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Solving the Problem of Pressure Ulcers Resulting from Cervical Collars: A Step-By-Step Approach

Blaylock, B
ET Nursing Department, St. Vincent Medical Center, Toledo, Ohio
Published in Ostomy Wound Management, 1996 May, Vol. 42 (4), 26-33.

Abstract

Cervical Orthotic devices (cervical collars) are integral to the treatment of patients with suspected or confirmed fracture of the cervical spine. Pressure ulcers can develop under the cervical collar on the occipital protuberance and on the chin due to both prolonged immobilization and the collar construction. A multidisciplinary team at a Northwest Ohio trauma center led an investigation of this problem when a one-day study of pressure ulcer prevalence revealed that 4% of nosocomial pressure ulcers, 2% were attributed to cervical collars.

Selected Quotations

“… in 1993 an average of 6 cases per quarter were seen.”

(Pg. 27)

“At this trauma center, we had been using a closed cell foam collar for many years.”

(Pg. 28)

“We discovered that another hard cervical collar had been brought into the institution in March 1993, just prior to the development of some of the most severe occipital ulcers.”

(Pg. 28)

“After the educational programs were conducted, … We again concluded/hypothesized that the main contributing factor in the development of pressure ulcers was the type of collar itself, and not the care provided for the patient.”

(Pg. 29)

“The product trial resulted in zero skin breakdown for the 20 patients involved.”

(Pg. 26)

“Repeated CQI studies have demonstrated that the problem of pressure ulcers resulting from cervical collars has been eliminated at this institution.”

(Pg. 32)

A Multidisciplinary Approach to Occipital  Pressure Ulcers Related to Cervical Collars

Powers, J
Wishard Memorial Hospital, Indianapolis, Indiana
Published in Journal of Nursing Care Quality, 1997 Oct., Vol. 12, No. 1.

Abstract

Pressure ulcers related to cervical collars are a common difficult-to-manage complication of cervical immobilization in the trauma patient. After many cases of occipital pressure ulcers occurred at our institution, a multidisciplinary task force was formed to look at this issue. The group was to identify causes for this problem and develop a plan to decrease the occurrence of pressure ulcers related to cervical immobilization. The problem involved three areas that needed improvement. These were: nursing care, the type of collar used, and the lengthy process of clearing C-spines.

Selected Quotations

“Occipital pressure ulcers are largely preventable and in the early stages are readily responsive to the appropriate therapies.”

(Pg. 47)

“At our institution we noticed an increase in occipital breakdown related to the presence of cervical collars. We observed 19 documented cases of skin breakdown in a one-year period.”

(Pg. 285)

“We began official implementation of the collars [sic. Aspen], in January of 1996. After one year and 76 patients in collars we had only one case of skin breakdown and this was attributed to the patient not being placed in the appropriate sized collar.”

(Pg. 50)

“The cost of treating just one occipital breakdown was calculated to be $4,323.00.”

(Pg. 50)

“The cost of treating just one occipital breakdown was calculated to be $4,323.00.”

(Pgs. 50-52)

The Incidence of Skin Breakdown Associated with Use of Cervical Collars

Powers, J; Daniels, D; McGuire, C; Hilbish, C
Clarian Health Partners, Methodist Hospital, Indianapolis, Indiana
Published in J Trauma Nursing. 2006, Vol. 13, No. 4, 198 – 200

Abstract

The most common adverse complication associated with cervical immobilization is skin breakdown. The purpose of this prospective, descriptive study was to assess the incidence of tissue breakdown associated with cervical immobilization. In this convenience sample of 484 patients, skin breakdown was noted in 33 (6.8%) patients. All cases of documented skin breakdown were stage I or II, with only 2% (0.4%) patients having stage III breakdown. Days in cervical collar is a significant predictor of skin breakdown, along with presence of edema. Results from this study demonstrate that there is a very low incidence of complications of skin breakdown associated with the use of Aspen cervical collars. The collars are safe and effective to use in patients with actual or suspected head or spine injuries.

Selected Quotations

“It has been reported that up to 55% of patients in a cervical collar for 5 days or greater develop skin breakdown …”

(Pg. 198)

“Previous studies have reported increased hospital costs ranging from $4,323 to $30,000.”

(Pg. 198)

“Powers (1997) reported a decreased incidence of skin breakdown from 19 ulcers to 0 with improved process of care and a change to Aspen cervical collars …”

(Pg. 198)

“There is a very low incidence of complications of skin breakdown associated with the use of Aspen cervical collars. These collars are safe and effective to use in patients with actual or suspected head or spine injuries.”

