# C-spine collar to help secure tube



## goidf (Nov 30, 2015)

I have heard of medics using a c-spine collar to secure he intubation tube. I am talking about medical cases with no trauma, he collar is only being used to secure the tube. does anyone actually do this? does anyone have any reference material for this?


----------



## epipusher (Nov 30, 2015)

Yes I favor this as tool when moving a patient from a cumbersome location.


----------



## NomadicMedic (Nov 30, 2015)

It's part of our intubation protocol. Once the patient has been intubated, a c-collar is placed to minimized neck flexion which may dislodge the tube. Don't know how legit it is, but every little bit helps, right?


----------



## goidf (Nov 30, 2015)

can you send me a copy/link of that protocol?
I'm looking for references in writing....


----------



## TXmed (Nov 30, 2015)

I try and do this on all my Intubation and even when I place a supraglottic device. It just helps keep thing inline and reduce any movement that could compromise the airway.

At my previous service in north texas, our protocol was that "IF POSSIBLE" patients who are intubated should be placed on a backboard (for ease of movement) have a c-collar placed and be secured with CID or head bead. Nobody ever did the CID.

Sorry I don't have any reference documents to send you.


----------



## bizzy522 (Nov 30, 2015)

What they said^


----------



## NomadicMedic (Nov 30, 2015)

You can print what I wrote. That's what it says.


----------



## Tigger (Nov 30, 2015)

We do the same, it's the standard here. Not sure if it's a made up standard however.


----------



## ERDoc (Nov 30, 2015)

It probably does more to secure the tube than it does to secure the c spine.


----------



## Aprz (Dec 1, 2015)

Heh, I can see why you are asking for text. I am having a hard time finding text on this too.

I think prior to starting my internship in Santa Clara County, CA, there was an EMS update class for 2014 where the medical director Eric Rudnick had several power point presentations on airway management, pediatric trauma, and strokes. He made an audio recording to go with each slide and it was available online to anyone that worked for the contracted 911 provider. I think that's when I was introduced to the idea of putting on a c-collar on the patient after they are intubated to prevent extubation (and he mentioned bronchial intubation if the patient's head is flexed). I briefly tried going through the power point, but couldn't find it in text or him flat out saying it in the audio. Perhaps it's because I wasn't willing to watch the whole thing for an hour and a half again, lol.

I tried looking through Santa Clara County's protocols for it, but couldn't find anything that flat out says it. I couldn't find it in the current protocol, but in the old version of it. In the (older) protocol, it only mentions it for pediatric intubation on page 4 and 5.



> *Equipment*
> See adult equipment above.
> • Backboard, cervical collar or other immobilization device to limit neck extension
> 
> ...


Advanced Airway Management - Adult/Pediatrics (M01) prior to revision of protocol.

I tried looking online for more on it.

I found an article on EMS World that mentions it.



> *10. Secure the tube*
> Once tube placement is confirmed it must be secured with a commercial device or tape. Never rush this step and pay close attention to details. If vomit or blood is near the patient’s mouth, wipe it off before the tube is secured. A cervical collar can help keep the tube in place by limiting head movement during patient movement.


EMS Airway Management

Found one study from NCBI here.

That's about as much effort as I am gonna put into research this tonight.

Maybe you could try e-mailing Eric Rudnick if you can find his e-mail on the Santa Clara County EMS website?


----------



## MrJones (Dec 1, 2015)

Don't know about all that, but I do know that forming the C-Collar, setting it on the floor/bed/whatever (oriented with the opening top and bottom) and then placing the back of the patient's head on it puts the head in a virtually perfect sniffing position for intubating. 

Don't believe me? Try it the next time you're practicing on a mannequin.


----------



## triemal04 (Dec 1, 2015)

In all honesty, if you actually *have *to use a c-collar to help secure an ET tube, there are some other problems that need to be addressed.  Not that it's a bad idea at all, just that it really shouldn't be needed.

Either your securing of the ET tube is piss poor, you (and the people that you are responsible for) are being way to rough in moving patients, or the trucks you ride in have shocks that are non-existent.  

Can't really do anything about the last one, and sometimes there are circumstances where moving an intubated patient is not the smoothest evolution (but there are other ways to overcome that), but the first one is definitely on the individual provider.  

