What are the criteria for applying a cervical collar (c-collar) to a patient in an in-hospital setting?

From the Guidelines

In a hospital setting, a cervical collar (c-collar) should be applied to patients with suspected cervical spine injury based on specific clinical criteria, including trauma patients with neck pain, neurological deficits, altered mental status, high-energy mechanism of injury, or significant distracting injuries, as outlined in the most recent guidelines 1. The primary indications for c-collar application include:

• Trauma patients with neck pain
• Neurological deficits suggesting spinal cord injury
• Altered mental status preventing reliable examination
• High-energy mechanism of injury
• Significant distracting injuries The decision to apply a c-collar should follow assessment tools like the NEXUS criteria or Canadian C-Spine Rule, which evaluate factors such as midline cervical tenderness, focal neurological deficits, and mechanism of injury 1. Proper application involves measuring the patient's neck, selecting an appropriately sized collar, maintaining neutral alignment of the cervical spine during application, and ensuring the collar is secure but not overly tight. C-collars work by restricting movement and providing external stabilization to prevent secondary injury to the spinal cord from unstable vertebral segments. However, they should be removed as soon as cervical spine injury is ruled out, as prolonged use can lead to pressure ulcers, increased intracranial pressure, and patient discomfort, as highlighted in a study published in 2015 1. It is also important to note that the use of c-collars should be balanced with the potential risks, such as increased intracranial pressure, and that alternative methods of stabilization, such as manual stabilization, may be considered in certain circumstances. The most recent guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AOA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCs), Faculty of Prehospital Care, and Royal College of Emergency Medicine (RCEM) provide recommendations for airway management in patients with suspected or confirmed cervical spine injury, including the use of videolaryngoscopy and the removal of semi-rigid or rigid cervical collars during tracheal intubation attempts 1.

From the Research

Criteria for Applying a Cervical Collar

The criteria for applying a cervical collar (c-collar) to a patient in an in-hospital setting are not strictly defined, but several studies provide guidance on the use of cervical collars in trauma patients.

• The decision to apply a cervical collar should be based on a thorough assessment of the patient's condition, including their level of consciousness, stability, and cooperation 2.
• Fully alert, stable, and cooperative trauma patients may not require the application of a semi-rigid cervical collar, unless their conscious level deteriorates or they find the short-term support of a cervical collar helpful 2.
• In intubated patients, a normal computed tomography (CT) cervical spine can be used to clear the cervical spine and remove the collar, provided certain quality conditions related to the CT scan are met 3.
• The use of clinical cervical spine clearance in trauma patients is becoming more commonplace, with few missed injuries or poor outcomes 4.
• Older patients placed in cervical collars for more than 24 hours are at greater risk of developing collar-related complications, such as nosocomial pneumonia and pressure ulcers 5.

Considerations for Cervical Collar Use

When considering the use of a cervical collar, healthcare providers should weigh the potential benefits against the potential risks, including:

• The risk of missed cervical injuries 4
• The risk of collar-related complications, such as nosocomial pneumonia and pressure ulcers 5
• The potential for harm from cervical collars, including increased risk of respiratory complications and skin breakdown 6, 4, 5

Clearance of Cervical Collars

Cervical collars can be cleared in patients with a normal CT cervical spine, provided certain quality conditions related to the CT scan are met 3.

• Intensive care physicians can safely remove cervical collars in intubated patients based on a normal CT cervical spine 3.
• Early collar clearance is recommended for older trauma patients to reduce the risk of collar-related complications 5.