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Published Online: 10 March 2014

Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review

Publication: Journal of Neurotrauma
Volume 31, Issue Number 6


The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

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American College of Surgeons Committee on Trauma (2012). Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed. American College of Surgeons: Chicago, IL.
Prehospital Trauma Life Support Committee of The National Association of Emergency Medical Technicians in Cooperation with The Committee on Trauma of The American College of Suregons (2010). Prehospital Trauma Life Support (PHTLS), 7th ed. Jones & Bartlett Learning: Burlington, MA.
Bohlman H.H. (1979). Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J. Bone Joint Surg. Am. 61, 1119–1142.
Gunby I. (1981). New focus on spinal cord injury. JAMA 245, 1201–1206.
Rogers W.A. (1957). Fractures and dislocations of the cervical spine; an end-result study. J. Bone Joint Surg. Am. 39-A, 341–376.
De Lorenzo R.A. (1996). A review of spinal immobilization techniques. J. Emerg. Med. 14, 603–613.
Dick T., and Land R. (1982). Spinal immobilization devices. Part 1: cervical extrication collars. J. Emerg. Med. Serv. 7, 26–32.
Frohna W.J. (1999). Emergency department evaluation and treatment of the neck and cervical spine injuries. Emerg. Med. Clin. North Am. 17, 739–791, v.
Kwan I., Bunn F., and Roberts I.; WHO Pre-Hospital Trauma Care Steering Committee. (2001). Spinal immobilisation for trauma patients. Cochrane Database Syst. Rev. Issue 2. Art. No.: CD002803.
Abram S., and Bulstrode C. (2010). Routine spinal immobilization in trauma patients: what are the advantages and disadvantages? Surgeon 8, 218–222.
Benger J., and Blackham J. (2009). Why do we put cervical collars on conscious trauma patients? Scand. J. Trauma Resusc. Emerg. Med. 17, 44.
Deasy C., and Cameron P. (2011). Routine application of cervical collars—what is the evidence? Injury 42, 841–842.
Hauswald M., and Braude D. (2002). Spinal immobilization in trauma patients: is it really necessary? Curr. Opin. Crit. Care 8, 566–570.
Sporer K.A. (2012). Why we need to rethink C-spine immobilization: we need to reevaluate current practices and develop a saner cervical policy. EMS World 41, 74–76.
Snooks H., Evans A., Wells B., Peconi J., Thomas M., Woollard M., Guly H., Jenkinson E., Turner J., andHartley-Sharpe C.; 999 EMS Research Forum Board. (2009). What are the highest priorities for research in emergency prehospital care? Emerg. Med. J. 26, 549–550.
Chiu W.C., Haan J.M., Cushing B.M., Kramer M.E., and Scalea T.M. (2001). Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome. J. Trauma 50, 457–463.
Davis J.W., Phreaner D.L., Hoyt D.B., and Mackersie R.C. (1993). The etiology of missed cervical spine injuries. J. Trauma 34, 342–346.
Demetriades D., Charalambides K., Chahwan S., Hanpeter D., Alo K., Velmahos G., Murray J., and Asensio J. (2000). Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. J. Trauma 48, 724–727.
Goldberg W., Mueller C., Panacek E., Tigges S., Hoffman J.R., and Mower W.R.; NEXUS Group. (2001). Distribution and patterns of blunt traumatic cervical spine injury. Ann. Emerg. Med. 38, 17–21.
Grossman M.D., Reilly P.M., Gillett T., and Gillett D. (1999) National survey of the incidence of cervical spine injury and approach to cervical spine clearance in U.S. trauma centers. J. Trauma 47, 684–690.
Hasler R.M., Exadaktylos A.K., Bouamra O., Benneker L.M., Clancy M., Sieber R., Zimmermann H., and Lecky F. (2011). Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study. Eur. Spine J. 20, 2174–2180.
Hasler R.M., Exadaktylos A.K., Bouamra O., Benneker L.M., Clancy M., Sieber R., Zimmermann H., and Lecky F. (2012). Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study. J. Trauma Acute Care Surg. 72, 975–981.
Hoffman J.R., Mower W.R., Wolfson A.B., Todd K.H., and Zucker M.I. (2000). Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N. Engl. J. Med. 343, 94–99.
Milby A.H., Halpern C.H., Guo W., and Stein S.C. (2008). Prevalence of cervical spinal injury in trauma. Neurosurg. Focus 25, E10.
Stawicki S.P., Holmes J.H., Kallan M.J., and Nance M.L. (2009). Fatal child cervical spine injuries in motor vehicle collisions: analysis using unique linked national datasets. Injury 40, 864–867.
Stiell I.G., Wells G.A., Vandemheen K.L., Clement C.M., Lesiuk H., De Maio V.J., Laupacis A., Schull M., McKnight R.D., Verbeek R., Brison R., Cass D., Dreyer J., Eisenhauer M.A., Greenberg G.H., MacPhail I., Morrison L., Reardon M., and Worthington J. (2001). The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 286, 1841–1848.
Morris C.G., McCoy E.P., Lavery G.G., and McCoy E. (2004). Spinal immobilisation for unconscious patients with multiple injuries. BMJ 329, 495–499.
Fredø H.L., Rizvi S.A., Lied B., Rønning P., and Helseth E. (2012). The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway. Scand. J. Trauma Resusc. Emerg. Med. 20, 85.
The National Spinal Cord Injury Statistical Center. (2011). Complete public version of the 2011 annual statistical report for the spinal cord injury models systems. The National Spinal Cord Injury Statistical Center: Birmingham, AL.
