CERVICAL COLLARS SLASHED FROM GUIDELINES

cervical-collar-slashThere’s been a big discussion on cervical collars in trauma the recent years. We’ve covered the controversy here. Guidelines are usually slow to adapt, but now both national guidelines from the Netherlands and state guidelines from Queensland in Australia seems to be removing the hard collar from their guidelines, as we have in Bergen, Norway. And recently ILCOR has released a preliminary guideline on spinal stabilisation. They conclude that with current evidence, cervical collars can’t be recommended for routine application in trauma(!)

Cervical collar evidence
Scancrit having promoted a rethink of the use of cervical collars the recent years. As with many other areas in medicine, especially emergent settings, data is lacking.

Our belief is that we have to reach a conclusion on the data we’ve got. This is similar to how we have to make decisions on emergent patients without knowing the full story or background; You work with what you got, and adjust as you get new information. Too many guideline bodies walk away from that responsibility and end up with recommending nothing but more research urgently needed.

Still room for the cervical collar?
We all agree that the spine needs stabilisation and to be looked after when spine injuries suspected in trauma patients. In Bergen, Norway, we have removed the hard cervical collar from routine placement, only occasionally using it for extrication in unconscious patients where manual stabilisation is difficult or impossible.

ILCOR advice
So it was fantastic to see the ILCOR group, mostly known for their advice on cardiac emergencies, to come up with definitive advice on handling spinal stabilisation in trauma patients. This is a draft that might get changed down the road, but as it has been published online, we think the main conclusion will stay.

They were seeking to answer the question: “Among adults and children with suspected traumatic cervical spinal injury (P), does spinal motion restriction (I), compared with no spinal motion restriction (C), change neurological injury, complications, overall mortality, pain, patient comfort, movement of the spine, hospital length of stay (O)?”. Their answer was:

“We suggest against spinal motion restriction, defined as the reduction of or limitation of cervical spinal movement, by routine application of a cervical collar or bilateral sandbags (joined with 3-inch-wide cloth tape across the forehead) in comparison to no cervical spine restriction in adults and children with blunt suspected traumatic cervical spinal injury (weak recommendation, very low quality of evidence).
Values and preferences statement: Because of proven adverse effects in studies with injured patients, and evidence concerning a decrease in head movement only comes from studies with cadavers or healthy volunteers, benefits do not outweigh harms, and routine application of cervical collars is not recommended.”

Mind blown. We’ve been thinking this for a long time, but we never actually though an “official” body would come out and say it!

Please mind this is based on very low quality “evidence”, but this low quality evidence against the cervical collar seems to be stronger than any “evidence” possible to dig up FOR the cervical collar. Seems ILCOR agrees that the burden of evidence must rest on those who wants to implement a new treatment, as the cervical collar. Will there be proper trials? Ever? Interesting times.

Link to PDF of ILCOR Cervical Collar Guidelines DRAFT 2015

Web-link here: https://volunteer.heart.org/apps/pico/Pages/PublicComment.aspx?q=772

More posts on Cervical Collars in Trauma from ScanCrit

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17 Responses to CERVICAL COLLARS SLASHED FROM GUIDELINES

  1. Brian says:

    ILCOR changes the verbiage on the draft and it is now less clear. I posted a comment asking for clarification.

    POSTED FOLLOWING ILCOR MEETING TASK FORCE DISCUSSION ON 4 FEBRUARY, 2015

    We suggest against the use of cervical collars by first aid providers (weak recommendation, very low quality of evidence).

    Values and preferences statement:
    • Consistent with the First Aid principle of preventing further harm, the potential benefits of applying a cervical collar do not outweigh harms such as increased intracranial pressure and the consequences of unnecessary neck movement.
    • We recognize that first aid providers might not be able to discriminate between high or low risk individuals.
    • We recognize the potential value of manual stabilization in certain circumstances, but this was not evaluated in this review.”

    -https://volunteer.heart.org/apps/pico/Pages/PublicComment.aspx?q=772

    • Thomas D says:

      Thanks for the update. I would expect the guideline recommendations to become more muddled and toned down as everyone has their say. That’s one reason I wanted to put focus on the draft – get the fresh (as in “new”, but also as in “unspoiled”) opinion out there.

  2. @cannulator says:

    So as a Victorian paramedic, what guidelines are you referring to That we have adopted??

    • Thomas D says:

      I’m sorry for the mistake, I had a mix-up of guideliness and states. I was referring to the guidelines in QLD removing the stiff collar in place of the soft collar – not Victoria. Again, sorry about the mix-up. Thanks for making me aware. It is straightened out in the post now.

