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Gräff P, Bolduan L, Macke C, Clausen JD, Sehmisch S, Winkelmann M. Where Do We Stand on Cervical Spine Immobilisation? A Questionnaire among Prehospital Staff. J Clin Med 2024; 13:2325. [PMID: 38673598 PMCID: PMC11050990 DOI: 10.3390/jcm13082325] [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: 03/10/2024] [Revised: 04/07/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Cervical collars (CC) are routinely used in prehospital trauma treatment. However, over the past years, their application was discussed more critically since they increase intravenous pressure due to reduced venous drainage and the possibility of secondary cervical spine injury. Guidelines have been adjusted accordingly. The question is how efficient has this been put into practice, and how good, as well as up to date, is the knowledge of prehospital emergency medicine personnel about indications on cervical spine immobilisation? Methods: A 15-item questionnaire regarding the self-evaluation and result checking of the right indications for the use of a cervical collar in the prehospital setting was sent to paramedics and emergency doctors in Germany. Two hundred and nineteen completed surveys were statistically analysed. Results: Mean age of the participants was 30.45 ± 8.8. 72% were male. Regarding subjective safety, the appropriate indication of CC participants reached 79.8 ± 19.5 on a metric scale from 0 (no safety) to 100 (full safety). Mean right answers were as follows: Ambulance man (RS) 0.78 ± 0.84, paramedic (RA) 0.9 ± 0.74, paramedic (NFS) 1.03 ± 0.83 and emergency doctor (ED) 1.75 ± 1.06 (p = 0.013, Kruskal-Wallis Test). Participants who estimated their knowledge < 85% had 0.83 ± 0.8 right answers, and > 85% had 1.14 ± 0.9 right answers. Conclusions: Rational spine immobilisation is still necessary in severely injured patients. This study highlights the importance of continuing education using ongoing training, lectures or online learning with a questionnaire as a monitor for success to ensure the transfer of evidence-based medicine into daily practice.
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Affiliation(s)
- Pascal Gräff
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany (M.W.)
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Hawkins SC, Williams J, Bennett BL, Islas A, Quinn R. Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update. Wilderness Environ Med 2024; 35:78S-93S. [PMID: 38379496 DOI: 10.1177/10806032241227232] [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] [Indexed: 02/22/2024]
Abstract
The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.
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Affiliation(s)
- Seth C Hawkins
- Department of Emergency Medicine, Wake Forest University, Winston-Salem, NC
| | - Jason Williams
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Arthur Islas
- Department of Family and Community Medicine, University of Nevada, Reno School of Medicine, Reno, NV
| | - Robert Quinn
- Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX
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Roebke AJ, Bates N, Jurenovich K, Yu E, Karnes J, Khan S, Kman N, Groth A, Martin KD. Cervical Spinal Immobilization: A Head-to-Head Comparison of a One-Step Spray-on Foam Splint Versus Structural Aluminum Malleable Splint Immobilization. Mil Med 2023; 188:e2987-e2991. [PMID: 36943370 DOI: 10.1093/milmed/usad081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/12/2023] [Accepted: 03/08/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Cervical spine immobilization in a low-resource environment is difficult secondary to limited equipment, prolonged transportation, and secondary complications. A structural aluminum malleable (SAM) splint is commonly utilized because of its availability and multipurpose intention. A one-step spray-on foam immobilization technique (Fast Cast) has been shown to be effective in lower-extremity splinting. The aim of this study was to demonstrate the ability of the Fast Cast to effectively immobilize the cervical spine in a head-to-head comparison against the SAM splint. We hypothesized that there would be no difference in surgeon scoring between Fast Cast and SAM splints for the immobilization of the cervical spine. METHODS This was a cadaveric experimental comparative study that compared a SAM splint versus Fast Cast for the immobilization of an unstable cervical spine. Each of the three cadaveric specimens had a corpectomy without fixation performed. A board-certified emergency medicine physician specialized in disaster medicine performed all SAM immobilizations. An orthopedic surgeon performed Fast Cast immobilizations. Each method of immobilization was done on each cadaver. Lateral fluoroscopic imaging was taken before and after immobilization and after log roll/gravity stress. Five board-certified orthopedic surgeons served as graders to independently score each splint. A 5-point Likert scale based on 10 splinting criteria (50 total points possible) was utilized to evaluate cervical spine immobilization. The lead statistical analyst was blinded to the immobilization groups. The statistical significance was assessed via a Wilcoxon signed-rank test and chi-square Fisher's exact test with significance between groups set at α < .05. Inter-rater reliability of the Likert scale results was assessed with the interclass correlation coefficient. RESULTS Inter-rater reliability for the current Likert scale in the evaluation of cervical spine stabilization was good (interclass correlation coefficient = 0.76). For the cumulative Likert scale score, Fast Cast (32 [28-34]) exhibited a higher total score than SAM (44 [42-47]; P < .01). Likewise, Fast Cast exhibited a greater likelihood of higher Likert scores within each individual question as compared to SAM (P ≤ 0.04). In 100% of cases, raters indicated that Fast Cast passed the gravity stress examination without intrinsic loss of reduction or splinting material, whereas 33% of SAM passed (P < .01). In 100% of cases, raters indicated that Fast Cast passed the initial radiographic alignment following immobilization, whereas 66% of SAM passed (P = .04). In 100% of cases, raters indicated that Fast Cast passed radiographic alignment after the gravity stress examination, whereas 47% of SAM passed (P < .01). CONCLUSION The Fast Cast exceeded our expectations and was shown to be rated not equivalent but superior to SAM splint immobilization for the cervical spine. This has significant clinical implications as the single-step spray-on foam is easy to transport and has multifaceted applications. It also eliminates pressure points and circumferential wrapping and obstruction to airway/vascular access while immobilizing the cervical spine and allowing for radiographic examination. Further studies are needed for human use and application.