I suppose I'm just a fan of actually learning how to do things correctly, instead of using gimmicks to make up for poor performance.


----------



## Carlos Danger (Dec 2, 2015)

For a few years now, the trends in emergency airway management have been towards taking all sorts of precautions in order to maximize the chances of success and minimize the risk  of harm to the patient during intubation. If we aren't going to refer to VL, bougies, and pre-intubation checklists as "gimmicks" meant to "make up for poor performance", then I'm not sure why we'd view precautions intended to help prevent potentially catastrophic post-intubation complications that way.

Securing the ET tube properly does nothing to prevent tube migration due to head flexion or extension......in fact, it increases the chance of it, especially in pediatrics, because it ensures that the distal tip of the ETT will move every time the head moves. Only restriction of head and neck motion does so. I don't know that using a c-collar has ever been proven to reduce the risk of inadvertent extubation, but it makes good sense to me.

In medicine we take all sorts of precautions that wouldn't be necessary if everyone were perfect all the time. But even if _you_ are perfect, other people and events beyond your control will still be a factor.


----------



## triemal04 (Dec 2, 2015)

Remi said:


> For a few years now, the trends in emergency airway management have been towards taking all sorts of precautions in order to maximize the chances of success and minimize the risk  of harm to the patient during intubation. If we aren't going to refer to VL, bougies, and pre-intubation checklists as "gimmicks" meant to "make up for poor performance", then I'm not sure why we'd view precautions intended to help prevent potentially catastrophic post-intubation complications that way.
> 
> Securing the ET tube properly does nothing to prevent tube migration due to head flexion or extension......in fact, it increases the chance of it, especially in pediatrics, because it ensures that the distal tip of the ETT will move every time the head moves. Only restriction of head and neck motion does so. I don't know that using a c-collar has ever been proven to reduce the risk of inadvertent extubation, but it makes good sense to me.
> 
> In medicine we take all sorts of precautions that wouldn't be necessary if everyone were perfect all the time. But even if _you_ are perfect, other people and events beyond your control will still be a factor.


There is a big difference between using VL, a bougie, or similar device for difficult and anticipated difficult airways and using them on *each and every* airway because the provider isn't skilled.  I suppose I should be clear and mention that there is a difference between using something and simply having it at hand in case it's needed. There is also a difference in using VL for every airway because the provider believes it is the superior method, versus because the provider isn't skilled at DL.  The same holds true for a checklist; using it to make sure that everyone is aware of what is going on to increase safety and team dynamics is different than using one because the provider isn't skilled at the same (this isn't meant to take away from using a checklist at all for any reason; for inexperienced and experienced providers it is a very handy thing to do).

If motion and movement of the patient is such that a c-collar *needs* to be placed every time then yes, unless there are some extenuating circumstances, it is being used as a crutch, because the provider isn't properly doing their job.  It's not that it is a bad idea, it's just that (barring those extenuating circumstances) it shouldn't be really needed.


----------



## Underoath87 (Dec 3, 2015)

Even if it were a "crutch", I don't see how one can argue that placing a c-collar on intubated patients isn't a good idea.  A tube coming dislodged has little to do with the medic's skills at placing a tube, nor managing that patient, since a bunch of other people will be handling and bagging the patient as well.

There isn't even a potential downside to doing it, since the collar is not potentially harmful to the patient and it only takes maybe 10 seconds to apply.

It isn't in our protocols, but it was in my ITLS textbook.


----------



## jwk (Dec 3, 2015)

triemal04 said:


> In all honesty, if you actually *have *to use a c-collar to help secure an ET tube, there are some other problems that need to be addressed.  Not that it's a bad idea at all, just that it really shouldn't be needed.
> 
> Either your securing of the ET tube is piss poor, you (and the people that you are responsible for) are being way to rough in moving patients, or the trucks you ride in have shocks that are non-existent.
> 
> ...


Thank you for some common sense.

