Adding Insult to Injury: Developing Pressure Ulcers Before Hospitalization in Trauma Patients

It is always interesting when someone asks a question about a familiar subject but in a way that you had not previously considered. Most of us have treated trauma patients who have developed pressure ulcers, but someone recently asked me how many of those pressure ulcers start before the patient arrives at the hospital or start in the emergency department? I had not considered that question before and was surprised to learn about the subject. The literature reports that 9% to 66% of trauma patients admitted to the hospital will develop a pressure ulcer.^1,2 Surprisingly to me, about 30% of pressure ulcers in trauma patients are caused by a pressure-related injury that occurs during transport to the hospital or during the evaluation period. They most commonly result from pressure while using the “standard” protective devices: cervical collars and spine or back boards. 

Cervical collars have been considered the standard of care for trauma patients with a potential cervical spine injury for more than 30 years.³ The use of cervical collars in the field is taught as part of prehospital care in more than 50 countries and are used on millions of trauma patients each year.⁴ It is reported that up to 38% of pressure ulcers in trauma patients are due to cervical collars. Stage 1 through stage 4 ulcers have been reported most commonly in the occipital region, chin, shoulders, and back.⁵ Risk factors associated with the development of a pressure ulcer from a cervical collar include inappropriate application and fit of the collar, prolonged use of the collar, hypotension, and advanced age. 

The other “safety” device used for trauma patients that can cause pressure ulcers is the spine or back board. Interestingly, the board was not designed to be used for transportation of patients but to aid in safely removing a patient with a suspected spinal injury from a place when trapped. Spine board use is considered responsible for up to 50% of prehospital pressure-related injuries.⁶ The incidence of pressure-related injury from a spine board is directly related to the length of time spent on the board. Lerner and Moscati⁷ found the average duration of time spent on a spine board was 63 minutes when the board was used for transportation only and 3 hours when the patient was left on the board until radiology studies were completed. Keller and colleagues⁸ showed the pressure on the tissue over bony prominences are up to 3 times the acceptable level when the patient is lying on a spine board. In most instances, these patients are secured to the board and cannot reposition themselves.

The above information is causing health care and emergency personnel around the world to reconsider the “standard of care” for trauma patients. It is now suggested that cervical collars not be used on a routine basis, time spent wearing a cervical collar or lying on a spine board be minimized, and, if patients require these devices for prolonged periods, the patient and/or device should be repositioned frequently. The bottom-line recommendation is that we utilize current technology and materials to develop safer and more comfortable surfaces on which to transport severely injured patients. 

To say the least, I was surprised at the answer to the seemingly simple question I was asked. What I found will certainly help me make better recommendations to our emergency personnel and trauma teams so our trauma patients can receive better care beginning at the site of injury. Again, this proves there is no such thing as a silly question.

Terry Treadwell, MD, FACS
woundseditor@hmpglobal.com

This article was not subject to the WOUNDS peer-review process.