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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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Lee SJ, Jian L, Liu CY, Tzeng IS, Chien DS, Hou YT, Lin PC, Chen YL, Wu MY, Yiang GT. A Ten-Year Retrospective Cohort Study on Neck Collar Immobilization in Trauma Patients with Head and Neck Injuries. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1974. [PMID: 38004023 PMCID: PMC10673496 DOI: 10.3390/medicina59111974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/23/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: In the context of prehospital care, spinal immobilization is commonly employed to maintain cervical stability in head and neck injury patients. However, its use in cases of unclear consciousness or major trauma patients is often precautionary, pending the exclusion of unstable spinal injuries through appropriate diagnostic imaging. The impact of prehospital C-spinal immobilization in these specific patient populations remains uncertain. Materials and Methods: We conducted a retrospective cohort study at Taipei Tzu Chi Hospital from January 2009 to May 2019, focusing on trauma patients suspected of head and neck injuries. The primary outcome assessed was in-hospital mortality. We employed multivariable logistic regression to investigate the relationship between prehospital C-spine immobilization and outcomes, while adjusting for various factors such as age, gender, type of traumatic brain injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and activation of trauma team. Results: Our analysis encompassed 2733 patients. Among these, patients in the unclear consciousness group (GCS ≤ 8) who underwent C-spine immobilization exhibited a higher mortality rate than those without immobilization. However, there was no statistically significant difference in mortality among patients with alert consciousness (GCS > 8). Multivariable logistic regression analysis revealed that advanced age (age ≥ 65), unclear consciousness (GCS ≤ 8), major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and the use of neck collars for immobilization (adjusted OR: 1.850, 95% CI: 1.240-2.760, p = 0.003) were significantly associated with an increased risk of mortality. Subgroup analysis indicated that C-spine immobilization was significantly linked to an elevated risk of mortality in older adults (age ≥ 65), patients with unclear consciousness (GCS ≤ 8), those with major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and individuals in shock (shock index > 1). Conclusions: While our findings do not advocate for the complete abandonment of neck collars in all suspected head and neck injury patients, our study suggests that prehospital cervical and spinal immobilization should be applied more selectively in certain head and neck injury populations. This approach is particularly relevant for older individuals (age ≥ 65), those with unclear consciousness (GCS ≤ 8), individuals experiencing major traumatic injuries (ISS ≥ 16 or RTS ≤ 7), and patients in a state of shock (shock index ≥ 1). Our study employs a retrospective cohort design, which may introduce selection bias. Therefore, in the future, there is a need for confirmation of our results through a two-arm randomized controlled trial (RCT) arises, as this design is considered ideal for addressing this issue.
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Affiliation(s)
- Shu-Jui Lee
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Lin Jian
- Department of Medical Education, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Medicine, College of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Chi-Yuan Liu
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
- Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - I-Shiang Tzeng
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
| | - Da-Sen Chien
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Yueh-Tseng Hou
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Po-Chen Lin
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Yu-Long Chen
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
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Practice patterns after implementation of a selective spinal immobilization protocol in a regional trauma system. J Trauma Acute Care Surg 2022; 93:806-812. [PMID: 35234714 DOI: 10.1097/ta.0000000000003589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Universal spinal immobilization has been the standard of prehospital trauma care since the 1960s. Selective immobilization has been shown to be safe and effective for emergency medical services use, but it is unclear whether such protocols reduce unnecessary and potentially harmful immobilization practices. This study evaluated the impact of a selective spinal immobilization protocol on practice patterns in a regional trauma system. METHODS All encounters for traumatic injury in the Tidewater Emergency Medical Services region from 2010 to 2016 were extracted from the Virginia Pre-Hospital Information Bridge. An interrupted time series analysis was used to assess practice change after system-wide protocol implementation in 2013. Intravenous access was used as a nonequivalent outcome measure in the absence of an appropriate control group. RESULTS A total of 63,981 encounters were analyzed. At baseline, 16.7% of patients underwent full immobilization. The preprotocol slope was slightly positive (0.2% per month; 95% confidence interval, 0.1-0.2%). Slope and level changes after protocol implementation did not differ from those observed for intravenous access (-0.4% vs. -0.4% per month [ p = 0.4917] and -1.6% vs. -1.1% [ p = 0.1202], respectively). Cervical spinal immobilization became more common over the postimplementation period (0.1% per month; 95% confidence interval, 0.1-0.1%). Rates of immobilization for isolated penetrating trauma remained unchanged. CONCLUSION Implementation of a selective spinal immobilization protocol did not reduce prehospital immobilization rates in a regional trauma system. Given the entrenched nature of immobilization practices, more intensive education and training strategies are needed. Efforts should prioritize eliminating immobilization for isolated penetrating trauma given its association with increased mortality. