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Prehospital guidelines on in-water traumatic spinal injuries for lifeguards and prehospital emergency medical services: an international Delphi consensus study

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine volume 32, Article number: 76 (2024) Cite this article

Abstract

Background

Trauma guidelines on spinal motion restriction (SMR) have changed drastically in recent years. An international group of experts explored whether consensus could be reached and if guidelines on SMR performed by trained lifeguards and prehospital EMS following in-water traumatic spinal cord injury (TSCI) should also be changed.

Methods

An international three-round Delphi process was conducted from October 2022 to November 2023. In Delphi round one, brainstorming resulted in an exhaustive list of recommendations for handling patients with suspected in-water TSCI. The list was also used to construct a preliminary flowchart for in-water SMR. In Delphi round two, three levels of agreement for each recommendation and the flowchart were established. Recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three; recommendations with moderate consensus (75–85% agreement) underwent major revisions in two consecutive phases; and recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2.

Results

Twenty-four experts participated in Delphi round one. The response rates for Delphi rounds two and three were 92% and 88%, respectively. The study resulted in 25 recommendations and one flowchart with four flowchart paths; 24 recommendations received strong consensus (≥ 85%), and one recommendation received moderate consensus (81%). Each of the four paths in the flowchart received strong consensus (90–95%). The integral flowchart received strong consensus (93%).

Conclusions

This study produced expert consensus on 25 recommendations and a flowchart on handling patients with suspected in-water TSCI by trained lifeguards and prehospital EMS. These results provide clear and simple guidelines on SMR, which can standardise training and guidelines on SMR performed by trained lifeguards or prehospital EMS.

Introduction

Traumatic spinal cord injury (TSCI) is defined as damage to the spinal cord following external physical impact [1]. A primary spinal cord injury happens as a result of the initial mechanical injury [2, 3]. Following the initial mechanical injury [4], a secondary spinal cord injury may be caused by vascular and biochemical effects [5, 6] such as haemorrhage [7, 8] and swelling at the site of injury into the spinal cord. Inept handling may also lead to secondary injury, and guidelines on spinal motion restrictions (SMR) are aimed at preventing this by handling patients with care. The guidelines on SMR of adult trauma patients have changed drastically in recent years [9,10,11]. The meaningful changes in on-land SMR fuelled the need to explore the implications for in-water SMR after in-water TCSI.

In-water TSCI most commonly occurs because of axial loading, resulting in compression of the relatively fragile cervical spine between the rapidly decelerating head and the continued momentum of the body [2, 3]. Common high-risk situations resulting in in-water TCSI are a poorly executed dive into a shallow body of water or wave-forced impacts typically occurring at moderate to severe shore breaks. Observational studies report a prevalence of spinal fractures from diving accidents of approximately 10% of the total population admitted with TSCI [12,13,14,15,16,17,18]. In-water TSCI typically occurs in young, healthy males under 30 who sustain no other associated intracranial or systemic injuries. Most spinal cord injuries in swimming pools result from reckless behaviour [19], involvement of alcohol [20], a lack of warning signs or depth indicators [20], and no lifeguard on duty. [20]

The most common levels of injury are C-5 and C-6 [13, 21], The rate of neurological injuries such as paralysis and sensory deficits following in-water TSCI is high and varies between 22 and 90%. [2, 12, 13, 17, 18].

In-water TSCI is a rare and complicated situation for trained lifeguards and prehospital EMS [22]. No standard exists, and various procedures are used worldwide [19].

This study aimed to establish international expert consensus on handling patients with suspected in-water TSCI to standardise guidelines on SMR performed by trained lifeguards and prehospital EMS.

Materials and methods

Study design

A Delphi process is a well‐established, systematic, consensus‐building method for collecting expert opinions and achieving agreement when objective information is unavailable [23]. We conducted a modified Delphi process with international participation. The study used three iterative rounds of online survey questionnaires, including structured and semi-structured questions: Delphi round 1 (brainstorm), Delphi round 2 (consensus), and Delphi round 3 (approval). The study was conducted in adherence with a detailed prespecified protocol available from the corresponding author upon request and is reported in compliance with the ACcurate COnsensus Reporting Document (ACCORD) [24] (Online Supplement, Appendix A).

Steering committee

Before the study started, a steering committee was installed to manage all the steps in the modified Delphi process, including drafting the invitations to participate and the first version of the recommendations, developing and pretesting survey questionnaires, and adapting the recommendations and the flowchart based on experts’ comments. The steering committee included a multi-national and multi-professional team experienced in medical research, prehospital and emergency medicine, spinal trauma management, and lifeguarding. The steering committee members were not allowed to participate as experts in the consensus process during the Delphi rounds.

Sample characteristics

Strict criteria were defined to select experts competent to establish consensus on recommendations for handling patients with suspected in-water TSCI. Members of the International Drowning Researchers’ Alliance (IDRA), the International Life Saving Federation (ILS) Medical Committee (ILS-MC), and the ILS Rescue Commission (ILS-RC) were regarded as eligible for inclusion as potential experts.

