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/
Sean G., M.D. - February 6, 2016 9:03 AM
I am forever comforted by the fact that things I pretty much did by winging it on my own with that oft neglected skill(common sense) is getting evidenced based...I always thought it was stupid and useless to fight a collar onto a combative patient and most of my career I would tell the nurses to leave em be....scan them, but leave the collar off.
Brad S. - February 13, 2016 4:06 PM
Agree Sean, my practice also, the 'dirty little secret", turned out not to be dirty at all.
In review of the lit, still not great consensus or ED protocols(some pre-hospital stuff), which we need to change culture
So Chris, if you have an awake blunt trauma patient with high degree of suspicion for fracture or even documented fracture do you place in a well-fitting, less rigid Aspen or Philly collar, or do something different?
Neil L. - February 16, 2016 3:08 AM
Just after some clarity. Is this literature just for rigid collars or does this include the practise of using an Aspen or phili collar while you wait for the scan. Also the example of the 80 yrs old with a C1 fracture - so what are you putting them in if the n.surgeon says its for medical management only?? Thanks.
Paul B., M.D. - February 25, 2016 5:32 AM
Most of the papers mentioned here had a focus on spinal immobilization with a longboard, not simply a cervical collar. It concerns me to hear the longboard literature being used as a reason to remove collars. Combative patients aside, I agree ... no reason to fight the patient. However, sedation is an oft-forgotten critical management piece of the altered trauma patient. Avoid pithing the patient.
I'm an EMS physician in NYC and a strong proponent of reducing longboard use. I am NOT a "no-collar" EM/EMS doc, however, for both the ED and the EMS system. I've seen enough "wow, I'm glad we scanned them" trauma patients in my career to know that we don't know all, and I feel our system has far too many providers getting a suboptimal exam to safely reduce collar use in the right population.
My concern here is the complete lack of recognition of the person who should be spearheading the Longboard Revolution in your respective location, and subsequently the coming Cervical Collar Revolution: the EMS physician. Yes, we exist. We have an increasing number of fellowship trained docs in the medical community. We have a board now through ABEM. One of us probably works in your hospital ... even if they haven't gone through the board yet.
Again, the EM:RAP moderators forget to mention the importance of an EMS Physician in a prehospital care topic. This is a topic that should have been handled by Dr. Mell, as Dr. Swaminathan mentions just about every sub-specialist to involve except the colleague you have in your faculty that likely knows this material best.
Rob O - April 6, 2016 1:23 PM
Hi Paul, Thanks for bringing up these issues. As to the credentials, Dr Colwell is indeed board certified EMS physician and ran the Denver EMS program for 15 years. Since there has been so much discussion on this particular segment, we are putting together a special edition to flush out the questions and controversies.
Abdullah Al-Somali - May 19, 2016 5:34 PM
i was about to intubate a pt who fell in the bathroom & sustained a subdural hematoma today and my attending was so far up his ass concentrating on the c collar making a huge fuss that his not on a collar! i can't wait for that special edition episode :) thanks for all what you guys redoing on EM:RAP.