Spine Immobilization Research Articles

Spinal Immobilization in Disasters: A Systematic Literature Review

Background/Introduction:A roundtable was hosted by the World Association for Disaster and Emergency Medicine (WADEM) World Congress to explore prehospital spinal immobilization (SI). The participants queried prehospital SI in resource-scarce environments (RSE), whether the disaster or humanitarian setting was applicable to the then recently released ILCOR statement, and identified challenges in maintaining appropriate application of SI in the prehospital RSE. A specific call was requested as an output of the roundtable for WADEM to provide guidance in this area of practice.Objectives:This systematic review informed a subsequent Delphi study to develop prehospital guidelines for SI in disaster and humanitarian settings.Method/Description:A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. The review included English language papers published from January 2000 through July 2019.Results/Outcomes:The search strategy yielded a total of 1,029 references. After exclusion of duplicates, 919 titles were identified for further screening. After applying exclusion criteria, a total of 14 references underwent evaluation. The reviewed articles comprised six types of studies and represented research from institutions in ten different countries.Conclusion:There is a lack of high-level evidence on the utility or effect of spinal motion restriction or immobilization on patient outcomes in disasters. There is a need for robust research to determine the clinical benefit of spinal restriction or immobilization in disasters and across disaster types. This systematic review informed a subsequent Delphi study to develop recommendations and guidance for practice related to prehospital SI in disaster and humanitarian settings.

A T2 Translational Science Modified Delphi Study: Spinal Motion Restriction in a Resource-Scarce Environment

Background/Introduction:Emerging evidence is guiding changes in prehospital management of potential spinal injuries. The majority of settings related to current recommendations are in resource-rich environments. Whereas there is a lack of guidance on the provision of spinal motion restriction (SMR) in resource-scarce environments (RSE).Objectives:What is appropriate SMR in RSE?Method/Description:The first round of this Modified Delphi (mD) study was a structured focus group. The result of the focus group discussion of open-ended questions produced ten statements that were added to ten statements derived from Fischer (2018) to create the 20 mD statements presented to the experts.Experts rated their agreement with each statement on a scale from one to seven. Consensus amongst experts was defined as SD≤1.0. Statements that were in agreement reaching consensus were included in the final report. Those not reaching consensus advanced to the next mD round.For these subsequent rounds, experts were shown the mean response and their own response for each of the remaining statements and asked to reconsider their rating. As above, those that did not reach consensus advanced to the next round until consensus was reached for each statement.Results/Outcomes:Twenty-two experts completed the first mD round, 19 completed the second mD round, and 16 completed the third mD round. Eleven statements reached consensus (Table 1). Nine statements did not reach consensus (Table 2).Conclusion:Experts reached consensus offering 11 statements to be incorporated into the creation of SMR clinical guidelines in RSE.Tables and Figures (optional)Table 1.Table 2.

Cervical spine movements during laryngoscopy and orotracheal intubation: a systematic review and meta-analysis

BackgroundAirway management is challenging in trauma patients because of the fear of worsening cervical spinal cord damage. Video-integrated and optic-integrated devices and intubation laryngeal mask airways have been proposed as...

ICU management of Traumatic Brain Injury

Traumatic brain injury (TBI) can be defined as the disruption in brain function, or other evidence of brain pathology, caused by an external physical force. Management of TBI depends on, if the injury is focal or diffuse. Focal can be epidural or intra cerebral and diffuse lesions can present as multiple contusions/DAI. A basic understanding of anatomy of central nervous system and some working knowledge of physiology of brain help in management of TBI. According to severity there are three types of TBI patients. They are: mild (GCS 13-15), moderate (GCS 9-12) and severe (GCS 3-8). TBI may be primary or secondary. Primary injuries include contusion, hematoma, subarachnoid hemorrhage, diffuse axonal injury etc. Secondary injuries can manifest as cerebral oedema, raised intra cranial pressure etc. Airway management and cervical spine immobilization are important early steps in management. Hypoxia and hypercarbia must be avoided and attention is always paid to ventilation status of patients. Mean arterial pressure (MAP) should be monitored and maintained at 80-90 mm of Hg. Intracranial pressure (ICP) should be checked whenever feasible and monitored so raised ICP can be controlled. Adequate pain control and sedation, using mannitol, hypertonic saline should be used as needed to control raised ICP. Invasive ICP monitoring and cerebrospinal fluid diversion should be used in patient who decompensate and decision to do decompressive craniectomy is often made by neurosurgeons. Body temperature in TBI patients should be maintained under 37o C. Neurologic conditions like brainstem dysfunction, intracranial hypertension, altered level of consciousness etc. and respiratory conditions like ARDS, hypoxaemia , neurogenic pulmonary oedema etc. warrants endotracheal intubation and mechanical ventilation. TBI patients requiring haemo dialysis usually need special modification in protocol to avoid pulmonary oedema and fluctuation in blood pressure. Monitoring TBI patients is done by routine assessment of GCS, pupillary size and reaction, motor responses. ICP monitoring is to be done if feasible. By aggressive monitoring secondary brain injuries can be avoided or managed. Outcome of management of TBI patients in ICU depends on severity of primary and secondary injuries of brain, status of GCS on presentation, advanced age (>65yrs), presence or absence of co morbidities and severity of associated injuries. Bangladesh Crit Care J September 2022; 10(2): 135-141

