Collar, or no collar? Gsw to the head.

[NomadicMedic]

Maybe they'd get one before I arrived at the ED, if I had time after doing everything else.

I wouldn't lose any sleep over it, and if I didn't collar this patient (if required by protocol) I'd document to cover myself.

 

[Tigger]

I have not found any research to suggest that c-spine precautions make a lick of difference in any patient. I have also found studies that show no improvement in outcomes in penetrating trauma patients when c-spine precautions are used.

http://www.east.org/resources/treatment-guidelines/cervical-spine-injuries-following-trauma

Also, how many people you have on scene is meaningless aside from how fast you can put them in the ambulance. Transport to a trauma center is what improves outcomes.

 

[Ensihoitaja]

Also, how many people you have on scene is meaningless aside from how fast you can put them in the ambulance. Transport to a trauma center is what improves outcomes.

This, times about a billion!

 

[Jim37F]

In my mind, a C-Collar is perfectly appropriate if the GSW was to the neck. Besides stabilizing the C-spine itself, a collar would help hold your occlusive dressings and other bandages in place and minimizing movement that would dislodge them, aggravate the injury, etc.

For a penetrating trauma to the head, especially a GSW, if there was enough kinetic energy imparted to transfer to, and compromise the C-spine, well you're probably gonna have some eviscerated grey matter to go along with it...

Now since her we do have 5-6 providers on scene I'm certainly not going to stop you from putting on a C-collar for a head shot, well not unless it was getting in the way of airway management or something else similarly vital.. Now since collars and boards aren't part of our first in kit (unless the engine company is on scene first and asks us to bring it in as we pull up) I'm not going to sit around and wait for you to go get one to move the patient to the gurney and start moving towards the ambulance (though I suppose you could always put one on en route to the trauma center) ESPECIALLY when my county protocols on the matter state very clearly "SMR for penetrating injuries is generally not indicated and transport must not be delayed to apply SMR. Treatment of patients with penetrating trauma should not involve a backboard unless it is required as an extrication device or if there is a significant concomitant blunt mechanism."

Now as others have said, if your local policies and protocols say otherwise that you're supposed to collar and/or board this patient, that kinda overrides my opinion juuuusst a little lol

 

[RocketMedic]

A full-on motion-cancelling sci-fi immobilization field will not resolve the problem- disruption of brain matter by a projectile. Everything else here is gravy. The only real reason to even transport this body is for donation.

 

[Jim37F]

A full-on motion-cancelling sci-fi immobilization field will not resolve the problem- disruption of brain matter by a projectile. Everything else here is gravy.

True

The only real reason to even transport this body is for donation.

Less true. Not all GSWs to the head are fatal. There are plenty of patients who have survived (with varying degrees of being) neurologically intact. Granted there are plenty of patients with penetrating head trauma who are beyond mortal resuscitation before hitting the ground. It all depends on the projectile, what it hit, cavitation and other energy transfer to surrounding tissues, etc.

 

[DesertMedic66]

True

Less true. Not all GSWs to the head are fatal. There are plenty of patients who have survived (with varying degrees of being) neurologically intact. Granted there are plenty of patients with penetrating head trauma who are beyond mortal resuscitation before hitting the ground. It all depends on the projectile, what it hit, cavitation and other energy transfer to surrounding tissues, etc.

Always double tap

 

[RocketMedic]

Multiple GSW with severe and sudden loc is not likely to survive

 

[Christopher]

To those that say a collar is a waste of time, I understand where you're coming from, but when you have 3+ emts on a scene, and 2+ paramedics, I don't see putting on a collar as being a problem.

Well besides being harmful, sure there is no problem ;-)

(I'll grant that the GSW location is likely contributing the most to this patient's M&M; doesn't change the harm inherent in C-Collar/LSB application in penetrating trauma victims)

 

[Brandon O]

Do Not Collar Penetrating Trauma.

It kills people. If we know anything about spinal trauma (hint: we don't know much), we know that. Guidelines and the evidence agree.

