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The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury

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The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0345-x) contains supplementary material, which is available to authorized users.
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R E V I E W Open Access
The Norwegian guidelines for the
prehospital management of adult trauma
patients with potential spinal injury
Daniel K Kornhall
1,2,3*
, Jørgen Joakim Jørgensen
4,5
, Tor Brommeland
6
, Per Kristian Hyldmo
7,8
, Helge Asbjørnsen
9,10
,
Thomas Dolven
9
, Thomas Hansen
11
and Elisabeth Jeppesen
12,13
Abstract
The traditional prehospital management of trauma victims with potential spinal injury has become increasingly
questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these
concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a
national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available
literature and a standardised consensus process. The faculty recommends a selective approach to spinal
stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal
handling should be observed.
Keywords: Prehospital emergency care, Spinal cord injury, Stabilisation, Airway management, Guideline
Background
Traumatic injury to the spinal cord (SCI) or cauda
equina is uncommon but may have devastating con-
sequences [1, 2]. Spinal instability occurs when the
integrity of the spinal column is compromised by
fractures and/or joint dislocations so that it no longer
can maintain its protective configuration under normal
physiologic loading, predisposing to further injury [3, 4].
Since the 1960s, mishandling of the traumatised spine
has been thought to cause neurological deterioration
and field spinal stabilisation has been considered pivotal
for preventing such secondary injury [515]. Through
adding external supports to the victims body before
extrication, treatment and transport to hospital, clini-
cians aim to reduce spinal movement and prevent
further secondary injury [1619]. The spine is to be
stabilised in a neutral position. While this position is
poorly defined and subject to controversy and individual
variation, it is similar to the position one assumes when
standing and looking ahead [2024]. For decades, the
dominant strategy has been to generously assume the
presence of unstable spinal injury in all patients with a
relevant mechanism of injury or clinical findings and
then to stabilise using a combination of a rigid cervical
collar, head-blocks, straps and a rigid stretcher system
[2532]. While numerous other devices exist, this
combination is widely implemented [3339].
Many authors have raised concerns over this strategy and
have questioned its efficacy, over-triage, costs and potential
harmful effects [4045]. Consequently, several organisa-
tions and authors have promoted a more selective strategy
[2, 44, 46]. This controversy has generated regional varia-
tions in stabilisation strategies within the Emergency Med-
ical Services (EMS) [44]. In order to address these concerns
from a national perspective, the Norwegian National Com-
petence Service for Traumatology (NKT-T) in collaboration
with The Norwegian Knowledge Centre for the Health Ser-
vices (NOKC) commissioned a multi-disciplinary faculty to
provide a national guideline designed to facilitate the pre-
hospital management of adult trauma victims with potential
spinal injury. The GRADE system (grading of recommen-
dations, assessment, development and evaluation) has been
combined with standards for clinical practice guidelines
and best available evidence to improve pre-hospital man-
agement of adult patients with potential spinal injury.
* Correspondence: danielkornhall@me.com
1
East Anglian Air Ambulance, Cambridge, UK
2
Department of Acute Medicine, Nordland Central Hospital, Postboks 1480,
8092 Bodø, Norway
Full list of author information is available at the end of the article
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the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
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Kornhall et al. Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine (2017) 25:2
DOI 10.1186/s13049-016-0345-x
Methods
The multi-disciplinary faculty included members from
all Norwegian health trusts representing the medical
specialties of neurosurgery (1), trauma surgery (1), pre-
hospital care (3), anesthesiology (1) and EMS (1), all
with expert knowledge of trauma management. In
addition, one methodologist directed the systematic evi-
dence work, including evidence appraisal and synthesis.
The standards for developing clinical practice guidelines
using The Appraisal of Guidelines for Research and
Evaluation (AGREE) tool were followed [47]. Key clinical
questions were created in accordance with the PICO
format (Population, Intervention, Comparison, Outcome)
(Table 1). In December 2014, a research librarian per-
formed a scoping search for existing international guide-
lines and systematic reviews [4852].
In March 2015, a systematic literature search for pri-
mary studies was performed on core databases Medline,
Embase The Cochrane Library and the Cochrane Central
Register of Controlled Trials (CENTRAL). Medical
Subject Headings (MeSH) search terms are listed in
Additional file 1 that is available as a supplementary on-
line material. Search was further limited to human stud-
ies published in English language.
Two reviewers independently screened titles and ab-
stracts of all records identified in the searches for inclu-
sion. Any discrepancy was resolved through discussion
and consensus in the faculty. For completeness, add-
itional records were identified by scanning reference lists
and the authors contributing papers known to them. Full
text records were critically appraised using the PRISMA
checklist for systematic reviews, the CASP checklist for
observational studies and the AGREE tool for guidelines
[47, 53]. The quality of evidence and strength of recom-
mendations were described using the GRADE tool. In
line with the principles of the GRADE methodology, we
downgraded the quality of evidence of an intervention
for identified risks of bias (methodological quality), in-
consistency, indirectness, imprecision or publication
bias. Evidence was rated as one of four levels of quality
(high, moderate, low and very low). When agreeing on
strength of recommendations, three factors were consid-
ered and integrated in a group consensus process: bene-
fits and harms, quality of evidence and the preferences
of patients and clinicians. The strength of recommenda-
tions were graded as strong or conditional. A strong
recommendation indicates that the benefits of an inter-
vention far outweigh the harms (or vice versa). A condi-
tional recommendation denotes uncertainty over the
balance of benefits and harms. Finally, the faculty opted
to use the term good clinical practicein instances
where a recommendation was considered obviously ra-
tional, but where the literature was found too heteroge-
neous for meta-analysis.
Results
Six guidelines were identified in the scoping stage [2, 19,
46, 5456]. One publication was of particularly high
methodological quality. In 2013, A joint committee from
The American Association of Neurological Surgeons
(AANS) and the Congress of Neurological Surgeons
(CNS) issued updated guidelines for the management of
acute cervical spine and spinal cord injuries [46]. These
comprehensive guidelines are based on systematic litera-
ture searches between 1966 and 2011 and was consid-
ered to be both relevant and complete by our faculty.
Therefore, we limited our further searches to papers
published after 2010 overlapping the AANS/CNS joint
committeessearches by 1 year. In their guideline, Theo-
dore et al. relied on 109 records for their literature
review of which one was excluded as it was found as a
duplicate amongst our search results. Of the remaining
108, 93 were available in full text format for inclusion
into our literature review. The 15 records that were
not available were non-peer-reviewed magazine arti-
cles, meeting proceedings, local EMS protocols and
chapters in textbooks no longer in print or otherwise
not available.
Our core database search generated 9.441 abstracts
and titles. After independent author review, 9372 were
Table 1 Overview of key clinical questions in the PICO format
Clinical question P I C O
Does routine use of spinal stabilisation
prevent secondary neurological injury?
