1
|
Evaluating prehospital care of patients with potential traumatic spinal cord injury: scoping review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1309-1329. [PMID: 35312863 DOI: 10.1007/s00586-022-07164-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/17/2022] [Accepted: 02/25/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To gain insight into current research regarding prehospital care (PHC) in patients with potential traumatic spinal cord injury (TSCI) and to disseminate the findings to the research community. METHODS In March 2019, we performed a literature search of publications from January 1990 to March 2019 indexed in PubMed, gray literature including professional websites; and reference sections of selected articles for other relevant literature. This review was performed according to Arksey and O'Malley's framework. RESULTS There were 42 studies selected based on the inclusion criteria for review; 18 articles regarding immobilization; 12 articles regarding movement, positioning and transport; four for spinal clearance; three for airway protection; and two for the role of PHC providers. There were some articles that covered two topics: one article was regarding movement, positioning and transport and airway protection, and two were regarding spinal clearance and the role of PHC providers. CONCLUSION There was no uniform opinion about spinal immobilization of patients with suspected TSCI. The novel lateral trauma position and one of two High Arm IN Endangered Spine (HAINES) methods are preferred methods for unconscious patients. Controlled self-extrication for patients with stable hemodynamic status is recommended. Early and proper identifying of potential TSCI by PHC providers can significantly improve patients' outcomes and can result in avoiding unwanted spinal immobilization. Future prospective studies with a large sample size in real-life settings are needed to provide clear and evidence-based data in PHC of patients with suspected TSCI.
Collapse
|
2
|
Courson R, Ellis J, Herring SA, Boden BP, Henry G, Conway D, McNamara L, Neal TL, Putukian M, Sills AK, Walpert KP. Best Practices and Current Care Concepts in Prehospital Care of the Spine-Injured Athlete in American Tackle Football March 2-3, 2019; Atlanta, GA. J Athl Train 2020; 55:545-562. [PMID: 32579669 PMCID: PMC7319739 DOI: 10.4085/1062-6050-430-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Sport-related spine injury can be devastating and have long-lasting effects on athletes and their families. Providing evidence-based care for patients with spine injury is essential for optimizing postinjury outcomes. When caring for an injured athlete in American tackle football, clinicians must make decisions that involve unique challenges related to protective equipment (eg, helmet and shoulder pads). The Spine Injury in Sport Group (SISG) met in Atlanta, Georgia, March 2-3, 2019, and involved 25 health care professionals with expertise in emergency medicine, sports medicine, neurologic surgery, orthopaedic surgery, neurology, physiatry, athletic training, and research to review the current literature and discuss evidence-based medicine, best practices, and care options available for the prehospital treatment of athletes with suspected cervical spine injuries.1,2 That meeting and the subsequent Mills et al publication delineate the quality and quantity of published evidence regarding many aspects of prehospital care for the athlete with a suspected cervical spine injury. This paper offers a practical treatment guide based on the experience of those who attended the Atlanta meeting as well as the evidence presented in the Mills et al article. Ongoing research will help to further advance clinical treatment recommendations.
