Recommendation for changes to the guidelines of trauma patients with potential spinal injury within a regional UK ambulance trust

Cervical spine immobilisation following blunt trauma in pre-hospital and emergency care: A systematic review

OBJECTIVES

To assess whether different cervical spine immobilisation strategies (full immobilisation, movement minimisation or no immobilisation), impact neurological and/or other outcomes for patients with suspected cervical spinal injury in the pre-hospital and emergency department setting.

DESIGN

Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Library and two research registers were searched until September 2023.

ELIGIBILITY CRITERIA

All comparative studies (prospective or retrospective) that examined the potential benefits and/or harms of immobilisation practices during pre-hospital and emergency care of patients with a potential cervical spine injury (pre-imaging) following blunt trauma.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected and extracted data. Risk of bias was appraised using the Cochrane ROBINS-I tool for non-randomised studies. Data were synthesised without meta-analysis.

RESULTS

Six observational studies met the inclusion criteria. The methodological quality was variable, with most studies having serious or critical risk of bias. The effect of cervical spine immobilisation practices such as full immobilisation or movement minimisation during pre-hospital and emergency care did not show clear evidence of benefit for the prevention of neurological deterioration, spinal injuries and death compared with no immobilisation. However, increased pain, discomfort and anatomical complications were associated with collar application during immobilisation.

CONCLUSIONS

Despite the limited evidence, weak designs and limited generalisability, the available data suggest that pre-hospital cervical spine immobilisation (full immobilisation or movement minimisation) was of uncertain value due to the lack of demonstrable benefit and may lead to potential complications and adverse outcomes. High-quality randomised comparative studies are required to address this important question.

TRIAL REGISTRATION

PROSPERO REGISTRATION Fiona Lecky, Abdullah Pandor, Munira Essat, Anthea Sutton, Carl Marincowitz, Gordon Fuller, Stuart Reid, Jason Smith. A systematic review of cervical spine immobilisation following blunt trauma in pre-hospital and emergency care. PROSPERO 2022 CRD42022349600 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022349600.

Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update

The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.

A data-driven algorithm to support the clinical decision-making of patient extrication following a road traffic collision

BACKGROUND

Some patients involved in a road traffic collision (RTC) are physically entrapped and extrication is required to provide critical interventions. This can be performed either in an expedited way, or in a more controlled manner. In this study we aimed to derive a data-driven extrication algorithm intended to be used as a decision-support tool by on scene emergency service providers to decide on the optimal method of patient extrication from the vehicle.

METHODS

A retrospective observational study was performed of all trauma patients trapped after an RTC who were attended by a Helicopter Emergency Medical Service (HEMS) in the United Kingdom between March 2013 and December 2021. Variables were identified that were associated with the need for HEMS interventions (as a surrogate for the need for expedited extrication), based on which a practical extrication algorithm was devised.

RESULTS

During the study period 12,931 patients were attended, of which 920 were physically trapped. Patients who scored an "A" on the AVPU score (n = 531) rarely required HEMS interventions (3%). Those who did were characterised by a shorter than average (29 vs. 37 min) 999/112 emergency call to HEMS on-scene arrival interval. A third of all patients responding to voice required HEMS interventions. Absence of a patent airway (OR 6.98 [1.74-28.03] p < .001) and the absence of palpable radial pulses (OR 9.99 [2.48-40.18] p < .001) were independently associated with the need for (one or more) HEMS interventions in this group. Patients only responding to pain and unresponsive patients almost invariably needed HEMS interventions post extrication (90% and 86% respectively). Based on these findings, a practical and easy to remember algorithm "APEX" was derived.

CONCLUSION

A simple, data-driven algorithm, remembered by the acronym "APEX", may help emergency service providers on scene to determine the preferred method of extrication for patients who are trapped after a road traffic collision. This has the potential to facilitate earlier recognition of a 'sick' critical patient trapped in an RTC, decrease entrapment and extrication time, and may contribute to an improved outcome for these patients.

Comparison of different techniques for prehospital cervical spine immobilization: Biomechanical measurements with a wireless motion capture system

BACKGROUND

Various rescue techniques are used for the prehospital transport of trauma patients. This study compares different techniques in terms of immobilization of the cervical spine and the rescue time.

METHODS

A wireless motion capture system (Xsens Technologies, Enschede, The Netherlands) was used to record motion in three-dimensional space and the rescue time in a standardized environment. Immobilization was performed by applying different techniques through different teams of trained paramedics and physicians. All tests were performed on the set course, starting with the test person lying on the floor and ending with the test person lying on an ambulance cot ready to be loaded into an ambulance. Six different settings for rescue techniques were examined: rescue sheet with/without rigid cervical collar (P1S1, P1S0), vacuum mattress and scoop stretcher with/without rigid cervical collar (P2S1, P2S0), and long spinal board with/without rigid cervical collar (P3S1, P3S0). Four time intervals were defined: the time interval in which the rigid cervical collar is applied (T0), the time interval in which the test person is positioned on rescue sheet, vacuum mattress and scoop stretcher, or long spinal board (T1), the time interval in which the test person is carried to the ambulance cot (T2), and the time interval in which the ambulance cot is rolled to the ambulance (T3). An ANOVA was performed to compare the different techniques.

RESULTS

During the simulated extrication procedures, a rigid cervical collar provided biomechanical stability at all angles with hardly any loss of time (mean angle ranges during T1: axial rotation P1S0 vs P1S1 p<0.0001, P2S0 vs P2S1 p<0.0001, P3S0 vs P3S1 p<0.0001; lateral bending P1S0 vs P1S1 p = 0.0263, P2S0 vs P2S1 p<0.0001, P3S0 vs P3S1 p<0.0001; flexion/extension P1S0 vs P1S1 p = 0.0023, P2S0 vs P2S1 p<0.0001). Of the three techniques examined, the scoop stretcher and vacuum mattress were best for reducing lateral bending in the frontal plane (mean angle ranges during T1: P2S1 vs P3S1 p = 0.0333; P2S0 vs P3S0 p = 0.0123) as well as flexion and extension in the sagittal plane (mean angle ranges during T2: P1S1 vs P2S1 p<0.0001; P1S0 vs P2S0 p<0.0001). On the other hand, the rescue sheet was clearly superior in terms of time (total duration P1S0 vs P2S0 p<0.001, P1S1 vs P2S1 p<0.001, P1S0 vs P3S0 p<0.001, P1S1 vs P3S1 p<0.001) but was always associated with significantly larger angular ranges of the cervical spine during the procedure. Therefore, the choice of technique depends on various factors such as the rescue time, the available personnel, as well as the severity of the suspected instability.