- Email: [email protected]
Managing spinal immobilisation devices in the emergency department
Australasian Emergency Nursing Journal (2005) 8, 79—83
Managing spinal immobilisation devices in the emergency department Anne E. Brownlee, RN, MN ∗ Emergency Department, Prince of Wales Hospital, Randwick, NSW, Australia KEYWORDS Trauma care; Spinal immobilisation devices
Summary The management of spinal immobilisation devices is an important component of trauma care. Prolonged immobilisation is associated with notable morbidity, most commonly cutaneous pressure necrosis. This paper evaluates current thinking on the management of spinal immobilisation devices in the emergency department, and concludes that a pathway to expedite device removal could improve trauma care. © 2005 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Following trauma, care providers appropriately assume injury is present until it can be excluded. In the trauma patient, the importance of stabilising and immobilising the spine as a precaution is well documented. In the initial pre-hospital phase of care, pre-hospital care providers routinely apply a rigid spine board, straps, rigid neck collar, and lateral neck supports to keep the spine in a neutral position and prevent mobility in potentially damaged vertebra and ligaments during extrication and transfer. During the hospital phase of care, protection of the spine with appropriate immobilisation devices is an important management principle. It is considered best practice to maintain the neck collar as protection for the cervical spine until it is cleared of injury. Maintaining the spine board to protect the thoracolumbar spine, however, is controversial. ∗
Tel.: +61 95534883. E-mail address: [email protected].
Current thinking in trauma care limits spine board use to the pre-hospital setting, and regards board removal on presentation to hospital as best practice. Board removal on presentation is recommended to avoid the complications associated with remaining in spinal immobilisation. To expedite the removal of spinal immobilisation devices clinical pathways have been initiated in some American trauma centers. It is proposed that a similar pathway could improve trauma care in Australian emergency departments.
Literature review Random controlled trials quantifying the effect of spinal immobilisation in trauma patients cannot be found in relevant literature.1 The lack of research is most likely due to ethical considerations, the potentially devastating consequence for patients, and medicolegal concerns related to a missed injury. The real value of spinal immobilisation following trauma is uncertain. Its use is not based on scientific evidence but on concern that a
1574-6267/$ — see front matter © 2005 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2005.10.001
80
A.E. Brownlee
patient with a potential spinal injury could deteriorate neurologically without immobilisation.1 The management of cervical immobilisation devices has been widely explored in the literature. Authors have examined the effect of rigid cervical collars on skin integrity and established a direct relationship between increased interface pressure over the chin and occipital region with ulcer formation. Pressure ulcers have been found to occur in these areas in up to 55% of trauma patients following prolonged immobilisation in rigid cervical collars. Cervical collars can also obstruct venous flow and elevate intracranial pressure and this may produce secondary ischaemic brain injury in the patient with a traumatic head injury.2 This has concerned physicians providing trauma care and they have subsequently developed guidelines to expedite cervical spine clearance and removal of extrication collars. The Eastern Association for the Surgery of Trauma (EAST), for instance, developed evidencebased guidelines for safe and effective cervical spine clearance.3 A number of large studies, including the NEXUS study, support the guidelines. The NEXUS study of >34,000 patients validates a set of clinical criteria on which to clear the cervical spine in blunt trauma with an overall sensitivity of 99%.4 In accordance with EAST guidelines, the cervical spine can be examined and clinically cleared without radiology when the following NEXUS criteria are met:
gest the removal of the board during the secondary survey and utilisation of clinical criteria to exclude injury. In the awake and alert patient, the thoracolumbar spine may be clinically cleared when pain or tenderness along the spine is absent on palpation. If the patient has a depressed level of consciousness, or the alert patient reports pain on palpation, appropriate radiography and or CT scanning is required.6 Until the thoracolumbar spine can be cleared of injury, spinal precautions involve supine positioning on a firm surface, such as the trauma bed.6 Current thinking in trauma care supports the use of clinical criteria to clear the thoracolumbar spine, but advocates removal of the spine board much sooner, ideally on transfer from ambulance trolley to trauma bed.1,7—13 Past teaching held the spine board necessary to splint the entire vertebral column to prevent flexion, extension, rotation and lateral movement until radiography cleared the thoracolumbar spine of injury.14 Currently, the firm surface of the trauma bed is regarded a sufficient splint for the thoracolumbar spine.1,10 Spinal damage requires the high force that occurred at the time of impact; movement thereafter is unlikely to cause further damage.1 When transfer is required, a Jordan frame to lift the patient is recommended because the device allows limited movement of the lower spine.