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Affiliation(s)
- Austin J Roebke
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Nathaniel Bates
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Kathryn Jurenovich
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Elizabeth Yu
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Jonathan Karnes
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Safdar Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Nicholas Kman
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Adam Groth
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
| | - Kevin D Martin
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43202, USA
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McDonald N, Kriellaars D, Pryce RT. Patterns of change in prehospital spinal motion restriction: A retrospective database review. Acad Emerg Med 2023; 30:698-708. [PMID: 36734048 DOI: 10.1111/acem.14678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute management of trauma patients with potential spine injuries has evolved from uniform spinal immobilization (SI) to spinal motion restriction (SMR). Little research exists describing how these changes have been implemented. This study aims to describe and analyze the practice of SMR in one emergency medical services (EMS) agency over the time frame of SMR adoption. METHODS This was a retrospective database review of electronic patient care reports from 2009 to 2020. The effects of key practice changes (revised documentation and a collar-only treatment option) were analyzed in an interrupted time series using the rate of SI/SMR as the primary outcome. Secondary outcomes included patient age, sex, acuity, mechanism of injury, treatment provided, cervical collar size, and positioning. These were assessed for changes from year to year by Poisson regression. Associations between patient and treatment characteristics were investigated with binomial logistic regression. RESULTS There were 25,747 instances of SI/SMR included. Among all patients, the median age was 40 (interquartile range 24-56), 58% (14,970) were male, and 20% (5062) were high-acuity. The rate of SI/SMR declined from 31.2 to 12.7 treatments per 100 trauma calls per month. The proportion of high-acuity patients increased by 9.6% per year on average (95% CI 8.7%-10.0%). When first available, collar-only treatment was provided to 47% of patients, rising by 6.3% per year (95% CI 3.2%-9.5%) to 60% in 2020. Collar-only treatment (compared to board-and-collar) was more likely to be applied to low-acuity patients (as compared to high): odds ratio 3.01 (95% CI 2.64-3.43). CONCLUSIONS This study shows decreasing SI/SMR treatment and changing patient and practice characteristics. These patterns of care cannot be attributed solely to formal protocol changes. Similar patterns and their possible explanations should be investigated elsewhere.
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Affiliation(s)
- Neil McDonald
- Applied Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Winnipeg Fire Paramedic Service, Winnipeg, Manitoba, Canada
| | - Dean Kriellaars
- College of Rehabilitation Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rob T Pryce
- Department of Kinesiology and Applied Health, Gupta Faculty of Kinesiology, University of Winnipeg, Winnipeg, Manitoba, Canada
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Hoseini Kasnavieh M, Kookli K, Veisi M, Amerzadeh M, Hosseinifar H, Tahmasebi A. Investigating the Rate and Affecting Factors of Unnecessary Cervical Collar Use in Trauma Patients. Bull Emerg Trauma 2023; 11:178-183. [PMID: 38143523 PMCID: PMC10743316 DOI: 10.30476/beat.2023.98793.1441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/05/2023] [Accepted: 08/29/2023] [Indexed: 12/26/2023] Open
Abstract
Objective This study aimed to investigate the necessity of cervical collars in patients with neck problems. Methods This cross-sectional study was conducted on 114 patients who were admitted to the Haft Tir and Rasoul Akram Hospitals (Tehran, Iran) from August to September 2022. The Nexus protocol was used to select the patients with cervical collars. According to the protocol, a cervical collar was required for individuals who had at least one symptom. If none of these symptoms existed, the cervical collar was deemed unnecessary. The data were analyzed using the Chi-square test and Fisher's exact test. Results Of the 114 trauma patients, the cervical collar was used unnecessarily by 49 (43%) patients. Tenderness was the most common complication in 62 patients (54.4%). The prevalence of unnecessary cervical collar use was 37.5% in female trauma patients and 43.88% in male trauma patients, which was not statistically significant (p=0.63). The prevalence of unnecessary cervical collar use in trauma patients with multiple trauma was 39.42% and 80% in patients without multiple trauma, which was statistically significant (p=0.018). Patients with a medical history had a higher rate of unnecessary use of the cervical collar (47.96%) than those without a history (12.5%), and this difference was statistically significant (p=0.008). Conclusion The guidelines for using cervical collars need to be updated by the EMS. Due to the large number of trauma patients in Iran, cervical collars for necessary conditions can help to reduce the healthcare expenses and injuries caused by unnecessary cervical collars.
