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Category: Volume 02 | Issue 01 – January 2022

Management of coagulopathies in a non-permissive environment

VOL.2 | ISSUE 01 | YEAR 2022 DOI ON ASSIGNEMENT ENGLISH ISSN 2674-001X Author: Dr. Maj. Nadir Rachedi, Anaesthetist and military doctor, Celio Hospital, Rome Source:…

Rescue Press 27 January 2022

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Letter to the editor: Cervical Immobilization discussion

VOL.2 | ISSUE 01 | 2022 DOI ON ASSIGNEMENT ISSN: 2674-001X AUTHOR: Matthew J. Fuller, MD: Emergency Medicine Physician, University of Utah Hospital; Dear Editor,My name is…

Rescue Press 25 January 2022

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RESCUE PRESS

Scientific publication on pre-hospital procedures.

ENGLISH ISSN 2674-001X
ITALIAN ISSN 2674-0028

Publisher:

Rescue Press & Services
Gladbachstrasse 104, 8044 Zürich.
website: www.rescue.press
mail: info@rescue.press

Editorial Manager: Mario Robusti

Editorial Coordinator: Gloria Sebastio

Rescue Press is an official scientific review for pre-hospital emergency medicine and techniques.

Scientific Board

Scientific partners / Partner scientifici
– HEMS Association
– SIEMS
– SIIET

Scientific director / Direttore Scientifico
Guido Francesco Villa

Scientific board / Comitato Scientifico

Yari	Barnabino
Nicola	Bortoli
Mauro	Del Romano
Flavio	Gheri
Guglielmo	Imbriaco
Fulvio	Kette
Giacomo	Magagnotti
Lucia	Micheletti
Fabio	Mora
Michele	Musiari
Emanuele	Neri
Marcelo	Okamura
Andrea	Paoli
Daniele	Pomiato
Fabrizio	Pregliasco
Silvia	Roero
Mario	Rugna
Tommaso	Scquizzato
Valerio	Staccone
Guido F.	Villa

Disclaimer

Although the editors of the Rescue Press take the utmost care in reviewing papers that appear in this digital magazine, we cannot exclude the possibility that they contain inaccuracies or violate the proper use of academic referencing or copyright in general. The responsibility for these matters therefore remains with the authors of these papers and third parties that choose to make use of them entirely. In no event can the editorial board of the Rescue Press or the Rescue Press and Services Editor be held accountable for the contents of these papers.

ISSUES

Scientific Publications
Volume 01 | Issue 01 – June 2021 (ENGLISH)
Volume 01 | Issue 01 – Giugno 2021 (ITALIANO)

Forum Description

VOL.2 | ISSUE 01 | 2022

DOI ON ASSIGNEMENT

ISSN: 2674-001X

AUTHOR: Matthew J. Fuller, MD: Emergency Medicine Physician, University of Utah Hospital;

Dear Editor,
My name is Dr. Matthew Fuller, MD, and I am an Associate Professor of Emergency Medicine and Director of Global Health, active as an educator and academician. As many of your readers will know, it has become fashionable to argue that cervical immobilization is not only ineffective but potentially harmful to patients. Many point to observational studies and lack of high-quality data when making their argument. Some historical arguments against cervical immobilization include the following:

No “high quality” evidence proving efficacy
All published evidence either on healthy volunteers or cadaveric specimens.
Can increase ICP/Intracranial Pressure→ leading to further cerebral injury in TBI
Pressure ulcers can occur from prolonged use
Cervical Immobilization can complicate airway management

Addressing each of these criticisms, rather than dismissing them outright, is important in the discussion of appropriate cervical immobilization. Each is addressed in order, below.

1&2 -There will never come a time where a high-quality (Randomized-Control Trial) to study an immobilized vs an immobilized population in high-risk trauma is undertaken. This would be unethical to subject a study population to potential devastating neurologic injury(as a control where no collar is applied). The most often quoted study, comparing cervical injury in an immobilized patient population(New Mexico, USA) and a non-immobilized population(rural Malaysia) found no differences in neurologic injury/outcomes. However, this study compared two vastly different patient populations. The immobilized patient population suffered trauma in high-velocity mechanisms(MVC, motorcycle accident, falls from great height) whereas the non-immobilized population most often suffered low-velocity trauma(falls from ground level, falls from <10 feet, etc). This introduced significant bias in the data analysis because it assumed that the two study populations were similar in injury risk and pattern, rather than correctly assuming that they had vastly different risk for musculoskeletal injury. I contend that these populations were inappropriate for comparison. This was a poorly designed study with poor control and trial arms, and inappropriate for concluding that cervical immobilization does little to benefit patients with high-risk injury. As such, I contend it is imperative that a spinal motion reduction device is designed to minimize potential harm, and maximize potential benefit for any patient, and is used in conjunction with appropriate protocols and training for personnel.

3 - There is published literature suggesting that RIGID cervical immobilization devices may impede cerebral venous outflow, thereby increasing cerebral congestion and leading to increased cerebral parenchymal injury by further metabolic derangement. Traditional hard cervical collars have pressure points on points of venous outflow; namely the jugular vein. The AER collar is designed to avoid pressure points on these venous tracts and therefore is theorized**(pending study with U/S to quantify) to reduce any impedance on venous outflow. Further, the AER collar rigidity can be adjusted by inflating/releasing air to reduce pressure on any potential area of obstruction.

4 - Pressure ulcers are common in patients with prolonged cervical immobilization(ICU setting typically). Because the AER collar is designed to be adjustable without having to remove the collar, appropriate care can be made to minimize pressure points and reduce potential for soft tissue damage in patients who require prolonged immobilization.

5 - A rigid cervical collar or immobilization device that is difficult to remove or manipulate has been shown to be an impediment to airway control/intubation/cricothyroidotomy, etc. The AER collar is designed to provide adequate access to the patient for the medical practitioner in all airway emergencies. Quick deflation, adjustment of rigidity or access to the anterior neck is all possible with the AER collar.

I will conclude by saying that there are many medical interventions that not only fail to meet the standard of high-quality evidence but also may contribute to patient harm. There is evidence that tonsillectomy may lead to increased weight gain in children, bariatric surgery is cited as having a complication rate of close to 50%, with a mortality rate approximating 1 in 50 patients, circumcision, perhaps the most common surgical procedure worldwide, has little evidence of efficacy, and yet continues as a standard of care. We should be critically appraising all medical interventions-including cervical immobilization-and working to improve or clarify their benefit, while reducing their risk of harm to patients. The AER collar does just that.

As a final note, it is important to cite that the STANDARD OF CARE REMAINS CERVICAL IMMOBILIZATION IN SELECT POPULATIONS. The American Association of Neurological Surgeons(AANS) and The Congress of Neurological Surgeons(CNS) still recommends cervical immobilization. The American College of Emergency Physicians(ACEP), The American College of Surgeons-Committee on Trauma(ACS-COT) and The National Association of EMS Physicians(NAEMSP) published a joint position statement in 2018 supporting the use of devices assist with Spinal Motion Reduction(SMR)

Sincerely, Matthew J. Fuller

CONFLICT OF INTEREST: Matt J. Fuller is the co-founder with the designer Carl Yeip of the company OTEC (outdoor technical emergency care), producer of the AER Cervical Collar.

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