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Muzyka L, Bradford JM, Teixeira PG, DuBose J, Cardenas TCP, Bach M, Ali S, Robert M, Brown CVR. Trends in prehospital cervical collar utilization in trauma patients: Closer, but not there yet. Acad Emerg Med 2024; 31:36-41. [PMID: 37828864 DOI: 10.1111/acem.14822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/28/2023] [Accepted: 10/09/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE This study aims to assess the change in cervical spine (C-spine) immobilization frequency in trauma patients over time. We hypothesize that the frequency of unnecessary C-spine immobilization has decreased. METHODS A retrospective chart review of adult trauma patients transported to our American College of Surgeons-verified Level I trauma center from January 1, 2014, to December 31, 2021, was performed. Emergency medical services documentation was manually reviewed to record prehospital physiology and the application of a prehospital cervical collar (c-collar). C-spine injuries were defined as cervical vertebral fractures and/or spinal cord injuries. Univariate and year-by-year trend analyses were used to assess changes in C-spine injury and immobilization frequency. RESULTS Among 2906 patients meeting inclusion criteria, 12% sustained C-spine injuries, while 88% did not. Patients with C-spine injuries were more likely to experience blunt trauma (95% vs. 68%, p < 0.001), were older (46 years vs. 41 years, p < 0.001), and had higher Injury Severity Scores (31 vs. 18, p < 0.001). They also exhibited lower initial systolic blood pressures (108 mm Hg vs. 119 mm Hg, p < 0.001), lower heart rates (92 beats/min vs. 97 beats/min, p < 0.05), and lower Glasgow Coma Scale scores (9 vs. 11, p < 0.001). In blunt trauma, c-collars were applied to 83% of patients with C-spine injuries and 75% without; for penetrating trauma, c-collars were applied to 50% of patients with C-spine injuries and only 8% without. Among penetrating trauma patients with C-spine injury, all patients either arrived quadriplegic or did not require emergent neurosurgical intervention. The proportion of patients receiving a c-collar decreased in both blunt and penetrating traumas from 2014 to 2021 (blunt-82% in 2014 to 68% in 2021; penetrating-24% in 2014 to 6% in 2021). CONCLUSIONS Unnecessary C-spine stabilization has decreased from 2014 to 2021. However, c-collars are still being applied to patients who do not need them, both in blunt and in penetrating trauma cases, while not being applied to patients who would benefit from them.
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Affiliation(s)
- Logan Muzyka
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - James M Bradford
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Joseph DuBose
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Tatiana C P Cardenas
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Michelle Bach
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Sadia Ali
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Michelle Robert
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Carlos V R Brown
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
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Jao S, Wang Z, Mukhi A, Chaudhary N, Martin J, Yuan V, Laskowski R, Huang E, Vosswinkel J, Singer AJ, Jawa R. Radiographic cervical spine injury patterns in admitted blunt trauma patients with and without prehospital spinal motion restriction. Trauma Surg Acute Care Open 2023; 8:e001092. [PMID: 38020851 PMCID: PMC10668292 DOI: 10.1136/tsaco-2023-001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives Selective prehospital cervical spine motion restriction (C-SMR) following blunt trauma has increasingly been used by emergency medical service (EMS) providers. We determined rates of prehospital C-SMR and concomitant radiographic injury patterns. Methods A retrospective trauma registry and chart review was conducted for all adult blunt trauma patients who were transported by EMS and hospitalized with radiographic cervical spine injuries from 2011 to 2019 at a level 1 trauma center. Results Of 658 admitted blunt trauma patients with confirmed cervical spine injury by imaging, 117 (17.8%) did not receive prehospital C-SMR. Patients without prehospital C-SMR were significantly older (76 vs 54 years), more often had low fall as mechanism of injury (59.8% vs 15.9%) and had lower Injury Severity Score (10 vs 17). Patients without C-SMR (Non-SMR) experienced the full array of cervical spine injury types and locations. While the non-SMR patients most often had dens fractures,C-SMR patients most often had C7 fractures; frequencies of fractures at the remaining vertebral levels were comparable. On MRI, cervical spinal cord (8.5% vs 19.6%) and ligamentous injuries (5.1% vs 12.6%) occurred less often in non-SMR patients. Approximately 8.5% of non-SMR patients and 20% of C-SMR patients required cervical spine surgery. Conclusion Patients without prehospital C-SMR demonstrate a broad array of cervical spine injuries. While the rates of certain cervical injuries are lower in prehospital non-SMR patients, they are not insignificant. Level of evidence Level III.
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Affiliation(s)
- Susan Jao
- Stony Brook University, Stony Brook, New York, USA
| | - Zhe Wang
- Stony Brook University, Stony Brook, New York, USA
| | - Ambika Mukhi
- Stony Brook University, Stony Brook, New York, USA
| | | | | | | | | | - Emily Huang
- Stony Brook University, Stony Brook, New York, USA
| | | | - Adam J Singer
- Emergency Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Randeep Jawa
- Stony Brook University, Stony Brook, New York, USA
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Jung E, Ro YS, Ryu HH, Shin SD. Impact of cervical spine immobilization on clinical outcomes in traumatic brain injury patients according to prehospital mean arterial pressure: A multinational and multicenter observational study. Medicine (Baltimore) 2023; 102:e32849. [PMID: 36800598 PMCID: PMC9936025 DOI: 10.1097/md.0000000000032849] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
Cervical spine immobilization (CSI) has been considered an essential part of first aid management after severe trauma; however, the routine use of CSI for traumatic brain injury (TBI) patients is a matter of debate. The purpose of our study was to analyze the effect of CSI on the clinical outcomes of TBI patients and to analyze whether this effect depends on the prehospital mean arterial pressure (MAP) This was a prospective multi-national, multi-center cohort study using Pan-Asian trauma outcome study registry in Asian-Pacific, conducted on adult trauma patients. The main exposure was the implementation of CSI before hospital arrival. The main outcome was poor functional recovery at hospital discharge measured by the modified rankin scale. We performed multilevel logistic regression analysis to estimated the effect size of CSI for study outcomes. Interaction analysis between CSI and MAP on study outcomes were also conducted. CSI for TBI patients is significantly associated with an increased poor functional outcome (adjusted odd ratio, 95% confidence intervals: 1.23 [1.03 - 1.44]). The association of CSI with poor functional outcomes was maintained only in patients with decreased prehospital MAP (1.38 [1.14 - 1.56]), but not in patients with normal MAP (1.12 [0.93 - 1.24]) (P for interaction < .05). Routine use of CSI for patients with TBI, but without cervical spine injury, is associated with poor functional outcomes, but is significant only when the MAP, measured at the scene, was decreased.
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Affiliation(s)
- Eujene Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyun Ho Ryu
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, KoreaMedicine, Chonnam National University, Gwangju, Korea
- * Correspondence: Hyun Ho Ryu, Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-Gu, Gwangju 61469, Korea (e-mail: )
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Emergency Medicine, Seoul National University, Seoul, Korea
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Implementation of the Modified Canadian C-Spine Rule by Paramedics. Ann Emerg Med 2023; 81:187-196. [PMID: 36328852 DOI: 10.1016/j.annemergmed.2022.08.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/26/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE The Canadian C-spine rule was modified and validated for use by the paramedics in a multicenter study where patients were assessed with the Canadian C-spine rule yet all transported with immobilization. This study evaluated the clinical impact of the modified Canadian C-spine rule when implemented by paramedics. METHODS This single-center prospective cohort implementation study took place in Ottawa, Canada (from 2011 to 2015). Advanced and primary care paramedics were trained to use the modified Canadian C-spine rule, collect data on a standardized study form, and selectively transport eligible patients without immobilization. We evaluated all consecutive low-risk adult patients (Glasgow Coma Scale [GCS] 15, stable vital signs) at risk for a neck injury. We followed all patients without initial radiologic evaluation for 30 days. Analyses included descriptive statistics with 95% confidence intervals (CI), sensitivity, specificity, and kappa coefficients. RESULTS The 4,034 enrolled patients had a mean age of 43 (range 16 to 99), and 53.4% were female. Motor vehicle collisions were the most common mechanism of injury (55.1%), followed by falls (23.9%). There were 11 clinically important injuries. The paramedics classified these injuries with a sensitivity of 90.9% (95% CI, 58.7 to 99.8) and specificity of 66.5% (95% CI, 65.1 to 68.0). There was no adverse event or resulting spinal cord injury. The kappa agreement between paramedics and investigators was 0.94. A total of 2,583 (64.0%) immobilizations were avoided using the modified Canadian C-spine rule. CONCLUSION Paramedics could accurately apply the modified Canadian C-spine rule to low-risk trauma patients and significantly reduce the need for spinal immobilization during transport. This resulted in no adverse event or any spinal cord injury.