Trauma population Spinal stabilisation Stabilisation vs no stabilisation Neurological morbidity
Are there alternative ways of stabilising
the spinal column?
Trauma population Spinal stabilisation collar/MILS/stretcher/backboard Neurological morbidity
Pain/discomfort
Is there evidence of harmful side effects
caused by stabilisation devices?
Trauma population Spinal stabilisation Stabilisation vs no stabilisation Neurological morbidity
Pain, discomfort, ulceration
Are there sub-groups of patients that
in particular should not be stabilised?
Critical injuries
Minor injuries
No spinal stabilisation Stabilisation vs no stabilisation Neurological morbidity
& mortality
How should patients with potential
spinal injury be evacuated
and transported?
Trauma population Extrication & transport Stretcher, vacuum
mattress, backboard
Neurological morbidity
& mortality
Pain, discomfort, ulceration
PICO Population, Intervention, Comparator, Outcome
Kornhall et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2017) 25:2 Page 2 of 11
excluded by title or abstract for unrelated topics or for
not being primary studies or systematic reviews. A total
of 69 original papers were selected for full text reading
of which 16 were considered eligible for inclusion into
our literature base (Additional file 2). In addition,
six systematic reviews were identified and included
(Additional file 3) [42, 44, 45, 5759].
During guideline preparation, another 16 original stud-
ies were identified from screening bibliographies and from
the authors contributing articles known to them. In total,
we identified 63 original studies and 6 systematic reviews
that generated and supported 10 recommendations.
Our recommendations, the quality of supporting evi-
dence as well as the strength of recommendation are sum-
marised in Table 2. The original studies supporting each
recommendation are listed and described in a separate
evidentiary table that is available as supplementary mater-
ial (Additional file 4). The recommendations formed the
framework for an algorithm designed to facilitate the
prehospital management of adult trauma victims with
potential spinal injury (Fig. 1). A draft version of the
guideline was subjected to a national open hearing process
involving stakeholders such as the ambulance services of
the Norwegian hospital trusts, the air ambulance organisa-
tions, regional trauma leaders and the primary health care
services. This manuscript presents the finalised version of
these recommendations. The rationale and literature
behind each recommendation is expanded upon below.
The guideline is now undergoing national operatio-
nalisation as it is being implemented in the individual
Table 2 Summary of recommendations, quality of evidence and strength of recommendation
Recommendation Quality of evidence Strength of
recommendation
Rationale (Benefits, harms and the preferences of
patients and clinicians)
1 Victims with potential spinal injury
should have spinal stabilisation.
Very low Strong Paucity of literature supporting spinal stabilisation.
Very little literature documenting serious harm. Spinal
cord injury can have devastating consequences.
Potential benefits outweigh harms
2 A minimal handling strategy should
be observed.
Very low Strong Paucity of literature supporting spinal stabilisation.
Very little literature documenting serious harm. Spinal
cord injury can have devastating consequences.
Potential benefits outweigh possible harms
3 Spinal stabilisation should never delay
or preclude life-saving intervention in
the critically injured trauma victim.
Very low Good clinical practice Literature supporting this recommendation was
considered too heterogenous for synthesis. The
faculty finds that it is logical that spinal stabilisation
in the critically injured patient may cause serious harm
4 Victims of isolated penetrating injury
should not be immobilised.
Moderate Strong One large study of moderate quality directly supports
this recommendation. Spinal injury in patients with
isolated penetrating injury is rare
5 Triaging tools based on clinical
findings should be implemented.
Moderate Strong Consistent evidence supporting triaging tools based
on clinical findings rather than mechanism. No harmful
effects documented
6 Cervical stabilisation may be achieved
using manual in-line stabilisation,
head-blocks, a rigid collar or
combinations thereof.
Very low Conditional Consistent experimental evidence demonstrating how
rigid collars can stabilise the cervical spine. However,
there is also evidence suggesting harm from rigid
collars. No evidence proving superiority of any
one method
7 Transfer from the ground or between
stretchers should be achieved using
a scoop stretcher.
Very low Conditional General paucity of evidence. Some evidence for
significant spinal motion during log-roll. Some evidence
documenting improved stability with scoop stretcher
transfers. Safety of scoop stretcher systems is good.
No harmful effects documented
8 Patients with potential spinal injury
should be transported strapped supine
on a vacuum mattress or on an
ambulance stretcher system.
Very low Conditional Evidence supporting harm from hard surface stretcher
systems. No consistent evidence demonstrating
increased stability with any one method. Increased
comfort associated with soft surface systems. No
evidence exploring spinal stability of common
stretcher systems
9 Hard surface stretcher systems
may be used for transports of
shorter duration only.
Very low Conditional Evidence supporting harm from hard surface stretcher
systems. No consistent evidence demonstrating
increased stability with any one method. Increased
comfort associated with soft surface systems
10 Patients should under some
circumstances be invited to
self-extricate from vehicles.
Very low Conditional Two experimental studies demonstrating improved
stability with self-extrication from vehicles. Reasonable
and practical alternative as long as used cautiously
Kornhall et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2017) 25:2 Page 3 of 11
health trustsambulance operating procedures, is taught
on e-learning programs and is incorporated into the
training of new EMS personnel. The guideline is also
widely disseminated through meeting presentations and
in national care publications
Recommendation 1: Victims with potential spinal
injury should have spinal stabilisation.
Recommendation 2: a minimal handling strategy
should be observed.
Rationale and evidence base
Higher level evidence supporting spinal stabilisation is
lacking
Despite spinal stabilisation being one of the most fre-
quently performed prehospital interventions, higher
grade evidence demonstrating beneficial effects is lack-
ing [46]. From the 1970s to the 1980s the incidence and
mortality of complete spinal injury decreased signifi-
cantly. As this coincided with the introduction of mod-
ern spinal management strategies, authors have to
varying extents credited stabilisation for this reduction
[46, 6063]. Other than these assumptions, the evidence
directly supporting stabilisation consists of reports of
low quality associating failure to reduce spinal mobility
with neurological deterioration [6, 9, 6467]. In contrast,
in a controversial study comparing patients who had
spinal stabilisation in New Mexico, USA with patients in
Kuala Lumpur, Malaysia who had no spinal stabilisation,
Hauswald et al. demonstrated no protective effect from
stabilisation [68]. Nevertheless, taking into account the
existing evidence, the anatomical perspective as well as
decades of clinical experience, it is likely that the current
paradigm of spinal stabilisation has played a part in the
reduction of secondary neurological injury. The faculty
found no reason to abandon the strategy of external
spinal stabilisation. For the same reasons, after having
restored the patient to an anatomical position, it is
recommended that unnecessary patient handling and
movement is minimised. Authors have opined that work-
ing in accordance with such a minimal handling strategy
may not only reduce spinal movement but may also min-
imise pain as well as promote hemostasis [69].