The inclusion criteria for these members included a background in clinical health care as a medical doctor, nurse, paramedic/EMT or similar and at least one of the following three criteria: (1) Having clinical expertise in handling patients with suspected in-water TSCI, (2) Having teaching expertise in handling patients with suspected in-water TSCI, (3) Having research expertise on in-water TSCI. We aimed for approximately 23 participants, as other research findings suggest that that number of participants led to response stability during multiple Delphi rounds [25].

Survey administration

The secretaries from ILS-MC, ILS-RC, and IDRA emailed the invitations to their members. The invitation included background information outlining the purpose of the study, the importance of participation, and a link to the survey questionnaire for Delphi round 1. All responses in Delphi Round 1 generated a unique participant identification number in REDCap, which was used to send personal links during rounds 2 and 3, securing anonymity and preventing multiple participation. All communication between the experts and the primary investigator (NB) was conducted through email.

The answers to the surveys could be saved at any time by the experts, allowing them to access and edit their answers later until reaching the deadline. Non-respondents received deadline reminders every week until the deadline. After the deadline, access to the survey was closed to ensure the progression and termination of the study.

Data collection methods

Data were systematically collected through all Delphi rounds using the Research Electronic Data Capture (REDCap) system [26]. The predefined minimum number of experts to start the study was 20 participants. The risk of non-response error was minimised through weekly deadline reminders highlighting the importance of participation and providing a deadline extension. Experts who failed to answer before the extended deadline were excluded from the following rounds.

Delphi round 1 (brainstorm)

In Delphi round 1, the experts were asked to provide information about their sex, age, country, affiliations, local practices, and contact information. After completing these data, they were guided to a summary of the existing literature on in-water TSCI, including three questions to check their understanding of the current knowledge produced by the primary author (Online Supplement, Appendix B). Once the experts had answered the three questions correctly, they were asked to comment with free text on the 30 recommendations suggested by the steering committee. All recommendations were clarified by a rationale, including references to publications providing supporting arguments for some of the recommendations.

Following Delphi round 1, the steering committee adapted the recommendations based on the experts' comments, removed duplicates, and identified various textual expressions for each unique recommendation to consolidate the list of recommendations. The steering committee could change the wording if the meaning was preserved. Decisions were based on unanimous agreement among the steering committee members. The steering committee also constructed a preliminary flowchart for managing in-water TSCI based on the preliminary recommendations following Delphi round 1.

Delphi round 2 (consensus)

In Delphi round 2, the consensus level for the adapted recommendations and the flowchart were tested. The experts replied to the following question: “How much do you agree with the following recommendation/flowchart?” The experts could indicate their agreement with each recommendation on a 4-point Likert Scale: (1) Strongly disagree, (2) Disagree, (3) Agree, and (4) Strongly agree. The experts were urged to explain their ratings. The consensus levels were calculated as the combined frequencies of “agree” and “strongly agree". Three categories were defined: (1) Strong consensus with unanimous or almost unanimous agreement (≥ 85%), (2) Moderate consensus with a substantial agreement (75–85%), and (3) Weak consensus with a low agreement (< 75%). Items with weak consensus were excluded in Delphi round 2.

For the recommendations with moderate consensus, adaptations were made by the steering committee based on the comments made by the experts and Delphi round 2 was repeated. Recommendations with strong consensus were marginally adapted by the steering committee, based on the comments made by the experts, and then directly passed to Delphi round 3.

The steering committee also produced a preamble based on the experts’ comments explaining some core concepts as prerequisites for the recommendations to improve the readability. According to the preamble, all recommendations presented in this study can only be performed if the scene is safe. All recommendations are contraindicated in any circumstance with imminent danger of drowning or injury (e.g., high surf, fast-moving water, or rocky areas). A "lifeguard" was defined as a person who has completed professional training, including training in handling TSCI and performing SMR and extrication, and is competent to prevent injury, perform rescues, and provide first aid to those in and around aquatic environments [27]. “Spinal motion restriction” (SMR) was defined as the procedure used on a patient with suspected TSCI to reduce spinal movement, irrespective of adjuncts or devices [27]. “Extrication” was defined as transporting the patient with suspected in-water TSCI from the water to the land using the appropriate SMR measures.

Delphi round 3 (approval)

In Delphi round 3, the level of consensus for the final set of recommendations and the flowchart was tested. The consensus levels derived from Delphi Round 2 were unmasked, and the experts replied again to the question: “How much do you agree with the following recommendations/flowchart?” The identical 4-point Likert Scale was used as in Delphi round 2.

If the experts chose “disagree” or “strongly disagree” for a recommendation, they were asked to explain their ratings. The consensus levels were calculated as the combined frequencies of “agree” and “strongly agree”.

If the experts disagreed with any specific routes in the flowchart, they were asked to explain their ratings. The consensus levels were calculated as the combined frequencies of “agree” and “strongly agree” for the specific routes, and the average was used as the final consensus level. The threshold level of consensus for each route was ≥ 75% of the experts [28]. Items achieving the threshold were accepted without further adaptations.

