Trauma Update Newsletter - March 2020

TRAUMA UPDATE Volume 1, Issue 2

March 2020

Cervical Collars: Underused or Have We Gone Overboard?

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f you have been involved in healthcare there is a good chance that you have been faced with the decision of whether or not to apply a cervical collar. While the nature of cervical spine injury (CSI) can be severely debilitating and successful management depending on patient compliance, knowing when immobilization is warranted can be difficult. For many years, despite what curriculum you attended, the notion of immobilize them all and let the radiographs sort’em out was the dominating practice. It was not until 1992 that this dogmatic practice was challenged.

Growing concern that patients at risk for CSI were being exposed to unnecessary radiation led to National Emergency X-Radiograph Utilization Study (NEXUS). The NEXUS study sought to establish

guidelines to assist providers in determining if cervical spine imaging is recommended. The five criteria are 1) tenderness present upon palpation of the cervical spine, 2) evidence of intoxication, 3) alteration in level of consciousness, 4) presence of focal neurological deficits, and 5) painful distracting injuries present. All five of the criteria must be answered no to exclude a CSI patient from needing a radiograph.

After being published, there was immediate pushback, and many were hesitant to adopt the change.

In 2002, a different set of criteria was devised termed the Canadian C-Spine Rule (CCR). The criteria of the CCR attempts to assign the patient into either high risk or low risk and requires the patient to be able to rotate their head. When patients are identified as high-risk, the rule set immediately recommends a c-spine radiograph be performed.

If no high-risk criteria are met, the next criteria determines if there is a low-risk factor that would prohibit the safe assessment of the patient’s range of motion. Permitting there

March is the last month that Sacred Cross EMS will be the prehossital provider for Stephens County. American Medical Resposnse (AMR) will began operations on April 1st.

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Contact us philip.smith@smhtx.com The NEXUS criteria was an early attempt at forming a decision criteria to aid in preventing unesseccary radiological studies.

are no low-risk criteria, the provider then assesses the ability for the patient to move their neck to the left and right 45 degrees from center.

Rigid cervical collars come in a variety of types. Pictured from top to bottom are Aspen, Patriot, and Miami.

Is one system superior?

There have been multiple studies attempting to determine superiority between the two systems.

Regarding sensitivity, both NEXUS

and CCR have repeatedly demonstrated high sensitivity. However, the specificity does demonstrate some variability between the two sets, nevertheless, both sets have

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routinely shown the ability to safely rule out CSI. It should be noted that both sets have some limitations.

Beginning with NEXUS, although the application is usually easier the sharpest criticism is that it performs poorly when trying to identify CSI in patients over 65 years of age. Conversely, CCR can be more difficult to implement but does include advanced age as an automatic flag for high risk. So, what set should we as nurses use? Both!

Many institutions have adopted a

hybrid of the two combining the simplicity of NEXUS, with consideration for age extremes and highrisk mechanism of injury.

Practical Application From a nursing perspective, what is the significance of ruling out a CSI; isn’t that a function of the ED doctor? Well in that sense yes, but what if rather than identifying who doesn’t need a radiograph the scale was used to determine who does need a c-collar. Nurses can use this

Message From Dr. Kelli Windsor, D.O. Trauma Medical Director

In February, the importance of Glasgow Coma Scores, Revised Trauma Scores, and an introduction of Pediatric Trauma Scores was discussed. After performing trauma chart audits, the compliance for hourly documentation of GCS and RTS from 57% to 70%. This is really outstanding everyone! Keep up the great work. We have been seeing a steady increase in the number of fall presentations and will be working to provide some at-home education and distribution of fall prevention kits.

During March we are focusing on the use of c-collars. I cannot stress enough the importance of proper c-spine immobilization. In fact, just prior to the release of this newsletter, a patient presented to the emergency room eight days after suffering a ground-level fall and complaining of being unable to move his head.

The patient was quickly identified as having a high risk of a spinal injury. A c-collar was applied by the ED nursing staff and the patient was subsequently diagnosed with a C1 fracture. This demonstrates how important it is to thoroughly screen patients for the possible presence of a cervical spine injury.

An example of the Canadian C-Spine Rule demonstrating the high-risk, low-risk, and head movment criteria.

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Rather than identifying who doesn’t need an x-ray, the scale can be used to determine who does need a c-collar... tool to help determine who would benefit from a c-collar. In the event that a patient is found to need a radiograph, they should automatically be placed in a c-collar. If the suspicion of CSI is strong enough to prompt the need for a c-collar, the patient should remain immobilized until cleared through some type of imaging. After radiology has cleared the patient, the removal of the c-collar should be performed, at minimum, under the direct supervision of the treating physician.

The documentation associated with a c-collar application is also very

A screening tool combining elements of NEXUS and CCR screening criteria.

important and should include the time of application, and the status of the patient’s distal circulation, motor function, and sensation of all four extremities.

As trauma center nurses, being

weary of the need for cervical spine immobilization is fundamental. By using an objective decision tool to aid in the identification of possible CSI, you can help serve our patients and save them a real pain in the neck.