(Pg. 200)

Absorption and Transfer Characteristics of Cervical Collar Padding

Technical Report

OVERVIEW: Patients with moist skin are four times more likely to suffer skin breakdown than those who are kep dry.¹ Cervical collars with replaceable padding, such as the Aspen^® and Miami J^®, utilize open cell foam for comfort, and to control perspiration or other fluids at the skin surface. The padding in these two collars differs in the type of foam used² and lining material adhered to the foam. Since the lining material comes into direct contact with the skin, fluid absorption and transfer characteristics of the pads may significantly impact patient care.

This report evaluates the effectiveness of both Aspen^® and Miami J^® pads in keeping moisture away from a patient's skin. The results indicate that Aspe^® Collar Pads absorb more readily, and move fluid away from the skin contact surface much more effectively.

MATERIALS & METHODS: The pads tested were obtained from currently available Aspen^® and Miami J^® Collars. Two small pools of fluid (~.23 cc) were placed on a glass surface. The cotton side of the Aspen^® pad, and the smooth nylon side (referred to by the manufacturer as "Sorbatex^™"³) of the Miami J^® pad were placed flat, without pressure, over the fluid.

After eight seconds the pads were lifted off of the surface, and turned over so the wetted "skin contact" surface faced up. The fluid remaining on the surface was then observed.

A sheet of tissue paper was placed over both pads for 30 seconds.

Moisture on the skin contact surface was absorbed by the tissue and the wetted area was measured. The test was repeated three times and then averaged.

RESULTS: The Aspen^® pad appeared to be more effective in absorption. Significantly more fluid was observed on the glass surface under the Miami J^® pad. The area of the tissue that became wet when placed over the Aspen^® pad measured 24 (± .5) sq. mm., while the wetted are of the tissue placed over the Miami J^® pad measured 860 (±.5) sq. mm. When comparing the wetted ares, the Aspen^® pad transferred more fluid away from the surface. The Miami J^® pad produced a moist skin contact surface area that was 35 times larger than that produced by the Aspen^® pad.

DISCUSSION: Differences in materials used in cervical collar padding may result in significant differences in the ability of the pads to keep patients dry. Synthetic materials have been shown to offer advantages in cooling (i.e-athletic apparel) by dispersing perspiration for increased evaporation when there is substantial airflow.⁴ When assessing evaporation in cervical collar padding, however, there is no significant airflow, so evaporative cooling is not an important factor. The results of this evaluation show that the Aspen^® pads readily absorb and move fluid away from the patient's skin surface. Miami J^® pads proved to be less effective in absorbing fluid and substantially worse in transferring moisture away from the skin contact surface.

CONCLUSIONS: Aspen^® Collar Pads, absorbed moisture and transferred it away from the contact surface more effectively than the synthetic-lined padding used in the Miami J^® Collar. By minimizing the moist contact area and by transfering fluid away from the skin contact surface, Aspen^® Collar Pads keep patients comfortable and may reduce the likelihood of collar related skin breakdown.

ACKNOWLEDGMENT: Experiments were performed and data was collected by Orange County Materials Test Laboratories, Anaheim, California.

REFERENCES
1. Kosiak M: Etiology of decubitus ulcers. Arch Phys Med Rehabil 42:19, 1961.

2. Albero, Marc J., Foamex International Inc., personal correspondence, Feb. 28, 2002.

3. Spingarm, Neil E., Report of Spectrographic Analysis, SN Labs, Santa Ana, CA. Mar. 28, 2002.

4. Dupont Data website: www.dupont.com/coolmax/html/diagrams.html

Evaluation of the Cushioning Characteristics of Padding in Cervical Orthoses

Technical Report

OVERVIEW: Clinicians agree that sustained pressure greater than 32 mmHg can cause irreversible skin damage in as little as two hours.¹ Manufacturers of cervical orthoses must consider these parameters in their selection of padding materials, since the effectiveness of the padding can influence pressure at the skin surface.

Research sugggests that when properly fitted, both the Miami J^® Cervical Collar and the Aspe^® Cervical Collar generate a maximum average pressure of less than 25 mmHg.² While this is below the capillary closing pressure of healthy tissue, not all patients have healthy tissue.

In this report, the cushioning characteristics of the padding material used in the Aspen^® Collar and the Miami J^® Collar are evaluated. The results demonstrate that at pressures of ~25 mmHg the foam used in the Aspe^® pads provides cushioning that is approximately twice as effective as the pads used in the Miami J^® Collar.

