Injury, Int. J. Care Injured xxx (2014) xxxxxx
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Effects of unconsciousness during spinal immobilizationon tissue-interface pressures: A randomized controlledtrial comparing a standard rigid spineboard with a newlydeveloped soft-layered long spineboard
Baukje Hemmes a,*, Peter R.G. Brink a,b, Martijn Poeze a,b,c
a Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlandsb Department of Traumatology, Maastricht University Medical Center, Maastricht, The Netherlandsc NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
A R T I C L E I N F O
Accepted 9 June 2014
A B S T R A C T
Background: Immobilization of the spine of patients with trauma at risk of spinal damage is usually
performed using a rigid long spineboard or vacuum mattress, both during prehospital and in-hospital
care. However, disadvantages of these immobilization devices in terms of discomfort and tissue-
interface pressures have guided the development of soft-layered long spineboards. We compared tissue-
interface pressures between awake and anaesthetized (unconscious) patients during immobilization on
a rigid spineboard and a soft-layered long spineboard.
Methods: In this comparative study, 30 anaesthetized patients were randomized to immobilization on
either the rigid spineboard or the soft-layered spineboard for the duration of their elective surgery.
Tissue-interface pressures measured using an Xsensor pressure-mapping device were compared with
those of 30 healthy volunteers who were immobilized sequentially on the rigid spineboard and the soft-
layered spineboard. Redness of the sacrum was also recorded for the anaesthetized patients immediately
after the surgery.
Results: For both anaesthetized patients and awake volunteers, tissue-interface pressures were
significantly lower on the soft-layered spineboard than on the rigid spineboard, both at start and
after 15 min. On the soft-layered spineboard, tissue interface pressure and peak pressure index (PPI) for
the sacrum were significantly lower for anaesthetized patients than for awake volunteers. Peak
pressures and PPI on the rigid spineboard were equal for both groups. Tissue-interface pressures did not
change significantly over time. Redness of the sacrum was significantly more pronounced on the rigid
spineboard than on the soft-layered spineboard.
Conclusions: This prospective randomized controlled trial shows that using a soft-layered spineboard
compared to a rigid spineboard for spinal immobilization resulted in lower tissue-interface pressures in
both awake volunteers and anaesthetized patients. Moreover, tissue-interface pressures on the soft-
layered spineboard were lower in anaesthetized patients than in awake volunteers. These findings show
the importance of using a soft-layered spineboard to reduce tissue-interface pressure, especially for
patients who cannot relieve pressure themselves by changing position.
2014 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
jo ur n al ho m epag e: ww w.els evier . c om / lo cat e/ in ju r y
Results of this study were presented at the 2nd Focus meeting of the EPUAP on
skin health and the microclimate, Southampton, UK, April 9, 2014.
* Corresponding author at: Network Acute Care Limburg, Maastricht University
Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
Tel.: +31 43 3871435.
E-mail addresses: email@example.com (B. Hemmes),
firstname.lastname@example.org (Peter R.G. Brink), email@example.com (M. Poeze).
Please cite this article in press as: Hemmes B, et al. Effects of uncpressures: A randomized controlled trial comparing a standard rigid sInjury (2014), http://dx.doi.org/10.1016/j.injury.2014.06.006
00201383/ 2014 Elsevier Ltd. All rights reserved.
Spinal immobilization with long spineboards and cervicalcollars for extrication and transfer of trauma patients is a standardprecaution in both prehospital and in-hospital protocols .Especially for unconscious trauma patients, who are unable tomaintain spinal alignment by muscular tone, these methods areconsidered essential to protect the spine from further injury.
Although there is a general consensus that the patient shouldbe removed from the spineboard as soon as reasonably possible,
onsciousness during spinal immobilization on tissue-interfacepineboard with a newly developed soft-layered long spineboard.http://dx.doi.org/10.1016/j.injury.2014.06.006mailto:firstname.lastname@example.org:email@example.com:firstname.lastname@example.org://dx.doi.org/10.1016/j.injury.2014.06.006http://www.sciencedirect.com/science/journal/00201383www.elsevier.com/locate/injuryhttp://dx.doi.org/10.1016/j.injury.2014.06.006
B. Hemmes et al. / Injury, Int. J. Care Injured xxx (2014) xxxxxx2
JINJ-5775; No. of Pages 6
the average time patients are reported to spend on a spineboardhas been estimated to be around 1 h [2,3]. There is extensiveevidence, however, that prolonged immobilization causes signifi-cant discomfort and pain, and on occasion may cause pressureulceration over bony prominences, leading to prolonged hospitalstay and increased cost of care .
