CERVICAL COLLAR R.I.P.

Dog collarAnd 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.

C-collar killer
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:

Awake patients
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 patients
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.

Summary
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.

References
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:

  1. 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.
  2. 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.
  3.  Abram, S., and Bulstrode, C. (2010). Routine spinal immobilization in trauma patients: what are the advantages and disadvantages? Surgeon 8, 218–222.
  4. Benger, J., and Blackham, J. (2009). Why do we put cervical collars on conscious trauma patients? Scand. J. Trauma Resusc. Emerg.Med. 17, 44.
  5. 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.
  6. 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.
  7. 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
  8. Deasy, C., and Cameron, P. (2011). Routine application of cervical collars—what is the evidence? Injury 42, 841–842.
  9. Hauswald, M., and Braude, D. (2002). Spinal immobilization in trauma patients: is it really necessary? Curr. Opin. Crit. Care 8,566–570.
  10. 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.
  11.  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.
  12.  Craig, G.R., and Nielsen, M.S. (1991). Rigid cervical collars and intracranial pressure. Intensive Care Med. 17, 504–505.
  13.  Davies, G., Deakin, C., and Wilson, A. (1996). The effect of a rigid collar on intracranial pressure. Injury 27, 647–649.
  14. Hunt, K., Hallworth, S., and Smith, M. (2001). The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia 56, 511–513.
  15. Kolb, J.C., Summers, R.L., and Galli, R.L. (1999). Cervical collarinduced changes in intracranial pressure. Am. J. Emerg. Med. 17. 135–137.
  16.  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.
  17. 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.
  18. Holla, M. (2012). Value of a rigid collar in addition to head blocks: aproof of principle study. Emerg. Med. J. 29, 104–107.
  19.  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.
  20. Criswell, J.C., Parr, M.J., and Nolan, J.P. (1994). Emergency airway management in patients with cervical spine injuries. Anaesthesia 49, 900–903.
  21.  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.
  22.  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.
  23. Goutcher, C.M., and Lochhead, V. (2005). Reduction in mouth opening with semi-rigid cervical collars. Br. J. Anaesth. 95, 344–348.
  24.  Heath, K.J. (1994). The effect of laryngoscopy of different cervical spine immobilisation techniques. Anaesthesia 49, 843–845.
  25.  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.
  26.  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.
  27.  Robitaille, A. (2011). Airway management in the patient with potential cervical spine instability: continuing professional development. Can. J. Anaesth. 58, 1125–1139.
  28. 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.
  29. 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.
  30. 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.
  31. Houghton, D.J., and Curley, J.W. (1996). Dysphagia caused by a hard cervical collar. Br. J. Neurosurg. 10, 501–502.
  32.  Lockey, D.J., Coats, T., and Parr, M.J. (1999). Aspiration in severe trauma: a prospective study. Anaesthesia 54, 1097–1098.
  33. 33.   Barney RN, Cordell WH, Miller E: Pain associated with immobilization on rigid spine boards. Ann Emerg Med 1989, 18:918.
  34. Main PW, Lovell ME: A review of 7 support surfaces with emphasis on their protection of the spinally injured. J Accid Emerg Med 1996, 13:34-37.
  35. Kosiak M: Etiology of decubitus ulcers. Arch Phys Med Rehabil 1961, 42:19-29.
  36. 36.   Patterson RP, Cranmer HH, Fisher SV, Engel RR: The impaired response of spinal cord injured individuals to repeated surface pressure loads. Arch Phys Med Rehabil 1993, 74:947-53.
  37. 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. 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.
  39. Totten, V.Y., and Sugarman, D.B. (1999). Respiratory effects of spinal immobilization. Prehosp. Emerg. Care. 3, 347–352.

 

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30 Responses to CERVICAL COLLAR R.I.P.

  1. Anne Creaton says:

    A great brave step! Like cricoid pressure seeped in medical culture but never proven to do good..

  2. Fantastic to see this happen. I expect to see a backlash so I hope that Bergen EMS will stick to their guns. Rejecting the holy sacrament of EMS will not be easy, but nothing worthwhile is!

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  5. Dan White says:

    Great list of references!

    But you made 5 broad and sweeping statements of conclusion they don’t support. Truth; nothing supports what we have been doing.

    We use inferior products incorrectly and get bad results. Then we act all shocked and claim this means we should use nothing.

    Lemmings To The Sea. Lead On.

    • Thomas D says:

      Hehe, you might be right. But I disagree that all the 5 statements are unsupported. Airway management has always been known to be the sacrifice of spinal immobilisation. Also, the increased aspiration risk follows the same lines, as long as the patient has immobilised the neck and is lying supine.

      The other three statements are supported by the references, but as I’ve stated, this is weak ‘evidence’. And, sure, this is based on current c-collar technology. This SOP does not say that Bergen EMS won’t – at some point – re-evaluate if different technology or evidence comes to market. The SOP is just saying that CURRENTLY, the best option is leaving the c-collar off.

      Also, leaving the c-collar off doesn’t mean we don’t care about the c-spine. We still watch over the patient and try to keep the spine aligned and avoid excessive movement of the neck.