MATERIALS & METHODS: Replacement pads were obtained from currently available Aspen^® and Miami J^® Cervical Collars. Analysis showed that the Miami J^® pads are manufactured from a "non-clickable" foam with a density of 1.6 lbs. "Non-clickable" foam does not readily spring back after it is die cut, so the edges appear to be sealed. Aspen^® pads are manufactured from 1.6 lbs foam tha is "clickable." Clickable foam is desigend to have superior resilency so that edges do spring back and do not stay compressed after it is die cut.³

The thickness of each pad was measured. A 1 Kg weight, fitted with a base plate designed to yield a pressure of ~25 mmHg was pressed into both pads and allowed to rebound. After 60 seconds, with the weight in place, the thickness of each pad was again measured.

RESULTS: The Miami J^® pad averaged an initial, uncompressed thickness of .4015 inches and showed an average compressed thickness of .1860 inches after 60 seconds. The Aspen^® pad had an average, uncompressed thickness of .4280 inches and rebounded to an average compressed thickness of .3180 after 60 seconds.

DISCUSSION: While the Aspen^® padding rebounded to 75% of its original cushioning height, the Miami J^® padding rebounded to less than half (46%) of its original height. These differences in performance may explain why using Aspen^® Cervical Collars, in conjunction with comprehensive protocols, can significantly reduce the incidence of skin breakdown commonly seen when other cervical collars are used.^4,5

CONCLUSIONS: The results of this evaluation demonstrate that there are clear differences in the cushioning ability of the pads used in the Miami J^® and Aspen^® Collars. The clickable foam used in Aspen^® Cervical Collars offers superior cushioning to the non-clickable foam used in Miami J^® Collars. The padding material used in Miami J^® Collars lost significantly below capillary closing pressure.

ACKNOWLEDGMENT: This report data was generated by Orange County Materials Test Laboratories, Anaheim, California.

REFERENCES
1. Kosiak M: Etiology of decubitus ulcers. Archives of Physical Medicine and Rehabilitation 42:19, 1961.

2. Plaisier, B., Gabram, S.G., Schwartz, R.J., and Jacobs, I.M. "Prospective Evaluation of Craniofacial Pressure in Four Different Cervical Orthoses."
Journal of Trauma 37 (1994):714-720.

3. Foamex Report

4. Powers, Jan. "A Multidisciplinary Approach to Occipital Pressure Ulcers Related to Cervical Collars." Journal of Nursing Care Quality 1997;12(1), 46-52.

5. Blaylock, Barbara. "Solving the Problem of Pressure Ulcers Resulting from Cervical Collar: A Step-by-Step Approach" Ostomy Wound Management.
May 1996;42(4):26-33.

Assessing Range of Motion to Evaluate the Adverse Effects of Ill-Fitting Cervical Orthoses

Bell, K; Frazier, E; Shively, C; Hartman, R; Ulibarri, J; Lee, J; Kang, J; Donaldson III, W 
Ferguson Laboratory for Spine Research, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Published in The Spine Journal, 9 (2009), 225-231

Abstract

BACKGROUND CONTEXT: Although previous studies have primarily focused on testing the effectiveness of cervical orthoses under properly fit conditions, this study focuses on analyzing the effects of an ill-fitted cervical orthoses (Miami J). This may have significance to health-care providers in understanding the effects of an improperly fitted neck brace.

PURPOSE: The aims of this study were threefold: first, to apply virtual reality (VR) feedback control to repeatedly measure orthoses effectiveness in the primary motions; second, to use this control methodology to test the orthoses ability to restrict fexion/extension (FE) as a function fo axial rotation (AR); third, to test the effects of an ill-fitting Miami J on cervical motion.

Selected Quotations

Introduction
“…because of limited availability, emergency application, and financial constraints, it is not uncommon that a patient is fitted with a cervical orthoses that is not optimal for his or her size and body type...Additionally, ill-fitting braces may be used in rural or other low-volume healthcare facilities where it is unreasonable to have all possible brace sizes available.”

(Pg. 226)

Discussion
“…after a cervical injury, a patient wearing a collar that is either too big or too small could experience added cervical impairment because of the lack of restriction and under-restrained motion of the neck...Patient care could be compromised as a result of the increased motion permitted by improper fitting of cervical orthoses. Other researchers investigating clinical implications of ill-fitting orthoses have shown that dermal contact with an ill-fitted cervical brace can cause skin lesions and affect CRoM and patient satisfaction [17,18]. The results show that the ill-fitting Miami J does not restrict motion as completely as the correctly sized Miami J, potentiallly adding to the 3% to 25% of spinal cord injuries that occur after the initial injury.”

(Pg. 230)