INTRODUCTION

Prehospital professionals universally apply the stabilization of the spine to victims of trauma. This procedure aims to prevent spinal movement and avoid spinal cord injury ¹ and involves the use of a cervical collar, the placement of the victim lying on a hard plane, lateral stabilizers of the head and attachment of the victim to the spine ². However, their application is not without risk ^2,3,4 and in some cases it’s not indicated.

Over time, in the prehospital emergency of the United Kingdom, it was possible to verify the discomfort experienced by the victims of trauma subject to the stabilization of the vertebral column as it has been possible to identify collateral damage ³.

In this sense, it is crucial to improve the quality of the care provided, to question the universal application of devices for stabilization of the spine in the prehospital approach, and to identify the situations in which it is contraindicated.

Therefore, it was decided to carry out an integrative review of the literature, since it allows the inclusion of several research methods, giving great potential for evidence-based nursing practice ⁶.

In this perspective, we proposed to investigate: Is there scientific evidence of harmful side effects in trauma victims caused by spinal stabilization in prehospital care? Are there situations of trauma without an indication for the stabilization of the spine?

METHOD

The integrative review of the literature represents an instrument that allows the synthesis of knowledge and the inclusion of the results of significant studies in clinical practice ⁶.

The objective of this integrative review is to identify harmful effects caused by stabilization of the vertebral column in the trauma victim and situations of trauma with no indication for stabilization of the spine in the prehospital.

According to the consulted authors, the elaboration of the integrative revision comprises six stages ⁶ that we will go through to construct this revision.

In the first step, we construct the research questions using the PICO strategy ⁷. This strategy means respectively: (P) problem or patient, (I) intervention, (C) comparison, (O) Outcomes.

Our (P) correspond the victims of trauma, (I) is concerned to the stabilization of the spine, (C) refers to the stabilization vs non-stabilization and finally (O) corresponds to discomfort, pain and injury.

The issues raised were as follows: Is there a scientific evidence of harmful side effects in trauma victims caused by spinal stabilization in prehospital care? Are there situations of trauma without an indication for the stabilization of the spine?

In the second step of the review, the literature search ⁶, with the intention of using single terminology, the Portuguese language descriptors were consulted in DeCS ⁸ and translated into Mesh ⁹.

Prehospital emergency care and spinal cord injuries were the descriptors adopted. Next, the descriptors were combined for the search with the boolean operator (and).

A sampling was performed with the establishment of the inclusion and exclusion criteria for this review, presented in Table 1.

The articles search was conducted online, in December 2018, in the electronic bases Cochrane Library (0 articles) and Pubmed (4 articles) and through the search engine EBSCOhost (6 articles) in the databases CINAHL Plus with Full Text , MEDLINE with Full Text, MedicLatina, SPORTDiscus with Full Text, PsycARTICLES, PsycBOOKS, Psychology and Behavioral Sciences Collection, Academic Search Complete, with the time limit of six years (2012-2018).

Twelve articles were obtained, 2 of which were bibliographical references. After applying the inclusion and exclusion criteria (Table 1), 5 articles representing the sample were selected.

The third step represents the organization and summarization of the information of the articles in the sample.

The items in Table 2 were applied, after reading the articles in full, to gather relevant data: origin, title of the article, authors, periodical and objectives.

In the fourth step, a critical analysis of the studies constituting the sample was carried out, and a support instrument (Table 3) was elaborated with the following information: article title, sample, type of investigation, method of analysis, main results and level of evidence. For a hierarchical perspective of knowledge, the studies were classified according to the level of evidence, by the pyramid proposed by Melnyk and Fineout-Overholt ¹⁰.

With the information provided by the included articles, a content analysis was performed ¹¹ resulting in three categories on the stabilization of the vertebral column in the trauma victim.

In the fifth stage, the discussion of the results was carried out, comparing the evidenced data. We will be able to identify possible knowledge gaps and suggest future studies, as well as those that may compromise the disclosed results.