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Pediatric Trauma. Emerg Med Clin North Am 2023; 41:205-222. [DOI: 10.1016/j.emc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Hofstetter P, Schröder H, Beckers SK, Borgs C, Rossaint R, Felzen M. Immobilization in Emergency Medical Service - Are CSR and NEXUS-Criteria Considered? A Matched-Pairs Analysis Between Trauma Patients Treated by Onsite EMS Physicians and Patients Treated by Tele-EMS Physicians. Open Access Emerg Med 2023; 15:145-155. [PMID: 37187612 PMCID: PMC10178902 DOI: 10.2147/oaem.s386650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 03/28/2023] [Indexed: 05/17/2023] Open
Abstract
Background The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over- as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS- and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device. Methods A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter. Results Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard. Conclusion It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS- and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.
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Affiliation(s)
- Paula Hofstetter
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Department of Anesthesiology, Rhein-Maas Klinikum, Würselen, Germany
| | - Hanna Schröder
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany
| | - Stefan K Beckers
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany
- Medical Direction of Aachen Fire Department, Aachen, Germany
| | - Christina Borgs
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marc Felzen
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
- Aachen Institute for Rescue Management & Public Safety, City of Aachen and University Hospital RWTH Aachen, Aachen, Germany
- Medical Direction of Aachen Fire Department, Aachen, Germany
- Correspondence: Marc Felzen, Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany, Tel +49 241 8088179, Fax +49 241 82406, Email
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Cowley A, Nelson M, Hall C, Goodwin S, Kumar DS, Moore F. Recommendation for changes to the guidelines of trauma patients with potential spinal injury within a regional UK ambulance trust. Br Paramed J 2022; 7:59-67. [PMID: 36531802 PMCID: PMC9730189 DOI: 10.29045/14784726.2022.12.7.3.59] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Spinal assessment and immobilisation has been a topic of debate for many years where, despite an emerging evidence base and the delivery of new guidance overseas, little has changed within UK pre-hospital practice. Since 2018, South East Coast Ambulance Service NHS Foundation Trust has spent time working with local trauma networks and expertise from within the region and international colleagues to develop a set of C-spine assessment and immobilisation guidelines that reflect the current best available international evidence and significant changes in international pre-hospital practice from settings such as Scandinavia and Australasia. METHODS A specialist group was commissioned to review the topic of pre-hospital spinal immobilisation and explore potential for evidence-based improvement. In conjunction with local trauma networks, subject matter experts and a thorough review of recent literature, a series of recommendations were made in order to improve spinal care within the authoring trust. RESULTS Seven recommendations were made, and an updated set of guidelines produced. These included the removal of semi-rigid collars from pre-hospital spinal immobilisation; the creation of two tiers of patients to ensure that the high-risk and low-risk populations are considered separately and an accompanying decision tool to safeguard both cohorts; an increased emphasis on the risk of spinal injury in the frail and older patient; an emphasis on spinal motion restriction rather than rigid immobilisation; an increased emphasis on self-extrication; and the use of a marker for emergency departments. SUMMARY An updated set of guidance has been produced using a combination of specialist and expert opinion alongside a literature review with close involvement of key stakeholders, both public and professional. The new guidance helps to ensure a patient-centred approach where each person is considered an individual with their risk of injury and management measures tailored to their specific needs.
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Affiliation(s)
- Alan Cowley
- South East Coast Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0002-3093-4395
| | - Magnus Nelson
- South East Coast Ambulance Service NHS Foundation Trust
| | - Claire Hall
- South East Coast Ambulance Service NHS Foundation Trust
| | - Simon Goodwin
- South East Coast Ambulance Service NHS Foundation Trust
| | | | - Fionna Moore
- South East Coast Ambulance Service NHS Foundation Trust
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Neurosurgeons Relate Heterogeneous Practices Regarding Activity and Return to Work After Spine Surgery. World Neurosurg 2022; 162:e309-e318. [PMID: 35259506 DOI: 10.1016/j.wneu.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Given the paucity of relevant data, the Council of State Neurosurgical Societies Workforce Committee launched a survey of neurosurgeons to assess patterns in activity restriction recommendations following spine surgery; the ultimate goal was to optimize and potentially standardize these recommendations. The aim of this initial study was to determine current practices in activity restrictions and return to work guidelines following common spinal procedures. METHODS The survey included questions regarding general demographics and practice data, postoperative bracing/orthosis utilization, and guidelines for postoperative return to different levels of activity/types of work following specific spine surgery interventions. A spectrum of typical spine surgeries was assessed, including microdiscectomy, anterior cervical discectomy and fusion (ACDF), and lumbar fusion, both open and minimal invasive surgery (MIS) approaches. RESULTS There was significant interprocedure and intraprocedure variation in the neurosurgeons' recommendations for postoperative activity and return to work recommendations after various spinal surgery procedures. Comparisons of the different surgical procedures evaluated revealed significant differences in cervical collar use (more often used following ≥2-level ACDF than single-level ACDF; P < 0.001), return to both sedentary and light physical work (greater restriction with ≥2-level ACDF than with single-level ACDF; P < 0.001), and return to a light exercise regimen (sooner following MIS versus open lumbar fusion; P < 0.001). CONCLUSIONS This survey demonstrated little consistency regarding return to work recommendations, general activity restrictions, and orthosis utilization following common spinal surgical procedures. Addressing this issue also has significant implications for the societal and personal costs of spine surgery.
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ResQbot 2.0: An Improved Design of a Mobile Rescue Robot with an Inflatable Neck Securing Device for Safe Casualty Extraction. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11125414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the fact that a large number of research studies have been conducted in the field of search and rescue robotics, significantly little attention has been given to the development of rescue robots capable of performing physical rescue interventions, including loading and transporting victims to a safe zone—i.e., casualty extraction tasks. The aim of this study is to develop a mobile rescue robot that could assist first responders when saving casualties from a dangerous area by performing a casualty extraction procedure whilst ensuring that no additional injury is caused by the operation and no additional lives are put at risk. In this paper, we present a novel design of ResQbot 2.0—a mobile rescue robot designed for performing the casualty extraction task. This robot is a stretcher-type casualty extraction robot, which is a significantly improved version of the initial proof-of-concept prototype, ResQbot (retrospectively referred to as ResQbot 1.0), that has been developed in our previous work. The proposed designs and development of the mechanical system of ResQbot 2.0, as well as the method for safely loading a full-body casualty onto the robot’s ‘stretcher bed’, are described in detail based on the conducted literature review, evaluation of our previous work, and feedback provided by medical professionals. We perform simulation experiments in the Gazebo physics engine simulator to verify the proposed design and the casualty extraction procedure. The simulation results demonstrate the capability of ResQbot 2.0 to carry out safe casualty extractions successfully.
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Erste Hilfe. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00886-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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11
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Serigano O, Riscinti M. Cervical Spine Motion Restriction After Blunt Trauma. Acad Emerg Med 2021; 28:472-474. [PMID: 32959426 DOI: 10.1111/acem.14134] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Olivia Serigano
- From Department of Emergency Medicine Denver Health Denver COUSA
| | - Matthew Riscinti
- From Department of Emergency Medicine Denver Health Denver COUSA
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Zideman DA, Singletary EM, Borra V, Cassan P, Cimpoesu CD, De Buck E, Djärv T, Handley AJ, Klaassen B, Meyran D, Oliver E, Poole K. European Resuscitation Council Guidelines 2021: First aid. Resuscitation 2021; 161:270-290. [PMID: 33773828 DOI: 10.1016/j.resuscitation.2021.02.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.