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Affiliation(s)
| | - Keihan Kookli
- International Campus, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Veisi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amerzadeh
- Department of Health Services Management, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Hossein Hosseinifar
- Evidence-Based Medicine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Tahmasebi
- Hospital Management Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
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McDonald N, Kriellaars D, Pryce RT. Paramedic attitudes towards prehospital spinal care: a cross-sectional survey. BMC Emerg Med 2022; 22:162. [PMID: 36123619 PMCID: PMC9487099 DOI: 10.1186/s12873-022-00717-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The optimal application of spinal motion restriction (SMR) in the prehospital setting continues to be debated. Few studies have examined how changing guidelines have been received and interpreted by emergency medical services (EMS) personnel. This study surveys paramedics' attitudes, observations, and self-reported practices around the treatment of potential spine injuries in the prehospital setting. METHODS This was a cross-sectional survey of a North American EMS agency. After development and piloting, the final version of the survey contained four sections covering attitudes towards 1) general practice, 2) specific techniques, 3) assessment protocols, and 4) mechanisms of injury (MOI). Questions used Likert-scale, multiple-choice, yes/no, and free-text responses. Exploratory factor analysis (EFA) was used to identify latent constructs within responses, and factor scores were analyzed by ordinal logistic regression for associations with demographic characteristics (including qualification level, gender, and years of experience). MOI evaluations were assessed for inter-rater reliability (Fleiss' kappa). Inductive qualitative content analysis, following Elo & Kyngäs (2008), was used to examine free-text responses. RESULTS Two hundred twenty responses were received (36% of staff). Raw results indicated that respondents felt that SMR was seen as less important than in the past, that they were treating fewer patients than previously, and that they follow protocol in most situations. The EFA identified two factors: one (Judging MOIs) captured paramedics' estimation that the presented MOI could potentially cause a spine injury, and another (Treatment Value) reflected respondents' composite view of the effectiveness, importance, and applicability of SMR. Respondents with advanced life support (ALS) qualification were more likely to be skeptical of the value of SMR compared to those at the basic life support (BLS) level (OR: 2.40, 95%CI: 1.21-4.76, p = 0.01). Overall, respondents showed fair agreement in the evaluation of MOIs (k = 0.31, 95%CI: 0.09-0.49). Content analysis identified tension expressed by respondents between SMR-as-directed and SMR-as-applied. CONCLUSION Results of this survey show that EMS personnel are skeptical of many elements of SMR but use various strategies to balance protocol adherence with optimizing patient care. While identifying several areas for future research, these findings argue for incorporating provider feedback and judgement into future guideline revision.
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Affiliation(s)
- Neil McDonald
- Applied Health Sciences, University of Manitoba, Winnipeg, MB, Canada. .,Winnipeg Fire Paramedic Service, 2546 McPhillips St, Winnipeg, Manitoba, R2P 2T2, Canada.
| | - Dean Kriellaars
- College of Rehabilitation Sciences, Rady Faculty of Health Sciences University of Manitoba, 771 Mc Dermot Ave, Winnipeg, Manitoba, R3E 0T6, Canada
| | - Rob T Pryce
- Department of Kinesiology and Applied Health, Gupta Faculty of Kinesiology University of Winnipeg, 400 Spence St, Winnipeg, Manitoba, R3B 2E9, Canada
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Grenier G, Despatis MA, Lebel K, Hamel M, Martin C, Boissy P. Removal of the cervical collar from alpine rescue protocols? A biomechanical non-inferiority trial in real-life mountain conditions. Scand J Trauma Resusc Emerg Med 2022; 30:42. [PMID: 35761355 PMCID: PMC9235139 DOI: 10.1186/s13049-022-01031-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 06/20/2022] [Indexed: 11/15/2022] Open
Abstract
Background Alpine skiing rescues are challenging because of the mountainous environment and risks of cervical spine motion (CSM) induced during victims’ extrications (EXs) and downhill evacuations (DEs). The benefits of applying a cervical collar (CC) over manual in-line stabilization without CC (MILS) in terms of spinal motion restriction during simulated alpine rescues are undocumented. Our hypothesis was that CSM recorded using MILS alone is non-inferior to CSM recorded with a CC according to a 10 degrees margin.
Methods A total of 32 alpine extrications and 4 downhill evacuations on different slope conditions were performed using a high fidelity mannequin designed with a motion sensors instrumented cervical spine. The primary outcome was the peak extrication 3D excursion angle (Peak 3D θEX,) of the mannequin’s head. The secondary objectives were to describe the time to extrication completion (tEX) and to highlight which extrication manipulation is more likely to induce CSM. Results The median Peak 3D θEX recorded during flat terrain extrications using CC was 10.77° (95% CI 7.31°–16.45°) compared to 13.06° (95% CI 10.20°–30.36°) using MILS, and 16.09° (95% CI 9.07°–37.43°) for CC versus 16.65° (95% CI 13.80°–23.40°) using MILS on a steep slope. Peak 3D θEX with CC or using MILS during extrications were equivalent according to a 10 degrees non-inferiority hypothesis testing (p < 0.05). Time to extrication completion (tEX) was significantly reduced using MILS without CC on a flat terrain with a median duration of 237,3 s (95% CI 197.8 s, 272.2 s) compared to 358.7 s (95% CI 324.1 s, 472.4 s). During downhill evacuations, CSM with and without CC across all terrain conditions were negligible (< 5°). When CC is used; its installation manipulation induces the highest CSM. When EXs are done using MILS without CC, the logroll initiation is the manipulation inducing the highest risk of CSM. Conclusion For experienced ski patrollers, the biomechanical benefits of spinal motion restriction provided by CC over MILS during alpine skiing rescues appear to be marginal and CC use negatively affects rescue time. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01031-3.
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Affiliation(s)
- Guillaume Grenier
- Faculty of Medicine and Health Sciences, Department of Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Marc-Antoine Despatis
- Faculty of Medicine and Health Sciences, Department of Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Karina Lebel
- Faculty of Engineering, Department of Electrical and Computing Engineering, Université de Sherbrooke, Sherbrooke, QC, Canada.,Research Center on Aging, CIUSSS Estrie CHUS, Sherbrooke, QC, Canada
| | - Mathieu Hamel
- Research Center on Aging, CIUSSS Estrie CHUS, Sherbrooke, QC, Canada
| | - Camille Martin
- Faculty of Engineering, Department of Electrical and Computing Engineering, Université de Sherbrooke, Sherbrooke, QC, Canada.,Research Center on Aging, CIUSSS Estrie CHUS, Sherbrooke, QC, Canada
| | - Patrick Boissy
- Faculty of Medicine and Health Sciences, Department of Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada. .,Research Center on Aging, CIUSSS Estrie CHUS, Sherbrooke, QC, Canada.