Recommendation 3: Spinal stabilisation should
never delay or preclude life-saving intervention in
the critically injured trauma victim.
Rationale and evidence base
While the faculty recommends adhering to the prehospi-
tal stabilisation doctrine, it must also be recognised that
SCI is uncommon and that spinal stabilisation is not, in
itself, always a benign intervention [43, 46].
Spinal stabilisation may interfere with or delay life-saving
intervention
The incidence of SCI in hospitalised trauma victims has
been reported in the range of 0.5 to 3% [2]. Spinal stabil-
isation may preclude or delay the effective management
of life-threatening reversible insults such as airway com-
promise, hypoxemia, tension pneumothorax, cardiac
tamponade, haemorrhage or brain trauma which may re-
quire urgent prehospital or hospital interventions. Spinal
stabilisation has been associated with difficult airway
management, restricted thoracopulmonary function and
delayed time to intervention [42, 44, 7074]. In light of
this, spinal stabilisation must be de-emphasised in the
critically injured patient. While remaining important,
Fig. 1 Flowchart describing pre-hospital spinal stabilisation in patients with suspected spinal injury
Kornhall et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2017) 25:2 Page 4 of 11
spinal stabilisation should never interfere with or delay
life-saving intervention nor be allowed to cause or
worsen critical injury (Fig. 1).
Recognising time critical injury
Staging and defining time critical injury in trauma is
controversial. Identifying patients with critical injury that
are unlikely to tolerate prolonged extrication and spinal
stabilisation is ultimately up to the attending clinician.
Vital parameters may support the decision but should be
interpreted cautiously. Nevertheless, we have opted to
include a supporting definition of critical injury previ-
ously issued by The Norwegian Directorate of Health in
a guideline for the management of mass casualty inci-
dents. This definition is designed for individual triage, is
based on readily obtainable clinical findings and is
nationally recognised by our EMS [75].
Airway compromise, respiratory rate lower than 10 or
above 30 breaths per minute, pulse frequency above 120
beats per minute, absent radial pulses or no motor
response to verbal commands are signs suggestive of
time critical injury. Patients with injuries designated as
time critical should not suffer prolonged extrication or
evacuation due to spinal concerns. Importantly, this does
not imply that spinal precautions are entirely aban-
doned, but only applied to an extent and in a way that
does not delay extrication nor intervention.
The lateral trauma position
Historically, first responders without advanced airway
skills have placed unconscious or obtunded victims in
the recovery position in order to facilitate the clearance
of fluids and to maintain airway patency [45]. Unfortu-
nately, this contradicts the principle of spinal stabilisa-
tion in trauma victims as it generates unacceptable
spinal movement [76]. The lateral trauma position (LTP)
is a variation of the established recovery position that is
achieved using a modified two-person log-roll with man-
ual cervical spine control and, eventually, blankets and a
rigid collar for cervical stabilisation [77]. While the log-
roll involved may generate spinal motion, this may be
offset by the beneficial effects of gaining airway patency
and clearance. Clinicians not trained in advanced airway
management should be encouraged to consider the LTP
when transporting obtunded patients.
Recommendation 4: Victims of isolated penetrating
injury should not be immobilised.
Rationale and evidence base
Victims of isolated penetrating trauma suffer increased
mortality with routine spinal stabilisation [57]. In a 2010
retrospective review of hospitalised victims of penetrat-
ing trauma, Haut et al. demonstrated how patients with
penetrating injuries who had spinal stabilisation had
twice the mortality (14.7%) as those who were not
stabilised, likely through delaying transport to surgical
intervention. Moreover, the authors found that spinal
cord injury in isolated penetrating injury was extremely
rare at a rate of 0.01% of victims [74].
Recommendation 5: Triaging tools based on clinical
findings should be implemented.
Rationale and evidence base
Triaging tools
In order to address over-triage, authors have advocated
implementing triaging tools to assist in identifying
low-risk patients who do not require stabilisation
[41, 7881]. The National Emergency X-radiography
Utilisation Study (NEXUS) tool and the Canadian C-Spine
Rule Criteria (CCR) were originally developed to aid
physicians in determining which trauma patients require
imaging of the cervical spine [2, 82, 83]. Protocols similar
to NEXUS have proven to be useful triaging tools for
prehospital spinal stabilisation. Since the early 1990s the
Fresno/Kings/Madera EMS system in California have
implemented a selective stabilisation protocol similar to
NEXUS. In a 2001 retrospective review, Stroh and Braude
reported that this protocol had a 99% sensitivity for
the correct stabilisation of patients with actual cer-
vical injury [84]. In a prospective observational study
of EMS personnel in Maine, also using a tool similar
to NEXUS, Burton et al. found that the protocol sen-
sitivity for stabilisation of any spinal fracture was 87%
withanegativepredictivevalueof99.9%[85].
Triaging tools based on clinical findings reduce over-triage
Authors have recommended implementing tools that,
similar to NEXUS, are predominantly based on clinical
findings [78, 86, 87]. Tools that emphasise the mechan-
ism of injury result in over-triage without increasing
accuracy. In a prospective review of 498 trauma patients,
Hong et al. found that 95.4% of patients would have
been immobilised if EMS personnel had stabilised in
accordance with the mechanism based 7th edition
PHTLS criteria. In contrast, stabilisation in accordance
with protocols based on clinical findings, NEXUS or
Hankins protocols, would result in stabilisation rates of
68.7% and 81.5%, respectively. All patients with actual
spinal injury would have been stabilised using any of the
protocols [88]. In 1999, Muhr et al. reported how the
implementation of an out-of-hospital clearance protocol
based on clinical findings reduced stabilisation by one
third [87]. These and other reports provide evidence of
how EMS successfully can implement selective prehospi-
tal stabilisation strategies given that they are coupled
with training and clinical governance [8993]. The
faculty recommends applying the NEXUS criteria on the
entire spine for triage in the prehospital setting. In the
Kornhall et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2017) 25:2 Page 5 of 11
absence of midline tenderness, focal neurologic deficit,
altered level of consciousness, intoxication, and signifi-
cant distracting injury, it is safe to withhold stabilisation.
Recommendation 6: Cervical stabilisation may be
achieved using manual in-line stabilisation, head-
blocks, a rigid collar or combinations thereof.
Rationale and evidence base
The approach to cervical stabilisation should be in-
formed and selective, observing the pros and cons of
several techniques. The goal is to achieve stabilisation of
the cervical spine. The means will vary.