 

[MedicRx]

I'm reading an awful lot of posts that are saying to collar and board this patient. My question is why? What exactly are you hoping to achieve? What do you think the collar and board are going to do? If this patient just happened to be the literal one in a million that has spinal trauma from a penetrating injury, that damage is done. All the boards and collars in the world aren't going to repair, or even help, that spinal cord. And unless you're planning on beating your patient, or trying to finish the job that the shooter didn't (hey, maybe you're a psycho killer), SMR won't even help prevent further injury any better than your stretcher. It's a waste of time for a patient that needs definitive treatment, and shouldn't even be considered.

 

[SixEightWhiskey]

My state finally figured out that collaring and boarding everyone is useless. even when 95 year old nana complains of neck pain and extremity numbness s/p fall, we simply collar them and put them on the stretcher. backboards are simply a hard surface for CPR, or an extrication device if need be, which thankfully we have replaced with more practical devices, such as the reeves stretcher (or as i like to call it, god's gift to EMTs). i agree with using a collar on neck trauma to simply keep all the dressings intact, etc. but that is simply for convenience. there's no clinical reason why someone with a penetrating wound to the head needs full board-and-collar c-spine precautions. any time spent on a scene doing this is taking away precious time from a trauma surgeon, and is unequivocally bad medicine.

obviously, follow your medical direction and your state protocols. I just hope they all catch up and use evidence-based medicine as a reference someday, because the c-spine thing is such a quagmire of tradition and policy and CYA stuff, when it really has no added benefit for your patient care.

 

[Tigger]

True

Less true. Not all GSWs to the head are fatal. There are plenty of patients who have survived (with varying degrees of being) neurologically intact. Granted there are plenty of patients with penetrating head trauma who are beyond mortal resuscitation before hitting the ground. It all depends on the projectile, what it hit, cavitation and other energy transfer to surrounding tissues, etc.

And c-collars have no bearing in improvement of well, anything here.

 

[Ensihoitaja]

Always double tap

And limber up.

 

[shindaga]

No immobilization in penetrating trauma, end of story. It's becoming ever more clear that backboards for immobilization are voodo for anything anyway.

 

[Emergency Metaphysics]

No immobilization in penetrating trauma, end of story. It's becoming ever more clear that backboards for immobilization are voodo for anything anyway.

In fact there is an article, I think, in the newest issue of JEMS that covers this topic and backs you up. The data just isn't there to back up c-collars and backboards. The article was emphasizing all the flaws and weaknesses of c-collars, but you're backed up by good science.

 

[rescue1]

In fact there is an article, I think, in the newest issue of JEMS that covers this topic and backs you up. The data just isn't there to back up c-collars and backboards. The article was emphasizing all the flaws and weaknesses of c-collars, but you're backed up by good science.

Its upsetting it only just made it into JEMS, the studies about the (lack of) effectiveness of spine boards and collars have been out for several years.

As to the question, no board or collar unless needed for intubation or extrication. My protocols actually specifically exclude penetrating head injury as a reason to immobilize. And assuming I had leeway, I wouldn't anyway, because spine boards and collars don't provide clinical benefit to anyone, penetrating trauma or no.

 

[Eleventy7]

Agree with the general sentiment. Boards for movement, collars for intubation. Even then, you'd be better off convincing your dept to replace the boards with BOTs. The only thing I'd recommend for your patient is a good ole fashion diesel bolus.

 

[COmedic17]

I would do it.

If I was running this same call in my "territory" I would have ample resources on scene and it would take no time to get done. If there's no exit wounds, I have zero idea where the bullet ended up. I wouldn't waste time back boarding the pt the way I would a pt who fell off a ladder, but I would still implement the backboard. If the patient codes, which is likely, the backboard is now my CPR board. The c-collar will help maintain the head when/ if the patient gets tubed. Also while log rolling the pt, I would check the posterior for any additional entry/exit wounds. If there's enough resources to get it done in a time efficient manner, I would def do it. It covers me for any "why isn't this pt back boarded" backlash, allows me to check the posterior, is a ready to go CPR board, and will keep the head from moving when the pt is incubated. If it was just me and a partner, and I knew it would take time that the patient didn't have, It wouldn't be at the top of my list. I wouldn't do it if it was going to waste time. I would need the resources there to consider it.

 

[Eleventy7]

Anyone coming at you aggressively with, "Why isn't this patient boarded?" needs to have a better understanding of "immobilization."