Middleton J.W., Dayton A., Walsh J., Rutkowski S.B., Leong G., and Duong S. (2012). Life expectancy after spinal cord injury: a 50-year study. Spinal Cord 50, 803–811.
Oliver M., Inaba K., Tang A., Branco B.C., Barmparas G., Schnüriger B., Lustenberger T., and Demetriades D. (2012). The changing epidemiology of spinal trauma: a 13-year review from a Level I trauma centre. Injury 43, 1296–1300.
Strauss D.J., Devivo M.J., Paculdo D.R., and Shavelle R.M. (2006). Trends in life expectancy after spinal cord injury. Arch. Phys. Med. Rehabil. 87, 1079–1085.
van den Berg M.E., Castellote J.M., de Pedro-Cuesta, J., and Mahillo-Fernandez I. (2010). Survival after spinal cord injury: a systematic review. J. Neurotrauma 27, 1517–1528.
Chesnut R.M. (2004). Management of brain and spine injuries. Crit. Care Clin. 20, 25–55.
Gupta R., Bathen M.E., Smith J.S., Levi A.D., Bhatia N.N., and Steward O. (2010). Advances in the management of spinal cord injury. J. Am. Acad. Orthop. Surg. 18, 210–222.
Kelly D.F., and Becker D.P. (2001). Advances in management of neurosurgical trauma: USA and Canada. World J. Surg. 25, 1179–1185.
Lee B.B., Cripps R.A., Fitzharris M., and Wing P.C. (2013). The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal Cord Feb 26. [Epub ahead of print].
Georgoff P., Meghan S., Mirza K., and Stein S.C. (2010). Geographic variation in outcomes from severe traumatic brain injury. World Neurosurg. 74, 331–345.
Stein S.C., Georgoff P., Meghan S., Mizra K., and Sonnad S.S. (2010). 150 years of treating severe traumatic brain injury: a systematic review of progress in mortality. J. Neurotrauma 27, 1343–1353.
Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS). (2013). Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery 72, Suppl. 2, 1–259.
Ryken T.C., Hadley M.N., Aarabi B., Dhall S.S., Gelb D.E., Hurlbert R.J., Rozzelle C.J., Theodore N., and Walters B.C. (2013). Management of isolated fractures of the axis in adults. Neurosurgery 72, Suppl. 2, 132–150.
Theodore N., Hadley M.N., Aarabi B., Dhall S.S., Gelb D.E., Hurlbert R.J., Rozzelle C.J., Ryken T.C., and Walters B.C. (2013). Prehospital cervical spinal immobilization after trauma. Neurosurgery 72, Suppl. 2, 22–34.
Ahn H., Singh J., Nathens A., MacDonald R.D., Travers A., Tallon J., Fehlings M.G., and Yee A. (2011). Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines. J. Neurotrauma 28, 1341–1361.
Como J.J., Diaz J.J., Dunham C.M., Chiu W.C., Duane T.M., Capella J.M., Holevar M.R., Khwaja K.A., Mayglothling J.A., Shapiro M.B., and Winston E.S. (2009). Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J. Trauma 67, 651–659.
Stein D.M., Roddy V., Marx J., Smith W.S., and Weingart S.D. (2012). Emergency neurological life support: traumatic spine injury. Neurocrit. Care 17, Suppl. 1, S102–S111.
Lekovic G.P., and Harrington T.R. (2007). Litigation of missed cervical spine injuries in patients presenting with blunt traumatic injury. Neurosurgery 60, 516–522.
Bell K.M., Frazier E.C., Shively C.M., Hartman R.A., Ulibarri J.C., Lee J.Y., Kang J.D., and Donaldson W.F. (2009). Assessing range of motion to evaluate the adverse effects of ill-fitting cervical orthoses. Spine J. 9, 225–231.
Sundheim S.M, and Cruz M. (2006). The evidence for spinal immobilization: an estimate of the magnitude of the treatment benefit. Ann. Emerg. Med. 48, 217–218.
Brunette D.D., and Rockswold G.L. (1987). Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury. J. Trauma 27, 445–447.
Burney R.E., Waggoner R., and Maynard F.M. (1989). Stabilization of spinal injury for early transfer. J. Trauma 29, 1497–1499.
Cloward R.B. (1980). Acute cervical spine injuries. Clin. Symp. 32, 1–32.
Geisler W.O., Wynne-Jones M., and Jousse A.T. (1966). Early management of the patient with trauma to the spinal cord. Med. Serv. J. Can. 22, 512–523.
Jeanneret B., Magerl F., and Ward J.C. (1991). Overdistraction: a hazard of skull traction in the management of acute injuries of the cervical spine. Arch. Orthop. Trauma Surg. 110, 242–245.
Hachen H.J. (1974). Emergency transportation in the event of acute spinal cord lesion. Paraplegia 12, 33–37.
Podolsky S., Baraff L.J., Simon R.R., Hoffman J.R., Larmon B., and Ablon W. (1983). Efficacy of cervical spine immobilization methods. J. Trauma 23, 461–465.
Prasad V.S., Schwartz A., Bhutani R., Sharkey P.W., and Schwartz M.L. (1999). Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit. Spinal Cord 37, 560–568.
Reid D.C., Henderson R., Saboe L., and Miller J.D. (1987). Etiology and clinical course of missed spine fractures. J. Trauma 27, 980–986.
Rosen P., and Wolfe R.E. (1989). Therapeutic legends of emergency medicine. J. Emerg. Med. 7, 387–389.
Sussman B.J. (1978). Proceedings of the Annual Scientific Meeting of the International Medical Society of Paraplegia held at Stoke Mandeville from 28–30 July 1977 (Part II). Fracture dislocation of the cervical spine: a critique of current management in the United States. Paraplegia 16, 15–38.
