The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces

Where Do We Stand on Cervical Spine Immobilisation? A Questionnaire among Prehospital Staff

Background: Cervical collars (CC) are routinely used in prehospital trauma treatment. However, over the past years, their application was discussed more critically since they increase intravenous pressure due to reduced venous drainage and the possibility of secondary cervical spine injury. Guidelines have been adjusted accordingly. The question is how efficient has this been put into practice, and how good, as well as up to date, is the knowledge of prehospital emergency medicine personnel about indications on cervical spine immobilisation? Methods: A 15-item questionnaire regarding the self-evaluation and result checking of the right indications for the use of a cervical collar in the prehospital setting was sent to paramedics and emergency doctors in Germany. Two hundred and nineteen completed surveys were statistically analysed. Results: Mean age of the participants was 30.45 ± 8.8. 72% were male. Regarding subjective safety, the appropriate indication of CC participants reached 79.8 ± 19.5 on a metric scale from 0 (no safety) to 100 (full safety). Mean right answers were as follows: Ambulance man (RS) 0.78 ± 0.84, paramedic (RA) 0.9 ± 0.74, paramedic (NFS) 1.03 ± 0.83 and emergency doctor (ED) 1.75 ± 1.06 (p = 0.013, Kruskal-Wallis Test). Participants who estimated their knowledge < 85% had 0.83 ± 0.8 right answers, and > 85% had 1.14 ± 0.9 right answers. Conclusions: Rational spine immobilisation is still necessary in severely injured patients. This study highlights the importance of continuing education using ongoing training, lectures or online learning with a questionnaire as a monitor for success to ensure the transfer of evidence-based medicine into daily practice.

The Management of Cervical Spine Injuries - A Literature Review

Due to the inherent bony instability of the cervical spine, there is an over-reliance on ligamentous structures for stability, making this segment of the vertebral column most prone to traumatic injuries. The frequently occurring mechanisms of injury include axial compression, hyper-flexion, hyper-extension, and rotational type injuries. Good pre-hospital care and a thorough assessment in the emergency department of patients suspected to have a cervical spine injury (CSI) leads to improved clinical outcomes. The objective of the initial evaluation of a patient with a suspected CSI is to identify the presence of injuries through thorough clinical and radiologic assessments as missed injuries are potentially catastrophic. The treatment of cervical spine injuries can be conservative, pharmacological, or surgical, and aims to halt SCI progression, stabilize the spine, and to allow rehabilitation of the patient.

Finnish and Swedish prehospital emergency care providers' knowledge and attitudes towards pressure ulcer prevention

BACKGROUND

Despite the knowledge that transportation by emergency medical services may increase the risk of pressure ulcers (PU), there is still lack of knowledge about the possibility of prehospital emergency care providers to be a part of preventing and reducing the risk of PUs.

METHODS

A survey was carried out during 2017 in Finland and Sweden. Validated questionnaires were used.

RESULTS

A total of 179 (72.7%) Finnish and 188 (28.8%) Swedish prehospital emergency care providers participated in the study. The overall rate of correct answers and the mean total knowledge score was 58.8% (SD 21.8), 20/34, in the Finnish group and 70.5% (SD 15.7), 24/34, in the Swedish group (p < 0.000). The percent of the total and the mean attitude score was in the Finnish group 71.3% (SD 0.48), 37.1/52, and in the Swedish group 69.4% (SD 0.77), 36.1/52 (p < 0.813). Half of the Finnish and most of the Swedish participants felt they needed more education about PUs (Fin 50.2% & Swe: 76.0%).

CONCLUSIONS

Prehospital emergency care providers don't see themselves as responsible for PU prevention. Therefore, there is a need for increasing the level of knowledge on PU prevention and classification among prehospital emergency care providers. They could play a key role in developing methods to improve PU prevention and identifying patients in risk of developing PUs.

