References

Bell KM, Frazier EC, Shively CM, Hartman RA Assessing range of motion to evaluate the adverse effects of ill-fitting cervical orthoses. The Spine Journal. 2009; 9:(3)225-31 https://doi.org/10.1016/j.spinee.2008.03.010

Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. The Journal of Trauma: Injury, Infection, and Critical Care. 2010; 69:(2)447-50 https://doi.org/10.1097/ta.0b013e3181be785a

Benger J, Blackham J Why do we put cervical collars on conscious trauma patients?. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2009; 17:(1) https://doi.org/10.1186/1757-7241-17-44

Biller D, Jacobson R Complications from pre-hospital immobilization. Journal of Paramedic Practice. 2012; 4:(5)277-82 https://doi.org/10.12968/jpar.2012.4.5.277

Blackham J, Benger J ‘Clearing’ the cervical spine in conscious trauma patients. Trauma. 2009; 11:(2)93-109 https://doi.org/10.1177/1460408608101856

Why EMS should limit the use of rigid cervical collars. 2015. http//www.jems.com/articles/print/volume-40/issue-2/patient-care/why-ems-should-limit-use-rigid-cervical.html (Accessed 20 February 2017)

The Evidence Against Backboards. 2013. http//www.emsworld.com/article/10964204/prehospital-spinal-immobilization (Accessed 20 February 2017)

Brown S UK Ambulance Service Clinical Practice Guidelines 2016.Warwick: Bridgwater: Class Professional; 2016

Campbell JE International trauma life support for emergency care providers (7th edition), 7th edn. Boston, MA, United States: Prentice Hall; 2011

Chan M, Al-Buali W, Charyk Stewart T, Singh RN Cervical spine injuries and collar complications in severely injured paediatric trauma patients. Spinal Cord. 2013; 51:(5)360-4 https://doi.org/10.1038/sc.2013.6

Chen Y, Ying Tang MS, Vogel L, DeVivo MJ Causes of spinal cord injury. Topics in Spinal Cord Injury Rehabilitation. 2013; 19:(1)1-8 https://doi.org/10.1310/sci1901–1

Connor D Prehospital spinal immobilisation: An initial consensus statement. Trauma. 2015; 17:(2)146-50 https://doi.org/10.1177/1460408614556441

Cowley A Self-extrication in road traffic collisions: Do we really need to cut the roof off?. Journal of Paramedic Practice. 2014; 6:(11)584-8 https://doi.org/10.12968/jpar.2014.6.11.584

Davies G, Deakin C, Wilson A The effect of a rigid collar on intracranial pressure. Injury. 1996; 27:(9)647-9 https://doi.org/10.1016/s0020-1383(96)00115–5

Deasy C, Cameron P Routine application of cervical collars – what is the evidence?. Injury. 2011; 42:(9)841-2 https://doi.org/10.1016/j.injury.2011.06.191

Dixon M, O'Halloran J, Hannigan A, Keenan S, Cummins M Confirmation of suboptimal protocols in spinal immobilisation?. Emergency Medicine Journal. 2015; 2014-204553 https://doi.org/10.1136/emermed-2014–204553

Dixon M, O'Halloran J, Cummins NM Biomechanical analysis of spinal immobilisation during prehospital extrication: A proof of concept study. Emergency Medicine Journal. 2013; 31:(9)745-9 https://doi.org/10.1136/emermed-2013–202500

Emergency care institute for New South Wales. C Spine Collars. 2016. https//www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/orthopaedic-and-musculoskeletal/cspine-collars (Accessed 27 February 2017)

Farrington D Death in a ditch. American College of Surgeons. 1967; 52:(3)121-30

Goutcher CM Reduction in mouth opening with semi-rigid cervical collars. British Journal of Anaesthesia. 2005; 95:(3)344-8 https://doi.org/10.1093/bja/aei190