Toscano J. (1988). Prevention of neurological deterioration before admission to a spinal cord injury unit. Paraplegia 26, 143–150.
Totten V.Y., and Sugarman D.B. (1999). Respiratory effects of spinal immobilization. Prehosp. Emerg. Care. 3, 347–352.
Marshall L.F., Knowlton S., Garfin S.R., Klauber M.R., Eisenberg H.M., Kopaniky D., Miner M.E., Tabbador K., and Clifton G.L. (1987). Deterioration following spinal cord injury. A multicenter study. J. Neurosurg. 66, 400–404.
Huang Y.H., Yang T.M., Lin W.C., Ho J.T., Lee T.C., Chen W.F., Rau C.S., and Wang H.C. (2009). The prognosis of acute blunt cervical spinal cord injury. J. Trauma 66, 1441–1445.
Tator C.H., and Fehlings M.G. (1991). Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J. Neurosurg. 75, 15–26.
Thumbikat P., Hariharan R.P., Ravichandran G., McClelland M.R., and Mathew K.M. (2007). Spinal cord injury in patients with ankylosing spondylitis: a 10-year review. Spine (Phila Pa 1976) 32, 2989–2995.
Prasarn M.L., Conrad B., Del Rossi, G., Horodyski M., and Rechtine G.R. (2012). Motion generated in the unstable cervical spine during the application and removal of cervical immobilization collars. J. Trauma Acute Care Surg. 72, 1609–1613.
Chin K.R., Auerbach J.D., Adams S.B., Sodl J.F., and Riew K.D. (2006). Mastication causing segmental spinal motion in common cervical orthoses. Spine (Phila Pa 1976) 31, 430–434.
Miller C.P., Bible J.E., Jegede K.A., Whang P.G., and Grauer J.N. (2010). Soft and rigid collars provide similar restriction in cervical range of motion during fifteen activities of daily living. Spine (Phila Pa 1976) 35, 1271–1278.
Conrad B.P., Rechtine G., Weight M., Clarke J., and Horodyski M. (2010). Motion in the unstable cervical spine during hospital bed transfers. J. Trauma 69, 432–436.
Horodyski M., DiPaola C.P., Conrad B.P., and Rechtine G.R. (2011). Cervical collars are insufficient for immobilizing an unstable cervical spine injury. J. Emerg. Med. 41, 513–519.
Lador R., Ben-Galim P., and Hipp J.A. (2011). Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon. J. Trauma 70, 247–250.
Holla M. (2012). Value of a rigid collar in addition to head blocks: a proof of principle study. Emerg. Med. J. 29, 104–107.
Chandler D.R., Nemejc C., Adkins R.H., and Waters R.L. (1992). Emergency cervical-spine immobilization. Ann. Emerg. Med. 21, 1185–1188.
Hostler D., Colburn D., and Seitz S.R. (2009). A comparison of three cervical immobilization devices. Prehosp. Emerg. Care 13, 256–260.
Hamilton R.S., and Pons P.T. (1996). The efficacy and comfort of full-body vacuum splints for cervical-spine immobilization. J. Emerg. Med. 14, 553–559.
Luscombe M.D., and Williams J.L. (2003). Comparison of a long spinal board and vacuum mattress for spinal immobilisation. Emerg. Med. J. 20, 476–478.
Cline J.R., Scheidel E., and Bigsby E.F. (1985). A comparison of methods of cervical immobilization used in patient extrication and transport. J. Trauma 25, 649–653.
Graziano A.F., Scheidel E.A., Cline J.R., and Baer L.J. (1987). A radiographic comparison of prehospital cervical immobilization methods. Ann. Emerg. Med. 16, 1127–1131.
Huerta C., Griffith R., and Joyce S.M. (1987). Cervical spine stabilization in pediatric patients: evaluation of current techniques. Ann. Emerg. Med. 16, 1121–1126.
Perry S.D., McLellan B., McIlroy W.E., Maki B.E., Schwartz M., and Fernie G.R. (1999). The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976) 24, 1839–1844.
Shafer J.S., and Naunheim R.S. (2009). Cervical spine motion during extrication: a pilot study. West. J. Emerg. Med. 10, 74–78.
Del Rossi, G., Heffernan T.P., Horodyski M., and Rechtine G.R. (2004). The effectiveness of extrication collars tested during the execution of spine-board transfer techniques. Spine J. 4, 619–623.
Karbi O.A., Caspari D.A., and Tator C.H. (1988). Extrication, immobilization and radiologic investigation of patients with cervical spine injuries. CMAJ 139, 617–621.
Sandler A.J., Dvorak J., Humke T., Grob D., and Daniels W. (1996). The effectiveness of various cervical orthoses. An in vivo comparison of the mechanical stability provided by several widely used models. Spine (Phila Pa 1976) 21, 1624–1629.
Smyth M., and Cooke M.W. (2013). Value of a rigid collar: in need of more research and better devices. Emerg. Med. J. 30, 516.
Levi A.D., Hurlbert R.J., Anderson P., Fehlings M., Rampersaud R., Massicotte E.M., France J.C., Le Huec J.C., Hedlund R., and Arnold P. (2006). Neurologic deterioration secondary to unrecognized spinal instability following trauma—a multicenter study. Spine (Phila Pa 1976) 31, 451–458.
Armstrong B.P., Simpson H.K., Crouch R., and Deakin C.D. (2007). Prehospital clearance of the cervical spine: does it need to be a pain in the neck? Emerg. Med. J. 24, 501–503.
Brown L.H., Gough J.E., and Simonds W.B. (1998). Can EMS providers adequately assess trauma patients for cervical spinal injury? Prehosp. Emerg. Care 2, 33–36.
