Which of the following is the most appropriate device to use when immobilizing a patient with suspected spinal injury?

8.1. Introduction

Chapters 7 and 8 have established when to immobilise the spine. The practice of how to immobilise the spine safely and effectively is no less complex or controversial. There is variation in the methods used to immobilise the spine during transportation to hospital from the scene of an accident. Full inline spinal immobilisation can include a cervical collar, head restraints and either a long spinal board or scoop stretcher. The different methods of spinal protection vary in their capacity to protect the spine, as well as their capacity to cause harm. Other considerations in the use of pre-hospital spinal immobilisation methods may include the cost of equipment and the time and training of pre-hospital clinicians to apply the devices. These factors may influence the variation in equipment that is available to use at an incident. In addition the situation and the injured person’s circumstances have to be considered when deciding on the best approach to carry out immobilisation. This chapter aims to identify the optimal strategies to carry out full in-line spinal immobilisation.

Inhaltsverzeichnis Show

8.1. Introduction
8.2. Review question: What pre-hospital strategies to protect the spine in people with suspected spinal injury are the most clinically and cost effective during transfer from the scene of the incident to acute medical care?
Table 16PICO characteristics of review question
8.3. Clinical evidence
8.4. Economic evidence
Published literature
8.5. Evidence statements
8.6. Recommendations and link to evidence
Which of the following is the most appropriate device to use when immobilizing a patient with a suspected spinal injury group of answer choices?
What is direct carry used for?
Which is the most appropriate method to use when moving a patient?
Which is the most appropriate method to use when moving a patient from his or her bed to a wheelchair?

8.2. Review question: What pre-hospital strategies to protect the spine in people with suspected spinal injury are the most clinically and cost effective during transfer from the scene of the incident to acute medical care?

For full details see review protocol in Appendix C.

Table 16PICO characteristics of review question

Population	Children, young people and adults experiencing a traumatic incident. If no evidence is identified the indirect population of healthy volunteers will be considered
Intervention/s	Spinal boards (long or short) Rescue board Scoop stretcher Spinal extrication devices Back boards Collar and back board combinations Vacuum mattress Mattress splints Collars (rigid or soft) Manual stabilization Sand bags, straps and tapes, head blocks, aqua board Kendrick Extrication Device (KED) Or any combinations of the above
Comparison/s	Standard care Do nothing Each other or combinations of above
Outcomes	Critical: Mortality at 1 month Mortality at 6 months Mortality at 12 months Health-related quality of life Rates of spinal cord injury (SCI) Missed spinal column/cord injury Spinal cord neurological function at 1 month (including American Spinal Injury Association [ASIA] and Frankel) Spinal cord neurological function at 6 months (including ASIA and Frankel) Spinal cord neurological function at 12 months (including ASIA and Frankel) Adverse effects: Pressure ulcers Airway compromise Raised ICP Neurological deterioration [ASIA]) associated with spinal protection/immobilisation. Important: Pain/discomfort Return to normal activities Psychological wellbeing
Study design	RCTs or Systematic reviews of RCTs; cohorts or case-controls if no RCTs retrieved.

8.3. Clinical evidence

Thirteen studies were included in the review.12,29,31,34,49,55,60,66,73,75,108,109,114 Six of these studies did not have any relevant outcomes are not considered further.31,49,55,66,75,108 Evidence from the remaining seven studies are summarised in the clinical evidence summary table below (Table 18). See also clinical GRADE evidence profiles in Appendix H, study selection flow chart in Appendix D, forest plots in Appendix I, study evidence tables in Appendix G and exclusion list in Appendix J.

Table 17

Summary of studies included in the review.

Table 18

Clinical evidence summary: methods of spinal immobilisation.

The population of the studies was indirect; all of the studies were in healthy volunteers.

The included studies compared the following classes of intervention:

Collars versus collars 12
Spinal boards versus spinal boards29,34,60,114
Spinal boards versus vacuum splints55,109
Head blocks (padded versus hard)73

A summary of the seven included studies is presented below (Table 17).