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A multicenter cohort study on the association between prehospital immobilization and functional outcome of patients following spinal injury in Asia. Sci Rep 2022; 12:3492. [PMID: 35241763 PMCID: PMC8894344 DOI: 10.1038/s41598-022-07481-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 02/18/2022] [Indexed: 12/12/2022] Open
Abstract
Prehospital spinal immobilization is a widely used procedure in the emergency medical service (EMS) system worldwide, while the incidence of patients with spinal injury (SI) is relatively low, and unnecessary prehospital spinal immobilization is associated with patient complications. This study aimed to determine the association between prehospital spine immobilization and favorable functional outcomes at hospital discharge among trauma patients with SI. We conducted a retrospective cohort study using the Pan-Asia Trauma Outcomes Study (PATOS) registry data from January 1, 2016, to November 30, 2018. A total of 759 patients with SI were enrolled from 43,752 trauma patients in the PATOS registry during the study period. The subjects had a median age of 58 years (Q1–Q3, 41–72), and 438 (57.7%) patients had prehospital spine immobilization. Overall, prehospital spinal immobilization was not associated with favorable functional outcomes at discharge in multivariable logistic regression (aOR 1.06; 95% CI 0.62–1.81, p = 0.826). However, in the subgroup of cervical SI, prehospital spinal immobilization was associated with favorable functional outcomes at discharge (aOR 3.14; 95% CI 1.04–9.50; p = 0.043). Therefore, we suggest that paramedics should be more careful when determining the presence of a cervical SI and should apply full spine immobilization if possible.
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A survey on the early management of spinal trauma in low and middle-income countries: From the scene of injury to the diagnostic phase (part II). BRAIN AND SPINE 2022; 2:101185. [PMID: 36248114 PMCID: PMC9560661 DOI: 10.1016/j.bas.2022.101185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/17/2022] [Accepted: 09/02/2022] [Indexed: 11/20/2022]
Abstract
Most spinal trauma worldwide occurs in low-and middle-income countries (LMICs). Several factors may limit the applicability of current guidelines as regards the early management of spinal injury. The pre-hospital management per se of spinal trauma in LMICs is subject to partial adherence to recommendations, with possible impact on patient outcomes. The use of clinical (eg ASIA) and morphological (eg SLIC, TLICS, AO Spine) grading scales is not homogeneous. The availability and cost of diagnostic equipment, and the timing of emergency imaging can vary significantly from one region to another, probably affecting the timely management of spinal injury patients. The introduction of resource-targeted guidelines for spinal trauma may be a valuable option to overcome the limitations of real-life application of current guidelines.
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10
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Jung MK, von Ehrlich-Treuenstätt GVR, Keil H, Grützner PA, Schneider NRE, Kreinest M. Analysis of remaining motion using one innovative upper airway opening cervical collar and two traditional cervical collars. Sci Rep 2021; 11:20619. [PMID: 34663847 PMCID: PMC8523562 DOI: 10.1038/s41598-021-00194-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 09/24/2021] [Indexed: 12/20/2022] Open
Abstract
The aim of this study was to compare the remaining motion of an immobilized cervical spine using an innovative cervical collar as well as two traditional cervical collars. The study was performed on eight fresh human cadavers. The cervical spine was immobilized with one innovative (Lubo Airway Collar) and two traditional cervical collars (Stifneck and Perfit ACE). The flexion and lateral bending of the cervical spine were measured using a wireless motion tracker (Xsens). With the Weinman Lubo Airway Collar attached, the mean remaining flexion was 20.0 ± 9.0°. The mean remaining flexion was lowest with the Laerdal Stifneck (13.1 ± 6.6°) or Ambu Perfit ACE (10.8 ± 5.8°) applied. Compared to that of the innovative Weinmann Lubo Airway Collar, the remaining cervical spine flexion was significantly decreased with the Ambu Perfit ACE. There was no significant difference in lateral bending between the three examined collars. The most effective immobilization of the cervical spine was achieved when traditional cervical collars were implemented. However, all tested cervical collars showed remaining motion of the cervical spine. Thus, alternative immobilization techniques should be considered.
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Affiliation(s)
- Matthias K Jung
- BG Trauma Center Ludwigshafen, Clinic for Trauma and Orthopaedic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Gregor V R von Ehrlich-Treuenstätt
- BG Trauma Center Ludwigshafen, Clinic for Trauma and Orthopaedic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Holger Keil
- Clinic for Trauma and Orthopaedic Surgery, Universitätsklinikum Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Paul A Grützner
- BG Trauma Center Ludwigshafen, Clinic for Trauma and Orthopaedic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen on the Rhine, Germany
| | - Niko R E Schneider
- Clinic of Anesthesiology, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Michael Kreinest
- BG Trauma Center Ludwigshafen, Clinic for Trauma and Orthopaedic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen on the Rhine, Germany.