Domeier R.M., Swor R.A., Evans R.W., Hancock J.B., Fales W., Krohmer J., Frederiksen S.M., Rivera-Rivera E.J., and Schork M.A. (2002). Multicenter prospective validation of prehospital clinical spinal clearance criteria. J. Trauma 53, 744–750.
Domeier R.M., Frederiksen S.M., and Welch K. (2005). Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann. Emerg. Med. 46, 123–131.
Stroh G., and Braude D. (2001). Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann. Emerg. Med. 37, 609–615.
Gerrelts B.D., Petersen E.U., Mabry J., and Petersen S.R. (1991). Delayed diagnosis of cervical spine injuries. J. Trauma 31, 1622–1626.
Platzer P., Hauswirth N., Jaindl M., Chatwani S., Vecsei V., and Gaebler C. (2006). Delayed or missed diagnosis of cervical spine injuries. J. Trauma 61, 150–155.
Hauswald M., Ong G., Tandberg D., and Omar Z. (1998). Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad. Emerg. Med. 5, 214–219.
Plumb J.O., and Morris C.G. (2013). Cervical collars: probably useless; definitely cause harm! J. Emerg. Med. 44, e143.
Hauswald M. (2012). A re-conceptualisation of acute spinal care. Emerg. Med. J. 30, 720–723.
Lin H.L., Lee W.C., Chen C.W., Lin T.Y., Cheng Y.C., Yeh Y.S., Lin Y.K., and Kuo L.C. (2011). Neck collar used in treatment of victims of urban motorcycle accidents: over- or underprotection? Am. J. Emerg. Med. 29, 1028–1033.
Tiska M.A., Adu-Ampofo M., Boakye G., Tuuli L., and Mock C.N. (2004). A model of prehospital trauma training for lay persons devised in Africa. Emerg. Med. J. 21, 237–239.
Jayaraman S., and Sethi D. (2009). Advanced trauma life support training for hospital staff. Cochrane Database Syst. Rev. Issue 2. Art. No.: CD004173.
Jayaraman S., and Sethi D. (2010). Advanced trauma life support training for ambulance crews. Cochrane Database Syst. Rev. Issue 1. Art. No.: CD003109.
Ben-Galim P., Dreiangel N., Mattox K.L., Reitman C.A., Kalantar S.B., and Hipp J.A. (2010). Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J. Trauma 69, 447–450.
Bivins H.G., Ford S., Bezmalinovic Z., Price H.M., and Williams J.L. (1988). The effect of axial traction during orotracheal intubation of the trauma victim with an unstable cervical spine. Ann. Emerg. Med. 17, 25–29.
Papadopoulos M.C., Chakraborty A., Waldron G., and Bell B.A. (1999). Lesson of the week: exacerbating cervical spine injury by applying a hard collar. BMJ 319, 171–172.
Podolsky S.M., Hoffman J.R., and Pietrafesa C.A. (1983). Neurologic complications following immobilization of cervical spine fracture in a patient with ankylosing spondylitis. Ann. Emerg. Med. 12, 578–580.
Engsberg J.R., Standeven J.W., Shurtleff T.L., Eggars J.L., Shafer J.S., and Naunheim R.S. (2013). Cervical spine motion during extrication. J. Emerg. Med. 44, 122–127.
Clarke A., James S., and Ahuja S. (2010). Ankylosing spondylitis: inadvertent application of a rigid collar after cervical fracture, leading to neurological complications and death. Acta. Orthop. Belg. 76, 413–415.
Craig G.R., and Nielsen M.S. (1991). Rigid cervical collars and intracranial pressure. Intensive Care Med. 17, 504–505.
Davies G., Deakin C., and Wilson A. (1996). The effect of a rigid collar on intracranial pressure. Injury 27, 647–649.
Hunt K., Hallworth S., and Smith M. (2001). The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia 56, 511–513.
Kolb J.C., Summers R.L., and Galli R.L. (1999). Cervical collar-induced changes in intracranial pressure. Am. J. Emerg. Med. 17, 135–137.
Mobbs R.J., Stoodley M.A., and Fuller J. (2002). Effect of cervical hard collar on intracranial pressure after head injury. ANZ J. Surg. 72, 389–391.
Stone M.B., Tubridy C.M., and Curran R. (2010). The effect of rigid cervical collars on internal jugular vein dimensions. Acad. Emerg. Med. 17, 100–102.
Stiell I.G., Nesbitt L.P., Pickett W., Munkley D., Spaite D.W., Banek J., Field B., Luinstra-Toohey L., Maloney J., Dreyer. J., Lyver M., Campeau T., and Wells G.A.; OPALS Study Group. (2008). The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ 178, 1141–1152.
Lemyze M., Palud A., Favory R., and Mathieu D. (2011). Unintentional strangulation by a cervical collar after attempted suicide by hanging. Emerg. Med. J. 28, 532.
Aoi Y., Inagawa G., Nakamura K., Sato H., Kariya T., and Goto T. (2010). Airway scope versus macintosh laryngoscope in patients with simulated limitation of neck movements. J. Trauma 69, 838–842.
Criswell J.C., Parr M.J., and Nolan J.P. (1994). Emergency airway management in patients with cervical spine injuries. Anaesthesia 49, 900–903.
Doran J.V., Tortella B.J., Drivet W.J., and Lavery R.F. (1995). Factors influencing successful intubation in the prehospital setting. Prehosp. Disaster Med. 10, 259–264.
Ghafoor A.U., Martin T.W., Gopalakrishnan S., and Viswamitra S. (2005). Caring for the patients with cervical spine injuries: what have we learned? J. Clin. Anesth. 17, 640–649.