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Affiliation(s)
| | | | - Vere Borra
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium
| | - Pascal Cassan
- International Federation of Red Cross and Red Crescent, France
| | - Carmen D Cimpoesu
- University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Emergency Department and Prehospital EMS SMURD Iasi Emergency County Hospital "Sf. Spiridon" Iasi, Romania
| | - Emmy De Buck
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium; Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institute and Division of Acute and Reparative Medicine, Karolinska University Hospital, Sweden
| | | | - Barry Klaassen
- Emergency Medicine, Ninewells Hospital and Medical School Dundee, UK; British Red Cross, UK
| | - Daniel Meyran
- French Red Cross, Bataillon de Marins Pompiers de Marseille, France
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Asha SE, Curtis K, Healy G, Neuhaus L, Tzannes A, Wright K. Neurologic outcomes following the introduction of a policy for using soft cervical collars in suspected traumatic cervical spine injury: A retrospective chart review. Emerg Med Australas 2020; 33:19-24. [DOI: 10.1111/1742-6723.13646] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Stephen E Asha
- Emergency Department St George Hospital Sydney New South Wales Australia
- St George and Sutherland Clinical School, Faculty of Medicine The University of New South Wales Sydney New South Wales Australia
| | - Kate Curtis
- Sydney Nursing School The University of Sydney Sydney New South Wales Australia
- Emergency Services Illawarra Shoalhaven Local Health District Wollongong New South Wales Australia
- Illawarra Health and Medical Research Institute Wollongong New South Wales Australia
- The George Institute for Global Health Sydney New South Wales Australia
- Faculty of Science, Medicine and Health University of Wollongong Wollongong New South Wales Australia
| | - Georgina Healy
- Emergency Services Illawarra Shoalhaven Local Health District Wollongong New South Wales Australia
- Faculty of Science, Medicine and Health University of Wollongong Wollongong New South Wales Australia
| | - Lauren Neuhaus
- Emergency Department St George Hospital Sydney New South Wales Australia
| | - Alexander Tzannes
- Emergency Department St George Hospital Sydney New South Wales Australia
- St George and Sutherland Clinical School, Faculty of Medicine The University of New South Wales Sydney New South Wales Australia
- NSW Ambulance Aeromedical Operations Sydney New South Wales Australia
| | - Kelly Wright
- Emergency Department The Sutherland Hospital Sydney New South Wales Australia
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Vaillancourt C, Charette M, Taljaard M, Thavorn K, Hall E, McLeod B, Fergusson D, Brehaut J, Graham I, Calder L, Ramsay T, Tugwell P, Kelly P, Cheskes S, Saskin R, Plint A, Osmond M, Macarthur C, Straus S, Rochon P, Prud'homme D, Dahrouge S, Marlin S, Stiell IG. Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial. JMIR Res Protoc 2020; 9:e16966. [PMID: 32348267 PMCID: PMC7296410 DOI: 10.2196/16966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/23/2019] [Accepted: 12/31/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. OBJECTIVE This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. METHODS We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. RESULTS Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. CONCLUSIONS We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). TRIAL REGISTRATION ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/16966.
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Affiliation(s)
- Christian Vaillancourt
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | | | - Elizabeth Hall
- Patient Representative, Owner-Hall Consulting, Director-Helping Hands for India, Kanata, ON, Canada
| | - Brent McLeod
- Paramedic Representative, Hamilton Paramedic Service, Hamilton, ON, Canada
| | | | - Jamie Brehaut
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian Graham
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lisa Calder
- Medical Care Analytics, Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Tugwell
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Kelly
- Ottawa Paramedic Service, Ottawa, ON, Canada
| | - Sheldon Cheskes
- Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Amy Plint
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Martin Osmond
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | | | - Sharon Straus
- Knowledge Translation Program, St. Michael's Hospital, Toronto, ON, Canada
| | - Paula Rochon
- Women's College Research Institute, Toronto, ON, Canada
| | | | | | | | - Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Ladny M, Smereka J, Ahuja S, Szarpak L, Ruetzler K, Ladny JR. Effect of 5 different cervical collars on optic nerve sheath diameter: A randomized crossover trial. Medicine (Baltimore) 2020; 99:e19740. [PMID: 32311968 PMCID: PMC7220316 DOI: 10.1097/md.0000000000019740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There is considerable evidence that prolonged use of cervical collars potentially cause detrimental effects including increase in optic nerve sheath diameter (ONSD) among healthy volunteers. Different types of cervical collars immobilize cervical spine variably well and may presumably differently influence the venous compression and hence the intracranial pressure. We therefore aimed to evaluate the influence of cervical spine immobilization with 5 different types of cervical collars on ONSD measured noninvasively by ultrasound on healthy volunteers. METHODS We conducted a randomized crossover trial including 60 adult healthy volunteers. Control assessment of the optic nerve sheath thickness was performed in both sagittal and transverse planes. Patient was placed supine on a transport stretcher, cervical collar was placed, and ONSD measurement was performed after 5 and 20 minutes. During the next days, the procedure was repeated with random allocation of participants and random cervical collar. RESULTS Sixty healthy volunteers were included in our study. ONSD left diameter [mm] for the baseline was 3.8 [interquartile range (IQR): 3.65-3.93)] mm. Using AMBU after 5 min, ONSD was changed up to 4.505 (IQR 4.285-4.61; P < .001) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.73 (IQR: 4.49-4.895; P < .001) and 4.925 (IQR: 4.65-5.06; P < .001), respectively. Necklite reported the lower change in ONSD: 3.92 (IQR: 3.795-4; P = 1.0) mm in 5 minutes and 3.995 (IQR: 3.875 - 4.1; P = 1.0) mm in 20 minutes. ONSD right diameter [mm] for the baseline was 3.8 (IQR 3.675-3.9) mm. Using AMBU after 5 minutes, ONSD was changed up to 4.5 (IQR 4.21-4.6) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.705 (IQR 4.455-4.9) and 4.93 (IQR 4.645-5.075), respectively. Necklite reported the lower change in ONSD -33.9 (IQR 3.795-3.99) mm in 5 minutes and 3.995 (IQR 3.86-4.09) mm in 20 minutes. CONCLUSION We report significant increase of ONSD from the baseline after cervical collar placement among healthy volunteers at 5 minutes and 20 minutes interval. In addition, no significant difference was noted between ONSD measurements at 5 and 20 minutes. Clinicians should take proactive steps to assess the actual need of cervical collar case by case basis. Nonetheless, when needed, Necklite moldable neck brace seems to be a reasonable option.Registration: ClinicalTrials database (www.clinicaltrials.gov, NCT03609879).
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Affiliation(s)
- Michal Ladny
- Department of Trauma-Orthopedic Surgery, Solec Hospital, Warsaw, Poland
| | - Jacek Smereka
- Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland
| | - Sanchit Ahuja
- Department of Anesthesiology, Pain management and Perioperative Medicine, Henry Ford Health System, Detroit, MI
| | - Lukasz Szarpak
- Medical Simulation Center, Lazarski University, Warsaw, Poland
| | - Kurt Ruetzler
- Departments of Outcomes Research and General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Jerzy Robert Ladny
- Clinic of Emergency Medicine, Medical University Bialystok, Bialystok, Poland
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16
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Dağar S, Çorbacıoğlu ŞK, Emektar E, Uzunosmanoğlu H, Çevik Y. Effects of spinal immobilization at 20° on end-tidal carbon dioxide. Am J Emerg Med 2020; 38:1180-1184. [PMID: 32122717 DOI: 10.1016/j.ajem.2020.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE The aim was to determine the effect on end-tidal carbon dioxide (ETCO2) of spinal immobilization (SI) at a conventional 0° angle and to investigate the usefulness of immobilization at a 20° angle for preventing possible hypoventilation. METHODS The study included 80 healthy volunteers, randomly divided into two groups. Spinal backboards and cervical collars were applied in Group 1 using a 0° angle and in Group 2 using a 20° angle, with the head up. SI was continued for 1 h, and ETCO2 values were measured at the 0th, 30th and 60th minute. RESULTS There were no significant differences between the groups in 0th and 30th minute ETCO2. However, after 60th minute, results showed a statistically significant increase in ETCO2 in Group 1 (35.5 mmHg [IQR 25-75:35-38]) compared to Group 2 (34 mmHg [IQR 25-75:33-36]) (p < 0.001). During SI, there was a statistically significant increase in ETCO2 in Group 1 (35 mmHg [IQR 25-75:34-36], 35.5 mmHg [IQR 25-75:34-37] and 36 mmHg [IQR 25-75:35-38] respectively at the 0th, 30th and 60th minute after SI) (p < 0.001) and no change in Group 2. Also, we found statistically significant differences between ΔETCO2 levels in Groups 1 and 2 at all 3 time intervals. CONCLUSION Conventional SI with an angle of 0° led to an increase in ETCO2 while subjects immobilization at a 20° angle maintained their initial ETCO2 values. Immobilization at 20° may prevent decompensation in patients who have thoracic trauma or lung diseases or those who are elderly, pregnant, or obese.