The efficacy and harms of the rigid cervical collar
No high quality studies have identified the true efficacy
of the rigid collar. The existing evidence is difficult to
compare due to variations in methodology and types of
collars tested [94]. However, numerous studies docu-
ment how the application of a rigid cervical collar will
limit motion in the cervical spine [34, 36, 95101]. It is
also apparent, from these same studies, that movement
restriction is limited. Moreover, there is a growing body
of evidence documenting harm. As rigid collars achieve
cervical stabilisation through compression of the man-
dible, mouth opening will be reduced. Thus, application
may impede breathing and airway management includ-
ing the clearing of vomit or secretions [43, 102]. Rigid
cervical collars can increase intracranial pressure by
inducing pain or through blocking cranial venous return
[103105]. In a study on cadavers with an artificially
induced unstable C1-C2 lesion, Ben-Galim et al. demon-
strated how cervical traction from a collar caused separ-
ation between C1 and C2, suggesting a mechanism that
could aggravate injury [106]. Severe neurological deteri-
oration has been reported in patients with ankylosing
spondylitis after receiving triple stabilisation [107, 108].
Finally, rigid collars may induce pain or discomfort that
may trigger non-compliance, agitation and even in-
creased spinal movement in some patients [109111].
Cervical collar use has also been associated with pres-
sure point ulceration, necrosis and mandibular nerve
palsy with prolonged use [112116].
The rigid collar should not be applied routinely
The aforementioned reports support a selective ap-
proach to rigid collar use. While collars are safe to use
in the majority of patients, they should be used select-
ively in patients with traumatic brain injury, airway com-
promise, ankylosing spondylitis or agitation. In such
cases the collar may be withheld or used intermittently.
The collar may provide support during certain manoeu-
vres, such as in stretcher transfers or during evacuation
from a vehicle, after which the collar may be opened or
removed [99, 117]. With adequate MILS this can be
achieved with minimal spinal displacement [118]. Trans-
port may proceed using only MILS and/or head blocks.
Holla et al. recently demonstrated how the addition of a
rigid collar did not result in improved movement restric-
tion in volunteers already strapped to a rigid stretcher
with head blocks [102]. Patients with a kyphotic spine,
such as in ankylosing spondylitis, should be stabilised in a
position similar to their habitual spinal curvature [108].
Recommendation 7: Transfer from the ground or
between stretchers systems should be achieved using
a scoop stretcher.
Rationale and evidence base
A significant amount of spinal motion is generated as
the patient is transferred from the ground onto or be-
tween stretcher systems or beds. Working in accordance
with a minimal handling strategy, clinicians must take
care to minimise spinal movement during these critical
stages of extrication.
The log-roll may generate undue spinal motion and should
be avoided in favour of alternative techniques
Log-rolling has traditionally been used to transfer the
patient onto or off stretcher systems or to gain access to
patients back for examination, despite authors questioning
its safety [119]. The log-roll is a potentially dangerous pro-
cedure as it may cause fracture dislocation, pain, distress
or clot disruption in patients with pelvic fractures or other
injuries. The diagnostic value is limited [69, 120, 121].
Moreover, as the head, hips and pelvis are of different
diameters, spinal motion is inherent to the technique, and
several studies have demonstrated how log-rolling gener-
ates more motion than readily available alternative tech-
niques such as lift-and-slide or scoop stretcher techniques
[122128]. The faculty believes that the potential spinal
motion generated by the log-roll may be further aggra-
vated in the prehospital setting where it is commonly per-
formed with limited personell and under difficult working
conditions. Usage of the technique in the prehospital con-
text should therefore be minimised, if not abolished.
For transfers from the ground or between stretcher
systems, we recommend employing a scoop stretcher
system. As the scoop stretcher is split vertically and then
reassembled underneath the patient, transfer from the
ground or between stretchers requires minimal or no
rolling [129]. Stabilisation and comfort has been demon-
strated to be comparable or better than that of the
classic backboard [122, 127, 130].
Recommendation 8: Patients with potential spinal
injury should be transported strapped supine on a
vacuum mattress or on an ambulance stretcher
system.
Recommendation 9: Hard surface stretcher systems
may be used for transports of shorter duration only.
Kornhall et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2017) 25:2 Page 6 of 11
Rationale and evidence base
We wish to differentiate between hard and soft surface
stretcher systems. Hard surface systems are those where
the patient is directly lying on hard plastic or metal
while soft surface systems have padding designed to
increase comfort and decrease point pressure.
Hard surface stretcher systems
The backboard was designed to facilitate extrication but
has since its inception been used as a transportation
device and quickly became the gold standard for spinal
stabilisation during transport [131, 132]. The literature,
on the contrary, suggests that it is not appropriate for
transports of longer duration. Within short time, pa-
tients will develop significant discomfort and moderate
to severe pain [133135]. Prolonged exposure may result
in pressure ulcers [136, 137]. Pain and discomfort may
also result in undue voluntary spinal movement [133].
The scoop stretcher, like the backboard, has hard surfaces
that could induce pain, discomfort or pressure point
injury. While it is an excellent extrication device and an
appropriate transportation device for short distances, for
longer duration transport the scoop stretcher, like the
backboard, should be removed after transferring the
victim onto a vacuum splint mattress or onto a standard
ambulance trolley.
Soft surface stretcher systems
The vacuum mattress, while not rigid enough for extri-
cation, is a useful transportation device. As vacuum is
applied, the mattress moulds to the patients contours,
minimising point pressure, making it more comfortable,
less painful and, arguably, less likely to produce ul-
ceration [73, 138141]. The vacuum mattress has
been shown to provide a similar, or superior, degree
of stabilisation when compared to that of the back-
board [132, 139, 140, 142].
Recommendation 10: Patients should under some
circumstances be invited to self-extricate from
vehicles.
Rationale and evidence base
The traditional approach to extrication of victims with
potential spine injury from vehicles or other settings has
been to stabilise the victim with a cervical collar and
then to carefully transfer the passive victim onto a back-
board for extrication [143].
Self-extrication
Over the years, authors have argued that this practice
often is unnecessary, resulting in prolonged extrication
times and avoidable complications related to spinal sta-
bilisation. Authors have argued that spinal movement
within the normal range of motion requires so little
energy, of many magnitudes less than the energy at the
initial impact, that it is highly unlikely to cause further
injury. Furthermore, the alert victims own muscular
tone will suffice to protect the spine from further injury
[41, 68, 144]. In 2013, the British Faculty of Pre-Hospital
care acknowledged this in a statement recommending
that the fully alert patient a potential spinal injury who
is without distracting injury, should be allowed to self-
extricate without external stabilisation [2]. Unfortu-
nately, such a position is supported by very few studies.
Shafer and Naunheim, in 2009, demonstrated how vol-
unteers stabilised only with a rigid collar who exited a
vehicle on their own volition, generated less spinal mo-
tion than when extricated using traditional assisted long-
board techniques [145]. More recently, Dixon et al., in a
biomechanical study on healthy volunteers found that
controlled self-extrication without collar generated less
movement in the cervical spine when compared to
equipment aided extrication techniques [146].