Spinal Immobilization in the Trauma Room - a Survey-Based Analysis at German Level I Trauma Centers

BACKGROUND

Spinal immobilization is a standard procedure in daily out-of-hospital emergency care. Homogenous recommendations concerning the immobilization of trauma patients during the first therapy in the emergency department do not exist. The aim of the current study was the analysis of the existing strategies concerning spinal immobilization in German level I trauma centers by an internet-based survey.

MATERIALS AND METHODS

The current study is a survey-based analysis of the current strategies concerning spinal immobilization in all 107 level I trauma centers in Germany. The internet-based survey consists of 6 items asking about immobilization in the emergency department.

RESULTS

The return rate was 47.7%. In 14 (28.6%) level I trauma centers the patients remained immobilized on the immobilization tool used by the professional emergency care providers. In 19 (38.8%) level I trauma centers the patients were transferred to a stretcher with a soft positioning mattress on it. Patient transfer to a spineboard or to a TraumaMattress was performed in 11 (22.4%) and 7 (14.3%) level I trauma centers, respectively. Trauma patients were never transferred to a vacuum mattress. Cervical spine protection was most of the time performed by a cervical collar (n = 48; 98.0%). In general, the survey's participants were mainly satisfied (mean = 84/100) with the current strategy of spinal immobilization. The satisfaction was best if the spineboard is used.

DISCUSSION

Patient positioning during initial emergency therapy in the emergency department of German level I trauma centers is highly heterogenous. Besides complete full body immobilization, also the lack of any immobilization was reported by the survey's participants.

Preventing pressure injuries in the emergency department: Current evidence and practice considerations

The emergency department (ED) is at the front line of hospital pressure injury (PI) prevention, yet ED clinicians must balance many competing clinical priorities in the care of seriously ill patients. This paper presents the current biomechanical and clinical evidence and management considerations to assist EDs to continue to develop and implement evidence-based PI prevention protocols for the high-risk emergency/trauma patient. The prevention of hospital-acquired pressure injuries has received significant focus internationally over many years because of the additional burden that these injuries place on the patient, the additional costs and impact to the efficiency of the hospital, and the potential for litigation. The development of a PI is the result of a complex number of biomechanical, physiological, and environmental interactions. Our understanding of the interaction of these factors has improved significantly over the past 10 years. We have demonstrated that large reductions in PI incidence rates can be achieved in critical care and general hospital wards through the application of advanced evidence-based prevention protocols and believe that further improvement can be achieved through the application of these approaches in the ED.

Removal of the Long Spine Board From Clinical Practice: A Historical Perspective

Since the early 1970s, initial management of patients with suspected spinal injuries has involved the use of a cervical collar and long spine board for full immobilization, which was thought to prevent additional injury to the cervical spine. Despite a growing body of literature demonstrating the detrimental effects and questionable efficacy of spinal immobilization, the practice continued until 2013, when the National Association of EMS Physicians issued a position statement calling for a reduction in the use of spinal immobilization and a shift to spinal-motion restriction. This article examines the literature that prompted the change in spinal-injury management and the virtual elimination of the long spine board as a tool for transport.

Comparing the Efficacy of Methods for Immobilizing the Thoracic-Lumbar Spine

OBJECTIVE

The purpose of this study was to compare the relative efficacy of immobilization systems in limiting thoracic-lumbar movements.

METHODS

A dynamic simulation system was used to reproduce transport-related shocks and vibration, and involuntary movements of the thoracic-lumbar region were measured using 3 immobilization configurations.

RESULTS

The vacuum mattress and the long spine board were generally more effective than the cot alone in reducing thoracic-lumbar rotation and flexion/extension. However, the vacuum mattress reduced these thoracic-lumbar movements to a greater extent than the long spine board. In addition, the vacuum mattress significantly decreased thoracic-lumbar lateral movement relative to the cot alone under all simulated transport conditions. In contrast, the long spine board allowed greater lateral movement than the cot alone in a number of the simulated transport rides.

CONCLUSION

Under the study conditions, the vacuum mattress was more effective for limiting involuntary movements of the thoracic-lumbar region than the long spine board. Moreover, the increased lateral bend observed with the long spine board under some conditions suggests it may be inadequate for immobilizing this anatomic region as presently designed. Should emergency medical service providers choose to immobilize patients with suspected injuries of the thoracic-lumbar spine, study results support the use of the vacuum mattress.

