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Developing a Standard of Care for Halo Vest and Pin

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Developing a Standard of Care for Halo Vest and Pin Volume 42 & Number 3 & June 2010 169 Developing a Standard of Care for Halo Vest and Pin Site Care Including Patient and Family Education: A Collaborative Approach Among Three Greater Toronto Area Teaching Hospitals Angela Sarro, Tracy Anthony, Rosalie Magtoto, Julie Mauceri ABSTRACT Caring for an individual with a halo vest can be a frustrating and anxiety-provoking experience for healthcare professionals, the patient, and their families. Physicians or trained nurses apply halo vests in various situations in which cervical spine stabilization is required for an extended period. This device can be used as a first-line treatment in the management of nonoperative cervical trauma, that is, fractures, or placed following cervical surgery. Standardizing the application techniques and care associated with the halo vest, pin site care, and day-to-day activities of daily living will increase the comfort and self-confidence of healthcare professionals and the patient and family members in the provision of care. A collaborative approach among three greater Toronto area teaching hospitals aided in the development of standardizing care and patient educational materials for patients with halo vests. he halo brace is a device that is used to im- Literature Review mobilize the head and neck following a cervical A review of the nursing literature surrounding the Tfracture or postoperatively to allow bone heal- application, care, and management of halo vests and ing. The system consists of a ring that is attached to the pin sites is limited and outdated (Botte et al., 1996; outer table of the skull with four pins and supporting Marr & Edmonds, 1992; Marr & Reid, 1993; North, rods attached to a vest (Botte, Byrne, Abrams, & North, & Lee, 1992; Olson & Ustanko, 1990; Olson, Garfin, 1996). In turn, this allows the patient to be 1996; Reid, 1993). For example, there is no clear mobile, whether it is independent or assisted ambu- consensus regarding pin site care for halo vests, that lation or movement, and reduces complications asso- is, time frequency and cleaning solutions, or any con- ciated with immobility. However, this generally clusive evidence to support use of any one method. creates significant anxiety and frustration for patients Most patients require specific teaching regarding and their families because it requires significant self-care, activities of daily living, coping mecha- adjustments to the individual’s lifestyle and activities nisms, and activity limitations. Given this, there was of daily living (Olson & Ustanko, 1990). Given that a strong need to develop standardized methods of most patients are discharged back into the commu- care for nurses involved with halo crown applica- nity, halo vest care standardization is essential for tion, halo vest application, halo pin and vest care, optimizing care to reduce patient anxiety, frustrations, and patient and family educational materials. and complications. In an attempt to standardize the care with halo vests and associated patient education, three greater Toronto area hospitals began a collaborative process Questions or comments about this article may be directed to in this development. A review of each hospital’s Angela Sarro, RN(EC) MN, at [email protected]. She is a policies, procedures, and protocols was undertaken. nurse practitioner-spine at Toronto Western Hospital, Krembil Neuroscience Centre, Toronto, Ontario, Canada. Gaps and similarities with respect to care of these patients were noted, and subsequent standardized Tracy Anthony, RN BScN, is an acute spinal cord injury nurse at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. guidelines were developed. In addition, comments from patients and nurses identified the need for this Rosalie Magtoto, RN BScN, is a clinical co-ordinator in the Spinal Program, Toronto Western Hospital, Krembil Neuroscience Centre, information. Toronto, Ontario, Canada. Julie Mauceri, RN BScN, is a clinical nurse educator in Trauma & Application Neurosurgery, St. Michael’s Hospital, Toronto, Ontario, Canada. Halo traction is typically used for stabilizing cervical Copyright B 2010 American Association of Neuroscience Nurses spine fractures and preoperatively to reduce spinal Copyright @ 2010 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited. 170 Journal of Neuroscience Nursing Vest Application Standardization of halo vest and Once the physician is satisfied with spine alignment, pin care is a key component the patient will be placed into the vest component of the apparatus. The upright bars will need to be at- in providing optimal patient tached to the anterior and posterior portions of the vest. The patient is then log rolled, and the Bspoon[ is care once patients leave the removed. The posterior portion of the vest is placed acute care setting. under the patient and gently centered. The upper portion of