Hauswald M, Ong G, Tandberg D, Omar Z Out-of-hospital spinal Immobilization: Its effect on Neurologic injury. Academic Emergency Medicine. 1998; 5:(3)214-9 https://doi.org/10.1111/j.1553-2712.1998.tb02615.x

Hauswald M, Braude D Spinal immobilization in trauma patients: Is it really necessary?. Current Opinion in Critical Care. 2002; 8:(6)566-70 https://doi.org/10.1097/00075198-200212000–00014

Standards of proficiency – Paramedics. 2014;

NEXUS criteria for c-spine imaging. 2016. http//www.mdcalc.com/nexus-criteria-for-c-spine-imaging/ (Accessed 20 February 2017)

James C, Riemann B, Munkasy B, Joyner B Comparison of Cervical Spine Motion During Application Among 4 Rigid Immobilization Collars. Journal of Athletic Training. 2004; 39:(2)138-45

Kolb JC, Summers RL, Galli RL Cervical collar-induced changes in intracranial pressure. The American Journal of Emergency Medicine. 1999; 17:(2)135-7 https://doi.org/10.1016/s0735-6757(99)90044-x

Kwan I, Bunn F Effects of Prehospital spinal Immobilization: A systematic review of Randomized trials on healthy subjects. Prehospital and Disaster Medicine. 2005; 20:(01)47-53 https://doi.org/10.1017/s1049023x00002144

Spinal immobilisation for trauma patients'. 2001. https://doi.org/10.1002/14651858.CD002803 (Accessed 20 February 2015)

Lovegrove M, Davis J Paramedic Evidence Based Education Project (PEEP).Buckinghamshire: Allied Health Solutions; 2013

Manoach S, Paladino L Manual in-line stabilization for acute airway management of suspected cervical spine injury: Historical review and current questions. Annals of Emergency Medicine. 2007; 50:(3)236-45 https://doi.org/10.1016/j.annemergmed.2007.01.009

March J, Ausband S, Brown L Changes in physical examination caused by use of spinal immobilization. Prehospital Emergency Care. 2002; 6:(4)421-4

Mobbs RJ, Stoodley MA, Fuller J Effect of cervical hard collar on intracranial pressure after head injury. ANZ Journal of Surgery. 2002; 72:(6)389-91 https://doi.org/10.1046/j.1445-2197.2002.02462.x

Morris C, McCoy W, LAvery G Spinal immobilisation for unconscious patients with multiple injuries. BMJ. 2004; 329:(7469)495-9 https://doi.org/10.1136/bmj.329.7469.773

Research suggests time for change in Prehospital spinal Immobilization. 2013. http//www.jems.com/articles/print/volume-38/issue-3/patient-care/research-suggests-time-change-prehospita.html (Accessed 20 February 2016)

NICE. Spinal injury: Assessment and initial management. 2016. https//www.nice.org.uk/guidance/NG41# (Accessed 27 February 2017)

Papadopoulos MC Lesson of the week: Exacerbating cervical spine injury by applying a hard collar. BMJ. 1999; 319:(7203)171-2 https://doi.org/10.1136/bmj.319.7203.171

PHTLS: Prehospital trauma life support [With DVD] - 7th edition, 7th edn. United States: Elsevier Health Sciences; 2010

Plumb J.O.M., Morris C.G. ‘Cervical collars: Probably useless; definitely cause harm!’. The Journal of Emergency Medicine. 2013; 44:(1) https://doi.org/10.1016/j.jemermed.2012.05.031

Queensland Ambulance Service (QAS). Spinal Immobilisation: Evidence Review. Queensland, Australia: Queensland Government. 2014. https//prehospitalandretrievalmedicine.files.wordpress.com/2015/05/spinal-immobilisation_evidence-review_170314_v3_eem.pdf (Accessed 27 February 2017)