Finally, in the sixth stage, we proceed to the synthesis of the knowledge about the stabilization of the spine, in the form of a schematic Figure.

RESULTS AND DISCUSSION

The analysis and discussion of the data allows us to identify the relevant content of the studies. We begin the discussion with the presentation of the synthesis of the data collected, in Table 3. This Table summarizes each article referring to its impact to the practice based on evidence.

According to the hierarchical pyramid of evidence ¹⁰, we found that four studies presented have an average strength of evidence (level IV) and a top-level study, level I. For this reason, the recommendations that may arise should always be subject to a process of critical reflection.

The five articles are published in journals that address emergency and trauma care. The authors, in the majority, play roles in these areas, not being clear the membership of all. The participation of authors of the clinical and academic domain is verified simultaneously. The union of the two domains of knowledge represents an added value to the research process. A study has authors from several professional areas which enriches the same, due to the multidisciplinary character that it introduces.

The studies were carried out in Europe and the United States of America.

The methodological options of the articles (described in Table 3) are in imbalance since one study followed the quantitative paradigm, three qualitative and one mixed.

Of the articles included in this review, two suggest performance protocols for spinal stabilization (Table 3), which represents an added value. The emergency context requires decision and rapid action. In a pre-hospital environment, this decision is often made in environmental conditions and with delicate resources. In this sense, having the organized knowledge in the schematic and protocol form allows an easier dissemination among professionals and provides a quick access to make decisions.

Stabilization of the spine integrates prehospital care for trauma victims routinely, translating into a universal strategy to prevent further spinal injury from worsening ^12,13,14.

For stabilization of the spine, a combination of devices is comprised which includes: rigid cervical collar, side head blocks, straps to support the victim's body to a rigid stretcher ^6,7,8,14. stabilization of the spine is achieved the neutral alignment of the spine, reduced movement, reduced secondary injuries in potentially unsTable spinal column situations and optimized the safety of the victim during transport to the hospital ¹⁷.

In particular, the practical recommendation for the application of cervical collars to trauma victims has remained almost unchanged for more than 30 years ¹⁵.

The application of cervical collar to the trauma victim is presented as a priority procedure in the American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) guidelines and in the Prehospital Trauma Life Support guidelines^15,16.

This priority for the protection of the spine is given by the application of cervical collar ABCDE principles (Breathing, Circulation, Neurological Dysfunction, Exposure) that aim to identify and treat life-threatening injuries to the trauma victim ^15,16,17).

Currently, it is discussed the need to change this strategy applied to all victims of trauma, due to the harmful effects ^{12,13,14,18,19}.

The results of the articles included in this review ^{12,13,14,18,19} allowed us to identify three categories:

Harmful effects resulting from spinal stabilization, trauma situations without indication for immobilization and recommendations for prehospital decision in trauma victims.

Figure 1. Harmful effects resulting from stabilization of the vertebral column 

Regarding the approach of the airway, the application of the cervical collar may become harmful at this stage because: it may lead to greater difficulty in the management of the airways ^14,18 the mouth opening may be compromised ¹⁴ aspiration can ¹⁴, especially in the supine position ¹⁴ and may cause respiratory restriction ^14,18.

It is important to bear in mind that cervical collar placement may increase the mean intracranial pressure (ICP) by 4,5 mmHg ¹⁴ through jugular venous compression. ^14,18 This is an aspect to be considered in victims with traumatic brain injury (TBI), since in their treatment it is essential to avoid or reduce ICP ¹⁴.

Therefore, venous congestion secondary to the cervical collar may also exacerbate global brain lesions, similar to the lesions observed after attempted suicide by hanging ¹⁴.

In patients with ankylosing spondylitis, the extension of the cervical spine during universal pre-hospital immobilization may become very harmful ¹⁴.

Prioritization of advanced airway management and spinal immobilization can also delay release and rescue procedures, delaying definitive treatment of critical victims with non-neurological injuries ^14,18, as well as making it difficult to screen trauma in theater, during transport and admission ¹⁴.

