Turgeon, A.F., and Lessard, M.R. (2009). Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can. J. Anaesth. 56, 412–418.
- Houghton, D.J., and Curley, J.W. (1996). Dysphagia caused by a hard cervical collar. Br. J. Neurosurg. 10, 501–502.
- Lockey, D.J., Coats, T., and Parr, M.J. (1999). Aspiration in severe trauma: a prospective study. Anaesthesia 54, 1097–1098.
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- Krell JM, McCoy MS, Sparto PJ et al. Comparison of the Ferno Scoop Stretcher with the long backboard for spinal immobilization. Prehosp Emerg Care 10, 46-51 (2006)
- 38. Bauer D, Kowalski R: Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med 1983, 17(9):915-918.
- Totten, V.Y., and Sugarman, D.B. (1999). Respiratory effects of spinal immobilization. Prehosp. Emerg. Care. 3, 347–352.