(1) (2) (3) (4) (5)
Complications of spinal immobilisation
the patient has normal alertness; there is no evidence of drug or alcohol use; there is no painful distracting injury; there is no midline cervical tenderness or pain; there is no focal neurological deficit.
When the clinical criteria are not met and examination is uncertain, cervical spine radiography and computerised tomography scanning are required.4 If cervical spine clearance has not been completed within 4 h, a more comfortable collar, such as a Philadelphia Collar, may replace the extrication collar.3 Nursing management involves cleaning the skin and monitoring the occiput, chin/mandible, ears, shoulders and sternum for pressure areas. If an area of pressure is evident, a thin dressing may be applied. The area is not padded because this can increase pressure and cause other pressure areas or may affect the alignment of the spine.5 Clear guidelines for spine board management and thoracolumbar spinal clearance are not evident in the literature. Advanced trauma life support guidelines, which inform trauma care in Australia, allow the trauma patient to remain immobilised on a spine board for up to 2 h.6 These guidelines sug-
Spinal immobilisation is not a gentle procedure; it is uncomfortable and increases the patient’s risk for a number of complications. Prolonged supine positioning and use of a cervical collar and spine board is associated with aspiration, respiratory compromise, iatrogenic pain, cutaneous pressure ulceration and poor quality radiography.1,9,13,15
Aspiration The risk of aspiration is increased for the supine trauma patient. Because trauma is unexpected, the patient is likely to have a full stomach and injury may reduce their ability to protect the airway.9 In the supine position, passive regurgitation or vomiting may result in aspiration of gastric contents and impaired oxygenation.9 In the past, it was believed the spine board could protect against aspiration because it facilitated turning a vomiting patient onto their side. Rapid log-rolling is now considered a more appropriate strategy to turn the
Managing spinal immobilisation devices in the emergency department trauma patient that is vomiting.12 Rapid log-rolling requires four people to carry out the maneuver and one person to suction the patient. One person holds the head and coordinates the roll, while three others roll the chest, pelvis, and limbs so that the head, neck, body and limbs move in an aligned manner. The fifth person carefully suctions the oral cavity and avoids inducing further gagging or vomiting.14 Management may also include administration of a suitable antiemetic and gastric decompression. Gastric decompression is accomplished through intubating the stomach by passing a tube nasally or orally and attaching it to suction to evacuate gastric contents.6
Respiratory compromise The supine trauma patient has an increased risk of respiratory compromise. In studies on healthy volunteers, subjects with full spinal immobilisation demonstrate increased respiratory effort and reduction in chest expansion from torso straps on the spine board.1,11 The finding is significant because restricted chest expansion can result in low tidal volumes and accentuate the physiological effects of the supine position on respiratory function.11 In the supine position, functional residual capacity is reduced and less alveoli are available for external respiration. This is important because metabolic rate and oxygen demand increase following trauma hence the need for highflow supplemental oxygen to meet the patients oxygen requirements.14 If chest trauma involves pneumo/haemothorax, rib and sternum fractures or lung contusions, respiratory function and oxygenation is further compromised and the patient may require ventilatory support.14
Iatrogenic pain Spinal immobilisation devices are a potential source of iatrogenic pain in trauma patients. Studies on healthy volunteers in spinal immobilisation devices found subjects complain of pain and discomfort at approximately 30 min when rigid neck collars and spine boards were used.11,12 Rigid immobilisation devices were found to cause high tissue-interface pressure over the heels, sacrum, thoracic spine, elbows, occipital region and chin causing ischemic pain.1,11,12 The results suggest that after 30 min it may well be difficult to differentiate between pain generated by immobilisation devices and pain caused by actual trauma. In immobilised trauma
81
patients, iatrogenic pain may be misleading and subject people to unnecessary imaging if clinicians wrongly believe pain is related to injury.11,12