Collapse
Affiliation(s)
| | - James Ellis
- University of South Carolina School of Medicine, Greenville
| | - Stanley A Herring
- Department of Rehabilitation Medicine and The Sports Institute, University of Washington, Seattle
| | - Barry P Boden
- The Orthopaedic Center, A Division of CAO, Rockville, MD
| | | | | | - Lance McNamara
- Barrow County Schools, Winder-Barrow High School, Winder, GA
| | | | - Margot Putukian
- University Health Services, Rugers Robert Wood Johnson Medical School, Princeton, NJ
| | | | | |
Collapse
|
3
|
A New Craniothoracic Mattress for Immobilization of the Cervical Spine in Critical Care Patients. J Trauma Nurs 2018; 24:261-269. [PMID: 28692625 DOI: 10.1097/jtn.0000000000000302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Current immobilization techniques of the cervical spine are associated with complications including pressure ulcers, discomfort, and elevated intracranial pressures with limited access to the thorax and airway. In this study, a newly developed craniothoracic immobilizer (Pharaoh mattress) for critical care patients with cervical injury was tested for its restriction of cervical movement, peak interface pressures, comfort, and radiolucency, and compared with headblocks strapped to a spineboard. Cervical movement was measured by roentgen stereophotogrammetric analysis in 5 fresh frozen cadavers. Peak interface and discomfort pressures were measured in 10 healthy volunteers. Radiographic absorption was calculated by measuring the total emission radiation with and without immobilizer. The Pharaoh mattress caused a mean restriction of 59% (SD: 15) flexion-extension, 77% (SD: 14) lateral bending, and 93% (SD: 3) rotation, compared with the unrestricted situation. No significant differences in restriction of cervical movement were found between headblocks strapped to a spineboard and the Pharaoh mattress. The mean peak pressures on the Pharaoh mattress were significantly lower than on the spineboard. Healthy volunteers gave significantly lower numeric discomfort scores on the Pharaoh mattress than on the spineboard. The Pharaoh mattress absorbed more x-rays than the spineboard. The Pharaoh mattress provides similar restriction of cervical movement compared with headblocks strapped to a spineboard but with lower interface pressures and increased comfort. This new mattress could be useful for immobilization of the cervical spine in critical care patients with mechanically instable spinal fractures.
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Hood N, Considine J. Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature. ACTA ACUST UNITED AC 2015; 18:118-37. [PMID: 26051883 DOI: 10.1016/j.aenj.2015.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 03/13/2015] [Accepted: 03/20/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Spinal immobilisation has been a mainstay of trauma care for decades and is based on the premise that immobilisation will prevent further neurological compromise in patients with a spinal column injury. The aim of this systematic review was to examine the evidence related to spinal immobilisation in pre-hospital and emergency care settings. METHODS In February 2015, we performed a systematic literature review of English language publications from 1966 to January 2015 indexed in MEDLINE and Cochrane library using the following search terms: 'spinal injuries' OR 'spinal cord injuries' AND 'emergency treatment' OR 'emergency care' OR 'first aid' AND immobilisation. EMBASE was searched for keywords 'spinal injury OR 'spinal cord injury' OR 'spine fracture AND 'emergency care' OR 'prehospital care'. RESULTS There were 47 studies meeting inclusion criteria for further review. Ten studies were case series (level of evidence IV) and there were 37 studies from which data were extrapolated from healthy volunteers, cadavers or multiple trauma patients. There were 15 studies that were supportive, 13 studies that were neutral, and 19 studies opposing spinal immobilisation. CONCLUSION There are no published high-level studies that assess the efficacy of spinal immobilisation in pre-hospital and emergency care settings. Almost all of the current evidence is related to spinal immobilisation is extrapolated data, mostly from healthy volunteers.
Collapse
Affiliation(s)
- Natalie Hood
- Emergency Department, Monash Medical Centre, Monash Health Surf Life Saving Australia Representative, Australian Resuscitation Council, Clayton Road, Clayton, Victoria 3125, Australia.
| | - Julie Considine
- Eastern Health - Deakin University Nursing Research Centre, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University College of Emergency Nursing Australasia Representative, Australian Resuscitation Council, 221 Burwood Highway, Burwood, Victoria 3125, Australia.
| |
Collapse
|
6
|
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.
