THE FINAL ON SPINAL: ARC Recommendations
Recent changes to the Australian Resuscitation Council (ARC) Guideline in respect of acute management of spinal injuries deserves comment. The latest policy is reflected in “ANZCOR Guideline 9.1.6 – Management of Suspected Spinal” Injury dated January 2016 http://resus.org.au/guidelines/
4.1 Cervical Collars
The use of semi rigid (SR) cervical collars by first aid providers should be reviewed, based on their Consensus on Science and Treatment Recommendations (CoSTR 2015) finding: “weak recommendation, low quality evidence”.
ANZCOR recommends all rescuers in the pre-hospital environment review their approach to the management of suspected spinal injury with regards to SR cervical collars. Consistent with the first aid principle of preventing further harm, the potential benefits of applying a cervical collar do not outweigh harms such as increased intracranial pressure, pressure injuries or pain and unnecessary movement that can occur with the fitting and application of a collar.
In suspected cervical spine injury, ANZCOR recommends that the initial management should be manual support of the head in a natural, neutral position, limiting angular movement (expert consensus opinion).
In healthy adults, padding under the head (approximately 2cm) may optimise the neutral position.
The potential adverse effects of SR cervical collars increase with duration of use and include:
- unnecessary movement of the head and neck with the sizing and fitting of the collar
- discomfort and pain
- restricted mouth opening and difficulty swallowing
- airway compromise should the victim vomit
- pressure on neck veins raising intra-cranial pressure (harmful to head injured victims)
- hiding potential life-threatening conditions.
Their recommendations are based on their own Consensus on Science and Treatment Recommendations Committee (CoSTR 2015) finding “weak recommendation, low quality evidence”. Weak evidence that using a Cervical Collar works. Well, no surprise here…………..it is impossible to test in practice, and studies to this affect use uninjured volunteers, cadavers and radiological findings. The Gold Standard of Randomised Controlled Trial (RCT) would mean some people getting collars after trauma and some not (control group) and is clearly untenable.
So in these cases, if we can’t test the hypothesis, go back to first principles. Professor John Yeo, Australia’s (foremost expert on spinal injury and Founding Necksafe Patron) went along to the NSW Ambulance Service last year to discuss their spinal management policy. Professor Yeo reminded them:
“You simply cannot ignore the anatomy…..the spinal cord is at risk when the neck is FLEXED and ROTATED…this must be prevented AT ALL COSTS”
This has meant limiting as much movement as possible, (accepting that full “immobilisation” is not achievable) and principle flexion and rotation. To do this, the teaching has always been that this is best achieved AT, ABOVE and BELOW the level of injury, using a properly fitted semi-rigid Cervical Collar, spineboard with (4) correctly applied straps and a head immobilisation device (or “headbed”). Examples of improperly applied collars and spineboards do not prove that they don’t work, but highlight the importance of getting the skills correct.
The alternatives (soft collars, or in some jurisdictions, no collar) seems to decrease the limitation of flexion/rotation to the patient’s spine and could (potentially at least, and bearing in mind the mechanism of injury) exacerbate the spinal cord compromise.
Certainly, prolonged positioning on a spineboard is to be avoided, and the vacuum mattress offers an alternative. Few of these seem in use in metropolitan ambulance services in Australia, and in any case one would expect the transport times to be short enough to limit time spent on the spineboard. Aeromedical services more regularly use vacuum mattresses, achieving the dual goals of limiting movement and preventing pressure areas.
The ARC recommendation suggests that Manual Inline Support (provided as INITIAL stabilisation) can be maintained throughout the process of attending to a casualty, moving them to safety, handing over to ambulance officers, transporting to hospital and transferring into the Emergency Department, all with one person rigidly and unmovingly fixed to the head of the patient, supporting the neck without adverse movement. This is unrealistic in the pre-hospital world, and the question remains whether a soft collar (or no collar) is adequate in the moving environment of an ambulance and multiple lifts onto and off stretchers? The Head Immobilisation Device (“headbed” ) offers a solution, and particularly in the back of an ambulance where a single officer may have to log-roll a patient whose airway is compromised, a “packaged” patient can be controlled more readily than one lying with relatively little restraint on a soft mattress of the gurney.
So at present there is no perfect solution, and plenty of detractors for the use of semi-rigid collars, but little in the way of alternative.
Regarding the “potential adverse effects” of semi-rigid cervical collars, the references cited also show a lack , i.e. “CoSTR 2015, weak recommendation, low quality evidence”. In other words, the ARC propose NOT using cervical collars because of “weak evidence”, and support this with (weakly evidenced) potential adverse effects.
The price of getting it wrong, $20 million and rest-of-life misery for the patient and all those around them seems too much to risk. Being over-cautious a thousand times rather than getting it wrong once is the concept. Stroh’s 2001 study showed that adverse outcomes were experienced in 5 of 861 patients, including one resulting in residual quadriparesis, and original Australian work by Toscano highlighted that inadequate recognition and inadequate immobilisation were the likely causes of neurological deterioration in nearly 25% of spinal cord injured patients he studied.
So, what can we conclude?
- There does not appear to be enough justification for changing management of suspected spinal injury, although each case should be managed individually
- Suspected spinal injuries meeting should be immobilised to the best of our abilities, with Manual Inline Support initially and then, from a practical standing, utilising the relatively low-cost aids for immobilisation we have at our disposal:
- semi-rigid cervical collars
- spineboards and straps
- head immobilisation devices
- all properly applied by trained personnel
- If equipment it’s not available, the principles of maintaining the neck in the neutral position using whatever means are to hand are to be respected to prevent flexion and rotation of the neck
- Patients should not be on spineboards for longer than necessary, vacuum mattresses offer an alternative