Cutaneous pressure ulceration Time and high interface pressure are predictors of cutaneous pressure ulceration in the trauma patient. Ischemia occurs when interface pressure exceeds or approaches capillary pressure. At 32 mmHg of pressure, capillary blood flow becomes compromised and impedes the supply of oxygen and nutrient to tissues causing hypoxia, necrosis and ulceration.16 The intensity of pressure is proportional to the time necessary to cause tissue damage. That is, high pressure over a short time and low pressure of longer duration.16 A sustained interface pressure of 35 mmHg for 2 h and 60 mmHg for 1 h is sufficient to cause irreversible tissue damage.16 Studies on healthy subjects have recorded interface pressures of 233.5 mmHg and 82.9 mmHg at the sacrum and thorax on a rigid spine board.11,17 Studies show that patients can spend an average 63 min on a spine board in the emergency department before being cleared of injury.12
Inferior radiography Reliable imaging is important in excluding injury after trauma in high-risk patients. A series of X-rays to evaluate the cervical spine, chest, pelvis and thoracolumbar spine and or computerised tomography may be required to exclude injury.7 Recent research indicates that computerised tomography is the most effective, however, immediate access to computerised tomography is not available in all Australian emergency departments, particularly in regional areas. Clinicians therefore rely upon radiographic studies but the quality of imaging is problematic when performed while the patient is on a spine board.18 Imaging performed while the patient is on a spine board is frequently of poor quality. Imaging is inferior because the X-ray plate is beneath the trauma bed and the X-ray beam must penetrate the spine board and patients clothing.13,18 One study that measured the time taken to exclude cervical spine injury in the resuscitation bay, found X-rays needed to be repeated often because of poor quality films.18 Because imaging had to be repeated to exclude injury, spinal immobilisation devices remained on the patient between 100 and 282 min.18 The spine board ought to be removed to
82 Table 1
A.E. Brownlee Clinical pathway for removal of spinal immobilisation devices in the ED
improve the quality of films and avoid prolonged immobilisation.
Discussion Pressure induced tissue injury can begin in the prehospital and initial hospital phase of care. Rigid extrication neck collars and spine boards generate high tissue interface pressures capable of causing ischemia and necrosis in contact tissues. Following trauma, tissue is susceptible and damage accelerates. Injury, vasoconstriction and hypoperfusion, loss of movement and/or sensation, time lying immobile before rescue, and environmental moisture increase the risk for tissue necrosis. The
seriously injured may remain immobilised for a long time because of unconsciousness, surgical intervention, spinal or orthopedic injury and develop cutaneous pressure ulceration. Cutaneous ulcers are a source of pain, potential infection and sepsis that delay recovery. The timely removal of immobilisation devices reduce the risk for such complications arising. Random controlled trials comparing spinal immobilisation strategies on healthy volunteers support removal of spinal immobilisation devices as soon as possible, and recommend removal of the spine board as a priority for management.19—21 Backboard spinal immobilisation is a useful component of pre-hospital care but it is not a tool for hospital care. To expedite removal of the spine board clinical pathways are being successfully implemented
Managing spinal immobilisation devices in the emergency department in trauma centers abroad.22,23 On arrival to hospital unless the patient is undergoing intensive resuscitation, they are log rolled and the board removed immediately after transfer from ambulance trolley to trauma bed. Spine board time is reduced significantly and the incidence of cutaneous pressure ulceration is lower.19,20 An example of a clinical pathway for the removal of spinal immobilisation devices is shown in Table 1. The pathway is based on EAST guidelines for cervical collar management and current thinking on spine board use. The pathway’s goal is to ensure management of airway, breathing and circulation are the main concern of clinicians, and spinal immobilisation a management priority. It aims to raise awareness of cutaneous pressure problems in the trauma patient and thus facilitate removal of immobilisation devices. Prolonged immobilisation increases morbidity and mortality after trauma. A clinical pathway to manage spinal immobilisation in the emergency department may improve trauma care through prevention.