Collapse
Affiliation(s)
- Terje Sundstrøm
- 1 Department of Biomedicine, University of Bergen , Bergen, Norway
| | | | | | | | | |
Collapse
|
7
|
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
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Effect of spinal immobilization on heart rate, blood pressure and respiratory rate. Prehosp Disaster Med 2013; 28:210-4. [PMID: 23522699 DOI: 10.1017/s1049023x13000034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Vital signs remain important clinical indicators in the management of trauma. Tissue injury and ischemia cause tachycardia and hypertension, which are mediated via the sympathetic nervous system (SNS). Spinal immobilization is known to cause discomfort, and it is not known how this might influence the SNS and contribute to abnormal vital signs. Hypothesis This study aimed to establish whether the pain and discomfort associated with spinal immobilization and the maneuvers commonly used in injured patients (eg, log roll) affect the Heart rate (HR), Systolic Blood Pressure (SBP) and Respiratory rate (RR). The null hypothesis was that there are no effects. METHODS A prospective, unblinded, repeated-measure study of 53 healthy subjects was used to test the null hypothesis. Heart rate, BP and RR were measured at rest (five minutes), after spinal immobilization (10 minutes), following log roll, with partial immobilization (10 minutes) and again at rest (five minutes). A visual analog scale (VAS) for both pain and discomfort were also collected at each stage. Results were statistically compared. RESULTS Pain VAS increased significantly during spinal immobilization (3.8 mm, P < .01). Discomfort VAS increased significantly during spinal immobilization, after log roll and during partial immobilization (17.7 mm, 5.8 mm and 8.9 mm, respectively; P < .001). Vital signs however, showed no clinically relevant changes. Discussion Spinal immobilization does not cause a change in vital signs despite a significant increase in pain and discomfort. Since no relationship appears to exist between immobilization and abnormal vital signs, abnormal vital signs in a clinical situation should not be considered to be the result of immobilization. Likewise, pain and discomfort in immobilized patients should not be disregarded due to lack of changes in vital signs.
Collapse
|
9
|
Pressure ulcers in the trauma population: are reimbursement penalties appropriate? J Trauma Acute Care Surg 2012; 72:793-5. [PMID: 22491571 DOI: 10.1097/ta.0b013e3182395fe4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
10
|
Jia X, Kowalski RG, Sciubba DM, Geocadin RG. Critical care of traumatic spinal cord injury. J Intensive Care Med 2011; 28:12-23. [PMID: 21482574 DOI: 10.1177/0885066611403270] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Approximately 11 000 people suffer traumatic spinal cord injury (TSCI) in the United States, each year. TSCI incidences vary from 13.1 to 52.2 per million people and the mortality rates ranged from 3.1 to 17.5 per million people. This review examines the critical care of TSCI. The discussion will focus on primary and secondary mechanisms of injury, spine stabilization and immobilization, surgery, intensive care management, airway and respiratory management, cardiovascular complication management, venous thromboembolism, nutrition and glucose control, infection management, pressure ulcers and early rehabilitation, pharmacologic cord protection, and evolving treatment options including the use of pluripotent stem cells and hypothermia.
Collapse
Affiliation(s)
- Xiaofeng Jia
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | | | | | | |
Collapse
|
11
|
Ahn H, Singh J, Nathens A, MacDonald RD, Travers A, Tallon J, Fehlings MG, Yee A. Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines. J Neurotrauma 2010; 28:1341-61. [PMID: 20175667 DOI: 10.1089/neu.2009.1168] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
An interdisciplinary expert panel of medical and surgical specialists involved in the management of patients with potential spinal cord injuries (SCI) was assembled. Four key questions were created that were of significant interest. These were: (1) what is the optimal type and duration of pre-hospital spinal immobilization in patients with acute SCI?; (2) during airway manipulation in the pre-hospital setting, what is the ideal method of spinal immobilization?; (3) what is the impact of pre-hospital transport time to definitive care on the outcomes of patients with acute spinal cord injury?; and (4) what is the role of pre-hospital care providers in cervical spine clearance and immobilization? A systematic review utilizing multiple databases was performed to determine the current evidence about the specific questions, and each article was independently reviewed and assessed by two reviewers based on inclusion and exclusion criteria. Guidelines were then created related to the questions by a national Canadian expert panel using the Delphi method for reviewing the evidence-based guidelines about each question. Recommendations about the key questions included: the pre-hospital immobilization of patients using a cervical collar, head immobilization, and a spinal board; utilization of padded boards or inflatable bean bag boards to reduce pressure; transfer of patients off of spine boards as soon as feasible, including transfer of patients off spinal boards while awaiting transfer from one hospital institution to another hospital center for definitive care; inclusion of manual in-line cervical spine traction for airway management in patients requiring intubation in the pre-hospital setting; transport of patients with acute traumatic SCI to the definitive hospital center for care within 24 h of injury; and training of emergency medical personnel in the pre-hospital setting to apply criteria to clear patients of cervical spinal injuries, and immobilize patients suspected of having cervical spinal injury.