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Häske D, Blumenstock G, Hossfeld B, Wölfl C, Schweigkofler U, Stock JP. The Immo Traffic Light System as a Decision-Making Tool for Prehospital Spinal Immobilization. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:753-758. [PMID: 35978468 PMCID: PMC9853232 DOI: 10.3238/arztebl.m2022.0291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 01/24/2022] [Accepted: 07/21/2022] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
- David Häske
- Center for Public Health and Health Services Research, University Hospital of Tübingen, and German Red Cross Emergency Services Reutlingen,*Center for Public Health and Health Services Research University Hospital of Tübingen Osianderstr. 5 72076 Tübingen, Germany
| | - Gunnar Blumenstock
- Institute of Clinical Epidemiology and Applied Biometry, University Hospital of Tübingen
| | - Björn Hossfeld
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Federal Armed Forces Hospital of Ulm
| | - Christoph Wölfl
- Department for Orthopedic Surgery, Trauma and Sports Traumatology – Hand and Plastic Surgery, Musculoskeletal Center Neuwied, Marienhaus Hospital Neuwied
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Trauma Center, Frankfurt am Main
| | - Jan-Philipp Stock
- Department for Anesthesiology, Intensive Care Medicine, Emergency Medicine, Pain Therapy and Palliative Care, am Steinenberg Hospital, Reutlingen: Jan-Philipp Stock
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The Impact of Prehospital Spinal Immobilization in Patients with Penetrating Spinal Injuries: A Systematic Review and Meta-Analysis. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2020019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Penetrating injuries, such as gunshot or stab wounds, may cause spinal cord injuries and require prehospital spinal immobilization (PHSI) to stabilize the spine. However, the use of PHSI in penetrating spinal injuries remains controversial. This systematic review aimed to investigate the efficacy of prehospital PHSI in patients with penetrating trauma. We systematically searched Google Scholar, Medline (PubMed), The Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE between January 2000 and July 2021. All studies in English that assessed PHSI in patients (>16 years) with penetrating spinal injuries were included. Quality and risk of bias assessments were performed using the modified Newcastle-Ottawa scale. A narrative synthesis and a meta-analysis was conducted. Our search identified 928 studies but only 6 met our inclusion and exclusion criteria. All of the included studies were conducted in the US and the number of patients ranged from 156–75,567 over 3–9 study years. The majority of patients were gunshot or stab wounds. Three studies demonstrated an increased risk of mortality with spinal collars whilst the remaining three studies failed to show any benefits or the benefits remained unproven. All studies were retrospective studies with some risks of bias. This review highlights that the evidence from the literature on PHSI in penetrating trauma outweigh its benefits; thus, its use is discouraged in penetrating spinal trauma. However, further high-quality research is necessary to reach definitive conclusions and to possibly identify suitable alternatives to PHSI for penetrating spinal trauma.
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Simpson C, Tucker H, Hudson A. Pre-hospital management of penetrating neck injuries: a scoping review of current evidence and guidance. Scand J Trauma Resusc Emerg Med 2021; 29:137. [PMID: 34530879 PMCID: PMC8447707 DOI: 10.1186/s13049-021-00949-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/02/2021] [Indexed: 01/15/2023] Open
Abstract
Penetrating injuries to the neck pose a unique challenge to clinicians due to the proximity of multiple significant anatomical structures with little protective soft tissue coverage. Injuries to this area, whilst low in incidence, are potentially devastating. Respiratory, vascular, gastro-oesophageal and neurological structures may all be involved, either in isolation or combination. These injuries are particularly difficult to manage in the resource poor, often austere and/or remote, pre-hospital environment. A systematic scoping review of the literature was conducted to evaluate the current available research pertaining to managing this injury profile, prior to the patient arriving in the emergency department. The available research is discussed in sections based on the commonly used trauma management acronym ‘cABCD’ (catastrophic haemorrhage, Airway, Breathing, Circulation, Disability) to facilitate a systematic approach and clinical evaluation familiar to clinicians. Based on the available reviewed evidence, we have proposed a management algorithm for this cohort of patients. From this we plan to instigate a Delphi process to develop a consensus statement on the pre-hospital management of this challenging presentation.
