Cervical Collar Use in Trauma Patients

Evidence Against Routine Cervical Collar Use

Cervical collars increase intracranial pressure, which is particularly concerning in patients with co-existing head trauma 1
Pressure sores develop with prolonged collar use, which may require skin grafting and can become sources of sepsis 2, 1
Airway management becomes more difficult, potentially leading to life-threatening complications 1
Poor oral care associated with collar use has been linked to bacteraemia and sepsis 1
Prolonged immobilization leads to higher rates of ventilator-associated pneumonia and delirium 3
Cervical collars paradoxically may not effectively restrict movement of unstable cervical injuries, particularly at the craniocervical and cervicothoracic junctions 2

No good quality evidence shows clinical benefit of cervical collar use for injured patients 4
Multiple studies on healthy volunteers and cadavers show that while collars may limit some movement, they don't prevent all motion 4, 5
The practice is based primarily on expert consensus and tradition rather than strong evidence 4

The American Heart Association recommends against routine application of cervical collars by first aid providers due to growing evidence of harm and lack of proven benefit 6, 7
If spinal injury is suspected, the person should remain as still as possible while awaiting EMS arrival 6

Increased intracranial pressure in patients with head trauma is a risk of collar use 1
Tissue ischemia from prolonged immobilization is a risk of collar use 3
Pressure ulcers and skin breakdown are risks of collar use 2
Airway complications and difficulty with management are risks of collar use 1
May provide some limitation of cervical motion, though not complete immobilization 4

The American Heart Association recommends having the person remain as still as possible while awaiting EMS arrival 6, 7
Manual stabilization may be considered in certain high-risk circumstances 5, 8
Avoid unnecessary movement of the patient 6

Application of a cervical collar requires proper training and regular practice to be performed correctly 5
First aid providers may not be able to accurately discriminate between high-risk and low-risk patients 5
If using NSAIDs criteria for spinal clearance and imaging shows no evidence of injury, prolonged immobilization with a collar is unnecessary 3
For patients with decreased level of consciousness who cannot be clinically cleared, modern CT imaging is highly sensitive for detecting unstable injuries 3

Prolonged use of collars when not indicated by clinical or radiographic findings is a pitfall to avoid 1
Delaying removal of collars in patients who have been cleared by appropriate imaging is a pitfall to avoid 3
Failure to recognize that the risks of prolonged immobilization may exceed the risks of a missed cervical spine injury in many cases 2

The American College of Cardiology and other guideline societies suggest that cervical collars provide incomplete immobilization of the cervical spine, with limited ability to restrict movement, particularly at the craniocervical and cervicothoracic junctions, based on low-quality evidence 9
In cadaveric models with surgically induced injuries, application of a cervical collar caused a greater degree of cervical spine movement (anterior-posterior subluxation) compared with manual in-line stabilization during direct laryngoscopy, indicating limited efficacy of cervical collars 10

Cervical collars increase intracranial pressure, which is particularly concerning in patients with co-existing head trauma, according to the American Heart Association 11
The presence of rigid/semi-rigid collars during airway management is associated with an increased incidence of difficult tracheal intubation, primarily due to reduction in mouth opening, as reported by the American College of Cardiology 10, 12

During airway management, guidelines from the American College of Cardiology recommend removal of semi-rigid or rigid cervical collars (at least the anterior portion) to facilitate intubation while minimizing cervical spine movement, based on evidence from multiple studies 10, 13, 12
Manual in-line stabilization (MILS) is suggested during airway management procedures, though evidence for its efficacy is also limited, according to the American College of Cardiology 14

For airway management in patients with suspected cervical spine injury, remove at least the anterior portion of the collar during intubation attempts to improve glottic exposure, as recommended by the American College of Cardiology 10, 13, 14
Consider using videolaryngoscopy rather than direct laryngoscopy for intubation in patients with suspected cervical spine injury, based on evidence from recent studies 15
Use adjuncts such as a stylet or bougie when performing tracheal intubation in patients whose cervical spine is immobilized, as suggested by the American College of Cardiology 15

The Intensive Care Medicine journal reports that prolonged collar use can lead to increased risks, and cervical collars should be removed on hospital day 3 rather than day 7.5 when CT is negative 16
The Difficult Airway Society guidelines acknowledge that there is no strong evidence that airway management increases risk of secondary spinal cord injury, and recommend removing at least the anterior portion of the collar during intubation attempts to improve glottic exposure and reduce difficult intubation rates 17
The Anaesthesia journal recommends using manual in-line stabilization combined with anterior collar removal during airway management, and consider videolaryngoscopy over direct laryngoscopy (Grade A recommendation) 17, 18, 19

The Intensive Care Medicine journal suggests that for obtunded patients, high-quality cervical spine CT (axial thickness <3 mm) should be obtained, and if CT negative, remove collar without additional MRI or flexion-extension views 16
The Anaesthesia journal recommends removing at least the anterior portion of the collar during intubation attempts to improve glottic exposure and reduce difficult intubation rates, and consider videolaryngoscopy over direct laryngoscopy (Grade A recommendation) 17

The Difficult Airway Society guidelines acknowledge that despite traditional concerns, there is no strong evidence that airway management increases risk of secondary spinal cord injury, and the documented harms of prolonged immobilization are substantial and well-established 17, 16, 20