- Introduction8:26LIN Session - NEXUS Chest CT17:11Stupid Mistakes - Mel and Rob4:34Paper Chase 1 - Is Droperidol Safe?6:26Do We Still Need The C-CollarFree Chapter20:46Paper Chase 2 - Ketamine For Pain7:18Pharmacy Rounds Part 1: Tramadol and Death From NSAIDS16:43Stupid MIstakes - Admissions2:04Doc In The Bay - Stop Bleeding Without A Hospital8:44Medical Myths - The Loop Diuretic20:57Pharmacy Rounds Part 2 - Antidepressants + NSAIDS = Bad?14:10Atrial Fibrillation ADP - Part 1 - Cardioversion19:56Paper Chase 3 - No Need To Irrigate Abscesses4:09Stupid Mistakes - Wrong Place Wrong Time1:56Bougie Every Intubation7:49Atrial Fibrillation ADP - Part 2 - Rate Control and Anticoagulation18:35Paper Chase 4 - Who Should Get A Foley5:45Out Of Hospital Cardiac Arrest20:35Stupid Mistakes - Intern Days2:24Paper Chase 5 - Workload and Work Quality6:44Annals of Emergency Medicine - Why The Limp?18:43Summary19:42EMRAP 2016 February Canadian Edition21:15EMRAP 2016 February Aussie Edition33:57EMRAP 2016 Fevrier Résumé en Francais58:50EMRAP 2016 Febrero Resumen Español1h, 09mEMRAP 2016 February German Edition1h, 10m
Do We Still Need The C-Collar
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Last month, we talked about removing cervical collars in the obtunded patient. This conversation takes things one step further… do we even need c-collars in the first place?!?!?
Do We Still Need the Cervical Collar?
Rob Orman MD and Chris Colwell MD
Take Home Points
▪ There is no evidence that C-collars restrict harmful movement.
▪ C-collar use may result in harm to patients and pain.
● Most literature on the cervical collar discusses the non-utility of the cervical collar. How did every trauma patient end up in a C-collar? There has never been any evidence that suggests that the C-collar benefits our patients in any way.
● We use C-collars because trauma patients may have an unstable C-spine injury. If we move the injury, the patient could be paralyzed. We make every effort to not extend the neck, including during intubation. However, it is not motion that causes harm but energy. This terror of causing any mobility is unfounded and goes against reason.
● What is the harm of placing patients in a collar? Taking patients out of a position of comfort and placing them into a rigid cervical collar that extends their neck does not make them safer. There is evidence that C-collars reduce venous return and increase intracranial pressure.
o An article by Gaither on failed airways found that C-spine immobilization was a primary reason that we struggle with airways in the field. Gaither, JB et al. Prevalence of difficult airway predictors in cases of failed prehospital endotracheal intubation. J Emerg Med. 2014 Sep;47(3):294-300. PMID: 24906900
● This something that was never based on evidence, causes harm and pain and we have allowed it to become our standard and culture.
● A study by Hauswald on emergency immobilization on neurologic outcome of patients with spinal injuries comparing the US to Malaysia where spinal immobilization is not performed found patients that were immobilized did worse with similar injuries.
o Hauswald, M et al. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998 Mar;5(3):214-9. PMID: 9523928
● Culture is difficult to change.
● Forcing immobilization on a combative and resistant patient could increase the energy and potential for damage. Sedate the patient so they don’t move around so much.
● What about penetrating trauma? The literature shows the mortality doubles with immobilization. Immobilization is not indicated in penetrating trauma.
● Does the C-collar restrict movement? We have no evidence that C-collars restrict movements that could be harmful.
● A drunk patient found down gets placed in a cervical collar until sober. There are repeated battles; the patient sits up with the collar askew. Once they take off the collar, it rarely goes back on.
o Sedate these patients so they are not thrashing about. We don’t have to intubate and paralyze all these patients.
● A drunk patient arrives in a collar. You don’t know what happened to them. Do you leave the collar on?
o Practice varies. Colwell will remove the collar when they are sedated or cooperative. Sometimes the agitation is due to the collar. Sedation to keep the collar on can lead to respiratory compromise. Some of these patients will just fall asleep when the collar comes off.
● An 80 year old with fall and large hematoma with 8cm occipital scalp lac. They deny neck pain. You know they have a C1 fracture.
o These patients are very risk for high cervical spine injuries. These are the most concerning injuries and the reason we immobilize. However, we may be causing more harm.
o Rigid cervical collars can stretch the spinal cord in unstable high cervical fractures and reduce the blood flow to the spinal cord.
● A patient in a motor vehicle accident walks into triage with neck pain and tingling in the arms.
o The patient has proved to you that movement will not paralyze them. Putting them in a less comfortable position won’t benefit them.
● We can’t do this in isolation. We need to have this conversation with the entire team including orthopedics, trauma and neurosurgery.
● For more, check out http://www.scancrit.com/2013/10/10/cervical-collar/