We never put C-collars on as a way of securing ETTs anywhere in the hospital.  Tape it/secure it so it doesn't come out - period.  Our respiratory folks take off the tape we put on in the OR and put on a fancy adhesive thing with a tube clamp and a tie that goes all the way around the neck.  It works great.  We move intubated patients all over the place - bed to OR table, bed to CT, turned prone on the OR table, turning them on their side in the ICU q2hr, etc.  C-collars don't prevent anyone from somehow yanking on the tube, which is 99.9% of the reason tubes come out accidentally.

Using a C-collar sounds like a good idea, and it probably doesn't hurt anything, so it's hard to argue against it.  I just don't think it helps anything.  Better to learn how to tape a tube in properly so it doesn't come out.


----------



## Doczilla (Dec 3, 2015)

Lung sounds should be reconfirmed before and after each transition regardless. Now that everyone has ETCO2, there's even less room for an accidental extubation to go unnoticed. A few years back PHTLS said that somewhere around 30% of prehospital intubations were iatrogenically extubated at some point. 

I don't know however, how many of those tubes were "properly taped" and whatnot, so I can't intelligently debate if thats a factor or not. But I do think that a tube buys a c collar. It takes 5 seconds and some forethought. The risk/benefit ratio is too far apart to not do it.


----------



## Carlos Danger (Dec 3, 2015)

jwk said:


> Better to learn how to tape a tube in properly so it doesn't come out.



I think you guys are really missing the point.

Of course everyone should know how to properly tape a tube and transfer a patient. That's a given. No one is saying "hey bro - if you are having trouble with your tubes getting pulled, just start using a c-collar and your accidental extubations will go way down".

The c-collar is just a small extra measure of precaution - not unlike putting an extra piece of tape on the IV before you leave the ICU for the helicopter, or having that extra syringe of propofol already drawn up.


----------



## epipusher (Dec 3, 2015)

Obviously people who drive vehicles use a seatbelt due to the fact they are a poor driver and lack the proper skills needed to safely drive somewhere. A seatbelt serves as a crutch when safe driving skills are lacking.


----------



## Tigger (Dec 3, 2015)

I do not see much comparison to the hospital here. Patients get moved a lot in surgery, by a trained group of people who are used to moving intubated patients. The volunteer firefighters that are not even first responders? Not so much. I'm not sure how it was ever construed as a crutch, it's just a way to help. 

Also the bougie comment caught my eye. In school we were taught to use the bougie 100% time if that's what we found that worked. ABout half of our ED physicians started using it on most cases this year after attending some sort of magical training. But it's a crutch right, because not everyone learned something that way?


----------



## MS Medic (Dec 3, 2015)

A C-Collar and a bougie are like using capnography to confirm tube placement. They're all tools to help us perform better. I don't know why anyone would say any of these are crutches.


----------



## medicasaurus (Dec 3, 2015)

Problem is that C-Collars also have unwanted effects such as decreasing cerebral venous return and increasing intracranial pressures. 

http://www.ncbi.nlm.nih.gov/pubmed/12121154
emj.bmj.com/content/18/5/380.full


----------



## MS Medic (Dec 4, 2015)

I'm on shift right now so I'll read the study later when I get the chance but a concern over decreased venous return becomes irrelevant when a well intentioned But untrained FF dislodges the tube by rough handling. A good compromise that I will look into might be to pop the collar loose after the pt is loaded into the truck.


----------



## triemal04 (Dec 4, 2015)

Tigger said:


> I do not see much comparison to the hospital here. Patients get moved a lot in surgery, by a trained group of people who are used to moving intubated patients. The volunteer firefighters that are not even first responders? Not so much. I'm not sure how it was ever construed as a crutch, it's just a way to help.
> 
> Also the bougie comment caught my eye. In school we were taught to use the bougie 100% time if that's what we found that worked. ABout half of our ED physicians started using it on most cases this year after attending some sort of magical training. But it's a crutch right, because not everyone learned something that way?


Even with untrained people it doesn't take much to minimize the possibility of tube displacement.  If the providers are doing thier job correctly this can easily be accomplished.  I have no doubt though that often, due to lack of training, lack of familiarity with the process and situation, and excess adrenaline (aka panic) due to the above factors this is not possible.  So, in that situation, while it may be needed, its because of a failure on the part of the provider, not because of real neccesity.

