C-Collars on their way out?

[Dustdevil]

• Baylor study doubts neck brace standard
  In some cases, device might hurt accident victims
  
  By TODD ACKERMAN
  Copyright 2010 Houston Chronicle
  Jan. 23, 2010, 10:48AM
  
  Applying a brace to the neck of a trauma patient, standard procedure for
  many decades, can worsen the injury and lead to severe paralysis or death,
  according to a new study by Houston researchers.
  
  Baylor College of Medicine doctors used cadavers to confirm that so-called
  cervical collars can be counterproductive, a finding that could upturn the
  way emergency medical personnel and doctors act to stabilize and protect the
  upper spine in potentially fatal neck injuries, such as those that commonly
  occur in bad automobile accidents.
  
  "This study is a proof of concept that in cases of severely unstable neck
  injuries, cervical collars are not only not helpful, but harmful in many
  situations," said Dr. Peleg Ben-Galim, a professor of orthopedic surgery and
  the study's lead author. "More research needs to be done, but it might be
  that we can prevent some of the deaths and quadriplegia that occur in these
  injuries."
  
  The study appeared this week in the Journal of Trauma.
  
  Dr. David Persse, medical director of Houston's Emergency Management
  Services, called the study "compelling" and "concerning" and said it will
  come up for discussion at the annual meeting of the nation's 30 largest EMS
  departments in Dallas next month. But he also said he doesn't want to
  overreact.
  
  "We need to look at this thoughtfully before we change the standard of
  care," said Persse. "It concerned a particular kind of injury. It may apply
  to other injuries as well, but we don't know that yet."
  
  But Persse added that he understands the need to act quickly, that "it's not
  like a lot of areas where there's not as serious downside to waiting for the
  next study."
  
  Car-crash victims
  Ben-Galim said cervical spine injuries are found in the autopsies of up to
  94 percent of people who die in car crashes, which claim about 44,000 U.S.
  lives annually. There are about 11,000 people annually who survive spinal
  cord injuries.
  
  There is no obvious alternative to cervical collars, though hospitals often
  place sandbags under the back of the patient's head and, less commonly, some
  EMS teams at the scene of the crash wedge the head of the patient between
  foam bolsters on the backboard.
  
  The injuries in question involve the area where the brain connects to the
  spinal cord. Doctors treating such injuries work to stabilize the ligaments,
  muscle and bone to prevent secondary injury and to protect the brain stem
  and cord.
  
  Baylor researchers undertook the study after a case in which a broken jaw
  precluded the use of a cervical collar on the survivor of a car wreck
  brought to Ben Taub. When the doctors started to put a collar on the
  patient, fluoroscopy showed two of the patient's vertebrae separate, causing
  doctors to immediately remove the collar. The treated patient ultimately
  walked out of the hospital on his own.
  
  Ben-Galim noted that there are other such case histories in medical
  literature.
  
  To study the phenomenon, Baylor researchers made an incision in cadaver neck
  ligaments based on patient X-rays, then simulated clinical scenarios by
  applying cervical collars and putting the bodies in ambulances and driving a
  distance.
  
  In all of the cadavers, imaging technologies found that the collar increased
  the rupture.
  
  In effect, the collars pushed the head away from the shoulders, Ben-Galim
  said.
  
  He said the rupture stretching occurs because of both the application of the
  collars and their continued use.
  
  One national expert called the study interesting but said he wasn't sure it
  would one day change the standard of care.
  
  "There are certain cases, like the ones in this study, that can be
  dangerous, but they're rare - most people who suffer high neck injuries die
  immediately," said Dr. Tom Scaletta, the past president of the American
  Academy of Emergency Medicine. "I think the study's importance will be to
  raise awareness about the special care that must be taken - preserving
  patients' normal head position, making sure they're not having difficulty
  breathing."
  