Collapse
Affiliation(s)
- Henry Ahn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Survey of Emergency Preparedness in Michigan. Prehosp Disaster Med 2010. [DOI: 10.1017/s1049023x00022123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
13
|
LUNDGREN PETER, HENRIKSSON OTTO, WIDFELDT NINA, WIKSTRÖM THORE. Insulated Spine Boards for Prehospital Trauma Care in a Cold Environment. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/15031430410023913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
14
|
Peery CA, Brice J, White WD. Prehospital spinal immobilization and the backboard quality assessment study. PREHOSP EMERG CARE 2007; 11:293-7. [PMID: 17613902 DOI: 10.1080/10903120701348172] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Prehospital spinal immobilization (PSI) for patients with suspected spinal injury has been the universal standard of practice for emergency medical services (EMS) in the United States since the early 1970s. PSI research has faced numerous methodological difficulties, including an inability to evaluate whether the immobilizations being studied were carried out appropriately. The purpose of this study was to assess the quality of spinal immobilization to a long spine board in patients presenting via EMS to an emergency department (ED). METHODS All noncritically ill patients presenting to a tertiary care academic trauma center who had been immobilized on a long spine board for EMS transport were approached for enrollment. Each subject was evaluated for the number and location of restraining straps and their degree of tightness. RESULTS Of 50 consenting subjects, 15 (30%) had at least one unattached strap or piece of tape that should have attached their head to the board. Of 50 subjects, 44 (88%) were found to have greater than 2 cm of slack between their body and at least one strap. Among those with any straps looser than 2 cm, the average number of loose straps was 3.4. CONCLUSIONS This study suggests that many patients are not well immobilized on arrival at the Emergency department.
Collapse
Affiliation(s)
- Charles Andrew Peery
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
| | | | | |
Collapse
|
15
|
Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehosp Disaster Med 2005; 20:47-53. [PMID: 15748015 DOI: 10.1017/s1049023x00002144] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the effects of spinal immobilization on healthy participants. METHODS A systematic review of randomized, controlled trials of spinal immobilization on healthy participants. RESULTS Seventeen randomized, controlled trials compared different types of immobilization devices, including collars, backboards, splints, and body strapping. For immobilization efficacy, collars, spine boards, vacuum splints, and abdominal/torso strapping provided a significant reduction in spinal movement. Adverse effects of spinal immobilization included a significant increase in respiratory effort, skin ischemia, pain, and discomfort. CONCLUSIONS Data from this review provide the best available evidence to support the well-recognized efficacy and potential adverse effects of spinal immobilization. However, comparisons of different immobilization strategies on trauma victims must be considered in order to establish an evidence base for this practice.
Collapse
Affiliation(s)
- Irene Kwan
- National Collaborating Centre for Women's and Children's Health, Royal College of Obstetricians and Gynecologists, London, England, UK.
| | | |
Collapse
|
16
|
Porter KM, Allison KP. The UK emergency department practice for spinal board unloading. Is there conformity? Resuscitation 2003; 58:117-20. [PMID: 12867318 DOI: 10.1016/s0300-9572(03)00078-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Guidelines for the management of suspected spinal injury patients from the scene of their accident to the emergency department were published in September 1998. This study was commissioned on behalf of the Faculty of Pre-hospital Care at the Royal College of Surgeons of Edinburgh, to examine the handling of patients on spinal boards on arrival in the emergency department. METHOD In July 2000, 132 postal questionnaires were sent to the consultants of the emergency departments in the United Kingdom (UK) that receive more than 50000 patients per annum. Four simple questions related to spinal board handling were asked. RESULTS A response rate of 63.6% was achieved and analysis showed that log roll was the technique most commonly used to remove the patient from the board in 90% of cases. In 76.3% of departments this occurred as part of secondary survey although in which part of the secondary survey that this took place was less clear. CONCLUSIONS It is suggested that as the spine board is such a widely used piece of equipment, there should be some guidelines to standardise its use at the emergency department interface with pre-hospital care. We recommend that spinal board removal should be part of the completion of the primary survey.