Goutcher C.M., and Lochhead V. (2005). Reduction in mouth opening with semi-rigid cervical collars. Br. J. Anaesth. 95, 344–348.
Heath K.J. (1994). The effect of laryngoscopy of different cervical spine immobilisation techniques. Anaesthesia 49, 843–845.
LeGrand S.A., Hindman B.J., Dexter F., Weeks J.B., and Todd M.M. (2007). Craniocervical motion during direct laryngoscopy and orotracheal intubation with the Macintosh and Miller blades: an in vivo cinefluoroscopic study. Anesthesiology 107, 884–891.
Lubovsky O., Liebergall M., Weissman C., and Yuval M. (2010). A new external upper airway opening device combined with a cervical collar. Resuscitation 81, 817–821.
Robitaille A. (2011). Airway management in the patient with potential cervical spine instability: continuing professional development. Can. J. Anaesth. 58, 1125–1139.
Rodriguez-Nunez A., Oulego-Erroz I., Perez-Gay L., and Cortinas-Diaz J. (2010). Comparison of the GlideScope Videolaryngoscope to the standard Macintosh for intubation by pediatric residents in simulated child airway scenarios. Pediatr. Emerg. Care 26, 726–729.
Santoni B.G., Hindman B.J., Puttlitz C.M., Weeks J.B., Johnson N., Maktabi M.A., and Todd M.M. (2009). Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology 110, 24–31.
Thiboutot F., Nicole P.C., Trépanier C.A., Turgeon A.F., and Lessard M.R. (2009). Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can. J. Anaesth. 56, 412–418.
Houghton D.J., and Curley J.W. (1996). Dysphagia caused by a hard cervical collar. Br. J. Neurosurg. 10, 501–502.
Lockey D.J., Coats T., and Parr M.J. (1999). Aspiration in severe trauma: a prospective study. Anaesthesia 54, 1097–1098.
Bauer D., and Kowalski R. (1988). Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann. Emerg. Med. 17, 915–918.
Meschino A., Devitt J.H., Koch J.P., Szalai J.P., and Schwartz M.L. (1992). The safety of awake tracheal intubation in cervical spine injury. Can. J. Anaesth. 39, 114–117.
Patterson H. (2004). Emergency department intubation of trauma patients with undiagnosed cervical spine injury. Emerg. Med. J. 21, 302–305.
Shatney C.H., Brunner R.D., and Nguyen T.Q. (1995). The safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury. Am. J. Surg. 170, 676–679.
Bernard S.A., Nguyen V., Cameron P., Masci K., Fitzgerald M., Cooper D.J., Walker T., Std B.P., Myles P., Murray L., Taylor D., Smith K., Patrick I., Edington J., Bacon A., Rosenfeld J.V., and Judson R. (2010). Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann. Surg. 252, 959–965.
Bulger E.M., Copass M.K., Sabath D.R., Maier R.V., and Jurkovich G.J. (2005). The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury. J. Trauma 58, 718–723.
Davis D.P., Peay J., Serrano J.A., Buono C., Vilke G.M., Sise M.J., Kennedy F., Eastman A.B., Velky T., and Hoyt D.B. (2005). The impact of aeromedical response to patients with moderate to severe traumatic brain injury. Ann. Emerg. Med. 46, 115–122.
Winchell R.J., and Hoyt D.B. (1997). Endotracheal intubation in the field improves survival in patients with severe head injury. Trauma Research and Education Foundation of San Diego. Arch. Surg. 132, 592–597.
Eckstein M., Chan L., Schneir A., and Palmer R. (2000). Effect of prehospital advanced life support on outcomes of major trauma patients. J. Trauma 48, 643–648.
Gausche M., Lewis R.J., Stratton S.J., Haynes B.E., Gunter C.S., Goodrich S.M., Poore P.D., McCollough M.D., Henderson D.P., Pratt F.D., and Seidel J.S. (2000). Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 283, 783–790.
Murray J.A., Demetriades D., Berne T.V., Stratton S.J., Cryer H.G., Bongard F., Fleming A., and Gaspard D. (2000). Prehospital intubation in patients with severe head injury. J. Trauma 49, 1065–1070.
Bochicchio G.V., Ilahi O., Joshi M., Bochicchio K., and Scalea T.M. (2003). Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. J. Trauma 54, 307–311.
Davis D.P., Hoyt D.B., Ochs M., Fortlage D., Holbrook T., Marshall L.K., and Rosen P. (2003). The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J. Trauma 54, 444–453.
Davis D.P., Peay J., Sise M.J., Vilke G.M., Kennedy F., Eastman A.B., Velky T., and Hoyt D.B. (2005). The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. J. Trauma 58, 933–939.
Wang H.E., Peitzman A.B., Cassidy L.D., Adelson P.D., and Yealy D.M. (2004). Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann. Emerg. Med. 44, 439–450.
Adnet F., Cydulka R.K., and Lapandry C. (1998). Emergency tracheal intubation of patients lying supine on the ground: influence of operator body position. Can. J. Anaesth. 45, 266–269.
Combes X., Jabre P., Jbeili C., Leroux B., Bastuji-Garin S., Margenet A., Adnet F., and Dhonneur G. (2006). Prehospital standardization of medical airway management: incidence and risk factors of difficult airway. Acad. Emerg. Med. 13, 828–834.
Gunning M., O'Loughlin E., Fletcher M., Crilly J., Hooper M., and Ellis D.Y. (2009). Emergency intubation: a prospective multicentre descriptive audit in an Australian helicopter emergency medical service. Emerg. Med. J. 26, 65–69.
