Recommendation for changes to the guidelines of trauma patients with potential spinal injury within a regional UK ambulance trust

Abstract

Background: Spinal assessment and immobilisation has been a topic of debate for many years where, despite an emerging evidence base and the delivery of new guidance overseas, little has changed within UK pre-hospital practice. Since 2018, South East Coast Ambulance Service NHS Foundation Trust has spent time working with local trauma networks and expertise from within the region and international colleagues to develop a set of C-spine assessment and immobilisation guidelines that reflect the current best available international evidence and significant changes in international pre-hospital practice from settings such as Scandinavia and Australasia.Methods: A specialist group was commissioned to review the topic of pre-hospital spinal immobilisation and explore potential for evidence-based improvement. In conjunction with local trauma networks, subject matter experts and a thorough review of recent literature, a series of recommendations were made in order to improve spinal care within the authoring trust.Results: Seven recommendations were made, and an updated set of guidelines produced. These included the removal of semi-rigid collars from pre-hospital spinal immobilisation; the creation of two tiers of patients to ensure that the high-risk and low-risk populations are considered separately and an accompanying decision tool to safeguard both cohorts; an increased emphasis on the risk of spinal injury in the frail and older patient; an emphasis on spinal motion restriction rather than rigid immobilisation; an increased emphasis on self-extrication; and the use of a marker for emergency departments.Summary: An updated set of guidance has been produced using a combination of specialist and expert opinion alongside a literature review with close involvement of key stakeholders, both public and professional. The new guidance helps to ensure a patient-centred approach where each person is considered an individual with their risk of injury and management measures tailored to their specific needs.

Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update

“…Since our 2019 recommendations that rigid cervical collars and spinal immobilization had no requisite role in wilderness EMS or rescue operations, numerous organizations have followed suit with similar recommendations, guidelines, and protocols. 126…”

“…Since our 2019 recommendations that rigid cervical collars and spinal immobilization had no requisite role in wilderness EMS or rescue operations, numerous organizations have followed suit with similar recommendations, guidelines, and protocols. 126 In 2022, Geduld et al designed a scoping review of 42 articles that explored possible barriers to implementation of SCP (manifested as SMR) in low resource settings versus older models of universal immobilization. Key issues they identified include confusion in terminology, poor guideline compliance and implementation, and a lack of context-specific evidence.…”

Cervical spine immobilisation following blunt trauma in pre-hospital and emergency care: A systematic review

“…Studies and expert consensus continue to emerge questioning the use of pre-hospital spinal immobilisation. Some regions have now moved away from universal cervical spine immobilisation in conscious, fully alert, stable and co-operative patients [ 17 ]. As suggested by Hauswald et al [ 23 ] a significant amount of force is required to create an unstable injury to the cervical spine during the initial trauma, and additional movements of the spine are unlikely to cause further damage.…”

“…However, for high-risk patients unable to protect their own cervical spine (e.g. those with a reduced level of consciousness, or apparently under the influence of alcohol and/or drugs) a policy of immobilisation remains in place [ 17 , 31 ] with the intention of preventing the devastating effects of cord damage.…”

“…Furthermore meticulous attention to cervical spine management may distract clinicians from treating immediately life-threatening traumatic pathology and prolong on-scene times. This evolving understanding has led some emergency medical services to abandon all or part of cervical spine immobilisation [ 17 ], but there is variation in practice resulting from uncertainty as to its benefits [ 1 , 12 ]. Hence, with this systematic review we aimed to determine if selection of different cervical spine immobilisation practices—during the pre-hospital and emergency department care of patients with possible cervical spine injury—impacts neurological and other outcomes.…”