Statistical analysis

Categorical data from Delphi round 1 were presented as counts and percentages and numerical variables as medians with interquartile ranges [IQR] and range as appropriate. All analyses were performed using R Statistical software (R version 4.3.1 [2023-06-16 ucrt]) [29]. There was no imputation of missing data. This study did not adjust for the non-representativeness of the sample or use sensitivity analysis.

Results

Expert demographics are summarised in Table 1. A total of 18 (75%) experts did not have a local or national guideline on handling in-water TSCI before initiating this study.

Table 1 Expert demographic
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The data were collected during the three Delphi rounds from October 2022 to November 2023 (Fig. 1). A detailed workflow diagram is available in Fig. 2.

Fig. 1
figure 1

Study flow. Members of the International Life Saving Federation (ILS) Medical Committee (ILS-MC), the ILS Rescue Commission (ILS-RC), and the International Drowning Researchers’ Alliance (IDRA) with a background in clinical health care as a medical doctor, nurse, paramedic/EMT or similar were eligible for inclusion as potential experts. The inclusion criteria included at least one of the following three criteria: (1) Having clinical expertise in handling patients with suspected in-water TSCI, (2) Having teaching expertise in handling patients with suspected in-water TSCI, and (3) Having research expertise on in-water TSCI. The study was initiated in October 2022, concluded in November 2023, and consisted of three Delphi rounds. In Delphi round two, the level of agreement for each recommendation and the flowchart was calculated as the frequency of “agree” (3) and “strongly agree” (4) on a 4-point Likert-like scale and divided into three levels: (1) recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three, (2) recommendations with moderate consensus (75–85% agreement) underwent major revisions and repeated round two, (3) recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2. The consensus threshold was an agreement of ≥ 75% among the experts

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Fig. 2
figure 2

Workflow diagram of the modified Delphi study. The study was initiated in October 2022, concluded in November 2023, and consisted of three Delphi rounds. In Delphi round two, the level of agreement for each recommendation and the flowchart was calculated as the frequency of “agree” (3) and “strongly agree” (4) on a 4-point Likert-like scale and divided into three levels: (1) recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three, (2) recommendations with moderate consensus (75–85% agreement) underwent major revisions and repeated round two, (3) recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2. The consensus threshold was an agreement of ≥ 75% among the experts

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In Delphi round 1, 30 recommendations were suggested by the steering committee. Based on the experts’ comments, 8 recommendations were removed, and 4 recommendations were added. Based on the 26 recommendations, the steering committee constructed a flowchart.

In the first phase of Delphi round 2, 22/24 experts responded (92%). One recommendation received weak consensus and was removed. Seven recommendations received moderate consensus, and 18 recommendations received strong consensus. The recommendations with moderate consensus were adapted and passed to the second phase of Delphi round 2.

In the second phase of Delphi round 2, 21/24 experts responded (88%). One recommendation received moderate consensus, and six recommendations received strong consensus. A total of 25 recommendations were passed to Delphi round 3: 24/25 recommendations with strong consensus and 1/25 recommendations with moderate consensus. A complete list of recommendations and consensus levels from Delphi rounds 2 and 3 are available (Online Supplement, Appendix C).

The flowchart received weak consensus (64%) in the first phase of Delphi round 2 and was adapted. In the second phase of Delphi round 2, the flowchart received moderate consensus (76%) and was adapted bases on the comments received before being passed to Delphi round 3.

In Delphi round 3, 21/24 experts responded (88%). All 25 recommendations were individually approved, with a consensus of 81–100% (Table 2). The only recommendation with a moderate level of consensus was: “It is recommended to use at least three persons to perform spinal motion restriction to extricate a patient suspected of in-water traumatic spinal cord injury. At least one person should be specifically trained. If the necessary number of persons is not available, do not further delay extrication.” All other recommendations received a strong consensus level. The final set of 25 recommendations was divided into four sections: (1) a pre-rescue section consisting of five recommendations, (2) a rescue section consisting of 14 recommendations, (3) a post-rescue section consisting of two recommendations, and (4) a patient selection section consisting of four recommendations.

Table 2 The final set of recommendations clarified by a rationale with levels of agreement
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The final flowchart (Fig. 3) received a strong level of consensus with an overall agreement of 93%. Each of the four routes in the flowchart received a strong level of consensus (90–95%) (Table 3).

Fig. 3
figure 3

In-water spinal trauma flowchart—prehospital guidelines for trained lifeguards and prehospital EMS. The flowchart was constructed and adjusted according to the recommendations. The flowchart received strong consensus (93%) in Delphi round 3. Each of the four routes in the flowchart received strong consensus: Route 1 to the left (90%), route 2 in the middle left (95%), route 3 in the middle right (95%), and route 4 to the right (90%). Footnotes are provided and should be used together with the flowchart

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Table 3 Flowchart with levels of agreement
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Discussion

A total of 24 experts from 15 countries participated in this study to produce an international expert consensus on handling patients with suspected in-water TSCI. Eighteen (75% of the experts) did not have a local or national guideline on handling in-water TSCI before the initiation of this study emphasizing the need for development of guidelines. This study produced a list of 25 recommendations and a flowchart to standardise guidelines on SMR performed by trained lifeguards or prehospital EMS of patients with suspected in-water TSCI. All 25 recommendations were individually approved, with a consensus of 81–100%. The final flowchart received a strong level of consensus with an overall agreement of 93%. Each of the four routes in the flowchart received a strong level of consensus (90–95%).