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Baril L, Nguyen E, Dufresne-Santerre L, Émond V, Émond M, Berthelot S, Gagnon AP, Nadeau A, Carmichael PH, Mercier E. Pain induced by investigations and procedures commonly administered to older adults in the emergency department: a prospective cohort study. Emerg Med J 2021; 38:825-829. [PMID: 34344731 DOI: 10.1136/emermed-2020-210535] [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: 08/24/2020] [Accepted: 07/16/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND This study aimed to assess the level of pain induced by common interventions performed in older adults consulting to the ED. METHODS We conducted a prospective multicentre observational cohort study in two academic EDs (Quebec City, Canada) between June 2018 and December 2019. A convenience sample of well-oriented and haemodynamically stable older adults (≥65 years old) who underwent at least two interventions during their ED stay was recruited. The level of pain was assessed using an 11-point Numerous Rating Scale (NRS) and is presented using median and IQR or categorised as no pain (0), mild (1-3), moderate (4-6) or severe pain (7-10). RESULTS A total of 318 patients were included. The mean age was 77.8±8.0 years old and 54.4% were female . The number of pain assessments per intervention ranged between 22 (urinary catheterisation) and 240 (intravenous catheter). All imaging investigations (X-rays, CT and bedside ultrasound) were associated with a median level of pain of 0. The median level of pain for other interventions was as follows: blood samplings (n=231, NRS 1 (IQR 0-3)), intravenous catheters (n=240, NRS 2 (IQR 0-4)), urinary catheterisations (n=22, NRS 4.5 (IQR 2-6)), cervical collars (n=50, NRS 5 (IQR 0-8)) and immobilisation mattresses (n=34, NRS 5 (IQR 0-8)). Urinary catheterisations (63.8%), cervical collars (56.0%) and immobilisation mattresses (52.9%) frequently induced moderate or severe pain. CONCLUSIONS Most interventions administered to older adults in the ED are associated with no or low pain intensity. However, urinary catheterisation and spinal motion restriction devices are frequently associated with moderate or severe pain.
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Affiliation(s)
- Laurence Baril
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Elisabeth Nguyen
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | | | - Virginie Émond
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Marcel Émond
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada.,Emergency Department, CHU de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Simon Berthelot
- Emergency Department, CHU de Québec - Université Laval, Quebec City, Quebec, Canada.,Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgences - Soins Intensifs, Centre de recherche du CHU de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Ann-Pier Gagnon
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgences - Soins Intensifs, Centre de recherche du CHU de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Alexandra Nadeau
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgences - Soins Intensifs, Centre de recherche du CHU de Québec - Université Laval, Quebec City, Quebec, Canada.,VITAM - Centre de recherche en santé durable de l'Université Laval, Quebec City, Quebec, Canada
| | | | - Eric Mercier
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada .,VITAM - Centre de recherche en santé durable de l'Université Laval, Quebec City, Quebec, Canada
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12
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Benchetrit S, Blackham J, Braude P, Halliday R, Shipway D, Williams A, Carlton E. Emergency management of older people with cervical spine injuries: an expert practice review. Emerg Med J 2021; 39:331-336. [PMID: 34344732 DOI: 10.1136/emermed-2020-211002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/26/2021] [Indexed: 11/03/2022]
Abstract
Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.
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Affiliation(s)
| | | | - Philip Braude
- Department of Medicine for Older People, Southmead Hospital, Bristol, UK
| | - Ruth Halliday
- Trauma & Orthopaedic Research Team, Southmead Hospital, Bristol, UK
| | - David Shipway
- Department of Medicine for Older People, Southmead Hospital, Bristol, UK
| | - Adam Williams
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
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13
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Zileli M, Osorio-Fonseca E, Konovalov N, Cardenas-Jalabe C, Kaprovoy S, Mlyavykh S, Pogosyan A. Early Management of Cervical Spine Trauma: WFNS Spine Committee Recommendations. Neurospine 2021; 17:710-722. [PMID: 33401852 PMCID: PMC7788428 DOI: 10.14245/ns.2040282.141] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/06/2020] [Indexed: 12/12/2022] Open
Abstract
Epidemiology, prevention, early management of cervical spine trauma and it's reduction are the objectives of this review paper. A PubMed and MEDLINE search between 2009 and 2019 were conducted using keywords. Case reports, experimental studies, papers other than English language and and unrelated studies were excluded. Up-to-date information on epidemiology of spine trauma, prevention, early emergency management, transportation, and closed reduction were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Global incidence of traumatic spinal injury is higher in low- and middle-income countries. The most frequent reasons are road traffic accidents and falls. The incidence from low falls in the elderly are increasing in high-income countries due to ageing populations. Prevention needs legislative, engineering, educational, and social efforts that need common efforts of all society. Emergency care of the trauma patient, transportation, and in-hospital acute management should be planned by implementing detailed protocols to prevent further damage to the spinal cord. This review summarizes the WFNS Spine Committee recommendations on epidemiology, prevention, and early management of cervical spine injuries.
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Affiliation(s)
- Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
| | | | - Nikolay Konovalov
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | | | - Stanislav Kaprovoy
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | - Sergey Mlyavykh
- Trauma and Orthopedics Institute, Privolzhsky Research Medical University, Nizhniy Novgorod, Russian Federation
| | - Artur Pogosyan
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
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14
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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A T2 Translational Science Modified Delphi Study: Spinal Motion Restriction in a Resource-Scarce Environment. Prehosp Disaster Med 2020; 35:538-545. [PMID: 32641192 DOI: 10.1017/s1049023x20000862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Emerging evidence is guiding changes in prehospital management of potential spinal injuries. The majority of settings related to current recommendations are in resource-rich environments (RREs), whereas there is a lack of guidance on the provision of spinal motion restriction (SMR) in resource-scarce environments (RSEs), such as: mass-casualty incidents (MCIs); low-middle income countries; complex humanitarian emergencies; conflict zones; and prolonged transport times. The application of Translational Science (TS) in the Disaster Medicine (DM) context was used to develop this study, leading to statements that can be used in the creation of evidence-based clinical guidelines (CGs). OBJECTIVE What is appropriate SMR in RSEs? METHODS The first round of this modified Delphi (mD) study was a structured focus group conducted at the World Association for Disaster and Emergency Medicine (WADEM) Congress in Brisbane Australia on May 9, 2019. The result of the focus group discussion of open-ended questions produced ten statements that were added to ten statements derived from Fischer (2018) to create the second mD round questionnaire.Academic researchers and educators, operational first responders, or first receivers of patients with suspected spinal injuries were identified to be mD experts. Experts rated their agreement with each statement on a seven-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤1.0. Statements that were in agreement reaching consensus were included in the final report; those that were not in agreement but reached consensus were removed from further consideration. Those not reaching consensus advanced to the third mD round.For subsequent rounds, experts were shown the mean response and their own response for each of the remaining statements and asked to reconsider their rating. As above, those that did not reach consensus advanced to the next round until consensus was reached for each statement. RESULTS Twenty-two experts agreed to participate with 19 completing the second mD round and 16 completing the third mD round. Eleven statements reached consensus. Nine statements did not reach consensus. CONCLUSIONS Experts reached consensus offering 11 statements to be incorporated into the creation of SMR CGs in RSEs. The nine statements that did not reach consensus can be further studied and potentially modified to determine if these can be considered in SMR CGs in RSEs.
