Präklinische Immobilisation der Wirbelsäule: Freund oder Feind des Traumapatienten?

The Immo Traffic Light System as a Decision-Making Tool for Prehospital Spinal Immobilization

BACKGROUND

Spinal injuries are difficult injuries to assess yet can be associated with significant neurological damage. To avoid secondary damage, immobilization is considered state of the art trauma care. The indication for spinal immobilization must be assessed, however, for potential complications as well as its advantages and disadvantages.

METHODS

This systematic review addressing the question of the correct indication for spinal immobilization in trauma patients was compiled on the basis of our previously published analysis of possible predictors from the Trauma Registry of the German Society for Trauma Surgery. A Delphi procedure was then used to develop suggestions for action regarding immobilization based on the results of this review.

RESULTS

The search of the literature yielded 576 publications. The 24 publications included in the qualitative analysis report of 2 228 076 patients. A decision tool for spinal immobilization in prehospital trauma care was developed (Immo traffic light system) based on the results of the Delphi procedure. According to this system, severely injured patients with blunt trauma, severe traumatic brain injury, peripheral neurological symptoms, or spinal pain requiring treatment should be immobilized. Patients with a statistically increased risk of spinal injury as a result of the four cardinal features (fall >3m, severe trunk injury, supra clavicular injury, seniority [age >65 years]) should only have their spinal motion restricted after weighing up the pros and cons. Isolated penetrating trunk injuries should not be immobilized.

CONCLUSION

High-quality studies demonstrating the benefit of prehospital spinal immobilization are still lacking. Decision tools such as the Immo traffic light system can help weigh up the pros and cons of immobilization.

A multicenter cohort study on the association between prehospital immobilization and functional outcome of patients following spinal injury in Asia

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.

Epidemiology and predictors of traumatic spine injury in severely injured patients: implications for emergency procedures

PURPOSE

This study aimed to identify the prevalence and predictors of spinal injuries that are suitable for immobilization.

METHODS

Retrospective cohort study drawing from the multi-center database of the TraumaRegister DGU^®, spinal injury patients ≥ 16 years of age who scored ≥ 3 on the Abbreviated Injury Scale (AIS) between 2009 and 2016 were enrolled.

RESULTS

The mean age of the 145,833 patients enrolled was 52.7 ± 21.1 years. The hospital mortality rate was 13.9%, and the mean injury severity score (ISS) was 21.8 ± 11.8. Seventy percent of patients had no spine injury, 25.9% scored 2-3 on the AIS, and 4.1% scored 4-6 on the AIS. Among patients with isolated traumatic brain injury (TBI), 26.8% had spinal injuries with an AIS score of 4-6. Among patients with multi-system trauma and TBI, 44.7% had spinal injuries that scored 4-6 on the AIS. Regression analysis predicted a serious spine injury (SI; AIS 3-6) with a prevalence of 10.6% and cervical spine injury (CSI; AIS 3-6) with a prevalence of 5.1%. Blunt trauma was a predictor for SI and CSI (OR 4.066 and OR 3.640, respectively; both p < 0.001) and fall > 3 m for SI (OR 2.243; p < 0.001) but not CSI (OR 0.636; p < 0.001). Pre-hospital shock was predictive for SI and CSI (OR 1.87 and OR 2.342, respectively; both p < 0.001), and diminished or absent motor response was also predictive for SI (OR 3.171) and CSI (OR 7.462; both p < 0.001). Patients over 65 years of age were more frequently affected by CSI.

CONCLUSIONS

In addition to the clinical symptoms of pain, we identify '4S' [spill (fall) > 3 m, seniority (age > 65 years), seriously injured, skull/traumatic brain injury] as an indication for increased attention for CSIs or indication for spinal motion restriction.

[Influence of the trauma mechanism on cervical spine injuries]

BACKGROUND

The influence of trauma-related kinematics on the injury pattern of the cervical spine is currently not considered in the available classification systems, only the force vector. Whether the strength of the trauma has an additional influence on the number and complexity of the injuries and whether this can be classified, has not yet been finally investigated.

OBJECTIVE

What influence do different kinematics apart from the traumatic force vector have on injuries of the cervical spine?

MATERIAL AND METHODS

Based on the AOSpine classification system for the upper and subaxial cervical spine, data from 134 trauma patients from a first level trauma center were retrospectively analyzed. Analogue to the S3 guidelines on polytrauma, patients were assigned to six trauma groups and the injuries were classified on the basis of computed tomography (CT) cross-sectional imaging.

RESULTS

A higher trauma energy had a significant impact on the number of cervical spine injuries (p = 0.005). In low velocity accidents C2 was the most frequently injured vertebra (51%; p = 0.022) and high velocity accidents showed more C7 fractures (37%; p = 0.017). Furthermore, upper cervical spine injuries occurred more often in low energy trauma and older female patients (e.g. falling from a standing position). Subaxial cervical spine involvement was found significantly more often in high velocity accidents and younger male patients (p = 0.012).

CONCLUSION

Exact knowledge of the trauma mechanism is helpful in the primary treatment of an injured person. Injury patterns can be better estimated and the appropriate diagnostics can be initiated. The results underline the importance of immediate cervical spine immobilization even after minor trauma. In high velocity trauma, patients more often suffer from lower cervical spine injuries, especially C7. Due to the accumulation of multilevel spinal injuries in high velocity trauma, radiographic imaging of the whole spine is advisable.

Spinal Immobilization in the Trauma Room - a Survey-Based Analysis at German Level I Trauma Centers

BACKGROUND

Spinal immobilization is a standard procedure in daily out-of-hospital emergency care. Homogenous recommendations concerning the immobilization of trauma patients during the first therapy in the emergency department do not exist. The aim of the current study was the analysis of the existing strategies concerning spinal immobilization in German level I trauma centers by an internet-based survey.

MATERIALS AND METHODS

The current study is a survey-based analysis of the current strategies concerning spinal immobilization in all 107 level I trauma centers in Germany. The internet-based survey consists of 6 items asking about immobilization in the emergency department.

RESULTS

The return rate was 47.7%. In 14 (28.6%) level I trauma centers the patients remained immobilized on the immobilization tool used by the professional emergency care providers. In 19 (38.8%) level I trauma centers the patients were transferred to a stretcher with a soft positioning mattress on it. Patient transfer to a spineboard or to a TraumaMattress was performed in 11 (22.4%) and 7 (14.3%) level I trauma centers, respectively. Trauma patients were never transferred to a vacuum mattress. Cervical spine protection was most of the time performed by a cervical collar (n = 48; 98.0%). In general, the survey's participants were mainly satisfied (mean = 84/100) with the current strategy of spinal immobilization. The satisfaction was best if the spineboard is used.

DISCUSSION

Patient positioning during initial emergency therapy in the emergency department of German level I trauma centers is highly heterogenous. Besides complete full body immobilization, also the lack of any immobilization was reported by the survey's participants.

[Spinaltrauma : Clinical diagnosis and initial care]

DIAGNOSTIC WORK-UP

The rescue, treatment and transport of patients with an injured spine require a systematic scheme with the subsequent rating of the findings and suspected diagnoses. In addition to the assessment of temporal urgency, the available resources and personnel, the duration and complexity of any possible technical measures that might be anticipated, the rational selection of immobilisation tools also plays a significant role. The most important medical rescue aids are the scoop stretcher and the spine board; the spine board, vacuum mattress and cervical collar are used to immobilise the patient.

PRACTICAL RECOMMENDATIONS

This article is focused on the diagnosis and initial treatment of isolated spinal injuries. The prehospital care of polytraumatised patients and/or those with multiple injuries differs significantly and has different priorities.