Consistency with the existing literature

EMS systems worldwide use different triaging tools to decide whether to perform SMR [10, 59,60,61]. The recommendations and flowchart developed in this study have many similarities with recent Scandinavian guidelines, adding to the external validity of our findings [9,10,11]. One major exception is for patients with an altered level of consciousness or a critical ABC problem, where “Time-critical spinal motion restriction” has been replaced with “No spinal motion restriction”, as attempting to perform SMR on these groups of patients in the water may significantly increase the risk of drowning. The same applies to circumstances with imminent danger of drowning or injury, as performing SMR in locations with high surf, fast-moving water, or rocky areas will increase the risk to the lifeguard(s) and patient(s). Other triaging tools are based on decision aids like the Canadian C-Spine Rule (CCSR) [62], or the National Emergency X-radiography Utilisation Study (NEXUS) [63]. These decision aids were initially intended to decide whether the patient needed radiography and were later extrapolated as a decision aid on SMR [64]. The NEXUS rule addresses intoxication and distracting injuries specifically. The focus on intoxication and distracting injuries were removed in the Scandinavian guidelines [9]. It is impossible to rule out intoxication clinically and difficult to differentiate between intoxication symptoms, concussions, or critical neurological injuries [9, 53], and studies indicate that distracting injuries do not disturb the sensitivity of a spine examination [54,55,56].

During the Delphi process, some issues enriched the understanding of what makes in-water TSCI special.

Any patient face-down in the water is in imminent danger of hypoxia or drowning and must be turned face-up immediately and carefully. The word “carefully” highlights the need for securing a stable position of the head in relation to the thorax during the turn, as inept handling of these patients may also lead to secondary injury. However, this must not cause delay.

Clinical assessments in the aquatic environment are challenging, and lifeguards are not trained as healthcare professionals to perform clinical examinations. Simple and sensitive diagnostic tools should guide clinical decision-making. We recommend using the symptoms of spinal pain and neurological deficits to assess the need for spinal motion restriction in alert patients without a critical ABC problem suspected of in-water TSCI by asking the patient: “Do you feel pain in your neck or back?” and “Can you move your arms and legs?”. Once on land, EMS personnel should perform additional assessments of the patient as part of advanced patient care.

Alert patients suspected of in-water TSCI who can perform self-stabilisation and self-extrication should be guided to do so [9, 32], as the risk of an unstable spinal injury in alert patients is extremely low [34], and alert patients will automatically stabilise their spine in the most comfortable position [9, 34, 51]. This should also be the case for children [52], allowing them to sit with their parents when possible. Alert patients, including children without a critical ABC problem who cannot perform self-stabilisation and self-extrication, should be extricated using SMR. Children under eight may require an additional 2.5 cm back elevation under their shoulders to achieve a better neutral head position in the supine position [58]. Guiding self-extrication, performing SMR, and placing back elevation in young children require specific training. Therefore, we defined a “lifeguard” in the preamble as someone who has completed professional training in SMR and extrication.

Using at least three persons to perform SMR achieved consensus among the experts. However, depending on the local circumstances and availability of lifeguards, SMR can be practised with fewer lifeguards. We also recommended integrating untrained bystanders under the leadership of the lifeguard if there are not enough trained lifeguards available. This could delay extrication yet improve the quality of spinal motion restriction and lower the risks to the lifeguard and the patient and may be used in specific situations.

Strengths

This study has several strengths. We used purposive sampling to select a suitable group of experts with the necessary expertise. We used clear expert inclusion criteria to avoid introducing bias and sent invitations to the ILS-MC, ILS-RC, and IDRA. The experts represented high-, low-, and middle-income countries from Europe, North America, South America, Asia, Africa, and Oceania, adding to the generalizability of our findings. The Delphi rounds 2 and 3 achieved high response rates, limiting the risk of non-response bias. The risk of group pressure, frequently associated with expert panels, was minimised by providing a unique link for each expert per round and anonymising all responses before analyses [23, 65].

Finally, lifeguards worldwide spend considerable time practising complicated SMR techniques and extrication from challenging aquatic environments, believing that these techniques may prevent secondary injury [19]. This study provides international prehospital standards on handling in-water TSCI, which can be used to uniformise lifeguard training.

Limitations

This study has several limitations. The broad inclusion criteria might have diluted the qualification of being an “expert”. However, data showed that 79% of the experts had clinical expertise, and 92% had teaching expertise with in-water TSCI. Conversely, trained lifeguards, EMS personnel, patients, and the public were underrepresented or absent from the study. Future research should obtain the views of more diverse stakeholder groups. The steering committee may have gained influence and introduced confirmation and acquiescence bias by summarising the existing body of evidence and suggesting a preliminary set of recommendations in Delphi round 1, which was based on the recent Scandinavian guidelines [9]. This seems unlikely as the decision to remove or rephrase the recommendations was based exclusively on the experts’ opinions and was not in any way influenced by the steering committee. Also, the high levels of agreement in the subsequent Delphi rounds make this influence unlikely.

