Immobilizing the cervical spine

Pre-alert: A 3-year-old male fell from a 2nd-story window. No obvious external injury, and he is moving all 4 limbs.

Vital signs are not available, but he is alert. He has IV access, pelvic immobilisation, and 3-point spinal immobilisation and has been given intranasal analgesia.

ETA: 5 minutes.

Here’s a @DFTBubbles one for the prehospital peeps out there

A 3 year old falls from a 2nd storey window. He’s alert but terrified, crying & moving all 4 limbs. The mechanism is concerning for a c-spine injury. How will you protect his c-spine en route to hospital? pic.twitter.com/CPrkUMfKJZ

— Dani Hall (@danihalltweets) September 28, 2020

What is my role in this clinical situation? As a Specialist Registrar in Emergency Medicine, I am the one standing in resus with a red sticker across my chest, preparing myself, my team, my environment, and my equipment to receive this potential traumatised patient. 

Once my head is in the right space, I brief my team on the pre-alert and set out a shared mental model of the best- and worst-case scenarios. Space is made available, and we set about gathering our equipment. 

• Haemostatic dressings
• Pelvic binder
• IV/IO
• Rapid infuser
• Cervical collar

As the impending clinical challenges of this patient play out in my head, I prepare my team to deliver a trauma package of care. This may involve managing a brain injury, decompressing a tension, binding an open book, or drawing a long bone out to length. Major trauma is uncommon in paediatrics, with only 5% occurring in those less than 14 years of age. Most children are injured in their own homes (38%), with falls from height accounting for over half of the cases. While always being cognisant of possible spinal injuries in paediatric trauma, the actual incidence is low. Paediatric cervical spine injuries account for 1-10% of all spinal injuries. Various anatomic (large head size) and physiological reasons (flexible spine) account for this, which, of course, will change with age. 

Trauma resuscitation is being rewritten. ABC is now about turning off the tap and has become CACBCDE. If cervical spine consideration comes so early in our primary survey, can we just pop a hard collar on the neck and move on? As I ponder the clinical case outlined, I recall my early days as a newly qualified doctor and indeed think back to the very start and the Hippocratic oath; ‘before we try to make things better, first and foremost, don’t make things worse’. Is the collar more a curse than a cure?

The cervical collar was introduced into pre-hospital practice in 1967, but its perceived benefit has always been more theory than evidence. More and more of the evidence suggests that collars are not likely to make things better and are more likely to make things worse. So why do we apply collars in the first place?

Time for a little MYTHBUSTING.

MYTH: We reduce the risk of secondary injury

Studies have shown that in patients with a primary cervical spine injury, there were no significant differences in secondary injuries in those with or without a cervical collar. More worryingly, some of the available evidence points to larger neurological deficits in trauma patients with the cervical collar versus those without.

MYTH BUSTED.

MYTH: We can immobilise the injury

The collar is an ineffective means of immobilisation as it does not prevent movement. How often have you seen a patient looking around for the toilet or for their mate? The cervical collar can lead to increased movement in the upper parts of the neck compared to no collar, as patients struggle to deal with its presence. Advanced Trauma Life Support (ATLS) 10^th edition has acknowledged this futile exercise and has changed its terminology from C-spine immobilisation and replaced it with restriction. 

Cadaveric studies have shown that collars do not effectively reduce motion in cervical spine fractures, with studies showing the three-dimensional movement of up to 23 degrees during the application of the collar.

MYTH BUSTED.

MYTH: Use the collar as a label

Some courses and institutions advocate using a collar as a label, a label to say that the team remain concerned about possible c-spine injuries. While I can understand the thought process, this may detract from the detailed examination of the neck that is required as we search for potential life-threatening neck or thoracic injuries such as Tracheal deviation, Wounds and haematomas, External markings, Laryngeal disruption, Venous distention, Emphysema. 

The collar may interfere with airway assessment and management, and research supports this and may pose an aspiration risk. 

The presence of a collar limits neck exposure and thereby inhibits procedures such as vascular access or, indeed, front-of-neck access. Many of the time-critical interventions that are required in complex trauma resuscitation are potentially hampered by decision paralysis. One way of mitigating this risk is to plan and anticipate interventions such as using point-of-care ultrasound to mark the cricothyroid membrane in the predicted difficult airway or in cases of massive facial trauma. The presence of a collar, even if used as a label, may impact this lifesaving procedure.