      So for the time being, the lemmings to the sea all seem to be wearing c-collars.

  6. Fascinating and courageous. Fair play to you. The debate around hard c-spine collars has been around for a while and it’s great to see someone take on some credible leadership.

    Motorsports rescue lags behind much of prehospital practice, partly because of the mixed background of practitioners and partly because of the high publicity of some of the events (F1, WRC, etc). It will be interesting to follow how this plays out.

    Good luck

    • Thomas D says:

      Thanks for your comments! Yes, I can definitely see how a c-collar is hard to avoid at the circus!

      Also, in endemic high-litigation areas, the c-collar will be hard to avoid (even if evidence leans towards harm).

  7. Adan Atriham says:

    Interesting… very interesting and provocative new approach.
    However, let’s be cautious… There is not (and never will be) a randomized trial of collar vs no-collar in trauma. The fact that more significant injuries are seen with the collar may be just a reflection that these patients have had more severe trauma (that’s why they were kept on the collar) and not the collar it self causing more injuries. Hmmmm!
    I totally agree with back board thing. We stopped using it in London and when needed, we use the scoop board to transfer patients only. But I am not sure if the collar is death or even on life-support. Maybe some cadaver studies will answer this question…

    • Thomas D says:

      It is a bit provocative, especially if you look at it from the entrenched ATSL c-collar perspective. If the c-collar came to market now, with the references listed above, I don’t think it would come into use.

      I agree there will never be a RCT for c-collars. The numbers needed would also be very high to catch any differences, as clinically/neurologically significant cervical spine injuries are quite uncommon – and the whole concept of the injury worsening after initial trauma due to normal spine movement is not proven or at least very, very uncommon.

      The largest study on collar vs no collar is probably the one comparing an EMS in Mexico (using collars) to an EMS in Malaysia (not using collars). Here, the injuries should cover the worst trauma for both collar and no-collar. No advantage to the collar, actually more neurological injury in the collar group. But of course, comparisons like these are fraught with other problems. So this isn’t the final word on c-collars.

      Yes, the backboard should probably be switched with a scoop stretcher.

      On the cadaver studies so far, the c-collar doesn’t fare very well.

      At least now we have a western high-standard EMS service that doesn’t use c-collars. That should open up for another comparison study – preferably with another Norwegian EMS service for best comparison. Large numbers would be needed, but it would be an important study to do.

      • I’m not sure a collar/no collar trial could not be done. Other concrete bastions have had the door opened to being formally challenged; adrenalin for OHCA, the role of PA catheters in ICU, the need to ensure a patient in the ICU poops every day.

        Might be interesting to see what happens to the Bergen trauma population neurological outcomes over the next year and if there is no difference, or an improvement, perhaps you’ve got equipoise and justification for an RCT.

        Ethics may be less of an issue than logistics and willingness

  8. Bart Massaer says:

    We in Flanders, Belgium, often notice incorrectly applied cervical collars: too loose, wrong size, patients in sitting position or even walking in the ED. Even the decision to apply a collar is not consistent: some patients in minor accidents get one, other severely injured patients get none… There’s a need to reconsider this thing, I guess!

  9. Duncan Whte says:

    If we wear shoes that are too small we can cause damage to our feet, does this mean that we should stop wearing shoes? There is clearly a solid basis for the review of whether or not c-collars should be discontinued but personally I think the focus needs to be on finding conclusive proof that the use of such causes harm/damage. Should this be the case then yes, discontinuation is the correct course of action.
    The way I see it is that if there’s no conclusive proof that they cause harm, but that if correctly used there exists even the possibility that risk of antagonizing/worsening an existing injury is reduced, c-collars should remain in use.

    • Matt says:

      You just defined dogma!

    • David says:

      Surely the burden of proof should be on those wanting to introduce a procedure or new piece of equipment.

      Rigid / semi-rigid collars, along with strapping people to back boards, were introduced without any evidence to support their use and then quickly became entrenched in both the pre-hospital and in-hospital management of the actual or potentially spine injured patient.

      Based on your logic a drug company should be able to just introduce drug xyz by telling us that it works, without any trials, then say it is up to others to prove that it doesn’t work or is harmful.

      • Duncan Whte says:

        I agree, when wanting to introduce new procedures and/or equipment, the burden of proof should be on those wanting to introduce them. But thats not what we are talking about here, we are talking about kit that has been in use for decades, with more successful application than otherwise. The issue here is that we now have people claiming that C-collars can not only aggravate but can, and has actually caused injury. Such claims should not be allowed to be the basis for discontinuation without evidence and for that evidence to be acceptable the competence of those using the equipment in such cases should also be considered.
        Drugs are a completely different matter as they are generally used for ongoing treatment. As such the cumulative effect of repeated doses potentially carries far greater risk to the patient than a piece of equipment that is intended to be used to immobilise the patient to prevent further injury or trauma.

        Furthermore, ALL drugs are harmful ,including those that have been approved by the proper authorities, its responsible use and proper dosage that minimises risk and side effect. Even Paracetamol can be harmful, should we call that into question too?