The bougie is a seperate topic, but the same idea.  Like a c-collar, there cerainly are times when it is needed.  BUT if a bougie is *used *each time instead of just being *available *each time, either the provider is a true phenomonam who only gets truly bad airways, *or *they are not competant at intubation *or *don't understand what they are doing.

There is nothing wrong with using a backup airway device or alternate means of securing a tube *when the situation dictates it's use. *But that does not happen each time; if it is the cause likely lies with the provider.



MS Medic said:


> A C-Collar and a bougie are like using capnography to confirm tube placement. They're all tools to help us perform better. I don't know why anyone would say any of these are crutches.


See above.  ETCO2 is very different from what is being discussed.


----------



## TXmed (Dec 4, 2015)

So if I use a bougie every time, and am successful every time I use a bougie , I am not competant at performing Intubation?


----------



## triemal04 (Dec 4, 2015)

TXmed said:


> So if I use a bougie every time, and am successful every time I use a bougie , I am not competant at performing Intubation?


If you *use *it each time I think you don't completey understand what you are doing and aren't as good as you think you are.

Think of it like this:  if I am a whiz at putting together a table and chair from Ikea that comes premade, with instructions and all needed tools, does that mean I am competant at building a table and chair from scratch?


----------



## Underoath87 (Dec 4, 2015)

triemal04 said:


> If you *use *it each time I think you don't completey understand what you are doing and aren't as good as you think you are.
> 
> Think of it like this:  if I am a whiz at putting together a table and chair from Ikea that comes premade, with instructions and all needed tools, does that mean I am competant at building a table and chair from scratch?



It means that you won't have to build a table from scratch, since you can always assemble one from Ikea...

It's not like we're using C-collars because we're not sure how deep the tube should be inserted.  It's that things out of our direct control may cause the patient's head to move around, which could potentially cause dislodgement.

If you want a better analogy, it's like putting thread lock on a bolt when assembling some part of a car (or better yet, motorcycle, since mechanical failure would be more catastrophic).  Is it absolutely necessary?  No.  But it is an extra safety measure in case **** happens and in no way reflects poorly on our abilities.


----------



## triemal04 (Dec 4, 2015)

Underoath87 said:


> It means that you won't have to build a table from scratch, since you can always assemble one from Ikea...
> 
> It's not like we're using C-collars because we're not sure how deep the tube should be inserted.  It's that things out of our direct control may cause the patient's head to move around, which could potentially cause dislodgement.
> 
> If you want a better analogy, it's like putting thread lock on a bolt when assembling some part of a car (or better yet, motorcycle, since mechanical failure would be more catastrophic).  Is it absolutely necessary?  No.  But it is an extra safety measure in case **** happens and in no way reflects poorly on our abilities.


Really?  What happens when you lose the instructions or tools?  Just give up and build a sofa instead?  The problem with using a backup device each time, especially one as effective as a bougie, is it ups the odds of complacency tremendously, and allows people who arent really skilled and knowledgeable about something to do it.  Instead of really having to be good at intubation, always having to properly position the patient, knowing to use laryngeal manipulation, occipital adjustments, or many other simple manuevers that will easily improve your view, a bougie is used from the get go...but what happens when the bougie doesn't work?  Now all those simple and effective airway moves are not practised, likely not thought of, the patient was quite possibly in a crap position to start, the provider may never have been good at intubation and now they have no recourse except to use a SGA or BVM.

You can insert c-collar for bougie if you want.

Don't get me wrong, both devices have a role, it's just that they shouln't be needed each time.


----------



## epipusher (Dec 4, 2015)

Hes the worlds best prehospital provider or a troll, not sure which one yet. Really enjoying your responses regardless!


----------



## TXmed (Dec 4, 2015)

I'm pretty comfortable with my Intubation success rate. So I guess I will continue being an incompetent paramedic that uses the bougie for every tube, and uses etco2  and then puts on a c-collar. Just being incompetent


----------



## triemal04 (Dec 4, 2015)

TXmed said:


> I'm pretty comfortable with my Intubation success rate. So I guess I will continue being an incompetent paramedic that uses the bougie for every tube, and uses etco2  and then puts on a c-collar. Just being incompetent


That isn't quite what I said, but it's ok, you can take this personally if you want to.