the vest should match the superior aspect of the scapulae, and the opening in the posterior vest should be in line with the spine. The transverse bars misalignment. Once proper alignment has been es- are then placed into the posterior joints, ensuring that tablished, a halo vest is often applied to provide the bolts are on the outside and access to the posterior ongoing immobilization of the cervical spine. Treat- pins is not blocked. The sternal notch should be ex- ment time with the halo vest can vary but is usually up posed about 2 in. above the upper edge of the anterior to 12 weeks in duration. Components of the brace vest. Slide the thoracic bands through each guide on include the halo ring, skull pins, anterior and posterior the anterior vest, being careful not to restrict the pa- vest, Bsheepskin[ type vest lining, four upright bars, tient’s breathing, and then lock into place. Attach and two transverse bars. For application, torquing caps shoulder straps. Position patient’s head and cervical or torque wrench, positioning pads, and a Bspoon[ are spine into correct placement and tighten all clamps. required. Contraindications for the application of the Secure the halo wrench onto front of the vest or up- halo crown include skull fractures, chest trauma, right bars (DePuy, 2003). obesity, and advanced age. Adjustments Crown Upon completion of the halo vest application, a lateral Prior to application, analgesics along with topical cervical spine x-ray is required to ensure proper align- anesthetic to assist with patient anxiety and pain man- ment and positioning. In the event that the patient agement should be considered. The patient is carefully complains of difficulty swallowing or of having pres- log rolled onto the Bspoon,[ which helps support the sure on the top of his or her head, that is, a Bscrunched[ occiput and lies flat under the patient’s spine. Three feeling, these symptoms could indicate that the vest positioning pads (suction cups) are inserted through may have been applied too tightly, too high, or too low. the crown, resting one between the patient’s eye brows Adjustments to improve patient comfort may be and one on each side of the crown. These are used to necessary. Adjustments to improve alignment will be stabilize the crown on the patient’s head while the based on the results of the cervical spine x-rays. clinician assesses pin placement, making it possible for one individual to apply the halo crown. The pins are positioned and then inserted approximately 1 mm into Complications the outer table of the skull through direct puncture. Halo vest and crown fixation are generally quite Optimal placement is essential because this will help to effective; however, complications may occur (Botte decrease future complications. Two anterior pins are et al., 1996; van Middendorp, Sloof, Nellestein, & placed in the outer two thirds region of the eyebrows, Oner, 2009; Vertullo, Duke, & Askin, 1997). The approximately 1 cm above the eyebrows, with no more halo vest brace is associated with complications such than 1 cm between the halo crown and the patient’s as pin site infections, pin site loosening or dislodge- forehead. Two posterior pins are placed just behind the ment, skin breakdown, swallowing problems, and ears below the equator of the skull. These areas are dural tears. Complications are typically minor in infiltrated with local anesthetic prior to pin insertion. nature and easily treated. Positioning of the crown should be done carefully so as not to have any part of it touching the top of the head or Pin Loosening ears. A careful observation during pin insertion is nec- Pin loosening is one of the most common complica- essary to help prevent misalignment of the crown. Op- tions seen. The reason for pin loosening is thought to posing pins are tightened two turns at a time until the be resorption of the bone at the tip of the pin. Pin torquing caps break off; indicating that 8 lb/in.2 has loosening may cause instability and possible infec- been attained. Halo pins are retorqued to 6Y8lb/in.2 tion. It occurs in 36%Y60% of patients with a halo within the first 24Y48 hours after halo application vest. In the absence of infection, halo pins can be (DePuy, 2003). retightened to 4Y6 lb/in.2. One needs to be cognizant Copyright @ 2010 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited. Volume 42 & Number 3 & June 2010 171 of meeting resistance within the first few turns of the 1990). Adjustment of the halo by flexion of cervical pin. If no resistance is met, the pin(s) should be re- spine while monitoring reduction of the cervical spine moved and replaced. The old pin should not be re- may help in resolving dysphagia. A referral with a moved until the new pin is rigidly in place in an speech language pathologist may be helpful in adjacent position. Also, if a pin frequently requires assessing and resolving the swallowing problem. tightening, the clinician should consider removing the pin and inserting a new one into a different location.
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