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Affiliation(s)
- Seda Dağar
- Kecioren Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey.
| | | | - Emine Emektar
- Kecioren Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey
| | - Hüseyin Uzunosmanoğlu
- Kecioren Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey
| | - Yunsur Çevik
- Kecioren Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey
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A profile of traumatic injury in the prehospital setting in India: A prospective observational study across seven states. Injury 2020; 51:286-293. [PMID: 31761424 DOI: 10.1016/j.injury.2019.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/12/2019] [Accepted: 11/10/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traumatic injury continues to be a leading cause of mortality and morbidity in low-income and middle-income countries (LMIC). The World Health Organization has called for a strengthening of prehospital care in order to improve outcomes from trauma. In this study we sought to profile traumatic injury seen in the prehospital setting in India and identify predictors of mortality in this patient population. METHODS We conducted a prospective observational study of a convenience sample of patients using a single emergency medical services (EMS) system for traumatic injuries across seven states in India from November 2015 through January 2016. Any patient with a chief complaints indicative of a traumatic injury was eligible for enrollment. Our primary outcome was 30-day mortality. RESULTS We enrolled 2905 patients. Follow-up rates were 76% at 2 days, 70% at 7 days, and 70% at 30 days. The median age was 36 years (IQR: 25-50) and were predominately male (72%, N = 2088), of lower economic status (97%, N = 2805 used a government issued ration card) and were from rural or tribal areas (74%, N = 2162). Cumulative mortality at 2, 7, and 30 days, was 3%, 4%, and 4% respectively. Predictors of 30-day mortality were prehospital abnormal mental status (OR 7.5 (95% CI: 4-14)), presence of hypoxia or hypotension (OR 4.0 (95% CI: 2.2-7)), on-scene mobility (OR 2.8 (95% CI: 1.3-6)), and multisystem injury inclusive of head injury (OR 2.3 (95% CI: 1.1-5)). CONCLUSIONS EMS in an LMIC can transport trauma patients from poor and rural areas that traditionally struggle to access timely trauma care to facilities in a timeframe consistent with current international recommendations. Information readily obtained by EMTs predicts 30-day mortality within this population and could be utilized for triaging patients with the potential to reduce morbidity and mortality.
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18
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Gabrieli A, Nardello F, Geronazzo M, Marchetti P, Liberto A, Arcozzi D, Polati E, Cesari P, Zamparo P. Cervical Spine Motion During Vehicle Extrication of Healthy Volunteers. PREHOSP EMERG CARE 2019; 24:712-720. [PMID: 31750763 DOI: 10.1080/10903127.2019.1695298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Prehospital spinal motion restriction as a prevention technique for secondary neurological injury is a key principle in emergency medicine. Our aim was to evaluate the effectiveness of different cervical spinal cord motion restriction techniques of awake and cooperative healthy volunteers during extrication.Methods: Twenty-three healthy volunteers were asked to exit a car (unassisted) with a rigid cervical collar (CC condition) or without it (autonomous exit: AE; instructed exit: IE); they were also extricated by two rescuers after setting a rigid cervical collar and by using an extrication device (CC + XT condition). Eight 3 D infrared cameras were calibrated around the vehicle to measure cervical spine angle, angular speed and acceleration in the sagittal plane. Surface wireless EMG electrodes were used to record superior trapezius, erector spinae and rectus abdominis muscle activity. All measures were recorded during two phases: device positioning (maneuver) and vehicle exiting.Results: The lowest range of motion was observed in CC during maneuver and exit (about 17°), the greatest in AE and IE (about 45°); when the extrication device was utilized along with the cervical collar (CC + XT) an increase, rather than a further decrease, in the range of motion was observed (about 25° during maneuver and exit). Larger values of angular speed and acceleration were observed in CC + XT when compared to CC, both during maneuver and exit (p < 0.001). The lowest EMG activity was observed during maneuver in CC and CC + XT; during exit a lower EMG activity was observed in CC + XT compared to CC (p < 0.001). Thus, when an extrication device is utilized (CC + XT), a lower active control of the cervical spine region is associated with faster and more brisk movements of the cervical spine compared to CC alone.Conclusions: Our findings support the idea that spinal motion restriction via rigid cervical collar of awake and cooperative trauma patients is effective in reducing cervical spine motion in the sagittal plane during vehicle extrication.
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19
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Ottosen CI, Steinmetz J, Larsen MH, Baekgaard JS, Rasmussen LS. Patient experience of spinal immobilisation after trauma. Scand J Trauma Resusc Emerg Med 2019; 27:70. [PMID: 31331379 PMCID: PMC6647237 DOI: 10.1186/s13049-019-0647-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/15/2019] [Indexed: 11/06/2022] Open
Abstract
Background Spinal immobilisation of blunt trauma victims with potential spinal cord injury is considered standard of care. The traditional management has, however, been increasingly questioned and concerns about harm have been raised. Few studies have described the perspective of the trauma patient regarding the spinal immobilisation. The objective of this study was therefore to evaluate the patient experience of immobilisation after trauma. Methods We prospectively screened adult trauma patients admitted to a level 1 trauma centre for eligibility. We included adult trauma patients who had been, and remembered being, immobilised for spinal protection with a cervical collar and a spine board prehospitally or upon arrival at the trauma centre. A semi-structured interview was conducted 2 to 72 h after admission either in person or by telephone. Results One hundred and fourteen patients were eligible for inclusion based on the patient charts. Out of 98 patients assessed for participation, 48 (49%) had no memory of being immobilised. We thus included 50 patients with a median age of 37 years (IQR: 26–60) of whom 38 (76%) were men. The median injury severity score was 9 (IQR: 3–15) and the median time with a cervical collar from initial application to in-hospital removal or until the interview was given was 91 min (IQR: 72–136). Nineteen patients (38%) reported discomfort and 12 patients (24%) experienced pain related to the immobilisation. Forty patients (80%) reported a sense of protection related to the immobilisation. Conclusion Discomfort related to spinal immobilisation was reported in 38% of trauma patients. However, a sense of protection was a recurring theme in 80% of the trauma patients, who recalled being immobilised. Nearly half of the awake trauma patients had no memory of being immobilised.
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Affiliation(s)
- Camilla Ikast Ottosen
- Department of Anaesthesia, Section 4231, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Juliane Maries Vej 10, DK-2100, Copenhagen, Denmark.
| | - Jacob Steinmetz
- Department of Anaesthesia, Section 4231, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Juliane Maries Vej 10, DK-2100, Copenhagen, Denmark.,Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mo Haslund Larsen
- Department of Anaesthesia, Section 4231, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Juliane Maries Vej 10, DK-2100, Copenhagen, Denmark
| | - Josefine S Baekgaard
- Department of Anaesthesia, Section 4231, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Juliane Maries Vej 10, DK-2100, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia, Section 4231, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Juliane Maries Vej 10, DK-2100, Copenhagen, Denmark
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20
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Abstract
In this paper, the design and control of a robotic device intended to stabilize the head and neck of a trauma patient during transport are presented. When transporting a patient who has suffered a traumatic head injury, the first action performed by paramedics is typically to restrain and stabilize the head and cervical spine of a patient. The proposed device would drastically reduce the time required to perform this action while also freeing a first responder to perform other possibly lifesaving actions. The applications for robotic casualty extraction are additionally explored. The design and construction are described, followed by control simulations demonstrating the improved behavior of the chosen controller paradigm, linear active disturbance rejection control (LADRC). Finally, experimental validation is presented, followed by future work and directions for the research.
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21
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Service Medical du Raid, Reuter PG, Baker C, Loeb T. Specific stretchers enhance rapid extraction by tactical medical support teams in mass casualty incidents. Injury 2019; 50:358-364. [PMID: 30594314 DOI: 10.1016/j.injury.2018.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/14/2018] [Accepted: 12/05/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE In mass casualty incidents where the threat is on-going, victim evacuation remains a challenge: fast extraction while respecting spinal immobilisation and haemorrhage control. Different devices can be used but their suitability has not been compared. METHODS We conducted a simulation study comparing eight extraction devices with a randomisation of the order of testing. Five teams, consisting of four officers, evacuated a single victim in five steps: device's deployment, loading the victim, carrying the victim along a corridor, negotiating a corner passage and a descent by staircase. Primary outcome was the emergency extraction time, from deployment to the first obstacle. Secondary outcomes included ease of transport and victim's stability, rated from 1 (worst) to 10 (best). RESULTS One hundred and sixty simulations were carried out. The median emergency extraction time was 16.7 [IQR: 11.6-24.9] seconds. The three speediest devices were the "firefighters' worn", "snogg" and "flexible tarp", taking 9.7 [8.1-11.0], 11.7 [10.9-15.4] and 12.2 [11.2-17.9] seconds respectively (p < 0.0001). Regarding the ease of transport, the three best-evaluated devices were the "firefighters' worn", "strap" and "flexible tarp" with 10 [9-10], 9 [8-9] and 8 [8-9] respectively (p < 0.0001). Considering stability reported by simulated victims, the three best-evaluated devices were the "inflated stretcher", "flexible tarp" and "firefighters' worn" with 8.0 [7.8-9.0], 8.0[7.0-8.0] and 6.5 [6.0-7.0] respectively. CONCLUSION Devices were not equivalent in terms of extraction time and suitability criteria. For rapid extraction of victims from danger zones, the "firefighter's worn" and "flexible tarp", as very simple stretchers, seem to be the most appropriate devices.