References 1. Kwan I, Bunn F, Roberts I, on behalf of the WHO PreHospital Trauma Care Steering Committee. Spinal immobilisation for trauma patients. Cochrane Database Syst Rev 2001, Issue 2. Art. No.: CD002803. Searches updated August 2003. 2. Morris C, McCoy E. Cervical immobilisation collars in ICU: friend or foe? Anaesthesia 2003;58(11):1051—3. 3. Eastern Association for the Surgery of Trauma. Determination of Cervical Spine Stability in Trauma Patients; 2000. http://www.east.org, accessed September 12, 2005. 4. Hoffman J, Mower W, Wolfson A, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma National Emergency X-Radiography Ulilisation Study Group. N Engl J Med 2000;343(2):94—9. 5. Powers J. A multidisciplinary approach to occipital pressure ulcers related to cervical collars. J Nurs Care Qual 1997;12(1):46—52.
83
6. American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors. 7th ed. Chicago American College of Surgeons; 2004. 7. Wardrope J, Ravichandran G, Locker T. Risk assessment for spinal injury after trauma. Br Med J 2004;328(7442):721—3. 8. Morris C, McCoy W, Lavery G. Spinal immobilisation for unconscious patients with multiple injuries. Br Med J 2004;329(7464):495—9. 9. Braude D, Domeier R. Prehospital care for road traffic casualties: Spinal immobilisation should be done selectively. Br Med J 2002;325(7358):279. 10. Brohi K. Initial Assessment of Spinal Trauma: Spinal Stabilization and Management. 2002; http://www.trauma.org, accessed 12 October 2005. 11. Vickery D. The use of the spinal board after the pre-hospital phase of trauma management. Emerg Med J 2001;18:51—4. 12. Lerner B, Moscati R. Duration of patient immobilization in the ED. Am J Emerg Med 2000;18(1):28—30. 13. Patel R, De Long W, Vresilovic E. Evaluation and treatment of spinal injuries in the patient with polytrauma. Clin Orthop & Related Res 2004;422:43—54. 14. Emergency Nurses Association. Spinal immobilisation. Trauma nursing core course, vol. 377, 5th ed. 2000. p. 81. 15. Cordell W, Hollingsworth J, Olinger M, Stroman S, Nelson D. Pain and tissue interface pressures during spine-board immobilization. Ann Emerg Med 1995;26(1):31—6. 16. Hampton S. Preventable pressure sores. Care of the Critically Ill 1997;13(5):193—7. 17. Boitano M, Tait D, Petrovic R, Nicosia S. The spine board: peak pressure assessment design implications for wound prevention. J Trauma Injury Infect Crit Care 2004; 57(2):460. 18. Curtis K, Din R, Chan A, Morris R. Reducing the time to clear the cervical spine of trauma patients in the emergency department. Aust Emerg Nurs J 2002;3(2):15—8. 19. Johnson DR, Hauswald M, Stockhoff C. Comparison of a vacuum splint device to a rigid backboard for spinal immobilization. Am J Emerg Med 1996;14:369—72. 20. Hamilton RS, Pons PT. The efficacy and comfort of full-body vacuum splint for cervical-spine immobilization. J Emerg Med 1996;14:553—9. 21. Chan D, Goldberg RM, Mason J, et al. Backboard vs mattress splint immobilization: a comparison of symptoms generated. J Emerg Med 1996;14:293—8. 22. Swartz C. Clinical decisions: resuscitation considerations to prevent pressure ulcers in trauma patients. Int J Trauma Nurs 2000;6(1):16—8. 23. Mikhail J. Backboard removal: guideline for trauma care. J Trauma Nurs 2002;9(3):7.