  Anecdotal cases
  Dr. Walter Lowe, director of the Memorial Hermann Sports Medicine Institute
  and team physician for the Houston Texans football team, said the study
  wouldn't change the care of injured football players removed from the field
  in collars and on stretchers because those injuries tend to involve lower
  areas of the spine.
  
  Ben-Galim said that since the study was undertaken, Ben Taub doctors have
  saved patients with severe neck injuries by loosening or removing cervical
  collars early and rushing them to the operating room, but he acknowledged
  such cases are anecdotal.
  
  He said the research team looked at 400 articles and found no scientific
  evidence that cervical collars can stabilize severely unstabilized spine
  injuries.

I found this quote interesting:

...less commonly, some

EMS teams at the scene of the crash wedge the head of the patient between

foam bolsters on the backboard.

Is this really less common these days? I've been out of the street medicine field for awhile, so it's an honest question.

[sportygirl]

wow interesting. so what would replace the c-collar?

[JTpaintball70]

Is this really less common these days? I've been out of the street medicine field for awhile, so it's an honest question.

No it;s not uncommon... Ever patient I board gets foam head-blocks as part of the stabilization. I've never seen a fully immobilized pt brought to any ER locally without those blocks.

[Lone Star]

I found this quote interesting:

Is this really less common these days? I've been out of the street medicine field for awhile, so it's an honest question.

Having just gone through the NREMT courses for EMT-B and EMT-I, I can tell you that they're still stressing the uses of 'head blocks', CID (Cervical Immobilization Devices) and other similar devices to immobilize the cervical spine when the patient is placed on the backboard.

They stress that the person holding the head/neck in a 'neutral, in-line position' does NOT release until the head is between those blocks (just as it's always been?)

Could that quote have been in reference to the patient's head in the CID/headblocks but with no cervical collar in place?

[JPINFV]

Is this really less common these days? I've been out of the street medicine field for awhile, so it's an honest question.

Not from what I've seen. Head beds are always used. The question could be, does the author know that there are different styles of head beds besides the big orange Ferno blocks? If you aren't sure what you're looking for, it could be easy to miss a different style/brand of head bed than what you're expecting to see.

Edited January 27, 2010 by JPINFV

[Dustdevil]

Could that quote have been in reference to the patient's head in the CID/headblocks but with no cervical collar in place?

Good point! That may have been what they meant. Of course, since we're talking about Houston FD EMS, anything is possible. When your paramedic school is a whole 10 weeks long, you're likely to see anything happen.

[AnthonyM83]

So much to question about this study as it relates to changing field procedures that I can't even start...

Well maybe start, yes... which kinds of collars did they use, what was their training on the collars, what positions where cadavers in, what percentage of patients have the specific types of spinal injuries that caused injuries in the lab, what was the rest of their immobilization like (head wedges, "cheese blocks", towels, none?).

And yes, using a lateral head immobilization device is still standard of care. Haven't heard of a place that doesn't use them.

[JTpaintball70]

Another thing to ask is if they're fans of the 'No-Neck for everyone' fan club

[Kiwiology]

Good point! That may have been what they meant. Of course, since we're talking about Houston FD EMS, anything is possible. When your paramedic school is a whole 10 weeks long, you're likely to see anything happen.

I do believe they are up to twelve weeks now.

[HellsBells]

There is no obvious alternative to cervical collars, though hospitals often

place sandbags under the back of the patient's head and, less commonly, some

EMS teams at the scene of the crash wedge the head of the patient between

foam bolsters on the backboard.

Yeah, I agree Dust, this quote kind of took me by suprise too. My immediate reaction was, what hospital uses sandbags under the pt's head? Is this common practice where anybody works? Actually, our service doesn't use foam blocks, we use blanket rolls. Same difference. Its an interesting study, of course a lot more research needs to be done on the issue.

There are certain cases, like the ones in this study, that can be

dangerous, but they're rare - most people who suffer high neck injuries die

immediately,"

However, this quote somewhat limits the application of the study. Is it reasonable to change practice for an injury that few patients actually survive?