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Affiliation(s)
- Service Medical du Raid
- RAID (Recherche, Assistance, Intervention, Dissuasion), Force d'Intervention de la Police Nationale, France.
| | | | - Chloe Baker
- Royal London Hospital, Whitechapel Road, E1 1BB, London, UK
| | - Thomas Loeb
- SAMU 92, hôpital Raymond Poincaré, AP-HP, 92380, Garches, France
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Parker M. Cervical spine can be assessed effectively by emergency department triage nurses. Evid Based Nurs 2018; 21:115. [PMID: 30158174 DOI: 10.1136/eb-2018-102970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Mike Parker
- Department of Health Sciences, University of York, York, UK
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23
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Phaily A, Khan M. Is our current method of cervical spine control doing more harm than good? TRAUMA-ENGLAND 2018. [DOI: 10.1177/1460408618777773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Early neurological care of patients with spinal cord injury. World J Urol 2018; 36:1529-1536. [PMID: 29808302 DOI: 10.1007/s00345-018-2343-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/17/2018] [Indexed: 10/14/2022] Open
Abstract
PURPOSE Considering the major clinical challenges of managing patients with spinal cord injury (SCI), we summarized the relevant aspects of the early (within 1 year after SCI) neurological care emphasizing common standards. METHODS This review was performed according to the methodology recommended by the Joint SIU-ICUD International Consultation. Embase and Medline databases were used to identify literature relevant to the early neurological care of SCI patients. Recommendations were developed by consensus and graded using a modified Oxford system which identifies level of evidence (LOE) and grade of recommendation (GOR). RESULTS Emergency health care providers must address altered mental status, evidence of intoxication, suspected extremity fracture/distracting injury, focal neurological deficit and spinal pain/tenderness to determine the risk of SCI in a trauma patient [LOE 1, GOR A]. Neurogenic shock must be recognized and treated [LOE 3, GOR A]. Spine surgeons should consider early decompression and spine fixation/stabilization, where indicated, and should promote early active rehabilitation to improve functional recovery [LOE 2, GOR B]. Clinicians should refer SCI patients to specialized SCI rehabilitation centers [LOE 4, GOR B], must apply interventions to prevent venous thromboembolism (i.e., compression devices and low-molecular weight heparin/unfractionated heparin) after acute SCI respecting contraindications [LOE 1, GOR A]. Contemporary guidelines to manage pain must be employed [LOE 1, GOR A] and methods to reduce the risk of pressure ulcers should be used [LOE 3, GOR B]. CONCLUSIONS Early treatment, prevention of associated complications and individualized patient-targeted rehabilitation programs provided by a specialized interdisciplinary team are crucial to optimize the outcome after SCI.
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Fontaine G, Forgione M, Lusignan F, Lanoue MA, Drouin S. Cervical Spine Collar Removal by Emergency Room Nurses: A Quality Improvement Project. J Emerg Nurs 2018; 44:228-235. [DOI: 10.1016/j.jen.2017.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/24/2017] [Accepted: 07/29/2017] [Indexed: 11/30/2022]
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Clemency BM, Tanski CT, Gibson Chambers J, O'Brien M, Knapp AS, Clark AJ, McGoff P, Innes J, Lindstrom HA, Hostler D. Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging. PREHOSP EMERG CARE 2018; 22:506-510. [PMID: 29447489 DOI: 10.1080/10903127.2017.1413465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a "Spinal Immobilization" protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new "Spinal Motion Restriction" protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging. METHODS This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January-June 2015 and January-June 2016. RESULTS There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p < 0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02). CONCLUSION A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.
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Underbrink L, Dalton AT, Leonard J, Bourg PW, Blackmore A, Valverde H, Candlin T, Caputo LM, Duran C, Peckham S, Beckman J, Daruna B, Furie K, Hopgood D. New Immobilization Guidelines Change EMS Critical Thinking in Older Adults With Spine Trauma. PREHOSP EMERG CARE 2018; 22:637-644. [PMID: 29405797 DOI: 10.1080/10903127.2017.1423138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The impact of immobilization techniques on older adult trauma patients with spinal injury has rarely been studied. Our advisory group implemented a change in the immobilization protocol used by emergency medical services (EMS) professionals across a region encompassing 9 trauma centers and 24 EMS agencies in a Rocky Mountain state using a decentralized process on July 1, 2014. We sought to determine whether implementing the protocol would alter immobilization methods and affect patient outcomes among adults ≥60 years with a cervical spine injury. METHODS This was a 4-year retrospective study of patients ≥60 years with a cervical spine injury (fracture or cord). Immobilization techniques used by EMS professionals, patient demographics, injury characteristics, and in-hospital outcomes were compared before (1/1/12-6/30/14) and after (7/1/14-12/31/15) implementation of the Spinal Precautions Protocol using bivariate and multivariate analyses. RESULTS Of 15,063 adult trauma patients admitted to nine trauma centers, 7,737 (51%) were ≥60 years. Of those, 237 patients had cervical spine injury and were included in the study; 123 (51.9%) and 114 (48.1%) were transported before and after protocol implementation, respectively. There was a significant shift in the immobilization methods used after protocol implementation, with less full immobilization (59.4% to 28.1%, p < 0.001) and an increase in the use of both a cervical collar only (8.9% to 27.2%, p < 0.001) and not using any immobilization device (15.5% to 31.6%, p = 0.003) after protocol implementation. While the proportion of patients who only received a cervical collar increased after implementing the Spinal Precautions Protocol, the overall proportion of patients who received a cervical collar alone or in combination with other immobilization techniques decreased (72.4% to 56.1%, p = 0.01). The presence of a neurological deficit (6.5% vs. 5.3, p = 0.69) was similar before and after protocol implementation; in-hospital mortality (adjusted odds ratio = 0.56, 95% confidence interval: 0.24-1.30, p = 0.18) was similar post-protocol implementation after adjusting for injury severity. CONCLUSIONS There were no differences in neurologic deficit or patient disposition in the older adult patient with cervical spine trauma despite changes in spinal restriction protocols and resulting differences in immobilization devices.
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Tsutsumi Y, Fukuma S, Tsuchiya A, Ikenoue T, Yamamoto Y, Shimizu S, Kimachi M, Fukuhara S. Association between spinal immobilization and survival at discharge for on-scene blunt traumatic cardiac arrest: A nationwide retrospective cohort study. Injury 2018; 49:124-129. [PMID: 28912021 DOI: 10.1016/j.injury.2017.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/18/2017] [Accepted: 09/06/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Spinal immobilization has been indicated for all blunt trauma patients suspected of having cervical spine injury. However, for traumatic cardiac arrest (TCA) patients, rapid transportation without compromising potentially reversible causes is necessary. Our objective was to investigate the temporal trend of spinal immobilization for TCA patients and to examine the association between spinal immobilization and survival. METHODS We conducted a retrospective cohort study using the Japan Trauma Data Bank 2004-2015 registry data. Our study population consisted of adult blunt TCA patients encountered at the scene of a trauma. The primary outcome was the survival proportion at hospital discharge, and the secondary outcome was the proportion achieving return of spontaneous circulation (ROSC). We examined the association between spinal immobilization and these outcomes using a logistic regression model based on imputed data sets with the multiple imputation method to account for missing data. RESULTS Among 4313 patients who met the inclusion criteria, 3307 (76.7%) were immobilized. The proportion of patients that underwent spinal immobilization gradually decreased from 82.7% in 2004-2006 to 74.0% in 2013-2015. 1.0% of immobilized and 0.9% of non-immobilized patients had severe cervical spine injury. Spinal immobilization was significantly associated with lower survival at discharge (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.42 to 0.98) and ROSC by admission (OR, 0.48; 95%CI, 0.27 to 0.87). There was no significant sub-group difference of the association between spinal immobilization and survival at discharge by patients with or without cervical spine injury (p for interaction 0.73). CONCLUSION Spinal immobilization is widely used even for blunt TCA patients, even though it is associated with a lower rate of survival at discharge and ROSC by admission. According to these results, we suggest that spinal immobilization should not be routinely recommended for all blunt TCA patients.