Helm M., Hossfeld B., Schäfer S., Hoitz J., and Lampl L. (2006). Factors influencing emergency intubation in the pre-hospital setting—a multicentre study in the German Helicopter Emergency Medical Service. Br. J. Anaesth. 96, 67–71.
Hussmann B., Lefering R., Waydhas C., Ruchholtz S., Wafaisade A., Kauther M.D., and Lendemans S. (2011). Prehospital intubation of the moderately injured patient: a cause of morbidity? A matched-pairs analysis of 1.200 patients from the DGU Trauma Registry. Crit. Care 15, R207.
Karch S.B., Lewis T., Young S., Hales D., and Ho C.H. (1996). Field intubation of trauma patients: complications, indications, and outcomes. Am. J. Emerg. Med. 14, 617–619.
Rose D.K., and Cohen M.M. (1994). The airway: problems and predictions in 18.500 patients. Can. J. Anaesth. 41, 372–383.
Lossius H.M., Røislien J., and Lockey D.J. (2012). Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers. Crit. Care 16, R24.
Haut E.R., Kalish B.T., Efron D.T., Haider A.H., Stevens K.A., Kieninger A.N., Cornwell E.E., and Chang D.C. (2010). Spine immobilization in penetrating trauma: more harm than good? J. Trauma 68, 115–120.
Theodore N., Aarabi B., Dhall S.S., Gelb D.E., Hurlbert R.J., Rozzelle C.J., Ryken T.C., Walters B.C., and Hadley M.N. (2013). Transportation of patients with acute traumatic cervical spine injuries. Neurosurgery 72, Suppl. 2, 35–39.
Crosby E.T. (2006). Airway management in adults after cervical spine trauma. Anesthesiology 104, 1293–1318.
Berlac P., Hyldmo P.K., Kongstad P., Kurola J., Nakstad A.R., and Sandberg M.; Scandinavian Society for Anesthesiology and Intensive Care Medicine. (2008). Pre-hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol. Scand. 52, 897–907.
Fattah S., Ekås G.R., Hyldmo P.K., and Wisborg T. (2011). The lateral trauma position: what do we know about it and how do we use it? A cross-sectional survey of all Norwegian emergency medical services. Scand. J. Trauma Resusc. Emerg. Med. 19, 45.
Blake W.E., Stillman B.C., Eizenberg N., Briggs C., and McMeeken J.M. (2002). The position of the spine in the recovery position—an experimental comparison between the lateral recovery position and the modified HAINES position. Resuscitation 53, 289–297.
Gunn B.D., Eizenberg N., Silberstein M., McMeeken J.M., Tully E.A., Stillman B.C., Brown D.J., and Gutteridge G.A. (1995). How should an unconscious person with a suspected neck injury be positioned? Prehosp. Disaster Med. 10, 239–244.
Ackland H.M., Cooper D.J., Cooper J.D., Malham G.M., and Kossmann T. (2007). Factors predicting cervical collar-related decubitus ulceration in major trauma patients. Spine (Phila Pa 1976) 32, 423–428.
Blaylock B. (1996). Solving the problem of pressure ulcers resulting from cervical collars. Ostomy Wound Manage. 42, 26–33.
Hewitt S. (1994). Skin necrosis caused by a semi-rigid cervical collar in a ventilated patient with multiple injuries. Injury 25, 323–324.
Hodgson N.F., Stewart T.C., and Girotti M.J. (2000). Autopsies and death certification in deaths due to blunt trauma: what are we missing? Can. J. Surg. 43, 130–136.
Powers J., Daniels D., McGuire C., and Hilbish C. (2006). The incidence of skin breakdown associated with use of cervical collars. J. Trauma Nurs. 13, 198–200.
Sheerin F., and de Frein R. (2007). The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces. J. Emerg. Nurs. 33, 447–450.
Walker J. (2012). Pressure ulcers in cervical spine immobilisation: a retrospective analysis. J. Wound Care 21, 323–326.
Watts D., Abrahams E., MacMillan C., Sanat J., Silver R., VanGorder S., Waller M., and York D. (1998). Insult after injury: pressure ulcers in trauma patients. Orthop. Nurs. 17, 84–91.
Chan D., Goldberg R., Tascone A., Harmon S., and Chan L. (1994). The effect of spinal immobilization on healthy volunteers. Ann. Emerg. Med. 23, 48–51.
Chan D., Goldberg R.M., Mason J., and Chan L. (1996). Backboard versus mattress splint immobilization: a comparison of symptoms generated. J. Emerg. Med. 14, 293–298.
Hauswald M., Hsu M., and Stockoff C. (2000). Maximizing comfort and minimizing ischemia: a comparison of four methods of spinal immobilization. Prehosp. Emerg. Care 4, 250–252.
Main P.W., and Lovell M.E. (1996). A review of seven support surfaces with emphasis on their protection of the spinally injured. J. Accid. Emerg. Med. 13, 34–37.
March J.A., Ausband S.C., and Brown L.H. (2002). Changes in physical examination caused by use of spinal immobilization. Prehosp. Emerg. Care 6, 421–424.
Walton R., DeSalvo J.F., Ernst A.A., and Shahane A. (1995). Padded vs unpadded spine board for cervical spine immobilization. Acad. Emerg. Med. 2, 725–728.
Leonard J.C., Mao J., and Jaffe D.M. (2012). Potential adverse effects of spinal immobilization in children. Prehosp. Emerg. Care 16, 513–518.
Brenner D.J., and Hall E.J. (2007). Computed tomography—an increasing source of radiation exposure. N. Engl. J. Med. 357, 2277–2284.