  3. Danado Saltarelli says:

    As a flight nurse/medic that works with multiple EMS systems, I am seeing protocols changing to reflect the limited use of the rigid C – collar based on severity of trauma and likelyhood of spinal injuries, and on the the over all evaluation of the patient and the mechanism of injury. That being said, the million dollar question is: When to apply or when not to apply?

    Once a protocol changes from objective to subjective application, the benefit to risk decision is be made by the individual clinician based on their experience, training and education.

    We define our protocols as guidelines and are encouraged to make our treatment decisions based on “the totality of the circumstances” then “benefit to risk ratio”.

    Since a clinician’s levels of experience, training and education can be from one end of the spectrum to the other, it will be interesting to see the retrospective studies (in the future) that will evaluate when it was a good idea and when it was not.

  4. Mike says:

    Gosh, that first paragraph in italics needs revising – very poor English/punctuation. And in the subsequent paragraph, it would be nice to know what the adverse effects were.

    • Thomas D says:

      Yeah, well, on the poor English/punctuation: you’ll have to talk to ILCOR about that… On possible adverse effects: If you clicked the link at the bottom, reading the full statement from ILCOR, you’d get some good pointers. If you need more, click the second link at the bottom to read more of our posts on the cervical collar.

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  6. The part I find amazing on here is the decision making based on very slim data that the research has happened on. This data gathering needs to change in a big way across primary care providers to provide a better body of evidence from which to pull.

    Healthcare data legislation like HIPAA have a big role to play here, in allowing technology enablers to share that data with research establishments so we can further improve the care provided.

    • Thomas D says:

      I agree it would be nice to have more data, but as spinal chord injury is quite rare, and a “second hit” in spinal chord injury is even more of a unicorn, it would be hard to get enough data to make good conclusions.

      Getting past data rules is a big issue in medicine. Patient data protection is very important, but we need to move on somehow. I often think patient data protection is hurting the patients more than it’s helping them.

      Also on the “very slim data” bit: the introduction of the collars were made on even slimmer data. That’s where the burden of proof lies.

  7. DaveC says:

    Quite a graphic you came up with there my friend. If you care to share, a bit larger, presentation size one would be cool.

    A comment on the ILCOR question & recommendation: They missed the concept of full body vacuum splints, and in particular the comparison with back boards. Back boards are losing favor in the States, but are still widely used. Full body vacuum splints are more expensive & less durable than back boards, but anecdotally, and with some published evidence, vacuum splints do provide better patient comfort than back boards. (Patient comfort was a criteria in the ILCOR question). Also note the CERVICAL COLLAR R.I.P. post references from the Bergen EMS “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.”

    Seems like an interesting retrospective study to compare Bergen & Oslo EMS outcomes if Oslo is still using cervical collars in their ambulance service.

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  9. Thomas D says:

    The graphics are awesome! I can see I didn’t give credit to @skimightythings on Twitter, who made the graphics! Please contact through Twitter to get hold of the graphics!

    On the scope of the ILCOR guidelines, I guess they had to focus their guidelines. It quickly becomes a huge taks if you don’t focus. I can see how the vacuum splints are getting attention again. The downside is that it takes time to apply, and it hinders patient access. But they immobilise the patients better, and they’re more comfortable.

    We’ve definitely made the backboard an extrication device (along with the c-collar, if neck can’t be manually stabilised during extrication). We avoid transporting patients on backboards.

    It would be interesting to compare outcomes, but it would be hard to pick up on the tiny percentage that has spinal chord injury AND has a second hit/worsening due to movement. It would take huge numbers. Neither Oslo nor Bergen can come up with enough patients for that.

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  11. Dan Barela says:

    Our service, Fire Department (NM US) and Remote Medicine are no longer using long spine boards at all. To much evidence showing secondary injury (albeit mostly minor) vs. any spinal restriction in the spinal compromised patient. Areas where remote medicine aspects should be considered like SAR and prolonged extractions (hour or greater), comfort during extraction is a huge concern. Evac splints are a great device in these environments. An uncomfortable patient in any type of restriction device will quickly begin to find a comfortable position by movement. Obviously this causing potential for exacerbating the suspected spinal injury. I am glad to see medicine taking a common sense approach to our patients that are and have been suffering. Sometimes doing the right thing and not injuring our patients any further (Primum Non Nocere) is the best approach until all data proves otherwise. Furthermore the impact that tossing away the backboards and c-collars will have on the industry will be huge and far reaching. The next few years will be interesting.

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