8.4. Economic evidence

Published literature

No relevant economic evaluations were identified.

See also the economic article selection flow diagram in Appendix E.

Unit costs

Relevant unit costs are provided below to aid consideration of cost effectiveness.

8.5. Evidence statements

Clinical

Aspen collar versus Philadelphia collar

Very low quality evidence from 1 crossover study comprising 20 participants showed that the Aspen collar was clinically effective compared with the Philadelphia collar in terms of temperature, with serious imprecision.

Very low quality evidence from 1 crossover study comprising 20 participants showed that there was no difference in clinical effectiveness between the Aspen collar and the Philadelphia collar in terms of occipital pain, with very serious imprecision.

Board versus vacuum mattress

Very low quality evidence from 1 crossover RCT study comprising 28 participants showed that the there was no difference in clinical effectiveness between board versus board/vacuum mattress for the respiratory outcomes (FVC, FEV, PEF and FEF) with no serious to serious imprecision.

Wooden board versus vacuum

Very low quality evidence from 1 RCT crossover study comprising 48 participants showed that the vacuum was more clinically effective compared with the wooden board in terms of comfort, with no imprecision.

Padded versus unpadded board

Low quality evidence from 1 RCT crossover study comprising 30 participants showed that the padded board was more clinically effective compared with the unpadded board in terms of pain (VAS), with serious imprecision.

Backboard versus vacuum mattress

Very low quality evidence from 1 RCT crossover study comprising 30 to 35 participants showed that the vacuum mattress was more clinically effective compared with the backboard in terms of any symptom – first exposure and second exposure, with serious imprecision.

Low quality evidence from 1 RCT crossover study comprising 37 participants showed that the vacuum mattress was more clinically effective compared with the backboard in terms of occipital pain – first exposure, with no imprecision.

Low quality evidence from 1 RCT crossover study comprising 35 participants showed that the vacuum mattress was more clinically effective compared with the backboard in terms of occipital pain – second exposure, with no imprecision.

Low quality evidence from 1 RCT crossover study comprising 36 participants showed that the vacuum mattress was more clinically effective compared with the backboard in terms lumbosacral pain – first exposure, with no imprecision.

Very low quality evidence from 1 RCT crossover study comprising 35 participants showed that there was no difference in clinical effectiveness between the backboard and vacuum mattress in terms of lumbosacral pain – second exposure, with very serious imprecision.

Very low quality evidence from 1 RCT crossover study comprising 35 participants showed that the backboard was more clinically effective compared with the vacuum mattress in terms of cervical pain – first exposure, with no imprecision.

Low quality evidence from 1 RCT crossover study comprising 35 participants showed that there was no difference in clinically effectiveness between the vacuum mattress and backboard in terms of cervical pain – second exposure, scapular pain – first and second exposure, with very serious imprecision.

Comfort backboard versus backboard plus blanket

Very low quality evidence from 1 RCT crossover study comprising 22 participants showed that backboard and blanket was more clinically effective compared with backboard and blanket in terms of comfort, with no imprecision.

Comfort backboard versus backboard plus mattress

Very low quality evidence from 1 RCT crossover study comprising 22 participants showed that backboard and mattress was more clinically effective compared with comfort backboard in terms of comfort, with no imprecision.

Comfort backboard versus backboard plus mattress plus eggcrate foam

Very low quality evidence from 1 RCT crossover study comprising 22 participants showed that backboard, mattress and eggcrate foam was more clinically effective compared with comfort backboard in terms of comfort, with no imprecision.

Backboard + mattress versus backboard plus blanket

Very low quality evidence from 1 RCT crossover study comprising 22 participants showed that backboard and mattress was more clinically effective compared with backboard and blanket in terms of comfort, with no imprecision.

Backboard + mattress versus backboard plus mattress plus eggcrate foam

Very low quality evidence from 1 RCT crossover study comprising 22 participants showed that backboard, mattress and eggcrate foam and blanket was more clinically effective compared with backboard and mattress in terms of comfort, with no imprecision.