Managing spinal immobilisation devices in the emergency department Anne E. Brownlee, RN, MN ∗ Emergency Department, Prince of Wales Hospital, Randwick, NSW, Australia KEYWORDS Trauma care; Spinal immobilisation devices
Summary The management of spinal immobilisation devices is an important component of trauma care. Prolonged immobilisation is associated with notable morbidity, most commonly cutaneous pressure necrosis. This paper evaluates current thinking on the management of spinal immobilisation devices in the emergency department, and concludes that a pathway to expedite device removal could improve trauma care. © 2005 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Following trauma, care providers appropriately assume injury is present until it can be excluded. In the trauma patient, the importance of stabilising and immobilising the spine as a precaution is well documented. In the initial pre-hospital phase of care, pre-hospital care providers routinely apply a rigid spine board, straps, rigid neck collar, and lateral neck supports to keep the spine in a neutral position and prevent mobility in potentially damaged vertebra and ligaments during extrication and transfer. During the hospital phase of care, protection of the spine with appropriate immobilisation devices is an important management principle. It is considered best practice to maintain the neck collar as protection for the cervical spine until it is cleared of injury. Maintaining the spine board to protect the thoracolumbar spine, however, is controversial. ∗
Tel.: +61 95534883. E-mail address: [email protected].
Current thinking in trauma care limits spine board use to the pre-hospital setting, and regards board removal on presentation to hospital as best practice. Board removal on presentation is recommended to avoid the complications associated with remaining in spinal immobilisation. To expedite the removal of spinal immobilisation devices clinical pathways have been initiated in some American trauma centers. It is proposed that a similar pathway could improve trauma care in Australian emergency departments.
Literature review Random controlled trials quantifying the effect of spinal immobilisation in trauma patients cannot be found in relevant literature.1 The lack of research is most likely due to ethical considerations, the potentially devastating consequence for patients, and medicolegal concerns related to a missed injury. The real value of spinal immobilisation following trauma is uncertain. Its use is not based on scientific evidence but on concern that a
1574-6267/$ — see front matter © 2005 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2005.10.001
80
A.E. Brownlee
patient with a potential spinal injury could deteriorate neurologically without immobilisation.1 The management of cervical immobilisation devices has been widely explored in the literature. Authors have examined the effect of rigid cervical collars on skin integrity and established a direct relationship between increased interface pressure over the chin and occipital region with ulcer formation. Pressure ulcers have been found to occur in these areas in up to 55% of trauma patients following prolonged immobilisation in rigid cervical collars. Cervical collars can also obstruct venous flow and elevate intracranial pressure and this may produce secondary ischaemic brain injury in the patient with a traumatic head injury.2 This has concerned physicians providing trauma care and they have subsequently developed guidelines to expedite cervical spine clearance and removal of extrication collars. The Eastern Association for the Surgery of Trauma (EAST), for instance, developed evidencebased guidelines for safe and effective cervical spine clearance.3 A number of large studies, including the NEXUS study, support the guidelines. The NEXUS study of >34,000 patients validates a set of clinical criteria on which to clear the cervical spine in blunt trauma with an overall sensitivity of 99%.4 In accordance with EAST guidelines, the cervical spine can be examined and clinically cleared without radiology when the following NEXUS criteria are met:
gest the removal of the board during the secondary survey and utilisation of clinical criteria to exclude injury. In the awake and alert patient, the thoracolumbar spine may be clinically cleared when pain or tenderness along the spine is absent on palpation. If the patient has a depressed level of consciousness, or the alert patient reports pain on palpation, appropriate radiography and or CT scanning is required.6 Until the thoracolumbar spine can be cleared of injury, spinal precautions involve supine positioning on a firm surface, such as the trauma bed.6 Current thinking in trauma care supports the use of clinical criteria to clear the thoracolumbar spine, but advocates removal of the spine board much sooner, ideally on transfer from ambulance trolley to trauma bed.1,7—13 Past teaching held the spine board necessary to splint the entire vertebral column to prevent flexion, extension, rotation and lateral movement until radiography cleared the thoracolumbar spine of injury.14 Currently, the firm surface of the trauma bed is regarded a sufficient splint for the thoracolumbar spine.1,10 Spinal damage requires the high force that occurred at the time of impact; movement thereafter is unlikely to cause further damage.1 When transfer is required, a Jordan frame to lift the patient is recommended because the device allows limited movement of the lower spine.
