Pressure Ulcers in Trauma Patients with Preventive Spinal Immobilization: Incidence, characteristics and risk factors

Introduction To protect the (possibly) injured spine, trauma patients are immobilized on a backboard, with an extrication collar, lateral headblocks, and straps. Although pressure ulcers are typically associated with older adults and chronic illness, of all patients in a hospital environment, these trauma patients may be particularly at risk for developing (device-related) pressure ulcers. Pressure ulcers are a serious health complication that develop as a result of pressure alone or pressure in combination with shear force. Trauma patients (with suspected spinal injury) have traumatic injuries, are immobile, and exposed to immobilizing and medical devices; these are all factors that increase the risk to develop pressure ulcers. Methods The thesis focuses primarily on the development of pressure ulcers in trauma patients with suspected spinal injury. We defined general research questions that served as a fundament for our studies: 1. What is the incidence of pressure ulcers in trauma patients, immobilized with a backboard, extrication collar and headblocks due to suspected spinal injury? 2. Which risk factors play a role in pressure ulcer development in trauma patients with suspected spinal injury? To answer these questions, we performed a systematic literature review (n=13), an experimental study (n=54), and three prospective observational studies (n= 342, n=254, n= 254). Furthermore, we wrote a discussion paper, covering the current discussion on preventive spinal immobilization. Results In the systematic literature review we found only four studies that included trauma patients, nine studies included healthy volunteers. The described incidence of pressure ulcers related to the cervical collar varied widely and risk factors for pressure ulcer development from immobilizing devices were related to the type of device, length on/in the device and the severity of illness. No studies were found that described the occurrence of pressure ulcers related to the application of backboards, vacuum mattresses or headblocks. In the experimental study with emergency nurses and physicians, we found that pressure ulcer identification and classification skills improved significantly after an educational intervention. In the prospective observational studies, we focused on the acute phase (the emergency department) and the follow-up phase (hospital admission). In the acute phase, we found very high incidence figures on pressure ulcer development (75.4%) and pain (63.2%) from the extrication collar and headblocks. In the follow-up phase, we found high incidence figures on pressure ulcer development (28.3%). Over 60% of the found pressure ulcers were related to devices. Pressure ulcer development was significantly associated with an older age, a lower Glasgow Coma Scale score and higher Injury Severity Scores. Extra nutrition significantly decreased the probability of pressure ulcer development during admission. Conclusions The incidence of pressure ulcers in trauma patients, immobilized with a backboard, extrication collar and headblocks is high. Patients experience pain and develop pressure ulcers from the extrication collar and headblocks. The risk for pressure ulcer development appears high in patients with an older age and severe injuries. It is necessary to revise the current practice of spinal immobilization.