Spinal Backboard-Necessity or Hazard? The IDF Clinical Practice Guidelines and Policy.

Prehospital spinal immobilization using a cervical collar and a backboard has been standard practice for suspected spinal cord injuries (SCIs) since the 1960s. Multiple studies have shown that the disadvantages of the spinal backboard outweigh its advantages. This report aims to present a review of the current literature along with the revised IDF protocol regarding patients with suspected SCI. In 2019, the IDF Medical Corps (IDFMC) convened a multidisciplinary expert committee to revise the IDFMC protocols regarding the use of spinal backboards. Prior to convening the committee, a review of the pertinent literature was done by conducting a thorough clinical evaluation in "PubMed" and "Google Scholar" databases to identify recent studies investigating traumatic SCI and the prehospital military use of spinal backboards. There were no documented studies that have managed to prove the efficacy of spinal backboards to prevent exacerbation of spinal injuries during mobilization. Despite being a good tool for extraction from vehicles and combat arenas, more than 11 studies have shown that backboards may even result in adverse outcomes such as pain due to the contact between board and skin, the formation of decubitus ulcers, hypothermia, and inadequate ventilation. In light of the evidence showing the potential harmful effects of the routine use of spinal backboards, the IDF guidelines have been revised and now recommends avoiding the routine use of spinal backboards and using a standard stretcher for transporting potential SCI patients. Current IDF guidelines recommend using a backboard for the extraction of an entrapped patient and for obtunded or unconscious patients with obvious deformity or mechanism for spinal trauma.

Paramedic attitudes towards prehospital spinal care: a cross-sectional survey

BackgroundThe optimal application of spinal motion restriction (SMR) in the prehospital setting continues to be debated. Few studies have examined how changing guidelines have been received and interpreted by emergency medical services (EMS) personnel. This study surveys paramedics’ attitudes, observations, and self-reported practices around the treatment of potential spine injuries in the prehospital setting.MethodsThis was a cross-sectional survey of a North American EMS agency. After development and piloting, the final version of the survey contained four sections covering attitudes towards 1) general practice, 2) specific techniques, 3) assessment protocols, and 4) mechanisms of injury (MOI). Questions used Likert-scale, multiple-choice, yes/no, and free-text responses. Exploratory factor analysis (EFA) was used to identify latent constructs within responses, and factor scores were analyzed by ordinal logistic regression for associations with demographic characteristics (including qualification level, gender, and years of experience). MOI evaluations were assessed for inter-rater reliability (Fleiss’ kappa). Inductive qualitative content analysis, following Elo & Kyngäs (2008), was used to examine free-text responses.ResultsTwo hundred twenty responses were received (36% of staff). Raw results indicated that respondents felt that SMR was seen as less important than in the past, that they were treating fewer patients than previously, and that they follow protocol in most situations. The EFA identified two factors: one (Judging MOIs) captured paramedics’ estimation that the presented MOI could potentially cause a spine injury, and another (Treatment Value) reflected respondents’ composite view of the effectiveness, importance, and applicability of SMR. Respondents with advanced life support (ALS) qualification were more likely to be skeptical of the value of SMR compared to those at the basic life support (BLS) level (OR: 2.40, 95%CI: 1.21–4.76, p = 0.01). Overall, respondents showed fair agreement in the evaluation of MOIs (k = 0.31, 95%CI: 0.09–0.49). Content analysis identified tension expressed by respondents between SMR-as-directed and SMR-as-applied.ConclusionResults of this survey show that EMS personnel are skeptical of many elements of SMR but use various strategies to balance protocol adherence with optimizing patient care. While identifying several areas for future research, these findings argue for incorporating provider feedback and judgement into future guideline revision.

Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: A scoping review.

The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners. We performed a focused scoping review of published literature on the prehospital use of clinical c-spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis. Following screening, forty-two articles were included in this scoping review. No studies conducted specifically in low resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting. This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety, and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation, and a lack of context-specific evidence. These may provide important considerations for future guideline development.

Patient handling and transportation from site of injury to tertiary trauma centres in Nepal following acute traumatic spinal cord injury: a descriptive study.

Descriptive study. To describe patient handling at injury site, number of healthcare centre transfers to reach tertiary trauma centre, modes of transportation, and time from injury to reaching tertiary trauma centres among individuals with acute traumatic spinal cord injury (tSCI). Acute SCI rehabilitation centre, Nepal. All individuals with new tSCI admitted for rehabilitation over period of 1 year were eligible for enrolment. Following written, informed consent, enroled individuals participated in structured one-on-one interview. Data collected included demographics, injury details, pre-hospital handling techniques, and transportation specifics to tertiary trauma centre. In total, 211 individuals were enroled in the study. Eight (4%) individuals were assisted by first responders or traffic police, with majority (n = 203, 96%) assisted by untrained individuals. One was transferred from injury site using spinal motion restriction measures. Half were transported exclusively by ambulance while others used combinations of transportation. Six (3.4%) individuals were cared for by trained medical person during transport. Half required two or more hospital transfers prior to reaching a tertiary trauma centre. In total, 98 individuals required >24 h to reach the tertiary trauma centre. Individuals sustaining a tSCI in Nepal often experience improper handling, multiple hospital transfers, and prolonged time to reach tertiary trauma centres following acute tSCI. Further expanding emergency medical response systems throughout the country, training and equipping first responders in spinal motion restriction techniques, and establishing clear referral pathways for individuals with suspected tSCI are warranted. Development in these specific areas may reduce morbidity and mortality following acute tSCI.

Comparison of video-stylet and conventional laryngoscope for endotracheal intubation in adults with cervical spine immobilization: A PRISMA-compliant meta-analysis.

Background:Although minimization of cervical spine motion by using a neck collar or manual in-line stabilization is recommended for urgent tracheal intubation (TI) in patients with known or suspected cervical spine injury (CSI), it may worsen glottic visualization. The overall performance of video-stylets during TI in patients with neck immobilization remains unclear. The current meta-analysis aimed at comparing the intubation outcomes of different video-stylets with those of conventional laryngoscopes in patients with cervical immobilization.Method:The databases of Embase, Medline, and the Cochrane Central Register of Controlled Trials were searched from inception to June 2021 to identify trials comparing intubation outcomes between video-stylets and conventional laryngoscopes. The primary outcome was first-pass success rate, while secondary outcomes included overall success rate, time to intubation, the risk of intubation-associated sore throat, or tissue damage.Results:Five randomized controlled trials published between 2007 and 2013 involving 487 participants, all in an operating room setting, were analyzed. The video-stylets investigated included Bonfils intubation fiberscope, Levitan FPS Scope, and Shikani optical stylet. There was no difference in first-pass success rate (risk ratio [RR] =1.08, 95% confidence interval [CI]: 0.89–1.31, P = .46], overall success rate (RR = 1.06, 95% CI: 0.93–1.22, P = .4), intubation time [mean difference = 4.53 seconds, 95% CI: –8.45 to 17.51, P = .49), and risk of tissue damage (RR = 0.46, 95% CI: 0.16–1.3, P = .14) between the 2 groups. The risk of sore throat was lower with video-stylets compared to that with laryngoscopes (RR = 0.45, 95% CI: 0.23–0.9, P = .02).Conclusion:Our results did not support the use of video-stylets as the first choice for patients with neck immobilization. Further studies are required to verify the efficacy of video-stylets in the nonoperating room setting.