Pressure ulceration occurs as a result of reduced perfusiondue to prolonged pressure and/or shear injury to the tissues.Increased pressure can lead to compression of the dermalcapillaries. When the pressure is relieved, reactive hyperaemia,clinically seen as a bright flush or reddened area that blanchesunder light pressure, can occur. At this stage of so-calledblanchable erythema, damage to the underlying tissues has notyet occurred . Shear injury occurs as the result of sliding,when the soft tissues are stretched relative to each other. Theprocess of shear injury can occur quickly and the first signs ofcell damage can be seen within minutes. In a recent study wedemonstrated that when using a rigid spineboard, the maximumstrains on the tissues can exceed the threshold for deformationdamage . Healthy conscious subjects may adopt pressurerelieving strategies, involving position changes, to minimize therisk of exceeding this threshold at specific body regions.However, unconscious patients are thought not to adopt thesestrategies and may therefore be at higher risk of developingpressure induced tissue damage.
Therefore, this study investigated the hypothesis that whenlying on a rigid spineboard, unconsciousness results in highertissue-interface pressure compared to the awake status. Inaddition, a recent comparative study reported significantly lowerinterface pressures on a prototype spine board with soft, coveredinlay . Since the soft inlay may compensate for the lack ofmovement during unconsciousness, our second hypothesis wasthat there would be no difference in tissue-interface pressurebetween anaesthetized and awake status when lying on the soft-layered long spineboard.
We conducted a prospective, randomized, single-blinded,comparative study on tissue-interface pressures and redness ofthe skin using a standard rigid long spineboard and a soft-layeredlong spineboard in patients undergoing surgery under generalanaesthesia. Tissue interface pressures were compared with thoseof a group of awake healthy volunteers. The study has beenassigned ISRCTN96064657.
Table 1Subject characteristics.
Device Rigid spineboard
Gender (M/F) 11/4
Age (years) 51.5 (16.2)
BMI (kg/m2) 24.5 (2.9)
Type of surgery
Hernia inguinalis 10/15
Hernia epigastrica 3/15
Hernia umbilicalis 2/15
Time on immobilization device (min) 63 (18)
n.a.: not applicable.* P: a = difference between anaesthetized rigid spineboard and awake rigid spineboard
soft-layered spineboard P < 0.05; n.s.: not significant (P > 0.05).
Please cite this article in press as: Hemmes B, et al. Effects of unpressures: A randomized controlled trial comparing a standard rigid sInjury (2014), http://dx.doi.org/10.1016/j.injury.2014.06.006
Recruitment of participants
A sample of 30 patients (25 men and 5 women) was recruited atthe outpatient department of the Maastricht University MedicalCenter. Patients included were scheduled for open abdominal wallhernia repair under general anaesthesia, with an expected durationof less than 2 h. Patients with pressure ulceration either at time ofinclusion or in the medical history, or with pain other than that dueto the operation indication were excluded. Approval was obtainedfrom the Medical Research Ethics Committee of the MaastrichtUniversity Medical Center. Written informed consent wasobtained from all participants before they were enrolled in thestudy.
A power analysis was performed using the peak pressuresfound previously  on the standard rigid spine board and thesoft-layered long spineboard in awake and healthy volunteers. Thepower analysis showed that if we included 12 patients in each ofthe conditions, we should be able to detect a 25% increase in peakpressure index (PPI, see below) between awake and unconsciouspatients on the soft-layered spine board (mean PPI 171 (SD 33))with an alpha error of 0.05 and a beta error of 0.2.
Two different support devices designed for prehospital traumacare were tested: a standard long spineboard (Ferno-Washingt