Collapse
Affiliation(s)
- K M Porter
- University Hospital Birmingham NHS Trust-Sellyoak, Raddlebarn Road, Birmingham B296JD, UK.
| | | |
Collapse
|
17
|
Bibliography. Neurosurgery 2002. [DOI: 10.1097/00006123-200203001-00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
18
|
Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC. Cervical spine immobilization before admission to the hospital. Neurosurgery 2002; 50:S7-17. [PMID: 12431281 DOI: 10.1097/00006123-200203001-00005] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STANDARDS There is insufficient evidence to support treatment standards. GUIDELINES There is insufficient evidence to support treatment guidelines. OPTIONS All trauma patients with a cervical spinal column injury or with a mechanism of injury having the potential to cause cervical spine injury should be immobilized at the scene and during transport by using one of several available methods. A combination of a rigid cervical collar and supportive blocks on a backboard with straps is effective in limiting motion of the cervical spine and is recommended. The long-standing practice of attempted cervical spine immobilization using sandbags and tape alone is not recommended.
Collapse
|
19
|
Abstract
BACKGROUND Spinal immobilisation involves the use of a number of devices and strategies to stabilise the spinal column after injury and thus prevent spinal cord damage. The practice is widely recommended and widely used in trauma patients with suspected spinal cord injury in the pre-hospital setting. OBJECTIVES To quantify the effect of different methods of spinal immobilisation (including immobilisation versus no immobilisation) on mortality, neurological disability, spinal stability and adverse effects in trauma patients. SEARCH STRATEGY We searched the Cochrane Controlled Trial Register (CCTR), the specialised register of the Cochrane Injuries Group, MEDLINE, EMBASE, CINAHL, PubMed and the National Research Register. We checked reference lists of all articles and contacted experts in the field to identify eligible trials. Manufacturers of spinal immobilisation devices were also contacted for information. SELECTION CRITERIA Randomised controlled trials comparing spinal immobilisation strategies in trauma patients with suspected spinal cord injury. Trials in healthy volunteers were excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently applied eligibility criteria to trial reports and extracted data. MAIN RESULTS We found no randomised controlled trials of spinal immobilisation strategies in trauma patients. REVIEWER'S CONCLUSIONS We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded. Large prospective studies are needed to validate the decision criteria for spinal immobilisation in trauma patients with high risk of spinal injury. Randomised controlled trials in trauma patients are required to establish the relative effectiveness of alternative strategies for spinal immobilisation.
Collapse
Affiliation(s)
- I Kwan
- Department of Paediatric Epidemiology and Biostatistics, Institute of Child Health, 30 Guilford Street, London, UK, WC1N 1EH.
| | | | | |
Collapse
|
20
|
Abstract
OBJECTIVES For pre-hospital spinal immobilisation the spinal board is the established gold standard. There are concerns that its subsequent use in hospital may adversely affect patient outcome. This review examines the effect of prolonged patient immobilisation on the spinal board. METHODS A database search of the literature and review of relevant trauma texts. RESULTS Complications associated with the use of the spinal board were found in five clinically relevant categories: pressure sore development; inadequacies of spinal immobilisation and support; pain and discomfort; respiratory compromise; and quality of radiological imaging. CONCLUSION The spinal board should be removed in all patients soon after arrival in accident and emergency departments, ideally after the primary survey and resuscitation phases.
Collapse
Affiliation(s)
- D Vickery
- Gloucestershire Royal Hospital, Department of Accident and Emergency Medicine, UK.