Davis F., Il'yasova D., Rankin K., McCarthy B., and Bigner D.D. (2011). Medical diagnostic radiation exposures and risk of gliomas. Radiat. Res. 175, 790–796.
Einstein A.J. (2012). Effects of radiation exposure from cardiac imaging: how good are the data? J. Am. Coll. Cardiol. 59, 553–565.
Berrington de González, A., Mahesh M., Kim K.P., Bhargavan M., Lewis R., Mettler F., and Land C. (2009). Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch. Intern. Med. 169, 2071–2077.
Brenner D., Elliston C., Hall E., and Berdon W. (2001). Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am. J. Roentgenol. 176, 289–296.
Broder J., Fordham L.A., and Warshauer D.M. (2007). Increasing utilization of computed tomography in the pediatric emergency department, 2000–2006. Emerg. Radiol. 14, 227–232.
Mathews J.D., Forsythe A.V., Brady Z., Butler M.W., Goergen S.K., Byrnes G.B., Giles G.G., Wallace A.B., Anderson P.R., Guiver T.A., McGale P., Cain T.M., Dowty J.G., Bickerstaffe A.C., and Darby S.C. (2013). Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 346, f2360.
Pearce M.S., Salotti J.A., Little M.P., McHugh K., Lee C., Kim K.P., Howe N.L., Ronckers C.M., Rajaraman P., Craft A.W., Parker L., and Berrington de González A. (2012). Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 380, 499–505.
Barkana Y., Stein M., Scope A., Maor R., Abramovich Y., Friedman Z., and Knoller N. (2000). Prehospital stabilization of the cervical spine for penetrating injuries of the neck—is it necessary? Injury 31, 305–309.
Connell R.A., Graham C.A., and Munro P.T. (2003). Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma? Injury 34, 912–914.
Kaups K.L., and Davis J.W. (1998). Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. J. Trauma 44, 865–867.
Stuke L.E., Pons P.T., Guy J.S., Chapleau W.P., Butler F.K., and McSwain N.E. (2011). Prehospital spine immobilization for penetrating trauma—review and recommendations from the Prehospital Trauma Life Support Executive Committee. J. Trauma 71, 763–769.
Tilt L., Babineau J., Fenster D., Ahmad F., and Roskind C.G. (2012). Blunt cervical spine injury in children. Curr. Opin. Pediatr. 24, 301–306.
Foltin G.L., Dayan P., Tunik M., Marr M., Leonard J., Brown K., Hoyle J., and Lerner E.B.; Prehospital Working Group of the Pediatric Emergency Care Applied Research Network. (2010). Priorities for pediatric prehospital research. Pediatr. Emerg. Care 26, 773–777.
Herzenberg J.E., Hensinger R.N., Dedrick D.K., and Phillips W.A. (1989). Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous. J. Bone Joint Surg. Am. 71, 15–22.
Brown R.L., Brunn M.A., and Garcia V.F. (2001). Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J. Pediatr. Surg. 36, 1107–1114.
Dietrich A.M., Ginn-Pease M.E., Bartkowski H.M., and King D.R. (1991). Pediatric cervical spine fractures: predominantly subtle presentation. J. Pediatr. Surg. 26, 995–999.
Kokoska E.R., Keller M.S., Rallo M.C., and Weber T.R. (2001). Characteristics of pediatric cervical spine injuries. J. Pediatr. Surg. 36, 100–105.
Patel J.C., Tepas J.J., Mollitt D.L., and Pieper P. (2001). Pediatric cervical spine injuries: defining the disease. J. Pediatr. Surg. 36, 373–376.
Platzer P., Jaindl M., Thalhammer G., Dittrich S., Kutscha-Lissberg F., Vecsei V., and Gaebler C. (2007). Cervical spine injuries in pediatric patients. J. Trauma 62, 389–396.
Viccellio P., Simon H., Pressman B.D., Shah M.N., Mower W.R., and Hoffman J.R.; NEXUS Group. (2001). A prospective multicenter study of cervical spine injury in children. Pediatrics 108, E20.
Oluigbo C.O., Gan Y.C., Sgouros S., Chapman S., Kay A., Solanki G., Walsh A.R., and Hockley A.D. (2008). Pattern, management and outcome of cervical spine injuries associated with head injuries in paediatric patients. Childs Nerv. Syst. 24, 87–92.
Jones T.M., Anderson P.A., and Noonan K.J. (2011). Pediatric cervical spine trauma. J. Am. Acad. Orthop. Surg. 19, 600–611.
Vaillancourt C., Charette M., Kasaboski A., Maloney J., Wells G.A., and Stiell I.G. (2011). Evaluation of the safety of C-spine clearance by paramedics: design and methodology. BMC Emerg. Med. 11, 1.
Coffey F., Hewitt S., Stiell I., Howarth N., Miller P., Clement C., Emberton P., and Jabbar A. (2011). Validation of the Canadian c-spine rule in the UK emergency department setting. Emerg. Med. J. 28, 873–876.
Michaleff Z.A., Maher C.G., Verhagen A.P., Rebbeck T., and Lin C.W. (2012). Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ 184, E867–E876.
Stiell I.G., Clement C.M., Grimshaw J., Brison R.J., Rowe B.H., Schull M.J., Lee J.S., Brehaut J., McKnight R.D., Eisenhauer M.A., Dreyer J., Letovsky E., Rutledge T., MacPhail I., Ross S., Shah A., Perry J.J., Holroyd B.R., Ip U., Lesiuk H., and Wells G.A. (2009). Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ 339, b4146.
Stiell I.G., Clement C.M., McKnight R.D., Brison R., Schull M.J., Rowe B.H., Worthington J.R., Eisenhauer M.A., Cass D., Greenberg G., MacPhail I., Dreyer J., Lee J.S., Bandiera G., Reardon M., Holroyd B., Lesiuk H., and Wells G.A. (2003). The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N. Engl. J. Med. 349, 2510–2518.
