Is a transition away from a cervical (c) collar recommended in stable trauma patients?

Transition Away from Cervical Collars in Stable Trauma Patients

Yes, there is a clear transition away from routine cervical collar use in stable trauma patients, driven by mounting evidence of harm and lack of proven benefit. The American Heart Association now recommends against routine application of cervical collars by first aid providers, and multiple international guidelines support early removal in appropriately cleared patients 1.

Current Guideline Recommendations

Against Routine Use

• The American Heart Association explicitly recommends against routine cervical collar application by first aid providers due to growing evidence of harm and lack of proven benefit 1
• If spinal injury is suspected, patients should remain as still as possible while awaiting EMS arrival rather than having a collar applied 1
• This represents a fundamental shift from decades of traditional practice 2

For Early Removal in Stable Patients

• In obtunded adult blunt trauma patients, cervical collars can be conditionally removed after a negative high-quality cervical spine CT scan (axial thickness <3 mm) alone, without requiring additional MRI or other imaging 3
• The negative predictive value of high-quality CT is 91%, with a 0% cumulative incidence of unstable injuries after negative initial CT imaging 3
• For alert, oriented, low-risk patients, appropriately trained emergency nurses can safely apply clinical decision rules (such as the Canadian C-Spine Rule) to remove collars, with 100% agreement rates with physician assessments 4, 5

Evidence of Harm from Prolonged Collar Use

Serious Complications

• Cervical collars increase intracranial pressure, which is particularly dangerous in patients with co-existing head trauma 1
• Pressure sores develop with prolonged use and may require skin grafting, potentially becoming sources of sepsis 1
• Airway management becomes significantly more difficult, with increased incidence of difficult intubation primarily due to reduced mouth opening 1
• Poor oral care associated with collar use has been linked to bacteremia and sepsis 1
• Prolonged immobilization leads to higher rates of ventilator-associated pneumonia and delirium 1

Limited Efficacy

• Cervical collars paradoxically may not effectively restrict movement of unstable cervical injuries, particularly at the craniocervical and cervicothoracic junctions 1
• In cadaveric models with surgically induced injuries, collar application caused greater cervical spine movement (anterior-posterior subluxation) compared with manual in-line stabilization during laryngoscopy 1
• No good quality randomized controlled trials demonstrate clinical benefit of cervical collar use for injured patients 1, 2

Practical Algorithm for Collar Management

For Alert, Stable Patients

1. Apply clinical decision rules (Canadian C-Spine Rule or NEXUS criteria) immediately upon assessment 4, 5
2. If low-risk criteria met, remove collar without imaging - trained emergency nurses can perform this safely 4, 5
3. If soft collar considered necessary, use it instead of rigid collar - significantly less painful (median pain score 3.0 vs 6.0, p<0.001) and causes less agitation (5% vs 17%, p=0.04) 6

For Obtunded Patients

1. Obtain high-quality cervical spine CT (axial thickness <3 mm) 3
2. If CT negative, remove collar - no additional MRI or flexion-extension views required 3
3. Do not delay removal - prolonged immobilization risks exceed benefits in CT-cleared patients 7, 1

During Airway Management

• Remove at least the anterior portion of the collar during intubation attempts to improve glottic exposure and reduce difficult intubation rates 7, 1
• Use manual in-line stabilization combined with anterior collar removal 7
• Consider videolaryngoscopy over direct laryngoscopy (Grade A recommendation) 7

Common Pitfalls to Avoid

• Prolonged collar use when not indicated by clinical or radiographic findings - the risks of immobilization often exceed the risks of missed injury 1
• Delaying removal in patients cleared by appropriate imaging - cervical collars should be removed on hospital day 3 rather than day 7.5 when CT is negative 7
• Failure to recognize that tissue ischemia, increased ICP, and airway complications may cause more harm than potential benefit 1
• Assuming collars provide complete immobilization - they provide incomplete restriction of movement, particularly at critical junctions 1

Special Considerations

Training Requirements

• Emergency nurses require appropriate training to apply clinical decision rules, but once trained, demonstrate high inter-rater reliability (kappa 0.61-0.80) with physicians 4
• Charge nurses can successfully implement the Canadian C-Spine Rule with 100% agreement with physician assessments 5

Risk-Benefit Analysis

The 2024 Difficult Airway Society guidelines acknowledge that despite traditional concerns, there is no strong evidence that airway management increases risk of secondary spinal cord injury 7. Meanwhile, the documented harms of prolonged immobilization are substantial and well-established 7, 1.