Should a cervical (C) collar be applied when using Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for pain management in patients with potential spinal injuries and head trauma?

Cervical Collar Use in Patients When Using NSAIDs Criteria for Spinal Clearance

Cervical collars should not be routinely applied to trauma patients when using NSAIDs criteria for spinal clearance due to growing evidence of harm and lack of proven benefit. 1

Evidence Against Routine Cervical Collar Use

Potential Harms of Cervical Collars

• Cervical collars increase intracranial pressure, which is particularly concerning in patients with co-existing head trauma 1, 2
• Pressure sores develop with prolonged collar use (especially after 48-72 hours), which may require skin grafting and can become sources of sepsis 1
• Airway management becomes more difficult, potentially leading to life-threatening complications 1
• Collars can restrict mouth opening, complicating airway management and oral care 3
• Poor oral care associated with collar use has been linked to bacteraemia and sepsis 1
• Prolonged immobilization leads to higher rates of ventilator-associated pneumonia and delirium 1
• Cervical collars paradoxically may not effectively restrict movement of unstable cervical injuries, particularly at the craniocervical and cervicothoracic junctions 1, 3

Limited Evidence of Benefit

• No good quality evidence shows clinical benefit of cervical collar use for injured patients 1
• Multiple studies on healthy volunteers and cadavers show that while collars may limit some movement, they don't prevent all motion 1
• The practice is based primarily on expert consensus and tradition rather than strong evidence 1

Current Guidelines Recommendation

The 2015 American Heart Association and American Red Cross guidelines specifically state:

• "With a growing body of evidence showing more actual harm and no good evidence showing clear benefit, we recommend against routine application of cervical collars by first aid providers" 1
• If spinal injury is suspected, the person should remain as still as possible while awaiting EMS arrival 1

Risk vs. Benefit Analysis

Risks of Collar Use

• Increased intracranial pressure in patients with head trauma 1, 2
• Tissue ischemia from prolonged immobilization 1
• Pressure ulcers and skin breakdown 1
• Airway complications and difficulty with management 1
• Increased risk of aspiration and pneumonia 1
• Impaired venous drainage 2

Benefits of Collar Use

• Theoretical prevention of secondary neurological injury, though evidence is lacking 4
• May provide some limitation of cervical motion, though not complete immobilization 1

Alternative Approach to Spinal Protection

For patients requiring spinal protection:

• Have the person remain as still as possible while awaiting EMS arrival 1
• Manual stabilization may be considered in certain high-risk circumstances, though this was not fully evaluated in reviews 1
• Avoid unnecessary movement of the patient 1
• If transport is necessary, use a backboard with head blocks and straps without a collar 3

Special Considerations

• Application of a cervical collar requires proper training and regular practice to be performed correctly 1
• First aid providers may not be able to accurately discriminate between high-risk and low-risk patients 1
• If using NSAIDs criteria for spinal clearance and imaging shows no evidence of injury, prolonged immobilization with a collar is unnecessary 1
• For patients with decreased level of consciousness who cannot be clinically cleared, modern CT imaging is highly sensitive for detecting unstable injuries 1

Pitfalls to Avoid

• Assuming that collar application is always beneficial and without risk 5
• Prolonged use of collars when not indicated by clinical or radiographic findings 1
• Delaying removal of collars in patients who have been cleared by appropriate imaging 1
• Relying solely on collar immobilization without considering the entire patient positioning 6
• Failure to recognize that the risks of prolonged immobilization may exceed the risks of a missed cervical spine injury in many cases 1, 5