Queensland Ambulance Service (QAS). Clinical practice procedures: Trauma/cervical collar disclaimer and copyright. 2016. https//www.ambulance.qld.gov.au/%5Cdocs%5Cclinical%5Ccpp%5CCPP_Cervical%20collar.pdf (Accessed 20 February 2017)

Rhee P, Kuncir EJ, Johnson L, Brown C Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. The Journal of Trauma: Injury, Infection, and Critical Care. 2006; 61:(5)1166-70 https://doi.org/10.1097/01.ta.0000188163.52226.97

Evidence against routine spinal Immobilization. 2012. http//www.emsworld.com/article/10813735/evidence-against-routine-spinal-immobilization (Accessed 10 May 2015)

Stiell IG, Clement C, McKnight D, Brison R The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma. New England Journal of Medicine. 2003; 349:(26)2510-8 https://doi.org/10.1056/nejmoa031375

Stone MB, Tubridy CM, Curran R The effect of rigid cervical collars on internal Jugular vein dimensions. Academic Emergency Medicine. 2010; 17:(1)100-2 https://doi.org/10.1111/j.1553-2712.2009.00624.x

Sugarman D, Totten V Respiratory effects of spinal immobilization. Prehospital Emergency Care. 1999; 3:(4)347-52

Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K Prehospital use of cervical collars in trauma patients: A critical review. Journal of Neurotrauma. 2014; 31:(6)531-40 https://doi.org/10.1089/neu.2013.3094

THE CURSE OF THE CERVICAL COLLAR. 2013. http//www.scancrit.com/2013/10/10/cervical-collar/ (Accessed 2 July 2015)

Thumbikat P, Hariharan RP, Ravichandran G, McClelland MR, Mathew KM Spinal Cord Injury in Patients With Ankylosing Spondylitis. Spine. 2007; 32:(26)2989-95

William Marsh Rice University. Students focus on creating a better cervical collar. 2012. http//news.rice.edu/2012/04/09/students-focus-on-creating-a-better-cervical-collar-2/ (Accessed 7 November 2015)

No place for the rigid cervical collar in pre-hospital care

02 May 2017
Volume 7 · Issue 1

Abstract

The cervical collar was introduced to pre-hospital practice in 1967. It has been widely acknowledged that evidence supporting its use has been lacking, and that its use was therefore based upon hypothetical benefit. However, modern evidence challenges the very principle of immobilisations on which the collar's use was justified, and argues that the cervical collar is an ineffective immobilisation tool regardless. Cervical collars have always been thought to be a relatively harmless measure, and their precautionary use therefore encouraged in order to protect those few patients who have sustained an injury. Yet, there is an increasing volume of evidence to say that the application of cervical collars can be harmful to patients. An assessment of today's evidence justifies an immediate change of practice, and EMS providers across the world are adapting accordingly. The UK remains entrenched in rigid trauma protocol, which is not consistent with the principles of patient safety, evidence-based practice or the HCPC's Standards of Proficiency for Paramedics. Practice change is well overdue.

This review article describes how the rigid cervical collar was introduced to practice, and explains the rationale for its inception. The same rationale is then critically analysed against a range of modern evidence challenging the validity and safety of the rigid collar. Practice changes across the world are highlighted, and relevant UK based guidance reviewed.

In 1967, Dr JD Farrington, an orthopaedic surgeon at Lakeland Memorial Hospital in Wisconsin, published a paper entitled ‘Death in a Ditch’ (Farrington, 1967). He explained that the purpose of his paper was to standardise pre-hospital training, equipment and practice which he appeared to attribute to an increased mortality\morbidity rate within his community. In particular, Farrington explains that physicians must apply a cervical collar in order to prevent the ‘sloppy and inefficient removal of a victim from their vehicle’. Whilst immobilisation principles and makeshift collars were used in the Vietnam war during the early 1960s (William Marsh Rice University, 2012), Farrington appears to be the first to recommend its practice in civilian medicine (Bledsoe, 2013).

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