A generous approach to self-extrication
Despite the scant evidence, we recommend self-extrication
in some circumstances. As long as patients with back or
neck pain are not obtunded, not under the influence of any
drug, and without significant distracting injury, they should
be invited to self-extricate to a nearby stretcher system. The
prerequisite for self-extrication is that it is done under safe
conditions. Should there be concerns about safety, then
strategy defaults back to traditional extrication techniques.
The patients should, after lying down on a stretcher system,
have full external stabilisation for final evacuation and
transport as they may then be subject to external force that
may overwhelm their muscular protection.
Summary
This guideline, based on consensus and the best avail-
able evidence, is an attempt to address concerns about
over-triage, harms and costs associated with the trad-
itional management of potential spinal injury. The fac-
ulty found no reason to abandon the current doctrine of
spinal immobilisation in patients with potential spinal
injury. We do, however, recommend implementing pre-
hospital triaging tools as well as maintaining a selective
approach to the use of the various stabilisation devices.
Additional files
Additional file 1: Search engine vocabulary. (DOCX 108 kb)
Additional file 2: Table S1. Original studies identified in our search for
new literature. (DOCX 24 kb)
Additional file 3: Table S2. The systematic reviews that were identified
in our search for new literature. (DOCX 23 kb)
Additional file 4: Table S3. Original studies supporting our 10
recommendations. (DOCX 44 kb)
Kornhall et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2017) 25:2 Page 7 of 11
Abbreviations
EMS: Emergency medical services; MILS: (Manual In-Line Stabilisation);
PHTLS: Pre-Hospital Trauma Life Support; SCI: Spinal Cord Injury
Acknowledgements
We are indebted to Anita Saur Haukvik, senior librarian at Sørlandet Hospital,
for performing the literature search, and Hilde Strømme, senior librarian at
The Norwegian Knowledge Centre for the Heath Services for peer-reviewing
the literature search and their strategies.
Funding
Designing this guideline required travelling to six meetings. The Norwegian
National Competence Service for Traumatology has covered travel expenses
for these meetings.
Availability of data and materials
We have submitted our detailed search vocabulary and literature tables as
supplementary material. There is no other data nor material.
Competing interest
PKH has been involved in the development of the Lateral Trauma Position.
Other than that the faculty/authors have no competing interests to declare.
PKH devised the Lateral Trauma Position method, but has gained no
economic benefits thereof.
Authorscontributions
DKK, TB, JJJ and EJ are the main authors of this manuscript. All authors (DKK,
JJJ, EJ, TB, TH, TD, HA) have participated in the research and consensus
process. All authors have contributed to the drafting of this manuscript and
have approved this final version.
Consent for publication
This manuscript contains no individual persons data in any form.
Ethics approval and consent to participate
Not applicable as this manuscript is a literature review and a
clinical guideline.
Meetings
This guideline has been presented by PKH at the London Trauma
Conference 2016.
Grant
The authors have received no financial support.
Author details
1
East Anglian Air Ambulance, Cambridge, UK.
2
Department of Acute
Medicine, Nordland Central Hospital, Postboks 1480, 8092 Bodø, Norway.
3
Swedish Air Ambulance, Mora, Sweden.
4
Department of Traumatology, Oslo
University Hospital, Oslo, Norway.
5
Department of Vascular Surgery, Oslo
University Hospital, Oslo, Norway.
6
Neurosurgical Department, Oslo University
Hospital, Oslo, Norway.
7
Trauma Unit, Sørlandet Hospital, Kristiansand,
Norway.
8
Department of Research, Norwegian Air Ambulance Foundation,
Drøbak, Norway.
9
Department of Anesthesia and Intensive Care, Haukeland
University Hospital, Bergen, Norway.
10
Helicopter Emergency Medical
Services, Bergen, Norway.
11
Emergency Medical Services, University Hospital
of North Norway, Tromsø, Norway.
12
Norwegian National Advisory Unit on
Trauma, Oslo University Hospital, Oslo, Norway.
13
Department of Health
Studies, University of Stavanger, Stavanger, Norway.
Received: 11 October 2016 Accepted: 12 December 2016
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Kornhall et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2017) 25:2 Page 11 of 11
... Considering the potentially serious sequelae of TSI, historical pre-hospital and hospital guidelines recommend the application of full spinal immobilization using various orthotic devices (e.g. cervical collars (CC), sandbags, straps, backboards, splints, vacuum mattresses, etc.) during mobilizations and transfers of individuals with a suspected TSI (5,(9)(10)(11)(12)(13)(14). ...
... SMR objective is to reduce motion which may be achieved using manual in-line stabilization (MILS) without the addition of a cervical collar. Orthotic devices may be used as well but are not mandatory considering data now shows that the proposed bene ts of full immobilization do not always outweigh the related risks (10,(15)(16)(17)(18)(19). Spinal immobilization with a CC may lead to serious complications such as pressure ulcers, airway di culties, increased intracranial pressure, increased imaging and radiation exposure (14,(20)(21)(22)(23)(24)(25)(26)(27); neurologic aggravations in ankylosing spondylitis (28,29) and elderly patients (30,31); and increased mortality in penetrating trauma patients (18,32). ...
... According to these, ski patrollers should use a CC for rescues unless they can safely clear the C-spine before the victim extrication by assessing the risk factors for C-spine injuries. This is partly in line with the recommendations by the Wilderness Medical Society (17) (10). The First Aid Task Force in their 2020 revised recommendations on cervical motion restriction and manual in-line stabilization suggests against the use of cervical collars by rst aid providers (weak recommendation, very low-quality evidence) and concluded that there is insu cient evidence for or against manual in-line stabilization (34). ...
Preprint
Full-text available
Background: Alpine skiing rescues are unique because of the mountainous environment and risks of cervical spine motion (CSM) induced during victims’ extrication (EX) and downhill evacuation (DE). Current pre-hospital guidelines recommend the application of full spinal immobilization using various orthotic devices such as cervical collars (CC) when mobilizing and transfer+ring a victim with a suspected spine injury. The biomechanical benefits of applying CC in terms of spinal motion restriction during simulated alpine rescue are undocumented. Methods: Observational design of CSM measurement on a high-fidelity simulation mannequin with a motion sensors-instrumented cervical spine during simulated alpine skiing EX and DE. A total of 32 EXs and 4 DEs on different slope conditions were performed by six experienced active ski patrollers at a Canadian ski resort. The primary outcome was the 3D excursion vector (PeakΔθ) of the mannequin’s head. The secondary objectives were the time to extrication completion (tEX) depending on CC use and to identify which EX event is more likely to induce CSM. Results: PeakΔθ recorded during flat terrain EX using CC was 11.71° +/- 3.61° compared to 16.00° +/- 7.93° using MILS, and 18.29° +/- 9.78° for CC versus 17.90° +/- 4.16° using MILS on a steep slope. PeakΔθ with CC or using MILS during EXs were equivalent according to a 10 degrees non-inferiority hypothesis testing. Time to extrication completion (tEX) was significantly higher using CC as opposed to MILS for both flat and steep terrain conditions (100.6s vs. 219.2s and 106.2s vs. 268.8s longer respectively, 95% confidence interval). During DEs, CSM with and without CC across all terrain conditions were negligible (<5°). Task analysis during EX showed that when CC is used, its installation induces the highest CSM. When EXs are done using MILS without CC, the logroll initiation is the manipulation inducing the highest risk of CSM. Conclusion: For experienced ski patrollers, the biomechanical benefits of motion restriction provided by CC over MILS during alpine skiing rescues were found to be at best marginal and CC use negatively affected rescue time. Systematic use of CC during alpine rescue should be reconsidered.