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Affiliation(s)
- Yusuke Tsutsumi
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan; Department of Emergency Medicine, National Hospital Organization Mito Medical Center, 280 Sakuranosato Ibaraki-machi Higashiibaraki-gun, Ibaraki 311-3117, Japan
| | - Shingo Fukuma
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.
| | - Asuka Tsuchiya
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Department of Emergency Medicine, National Hospital Organization Mito Medical Center, 280 Sakuranosato Ibaraki-machi Higashiibaraki-gun, Ibaraki 311-3117, Japan
| | - Tatsuyoshi Ikenoue
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Sayaka Shimizu
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Miho Kimachi
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
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Oosterwold JT, Sagel DC, van Grunsven PM, Holla M, de Man-van Ginkel J, Berben S. The characteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study. Eur J Trauma Emerg Surg 2017; 43:513-524. [PMID: 27277072 PMCID: PMC5533828 DOI: 10.1007/s00068-016-0688-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 05/28/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pre-hospital spinal immobilisation by emergency medical services (EMS) staff is currently the standard of care in cases of suspected spinal column injuries. There is, however, a lack of data on the characteristics of patients who received spinal immobilisation during the pre-hospital phase and on the adverse effects of immobilisation. The objectives of this study were threefold. First, we determined the pre-hospital characteristics of blunt trauma patients with suspected spinal column injuries who were immobilised by EMS staff. Second, we assessed the choices made by EMS staff regarding spinal immobilisation techniques and reasons for immobilisation. Third, we researched the possible adverse effects of immobilisation. DESIGN A retrospective observational study in a cohort of blunt trauma patients. STUDY METHOD Data of blunt trauma patients with suspected spinal column injuries were collected from one EMS organisation between January 2008 and January 2013. Coded data and free text notes were analysed. RESULTS A total of 1082 patients were included in this study. Spinal immobilisation was applied in 96.3 % of the patients based on valid pre-hospital criteria. In 2.1 % of the patients immobilisation was not based on valid criteria. Data of 1.6 % patients were missing. Main reasons for spinal immobilisation were posterior midline spinal tenderness (37.2 % of patients) and painful distracting injuries (13.5 % of patients). Spinal cord injury (SCI) was suspected in 5.7 % of the patients with posterior midline spinal tenderness. A total of 15.8 % patients were immobilised using non-standard methods. The reason for departure from the standard method was explained for 3 % of these patients. Reported adverse effects included pain (n = 10, 0.9 %,); shortness of breath (n = 3, 0.3 %); combativeness or anxiety (n = 6, 0.6 %); and worsening of pain when supine (n = 1, 0.1 %). CONCLUSION/RECOMMENDATION Spinal immobilisation was applied in 96.3 % of all included patients based on pre-hospital criteria. We found that consensus among EMS staff on how to interpret the criterion 'distracting injury' was lacking. Furthermore, the adverse effects of spinal immobilisation were incompletely documented in pre-hospital care reports. To provide validated information on potential symptoms of SCI, a uniform EMS scoring system for motoric assessment should be developed.
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Affiliation(s)
- J T Oosterwold
- School of Nursing and Health, University Medical Centre Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
- Ambulance Department, University Medical Centre Groningen, Roden, The Netherlands.
| | - D C Sagel
- Ambulance Department, University Medical Centre Groningen, Roden, The Netherlands
| | - P M van Grunsven
- Ambulance Emergency Medical Service Gelderland-Zuid, Nijmegen, The Netherlands
| | - M Holla
- Department of Orthopaedic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J de Man-van Ginkel
- Department of Rehabilitation, Nursing Science and Sports, University Medical Centre Utrecht, Utrecht, The Netherlands
- Faculty of Medicine, Clinical Health Sciences, Utrecht University, Utrecht, The Netherlands
| | - S Berben
- Eastern Regional Emergency Healthcare Network & IQ Scientific Centre for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Critical and Emergency Care, Knowledge Centre of Sustainable Healthcare, HAN University of Applied Sciences, Nijmegen, The Netherlands
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Stanton D, Hardcastle T, Muhlbauer D, van Zyl D. Cervical collars and immobilisation: A South African best practice recommendation. Afr J Emerg Med 2017; 7:4-8. [PMID: 30456099 PMCID: PMC6234176 DOI: 10.1016/j.afjem.2017.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/22/2016] [Accepted: 01/10/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The consequences of spinal injury as a result of trauma can be devastating. Spinal immobilisation using hard trauma boards and rigid cervical collars has traditionally been the standard response to suspected spinal injury patients even though the risk may be extremely low. Recently, adverse events due to the method of immobilisation have challenged the need for motion restriction in all trauma patients. International guidelines have been published for protection of the spine during transport and this article brings those guidelines into the South African context. RECOMMENDATIONS Trauma patients need to be properly assessed using both an approved list of high and low risk factors, as well as a thorough examination. They should then be managed accordingly. Internationally validated assessment strategies have been developed, and should be used as part of the patient assessment. The method of motion restriction should be selected to suit the situation. The use of a vacuum mattress is the preferable technique, with the use of a trauma board being the least desirable. CONCLUSION The need for motion restriction in suspected spinal injury should be properly evaluated and appropriate action taken. Not all trauma patients require spinal motion restriction.
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Affiliation(s)
- D. Stanton
- Netcare Education, Faculty of Emergency and Critical Care, South Africa
| | - T. Hardcastle
- University of Kwazulu Natal, Trauma Surgery Training Unit, Inkosi Albert Luthuli Central Hospital Trauma Service and Trauma ICU, South Africa
| | - D. Muhlbauer
- Department of Emergency Medical Care and Rescue, Durban University of Technology, South Africa
| | - D. van Zyl
- Life Flora Hospital Advanced Life Support Unit, South Africa
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Purvis TA, Carlin B, Driscoll P. The definite risks and questionable benefits of liberal pre-hospital spinal immobilisation. Am J Emerg Med 2017; 35:860-866. [PMID: 28169039 DOI: 10.1016/j.ajem.2017.01.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 01/03/2017] [Accepted: 01/23/2017] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The routine practice of pre-hospital spinal immobilisation (phSI) for patients with suspected spinal injury has existed for decades. However, the controversy surrounding it resulted in the 2013 publication of a Consensus document by the Faculty of Pre-Hospital Care. The question remains as to whether the quality of evidence in the literature is sufficient to support the Consensus guidelines. This critical review aims to determine the validity of current recommendations by balancing the potential benefits and side effects of phSI. METHOD A review of the literature was carried out by two independent assessors using Medline, PubMed, EMBASE and the Cochrane Library databases. Manual searches of related journals and reference lists were also completed. The selected body of evidence was subsequently appraised using a checklist derived from SIGN and CASP guidelines, as well as Crombie's guide to critical appraisal. RESULTS No reliable sources were found proving the benefit for patient immobilisation. In contrast there is strong evidence to show that pre-hospital spinal immobilisation is not benign with recognised complications ranging from discomfort to significant physiological compromise. The published literature supports the Consensus guideline recommendations for safely reducing the impact of these side effects without compromising the patient. CONCLUSION The literature supports the Consensus Guidelines but raises the question as to whether they go far enough as there is strong evidence to suggest phSI is an inherently harmful procedure without having any proven benefit. These results demonstrate an urgent need for further studies to determine its treatment effect.
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Affiliation(s)
| | - Brian Carlin
- Pre-hospital Care, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Peter Driscoll
- School of Medicine, St Andrews University, St Andrews, Scotland, United Kingdom
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Kornhall DK, Jørgensen JJ, Brommeland T, Hyldmo PK, Asbjørnsen H, Dolven T, Hansen T, Jeppesen E. The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury. Scand J Trauma Resusc Emerg Med 2017; 25:2. [PMID: 28057029 PMCID: PMC5217292 DOI: 10.1186/s13049-016-0345-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/12/2016] [Indexed: 11/10/2022] Open
Abstract
The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.