Intubation during spinal motion restriction using the LuboTM cervical collar - a manikin simulation study.

IntroductionThe LuboTM collar is a cervical motion restriction device featuring a unique external jaw-thrust mechanism designed to provide non-invasive airway patency. In addition, tracheal intubation is facilitated by releasing an anterior chin strap; this allows better mouth opening than the previous generation of semi-rigid cervical collars. This study aimed to compare tracheal intubation using the LuboTM collar combined with manual in-line stabilization (MILS) to intubation with MILS alone. The primary outcome was the time to successful intubation. Secondary outcomes compared intubation success rate, Cormack-Lehane grade, ease of intubation and dental trauma.MethodsA randomized, cross-over, equivalence study was performed. Eighty full-time physician anaesthesia providers were recruited. Participants performed tracheal intubation using direct laryngoscopy on a manikin under two different scenarios: with the LuboTM collar and MILS applied, and with MILS and no cervical collar. The time to successful intubation was measured and compared using two-one-sided and paired t-tests.ResultsIntubation times fell well within the a priori equivalence limits of 10 seconds, with a mean difference (95% CI) of 0.52 seconds (-1.30 to 2.56). There was no significant difference in intubation time with the LuboTM collar (mean [SD] 19.2 [4.5] seconds) compared to the MILS alone group (19.7 [5.2] seconds). The overall success rate was 98.7% in the Lubo group and 100% in the MILS group. Adequate laryngoscopy views (Cormack-Lehane grades I to IIb) were equivalent between groups (Lubo 92.5% versus MILS alone 93.7%).ConclusionIn this manikin-based study, the time to intubation with the LuboTM collar and MILS applied was equivalent to time to intubation with MILS alone, with similar intubating conditions. Thus, the LuboTM collar and MILS may simplify airway management by reducing the number of steps required to perform intubation in patients requiring cervical motion restriction.

Cervical spine immobilisation is only required in drowning patients at high risk of axial loading of the spine.

Wave forced impacts are known to result in cervical spine injuries (CSI) and approximately 20% of drownings in Australia occur at the beach. The most common mechanism of injury in studies examining the frequency of CSI in drowning patients is shallow water diving. The aim of the present study was to determine what proportion of CSIs occurring in bodies of water experienced a concomitant drowning injury in a location where wave forced impacts are likely to be an additional risk factor. Electronic medical records at the Sunshine Coast Hospital and Health Service EDs, Queensland Ambulance Service case records and Surf Life Saving Queensland data between 1 January 2015 and 21 April 2021 were manually linked. Outcomes recorded included victim demographics, scene information, hospital course and patient disposition. Ninety-one of 574 (15.9%) CSIs occurred in a body of water with risk of drowning. However, only 4 (4.3%) had a simultaneous drowning injury, representing 0.8% (4/483) of drowning presentations. Ten (10.9%) patients reported loss of consciousness, including the four with drowning. The principal mechanism of CSI was a wave forced impact (71/91, 78%). Most injuries occurred at the beach (79/91, 86.8%). Delayed presentation was common (28/91, 31%). A history of axial loading was 100% sensitive when indicating imaging. The combination of CSI and drowning is uncommon. Cervical spine precautions are only required in drowning patients with signs or a history, or at high risk of, axial loading of the spine. This paper supports the move away from routine cervical spine precautions even in a high-risk population.

Spine immobilization and neurological outcome in vertebral osteomyelitis SPONDIMMO, a prospective multicentric cohort.

The aim of our study was to describe spine immobilization in a multicentric cohort of vertebral osteomyelitis (VO), and evaluate its association with neurological complications during follow-up. We prospectively included patients from 2016 to 2019 in 11 centers. Immobilization, imaging, and neurological findings were specifically analyzed during a 6-month follow-up period. 250 patients were included, mostly men (67.2%, n=168). Mean age was 66.7±15 years. Diagnosis delay was 25 days. The lumbo-sacral spine was most frequently involved (56.4%). At diagnosis, 25.6% patients (n=64) had minor neurological signs and 9.2% (n=23) had major ones. Rigid bracing was prescribed for 63.5% (n=162) of patients, for a median of 6 weeks, with variability between centers (P<0.001). The presence of epidural inflammation and abscess on imaging was associated with higher rates of rigid bracing prescription (OR 2.33, P=0.01). Frailness and endocarditis were negatively associated with rigid bracing prescription (OR 0.65, P<0.01, and OR 0.42, P<0.05, respectively). During follow up, new minor or major neurological complications occurred in respectively 9.2% (n=23) and 6.8% (n=17) of patients, with similar distribution between immobilized and non-immobilized patients. Spine immobilization prescription during VO remains heterogeneous and seems associated inflammatory lesions on imaging but negatively associated with frailness and presence of endocarditis. Neurological complications can occur despite rigid bracing. Our data suggest that in absence of any factor associated with neurological complication spine bracing might not be systematically indicated. We suggest that spine immobilization should be discussed for each patient after carefully evaluating their clinical signs and imaging findings.