Backboard + blanket versus backboard plus mattress plus eggcrate foam

Very low quality evidence from 1 RCT crossover study comprising 22 participants showed that backboard, mattress and eggcrate foam was more clinically effective compared with backboard and blanket in terms of comfort, with no imprecision.

Head support – unpadded versus padded

Very low quality evidence from 1 RCT crossover study comprising 37 participants showed that the padded headrest was more clinically effective compared with unpadded headrest in terms of pain (head) immediately following the intervention, with very serious imprecision.

Very low quality evidence from 1 RCT crossover study comprising 37 participants showed that the unpadded headrest was more clinically effective compared with padded headrest in terms of pain (neck) immediately following the intervention, with serious imprecision.

Very low quality evidence from 1 RCT crossover study comprising 37 participants showed that the unpadded headrest was more clinically effective compared with padded headrest in terms of pain (shoulder) immediately following the intervention, with very serious imprecision.

Very low quality evidence from 1 RCT crossover study comprising 37 participants showed that the padded headrest was more clinically effective compared with unpadded headrest in terms of pain (lumbar) immediately following the intervention, with serious imprecision.

Very low quality evidence from 1 RCT crossover study comprising 37 participants showed that the unpadded headrest was more clinically effective compared with padded headrest in terms of pain (buttock) immediately following the intervention, with serious imprecision.

Very low quality evidence from 1 RCT crossover study comprising 37 participants showed that the there was no difference in clinical effectiveness between padded and unpadded headrests in terms of pain (ankle, head [front]) immediately following the intervention, with very serious imprecision.

Very low quality evidence from 1 RCT crossover study comprising 37 participants showed that the there was no difference in clinical effectiveness between padded and unpadded headrests in terms of pain (neck, thoracic) 24 hours following the intervention, with very serious imprecision.

Very low quality evidence from 1 RCT crossover study comprising 37 participants showed that the unpadded headrest was more clinically effective compared with padded headrest in terms of pain (lumbar) 24 hours following the intervention, with very serious imprecision.

Very low quality evidence from 1 RCT crossover study comprising 37 participants showed that the there was no difference in clinical effectiveness between padded and unpadded headrests in terms of pain (head [rear], shoulder, arm, buttock, thigh, knee, calf, ankle, feet) 24 hours following the intervention, with serious to very serious imprecision.

Economic

No relevant economic evaluations were identified.

