The Nurse’s Role in Safe and Effective Cervical Collar Use

Introduction

This article highlights key aspects of cervical collar application, maintenance, and removal for all nurses across the medical-surgical continuum. In addition to those working in a trauma unit or facility, this information may prove important if a patient has a fall, a cervical collar is applied, and further evaluation is being completed.

Why are cervical collars placed?

Cervical collars are placed on any trauma patient where the mechanism of injury increases the index of suspicion of a spinal cord injury, such as in the event of a motor vehicle rollover crash in which the lone passenger of the car (driver) is found on the passenger side.

In addition to addressing the mechanism of injury, cervical or “C-collars” are especially crucial for those patients who are experiencing new-onset neuromuscular abnormalities, including, but not limited to, paresthesia, paralysis, or mobility outside of their baseline.

When needed, the C-collar will help to maintain neutral alignment of the cervical spine to prevent secondary injury. They also help to serve as a visual awareness of potential or actual injury and to take precautions when moving or rotating the patient until radiographic imaging can be obtained and reviewed and actual injury complex can be determined.

What is the proper placement of a cervical collar?

There are numerous manufacturers of C-collars. Use will be dependent on what your facility has purchased, and more specific details can be found on their packaging. However, the two main classes of C-collars are rigid, or hard, collars and soft collars.

A rigid, or hard, collar comes in two pieces. The front piece should sit comfortably under the patient's jawline, and the back piece should rest flush with the back of the neck. The Velcro straps on the back piece should attach firmly to the front of the collar with a secure fit, but not too tight so that the patient feels as if they are being choked. These collars come in several sizes to accommodate pediatric, adult, and obese patients, and it is important that the fit is appropriate to limit how much range of motion the patient’s head and neck can go to protect their spine.

A soft collar comes in one piece, is often utilized more for comfort, and limits the side-to-side movement of the head. These collars also come in several sizes, and the nurse should ensure the Velcro straps connect but that the collar is not too tight to restrict cerebral blood flow or the patient's ability to breathe and swallow.

How long does the patient need to wear a cervical collar?

This is dependent on how hospital policies and procedures determine the decision-making capacity. It is important if you have a patient with a cervical collar that you (the nurse), the patient, and their support system understand the reason it was placed, the injury complex, and potential criteria for removal when advocating for your patient.

Case 1: The trauma team reviewed the cervical spine CT imaging, and there was no injury. If the patient is awake and can communicate, the front of the collar is removed, and the patient will be asked to turn their head side to side and up and down. If there is no pain, the collar is removed. If there is pain, the collar will be replaced, and the patient will need an MRI to rule out a ligamentous injury. This type of injury is particularly concerning if positive, as it can increase the risk for vertebral column instability, vertebrae dislocation, and subsequent spinal cord injury.

Case 2: The neurosurgical team reviewed the cervical spine CT imaging, and there was no injury. The patient is not tolerating their collar and keeps taking it off despite education to keep it on. The neurosurgical team can radiographically (by imaging only) remove the collar without assessing the patient, and it is discontinued.

Case 3: The orthopedic surgery team is responsible for managing spine cases at your hospital. The patient had a cervical collar in place in the ICU with an unstable spine injury but has since had their operation for fixation and is stabilized. Post-operatively, the collar will either stay on or be removed pending post-operative imaging and decision by the orthopedic surgery team.

What precautions do I need to take if I have a patient wearing a cervical collar?

In addition to understanding the injury complex of your patient, you must also ensure that the primary team responsible for managing the patient’s potential or actual spine injury place orders in the computer that help you best care for your patient and prevent worsening of the primary injury or the development of a secondary injury.

• Activity Orders
  • Does the patient need to always wear the collar or only when out of bed? If they wear it out of bed, is it always required or only if the patient needs it for comfort?
  • Are they able to get out of bed to a chair? Ambulate the hallway?
  • Are there any additional restrictions on physical or occupational therapy interactions? This is important because your therapy teams need a clear order in the computer before working with your patient; it should be provider-driven, not a nurse verbal order entry.
• Routine maintenance
  • With a partner, patients should have their cervical collar pads changed daily. This will help reduce moisture buildup and provide a chance to clean the skin and evaluate (if any) wound healing or pressure injury formation.
  • At discharge, the patient should be sent home with clear instructions on how to care for their equipment, as well as a second collar. This not only provides extra supplies but also the opportunity for patients to swap their collar after they shower with one on.
• Warnings
  • In the acute phase, it is important to hold cervical-spine precautions and avoid premature collar removal until the patient has been assessed and imaging has been completed for formal injury complex diagnoses.
  • In the sub-acute phase, ensure the primary team specifies the patient's requirements for wearing the collar, especially post-operatively and in the discharge instructions.

What are the risk factors associated with hospital-acquired pressure injury from a cervical collar?

Hospital-acquired pressure injuries from cervical collars can result from the collar being too tight, leading to pressure-related skin breakdown. If the collar is too big or ill-fitting, injuries can come from shearing because the jaw and chin are not resting on the collar where it is designed to sit. Moisture-related injuries can come from the patient sweating, if they have a fever or are diaphoretic, or after washing. This is why the internal pads should be changed daily at a minimum to allow the skin to dry.

Conclusion

Overall, when encountering a patient who has a cervical collar in place, the three biggest pieces of information you as the nurse should be aware of are: a clear understanding of why it was applied, what spinal precautions are being maintained, and what service is your point of contact if any questions arise related to the device itself or there are changes in a patient’s physical exam that may be related to the actual or potential injury of the spinal cord.

References

• Committee on Trauma. ATLS Student Course Manual: Advanced Trauma Life Support. 10th ed. American College of Surgeons; 2018.
• McQuillan, K. A., & Makic, M. B. F. (Eds.). (2020). Trauma Nursing: From Resuscitation Through Rehabilitation (Fifth edition). Elsevier Health Sciences.
• Patient Education: Cervical Collars for Adults (The Basics) - UpToDate