Miller P., Coffey F., Reid A.M., and Stevenson K. (2006). Can emergency nurses use the Canadian cervical spine rule to reduce unnecessary patient immobilisation? Accid. Emerg. Nurs. 14, 133–140.
Stiell I.G., Clement C.M., O'Connor A., Davies B., Leclair C., Sheehan P., Clavet T., Beland C., MacKenzie T., and Wells G.A. (2010). Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ 182, 1173–1179.
Vaillancourt C., Stiell I.G., Beaudoin T., Maloney J., Anton A.R., Bradford P., Cain E., Travers A., Stempien M., Lees M., Munkley D., Battram E., Banek J., and Wells G.A. (2009). The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann. Emerg. Med. 54, 663–671.
Anderson P.A., Muchow R.D., Munoz A., Tontz W.L., and Resnick D.K. (2010). Clearance of the asymptomatic cervical spine: a meta-analysis. J. Orthop. Trauma 24, 100–106.
Kamenetsky E., Esposito T.J., and Schermer C.R. (2013). Evaluation of distracting pain and clinical judgment in cervical spine clearance of trauma patients. World J. Surg. 37, 127–135.
Rose M.K., Rosal L.M., Gonzalez R.P., Rostas J.W., Baker J.A., Simmons J.D., Frotan M.A., and Brevard S.B. (2012). Clinical clearance of the cervical spine in patients with distracting injuries. J. Trauma 73, 498–502.
Konstantinidis A., Plurad D., Barmparas G., Inaba K., Lam L., Bukur M., Branco B.C., and Demetriades D. (2011). The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J. Trauma 71, 528–532.
Benner J.P., Brauning G., Green M., Caldwell W., Borloz M.P., and Brady W.J. (2006). Disagreement between transport team and ED staff regarding the prehospital assessment of air medically evacuated scene patients. Air Med. J. 25, 165–169.
Burton J.H., Harmon N.R., Dunn M.G., and Bradshaw J.R. (2005). EMS provider findings and interventions with a statewide EMS spine-assessment protocol. Prehosp. Emerg. Care 9, 303–309.
Burton J.H., Dunn M.G., Harmon N.R., Hermanson T.A., and Bradshaw J.R. (2006). A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J. Trauma 61, 161–167.
Campbell P. (1987). Comparison of flight nurses' prehospital assessments and emergency physicians' ED assessments of trauma patients. J. Emerg. Nurs. 13, 219–222.
Domeier R.M., Evans R.W., Swor R.A., Rivera-Rivera E.J., and Frederiksen S.M. (1997). Prospective validation of out-of-hospital spinal clearance criteria: a preliminary report. Acad. Emerg. Med. 4, 643–646.
Domeier R.M., Evans R.W., Swor R.A., Hancock J.B., Fales W., Krohmer J., Frederiksen S.M., and Shork M.A. (1999). The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehosp. Emerg. Care 3, 332–337.
Hankins D.G., Rivera-Rivera E.J., Ornato J.P., Swor R.A., Blackwell T., and Domeier R.M.; Turtle Creek Conference II. (2001). Spinal immobilization in the field: clinical clearance criteria and implementation. Prehosp. Emerg. Care 5, 88–93.
Meldon S.W., Brant T.A., Cydulka R.K., Collins T.E., and Shade B.R. (1998). Out-of-hospital cervical spine clearance: agreement between emergency medical technicians and emergency physicians. J. Trauma 45, 1058–1061.
Muhr M.D., Seabrook D.L., and Wittwer L.K. (1999). Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehosp. Emerg. Care 3, 1–6.
Sahni R., Menegazzi J.J., and Mosesso V.N. (1997). Paramedic evaluation of clinical indicators of cervical spinal injury. Prehosp. Emerg. Care 1, 16–18.
Ringdal K.G., Coats T.J., Lefering R., Di Bartolomeo, S., Steen P.A., Røise O., Handolin L., and Lossius H.M.; Utstein TCD expert panel. (2008). The Utstein template for uniform reporting of data following major trauma: a joint revision by SCANTEM, TARN, DGU-TR and RITG. Scand. J. Trauma Resusc. Emerg. Med. 16, 7.
Voss S., Page M., and Benger J. (2012). Methods for evaluating cervical range of motion in trauma settings. Scand. J. Trauma Resusc. Emerg. Med. 20, 50.

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cover image Journal of Neurotrauma
Journal of Neurotrauma
Volume 31Issue Number 6March 15, 2014
Pages: 531 - 540
PubMed: 23962031


Published in print: March 15, 2014
Published online: 10 March 2014
Published ahead of print: 6 November 2013
Published ahead of production: 20 August 2013


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Terje Sundstrøm
Department of Biomedicine, University of Bergen, Bergen, Norway.
Department of Clinical Medicine K1, University of Bergen, Bergen, Norway.
Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
Helge Asbjørnsen
Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.
Helicopter Emergency Medical Services, Bergen, Norway.
Samer Habiba
Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
Geir Arne Sunde
Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.
Helicopter Emergency Medical Services, Bergen, Norway.
The Norwegian Air Ambulance Foundation, Drøbak, Norway.
Knut Wester
Department of Clinical Medicine K1, University of Bergen, Bergen, Norway.
Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.


Address correspondence to:Terje Sundstrøm, MDDepartment of BiomedicineUniversity of BergenJonas Liesvei 915020 Bergen,Norway
E-mail: [email protected]

Author Disclosure Statement

No competing financial interests exist.

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