8.6. Recommendations and link to evidence

Recommendations	Pre-hospital in-line spinal Immobilisation 19. When immobilising the spine tailor the approach to the person’s specific circumstances (see recommendations 20 and 24 to 26). 20. The use of spinal immobilisation devices may be difficult (for example in people with short or wide necks, or people with a pre-existing deformity) and could be counterproductive (for example increasing pain, worsening neurological signs and symptoms). In uncooperative, agitated or distressed people, including children, think about letting them find a position where they are comfortable with manual in-line spinal immobilisation. 21. When carrying out full in-line spinal immobilisation in adults, manually stabilise the head with the spine in-line using the following stepwise approach: Fit an appropriately sized semi-rigid collar unless contraindicated by: – a compromised airway – known spinal deformities, such as ankylosing spondylitis (in these cases keep the spine in the person’s current position). Reassess the airway after applying the collar. Place and secure the person on a scoop stretcher. Secure the person with head blocks and tape, ideally in a vacuum mattress. 22. When carrying out full in-line spinal immobilisation in children, manually stabilise the head with the spine in-line using the stepwise approach in recommendation 21 and consider: involving family members and carers if appropriate keeping infants in their car seat if possible using a scoop stretcher with blanket rolls, vacuum mattress, vacuum limb splints or Kendrick extrication device. 23. When there is immediate threat to a person’s life and rapid extrication is needed, make all efforts to limit spinal movement without delaying treatment. 24. Consider asking a person to self-extricate if they are not physically trapped and have none of the following: significant distracting injuries abnormal neurological symptoms (paraesthesia or weakness or numbness) spinal pain high-risk factors for cervical spine injury as assessed by the Canadian C-spine rule. 25. Explain to a person who is self-extricating that if they develop any spinal pain, numbness, tingling or weakness, they should stop moving and wait to be moved. 26. When a person has self-extricated: ask them to lay supine on a stretcher positioned adjacent to the vehicle or incident in the ambulance, use recommendations 1 to 4, 9 to 14, and 19 to 21 to assess them for spinal injury and manage their condition. 27. Do not transport people with suspected spinal injury on a longboard or any other extrication device. A longboard should only be used as an extrication device. Hospital in-line spinal Immobilisation 28. When carrying out or maintaining full in-line immobilisation refer to recommendations 19 to 22.
Relative values of different outcomes	The outcomes critical to decision making were mortality, quality of life, rates of SCI, missed spinal column/cord injury, spinal cord neurological function (ASIA and Frankel) and adverse effects, including pressure ulcers, airway compromise, raised intracranial pressure, and neurological deterioration (ASIA) associated with spinal protection/immobilisation. Important outcomes were unnecessary imaging and patient-reported outcomes (pain/discomfort, return to normal activities, psychological wellbeing).
Trade-off between clinical benefits and harms	The GDG felt that the importance of adequate spinal immobilisation cannot be over emphasised with inadequate protection potentially resulting in deteriorating neurological function possibly leading to death. The GDG noted that there should always be supervision of someone who is fully immobilised. The GDG noted that despite the protective advantages of spinal immobilisation there are situations where a standard one size fits all immobilisation approach could be harmful or delay treatment. Full in-line spinal immobilisation may impede management of the airway, on-going haemorrhage control and may worsen pre-existing conditions, such as ankylosing spondylitis. Collars may result in airway and/or respiratory compromise, and spinal boards can cause pain and prolonged use may lead to pressure sores. All the evidence compared different types of equipment; no evidence was identified that compared the use of different strategies with not using any equipment. The majority of the evidence reported outcomes related to the comfort of the patient and it should be noted that the population in these studies are healthy volunteers and sponsored by the manufacturers. It is difficult to make a conclusion from this evidence about the risk and benefits of different types of strategies when immobilising a person with suspected spinal injuries who may also have other injuries that could be life threatening. The population in the studies were compliant healthy volunteers and do not reflect the real-life situation of the healthcare professional (both in the pre - hospital and emergency department [ED] situation) assessing and treating people in a stressful and frightening situation. It is not unusual for patients to be combative, agitated or frightened and a standard approach can result in further injury. As a result, the GDG made recommendations that emphasise the need to approach spinal immobilisation taking into account the patient’s specific situation, particularly noting the difficulties in uncooperative, agitated or distressed people, including children. Pre-hospital practitioners are often faced with difficult situations where people are trapped and the GDG agreed a consensus recommendation on the process of immobilisation during extrication was important. The GDG use the example of a person trapped in a vehicle, however, the principles apply to any trapped situation. In these circumstances, the patient may have an immediate threat to life (for example, catastrophic haemorrhage), full in-vehicle assessment may be impossible and there may be added life threatening dangers (to both the patient and attending emergency services), such as fire or flooding. In these situations, to expedite extrication the routine immobilisation of all trapped patients cannot be justified and rapid or self-extrication may be necessary. Supporting a person to self-extricate can be beneficial in a number of ways. Self-extrication is likely to reduce the time to definitive care, potentially improving the outcomes for many patients. It may also reduce the anxiety a person experiences in an entrapment situation. In addition it reduces use of resources for all the emergency services. Inviting a patient to remove themselves from a car is not a declaration of an uninjured cervical spine, and so immobilisation must still be used, in line with local policy, once the patient is out of the vehicle. Long boards A longboard is the terminology used for the boards that are used to as extrication device. The purpose of the longboard is to allow the safe transfer of a patient to a transport stretcher. These devices are rigid and uncomfortable. Prolonged time on a long spine board or prolonged time on scene applying these devices may be detrimental leading to pressure sores and can result in a poor patient outcome. In addition spinal immobilisation is not optimal on longboards. In order to minimize these negative occurrences, patients should be removed from the long spine board as soon as it is safe and practical to do so.