The scarcity of high-quality evidence regarding in-water TSCI is a significant limitation to developing clinical guidelines, including recommendations for or against certain types of equipment (e.g., backboard). For now, it remains unlikely that well-designed, prospective studies, including randomised clinical trials focusing on the aquatic environment, are possible. Despite the low-quality evidence supporting these guidelines, the recommendations and the flowchart can serve as the best standard for a useful decision aid for trained lifeguards and prehospital EMS. These guidelines provide a simple and realistic method for SMR which can be implemented in lifeguard training programs to reduce unnecessary time expenditure while maximising the lifeguards’ level of competency.

However, caution is needed in implementing some of the recommendations, as there may be legal issues regarding equipment use.

Conclusion

This study produced international expert consensus on 25 recommendations and a flowchart on handling patients with suspected in-water TSCI. These simple guidelines provide a feasible and structured approach to perform SMR of patients with suspected in-water TSCI and can serve to standardise lifeguard training, patient care, and cooperation with prehospital EMS.

Availability of data and materials

The survey questionnaires and datasets used and analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

ACCORD:

ACcurate COnsensus Reporting Document

EMS:

Emergency medical service

IDRA:

International Drowning Researchers’ Alliance

ILS:

International Life Saving Federation

ILS-MC:

International Life Saving Federation Medical Committee

ILS-RC:

International Life Saving Federation Rescue Commission

IQR:

Interquartile ranges

REDCap:

Research Electronic Data Capture

SMR:

Spinal motion restriction

TSCI:

Traumatic spinal cord injury

References

  1. Ahuja CS, Wilson JR, Nori S, et al. Traumatic spinal cord injury. Nat Rev Dis Primers. 2017;3(1):17018. https://doi.org/10.1038/nrdp.2017.18.

    Article  PubMed  Google Scholar 

  2. Chang SKY, Tominaga GT, Wong JH, Weldon EJ, Kaan KT. Risk factors for water sports-related cervical spine injuries. J Trauma Injury Infect Crit Care. 2006;60(5):1041–6. https://doi.org/10.1097/01.ta.0000218256.39295.8f.

    Article  Google Scholar 

  3. Torg JS. Epidemiology, pathomechanics, and prevention of athletic injuries to the cervical spine. Med Sci Sports Exerc. 1985;17(3):295–303.

    Article  CAS  PubMed  Google Scholar 

  4. Oyinbo CA. Secondary injury mechanisms in traumatic spinal cord injury: a nugget of this multiply cascade. Acta Neurobiol Exp (Wars). 2011;71(2):281–99.

    Article  PubMed  Google Scholar 

  5. Ray SK, Dixon CE, Banik NL. Molecular mechanisms in the pathogenesis of traumatic brain injury. Histol Histopathol. 2002;17(4):1137–52. https://doi.org/10.14670/HH-17.1137.

    Article  CAS  PubMed  Google Scholar 

  6. Rossignol S, Schwab M, Schwartz M, Fehlings MG. Spinal cord injury: time to move? J Neurosci. 2007;27(44):11782–92. https://doi.org/10.1523/JNEUROSCI.3444-07.2007.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg. 1991;75(1):15–26. https://doi.org/10.3171/jns.1991.75.1.0015.

    Article  CAS  PubMed  Google Scholar 

  8. Choo AM, Liu J, Lam CK, Dvorak M, Tetzlaff W, Oxland TR. Contusion, dislocation, and distraction: primary hemorrhage and membrane permeability in distinct mechanisms of spinal cord injury. SPI. 2007;6(3):255–66. https://doi.org/10.3171/spi.2007.6.3.255.

    Article  Google Scholar 

  9. Maschmann C, Jeppesen E, Rubin MA, Barfod C. New clinical guidelines on the spinal stabilisation of adult trauma patients - consensus and evidence based. Scand J Trauma Resusc Emerg Med. 2019;27(1):77. https://doi.org/10.1186/s13049-019-0655-x.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Kornhall DK. The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury. Scand J Trauma Resusc Emerg Med 2017.

  11. Yli-Hankala A, Chew MS, Olkkola KT, Rehn M, Sverrisson KÖ, Møller MH. Clinical practice guideline on spinal stabilisation of adult trauma patients: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand. 2021;65(7):986–7. https://doi.org/10.1111/aas.13933.

    Article  PubMed  Google Scholar 

  12. Amorim EC, Vetter H, Mascarenhas LB, Gomes EG, Carvalho JBF, Gomes JF. Spine trauma due to diving: main features and short-term neurological outcome. Spinal Cord. 2011;49(2):206–10. https://doi.org/10.1038/sc.2010.79.

    Article  CAS  PubMed  Google Scholar 

  13. Bailes JE, Herman JM, Quigley MR, Cerullo LJ, Meyer PR. Diving injuries of the cervical spine. Surg Neurol. 1990;34(3):155–8. https://doi.org/10.1016/0090-3019(90)90064-V.