(1) (2) (3) (4) (5)
Complications of spinal immobilisation
the patient has normal alertness; there is no evidence of drug or alcohol use; there is no painful distracting injury; there is no midline cervical tenderness or pain; there is no focal neurological deficit.
When the clinical criteria are not met and examination is uncertain, cervical spine radiography and computerised tomography scanning are required.4 If cervical spine clearance has not been completed within 4 h, a more comfortable collar, such as a Philadelphia Collar, may replace the extrication collar.3 Nursing management involves cleaning the skin and monitoring the occiput, chin/mandible, ears, shoulders and sternum for pressure areas. If an area of pressure is evident, a thin dressing may be applied. The area is not padded because this can increase pressure and cause other pressure areas or may affect the alignment of the spine.5 Clear guidelines for spine board management and thoracolumbar spinal clearance are not evident in the literature. Advanced trauma life support guidelines, which inform trauma care in Australia, allow the trauma patient to remain immobilised on a spine board for up to 2 h.6 These guidelines sug-
Spinal immobilisation is not a gentle procedure; it is uncomfortable and increases the patient’s risk for a number of complications. Prolonged supine positioning and use of a cervical collar and spine board is associated with aspiration, respiratory compromise, iatrogenic pain, cutaneous pressure ulceration and poor quality radiography.1,9,13,15
Aspiration The risk of aspiration is increased for the supine trauma patient. Because trauma is unexpected, the patient is likely to have a full stomach and injury may reduce their ability to protect the airway.9 In the supine position, passive regurgitation or vomiting may result in aspiration of gastric contents and impaired oxygenation.9 In the past, it was believed the spine board could protect against aspiration because it facilitated turning a vomiting patient onto their side. Rapid log-rolling is now considered a more appropriate strategy to turn the
Managing spinal immobilisation devices in the emergency department trauma patient that is vomiting.12 Rapid log-rolling requires four people to carry out the maneuver and one person to suction the patient. One person holds the head and coordinates the roll, while three others roll the chest, pelvis, and limbs so that the head, neck, body and limbs move in an aligned manner. The fifth person carefully suctions the oral cavity and avoids inducing further gagging or vomiting.14 Management may also include administration of a suitable antiemetic and gastric decompression. Gastric decompression is accomplished through intubating the stomach by passing a tube nasally or orally and attaching it to suction to evacuate gastric contents.6
Respiratory compromise The supine trauma patient has an increased risk of respiratory compromise. In studies on healthy volunteers, subjects with full spinal immobilisation demonstrate increased respiratory effort and reduction in chest expansion from torso straps on the spine board.1,11 The finding is significant because restricted chest expansion can result in low tidal volumes and accentuate the physiological effects of the supine position on respiratory function.11 In the supine position, functional residual capacity is reduced and less alveoli are available for external respiration. This is important because metabolic rate and oxygen demand increase following trauma hence the need for highflow supplemental oxygen to meet the patients oxygen requirements.14 If chest trauma involves pneumo/haemothorax, rib and sternum fractures or lung contusions, respiratory function and oxygenation is further compromised and the patient may require ventilatory support.14
Iatrogenic pain Spinal immobilisation devices are a potential source of iatrogenic pain in trauma patients. Studies on healthy volunteers in spinal immobilisation devices found subjects complain of pain and discomfort at approximately 30 min when rigid neck collars and spine boards were used.11,12 Rigid immobilisation devices were found to cause high tissue-interface pressure over the heels, sacrum, thoracic spine, elbows, occipital region and chin causing ischemic pain.1,11,12 The results suggest that after 30 min it may well be difficult to differentiate between pain generated by immobilisation devices and pain caused by actual trauma. In immobilised trauma
81
patients, iatrogenic pain may be misleading and subject people to unnecessary imaging if clinicians wrongly believe pain is related to injury.11,12