Economic considerations	Pre-hospital stabilisation strategies No economic evidence was found comparing different devices. The GDG were presented with a cost analysis of the various devices alongside economic considerations. This analysis was based on data from the Trauma Audit and Research Network (TARN), which included the number of different spinal protections used for each patient and the number of each type of protection, that are used pre-hospital, in the ED and in-hospital. This data did not have a breakdown of the type of protections used in combination for each patient so an overall cost per person immobilised was calculated based on all the devices used for the TARN population (average cost of spinal protection was £5.49 per person). It was thought that costs could be reduced by limiting the number of protections that patients could have, so as a comparison, the GDG were presented with the cost per person of a single application of full spinal protection. On the assumption that patients do not need re-immobilisation, the cost of full spinal protection per person is slightly lower than the average cost of protection in current practice (£4.97 per person). However, full spinal protection involves a combination of devices and as such, is the most expensive single measure for immobilisation. The vast majority of these costs come from the single use collar, which costs around £4.80 each. For reusable equipment, such as a vacuum mattress, even with a conservative lifetime usage estimate of 2000, the effect on the cost per person is minimal. The GDG took into consideration that the TARN population is a specific population with a higher severity of condition compared with the general trauma population and therefore, does not necessarily fully reflect the trauma population as a whole. The GDG agreed that the clinical review evidence was lacking in terms of informing the group about which device was better at immobilising people and not exacerbating an existing spinal injury. A consensus recommendation was reached using the expertise and guidance of the GDG on the devices which could be seen as the most appropriate. As a full immobilisation involves a combination of devices, this leads to a higher cost, however, it could prevent the need for re-immobilisation and potentially reduce the overall cost. The GDG agreed that the equipment listed in the recommendation was cost-effective due to the small cost per use and the important benefits of having the necessary equipment to provide appropriate protection for patients with spinal injury.
Quality of evidence	Seven parallel RCTs or randomised crossover trials reporting on outcomes specified in the protocol were identified. All of the studies were in the indirect population of healthy volunteers. The outcomes were graded as Low or Very low quality. Aspen collar versus Philadelphia collar There were clinically important benefits for the Aspen collar in terms of temperature and percentage relative humidity, and no harms were reported. Padded board versus unpadded board There were clinically important benefits for the padded board in terms of pain, and no harms were reported. Board versus vacuum There were clinically important harms for the board in terms of comfort, occipital pain, lumbosacral pain and any symptom at first exposure. Backboard versus backboard and mattress plus foam/blanket There were clinically important harms for the backboard in terms of comfort. Unpadded head support versus padded head support There were clinically important benefits for the unpadded head support in terms of immediate neck pain, immediate shoulder pain, immediate buttock pain and lumbar pain at 24 hours. However, there were also harms in terms of immediate head and immediate lumbar pain.
Other considerations	Immobilisation methods The GDG acknowledged there was a call for advice on how to immobilise the spine but noted that methods used to immobilise the spine are dependent on the circumstances and it is difficult to cover all scenarios in this guideline. Equally it is impossible to describe a, ‘one fits all’ situation without being appearing prescriptive and this could be potentially counterproductive if rigidly adhered to. To address this the GDG have listed the key principles of immobilising the spine in the recommendations but also noted the methods and practices to carry out spinal immobilisation are well documented in detail elsewhere (for example, ATLS, and in ‘Moving and handling patients with actual or suspected spinal cord injuries (SCI) produced by the Spinal Cord Injury Centres of the United Kingdom and Ireland). The GDG noted the following points about commonly used spinal immobilisation equipment. In general spinal immobilisation equipment in the hospital setting should not comprise of non-CE marked items e.g. rolled up towels, saline bags and tape. Such items are likely not to be fit for purpose and also can significantly reduce image quality. Collars A collar should be sized and fitted correctly (not too tightly and should be loosened if necessary, avoiding hyper-extension). For patients with ankylosing spondylitis and rheumatoid arthritis, manual in-line stabilisation is an appropriate substitute for a collar. This may also apply to people with short and wide necks. For patients with a suspected head injury, a collar may increase intracranial pressure and should be applied with caution. Vacuum mattress and scoop stretcher The GDG noted that when placing someone on a scoop it was important to minimise movement. To minimise movement of the spine utilise a 10 degrees tilt to left and right while two hemi scoops are inserted. This should ideally be undertaken by 5 people. The GDG considered that the vacuum mattress had particular benefits in terms of keeping patients warm, providing protection from adverse environments, providing secure immobilisation for extrications (for example, upstairs), allowing carriage over a distance to the hospital transport and providing additional security to a scoop stretcher, allowing patients to ‘feel secure’. The availability of a vacuum mattress on a helicopter and/or an ambulance may be down to space, weight and/or cost. It may not necessary place the scoop inside the vacuum mattress for every incident. If the journey to the receiving hospital is more than 45 minutes, the patient should be placed inside the vacuum mattress and the scoop removed. Some examples of when the scoop would be placed inside the vacuum mattress would be if there was a short distance carrying the patient to either the helicopter or the ambulance; carrying the patient down the stairs; or keeping the patient warm. The GDG noted a possible disadvantage of the scoop stretcher in terms of the need to be removed from it as soon as possible to avoid pressure-related injuries, despite the competing need for minimising movement at this stage.