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16
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Hawkins SC, Williams J, Bennett BL, Islas A, Kayser DW, Quinn R. Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection. Wilderness Environ Med 2019; 30:S87-S99. [DOI: 10.1016/j.wem.2019.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/25/2019] [Accepted: 08/01/2019] [Indexed: 11/30/2022]
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17
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[Development and first application testing of a new protocol for preclinical spinal immobilization in children : Assessment of indications based on the E.M.S. IMMO Protocol Pediatric]. Unfallchirurg 2019; 123:289-301. [PMID: 31768566 DOI: 10.1007/s00113-019-00744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND To protect the spine from secondary damage, spinal immobilization is a standard procedure in prehospital trauma management. Immobilization protocols aim to support emergency medicine personnel in quick decision making but predominantly focus on the adult spine; however, trauma mechanisms and injury patterns in adults differ from those in children and applying adult prehospital immobilization protocols to pediatric patients may be insufficient. Adequate protocols for children with spinal injuries are currently unavailable. OBJECTIVE The aim of this study was (i) to develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) to perform a first analysis of the quality of results if the protocol is used by emergency personnel. MATERIAL AND METHODS Based on a structured literature search a new immobilization protocol was developed. Analysis of the quality of results was performed by a questionnaire containing four case scenarios in order to assess correct decision making. The decision about spinal immobilization was made without and with the utilization of the protocol. RESULTS The E.M.S. IMMO Protocol Pediatric was developed based on the literature. The analysis of the quality of results was performed involving 39 emergency medicine providers. It could be shown that if the E.M.S. IMMO Protocol Pediatric was used, the correct type of immobilization was chosen more frequently. A total of 38 out of 39 participants evaluated the protocol as helpful. CONCLUSION The E.M.S. IMMO Protocol Pediatric provides decision-making support whether pediatric spine immobilization is indicated with respect to the cardiopulmonary status of the patient. In a first analysis, the E.M.S. IMMO Protocol Pediatric improves decision making by emergency medical care providers.
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18
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Kreinest M, Goller S, Rauch G, Gliwitzky B, Frank C, Matschke S, Wölfl CG, Münzberg M. [Parameters influencing the preclinical application of cervical collars]. Unfallchirurg 2019; 120:675-682. [PMID: 27357352 DOI: 10.1007/s00113-016-0207-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The application of cervical collars is a standard procedure in emergency care of trauma patients. It is often observed that the application of cervical collars is performed incorrectly, which may lead to reduced immobilization of the cervical spine. OBJECTIVES The objective of this study was to analyze the practical skills of professional emergency care providers concerning the application of cervical collars. MATERIALS AND METHODS Emergency care professionals (n = 104) were asked to apply a cervical collar to a training doll. Each performance step was assessed separately. Furthermore, personal and occupational data of all study participants were collected using a questionnaire. RESULTS The study participants included professional rescue personnel and emergency physicians. The average occupational experience of all study participants in out-of-hospital emergency care was 11.1 ± 8.9 years. Most participants had already received training on trauma care (61 %) and felt "very confident" in handling a cervical collar (84 %). The application of the cervical collar was performed correctly in 11 % of the performances. The most common error was incorrect size adjustment of the cervical collar (66 %). No association was found between the correct application of the cervical collar and possible parameters of influence, such as working experience in emergency care or participation in trauma courses. CONCLUSIONS Despite pronounced subjective confidence regarding the application of cervical collars, this study shows that there are general deficits in the practical skills of applying cervical collars. Therefore, a critical assessment of the current training contents on the subject of trauma care must be demanded.
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Affiliation(s)
- M Kreinest
- Klinik für Unfallchirurgie und Orthopädie, BG-Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- PHTLS Germany Research Group, Offenbach/Queich, Deutschland
| | - S Goller
- Klinik für Unfallchirurgie und Orthopädie, BG-Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- PHTLS Germany Research Group, Offenbach/Queich, Deutschland
| | - G Rauch
- Institut für Medizinische Biometrie und Informatik, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - B Gliwitzky
- PHTLS Germany Research Group, Offenbach/Queich, Deutschland
| | - C Frank
- PHTLS Germany Research Group, Offenbach/Queich, Deutschland
- Klinik für Orthopädie und Unfallchirurgie, Klinikum Mittelbaden, Baden-Baden, Deutschland
| | - S Matschke
- Klinik für Unfallchirurgie und Orthopädie, BG-Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
| | - C G Wölfl
- Klinik für Unfallchirurgie und Orthopädie, BG-Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- PHTLS Germany Research Group, Offenbach/Queich, Deutschland
| | - M Münzberg
- Klinik für Unfallchirurgie und Orthopädie, BG-Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
- PHTLS Germany Research Group, Offenbach/Queich, Deutschland.
