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Impact of Cervical Collar and Patient Position on the Cerebral Blood Flow

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Impact of Cervical Collar and Patient Position on the Cerebral Blood Flow Original Article J Neurol Res. 2020;10(5):177-182 Impact of Cervical Collar and Patient Position on the Cerebral Blood Flow David Wamplera, f, Brian Eastridgeb, Rena Summersc, Preston Lovec, Anand Dhariad, Ali Seifie Abstract is unknown but this change in cerebral blood flow may have clinical significance in traumatic brain injury or neurologic conditions that Background: Spinal protection during emergency medical service compromise autoregulation. (EMS) transport after trauma has become a focus of debate. Histori- Cervical collars; Head of bed elevation; Autoregulation; cally, patients at risk for spine injury are transported in a rigid col- Keywords: Cerebral perfusion; Cerebral blood flow lar, long spineboard and headblocks. The cervical collar (c-collar) is hypothesized to provide stabilization for the cervical spine. However, little is known how the c-collar affects cervical blood flow. Methods: Cerebral blood flow was measured in multiple conditions Introduction using a non-invasive cerebral blood flow monitor to establish cerebral blood flow index (CBFI). The CBFI data were collected at: standing, The process of protecting the spine during emergency medical sitting, 45°, 30°, 10° or 15°, and supine, with and without c-collar. De- service (EMS) transport after a traumatic event has become a scriptive statistics were used for CBFI in each condition, and paramet- contemporary focus of national attention in emergency medi- ric statistical methods were utilized to determine the significance of cal services [1, 2]. Historically, patients that have a suspected changes in CBFI. spinal fracture have been placed in a rigid cervical collar (c- collar), positioned supine on a rigid long spinal board (LSB), Results: Five volunteers were recruited, and each tested in six posi- with the head secured by some type of padded foam headblocks tions with and without c-collar. Mean age was 49 (standard devia- [3]. This process was executed on all potential civilian patients tion (SD) 15) years and 60% were male. The CBFI mean of means with suspected spine trauma regardless the mechanism of in- was 71.0 with and 69.4 without the c-collar. Only one subject dem- jury. Further, this transport mode was also recommended for onstrated a statistically significant difference in CBFI with c-collar. any patient with traumatic head injury due to the potential for The CBFI mean of means for position was 72.6 for head of bed less concomitant cervical spine injury [4, 5]. than 30° and 68.1 for greater than 30°. All subjects demonstrated > During transport, a potential spinal trauma victim is 99% confidence for a statistically significant difference in CBFI when subjected to multi-vectoral forces in all three axes of move- dichotomized using head of bed at 30°. ment. The LSB is intended to lessen the movement during extrication and transport, but does come with some signifi- Conclusions: Head of the bed position has greater influence on cant limitations [6]. One of the significant limitations is that CBFI than the c-collar . Clinical significance in healthy volunteers the subject must remain supine or very nearly supine during transport. During ambulance acceleration and breaking, the Manuscript submitted July 8, 2020, accepted July 15, 2020 weight of the patient has a tendency to shift, placing me- Published online August 2, 2020 chanical stress on the cervical spine adding potential risk to exacerbate cervical spine and spinal cord injury. The rigid c- aDepartment of Emergency Health Sciences, University of Texas Health Sci- collar is intended to stabilize the cervical spine and minimize ence Center at San Antonio, San Antonio, TX, USA the effect of mechanical forces acting upon the axial skeleton bDepartment of Surgery, University of Texas Health Science Center at San during transport [7]. Antonio, San Antonio, TX, USA C-collars are designed to fit around the neck to prevent cSouthwest Texas Regional Advisory Council, San Antonio TX, USA dDepartment of Neurosurgery, Kansas University Medical Center, Kansas City, MO, USA Key Points eDepartment of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA • Head of the bed position impacts cerebral blood flow index. fCorresponding Author: David Wampler, UTHSCSA Emergency Health Sci- • Application of cervical collar may not impact cerebral blood ences, 4201 Medical Drive, Suite 120, San Antonio, TX 78229, USA. index in intact subjects. Email: [email protected] • Initial management of trauma patients should prioritize maintenance of cerebral perfusion. doi: https://doi.org/10.14740/jnr611 Articles © The authors | Journal compilation © J Neurol Res and Elmer Press Inc™ | www.neurores.org This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits 177 unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited C-Collar and Patient Position on the CBF J Neurol Res. 2020;10(5):177-182 movement of the head and to provide support to the effect of