A repeat audit of spinal board usage in the emergency department

To log-roll or not to log-roll - That is the question! A review of the use of the log-roll for patients with pelvic fractures

Pelvic fractures are one of the most serious injuries in polytrauma - massive haemorrhage is a major complication and the leading cause of death. The assessment and early management of these injuries in the Emergency Department (ED) focuses on the recognition of haemodynamic instability and should follow Advanced Trauma Life Support (ATLS) guidelines. The log-roll technique, although an accepted practice in trauma care, has been reported to be inadvisable when a pelvic fracture is suspected. This paper, which includes a case study, briefly explains the pathophysiology and initial management of pelvic fractures. It aims to emphasise how the use of the log-roll can affect the haemodynamic stability of a patient with a pelvic fracture, highlighting gaps in research, along with the ethical and legal implications associated with polytrauma care. It also encourages practitioners to consider reasonable alternatives to the log-roll technique when beneficial and applicable.

Effect of spineboard and headblocks on the image quality of head CT scans

Trauma patients at risk for, or suspected of, spinal injury are frequently transported to hospital using full spinal immobilisation. At the emergency department, immobilisation is often maintained until radiological work-up is completed. In this study, we examined how these devices for spinal stabilization influence visual image quality. Image quality was judged for both patient CT scans and phantom CT scans. CT scans of 217 patients were assessed retrospectively by two radiologists for visual scoring of image quality, scoring both quantity and impact of artifacts caused by the immobilization devices. For the phantom CT scans, eight set-ups were made, using a vacuum mattress without headblocks and a rigid and a soft-layered spineboard without headblocks, with standard soft-foam headblocks, or with new design headblocks. Overall, artifacts were found in 67 % of CT scans of patients on immobilization devices, which hampered diagnosis in 10 % of the cases. In the phantom CT scans, artifacts were present in all set-ups with one or more devices present and were seen in 20 % of all scan slices. The presence of headblocks resulted in more artifacts in both the patient CT scans and the phantom CT scans. Considerable effort should therefore be made to adjust the design of the immobilization devices and to remove the headblocks before CT scans are made.

Ergonomics intervention on an alternative design of a spinal board

A spinal board is the evacuation tool of first aid to help the injured spinal cord. The existing spinal board has several weaknesses, both in terms of user comfort and the effectiveness and efficiency of the evacuation process. This study designs an ergonomic spinal board using the quality function deployment approach. A preliminary survey was conducted through direct observation and interviews with volunteers from the Indonesian Red Cross. Data gathered were translated into a questionnaire and answered by 47 participants in West Sumatra. The results indicate that the selection of materials, the application of strap systems as well as the addition of features are very important in designing an ergonomic spinal board. The data were used in designing an ergonomic spinal board. The use of anthropometric data ensures that this product can accommodate safety and comfort when immobilized, as well as the flexibility and speed of the rescue evacuation process.

Effect of spinal immobilisation devices on radiation exposure in conventional radiography and computed tomography

Trauma patients at risk for, or suspected of, spinal injury are frequently transported to hospital using full spinal immobilisation. At the emergency department, immobilisation is often maintained until radiological work-up is completed. In this study, we examined how these devices influence radiation exposure and noise, as a proxy for objective image quality. Conventional radiographs (CR) and computer tomography (CT) scans were made using a phantom immobilised on two types of spineboard and a vacuum mattress and using two types of headblocks. Images were compared for radiation transmission and quantitative image noise. In CR, up to 23 % and, in CT, up to 11 % of radiation were blocked by the devices. Without compensation for the decreased transmission, noise increased by up to 16 % in CT, depending on the device used. Removing the headblocks led to a statistically significant improvement in transmission with automatic exposure control (AEC) enabled. Physicians should make an informed decision whether the increased radiation exposure outweighs the risk of missing a clinically significant injury by not making a CR or CT scan. Manufacturers of immobilisation devices should take radiological properties of their devices into account in the development and production process.

A multi-centred audit of secondary spinal assessments in a trauma setting: are we ATLS compliant?

PURPOSE

The global incidence of spinal cord injuries varies with the developed world having improved survival and 1 year mortality in a poly-trauma setting. This improved survival has been estimated at 20 % in a recent Cochrane review of Advanced Trauma Life Support (ATLS).The aim of this audit is to evaluate the management of patients with suspected spinal cord injury by the trauma and orthopaedic team in three centres in South Wales.