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19
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Liao S, Schneider NRE, Hüttlin P, Grützner PA, Weilbacher F, Matschke S, Popp E, Kreinest M. Motion and dural sac compression in the upper cervical spine during the application of a cervical collar in case of unstable craniocervical junction-A study in two new cadaveric trauma models. PLoS One 2018; 13:e0195215. [PMID: 29624623 PMCID: PMC5889057 DOI: 10.1371/journal.pone.0195215] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/13/2018] [Indexed: 12/11/2022] Open
Abstract
Background Unstable conditions of the craniocervical junction such as atlanto-occipital dislocation (AOD) or atlanto-axial instability (AAI) are severe injuries with a high risk of tetraplegia or death. Immobilization by a cervical collar to protect the patient from secondary damage is a standard procedure in trauma patients. If the application of a cervical collar to a patient with an unstable craniocervical condition may cause segmental motion and secondary injury to the spinal cord is unknown. The aim of the current study is (i) to analyze compression on the dural sac and (ii) to determine relative motion of the cervical spine during the procedure of applying a cervical collar in case of ligamentous unstable craniocervical junction. Methods and findings Ligamentous AOD as well as AOD combined with ligamentous AAI was simulated in two newly developed cadaveric trauma models. Compression of the dural sac and segmental angulation in the upper cervical spine were measured on video fluoroscopy after myelography during the application of a cervical collar. Furthermore, overall three-dimensional motion of the cervical spine was measured by a motion tracking system. In six cadavers each, the two new trauma models on AOD and AOD combined with AAI could be implemented. Mean dural sac compression was significantly increased to -1.1 mm (-1.3 to -0.7 mm) in case of AOD and -1.2 mm (-1.6 to -0.6 mm) in the combined model of AOD and AAI. Furthermore, there is a significant increased angulation at the C0/C1 level in the AOD model. Immense three-dimensional movement up to 22.9° of cervical spine flexion was documented during the procedure. Conclusion The current study pointed out that applying a cervical collar in general will cause immense three-dimensional movement. In case of unstable craniocervical junction, this leads to a dural sac compression and thus to possible damage to the spinal cord.
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Affiliation(s)
- Shiyao Liao
- BG Trauma Center Ludwigshafen, Department of Trauma Surgery and Orthopaedics, Ludwigshafen, Germany
| | - Niko R. E. Schneider
- University Hospital Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Petra Hüttlin
- BG Trauma Center Ludwigshafen, Department of Trauma Surgery and Orthopaedics, Ludwigshafen, Germany
| | - Paul A. Grützner
- BG Trauma Center Ludwigshafen, Department of Trauma Surgery and Orthopaedics, Ludwigshafen, Germany
| | - Frank Weilbacher
- University Hospital Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Stefan Matschke
- BG Trauma Center Ludwigshafen, Department of Trauma Surgery and Orthopaedics, Ludwigshafen, Germany
| | - Erik Popp
- University Hospital Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Michael Kreinest
- BG Trauma Center Ludwigshafen, Department of Trauma Surgery and Orthopaedics, Ludwigshafen, Germany
- * E-mail:
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Peck GE, Shipway DJH, Tsang K, Fertleman M. Cervical spine immobilisation in the elderly: a literature review. Br J Neurosurg 2018; 32:286-290. [PMID: 29488398 DOI: 10.1080/02688697.2018.1445828] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Developed populations are ageing rapidly and by 2040, approximately 1 in 4 adults will be over 65 years of age. This is resulting in higher incidence of traumatic injury in older patients. Cognitive and physical comorbidities in this group can pose significant challenges. Due to mechanisms of injury and pre-existing degenerative spinal disease, cervical spine fractures are particularly prevalent in elderly patients. These are associated with significant morbidity and mortality. In this literature review we examine current evidence surrounding the use of cervical spine immobilisation in elderly patients in the pre-hospital and emergency department setting and also as a treatment option for cervical spine fractures. We explore evidence surrounding the complications that can arise from cervical spine immobilisation, including the development of pressure sores, raised intracranial pressure, dysphagia, breathing difficulties, delirium, compliance issues, mobility and functional outcome.
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Affiliation(s)
- George Edward Peck
- a Division of Surgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
| | | | - Kevin Tsang
- c Division of Neurosurgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
| | - Michael Fertleman
- a Division of Surgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
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Larson S, Delnat AU, Moore J. The Use of Clinical Cervical Spine Clearance in Trauma Patients: A Literature Review. J Emerg Nurs 2017; 44:368-374. [PMID: 29203049 DOI: 10.1016/j.jen.2017.10.013] [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: 05/11/2017] [Revised: 10/11/2017] [Accepted: 10/21/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Five million patients in America are placed in spinal immobilization annually, with only 1% to 2% of these patients suffering from an unstable cervical spine injury. Prehospital agencies are employing selective and limited immobilization practices, but there is concern that this practice misses cervical spine injuries and therefore possibly predisposes patients to worsening injuries. METHODS A systematic review was conducted that examined literature from the last 5 years that reviewed cervical spine immobilization application and/or clearance in alert trauma patients. RESULTS Prehospital selective immobilization protocols and bedside clinical clearance examinations are becoming more commonplace, with few missed injuries or poor outcomes. Prehospital providers can evaluate patients in the field safely to assess who needs or does not need cervical collars; similar criteria can be used in the emergency department. Harm from cervical collars is increasingly documented, with concerns that risks exceed possible benefits. DISCUSSION The literature suggests that alert trauma patients can be cleared from cervical spine immobilization safely through a structured algorithm in either the prehospital or ED setting. The evidence is primarily observational. Thus, many providers who fear missing cervical injuries may be reluctant to follow the recommendations despite few or no published cases of sudden deterioration from missed cervical spine injuries.