Comparison of three prehospital cervical spine protocols for missed injuries

Introduction

We wanted to compare 3 existing emergency medical services (EMS) immobilization protocols: the Prehospital Trauma Life Support (PHTLS, mechanism-based); the Domeier protocol (parallels the National Emergency X-Radiography Utilization Study [NEXUS] criteria); and the Hankins’ criteria (immobilization for patients <12 or >65 years, those with altered consciousness, focal neurologic deficit, distracting injury, or midline or paraspinal tenderness).To determine the proportion of patients who would require cervical immobilization per protocol and the number of missed cervical spine injuries, had each protocol been followed with 100% compliance.

Methods

This was a cross-sectional study of patients ≥18 years transported by EMS post-traumatic mechanism to an inner city emergency department. Demographic and clinical/historical data obtained by physicians were recorded prior to radiologic imaging. Medical record review ascertained cervical spine injuries. Both physicians and EMS were blinded to the objective of the study.

Results

Of 498 participants, 58% were male and mean age was 48 years. The following participants would have required cervical spine immobilization based on the respective protocol: PHTLS, 95.4% (95% CI: 93.1–96.9%); Domeier, 68.7% (95% CI: 64.5–72.6%); Hankins, 81.5% (95% CI: 77.9–84.7%). There were 18 cervical spine injuries: 12 vertebral fractures, 2 subluxations/dislocations and 4 spinal cord injuries. Compliance with each of the 3 protocols would have led to appropriate cervical spine immobilization of all injured patients. In practice, 2 injuries were missed when the PHTLS criteria were mis-applied.

Conclusion

Although physician-determined presence of cervical spine immobilization criteria cannot be generalized to the findings obtained by EMS personnel, our findings suggest that the mechanism-based PHTLS criteria may result in unnecessary cervical spine immobilization without apparent benefit to injured patients. PHTLS criteria may also be more difficult to implement due to the subjective interpretation of the severity of the mechanism, leading to non-compliance and missed injury.

The Effect of a Liner on the Dispersion of Sacral Interface Pressures During Spinal Immobilization

Sacral pressure ulcers are a significant problem following spinal cord injury and are felt to be in part due to the high interface-pressures generated while strapped to the spine board. The objective of this study was to determine sacral interface-pressure and sensing area in healthy volunteers on a spine board and the effects of a gel pressure dispersion liner. Thirty-seven volunteers were placed on a pressure-sensing mat between the subject and the spine board. Measurements were carried out with and without a gel liner. Pressures and sensing area were recorded every minute for 40 minutes. The highest pressure was generated at the sacral prominence of each subject. Mean interface-pressures were higher on the spine board alone than with the gel liner (p < .0001). Overall, mean sensing area was lower on the spine board than with the gel liner (p < .0001). Standard spinal immobilization causes high sacral interface-pressures. The addition of a gel liner on the spine board decreased overall mean sacral pressures and increased mean sensing area. Generation of sacral pressure ulcers may be related to the initial interface-pressures generated while the patient is strapped to the spine board. The addition of a gel liner may reduce the incidence of sacral pressure ulcers.

Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature

BACKGROUND

Spinal immobilisation has been a mainstay of trauma care for decades and is based on the premise that immobilisation will prevent further neurological compromise in patients with a spinal column injury. The aim of this systematic review was to examine the evidence related to spinal immobilisation in pre-hospital and emergency care settings.

METHODS

In February 2015, we performed a systematic literature review of English language publications from 1966 to January 2015 indexed in MEDLINE and Cochrane library using the following search terms: 'spinal injuries' OR 'spinal cord injuries' AND 'emergency treatment' OR 'emergency care' OR 'first aid' AND immobilisation. EMBASE was searched for keywords 'spinal injury OR 'spinal cord injury' OR 'spine fracture AND 'emergency care' OR 'prehospital care'.

