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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 it’s 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 [5–15]. Through
adding external supports to the victim’s body before
extrication, treatment and transport to hospital, clini-
cians aim to reduce spinal movement and prevent
further secondary injury [16–19]. 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 [20–24]. 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
[25–32]. While numerous other devices exist, this
combination is widely implemented [33–39].
Many authors have raised concerns over this strategy and
have questioned its efficacy, over-triage, costs and potential
harmful effects [40–45]. 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
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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 [48–52].
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 practice’in 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, 54–56]. 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
committees’searches 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, 57–59].
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 trusts’ambulance 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, 60–63]. 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, 64–67]. 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, 70–74]. 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, 78–81]. 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 [89–93]. 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, 95–101]. 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
[103–105]. 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 [109–111].
Cervical collar use has also been associated with pres-
sure point ulceration, necrosis and mandibular nerve
palsy with prolonged use [112–116].
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
[122–128]. 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 [133–135]. 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 patient’s contours,
minimising point pressure, making it more comfortable,
less painful and, arguably, less likely to produce ul-
ceration [73, 138–141]. 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 victim’s 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.
Authors’contributions
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 person’s 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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