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Liao S, Popp E, Hüttlin P, Weilbacher F, Münzberg M, Schneider N, Kreinest M. Cadaveric study of movement in the unstable upper cervical spine during emergency management: tracheal intubation and cervical spine immobilisation-a study protocol for a prospective randomised crossover trial. BMJ Open 2017; 7:e015307. [PMID: 28864483 PMCID: PMC5588953 DOI: 10.1136/bmjopen-2016-015307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Emergency management of upper cervical spine injuries often requires cervical spine immobilisation and some critical patients also require airway management. The movement of cervical spine created by tracheal intubation and cervical spine immobilisation can potentially exacerbate cervical spinal cord injury. However, the evidence that previous studies have provided remains unclear, due to lack of a direct measurement technique for dural sac's space during dynamic processes. Our study will use myelography method and a wireless human motion tracker to characterise and compare the change of dural sac's space during tracheal intubations and cervical spine immobilisation in the presence of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture. METHODS AND ANALYSIS Perform laryngoscopy and intubation, video laryngoscope intubation, laryngeal tube insertion, fiberoptic intubation and cervical collar application on cadaveric models of unstable upper cervical spine injury such as atlanto-occipital dislocation or type II odontoid fracture. The change of dural sac's space and the motion of unstable cervical segment are recorded by video fluoroscopy with previously performing myelography, which enables us to directly measure dural sac's space. Simultaneously, the whole cervical spine motion is recorded at a wireless human motion tracker. The maximum dural sac compression and the maximum angulation and distraction of the injured segment are measured by reviewing fluoroscopic and myelography images. ETHICS AND DISSEMINATION This study protocol has been approved by the Ethics Committee of the State Medical Association Rhineland-Palatinate, Mainz, Germany. The results will be published in relevant emergency journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER DRKS00010499.
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Affiliation(s)
- Shiyao Liao
- Department of Trauma Surgery and Orthopedics, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Erik Popp
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Petra Hüttlin
- Department of Trauma Surgery and Orthopedics, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Frank Weilbacher
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Münzberg
- Department of Trauma Surgery and Orthopedics, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Niko Schneider
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Kreinest
- Department of Trauma Surgery and Orthopedics, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
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Gather A, Beisemann N, Gebhard E, Gliwitzky B, Böttcher M, Geißert S, Swartman B, Kreinest M. Ruhigstellung von Frakturen in der präklinischen Notfallmedizin. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0348-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Häske D, Beckers SK, Hofmann M, Lefering R, Grützner PA, Stöckle U, Papathanassiou V, Münzberg M. Subjective safety and self-confidence in prehospital trauma care and learning progress after trauma-courses: part of the prospective longitudinal mixed-methods EPPTC-trial. Scand J Trauma Resusc Emerg Med 2017; 25:79. [PMID: 28806988 PMCID: PMC5557465 DOI: 10.1186/s13049-017-0426-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/02/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Prehospital trauma care is stressful and requires multi-professional teamwork. A decrease in the number of accident victims ultimately affects the routine and skills and underlines the importance of effective training. Standardized courses, like PHTLS, are established for health care professionals to improve the prehospital care of trauma patients. The aim of the study was to investigate the subjective safety in prehospital trauma care and learning progress by paramedics in a longitudinal analysis. METHODS This was a prospective intervention trial and part of the mixed-method longitudinal EPPTC-trial, evaluating subjective and objective changes among participants and real patient care as a result of PHTLS courses. Participants were evaluated with pre/post questionnaires as well as one year after the course. RESULTS We included 236 datasets. In the pre/post comparison, an increased performance could be observed in nearly all cases. The result shows that the expectations of the participants of the course were fully met even after one year (p = 0.002). The subjective safety in trauma care is significantly better even one year after the course (p < 0.001). Regression analysis showed that (ABCDE)-structure is decisive (p = 0.036) as well as safety in rare and common skills (both p < 0.001). Most skills are also rated better after one year. Knowledge and specific safety are assessed as worse after one year. CONCLUSION The courses meet the expectations of the participants and increase the subjective safety in the prehospital care of trauma patients. ABCDE-structure and safety in skills are crucial. In the short term, both safety in skills and knowledge can be increased, but the courses do not have the power to maintain knowledge and specific subjective safety issues over a year. TRIAL REGISTRATION German Clinical Trials Register, ID DRKS00004713 , registered 14. February 2014.
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Affiliation(s)
- David Häske
- Faculty of Medicine, Eberhard Karls University Tübingen, 72076 Tuebingen, Germany
| | - Stefan K. Beckers
- Department of Anesthesiology, University Hospital RWTH, Aachen, 52074 Aachen, Germany
- Emergency Medical Service, Fire Department, City of Aachen, 52057 Aachen, Germany
| | - Marzellus Hofmann
- Faculty of Health, University of Witten/Herdecke, 58448 Witten, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, University of Witten/Herdecke, 51109 Cologne, Germany
| | - Paul A. Grützner
- Department of Trauma Surgery and Orthopedics, BG Hospital Ludwigshafen, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Ulrich Stöckle
- Department of Traumatology and Reconstructive Surgery, BG Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Vassilios Papathanassiou
- Institute of Medical Psychology, University Hospital of the Saarland and Medical Faculty of the University of Saarland, /Saar, 66421 Homburg, Germany
| | - Matthias Münzberg
- Department of Trauma Surgery and Orthopedics, BG Hospital Ludwigshafen, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, 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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