... SMR may be achieved using manual in-line stabilization (MILS). Orthotic devices may be used as well but are challenged because data indicate that the proposed benefits do not always outweigh the related risks [7][8][9][10][11][12]. Cervical collars (CC) may lead to serious complications such as pressure ulcers, airway difficulties, increased intracranial pressure, increased imaging and radiation exposure [13][14][15][16][17][18][19][20][21]; neurologic aggravations in ankylosing spondylitis [22,23] and elderly patients [24,25]; and increased mortality in penetrating trauma patients [10,26,27]. ...
... Other guidelines include the Wilderness Medical Society [9] which despite its main recommendation in favor of the cervical collar, mentions that in some situations "[the cervical collar] should not be considered necessary if adequate immobilization can be accomplished by other means" which include manual in-line stabilization (MILS) [9]. Kornhall et al. [11] recently published prehospital Norwegian Guidelines emphasizing the limited evidence on CCs efficacy and supporting a selective approach to achieve timely rescues. The First Aid Task Force 2020 recommendations suggests against the use of cervical collars by first aid providers (weak recommendation, very low-quality evidence) and concluded that there is insufficient evidence for or against manual in-line stabilization [30]. ...
Article
Background: Alpine skiing rescues are challenging because of the mountainous environment and risks of cervical spine motion (CSM) induced during victims' extrications (EXs) and downhill evacuations (DEs). The benefits of applying a cervical collar (CC) over manual in-line stabilization without CC (MILS) in terms of spinal motion restriction during simulated alpine rescues are undocumented. Our hypothesis was that CSM recorded using MILS alone is non-inferior to CSM recorded with a CC according to a 10 degrees margin. Methods: A total of 32 alpine extrications and 4 downhill evacuations on different slope conditions were performed using a high fidelity mannequin designed with a motion sensors instrumented cervical spine. The primary outcome was the peak extrication 3D excursion angle (Peak 3D θEX,) of the mannequin's head. The secondary objectives were to describe the time to extrication completion (tEX) and to highlight which extrication manipulation is more likely to induce CSM. Results: The median Peak 3D θEX recorded during flat terrain extrications using CC was 10.77° (95% CI 7.31°-16.45°) compared to 13.06° (95% CI 10.20°-30.36°) using MILS, and 16.09° (95% CI 9.07°-37.43°) for CC versus 16.65° (95% CI 13.80°-23.40°) using MILS on a steep slope. Peak 3D θEX with CC or using MILS during extrications were equivalent according to a 10 degrees non-inferiority hypothesis testing (p < 0.05). Time to extrication completion (tEX) was significantly reduced using MILS without CC on a flat terrain with a median duration of 237,3 s (95% CI 197.8 s, 272.2 s) compared to 358.7 s (95% CI 324.1 s, 472.4 s). During downhill evacuations, CSM with and without CC across all terrain conditions were negligible (< 5°). When CC is used; its installation manipulation induces the highest CSM. When EXs are done using MILS without CC, the logroll initiation is the manipulation inducing the highest risk of CSM. Conclusion: For experienced ski patrollers, the biomechanical benefits of spinal motion restriction provided by CC over MILS during alpine skiing rescues appear to be marginal and CC use negatively affects rescue time.
... The most effective methods of spinal immobilisation are unclear, 4 but they typically include transfer and stabilisation of patients along a spinal board or an orthopaedic split device stretcher, as well as the selective application of a rigid cervical collar and head blocks and tape or straps. 3 The use of rigid collars is said to independently safeguard the cervical spine from adverse motion to a limited extent, 5 so are recommended in many prehospital care guidelines 1 2 5-7 and the Football Association (FA) Level 5 Advanced Trauma and Medical Management ...
... 3 These differing approaches may be because few studies support the beneficial effects of rigid collars on neurological and survival outcomes, compared with the mounting evidence of adverse effects, 9 such as airway compromise, increased intracranial pressure and patient distress. 5 However, the lack of high-quality evidence has made it difficult to establish the independent efficacy of rigid cervical collars as part of the immobilisation procedure. 5 9 The effects of rigid collars on cervical motion during immobilisation have been investigated with other devices such as spinal boards [10][11][12] or head blocks. ...
Article
Full-text available
When immobilisation after a cervical spine or head injury is required, the role of the rigid cervical collar is unclear and controversial. There is a need for further studies investigating the use of a rigid cervical collar when head and neck trauma occurs in sport. This study will compare present practice (immobilisation with a cervical collar) to the same procedure without a collar during a simulated spinal immobilisation and extraction scenario from the field of play to the side-line in football (soccer). It will use a prospective cohort within-subjects cross over randomised, controlled trial design. Healthy participants will assume the role of players with a head or neck injury. Clinical practitioners will perform the immobilisation and extrication procedure according to current clinical guidelines. Three dimensional linear and angular acceleration profiles of the head and torso will be measured and the time taken to complete the procedure. The interventions will be a ‘cervical collar’ or ‘no collar’ in random order. Data from the IMUs will be transferred wirelessly to a computer for analysis. Accordingly, within-subject differences between each condition (collar vs no collar) will be assessed with parametric or non-parametric inferential statistics. Statistical significance will be set at p<0.05. Trial registration number: ISRCTN16515969
... In Spain, annually serve approximately 28 million of pre-hospital emergencies (Ministry of Health, Social Services and Equality of Spain, 2016) and this makes it necessary that the nurses who treat these situations should be properly trained in specific techniques such as Basic and Advanced cardiopulmonary resuscitation (CPR), orotracheal intubation or attention to the polytraumathized patient. In addition, nurses must maintain updated permanently (McCaughey et al., 2010) their theoretical knowledge and practical skills (Abelsson et al., 2014;Brink et al., 2012;Kornhall et al., 2017) in that type of proceedings to be able to provide a proper service and quality. The competence of a nurse to assist emergency situations depends largely on, that has previously acquired theoretical knowledge to make appropriate decisions, as well as the corresponding practical skills to run swift and effective interventions (Gentil et al., 2008). ...