Immobilization of the collar with rigid collar and plane can cause discomfort and pain ^12,18 and may result in pressure injuries ^12,14,18.

With regard to the receipt of victims at the site of definitive treatment, victims who received immobilization of the prehospital column are more likely to undergo radiological exams ¹⁴ and professionals can understand immobilization as a guarantee of injuries and delay or limit necessary interventions to the victim ¹⁴.

Radiological examinations are often unnecessary in conscious victims, with no symptoms, neurological deficits or distractive lesions, and for those who have a full range of motion on functional examination ¹⁴.

Figure 2. Situations of trauma without indication for stabilization spine 

Prehospital immobilization of the spine has been associated with increased morbidity and mortality in patients with penetrating trauma ^14,18 and is unnecessary in patients with gunshot wounds to the head ¹⁴.

Victims of trauma with unsTable circulation due to penetrating trauma should not be immobilized ^13,14,18.

Unconscious victims, with unsafe airways, should not be transported supine ^14,18.

In the evaluation of neurological dysfunction, signs of increased ICP should be investigated and, if present, the cervical collar placement is contraindicated ¹⁸.

Figure 3. Recommendations for prehospital decision on trauma victims 

ABCDE principles can be maintained in the approach of the trauma victim ^13,18, however, in order to avoid delays with cervical stabilization, this can be done manually until all the systematic evaluation and treatment have been performed ^13,18.

In severely injured patients, whose time is critical for definitive treatment, their transport should not be delayed ^13,14,18,19 and a minimum spinal stabilization and rapid extraction should be applied ^13,18.

Victims with signs of increased ICP should be immobilized on a vacuum gurney without a cervical collar ¹⁸ allowing elevation of the upper body at 30º ¹⁸.

The final decision on the immobilization of the trauma victim is made after the ABCDE principles have been followed and clarified if the victim's assessment is adequate ¹⁸. The assessment is not appropriate if there are situations that distract attention such as language barriers, intoxications, distractive injuries, anxiety states, victims seriously injured or deceased in the accident ¹⁸. In this case, a complete immobilization of the victim is indicated ¹⁸.

In case of evaluation of the appropriate victim, factors associated with a higher risk of spinal injury should be covered ^13,18.

These factors are: median sensitivity of the cervical spine; age≥65 years; reduced sensitivity or motor function; supraclavicular lesions; accident with high speed (> 100 km / h), rollover, ejection of the vehicle; axial load on head, ≥2 m drop; locomotive or bicycle collision. If one of them is present, there is indication for complete immobilization ¹⁸.

If one is not present since criteria, the palpation of the spine does not present pain and there is pain to the rotation of the neck at 45º there is no indication for immobilization of the victim ^14,18.

In the references used in this review, pre-hospital decision support tools such as the National Emergency Radiography Utilization Study (NEXUS) and the Canadian C-Spine Rule Criteria (CCR) are recommended ^13,14.

CONCLUSION

In appreciating the results of this review, it is evident the need to abandon the universal approach to the trauma victim and adopt an individualized approach, related to the clinical state of the victim and the mechanisms involved.

We were able to answer the questions raised, although the data obtained did not completely suppress our expectations for this study. On the other hand, it was an opportunity for investigation and reflection on the stabilization of trauma victims in prehospital care.

The deleterious effects related to the stabilization of the spine that have been identified are largely associated with the placement of the cervical collar. This aspect seems extremely relevant because it represents a procedure with an emphasis on approaching the airway in the universal stabilization of the trauma victim, which seems to reinforce the need for change.

We believe that the fact that we have met traumatic situations without indication for stabilization of the spine and also recommendations for decision support may stimulate reflection on professionals and contribute to the improvement of prehospital care.

The scarcity of randomized controlled trials on this subject may be one of the reasons for not appreciating the harmful effects described.