Cutaneous pressure ulceration Time and high interface pressure are predictors of cutaneous pressure ulceration in the trauma patient. Ischemia occurs when interface pressure exceeds or approaches capillary pressure. At 32 mmHg of pressure, capillary blood flow becomes compromised and impedes the supply of oxygen and nutrient to tissues causing hypoxia, necrosis and ulceration.16 The intensity of pressure is proportional to the time necessary to cause tissue damage. That is, high pressure over a short time and low pressure of longer duration.16 A sustained interface pressure of 35 mmHg for 2 h and 60 mmHg for 1 h is sufficient to cause irreversible tissue damage.16 Studies on healthy subjects have recorded interface pressures of 233.5 mmHg and 82.9 mmHg at the sacrum and thorax on a rigid spine board.11,17 Studies show that patients can spend an average 63 min on a spine board in the emergency department before being cleared of injury.12
Inferior radiography Reliable imaging is important in excluding injury after trauma in high-risk patients. A series of X-rays to evaluate the cervical spine, chest, pelvis and thoracolumbar spine and or computerised tomography may be required to exclude injury.7 Recent research indicates that computerised tomography is the most effective, however, immediate access to computerised tomography is not available in all Australian emergency departments, particularly in regional areas. Clinicians therefore rely upon radiographic studies but the quality of imaging is problematic when performed while the patient is on a spine board.18 Imaging performed while the patient is on a spine board is frequently of poor quality. Imaging is inferior because the X-ray plate is beneath the trauma bed and the X-ray beam must penetrate the spine board and patients clothing.13,18 One study that measured the time taken to exclude cervical spine injury in the resuscitation bay, found X-rays needed to be repeated often because of poor quality films.18 Because imaging had to be repeated to exclude injury, spinal immobilisation devices remained on the patient between 100 and 282 min.18 The spine board ought to be removed to
82 Table 1
A.E. Brownlee Clinical pathway for removal of spinal immobilisation devices in the ED
improve the quality of films and avoid prolonged immobilisation.
Discussion Pressure induced tissue injury can begin in the prehospital and initial hospital phase of care. Rigid extrication neck collars and spine boards generate high tissue interface pressures capable of causing ischemia and necrosis in contact tissues. Following trauma, tissue is susceptible and damage accelerates. Injury, vasoconstriction and hypoperfusion, loss of movement and/or sensation, time lying immobile before rescue, and environmental moisture increase the risk for tissue necrosis. The
seriously injured may remain immobilised for a long time because of unconsciousness, surgical intervention, spinal or orthopedic injury and develop cutaneous pressure ulceration. Cutaneous ulcers are a source of pain, potential infection and sepsis that delay recovery. The timely removal of immobilisation devices reduce the risk for such complications arising. Random controlled trials comparing spinal immobilisation strategies on healthy volunteers support removal of spinal immobilisation devices as soon as possible, and recommend removal of the spine board as a priority for management.19—21 Backboard spinal immobilisation is a useful component of pre-hospital care but it is not a tool for hospital care. To expedite removal of the spine board clinical pathways are being successfully implemented
Managing spinal immobilisation devices in the emergency department in trauma centers abroad.22,23 On arrival to hospital unless the patient is undergoing intensive resuscitation, they are log rolled and the board removed immediately after transfer from ambulance trolley to trauma bed. Spine board time is reduced significantly and the incidence of cutaneous pressure ulceration is lower.19,20 An example of a clinical pathway for the removal of spinal immobilisation devices is shown in Table 1. The pathway is based on EAST guidelines for cervical collar management and current thinking on spine board use. The pathway’s goal is to ensure management of airway, breathing and circulation are the main concern of clinicians, and spinal immobilisation a management priority. It aims to raise awareness of cutaneous pressure problems in the trauma patient and thus facilitate removal of immobilisation devices. Prolonged immobilisation increases morbidity and mortality after trauma. A clinical pathway to manage spinal immobilisation in the emergency department may improve trauma care through prevention.