Which of the following is the most appropriate device to use when immobilizing a patient with a suspected spinal injury group of answer choices?

For decades, prehospital spinal stabilisation with a rigid cervical collar and a hard backboard has been considered to be the most appropriate procedure to prevent secondary spinal cord injuries during patient transportation.

What is direct carry used for?

The direct carry is used to transfer a patient: from a bed to the ambulance stretcher. In most instances, you should move a patient on a wheeled ambulance stretcher by: pushing the head of the stretcher while your partner guides the foot.

Which is the most appropriate method to use when moving a patient?

There are quite a few techniques that EMS crews utilize in order to facilitate the appropriate movement of the patient. The most recognized technique is the use of the stretcher. EMS and stretchers go together like peanut butter and jelly.

Which is the most appropriate method to use when moving a patient from his or her bed to a wheelchair?

Use your legs to lift. At the same time, the patient should place their hands by their sides and help push off the bed. The patient should help support their weight on their good leg during the transfer. Pivot towards the wheelchair, moving your feet so your back is aligned with your hips.

Which of the following is the most appropriate device to use when immobilizing a patient with suspected spinal injury?

8.1. Introduction

8.2. Review question: What pre-hospital strategies to protect the spine in people with suspected spinal injury are the most clinically and cost effective during transfer from the scene of the incident to acute medical care?

Table 16PICO characteristics of review question

8.3. Clinical evidence

Table 17

Table 18

8.4. Economic evidence

Published literature

Unit costs

8.5. Evidence statements

Clinical

Aspen collar versus Philadelphia collar

Board versus vacuum mattress

Wooden board versus vacuum

Padded versus unpadded board

Backboard versus vacuum mattress

Comfort backboard versus backboard plus blanket

Comfort backboard versus backboard plus mattress

Comfort backboard versus backboard plus mattress plus eggcrate foam

Backboard + mattress versus backboard plus blanket

Backboard + mattress versus backboard plus mattress plus eggcrate foam

Backboard + blanket versus backboard plus mattress plus eggcrate foam

Head support – unpadded versus padded

Economic

8.6. Recommendations and link to evidence

Which of the following is the most appropriate device to use when immobilizing a patient with a suspected spinal injury group of answer choices?

What is direct carry used for?

Which is the most appropriate method to use when moving a patient?

Which is the most appropriate method to use when moving a patient from his or her bed to a wheelchair?

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