Removal of the cervical collar from alpine rescue protocols? A biomechanical non-inferiority trial in real-life mountain conditions

BackgroundAlpine skiing rescues are challenging because of the mountainous environment and risks of cervical spine motion (CSM) induced during victims’ extrications (EXs) and downhill evacuations (DEs). The benefits of applying a cervical collar (CC) over manual in-line stabilization without CC (MILS) in terms of spinal motion restriction during simulated alpine rescues are undocumented. Our hypothesis was that CSM recorded using MILS alone is non-inferior to CSM recorded with a CC according to a 10 degrees margin.MethodsA total of 32 alpine extrications and 4 downhill evacuations on different slope conditions were performed using a high fidelity mannequin designed with a motion sensors instrumented cervical spine. The primary outcome was the peak extrication 3D excursion angle (Peak 3D θEX,) of the mannequin’s head. The secondary objectives were to describe the time to extrication completion (tEX) and to highlight which extrication manipulation is more likely to induce CSM.ResultsThe median Peak 3D θEX recorded during flat terrain extrications using CC was 10.77° (95% CI 7.31°–16.45°) compared to 13.06° (95% CI 10.20°–30.36°) using MILS, and 16.09° (95% CI 9.07°–37.43°) for CC versus 16.65° (95% CI 13.80°–23.40°) using MILS on a steep slope. Peak 3D θEX with CC or using MILS during extrications were equivalent according to a 10 degrees non-inferiority hypothesis testing (p < 0.05). Time to extrication completion (tEX) was significantly reduced using MILS without CC on a flat terrain with a median duration of 237,3 s (95% CI 197.8 s, 272.2 s) compared to 358.7 s (95% CI 324.1 s, 472.4 s). During downhill evacuations, CSM with and without CC across all terrain conditions were negligible (< 5°). When CC is used; its installation manipulation induces the highest CSM. When EXs are done using MILS without CC, the logroll initiation is the manipulation inducing the highest risk of CSM.ConclusionFor experienced ski patrollers, the biomechanical benefits of spinal motion restriction provided by CC over MILS during alpine skiing rescues appear to be marginal and CC use negatively affects rescue time.

Pre-Hospital Spinal Immobilization: Neurological Outcomes for Spinal Motion Restriction Versus Spinal Immobilization.

IntroductionNew recommendations for emergency medical services spinal precautions limit long spinal board use to extrication purposes only and are to be removed immediately. Outcomes for spinal motion restriction against spinal immobilization were studied.MethodsA retrospective chart review of trauma patients was conducted over a six-month period at a level I trauma center. Injury severity details and neurologic assessments were collected on 277 patients.ResultsUpon arrival, 25 (9.0%) patients had a spine board in place. Patients placed on spine boards were more likely to be moderately or severely injured [injury severity score (ISS) > 15: 36.0% vs. 9.9%, p = 0.001] and more likely to have neurological deficits documented by emergency medical services (EMS; 30.4% vs. 8.8%, p = 0.01) and the trauma team (29.2% vs. 10.9%, p = 0.02).ConclusionsThis study suggested that the long spine board was being used properly for more critically injured patients. Further research is needed to compare neurological outcomes using a larger sample size and more consistent documentation.