RESULTS

There were 47 studies meeting inclusion criteria for further review. Ten studies were case series (level of evidence IV) and there were 37 studies from which data were extrapolated from healthy volunteers, cadavers or multiple trauma patients. There were 15 studies that were supportive, 13 studies that were neutral, and 19 studies opposing spinal immobilisation.

CONCLUSION

There are no published high-level studies that assess the efficacy of spinal immobilisation in pre-hospital and emergency care settings. Almost all of the current evidence is related to spinal immobilisation is extrapolated data, mostly from healthy volunteers.

A multi-centred audit of secondary spinal assessments in a trauma setting: are we ATLS compliant?

PURPOSE

The global incidence of spinal cord injuries varies with the developed world having improved survival and 1 year mortality in a poly-trauma setting. This improved survival has been estimated at 20 % in a recent Cochrane review of Advanced Trauma Life Support (ATLS).The aim of this audit is to evaluate the management of patients with suspected spinal cord injury by the trauma and orthopaedic team in three centres in South Wales.

METHODS

A retrospective case note review of the secondary survey was performed. Inclusion criteria were patients 18 years and above, with poly-trauma and presenting to Accident and Emergency department at the treating hospital. We used ATLS guidelines as an audit tool and reviewed the documentation of key components of the secondary assessment.

RESULTS

Forty-nine patients were included (29 males, 20 females) with an average age of 53.7 years (19-92 years). We found that completion of all components of the secondary survey for spinal injury was poor, 29 % receiving a digital per rectal examination despite suspected spinal injury. Paralysis level was not documented in 20.4 % of patients. Medical Research Council grade was only documented in 24.5 % although was assessed in 73.5 %. The secondary survey took place after 2 h in 54.6 % of patients.

CONCLUSION

We found that the documentation of the performance of a secondary survey was poor. We found that most patients included in this study are not currently meeting the minimal standard suggested by the ATLS guidelines.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

EMS spinal precautions and the use of the long backboard - resource document to the position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma

Field spinal immobilization using a backboard and cervical collar has been standard practice for patients with suspected spine injury since the 1960s. The backboard has been a component of field spinal immobilization despite lack of efficacy evidence. While the backboard is a useful spinal protection tool during extrication, use of backboards is not without risk, as they have been shown to cause respiratory compromise, pain, and pressure sores. Backboards also alter a patient's physical exam, resulting in unnecessary radiographs. Because backboards present known risks, and their value in protecting the spinal cord of an injured patient remains unsubstantiated, they should only be used judiciously. The following provides a discussion of the elements of the National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACS-COT) position statement on EMS spinal precautions and the use of the long backboard. This discussion includes items where there is supporting literature and items where additional science is needed.

A numerical study to analyse the risk for pressure ulcer development on a spine board

BACKGROUND

Spine boards are used to immobilise accident victims suspected of having spinal injury. Guidelines about the maximum time patients remain on the board are often exceeded and on occasions may lead to pressure ulcers. Etiological research has shown that two processes ultimately lead to pressure ulcers:"Ischemic damage" which takes several hours to initiate and "deformation damage" at high strains. The latter process is very quick and the first signs of cell damage are already evident within minutes. Thus in order to minimise the risk of pressure ulcer development during prolonged loading, a new soft-layered long spine board has been designed.

METHODS

A subject specific numerical approach has been adopted to evaluate the prototype spine board in comparison to a conventional spine board, with reference to the estimated strains in the soft tissues adjacent to the sacrum in the supine position. The model geometry is derived from magnetic resonance images of three human volunteers in an unloaded situation. The loaded images are used to "tune" the material parameters of skin, fat and muscle. The prediction of the deformed contours on the soft-layered board is used to validate the model.

FINDINGS

Comparison of the internal strains in muscle tissue near the spine showed that internal strains on the soft-layered board are reduced and maximum strains are considerably less than the threshold at which deformation damage is possible. By contrast, on the rigid spine board this threshold is exceeded in all cases.

