Application of Cervical Collars An Analysis of Practical

Skills of Professional Emergency Medical Care Providers

Michael Kreinest, Sarah Goller,Geraldine Rauch, Christian Frank, Bernhard Gliwitzky,2 Christoph G. Wlfl,Stefan
Matschke, and Matthias Mnzberg

Source:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654515/

Abstract

Background/Objective
The application of a cervical collar is a standard procedure in trauma patients in emergency medicine. It is often
observed that cervical collars are applied incorrectly, resulting in reduced immobilization of the cervical spine.
The objective of this study was to analyze the practical skills of trained professional rescue personnel
concerning the application of cervical collars.

Material and Methods

Within emergency medical conferences, n = 104 voluntary test subjects were asked to apply a cervical collar to
a training doll, wherein each step that was performed received an evaluation. Furthermore, personal and
occupational data of all study participants were collected using a questionnaire.

Results
The test subjects included professional rescue personnel (80.8%) and emergency physicians (12.5%). The
average occupational experience of all study participants in pre-clinical emergency care was 11.18.9 years.
Most study participants had already attended a certified training on trauma care (61%) and felt "very confident"
in handling a cervical collar (84%). 11% applied the cervical collar to the training doll without errors. The most
common error consisted of incorrect adjustment of the size of the cervical collar (66%). No association was
found between the correct application of the cervical collar and the occupational group of the test subjects
(trained rescue personnel vs. emergency physicians) or the participation in certified trauma courses.

Conclusion
Despite pronounced subjective confidence regarding the application of cervical collars, this study allows the
conclusion that there are general deficits in practical skills when cervical collars are applied. A critical
assessment of the current training contents on the subject of trauma care must, therefore, be demanded.

Introduction
Depending on the injury mechanism, numerous trauma patients have injuries of the cervical spine. Current
literature states the incidence at 12 out of 100,000 residents [1]. Traffic accidents and falls, but also sports
accidents are among the most common causes of spinal injuries [2, 3].
The application of a cervical collar has been a part of standard procedures in trauma patients for many years [4].
Immobilization of the cervical spine is also highly recommended in numerous national and international
guidelines for patients who have suffered an accident [5].
However, current literature also describes increasing complications after the application of a cervical collar [6
9]. Incorrectly applied cervical collars result in poorer immobilization of the cervical spine [10]. It must,
therefore, be demanded that cervical collars have to be applied correctly.
Despite the increasing spread of certified course formats on care of the severely injured, e. g. PHTLS and
ATLS, errors in applying cervical collars to trauma patients are frequently observed in clinical everyday work.
The objective of this study was, therefore, to analyze the practical skills of professional emergency medical care
providers concerning the application of a cervical collar in a standardized model test.

Materials and Methods

The current study has been approved by the ethical committee in charge (Ethics committee of the State Medical
Association Rhineland-Palatinate, Mainz, Germany) under the reference number 837.371.13 (9056).
In the year 2013, event participants at various German emergency medical continued training events,
conferences, and exhibitions (trained rescue personnel and emergency physicians) were asked to complete a
questionnaire and then perform a cervical spinal immobilization on a training doll for this study. Participation in
the study took place on a voluntary basis.
At the outset, personal and occupational data were anonymously collected for all test subjects using a
questionnaire. Aside from age and current occupation of the participants, occupational experience in emergency
care was also surveyed. Furthermore, participation in certified continued education events in emergency
medicine, as well as the frequency of applying a cervical collar were documented. Lastly, the test subject was
asked to assess how confidently they rated themselves in the use of a cervical collar. A 7-point Likert-scale was
used for answering the questions on personal assessment regarding frequency of application and how confident
the test subjects felt in doing so. The scale used numbers ranging from -3 (not at all or does not apply at all) via
0 to +3 (applies very frequently or completely).
The test subjects were then asked to apply a commercially available cervical collar (Perfit ACETM, Ambu,
Denmark) to a training doll (Airway Management Trainer, Laerdal, Norway; Fig 1B). The manufacturer of the
cervical collar provides brief instructions for use in the form of pictograms on the cervical collar (Fig 1A).