----------



## triemal04 (Dec 4, 2015)

epipusher said:


> Hes the worlds best prehospital provider or a troll, not sure which one yet. Really enjoying your responses regardless!


I'm sorry, but can you explain what part is trolling?  I always thought that was something different than having a dissenting opinion, but I could be wrong.


----------



## MS Medic (Dec 4, 2015)

Since everything that needs to be said on the topic has been, can we lock the thread and stop the impending flame war please?


----------



## MS Medic (Dec 4, 2015)

MS Medic said:


> Since everything that needs to be said on the topic has been, can we lock the thread and stop the impending flame war please?


And paraphrasing the epic works of Forest Gump, that's all I have to say about that.


----------



## chaz90 (Dec 4, 2015)

There's no need to lock a thread as long as discussion is continuing and everyone remains civil. So far, this thread is still avoiding personal attacks for the most part. 

Keep the discussion focused on the pros and cons of cervical collars to maintain proper placement of ET tubes and we can keep the thread open for now. There's valuable information here.


----------



## jwk (Dec 9, 2015)

Remi said:


> I think you guys are really missing the point.
> 
> Of course everyone should know how to properly tape a tube and transfer a patient. That's a given. No one is saying "hey bro - if you are having trouble with your tubes getting pulled, just start using a c-collar and your accidental extubations will go way down".
> 
> The c-collar is just a small extra measure of precaution - not unlike putting an extra piece of tape on the IV before you leave the ICU for the helicopter, or having that extra syringe of propofol already drawn up.


I see the point - I just don't agree with it much.     Like I said before - it doesn't hurt anything.  Does it help much?  I doubt it - it's certainly not some magic cure-all or it would be used everywhere all the time.


----------



## Underoath87 (Dec 9, 2015)

jwk said:


> I see the point - I just don't agree with it much.     Like I said before - it doesn't hurt anything.  Does it help much?  I doubt it - *it's certainly not some magic cure-all or it would be used everywhere all the time*.




If that logic held true, backboards and epinephrine would be the most effective field treatments ever.


----------



## CANMAN (Dec 11, 2015)

If it makes you feel warm and cozy then go ahead and apply a c-collar. I will never knock a provider for it, however to date I believe I have transported close to 1,000 intubated patient's that were either IFT on a vent, or a scene run and bagging at some point during the transfer, and have yet to have an ETT migrate or be lost on a transport. Secure your tube in whatever fashion your program, protocols, training, etc states, confirm placement before you move patient, confirm placement with movement/transfers, monitor waveform end-tidal, Spo2, etc. It's really that easy. Is it going to hurt anything? Not at all. Is it needed or going to save an incident likely to cause an accidental extubation? My opinion is no. It's an extra step, and extra cost, but like I said if it makes you feel better go for it.


----------



## RocketMedic (Dec 16, 2015)

This incompetent paramedic uses a lot of VL and a bougie on every intubation and finds that they work pretty well to rectify his lack of daily real-world intubation experience.


----------



## onrope (Dec 17, 2015)

Not a bad idea, any good paramedic will reassess tube placement every time you move the patient. One of the many benefits of waveform capnography is how easy it is to glance at the monitor and be 99% sure your tube is still good. I am required to fully immobilize any intubated PT under 8 years old.


----------



## WestMetroMedic (Dec 18, 2015)

there is plenty of RECENT data that shows appreciable benefit to the utilization of a GEB in improving first attempt success rates as well as reductions in the time to intubate as well.

I have been busy on PubMed tonight trying to find a study that even addresses the use of a Cervical collar in non-trauma patients to prevent inadvertent extubation during patient movement. There isn't anything as far as i can find (which is what brought me here). I think the consensus of this entire deal is that there is no research associated with this action, and perhaps someone should look into this... Maybe we are actually hurting people, or maybe we are saving people. We don't know, but it would be nice to have some science associated with this trend.

Then we can cite the sauce...


----------



## highglyder (Jan 2, 2016)

We use twill tape (https://en.wikipedia.org/wiki/Twill_tape) and have never had an issue.  Use of c-collars here is rare as is the use of a backboard.  If we need to extricate we'll use the scoop and then remove it.

Considering that some research shows that c-collars increase ICP due to impeding venous return, I would be very judicious with its use.


----------