The Impact of Prehospital Spinal Immobilization in Patients with Penetrating Spinal Injuries: A Systematic Review and Meta-Analysis

Penetrating injuries, such as gunshot or stab wounds, may cause spinal cord injuries and require prehospital spinal immobilization (PHSI) to stabilize the spine. However, the use of PHSI in penetrating spinal injuries remains controversial. This systematic review aimed to investigate the efficacy of prehospital PHSI in patients with penetrating trauma. We systematically searched Google Scholar, Medline (PubMed), The Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE between January 2000 and July 2021. All studies in English that assessed PHSI in patients (&gt;16 years) with penetrating spinal injuries were included. Quality and risk of bias assessments were performed using the modified Newcastle-Ottawa scale. A narrative synthesis and a meta-analysis was conducted. Our search identified 928 studies but only 6 met our inclusion and exclusion criteria. All of the included studies were conducted in the US and the number of patients ranged from 156–75,567 over 3–9 study years. The majority of patients were gunshot or stab wounds. Three studies demonstrated an increased risk of mortality with spinal collars whilst the remaining three studies failed to show any benefits or the benefits remained unproven. All studies were retrospective studies with some risks of bias. This review highlights that the evidence from the literature on PHSI in penetrating trauma outweigh its benefits; thus, its use is discouraged in penetrating spinal trauma. However, further high-quality research is necessary to reach definitive conclusions and to possibly identify suitable alternatives to PHSI for penetrating spinal trauma.

To sim or not to sim-choosing wisely for procedural skills training in paediatrics.

Simulation is a commonly used modality to teach paediatric procedural skills, however, it is resource intensive. Which paediatric skills are best taught using simulation is not known. This study aims to examine what skills to simulate, allowing for the best use of resources in ever expanding curricula. We administered a questionnaire to community and hospitalist general paediatricians in Canada asking them to rate the importance of maintaining competency in each paediatric procedural skill and the frequency with which they perform the skill in their practice. Skills that were rated as highly important and also high frequency were: bag-mask ventilation (BMV), lumbar puncture, neonatal cardiopulmonary resuscitation (CPR), specimen procurement for infectious diseases, immunization, and ear curettage. Skills that were rated as highly important but low frequency were: paediatric CPR, intraosseous needle insertion, neonatal intubation, defibrillation, gathering specimens for evidence of child maltreatment, paediatric intubation, cervical spine immobilization, and oral/nasogastric tube placement. Paediatric procedural skills are rated variably in terms of importance and frequency of use in general paediatric practice. Eight skills of high importance are infrequently performed and should be targeted for teaching via simulation.

Success Rate on Endotracheal Intubation with Prone versus Kneeling Position in Mannequin Model with Limitation of Neck Movement: A Cross Over Study.

PurposeEndotracheal intubation is a lifesaving procedure for airway management but is more complex when performed in patients lying on the ground and requiring cervical spine immobilization. This study aims to compare the optimal technique between prone and kneeling positions in increasing intubation success rate on these prehospital trauma patients.Patients and MethodsThis study was an experimental study on a mannequin. Paramedic students performed intubation on the supine mannequin, which was applied with a rigid cervical collar and manual in-line stabilization. The participants were randomly assigned to intubate in a prone or kneeling position as the first method, then perform another method seven days later. Study outcomes include the percentage of successful intubation, time to perform intubation successfully, and Cormack and Lehane’s classification of laryngeal view.ResultsThirty-nine participants were enrolled in this study; 22 were male (56.41%). The mean age, weight, and height were 23.15 ± 4.75 years, 67.38 ± 17.39 kg, and 167.36 ± 8.70 cm., respectively. The percentage of successful intubation in prone (37 [94.90%]) was higher than kneeling position (35 [89.74%]), but there was no statistically significant (p-value = 0.675). Time to intubation successfully, the number of attempts, and Cormack & Lehane's laryngeal view classification were not significantly different between prone and kneeling groups (p-value = 0.808, 0.814, and 0.948, respectively).ConclusionIntubation with the prone or kneeling position on a mannequin, lying on the ground with cervical spine immobilization, has no statistical difference. Both intubation approaches appear to be effective in successful and rapid intubation, proper glottic visualization and low attempts.

Evaluating prehospital care of patients with potential traumatic spinal cord injury: scoping review.