axial loading. Properly sizing a c-collar is not always an easily accomplished task [8]. The collar must be fitted for proper height and proper tightness. Too loose a fit and the collar loses functionality; too tight a fit and there are possible hemodynamic consequences as well as a decrease in patient comfort and compliance with the device. To maximize ef- fectiveness, the c-collar must be properly fitted in order to provide the needed support without impinging blood flow into, or out of, the head or airflow into, and out of, the chest. Currently, there are no guidelines to direct the optimum tight- ness of the c-collar and the best position of injured subjects during transportation. In this study we sought to determine the effect of c-collar application and subject positioning on the cerebral blood flow. Materials and Methods Figure 1. The study design with a sensor that is adhered to the skin. Study design The monitor was applied to assess the changes of blood flow to the brain: before and after application of several c-collars, as the patient positions change from supine (with and without LSB), and as the head This study was conducted as a serial N-of-one study, where the of the bed is elevated. c-collar: cervical collar; LSB: long spinal board. cerebral blood flow index (CBFI) was monitored for each sub- ject under each condition in the study. Each subject was only or any history of anxiety, nausea, dizziness, headache, neck compared to himself/herself. This study was reviewed and ap- pain, or currently taking anxiolytic or analgesic medications. proved by the Institutional Review Board at the University of Texas Health Science Center at San Antonio; and this study Procedure was conducted in compliance with the ethical standards of the responsible institution on human subjects as well as with the Helsinki Declaration. After informed consent was obtained, each subject underwent an initial screening for inclusion and exclusion criteria. Subjects were fitted with the CBFI monitor and the monitor was allowed Instrumentation to establish a baseline index while the subject was relaxed in a comfortable position. Vital signs were monitored using stand- CBFI was measured with acousto-optic monitoring utilizing ard non-invasive monitoring (blood pressure, pulse rate, oxygen ultrasound (US)-tagged light (UTLight™). This is a form of saturation, and respiratory rate). Subjects were then provided a optical contrast measurement using a combination of highly randomization package which indicated their order of position- coherent near-infrared laser light spectroscopy (NIRS) cou- ing and whether the c-collar should be worn. Each subject was pled with US by the c-FLOW™ monitor (Ornim Medical, Kfar then tested in a random sequence of the following positions: Saba, Israel) [9]. The Ornim c-FLOW™ monitor is Food and standing with and without rigid c-collar, sitting upright with and Drug Administration (FDA) cleared for continuous non-inva- without rigid c-collar, laying on EMS stretcher with head of bed sive real-time cerebral blood flow monitoring. This monitor elevated greater than 45, 30, and 10 or 15° with and without was applied to assess the changes of blood flow to the brain: rigid c-collar, laying supine on EMS stretcher with and without before and after application of several c-collars, as the patient rigid c-collar, and laying supine on EMS stretcher with LSB and positions change from supine (with and without LSB), and as rigid c-collar. Thus, there are a total of six positions with and six the head of the bed is elevated. The patient interface is via a positions without c-collar. In all cases, the collar was fitted by a surface sensor that is adhered to the skin (Fig. 1). professional licensed paramedic as per manufacturer’s recom- mendations, and the head of the bed angle was determined using an electronic level. In each position, the subject was allowed to Participants rest as to reestablish a stable perfusion index and, once stabi- lized, a 3-min perfusion recording period was documented. Healthy volunteers were recruited, underwent a full informed consent process, and were assessed to have no medically sig- Measurements nificant spinal abnormalities, obvious pregnancy, nor contrain- dications for monitor placement on areas with which the LSB, c-collar, or stretcher mattress may come into contact. For each of the above described conditions, a 1-min stabiliza- Exclusion criteria are: pregnancy, prisoners, hypertension, tion period was followed by 3 min of cerebral perfusion moni- history of cardiovascular diseases, dermatologic problems, toring. Measurements taken included mean, standard deviation 178 Articles © The authors | Journal compilation © J Neurol Res and Elmer Press Inc™ | www.neurores.org Wampler et al J Neurol Res. 2020;10(5):177-182 Table 1. Subject Demographics Subject Gender Age (years) BMI Neck circumference (cm) 1 M 61 35.4 46 2 F 65 29.0 38 3 M 27 24.3 38.25 4 M 46 29.3 41 5 F 46 29.0 37.5 Mean (SD, 95% CI) 49 (15, 30 - 68) 29.4 (4, 24 - 34) 40.15 BMI: body mass index; M: male; F: female; SD: standard deviation; CI: confidence interval.
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