What is the management for a patient with a clear neck injury, specifically regarding the use of a cervical (c) collar?

Management of Clear Neck Injury: Cervical Collar Use

Cervical collars are not recommended for routine use in patients with clear neck injuries due to growing evidence of harm and lack of proven benefit. 1, 2

Evidence Against Routine Cervical Collar Use

• Cervical collars increase intracranial pressure, which is particularly concerning in patients with co-existing head trauma 2
• Prolonged immobilization with collars leads to higher rates of ventilator-associated pneumonia and delirium 1
• Pressure sores develop with prolonged collar use, potentially requiring skin grafting and becoming sources of sepsis 2
• Airway management becomes more difficult with collars in place, potentially leading to life-threatening complications 2
• Poor oral care associated with collar use has been linked to bacteremia and sepsis 2
• Cervical collars paradoxically may not effectively restrict movement of unstable cervical injuries, particularly at the craniocervical and cervicothoracic junctions 2, 3

Limited Evidence of Benefit

• No high-quality evidence demonstrates clinical benefit of cervical collar use for injured patients 2, 4
• Studies on healthy volunteers and cadavers show that while collars may limit some movement, they don't prevent all motion 3
• Rigid collars provide more immobilization than soft collars, but even rigid collars only limit lateral rotation by 18% 3

Alternative Approach to Spinal Protection

• For patients with suspected spinal injury, manual in-line stabilization is suggested during critical procedures like intubation 1, 2
• During airway management, remove at least the anterior portion of the collar to facilitate intubation while minimizing cervical spine movement 1, 2
• Have the person remain as still as possible while awaiting definitive care 2
• Avoid unnecessary movement of the patient 2

Risk Stratification for Collar Use

• For patients with clear consciousness (GCS > 8), there is no significant mortality benefit from cervical collar use 5
• Cervical collar use is associated with increased mortality risk in:
  • Older adults (age ≥ 65) 5
  • Patients with unclear consciousness (GCS ≤ 8) 5
  • Those with major traumatic injuries (ISS ≥ 16 or RTS ≤ 7) 5
  • Patients in shock (shock index > 1) 5

When Collars Are Used

• If a collar must be used, soft collars are better tolerated by patients and result in fewer pressure injuries compared to rigid collars 6
• Soft collars limit flexion by 39% and lateral rotation by only 11%, providing minimal immobilization 3
• Rigid collars provide greater immobilization (59% limitation of flexion, 18% limitation of lateral rotation) but with increased risk of complications 3

Pitfalls to Avoid

• Prolonged use of collars when not indicated by clinical or radiographic findings 2
• Delaying removal of collars in patients who have been cleared by appropriate imaging 1, 2
• Failure to recognize that the risks of prolonged immobilization may exceed the risks of a missed cervical spine injury in many cases 1, 2
• Overreliance on cervical collars as the primary method of spinal protection 1, 4