        C-Collars and backboards have been proven to be effective in minimising risk of further or worsened injury WHEN PROPERLY USED. I watched a video recently which was presented as an advocate for discontinuation of the use of C-collars but it was abundantly clear that the problem is not with the C-collar itself but rather with inability of the attending medics to properly apply it. The patient was jerked around, neck flopping about whilst the medics first attempted to apply one that was too large, and if that wasnt enough they were trying to apply it upside down! This was repeated 3 times with 3 incorrectly sized collars until another medic who actually knew what he was doing selected the correct size and applied it properly. The issue here is clearly one of training and proper staffing. Sending undertrained staff out to accident scenes and then blaming the equipment for ineffective treatment is a blatant copout and is nothing short of an attempt to sidestep responsibility for the result of incompetence. Dont get me wrong, Im not having a go at the medics, personally I blame the system. We need better trained people out there and more of them.

        • Thomas D says:

          We are all looking for the best treatment for our patients, and engaged discussions are great.

          Here, we’re discussing an area of treatment where proof is weak, and we’ll likely never get the ultimate answer.

          So far, I haven’t read any proof of the effectiveness of the c-collar and the backboard that you mention. I would love to see those references.

  10. Dave Tingey says:

    Brave move – in the right direction, hopefully! A key point I think is the continued need for head stabilisation (towel rolls – not taped, or vacuum mattress immobilisation) especially in the muscle relaxed patient post intubation.

    I wonder what this means for the 0.7% of “high risk” patients who ultimately have a C-spine injury? Is it better to to apply a risk assessment tool rather than generalise about all at-risk patients.

    And I fully agree on the backboard comments. Our state EMS re-labelled them “extrication boards” a number of years ago to reflect their intended (and limited) use.

  11. Karl jones says:

    Given that the evidence is, it seems, not clearly showing support one way or the other it seems a shame not to take this opportunity to actually do the RCT who’s absence we all bemoan.

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  13. Jiun Kae Pui says:

    Re-enactment of the published paper in BMJ 2003: “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials” though not as dramatic as 100% mortality without parachute use. The question is probably better with which variation of C Collar is better (ie which type of parachute is better) rather than collar vs no collar.

    • Thomas D says:

      I do agree we need to discuss how to look after the spine. But we might not need any fancy equipment.

      For the conscious patients, it seems they will protect their own spine.

      For the unconscious ones, we’ve settled on a simple, normal pillow to keep the head in place and neck aligned. The pillow will raise the head slightly (into a more natural position) and stabilise it a little against sideways/rotary movement when the patient is lying on the gurney/bed. In addition to that, the healthcare providers just need to be alert and keep the neck and spine in mind when handling/moving the patient (just as we must with a c-collar in place).

      So, simple, standard patient care is probably enough. With a little extra thought for the spine when handling.

  14. Marv Wayne says:

    We ( our EMS system) have been using a non immobilization non collar algorithm for 5 years now. We recently moved to relegate the the backboard to a movement transfer device only. We use cot or vacuum mattress for immobilization if needed. Results are a significant reduction in pain, unnecessary xrays etc, with no sacrifice in care. It is time to imagine a “world without backboards”!

  15. acls bls says:

    I think that this equipment give hope to people and it should be used. The risks? Let the people that need it to tell you that. I’m sure that the rewards are higher.

    Best regrads

  16. Matt L says:

    As a paramedic who reads this site I want to make a plea for improved education standards for my cohorts. How many of you when you find a medic or EMT (yes they’re different) who has incorrectly used a device and taken a moment to either teach or follow up with their managers to ensure a higher standard of care is issued during the next Ed visit? You might say that’s impossible because then you would be counseling every other EMS crew that walks in your doors. So take a look at our training. We are expected to be your physician extenders after not even am associates degree of education. On top of it add a horrible work environment, poor pay, and long hours and very few competent providers who are capable of doing more decide to stay. We need higher standards for these devices to be used properly. So if you see gross mistakes and take the time to follow up and show EMS that they are accountable for their poor care you may see some changes. I am tired of collaring patients who don’t need it because the physician written protocols dictate that treatment.

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  18. David B. says:

    Let’s not forget the distress inflicted upon the patient wearing this damned thing. How many times have you seen someone attempting/succeeding in removing their own C-collars?

  19. Hi Thomas,

    In your post you describe the Bergen c-spine approach to the fully conscious, self extricating patient and to the unconscious intubated and non-intubated patient. What’s the Bergen approach to the less than fully conscious patient who is a bit incoherent or unable to answer appropriately or assist with self extrication?

    Thanks

    Matthew

  20. John Davis says:

    I often remind my students and staff that “The cervical collar is like a yellow sticky note: it has the structural strength of a warm Kit Kat and only serves as a visible reminder that the c-spine has not been cleared.”

    Yes, apply precautions, but don’t assume that a single device (splint, c-collar, ETT) is the be-all and end-all. If mechanical devices never failed, we’d never need road trauma teams.

    Frankly, everyone should have to wear a collar for half an hour to get how much occipital discomfort it causes.

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