Fig 1

Step by step application of the cervical collar on the model.

The test subjects were observed by a study supervisor during the application of the cervical collar. The
following relevant partial steps were evaluated using a checklist:

i. The test subject has to instruct a trained, always available helper (study supervisor) to implement manual
stabilization of the cervical spine (Fig 1C).
ii. Following removal of upper body clothing, the neck length of the model must be determined according to the
manufacturer's instructions (Fig 1D).
 iii. The previously determined neck length of the model must be transferred to the cervical collar (Fig 1E). The
cervical collar which was used in this study has a "sizing line" for this purpose (Fig 1A). For a perfect fit of the
collar to the training doll, the maximum neck length is recommended.
iv. After setting the previously determined size, the cervical collar must be locked four times (Fig 1F).
v. Prior to applying the cervical collar to the training doll, the chin section of the cervical collar must be folded over
(Fig 1G).
vi. Finally, the cervical collar must be correctly applied to the training doll (Fig 1H).

Each of the aforementioned partial steps was evaluated by the study supervisor in a three-level scale
(implementation correct, implementation not correct, implementation not provided). Both incorrect
implementation and missing implementation were evaluated and documented as "incorrect".
The statistical evaluation of the questionnaire and checklist took place using the program SPSS Statistics 22.0
(IBM, Ehningen, Germany). Categorical variables were evaluated with the statement of absolute and relative
frequencies; average parameters and standard deviations were calculated for steady variables. In order to assess
associations of completely correct application of the cervical collar and the occupational group, the relative
frequencies of correct application of the cervical collar were compared between the applicable occupational
groups using the Chi Square test. The association between correct application of a cervical collar and
participation in certified continued education were examined in the same manner; likewise the procedure when
considering the association between error-free application of the cervical collar and the test subject's subjective
sense of confidence.

Results
N = 104 participants were included into this study. The average age of the participants was 34.5 10.3 years.
The greater share of test subjects consisted of professional rescue personnel (Advanced Life Support-providers)
(80.8%) and emergency physicians (12.5%). The remaining test subjects (6.7%) are classified as non-
professional assistance personnel in emergency medicine (Basic Life Support-providers). The average
occupational experience of all study participants in medical care was 12.8 9.1 years. Average occupational
experience of 11.1 8.9 years was stated for pre-clinical emergency care.
Most study participants (61%) stated that they had already attended certified continued education on the theme
of trauma care. Out-of-hospital courses has been attended by 41% (PHTLS: 34%; ITLS:- 7%) of the study
participants. An ATLS course has been attended by 7% of the study participants. Furthermore, the questionnaire
indicated that 84% of the test subjects felt "very confident" in the use of a cervical collar.
The assessment of the application of the cervical collar on the training doll using the checklist showed
completely correct implementation of all partial steps in 11% of the tests. Accordingly, incorrect, or absent
implementation in at least one partial step was documented in 89% of study participants. The most common
errors are shown in Table 1. In particular, the adjustment of the cervical collar size (66%) and locking it (49%)
were not correctly implemented.

Table 1

Depiction of the most common errors when applying a cervical collar on the model.
Other partial steps with incorrect implementation included the application of the cervical collar to the model
(39%) and the measurement of the neck length of the training doll (35%; Table 1).
No significant difference (Chi-Square-Test: p = 0.407) was shown between the rate of completely correct
applications of the cervical collar in the occupational groups of trained rescue personnel as compared to the rate
in the group of emergency physicians.
Furthermore, no association was found between the correct implementation of the test and participation in
certified continued education on severe trauma care (Chi-Square-Test: p = 0.826). Finally, no correlation was
found between completely correct application and the previously stated sense of certainty in handling the
cervical collar (Chi-Square-Test: p = 0.862).