    Article  CAS  PubMed  Google Scholar 

  14. Bárbara-Bataller E, Méndez-Suárez JL, Alemán-Sánchez C, Sánchez-Enríquez J, Sosa-Henríquez M. Lesión medular secundaria a zambullida en Canarias. Neurocirugía. 2017;28(4):183–9. https://doi.org/10.1016/j.neucir.2017.01.005.

    Article  PubMed  Google Scholar 

  15. Chan-Seng E, Perrin FE, Segnarbieux F, Lonjon N. Cervical spine injuries from diving accident: a 10-year retrospective descriptive study on 64 patients. Orthop Traumatol Surg Res. 2013;99(5):607–13. https://doi.org/10.1016/j.otsr.2013.04.003.

    Article  CAS  PubMed  Google Scholar 

  16. Frankel HL, Montero FA, Penny PT. Spinal cord injuries due to diving. Spinal Cord. 1980;18(2):118–22. https://doi.org/10.1038/sc.1980.19.

    Article  CAS  Google Scholar 

  17. Griffiths ER. Spinal injuries from swimming and diving treated in the spinal department of Royal Perth Rehabilitation Hospital: 1956–1978. Spinal Cord. 1980;18(2):109–17. https://doi.org/10.1038/sc.1980.18.

    Article  Google Scholar 

  18. Kiwerski J. Cervical spine injuries caused by diving into water. Spinal Cord. 1980;18(2):101–5. https://doi.org/10.1038/sc.1980.16.

    Article  CAS  Google Scholar 

  19. Green BA, Gabrielsen MA, Hall WJ, O’Heir J. Analysis of swimming pool accidents resulting in spinal cord injury. Spinal Cord. 1980;18(2):94–100. https://doi.org/10.1038/sc.1980.15.

    Article  CAS  Google Scholar 

  20. DeVivo MJ, Sekar P. Prevention of spinal cord injuries that occur in swimming pools. Spinal Cord. 1997;35(8):509–15. https://doi.org/10.1038/sj.sc.3100430.

    Article  CAS  PubMed  Google Scholar 

  21. Korres DS, Benetos IS, Themistocleous GS, Mavrogenis AF, Nikolakakos L, Liantis PT. Diving injuries of the cervical spine in amateur divers. Spine J. 2006;6(1):44–9. https://doi.org/10.1016/j.spinee.2005.06.013.

    Article  PubMed  Google Scholar 

  22. Breindahl N, Wolthers SA, Møller TP, et al. Characteristics and critical care interventions in drowning patients treated by the Danish Air Ambulance from 2016 to 2021: a nationwide registry-based study with 30-day follow-up. Scand J Trauma Resusc Emerg Med. 2024;32(1):17. https://doi.org/10.1186/s13049-024-01189-y.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Murphy MK, Black NA, Lamping DL, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998;2(3):i-iv, 1–88.

  24. Gattrell WT, Logullo P, van Zuuren EJ, et al. ACCORD (ACcurate COnsensus Reporting Document): A reporting guideline for consensus methods in biomedicine developed via a modified Delphi. PLoS Med. 2024;21(1): e1004326. https://doi.org/10.1371/journal.pmed.1004326.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Akins RB, Tolson H, Cole BR. Stability of response characteristics of a Delphi panel: application of bootstrap data expansion. BMC Med Res Methodol. 2005;5(1):37. https://doi.org/10.1186/1471-2288-5-37.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. https://doi.org/10.1016/j.jbi.2008.08.010.

    Article  PubMed  Google Scholar 

  27. Szpilman D, Palacios Aguilar J, Barcala-Furelos R, et al. Drowning and aquatic injuries dictionary. Resusc Plus. 2021;5: 100072. https://doi.org/10.1016/j.resplu.2020.100072.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Diamond IR, Grant RC, Feldman BM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401–9. https://doi.org/10.1016/j.jclinepi.2013.12.002.

    Article  PubMed  Google Scholar 

  29. R Core Team. R: A language and environment for statistical computing. Published 2022. https://www.R-project.org/

  30. Watson RS, Cummings P. Cervical spine injuries among submersion victims. J Trauma. 2001;51:658–62.

    Article  CAS  PubMed  Google Scholar 

  31. Australian Resuscitation Council, New Zealand Resuscitation Council. ANZCOR Guideline 9.1.6: Management of Suspected Spinal Injury. Published online January 2016. Accessed January 2, 2023. https://www.resus.org.nz/assets/Uploads/ANZCOR-Guideline-9-1-6-Spinal-Jan16.pdf

  32. Zideman DA, Singletary EM, Borra V, et al. European resuscitation council guidelines 2021: first aid. Resuscitation. 2021;161:270–90. https://doi.org/10.1016/j.resuscitation.2021.02.013.

    Article  PubMed  Google Scholar 

  33. Romanelli D, Farrell MW. AVPU (Alert, Voice, Pain, Unresponsive). In: StatPearls. StatPearls Publishing; 2020. Accessed June 19, 2020. http://www.ncbi.nlm.nih.gov/books/NBK538431/

  34. Benger J, Blackham J. Why do we put cervical collars on conscious trauma patients? Scand J Trauma Resusc Emerg Med. 2009;17(1):44. https://doi.org/10.1186/1757-7241-17-44.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Hood N, Considine J. Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature. Australas Emerg Nurs J. 2015;18(3):118–37. https://doi.org/10.1016/j.aenj.2015.03.003.