| |
Collapse
|
21
|
Hauswald M, Hsu M, Stockoff C. Maximizing comfort and minimizing ischemia: a comparison of four methods of spinal immobilization. PREHOSP EMERG CARE 2000; 4:250-2. [PMID: 10895921 DOI: 10.1080/10903120090941281] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine which of four methods of spinal immobilization causes the least ischemic pain. METHODS A prospective, nonblinded comparative trial was conducted at a statewide emergency medical services training facility using a convenience sample of emergency medical technician students. After lying motionless for 10 minutes, students evaluated each device using a 10-centimeter visual analog scale. Subjective comfort was used as a measure of ischemia. RESULTS Comfort scores were significantly different for all methods (F = 101, p < 0.001). A backboard padded with a gurney mattress and eggcrate foam (the equivalent of a spinal rehabilitation bed) caused the least ischemic pain (9.6 cm, 95% CI, 8.9 to 9.8 cm). A backboard padded with a gurney mattress was the second most comfortable device (7.0 cm, 95%/CI, 6.4 to 7.4 cm). A backboard padded with a folded blanket was the third most comfortable (3.3 cm, 95% CI, 2.6 to 4.9 cm). The backboard alone caused the most pain (0.8 cm, 95% CI, 0.7 to 2.1 cm). CONCLUSION Increasing the amount of padding on a backboard decreased the amount of ischemic pain caused by immobilization.
Collapse
Affiliation(s)
- M Hauswald
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque 87131-5246, USA.
| | | | | |
Collapse
|
22
|
Abstract
In this article we seek to determine the duration of immobilization in patients presenting to the emergency department (ED). We conducted a 10-week prospective study of a convenience sample of patients transported to a level one trauma center immobilized with a backboard and cervical collar. Total backboard time (TBT) was measured from the time the ambulance left the scene to the time the patient was removed from the backboard, while total ED backboard time (TEDBT) was measured from the time of arrival at the ED to the time of backboard removal. There were 138 patients entered in the study. Insufficient data excluded 36 patients from further analysis. TBT was available for 92 patients and averaged 63.63 (+/-45.87) minutes. Dividing patients into those who were removed from the backboard prior to radiographs (n = 85), the TBT average was 53.9 minutes (+/-30.1), whereas the average for those who had radiographs prior to removal from the backboard (n = 7) was 181.3 minutes (+/-41.6). There were 102 patients for whom TEDBT was available and averaged 46.36 (+/-44.88) minutes. Dividing patients into those who were removed from the backboard prior to radiographs (n = 95), the TEDBT average was 37.6 minutes (+/-29.6), whereas the average for those who had radiographs prior to removal from the backboard (n = 7) was 165.3 minutes (+/-49.7). Patients are left on backboards for significant periods of time even when no radiographs are taken prior to backboard removal.
Collapse
Affiliation(s)
- E B Lerner
- State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Department of Emergency Medicine, USA.
| | | |
Collapse
|
23
|
Abstract
Research can produce false-positive results just as can diagnostic tests. Uncontrolled studies have a specificity of only 11%, versus 88% for randomized controlled trials (RCTs), which have been designed to minimize the bias of investigators toward a positive outcome. A search of all the scientific studies in Medicine since 1985 revealed 5,842 publications on prehospital EMS, but only 54 were RCTs (and therefore unlikely to produce false-positive results). By way of comparison, during the same time hundreds of RCTs have been conducted on major medical emergency conditions, and RCTs on even minor topics such as urticaria and constipation exceed the scientific database on all of EMS. Of the 54 EMS RCTs, 4 (7%) reported harm from the new therapy, and 74% reported no effect of the new therapy at all. Only 7 (13%) RCTs showing a positive outcome of the intervention were uncontradicted; of these only 1 examined a major outcome such as survival, and only 1 compared the intervention with a placebo and could therefore evaluate the efficacy of EMS itself. Because there is such a paucity of scientific support for EMS interventions and because monitoring of outcomes and adverse effects is so poor, a serious reexamination of EMS practice is indicated.