Article
Full-text available
The objective of this study is to identify the training received, as well as the limitations and difficulties self-perceived for primary care nurses to provide health care to emergency and disaster, as well as analyze the differences according to the different areas of work. A cross sectional study was conducted by a self-administered survey to a representative simple random sample (with replacement) of 269 nurses (n) working at the Primary Health Care centers out of the total of 730 nurses (N) that form the staff of nurses of Primary Health Care system of Asturias (Spain). In rural areas, the most frequently mentioned reasons were the lack of practical skills (18.9%) and the absence of adequate material (14.4%). In the semi-urban area, the most common reasons were the lack of practical skills (13.2%) and the lack of theoretical knowledge (10.3%). Finally, in the urban area, the main reasons were the lack of practical skills (14.4%) and the absence of adequate material (7.2%). The differences were significant (p =.025) among the three work context only in lack of theoretical knowledge. The degree of self-perception and acquisition of this knowledge and skills is heterogeneous, with clear differences in their field of work. 2022 88(1) 4
... According to the data from the current study, external stabilization in geriatric patients should still be recommended if an odontoid fracture is suspected. This recommendation is supported by several other studies in which the authors appeal for external stabilization of the cervical spine as spinal trauma cannot be excluded until the final diagnosis in the trauma center [16][17][18][19][20]. Based on the results of the current study, prehospital treatment without external stabilization may be discouraged [32,57] since cervical spine motion increases significantly due to instability. Cervical spine instability can lead to serious complications, as described above [31,35]. ...
Article
Full-text available
Background Along with the growing geriatric population, the number of odontoid fractures is steadily increasing. However, the effectiveness of immobilizing geriatric odontoid fractures using a cervical collar has been questioned. The aim of the present study is to analyze the physiological and pathological motion in odontoid fractures and to assess limitation of motion in the cervical spine when applying a cervical collar. Methods Motion analysis was performed with wireless motion tracker on unfixed geriatric human cadavers. First, a new geriatric type II odontoid fracture model was developed. In this model, the type II odontoid fracture is operated via a transoral approach. The physiological and pathological flexion and lateral bending of the cervical spine resulting from this procedure was measured. The resulting motion after external stabilization using a cervical collar was analyzed. Results The new geriatric type II odontoid fracture model was successfully established using seven unfixed human cadavers. The pathological flexion of the cervical spine was significantly increased compared to the physiological flexion ( p = 0.027). Furthermore, the flexion was significantly reduced when a cervical collar was applied. In case of flexion the mean remaining motion was significantly reduced ( p = 0.0017) from 41° to 14°. For lateral bending the mean remaining motion was significantly reduced ( p = 0.0137) from 48° to 18°. Conclusions In case of type II odontoid fracture, flexion and lateral bending of the cervical spine are increased due to spinal instability. Thus, if an odontoid fracture is suspected in geriatric patients, the application of a cervical collar should always be considered since external stabilization can significantly reduce flexion and lateral bending.
... The consensus was not to abandon a strategy of immobilisation but to adopt a selective approach with minimal handling to reduce spinal movement, reduce pain and potentially promote haemostasis. However, spinal stabilisation should 'never delay or preclude lifesaving interventions' (Kornhall et al., 2017). ...
Article
Background: Spinal cord injury (SCI) is a rare event, with high numbers of patients unnecessarily immobilised with no potential benefit based on limited evidence from the 1950s and 1960s. Contemporary opinion now challenges the notion that traditional immobilisation prevents movement and protects the spine. Current literature suggests that these methods which include semi-rigid collars can potentially cause more movement of the spine and harm the patient. The purpose of this study was to explore the views and perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar. Methods: Focus groups were used to allow individuals to discuss and comment on a new method of immobilisation which omits the semi-rigid collar and to capture the thoughts, feelings and experiences of participants. Thematic analysis of the coded transcriptions was used to identify emerging themes. Results: Three focus groups were conducted with 15 participants in each. Participants were all exposed to patients sustaining trauma within their professional roles. Six intertwined themes emerged from the analysis: communication, conflict, education/training, empowerment, risk and the patient. Woven between these themes are the complex interactions that bring together the inter-professional relationships with other emergency services and hospital staff, the patient, the public and pre-hospital care providers. Discussion: Existing immobilisation practices are being challenged, with clinicians empowered to tailor practice to meet specific patient needs. There is limited empirical evidence to support current immobilisation practices. Contemporary literature suggests current practices may potentially cause harm. New pragmatic immobilisation practices are gradually being adopted by some pre-hospital care providers. Conclusion: This study explored the perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar for potential SCI. The consensus of the participants supports a pragmatic approach to managing potential SCI that provides safe, high-quality patient-centred care.
Article
Full-text available
Introduction Spinal cord injury (SCI) is a life-altering injury that leads to a complex constellation of changes in an individual’s sensory, motor, and autonomic function which is largely determined by the level and severity of cord impairment. Available SCI-specific clinical practice guidelines (CPG) address specific impairments, health conditions or a segment of the care continuum, however, fail to address all the important clinical questions arising throughout an individual’s care journey. To address this gap, an interprofessional panel of experts in SCI convened to develop the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline. This article provides an overview of the methods underpinning the Can-SCIP Guideline process. Methods The Can-SCIP Guideline was developed using the Guidelines Adaptation Cycle. A comprehensive search for existing SCI-specific CPGs was conducted. The quality of eligible CPGs was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. An expert panel (n = 52) convened, and groups of relevant experts met to review and recommend adoption or refinement of existing recommendations or develop new recommendations based on evidence from systematic reviews conducted by the Spinal Cord Injury Research Evidence (SCIRE) team. The expert panel voted to approve selected recommendations using an online survey tool. Results The Can-SCIP Guideline includes 585 total recommendations from 41 guidelines, 96 recommendations that pertain to the Components of the Ideal SCI Care System section, and 489 recommendations that pertain to the Management of Secondary Health Conditions section. Most recommendations (n = 281, 48%) were adopted from existing guidelines without revision, 215 (36.8%) recommendations were revised for application in a Canadian context, and 89 recommendations (15.2%) were created de novo. Conclusion The Can-SCIP Guideline is the first living comprehensive guideline for adults with SCI in Canada across the care continuum.