Discussion
The aim of the current study was to examine practical skills in the application of a common commercial cervical
collar. To standardize this test, the application of the cervical collar was implemented using a suitable training
doll.
In summary, this study showed that only 11% of test subjects were able to apply a cervical collar adequately in
all details. Common error sources included the correct size selection on the cervical collar and the correct size
measurement on the training doll, among other things. This can lead to the application of an excessively large
cervical collar and therefore, increased distraction of the cervical vertebrae. In the presence of an atlanto-
occipital dislocation, this can lead to an increased distraction of the cervical spine, which can result in severe
complications. Both the application of an excessively large and a too-small cervical collar can result in a
significant increase of the range of motion and therefore, reduced immobilization of the cervical spine. It is
therefore important that cervical collars are applied appropriately [6, 10].
In this study, however, it was observed that 89% of test implementations resulted in incorrectly applied cervical
collars. Incorrect application of a cervical collar occurred both with trained rescue personnel and with
emergency physicians. This allows the conclusion that there are general deficits in practical skills when
handling cervical collars, in both occupational groups. It is therefore necessary to engage in a critical discussion
concerning current training and continued education contents regarding practical skills in applying a cervical
collar. The need for more frequent practical training units regarding spinal immobilization was confirmed in a
current study [11]. Mnzberg et al were able to show that both practical skills and case examples in ATLS
courses were evaluated as very helpful by participants [12]. However, this study was able to show that solely
attending certified continued education events focusing on severe trauma care (PHTLS, ATLS) is not associated
with error-free application of a cervical collar. However, this could be attained at any time by focusing more
strongly on practical training in basic methods and techniques, such as immobilization of the cervical spine.
Furthermore, thought should be given to options to improve the sustained effects of such continued education
concepts. Short term refresher courses would surely make sense here.
The self-assessments by the study participants in this study (84% of test subjects felt very confident), however,
showed a clear discrepancy in relation to the results of the study concerning the technique of applying a cervical
collar.
The significance of this study is limited, since not all test subjects were familiar with the provided cervical
collar. There are currently numerous different models of cervical collars available whose handling differs
significantly in some details [13, 14]. The pictograms, which were provided by the manufacturer on the cervical
collar, were only taken into account by few of the participants during the aforementioned test implementation. It
remains to be questioned whether this is due to the existing feeling of confidence. Only a few individual
participants paid attention to the details of the cervical collar before applying it to the doll. The literature
describes models to test cervical collars; according to our knowledge, however, user friendliness is not recorded
in this tests [15]. Further studies on applicability and user friendliness of different models of cervical collars
should be performed. Additionally, study participants should be given the choice between different models or a
general introduction concerning the handling of the current collar should be given by the studys supervisor in
order to reduce bias.
Another limitation of the study consists of the number and selection of included study participants. Participants
were asked to participate in the study at emergency medicine conferences, exhibitions, and continued education
events. Both the pre-selection of the test subjects by attendance at the corresponding event and the voluntary
nature of study participation may result in bias regarding representative random sample selection.
Current literature increasingly shows complications due to the application of a cervical collar. A significant
increase in intracerebral pressure and development of brain edema are reported with the application of a cervical
collar [7, 8]. Wearing a cervical collar may also significantly reduce the ability to open the patients mouth,
which can make airway management more difficult. Worsening neurological symptoms of patients with spinal
injuries were also reported in individual cases when a cervical collar was applied [9, 16, 17].
Including this literature, the correct application of cervical collars must be urgently recommended, since
incorrect applied cervical collars mean that harming the patient cannot be excluded. On the other hand it
remains unknown, at what extent of deviation from the most optimal fitting of the cervical collar complications
may occur. Further studies should be performed to address this topic.
Despite pronounced subjective confidence regarding the application of cervical collars, trained rescue personnel
and emergency physicians show clear deficits in correct implementation. Restructuring of currently existing
training and continued education for emergency medical personnel towards focused practical training of basic
measures in spinal immobilization must therefore be demanded. Furthermore, every emergency medical care
professional must read the instruction manual or get a clear instruction in order to be familiar with the current
models of cervical collars used in the own sphere of action.

Funding Statement
The authors received no specific funding for this work

Data Availability
All relevant data are included in the manuscript.

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