    Article  PubMed  Google Scholar 

  36. Purvis TA, Carlin B, Driscoll P. The definite risks and questionable benefits of liberal pre-hospital spinal immobilisation. Am J Emerg Med. 2017;35(6):860–6. https://doi.org/10.1016/j.ajem.2017.01.045.

    Article  PubMed  Google Scholar 

  37. Barati KAM. The effect of soft and rigid cervical collars on head and neck immobilization in healthy subjects. Asian Spine J. 2017;11:390–5.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Ivancic PC. Do cervical collars and cervicothoracic orthoses effectively stabilize the injured cervical spine? A biomechanical investigation. Spine. 2013;38(13):E767–74. https://doi.org/10.1097/BRS.0b013e318290fb0f.

    Article  PubMed  Google Scholar 

  39. Horodyski M, DiPaola CP, Conrad BP, Rechtine GR. Cervical collars are insufficient for immobilizing an unstable cervical spine injury. J Emerg Med. 2011;41(5):513–9. https://doi.org/10.1016/j.jemermed.2011.02.001.

    Article  PubMed  Google Scholar 

  40. Connor D, Greaves I, Porter K, Bloch M, On behalf of the consensus group, Faculty of Pre-Hospital Care. Pre-hospital spinal immobilisation: an initial consensus statement. Emerg Med J. 2013;30(12):1067–1069. https://doi.org/10.1136/emermed-2013-203207

  41. Holla MHG. Restriction of cervical intervertebral movement with different types of external immobilizers a cadaveric 3D analysis study. Spine (Phila Pa 1976). 2017;42:E1182–9.

    Article  PubMed  Google Scholar 

  42. Podolsky SBL. Efficacy of cervical spine immobilization methods. J Trauma. 1983;23:461–5.

    Article  CAS  PubMed  Google Scholar 

  43. McCabe JB, Nolan DJ. Comparison of the effectiveness of different cervical immobilization collars. Ann Emerg Med. 1986;15:50–3.

    Article  CAS  PubMed  Google Scholar 

  44. Pryce RMN. Prehospital spinal immobilization: effect of effort on kinematics of voluntary head-neck motion assessed using accelerometry. Prehosp Disaster Med. 2016;31:36–42.

    Article  PubMed  Google Scholar 

  45. Davies G, Deakin C. The effect of a rigid collar on intracranial pressure. Injury. 1996;27:647–9.

    Article  CAS  PubMed  Google Scholar 

  46. Maissan IM, Ketelaars R, Vlottes B, Hoeks SE, den Hartog D, Stolker RJ. Increase in intracranial pressure by application of a rigid cervical collar: a pilot study in healthy volunteers. Eur J Emerg Med. 2018;25(6):e24–8. https://doi.org/10.1097/MEJ.0000000000000490.

    Article  PubMed  Google Scholar 

  47. Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;78(2):430–41. https://doi.org/10.1097/TA.0000000000000503.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Freauf M, Puckeridge N. To board or not to board: an evidence review of prehospital spinal immobilization. JEMS. 2015;40(11):43–5.

    PubMed  Google Scholar 

  49. Lerner EB, Billittier AJ, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects. Prehosp Emerg Care. 1998;2(2):112–6. https://doi.org/10.1080/10903129808958853.

    Article  CAS  PubMed  Google Scholar 

  50. Ham WHW, Schoonhoven L, Schuurmans MJ, Leenen LPH. Pressure ulcers, indentation marks and pain from cervical spine immobilization with extrication collars and headblocks: an observational study. Injury. 2016;47(9):1924–31. https://doi.org/10.1016/j.injury.2016.03.032.

    Article  PubMed  Google Scholar 

  51. Rogers L. No place for the rigid cervical collar in pre-hospital care. International Paramedic Practice. 2017;7(1):12–5. https://doi.org/10.12968/ippr.2017.7.1.12.

    Article  Google Scholar 

  52. International Life Saving Federation Medical Committee. Medical Position Statement 21: Spinal Injury Management. Published online 2016.

  53. Martin MJ, Bush L. Cervical spine evaluation and clearance in the intoxicated patient: a prospective Western trauma association multi-institutional trial and survey accreditation statement. J Trauma Acute Care Surg. 2017;83:1032–40.

    Article  PubMed  Google Scholar 

  54. Konstantinidis A, Plurad D. 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 Inj Infect Crit Care. 2011;71:528–32.

    Google Scholar 

  55. Dahlquist RT, Fischer PE, Desai H, et al. Femur fractures should not be considered distracting injuries for cervical spine assessment. Am J Emerg Med. 2015;33(12):1750–4. https://doi.org/10.1016/j.ajem.2015.08.009.

    Article  PubMed  Google Scholar 

  56. Cason BRJ. Thoracolumbar spine clearance: clinical examination for patients with distracting injuries. J Trauma Acute Care Surg. 2016;80:125–30.