Article
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Introduction Spinal cord injury (SCI) is a complex condition with substantial adverse personal, social and economic impacts necessitating evidence-based inter-professional care. To date, limited studies have assessed the quality of clinical practice guidelines (CPGs) within SCI. The aim of this study is to evaluate the quality of the development process and methodological rigour of published SCI CPGs across the care continuum from pre-hospital to community-based care. Methods Electronic health databases and indexes were searched to identify English or French language CPGs within SCI published within the last nine years with specific evidence-based recommendations applicable to the Canadian health care setting. Eligible CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Results A total of forty-one CPGs that met the inclusion criteria were appraised by at least four raters. There was high variability in quality. Twenty-seven CPGs achieved a good rigour of development domain score of >70%. Other standardized mean domain scores were scope and purpose (85.32%), stakeholder involvement (65.03%), clarity of presentation (84.81%), applicability (55.55%) and editorial independence (75.83%). The agreement between appraisers (intraclass correlation coefficient) was high (intraclass correlation coefficient > 0.80). Conclusion There is a paucity of CPGs that address community-based specialized rehabilitation and community reintegration. Furthermore, many CPGs only focus on a single impairment at one time point in the care continuum. As SCI is a complex condition that results in multimorbidity and requires health monitoring and intervention across the lifespan, a rigorously developed CPG that addresses high-quality, interprofessional comprehensive care is needed.
Article
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Objetivo: Descrever a elaboração de um protocolo de restrição de movimento de coluna (RMC) vertebral do Serviço de Atendimento Móvel de Urgência de Belo Horizonte. Relato da experiência: Trata-se de um relato de experiência sobre a construção de um protocolo de RMC vertebral. Foi realizada a busca na literatura das melhores evidências sobre o tema, seguida de análise crítica dos estudos e a construção de um fluxograma de decisão para indicação ou não de RMC vertebral. Ficou definido que a RMC vertebral será realizada sempre que a equipe atender pacientes, vítimas de trauma, que apresentarem ao menos uma das seguintes características: instabilidade na avaliação primária, idade maior que 65 anos, presença de dor em coluna, déficit de consciência, déficit sensitivo ou motor, deformidade na coluna, distração, dinâmica do trauma significativa. Considerações finais: Ficou evidente a importância de se construir um protocolo clínico para guiar os profissionais aos melhores cuidados aos pacientes acometidos por trauma, assim como a necessidade de mudança de paradigmas com relação ao manejo destas vítimas e por fim a redução do tempo para seu tratamento definitivo.
Article
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Background: Airway protection and spinal precautions are competing concerns in the treatment of unconscious trauma patients. The placement of such patients in a lateral position may facilitate the acquisition of an adequate airway. However, trauma dogma dictates that patients should be transported in the supine position to minimize spinal movement. In this systematic review, we sought to answer the following question: Given an existing spinal injury, will changing a patient's position from supine to lateral increase the risk of neurological deterioration? Methods: The review protocol was published in the PROSPERO database (Reg. no. CRD42012001190). We performed literature searches in PubMed, Medline, EMBASE, the Cochrane Library, CINAHL and the British Nursing Index and included studies of traumatic spinal injury, lateral positioning and neurological deterioration. The search was updated prior to submission. Two researchers independently completed each step in the review process. Results: We identified 1,164 publications. However, none of these publications reported mortality or neurological deterioration with lateral positioning as an outcome measure. Twelve studies used movement of the injured spine with lateral positioning as an outcome measure; eleven of these investigations were cadaver studies. All of these cadaver studies reported spinal movement during lateral positioning. The only identified human study included eighteen patients with thoracic or lumbar spinal fractures; according to the study authors, the logrolling technique did not result in any neurological deterioration among these patients. Conclusions: We identified no clinical studies demonstrating that rotating trauma patients from the supine position to a lateral position affects mortality or causes neurological deterioration. However, in various cadaver models, this type of rotation did produce statistically significant displacements of the injured spine. The clinical significance of these cadaver-based observations remains unclear. The present evidence for harm in rotating trauma patients from the supine position to a lateral position, including the logroll maneuver, is inconclusive.
Article
Full-text available
Airway compromise is a leading cause of death in unconscious trauma patients. Although endotracheal intubation is regarded as the gold standard treatment, most prehospital providers are not trained to perform ETI in such patients. Therefore, various lateral positions are advocated for unconscious patients, but their use remains controversial in trauma patients. We conducted a systematic review to investigate whether the supine position is associated with loss of airway patency compared to the lateral position. The review protocol was published in the PROSPERO database (Reg. no. CRD42012001190). We performed literature searches in PubMed, Medline, EMBASE, Cochrane Library, CINAHL and British Nursing Index and included studies related to airway patency, reduced level of consciousness and patient position. We conducted meta-analyses, where appropriate. We graded the quality of evidence with the GRADE methodology. The search was updated in June 2014. We identified 1,306 publications, 39 of which were included for further analysis. Sixteen of these publications were included in meta-analysis. We did not identify any studies reporting direct outcome measures (mortality or morbidity) related to airway compromise caused by the patient position (lateral vs. supine position) in trauma patients or in any other patient group. In studies reporting only indirect outcome measures, we found moderate evidence of reduced airway patency in the supine vs. the lateral position, which was measured by the apnea/hypopnea index (AHI). For other indirect outcomes, we only found low or very low quality evidence. Although concerns other than airway patency may influence how a trauma patient is positioned, our systematic review provides evidence supporting the long held recommendation that unconscious trauma patients should be placed in a lateral position.
Article
Background Spinal immobilisation during extrication of patients in road traffic collisions is routinely used despite the lack of evidence for this practice. In a previous proof of concept study (n=1), we recorded up to four times more cervical spine movement during extrication using conventional techniques than self-controlled extrication. Objective The objective of this study was to establish, using biomechanical analysis which technique provides the minimal deviation of the cervical spine from the neutral in-line position during extrication from a vehicle in a larger sample of variable age, height and mass. Methods A crew of two paramedics and four fire-fighters extricated 16 immobilised participants from a vehicle using six techniques for each participant. Participants were marked with biomechanical sensors and relative movement between the sensors was captured via high-speed infrared motion analysis cameras. A three-dimensional mathematical model was developed and a repeated-measures analysis of variance was used to compare movement across extrication techniques. Results Controlled self-extrication without a collar resulted in a mean movement of 13.33° from the neutral in-line position of the cervical spine compared to a mean movement of 18.84° during one of the equipment-aided extrications. Two equipment-aided techniques had significantly higher movement (p<0.05) than other techniques. Both height (p=0.003) and mass (p=0.02) of the participants were significant independent predictors of movement. Conclusions These data support the findings of the proof of concept study, for haemodynamically stable patients controlled self-extrication causes less movement of the cervical spine than extrications performed using traditional prehospital rescue equipment.
Article
Standards: There is insufficient evidence to support treatment standards. Guidelines: There is insufficient evidence to support treatment guidelines. Options: All trauma patients with a cervical spinal column injury or with a mechanism of injury having the potential to cause cervical spine injury should be immobilized at the scene and during transport by using one of several available methods. A combination of a rigid cervical collar and supportive blocks on a backboard with straps is effective in limiting motion of the cervical spine and is recommended. The long-standing practice of attempted cervical spine immobilization using sandbags and tape alone is not recommended.