Collapse
Affiliation(s)
- M Callaham
- Division of Emergency Medicine, University of California, San Francisco, USA
| |
Collapse
|
24
|
Pollock MJ, Brown LH, Dunn KA. The perceived importance of paramedic skills and the emphasis they receive during EMS education programs. PREHOSP EMERG CARE 1997; 1:263-8. [PMID: 9709368 DOI: 10.1080/10903129708958821] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The National Standard Curriculum for paramedics is currently being revised. There is little scientific evidence of what does and what does not work in prehospital care, and of whether the National Standard Curriculum prepares paramedics for the field. To provide some basis for the current revisions to the National Standard Curriculum, the authors determined which prehospital skills are perceived by paramedics to be the most important, and whether the emphasis placed on those skills during initial and continuing education programs corresponds with the perceived importance. METHODS Surveys listing 21 paramedic skills were mailed to the directors of 41 EMS agencies who agreed to participate in the study. The directors distributed the surveys to 1,364 paramedics affiliated with their organizations. The participants were asked to rate the importance of each skill, and the emphasis placed on each skill during their initial and continuing education. Skills were ranked on a scale of 0 to 4, with 0 representing no importance or emphasis, and 4 representing the most possible importance or emphasis. RESULTS Six-hundred of the 1,364 (44%) surveys were returned. Respondents had a mean of 9.9 +/- 5.6 years of EMS experience, and 5.4 +/- 4.0 years of experience as paramedics. The three skills ranked highest in importance were: 1) endotracheal intubation; 2) defibrillation; and 3) assessment. Importance in prehospital care was ranked equal to or higher than emphasis in both initial and continuing education for all skills except splinting and urinary catheterization, which received higher rankings for emphasis in initial education. Emphasis in initial education equaled or exceeded the emphasis in continuing education for all skills except intraosseous infusion. CONCLUSION The perceived importance of most prehospital skills is very high, and exceeds the emphasis placed on those skills during both initial and continuing education programs. These findings have implications for medical directors, EMS instructors, and persons involved with the revision of the National Standard Curriculum.
Collapse
Affiliation(s)
- M J Pollock
- Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina 27858, USA
| | | | | |
Collapse
|
25
|
Abstract
Immobilization of the spine is an important skill for all emergency providers. This article reviews the literature regarding the equipment, adjuncts, and techniques involved in spinal immobilization. Current prehospital practice is to apply spinal immobilization liberally in cases of suspected neck or back injury. Rigid cervical collars, long backboards, and straps remain the standard implements for immobilizing supine patients. Tape, foam blocks, and towels can complement the basic items and improve stability. Padding may improve positioning and comfort. Intermediate-stage devices include the short backboard and newer commercial devices. Properly used, all provide reasonable immobilization of the sitting patient. Future directions for study include refinement of optimal body position, dynamic performance of all devices, and broadening study populations to include children and the elderly.
Collapse
Affiliation(s)
- R A De Lorenzo
- Department of Emergency Medicine, Darnall Army Community Hospital, Ft. Hood, Texas 76544-5063, USA
| |
Collapse
|
26
|
Hamilton RS, Pons PT. The efficacy and comfort of full-body vacuum splints for cervical-spine immobilization. J Emerg Med 1996; 14:553-9. [PMID: 8933314 DOI: 10.1016/s0736-4679(96)00170-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We performed a prospective crossover study to determine the cervical spine immobilization and comfort level of healthy subjects on a full-body vacuum splint in comparison with a standard backboard, with and without cervical spine collars. Twenty-six healthy volunteers were immobilized on a backboard (BB) and a full-body vacuum splint (VS), both with and without a cervical collar (CC). Pre- and post-immobilization cervical spine range-of-motion measurements were made using an electronic digital inclinometer and a standard handheld goniometer. Subjects were also asked to subjectively grade their immobilization and discomfort both overall and in seven specific body regions. No statistically significant difference was found between the VS+CC and the BB+CC for flexion and rotation, although the VS+CC combination provided significantly superior immobilization to the BB+CC for extension and lateral bending. The VS alone, in all cases except extension, provided superior immobilization to the BB alone. A statistically significant difference in subjective perception of immobilization was noted, with the BB being less effective than the other three alternatives and the VS+CC providing the best immobilization. A significant difference in overall comfort and occipital region comfort, favoring the vacuum splint, was found. In conclusion, the vacuum splint is an effective and more comfortable alternative to the background for cervical spine immobilization.
Collapse
Affiliation(s)
- R S Hamilton
- University of California San Diego Medical Center/Mercy Hospital, CA 92103, USA.
| | | |
Collapse
|