To gain insight into current research regarding prehospital care (PHC) in patients with potential traumatic spinal cord injury (TSCI) and to disseminate the findings to the research community. In March 2019, we performed a literature search of publications from January 1990 to March 2019 indexed in PubMed, gray literature including professional websites; and reference sections of selected articles for other relevant literature. This review was performed according to Arksey and O'Malley's framework. There were 42 studies selected based on the inclusion criteria for review; 18 articles regarding immobilization; 12 articles regarding movement, positioning and transport; four for spinal clearance; three for airway protection; and two for the role of PHC providers. There were some articles that covered two topics: one article was regarding movement, positioning and transport and airway protection, and two were regarding spinal clearance and the role of PHC providers. There was no uniform opinion about spinal immobilization of patients with suspected TSCI. The novel lateral trauma position and one of two High Arm IN Endangered Spine (HAINES) methods are preferred methods for unconscious patients. Controlled self-extrication for patients with stable hemodynamic status is recommended. Early and proper identifying of potential TSCI by PHC providers can significantly improve patients' outcomes and can result in avoiding unwanted spinal immobilization. Future prospective studies with a large sample size in real-life settings are needed to provide clear and evidence-based data in PHC of patients with suspected TSCI.

Cervical spine immobilization does not interfere with nasotracheal intubation performed using GlideScope videolaryngoscopy: a randomized equivalence trial

GlideScope-assisted nasotracheal intubation (NTI) has been proposed as an alternative to difficult orotracheal intubation for critical patients or those under cervical immobilization. We evaluated the difficulty of performing NTI using GlideScope under cervical orthosis. A total of 170 patients scheduled for elective cervical spinal surgery that required NTI were randomized to receive cervical immobilization using a cervical collar (collar group) or no cervical immobilization at all (control group) before anesthetic induction (group assignment at 1:1 ratio). All NTI during anesthetic induction were performed using the GlideScope. The primary outcome was time to intubation. The secondary outcomes were ease of intubation, including the necessity of auxiliary manipulations to assist intubation, and the nasotracheal intubation difficulty scale (nasoIDS). An exploratory analysis identified morphometric parameters as predictors of time to intubation, the necessity of auxiliary manipulations, and a nasoIDS score ≥ 4. For time to intubation, the mean difference (collar group—control) was − 4.19 s, with a 95% confidence interval (CI) of − 13.9 to 5.52 that lay within our defined equivalence margin of 16 s. Multivariate regressions precluded the association of cervical immobilization with a necessity for auxiliary manipulations (adjusted odds ratio [aOR] 0.53, 95% CI [0.26–1.09], P = 0.083) and a nasoIDS ≥ 4 (aOR 0.94 [0.84–1.05], P = 0.280). Among all morphometric parameters, the upper lip bite test class was predictive of a longer time to intubation (all analyses relative to class 1, 14 s longer for class 2, P = 0.032; 24 s longer for class 3, P = 0.070), increased necessity for auxiliary manipulation (aOR 2.29 [1.06–4.94], P = 0.036 for class 2; aOR 6.12 [1.04–39.94], P = 0.045 for class 3), and nasoIDS ≥ 4 (aOR 1.46 [1.14–1.89], P = 0.003 for class 3).The present study demonstrated that GlideScope achieved NTI in patients with or without cervical immobilization equivalently with respect to intubation time and ease.

A multicenter cohort study on the association between prehospital immobilization and functional outcome of patients following spinal injury in Asia

Prehospital spinal immobilization is a widely used procedure in the emergency medical service (EMS) system worldwide, while the incidence of patients with spinal injury (SI) is relatively low, and unnecessary prehospital spinal immobilization is associated with patient complications. This study aimed to determine the association between prehospital spine immobilization and favorable functional outcomes at hospital discharge among trauma patients with SI. We conducted a retrospective cohort study using the Pan-Asia Trauma Outcomes Study (PATOS) registry data from January 1, 2016, to November 30, 2018. A total of 759 patients with SI were enrolled from 43,752 trauma patients in the PATOS registry during the study period. The subjects had a median age of 58 years (Q1–Q3, 41–72), and 438 (57.7%) patients had prehospital spine immobilization. Overall, prehospital spinal immobilization was not associated with favorable functional outcomes at discharge in multivariable logistic regression (aOR 1.06; 95% CI 0.62–1.81, p = 0.826). However, in the subgroup of cervical SI, prehospital spinal immobilization was associated with favorable functional outcomes at discharge (aOR 3.14; 95% CI 1.04–9.50; p = 0.043). Therefore, we suggest that paramedics should be more careful when determining the presence of a cervical SI and should apply full spine immobilization if possible.