Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee.

Spine immobilization in trauma patients suspected of having a spinal injury has been a cornerstone of prehospital treatment for decades. Current practices are based on the belief that a patient with an injured spinal column can deteriorate neurologically without immobilization. Most treatment protocols do not differentiate between blunt and penetrating mechanisms of injury. Current Emergency Medical Service (EMS) protocols for spinal immobilization of penetrating trauma are based on historic practices rather than scientific merits. Although blunt spinal column injuries will occasionally produce unstable vertebral injuries, which may result in subsequent neurologic propagation if not managed appropriately in the field, this has not been demonstrated to be the case with penetrating trauma.1 Patients with penetrating trauma have different management priorities than those with blunt mechanisms. In patients with penetrating wounds of the head and neck, cervical collars hinder provider assessment of the neck for evolving injuries, tissue edema, subcutaneous emphysema, hematoma development or expansion, and tracheal deviation— with many of these injuries often identified only after removal of the cervical collar.2,3 Airway management is a significant issue in the penetrating trauma population who have had their cervical spine immobilized by prehospital personnel. Endotracheal intubation is more difficult in patients with cervical immobilization.4 More attempts at intubation occur in patients with cervical spine immobilization than occur without, and there is a higher incidence of esophageal intubation and tube dislodgement in this group.5 In the case of penetrating injuries, delays in transport prolong the time before patients receive the prompt surgical care needed to arrest hemorrhage. Even with experienced prehospital providers, spine immobilization is time consuming. The time required for experienced emergency medical technicians to properly immobilize a cervical spine has been reported to be 5.64 minutes ( 1.49 minutes).6 This scene delay can be catastrophic for a patient with penetrating trauma requiring urgent surgical intervention for airway compromise or hemorrhage. Studies have demonstrated that cervical collars increase intracranial pressure in patients with head injuries.7–9 The mechanism for this rise in intracranial pressure is unknown but has been postulated to be due to jugular venous compression by the cervical collar.10 Finally, no study has demonstrated that penetrating trauma can produce an unstable spine injury. Progression of spinal cord injury has not been demonstrated to occur following penetrating trauma, which has a different mechanism of injury from blunt trauma. The PreHospital Trauma Life Support (PHTLS) program is a national and international educational effort sponsored jointly by the National Association of Emergency Medical Technicians and the American College of Surgeons Committee on Trauma. The Executive Committee of PHTLS is comprised of surgeons, emergency physicians, and paramedics. The mission of PHTLS is to further the knowledge of prehospital providers of all levels in the management of victims of trauma. To that end, PHTLS publishes textbooks and offers educational courses for prehospital providers at both basic and advanced levels of training. The PHTLS program was modeled after the American College of Surgeons Committee on Trauma Advanced Trauma Life Support course for physicians.