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Affiliation(s)
- Daniel K Kornhall
- East Anglian Air Ambulance, Cambridge, UK. .,Department of Acute Medicine, Nordland Central Hospital, Postboks 1480, 8092, Bodø, Norway. .,Swedish Air Ambulance, Mora, Sweden.
| | - Jørgen Joakim Jørgensen
- Department of Traumatology, Oslo University Hospital, Oslo, Norway.,Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
| | - Tor Brommeland
- Neurosurgical Department, Oslo University Hospital, Oslo, Norway
| | - Per Kristian Hyldmo
- Trauma Unit, Sørlandet Hospital, Kristiansand, Norway.,Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - Helge Asbjørnsen
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Helicopter Emergency Medical Services, Bergen, Norway
| | - Thomas Dolven
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Thomas Hansen
- Emergency Medical Services, University Hospital of North Norway, Tromsø, Norway
| | - Elisabeth Jeppesen
- Norwegian National Advisory Unit on Trauma, Oslo University Hospital, Oslo, Norway.,Department of Health Studies, University of Stavanger, Stavanger, Norway
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Kreinest M, Scholz M, Trafford P. On-scene treatment of spinal injuries in motor sports. Eur J Trauma Emerg Surg 2016; 43:191-200. [PMID: 28005155 DOI: 10.1007/s00068-016-0749-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/12/2016] [Indexed: 12/18/2022]
Abstract
Because spinal cord injuries can have fatal consequences for injured race car drivers, prehospital treatment of spinal injuries is a major concern in motor sports. A structured procedure for assessing trauma patients and their treatment should follow established ABCDE principles. Only then, a stable patient could be further examined and appropriate measures can be undertaken. For patients in an acute life-threatening condition, rapid transport must be initiated and should not be delayed by measures that are not indicated. If a competitor must first be extricated from the racing vehicle, the correct method of extrication must be chosen. To avoid secondary injury to the spine after a racing accident, in-line extrication from the vehicle and immobilization of the patient are standard procedures in motor sports and have been used for decades. Since immobilization can be associated with disadvantages and complications, the need for immobilization of trauma patients outside of motor sports medicine has become the subject of an increasing number of reports in the scientific literature. Even in motor sports, where specific safety systems that offer spinal protection are present, the indications for spinal immobilization need to be carefully considered rather than being blindly adopted as a matter of course. The aim of this article is to use recent literature to present an overview about the treatment of spinal injuries in motor sports. Further, we present a new protocol for indications for immobilizing the spine in motor sports that is based on the ABCDE principles and takes into account the condition of the patient.
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Affiliation(s)
- M Kreinest
- Department for Trauma Surgery, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
| | - M Scholz
- Department for Orthopedics and Anesthesia, Specialty Hospital Vogelsang-Gommern, Sophie-v.-Boetticher-Straße 1, 39245, Gommern, Germany
| | - P Trafford
- Department of Anesthesia, Arrowe Park Hospital, Arrowe Park Road, Upton, United Kingdom
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Stabile Seitenlage. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0153-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kreinest M, Gliwitzky B, Grützner PA, Münzberg M. Untersuchung der Anwendbarkeit eines neuen Protokolls zur Immobilisation der Wirbelsäule. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0154-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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36
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Kreinest M, Gliwitzky B, Schüler S, Grützner PA, Münzberg M. Development of a new Emergency Medicine Spinal Immobilization Protocol for trauma patients and a test of applicability by German emergency care providers. Scand J Trauma Resusc Emerg Med 2016; 24:71. [PMID: 27180045 PMCID: PMC4867978 DOI: 10.1186/s13049-016-0267-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 05/10/2016] [Indexed: 12/24/2022] Open
Abstract
Background In order to match the challenges of quickly recognizing and treating any life-threatening injuries, the ABCDE principles were established for the assessment and treatment of trauma patients. The high priority of spine protection is emphasized by the fact that immobilization of the cervical spine is performed at the very first step in the ABCDE principles. Immobilization is typically performed to prevent or minimize secondary damage to the spinal cord if instability of the spinal column is suspected. Due to increasing reports about disadvantages of spinal immobilization, the indications for performing spinal immobilization must be refined. The aim of this study was (i) to develop a protocol that supports decision-making for spinal immobilization in adult trauma patients and (ii) to carry out the first applicability test by emergency medical personnel. Methods A structured literature search considering the literature from 1980 to 2014 was performed. Based on this literature and on the current guidelines, a new protocol that supports on scene decision-making for spinal immobilization has been developed. Parameters found in the literature concerning mechanisms and factors increasing the likelihood of spinal injury have been included in the new protocol. In order to test the applicability of the new protocol two surveys were performed on German emergency care providers by means of a questionnaire focused on correct decision-making if applying the protocol. Results Based on the current literature and guidelines, the Emergency Medicine Spinal Immobilization Protocol (E.M.S. IMMO Protocol) for adult trauma patients was developed. Following a fist applicability test involving 21 participants, the first version of the E.M.S. IMMO Protocol has to be graphically re-organized. A second applicability test comprised 50 participants with the current version of the protocol confirmed good applicability. Questions regarding immobilization of trauma patients could be answered properly using the E.M.S. IMMO Protocol. Discussion Current literature increasingly reports of disadvantages that may be associated with immobilization. Based on the requirements of the current guidelines, a new protocol that supports decision-making for indications for out-of-hospital spinal immobilization has been developed in this study. In contrast to established protocols, the new protocol offers different options for immobilization as well as a decicion-support. Conclusions The E.M.S. IMMO protocol provides a decision-support tool for indications for spinal immobilization in adult trauma patients that permits variable decision-making depending on the current condition of the trauma patient and the pattern of injuries for immobilization in general and for immobilization method in particular.
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Affiliation(s)
- Michael Kreinest
- BG Trauma Center Ludwigshafen, Department of Trauma Surgery and Orthopaedics, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.,PHTLS Europe Research Group, Offenbach/Queich, Germany
| | | | - Svenja Schüler
- University of Heidelberg, Institute for Medical Biometry and Informatics, Heidelberg, Germany
| | - Paul A Grützner
- BG Trauma Center Ludwigshafen, Department of Trauma Surgery and Orthopaedics, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Matthias Münzberg
- BG Trauma Center Ludwigshafen, Department of Trauma Surgery and Orthopaedics, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany. .,PHTLS Europe Research Group, Offenbach/Queich, Germany.
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Expertise of German paramedics concerning the prehospital treatment of patients with spinal trauma. Eur J Trauma Emerg Surg 2016; 43:371-376. [PMID: 27173645 DOI: 10.1007/s00068-016-0682-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/02/2016] [Indexed: 01/21/2023]
Abstract
PURPOSE Spinal immobilization is a standard procedure in emergency medicine. Increasing awareness of complications associated with immobilization of trauma patients leads to controversial discussions in the literature. Current guidelines require to include considerations of accident mechanism, an assessment of the patient's condition and an examination of the spine in the decision-making process if immobilization of the spine should be performed. This requires sound knowledge of assessing these parameters. The aim of the current study is to analyze German paramedics' subjective uncertainty in terms of their prehospital assessment and treatment of patients suffering from spine injuries. METHODS Over a period of 17 months participants in a trauma course were asked to complete a standardized anonymous questionnaire about subjective uncertainty of prehospital assessment and management of spinal trauma before participation in that course. Questions about the frequency of application of different immobilization tools and skills training on spinal immobilization were also asked. RESULTS A total of 465 paramedics were surveyed. The participants did not indicate any uncertainty about the prehospital diagnosis and treatment of spinal injuries. The feeling of confidence was significantly greater in participants who had already attended another course on structured trauma care before. The participants agreed with the statements that standardized algorithms facilitate teamwork and that there is a need for a protocol for the prehospital treatment of spinal injuries. CONCLUSIONS Paramedics do not feel uncertain about the prehospital assessment and treatment of spinal injuries. The feeling of confidence in participants who had already attended a course on the treatment of trauma patients before was significantly higher.
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Smith N, Curtis K. Can emergency nurses safely and accurately remove cervical spine collars in low risk adult trauma patients: An integrative review. ACTA ACUST UNITED AC 2016; 19:63-74. [PMID: 27005407 DOI: 10.1016/j.aenj.2016.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/22/2016] [Accepted: 01/24/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Well validated clinical decision rules exist to facilitate the safe removal of collars in the alert, orientated, low risk adult trauma patient, however this practice is traditionally conducted by medical staff. The aim of this review is to synthesise current evidence to determine the efficacy of emergency nurses in safely and accurately removing cervical spine collars using cervical spine rules, in alert, orientated, low risk trauma adult patients. METHODS A multi-method search strategy was used to find primary research studies followed by a rigorous screening and quality appraisal process. Data from included articles were extracted, grouped and synthesised. RESULTS Nine quantitative research articles resulted in four key findings: the inter-rater reliability between nurses and doctors clearing the cervical spine was high (kappa range (0.61-0.80)); nurses can safely implement the cervical spine clinical decision rule; use of a cervical spine clinical decision rule decreases the time patients are immobilised and; nurses felt confident applying a cervical spine clinical decision rule. CONCLUSION Appropriately trained emergency nurses can safely apply cervical spine rules to alert, orientated, low risk adult trauma patients. Implementation of nurses clearing cervical spines should include training and ongoing monitoring.