Collars may raise intracerebral pressure, with recent studies demonstrating the effect that collar application has on optic nerve sheath diameter.

Collar application may result in respiratory compromise, with studies demonstrating a significant decrease in lung capacity and spirometry parameters in those with collars versus those without.

MYTH BUSTED.

MYTH: How about using international guidelines to clear the c-spine without imaging and removing the collar in this case?

We cannot use NEXUS (sensitive but not specific and PPV of only 1.2% in patients <8 years of age) or Canadian C-spine rules (excluded patients <16 years of age).

MYTH BUSTED.

I doubt many will disagree that cervical collars have proved as much of a pain in the neck for practitioners as their patients. They are intrusive, distressing, anxiety-inducing and may exacerbate pain, fear, and stress. They are difficult to size, awkward to fit, require at least two practitioners and never seem to be perfect. Poorly fitted or prolonged use has even been associated with pressure wounds.  

And so, back to the case. Our patient suffered a dangerous mechanism of injury, but with no evidence of improved patient outcome to support the use of cervical collars in trauma, we need to ask ourselves the question: before you intervene, do you need to? We should manage our patient in a gentle, supportive and age-appropriate manner and, where possible, with their parents by their side, who themselves could provide manual inline stabilisation in accordance with APLS (Advanced Paediatric Life Support) guidelines. What we do need to do is to trust the patient’s intuition. If doing something causes them pain, they will not do it.  Recalling our Oath and our promise not to do harm, it is worth bearing in mind that our three-year-old patient may be better able to protect their own injury than we can. 

References

Reid C, Brindley P, Hicks C, Carley S, Richmond C, Lauria M, Weingart S. Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. 2018 Sep;5(3):139-143. doi: 10.15441/ceem.17.269. Epub 2018 Sep 30. PMID: 30269449; PMCID: PMC6166036.

National Office of Clinical Audit, (2020) Major Trauma Audit National Report 2018.

Benger J, Blackham J: Why do we put cervical collars on conscious trauma patients? Scand J Trauma, Resuscitation Emerg Med. 2009, 17: 44-10.1186/1757-7241-17-44.

Hauswald M, Ong G, Tandberg D, Omal Z: Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998, 5 (3): 214-219. 10.1111/j.1553-2712.1998.tb02615.x.

Liao S, Schneider NRE, Hüttlin P, Grützner PA, Weilbacher F, Matschke S, Popp E, Kreinest M. Motion and dural sac compression in the upper cervical spine during the application of a cervical collar in case of unstable craniocervical junction-A study in two new cadaveric trauma models. PLoS One. 2018 Apr 6;13(4):e0195215. doi: 10.1371/journal.pone.0195215. PMID: 29624623; PMCID: PMC5889057.

Airway in Neck Trauma

Yuk M, Yeo W, Lee K, Ko J, Park T. Cervical collar makes difficult airway: a simulation study using the LEMON criteria. Clin Exp Emerg Med. 2018 Mar 30;5(1):22-28. doi: 10.15441/ceem.16.185. PMID: 29618189; PMCID: PMC5891742.

Rai Y, You-Ten E, Zasso F, De Castro C, Ye XY, Siddiqui N. The role of ultrasound in front-of-neck access for cricothyroid membrane identification: A systematic review. J Crit Care. 2020 Aug 13;60:161-168. doi: 10.1016/j.jcrc.2020.07.030. Epub ahead of print. PMID: 32836091

J, Richman PB, Leeson B, Leeson K, Youngblood G, Guardiola J, Miller M. The Influence of Cervical Collar Immobilization on Optic Nerve Sheath Diameter. J Emerg Trauma Shock. 2019 Apr-Jun;12(2):141-144. doi: 10.4103/JETS.JETS_80_18. PMID: 31198282; PMCID: PMC6557047.

Ala A, Shams-Vahdati S, Taghizadieh A, Miri SH, Kazemi N, Hodjati SR, Jalilzadeh-Binazar M. Cervical collar effect on pulmonary volumes in patients with trauma. Eur J Trauma Emerg Surg. 2016 Oct;42(5):657-660. doi: 10.1007/s00068-015-0565-1. Epub 2015 Sep 3. PMID: 26335538.