INTERPRETATION

The prototype comfort board is able to reduce the risk for deformation damage and thus reduces the risk of developing pressure ulcers.

Long backboard versus vacuum mattress splint to immobilize whole spine in trauma victims in the field: a randomized clinical trial

INTRODUCTION

Patients with possible spinal injury must be immobilized properly during transport to medical facilities. The aim of this research was comparing spinal immobilization using a long backboard (LBB) with using a vacuum mattress splint (VMS) in trauma victims transported by an Emergency Medical Services (EMS) system.

METHODS

In this randomized clinical trial, 60 trauma victims with possible spinal trauma were divided to two groups, each group immobilized with one of the two instruments. Speed and ease of application, immobilization rate, and the patients' comfort were recorded.

RESULTS

In this survey, LBB was faster to apply: 211.66 (SD = 28.53) seconds vs 654.00 (SD = 16.61) seconds. Various measures of immobilization were better by LBB. Also, LBB offered a significant improvement in comfort over a VMS for the patient with possible spinal injury. All of the results were statistically significant.

CONCLUSION

The results of this study showed that immobilization using LBB was easier, faster, and more comfortable for the patient, and provided additional decrease in spinal movement when compared with a VMS.

Randomised clinical trial comparing pressure characteristics of pelvic circumferential compression devices in healthy volunteers

INTRODUCTION

The role of pelvic circumferential compression devices (PCCDs) is to temporarily stabilise a pelvic fracture, reduce the volume and tamponade the bleeding. Tissue damage may occur when PCCDs are left in place longer than a few hours. The aim of this randomised clinical trial was to quantify the pressure at the region of the greater trochanters (GTs) and the sacrum, induced by PCCDs in healthy volunteers.

MATERIALS AND METHODS

In a crossover study, the Pelvic Binder(®), SAM-Sling(®) and T-POD(®) were applied successively onto 80 healthy participants in random order. The pressure was measured using a pressure mapping system, with the volunteers in supine position on a spine board and on a hospital bed. Data were analysed using Mixed Linear Modelling.

RESULTS

On a spine board, the pressure exceeded the tissue damaging threshold at the GTs and the sacrum. Pressure at the GTs was highest with the Pelvic Binder(®), and lowest with the SAM-Sling(®). Pressure at the sacrum was highest with the Pelvic Binder(®). The pressure at the GTs and sacrum was reduced significantly for all three PCCDs upon transfer to a hospital bed.

CONCLUSION

The results of this randomised clinical trial in healthy volunteers showed that patients with pelvic fractures, temporarily stabilised with a PCCD, are at risk for developing pressure sores. The pressure on the skin exceeded the tissue damaging threshold and is, besides PCCD type, influenced by BMI, waist size and age. Regardless with which PCCD trauma patients are stabilised, early transfer from the spine board is of key importance to reduce the pressure to a level below the tissue damaging threshold. Clinicians should be aware of the potential deleterious effects associated with the application of a PCCD, and every effort must be made to remove the PCCD once haemodynamic resuscitation has been established.

Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines

An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.

Estudos clínicos sobre úlcera por pressão

O estudo teve como objetivo sintetizar os estudos clínicos sobre úlcera por pressão (UP). Elaborou-se uma revisão integrativa através de busca de artigos nas bases de dados MEDLINE, Portal de Evidências, LILACS, e o periódico Joanna Briggs Institute (JBI), referência na área de ensaios clínicos em enfermagem, no período de 2004-2009. Selecionou-se 14 artigos e a análise destes permitiu a identificação de quatro categorias temáticas envolvendo a caracterização dos estudos, da amostra, das intervenções utilizadas, bem como dos resultados e conclusões alcançadas. Os resultados indicaram essencialmente o enfoque de estudos direcionados a temática da prevenção e a ausência desse tipo de estudo em nosso país. Reconhecer as limitações envolvidas nesse aspecto e buscar superá-las proporcionará avanços e impulsionará o desenvolvimento de pesquisas com fortes evidências clínicas que subsidiem a prática profissional da enfermagem.