BACKGROUND For over 30 years, the cervical spine immobilisation
collar (c-collar) has been the hallmark of excellence in pre-trauma
care. However, pre-existing research and evidence for this practice
is limited1. There is a growing body of evidence against the use of
the c-collar that causes more harm than good. Do we over use the
c-collar? If so, can nurses safely remove c-collars at triage?
Could the unthinkable be happening? IS THE C-COLLAR DEAD AND MERELY
AN ALERT TO STAFF THAT THE WEARER MAY HAVE A CERViCAL SpiNE iNjuRY
(CSi)?
What are you talking about? They are great. •Safe and effective
•Hallmark of high quality trauma patient care•A big part of
Emergency Medicine training•A (and c-spine immobilisation) BC very
powerful
mnemonic•Better to have a protocol which is straight
forward and uniform than an individualised one
What about the risk of Spinal Cord Injury (SCI)? •SCI is feared
because of the risk of permanent,
life threatening or changing consequence for the patient
•Medico legal and malpractice concerns especially in the U.S.
though less so in N.Z.2
What’s wrong with them?•Uncomfortable with prolonged
immobilisation •Probably do not prevent SCI•Often poorly fitted•Can
be confusion around fixing head and neck
with tape (old practice)•Risk of pressure necrosis in head,
heels and
sacrum with long immobilisation3. Increase in intracranial
pressure (ICP)
•Compression of jugular veins and decrease of venous return
•Poor access to neck during airway interventions.
AUDitA recent two month audit undertaken in Wellington ED
measuring 46 patients with c-collars applied (Dec 2013 - Jan
2014)
CURReNt pRACtiCe iN WelliNGtON eDUnconscious patient with
c-collar•Full protection – collar, ( rigid or Philadelphia)•Spinal
roll
Conscious patient•Acute injury comes in collar and remains so
until
clinically cleared (Canadian or NEXUS guidelines- more on this
later)
•IF NOT CLEARED – stays in either rigid or Philadelphia collar
with spinal precautions.
Delayed •Patient presentation to ED walking/talking – no
collar even if positive ‘Rules’ criteria or •If truly dangerous
mechanism of injury (MOI) of
other red flag, apply Philadelphia collar BUT do not insist on
lying flat or other precautions
Can ED nurses safely examine c-spines using reliable
guidelines?
A large three year clinical trial undertaken in six Canadian EDs
concluded that using the Canadian guidelines by triage nurses was
‘accurate, reliable and clinically acceptable’ .4 This is supported
by another study Pitt et al (2006) using the NEXUS clinical
decision making rules. Both studies showed no patient who was
assessed by the triage nurses using either tool had a SCI.
Teaching plan to ED nurses using the Canadian C-Spine Rule in
Wellington ED
Full study day by Nurse Educator and Senior Doctor with emphasis
on cervical spine anatomy, Canadian C-Spine Rule and individual
teaching followed by supervision.
CONClUsiON Simple criteria can be used by ED nurses to examine
and clear c-spines. The early, active intervention of clearing
c-spines will reduce the time patients spend immobilised in ED and
ultimately improve patient quality of care. Clearing c-spines by
using the Canadian guidelines will de-emphasize the importance of
the c-collar in an alert and conscious patient.
Can ED nurses safely remove c-collars at triage?
Marion Picken - Nurse Educator (RN, MA Nursing) Zaffer Malik -
(RN) Wellington Emergency Department
Fig 1 Pressure sores related to immobilisation. The elderly
patient shown here died principally because of the consequences of
his deep and extensive pressure ulcer. He had no spinal injury. The
application of a spinal board and prolonged supine positioning were
important risk factors. (BMJ 2004;329:495).
Canadian C-Spine RuleCanadian C-Spine RuleFor alert (GCS=15) and
stable trauma patients where cervical spine injury is a concern.1.
Any High-Risk Factor WhichMandates Radiography?
Age ≥ 65 yearsor
Dangerous mechanism*or
Paresthesias in extremities
2. Any Low-Risk Factor Which AllowsSafe Assessment of Range of
Motion?Simple rearend MVC**
orSitting position in ED
orAmbulatory at any time
orDelayed onset of neck pain***orAbsence of midline c-spine
tenderness
3. Able to Actively Rotate Neck?45° left and right
No Radiography
Rule Not Applicable If:- Non-trauma cases- GCS < 15- Unstable
vital signs- Age < 16 years- Acute paralysis- Known vertebral
disease- Previous C-spine surgery
* Dangerous Mechanism:- fall from elevation ≥ 3 feet / 5 stairs-
axial load to head, e.g. diving- MVC high speed (>100km/hr),
rollover, ejection- motorized recreational vehicles- bicycle struck
or collision
** Simple Rearend MVC Excludes:- pushed into oncoming traffic-
hit by bus / large truck- rollover- hit by high speed vehicle ***
Delayed:- i.e. not immediate onset of neck pain
No
Yes
Able
No
Yes
Unable
Radiography
Stiell IG, Clement CM, McKnight RD, Wells GA, Brison R, Schull
M, Rowe B, Worthington J, Eisenhauer M, Cass D, Greenberg G,
MacPhail I, Dreyer J, Lee J, Bandiera G, Reardon M, Holroyd B,
Lesiuk H. Comparative Validation of the Canadian C-Spine Rule
and the NEXUS Low-Risk Criteria in Alert and Stable Trauma
Patients. New Engl J Med 2003; in press.
10242 OTT. HEALTH -8x10s 11/6/03 2:16 PM Page 1
Thanks to: Dr’s Andre Cromhout and Daniel Watson FACEM’s
Wellington ED.
References: Sundstrom, T., Asbjornsen, H., Habiba, S., Sunde,
G., Wester, K. (2014). Prehosptial use of Cervical Collars in
Trauma Patients: A Critical Review. Journal of Neurotrauma. 31:531
- 540.
Pitt, E., Pedley, A., Nelson, M., Cumming, M., Johnson, M.(
2006). Removal of C-spine protection by A & E triage nurses: a
prospective trial of a clinical decision making instrument.
Emergency Medical Journal 23: 214-215
Stiell, I., Clement, C Flanagan, B., Marshall, S. (2010).
Simulation-based education for building clinical teams. Journal of
Emergencies, Trauma, and Shock. 3(4), P. 360 -368.
Marion Picken, Nurse Educator, Wellington ED, Riddiford St
Newtown, Wellington South. [email protected] ph: 04 385
5999 ext 6464
Zaffer Malik, Registered Nurse, Wellington ED, Riddiford St
Newtown, Wellington South. [email protected] ph:04 385 5999
ext 5838
Notes:
1 Pitt, Pedley, Nelson, Cummings, Johnson (2006) 2 Sunstrom,
Ashbjornsen, Habiba, Sunde, Wester (2014)3 Morris, McCoy, Lavery
(2004) 4 Steill, Clement, O’Connor, Davies, Leclair, Sheenhan,
Clavet, Beland, Mckenzie, Wells (2010)
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