    Article  PubMed  Google Scholar 

  57. National Association of Emergency Medical Technicians (U.S.), Pre-Hospital Trauma Life Support Committee, American College of Surgeons, Committee on Trauma. Spinal Trauma. In: Emerton C, Editor. PHTLS® Prehospital Trauma Life Support. 8th ed. Burlington, MA: Jones & Bartlett Learning; 2016:289–314.

  58. Nypaver M, Treloar D. Neutral cervical spine positioning in children. Ann Emerg Med. 1994;23(2):208–11. https://doi.org/10.1016/S0196-0644(94)70032-X.

    Article  CAS  PubMed  Google Scholar 

  59. Stroh G, Braude D. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med. 2001;37(6):609–15. https://doi.org/10.1067/mem.2001.114409.

    Article  CAS  PubMed  Google Scholar 

  60. Burton JH, Dunn MG, Harmon NR, Hermanson TA, Bradshaw JR. A Statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma Injury Infect Crit Care. 2006;61(1):161–7. https://doi.org/10.1097/01.ta.0000224214.72945.c4.

    Article  Google Scholar 

  61. Domeier RM. Indications for prehospital spinal immobilization. Prehosp Emerg Care. 1999;3(3):251–3. https://doi.org/10.1080/10903129908958946.

    Article  CAS  PubMed  Google Scholar 

  62. Stiell IG. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841. https://doi.org/10.1001/jama.286.15.1841.

    Article  CAS  PubMed  Google Scholar 

  63. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94–9. https://doi.org/10.1056/NEJM200007133430203.

    Article  CAS  PubMed  Google Scholar 

  64. Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CWC. 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. 2012;184(16):E867–76. https://doi.org/10.1503/cmaj.120675.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Mahajan V, Linstone HA, Turoff M. The Delphi method: techniques and applications. J Mark Res. 1976;13(3):317. https://doi.org/10.2307/3150755.

    Article  Google Scholar 

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Acknowledgements

The authors would like to acknowledge the support of the ILS and IDRA and the generous input of the experts who contributed to the generation of the recommendation and the flowchart during all three Delphi rounds. The following experts gave written consent to be acknowledged: Justin Sempsrott, Peter G. Wernicki, Andreas Claesson, Josh Carmine, Patrick Morgan, Monica Fernandez-Robles, Leonardo Springer, Manino Leonardo Andres, Mohamed Saleh, Alex Kam Hung Liu, Adrian Mayhew, Riley Huntley, Allart M. Venema, Ramses Marti Biosca, Cody Dunne, Gary Payinda, Eric Tellier, Silvia Aranda-García, Ismael Sanz Arribas, and Natalie Hood (Online Supplement, Appendix D).

Funding

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Authors and Affiliations

  1. Prehospital Center Region Zealand, Ringstedgade 61, 13, 4700, Næstved, Denmark

    Niklas Breindahl

  2. Department of Neonatal and Pediatric Intensive Care, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark

    Niklas Breindahl

  3. Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

    Niklas Breindahl & Sebastian Wiberg

  4. International Life Saving Federation, Leuven, Belgium

    Niklas Breindahl, Joost L. M. Bierens & Roberto Barcala-Furelos

  5. International Drowning Researchers’ Alliance, Kuna, ID, USA

    Niklas Breindahl, Joost L. M. Bierens & Roberto Barcala-Furelos

  6. Extreme Environments Laboratory, School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, UK

    Joost L. M. Bierens

  7. Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark

    Sebastian Wiberg

  8. REMOSS Research Group, Faculty of Education and Sports Sciences, Universidade de Vigo, Pontevedra, Spain

    Roberto Barcala-Furelos

  9. Department of Emergency Medicine NFZ, Cantonal Hospital St. Gallen, Gallen, Switzerland

    Christian Maschmann

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  4. Roberto Barcala-Furelos
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Contributions

NB, JLMB, SW, RBF, and CM (all authors) participated in the study conception and design. All authors were involved in the acquisition of data. NB analysed the data. All authors contributed to the interpretation of data. NB drafted the manuscript. JLMB, SW, RBF, and CM were involved in critically revising the manuscript. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Niklas Breindahl.

Ethics declarations

Ethics approval and consent to participate

Danish legislation states that survey questionnaires do not require Research Ethics Committee approval. Data management and processing were approved (ID-number: 2022-815). Participation in the study was voluntary and anonymous, and all participants gave written informed consent and signed a confidentiality declaration before accessing the survey for Delphi Round 1. Unauthorised access was impossible, as only the primary investigator could access the REDCAP forms. Datasets were de-identified prior to analyses, and all information was handled confidentially. The study is reported in compliance with the ACcurate COnsensus Reporting Document (ACCORD) [24] (Online Supplement, Appendix A).

Consent for publication

All participants gave written informed consent to participate and consented to the results being published.

Competing interests

The authors declare that they have no competing interests.

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Breindahl, N., Bierens, J.L.M., Wiberg, S. et al. Prehospital guidelines on in-water traumatic spinal injuries for lifeguards and prehospital emergency medical services: an international Delphi consensus study. Scand J Trauma Resusc Emerg Med 32, 76 (2024). https://doi.org/10.1186/s13049-024-01249-3

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Keywords

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

ISSN: 1757-7241