METHODS

A retrospective case note review of the secondary survey was performed. Inclusion criteria were patients 18 years and above, with poly-trauma and presenting to Accident and Emergency department at the treating hospital. We used ATLS guidelines as an audit tool and reviewed the documentation of key components of the secondary assessment.

RESULTS

Forty-nine patients were included (29 males, 20 females) with an average age of 53.7 years (19-92 years). We found that completion of all components of the secondary survey for spinal injury was poor, 29 % receiving a digital per rectal examination despite suspected spinal injury. Paralysis level was not documented in 20.4 % of patients. Medical Research Council grade was only documented in 24.5 % although was assessed in 73.5 %. The secondary survey took place after 2 h in 54.6 % of patients.

CONCLUSION

We found that the documentation of the performance of a secondary survey was poor. We found that most patients included in this study are not currently meeting the minimal standard suggested by the ATLS guidelines.

Outcome of trauma patients immobilized by emergency department staff, but not by emergency medical services providers: a quality assurance initiative

BACKGROUND

Prehospital selective cervical spine immobilization (CSI) is a relatively new concept. In our emergency medical services (EMS) system, protocols for selective CSI are widely used; yet, some patients who are brought to the hospital without CSI undergo secondary immobilization and cervical spine imaging in the emergency department (ED). Immobilization in the ED, after a decision not to immobilize by EMS, suggests that either the prehospital assessment is not trusted or the patient has developed new symptoms over time. We undertook a quality assurance initiative to evaluate whether trauma patients brought to the ED without CSI, who then underwent secondary CSI and imaging in the ED, had injuries that were initially missed by EMS selective CSI protocol.

METHODS

This was a 36-month retrospective data analysis of blunt trauma patients transported directly from the field to the University of New Mexico Hospital level I trauma center by Albuquerque Ambulance Service (AAS) between March 2009 and February 2012. Inclusion criteria were age 18 years and older, transported by AAS without CSI, and cervical spinal imaging done in the ED. Patients were excluded if they were being transported between facilities, were prisoners, and/or refused CSI. A positive finding was defined as any acute abnormality identified by the attending radiologist on the final imaging report.

RESULTS

The study included 101 patients who met inclusion criteria. There were no significant missed injuries. Ninety-four of the 101 patients received cervical spinal CT imaging at an estimated cost of $1,570 per scan, not including physician charges. The remaining patients had plain film radiographic imaging. No patients had magnetic resonance imaging.

CONCLUSIONS

In this retrospective quality assurance initiative, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury. No patients had any adverse effects or required treatment, yet these patients incurred substantial costs and increased radiation exposure. While our results suggest hospital personnel should have confidence in prehospital decisions regarding CSI, continued surveillance and a large-scale, prospective study are needed to confirm our findings.

A numerical study to analyse the risk for pressure ulcer development on a spine board

BACKGROUND

Spine boards are used to immobilise accident victims suspected of having spinal injury. Guidelines about the maximum time patients remain on the board are often exceeded and on occasions may lead to pressure ulcers. Etiological research has shown that two processes ultimately lead to pressure ulcers:"Ischemic damage" which takes several hours to initiate and "deformation damage" at high strains. The latter process is very quick and the first signs of cell damage are already evident within minutes. Thus in order to minimise the risk of pressure ulcer development during prolonged loading, a new soft-layered long spine board has been designed.

METHODS

A subject specific numerical approach has been adopted to evaluate the prototype spine board in comparison to a conventional spine board, with reference to the estimated strains in the soft tissues adjacent to the sacrum in the supine position. The model geometry is derived from magnetic resonance images of three human volunteers in an unloaded situation. The loaded images are used to "tune" the material parameters of skin, fat and muscle. The prediction of the deformed contours on the soft-layered board is used to validate the model.

FINDINGS

Comparison of the internal strains in muscle tissue near the spine showed that internal strains on the soft-layered board are reduced and maximum strains are considerably less than the threshold at which deformation damage is possible. By contrast, on the rigid spine board this threshold is exceeded in all cases.

INTERPRETATION

The prototype comfort board is able to reduce the risk for deformation damage and thus reduces the risk of developing pressure ulcers.