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Affiliation(s)
- Nicola Smith
- Sydney Nursing School, The University of Sydney, 88 Mallett Street, Camperdown, Sydney, NSW 2050, Australia; Emergency Department, St. Vincents Public Hospital, 390 Victoria Street, Darlinghurst, Sydney 2010, Australia.
| | - Kate Curtis
- Sydney Nursing School, The University of Sydney, 88 Mallett Street, Camperdown, Sydney, NSW 2050, Australia; Trauma Service, St George Hospital, Gray St, Kogarah 2217, Australia
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Clemency BM, Bart JA, Malhotra A, Klun T, Campanella V, Lindstrom HA. Patients Immobilized with a Long Spine Board Rarely Have Unstable Thoracolumbar Injuries. PREHOSP EMERG CARE 2016; 20:266-72. [DOI: 10.3109/10903127.2015.1086845] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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40
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Moss R, Porter K, Greaves I. Minimal patient handling: a faculty of prehospital care consensus statement. Emerg Med J 2015; 30:1065-6. [PMID: 24232010 DOI: 10.1136/emermed-2013-203205] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This paper outlines the emerging best practice when packaging a prehospital trauma patient while providing spinal immobilisation. The best practice described is based on the recommendations of a consensus meeting held by the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh, in the West Midlands in April 2012, where the opinion of experienced practitioners from across the prehospital and emergency care community considered the currently available evidence and reviewed current clinical practice. Initial consensus points were then subject to further review and dialogue with stakeholders from the initial meeting. The recommendations drawn from the meeting and subsequent dialogue represent a 'general agreement' to the principles and practices described in the paper. The recommendations will provide guidance for clinical practice and governance alongside other consensus statements from the Faculty of Pre-Hospital Care that seek to address prehospital spinal immobilisation and pelvic immobilisation.
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Affiliation(s)
- R Moss
- Department of Anaesthetics, University Hospital of North Staffordshire, , Stoke on Trent, UK
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Todd NV, Skinner D, Wilson-MacDonald J. Secondary neurological deterioration in traumatic spinal injury: data from medicolegal cases. Bone Joint J 2015; 97-B:527-31. [PMID: 25820893 DOI: 10.1302/0301-620x.97b4.34328] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.
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Affiliation(s)
- N V Todd
- Northern Medical Services, Sandyford, Newcastle upon Tyne, NE2 1DJ, UK
| | - D Skinner
- Oxford University Hospitals, Oxford, UK
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Moss R, Porter K, Greaves I. Minimal patient handling: a Faculty of Pre-hospital Care consensus statement. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408614556439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- R Moss
- Department of Anaesthetics, University Hospital of North Staffordshire, Stoke on Trent, UK
| | - K Porter
- Department of Trauma, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - I Greaves
- Department of Emergency Medicine, James Cook University Hospital Middlesborough, Middlesborough, UK
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Tello RR, Braude D, Fullerton L, Froman P. Outcome of trauma patients immobilized by emergency department staff, but not by emergency medical services providers: a quality assurance initiative. PREHOSP EMERG CARE 2014; 18:544-9. [PMID: 24878221 DOI: 10.3109/10903127.2014.912702] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Prehospital selective cervical spine immobilization (CSI) is a relatively new concept. In our emergency medical services (EMS) system, protocols for selective CSI are widely used; yet, some patients who are brought to the hospital without CSI undergo secondary immobilization and cervical spine imaging in the emergency department (ED). Immobilization in the ED, after a decision not to immobilize by EMS, suggests that either the prehospital assessment is not trusted or the patient has developed new symptoms over time. We undertook a quality assurance initiative to evaluate whether trauma patients brought to the ED without CSI, who then underwent secondary CSI and imaging in the ED, had injuries that were initially missed by EMS selective CSI protocol. METHODS This was a 36-month retrospective data analysis of blunt trauma patients transported directly from the field to the University of New Mexico Hospital level I trauma center by Albuquerque Ambulance Service (AAS) between March 2009 and February 2012. Inclusion criteria were age 18 years and older, transported by AAS without CSI, and cervical spinal imaging done in the ED. Patients were excluded if they were being transported between facilities, were prisoners, and/or refused CSI. A positive finding was defined as any acute abnormality identified by the attending radiologist on the final imaging report. RESULTS The study included 101 patients who met inclusion criteria. There were no significant missed injuries. Ninety-four of the 101 patients received cervical spinal CT imaging at an estimated cost of $1,570 per scan, not including physician charges. The remaining patients had plain film radiographic imaging. No patients had magnetic resonance imaging. CONCLUSIONS In this retrospective quality assurance initiative, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury. No patients had any adverse effects or required treatment, yet these patients incurred substantial costs and increased radiation exposure. While our results suggest hospital personnel should have confidence in prehospital decisions regarding CSI, continued surveillance and a large-scale, prospective study are needed to confirm our findings.
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Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma 2014; 31:531-40. [PMID: 23962031 PMCID: PMC3949434 DOI: 10.1089/neu.2013.3094] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
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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Affiliation(s)
- Terje Sundstrøm
- 1 Department of Biomedicine, University of Bergen , Bergen, Norway
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Mok JM, Jackson KL, Fang R, Freedman BA. Effect of vacuum spine board immobilization on incidence of pressure ulcers during evacuation of military casualties from theater. Spine J 2013; 13:1801-8. [PMID: 23816354 DOI: 10.1016/j.spinee.2013.05.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 03/05/2013] [Accepted: 05/04/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In the summer of 2009, the vacuum spine board (VSB) was designated by the US Air Force as the preferred method of external spinal immobilization during aeromedical transport of patients with suspected unstable thoracolumbar spine fractures. One purported advantage of the VSB is that, by distributing weight over a larger surface area, it decreases the risk of skin pressure ulceration. PURPOSE To examine whether the rate of pressure ulcers has changed since the introduction of the VSB. STUDY DESIGN Retrospective cohorts. PATIENT SAMPLE Injured US service members undergoing spinal immobilization during evacuation from the Iraq and Afghanistan theaters to Landstuhl, Germany. OUTCOME MEASURES Presence and stage of pressure ulceration, and deterioration in neurologic status. METHODS Records of the initial 60 patients medically evacuated on the VSB to Landstuhl Regional Medical Center were retrospectively analyzed for patient demographics, injury characteristics, and incidence of pressure injury. The incidence of pressure ulcers after the use of VSB was compared with that in a historical control consisting of 30 patients with unstable spinal injuries evacuated before the introduction of the VSB. No sources of external funding were used for this investigation. RESULTS The combined cohort had a mean age of 28.8 years and mean Injury Severity Score (ISS) of 20.63 and comprised 96% men. Most injury mechanisms were blunt (58%). The rate of neurological injury was 19%. There were no cases of progressive neurological deficit or deformity in either cohort. In the VSB group, using a broad definition of pressure ulcer, incidence was 13 of 60 patients (22%). Using a strict definition, incidence was eight of 60 (13%): five Stage I and three Stage II. In the non-VSB group, incidence of pressure ulcers was three of 30 (10%), using either definition, all Stage II. Difference in incidence between the groups was not statistically significant. Intubated patients had a significantly higher incidence of pressure ulcers. CONCLUSION Both the VSB and historic means (non-VSB) of spinal immobilization appear to be safe and produce only transient morbidity despite an average of 9 to 10 hours of transport. Intubated status was identified as the most important risk factor for the development of a pressure ulcer.
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Affiliation(s)
- James M Mok
- Orthopaedic Surgery Service, Department of Surgery, Madigan Army Medical Center, Bldg 9040A Fitzsimmons Dr, Tacoma, WA 98431, USA.
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Theodore N, Hadley MN, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Ryken TC, Walters BC. Prehospital cervical spinal immobilization after trauma. Neurosurgery 2013; 72 Suppl 2:22-34. [PMID: 23417176 DOI: 10.1227/neu.0b013e318276edb1] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Edwards MA, Verwey J, Herbert S, Horne S, Smith JE. Cervical spine clearance in the elderly: do elderly patients get a bad deal?: Table 1. Emerg Med J 2013; 31:591-592. [DOI: 10.1136/emermed-2012-202256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 04/24/2013] [Accepted: 04/25/2013] [Indexed: 11/03/2022]
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Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee. ACTA ACUST UNITED AC 2012; 71:763-9; discussion 769-70. [PMID: 21909006 DOI: 10.1097/ta.0b013e3182255cb9] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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