References 1. Kwan I, Bunn F, Roberts I, on behalf of the WHO PreHospital Trauma Care Steering Committee. Spinal immobilisation for trauma patients. Cochrane Database Syst Rev 2001, Issue 2. Art. No.: CD002803. Searches updated August 2003. 2. Morris C, McCoy E. Cervical immobilisation collars in ICU: friend or foe? Anaesthesia 2003;58(11):1051—3. 3. Eastern Association for the Surgery of Trauma. Determination of Cervical Spine Stability in Trauma Patients; 2000. http://www.east.org, accessed September 12, 2005. 4. Hoffman J, Mower W, Wolfson A, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma National Emergency X-Radiography Ulilisation Study Group. N Engl J Med 2000;343(2):94—9. 5. Powers J. A multidisciplinary approach to occipital pressure ulcers related to cervical collars. J Nurs Care Qual 1997;12(1):46—52.
83
6. American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors. 7th ed. Chicago American College of Surgeons; 2004. 7. Wardrope J, Ravichandran G, Locker T. Risk assessment for spinal injury after trauma. Br Med J 2004;328(7442):721—3. 8. Morris C, McCoy W, Lavery G. Spinal immobilisation for unconscious patients with multiple injuries. Br Med J 2004;329(7464):495—9. 9. Braude D, Domeier R. Prehospital care for road traffic casualties: Spinal immobilisation should be done selectively. Br Med J 2002;325(7358):279. 10. Brohi K. Initial Assessment of Spinal Trauma: Spinal Stabilization and Management. 2002; http://www.trauma.org, accessed 12 October 2005. 11. Vickery D. The use of the spinal board after the pre-hospital phase of trauma management. Emerg Med J 2001;18:51—4. 12. Lerner B, Moscati R. Duration of patient immobilization in the ED. Am J Emerg Med 2000;18(1):28—30. 13. Patel R, De Long W, Vresilovic E. Evaluation and treatment of spinal injuries in the patient with polytrauma. Clin Orthop & Related Res 2004;422:43—54. 14. Emergency Nurses Association. Spinal immobilisation. Trauma nursing core course, vol. 377, 5th ed. 2000. p. 81. 15. Cordell W, Hollingsworth J, Olinger M, Stroman S, Nelson D. Pain and tissue interface pressures during spine-board immobilization. Ann Emerg Med 1995;26(1):31—6. 16. Hampton S. Preventable pressure sores. Care of the Critically Ill 1997;13(5):193—7. 17. Boitano M, Tait D, Petrovic R, Nicosia S. The spine board: peak pressure assessment design implications for wound prevention. J Trauma Injury Infect Crit Care 2004; 57(2):460. 18. Curtis K, Din R, Chan A, Morris R. Reducing the time to clear the cervical spine of trauma patients in the emergency department. Aust Emerg Nurs J 2002;3(2):15—8. 19. Johnson DR, Hauswald M, Stockhoff C. Comparison of a vacuum splint device to a rigid backboard for spinal immobilization. Am J Emerg Med 1996;14:369—72. 20. Hamilton RS, Pons PT. The efficacy and comfort of full-body vacuum splint for cervical-spine immobilization. J Emerg Med 1996;14:553—9. 21. Chan D, Goldberg RM, Mason J, et al. Backboard vs mattress splint immobilization: a comparison of symptoms generated. J Emerg Med 1996;14:293—8. 22. Swartz C. Clinical decisions: resuscitation considerations to prevent pressure ulcers in trauma patients. Int J Trauma Nurs 2000;6(1):16—8. 23. Mikhail J. Backboard removal: guideline for trauma care. J Trauma Nurs 2002;9(3):7.