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Affiliation(s)
- Christopher Simpson
- Emergency Department, St. George's Hospital Trust, Blackshaw Rd., Tooting, London, SW17 0QT, UK.
| | - Harriet Tucker
- Emergency Department, St. George's Hospital Trust, Blackshaw Rd., Tooting, London, SW17 0QT, UK.,Air Ambulance Kent Surrey Sussex, Redhill Airfield, Redhill, RH1 5YP, Surrey, UK
| | - Anthony Hudson
- Emergency Department, St. George's Hospital Trust, Blackshaw Rd., Tooting, London, SW17 0QT, UK.,Air Ambulance Kent Surrey Sussex, Redhill Airfield, Redhill, RH1 5YP, Surrey, UK
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Evidence for the use of spinal collars in stabilising spinal injuries in the pre-hospital setting in trauma patients: a systematic review. Eur J Trauma Emerg Surg 2020; 48:647-657. [PMID: 33346863 PMCID: PMC8825572 DOI: 10.1007/s00068-020-01576-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/07/2020] [Indexed: 11/04/2022]
Abstract
Purpose Spinal collars were introduced in 1967 into the management of spinal trauma care as it was thought that this technique of immobilisation would prevent any further neurological or spinal damage in high-risk patients. The aim of this systematic review was to determine whether the use of spinal collars in the pre-hospital trauma patient was recommended by published literature. Methods A systematic search of the literature was conducted between 1990 and 2020, screening PubMed, Medline, Science Direct and Google Scholar. The consequent findings were then qualitatively synthesised with the aim of effectively evaluating the evidence to resolve the discrepancy between current practice and literature. Results Of the nine eligible studies, six deemed that spinal collars should not be used in pre-hospital trauma patients with the remaining three reporting uncertainty if spinal collars were best practice. Our results suggest that there is a discrepancy between current guidance and practice in that although the guidelines recommend the use of spinal collars in the pre-hospital setting the majority of the studies were against the use of spinal collars. Importantly, none of the studies reported any benefits of spinal collars. Conclusion Our study shows a disparity between current guidelines and the published literature and warrants further direct research to obtain a more comprehensive view of the use of spinal collars in a pre-hospital setting.
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Difficult Intubation due to Penetrating Trauma from a Crossbow Bolt. Air Med J 2020; 39:300-302. [PMID: 32690309 DOI: 10.1016/j.amj.2020.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 12/11/2022]
Abstract
We present the case of a patient with penetrating neck and craniofacial trauma from a self-inflicted crossbow bolt injury. This case highlights the challenges involved in prehospital airway management related to an in situ foreign object penetrating the oral cavity. We review the complications associated with such injuries and considerations for effective prehospital airway management.
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Jenkins LN, Rezende-Neto JB. Current Management of Penetrating Traumatic Cervical Vascular Injuries. CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00258-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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10
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Long B, Koyfman A, Gottlieb M. Utility of Spinal Immobilization in Patients With Penetrating Trauma. Acad Emerg Med 2020; 27:69-70. [PMID: 31495007 DOI: 10.1111/acem.13852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Brit Long
- Department of Emergency Medicine Brooke Army Medical Center Fort Sam Houston TX
| | - Alex Koyfman
- Department of Emergency Medicine The University of Texas Southwestern Medical Center Dallas TX
| | - Michael Gottlieb
- Department of Emergency Medicine Rush University Medical Center Chicago IL
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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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Bhalla K, Sriram V, Arora R, Ahuja R, Varghese M, Agrawal G, Tiwari G, Mohan D. The care and transport of trauma victims by layperson emergency medical systems: a qualitative study in Delhi, India. BMJ Glob Health 2019; 4:e001963. [PMID: 31803512 PMCID: PMC6882548 DOI: 10.1136/bmjgh-2019-001963] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/25/2019] [Accepted: 11/02/2019] [Indexed: 01/16/2023] Open
Abstract
Introduction Ambulance-based emergency medical systems (EMS) are expensive and remain rare in low- and middle-income countries, where trauma victims are usually transported to hospital by passing vehicles. Recent developments in transportation network technologies could potentially disrupt this status quo by allowing coordinated emergency response from layperson networks. We sought to understand the barriers to bystander assistance for trauma victims in Delhi, India, and implications for a layperson-EMS. Methods We used qualitative methods to analyse data from 50 interviews with frontline stakeholders (including taxi drivers, medical professionals, legal experts and police), one stakeholder consultation and a review of documents. Results Respondents noted that most trauma victims in Delhi are rapidly brought to hospital by bystanders, taxis and police. While ambulances are common, they are primarily used for interfacility transfers. Entrenched medico-legal practices result in substantial police presence at the hospital, which is a major source of harassment of good Samaritans and interferes with patient care. Trauma victims are often turned away by for-profit hospitals due to their inability to pay, leading to delays in treatment. Recent policy efforts to circumscribe the role of police and force for-profit hospitals to stabilise patients appear to have been unsuccessful. Conclusions Existing healthcare and medico-legal practices in India create large systemic impediments to improving trauma outcomes. Until India’s ongoing health and transport sector reforms succeed in ensuring that for-profit hospitals reliably provide care, good Samaritans and layperson-EMS providers should take victims with uncertain financial means to public facilities. To avoid difficulties with police, providers of a layperson-EMS would likely need official police sanction and carry visible symbols of their authority to provide emergency transport. Delhi already has several key components of an EMS (including dispatcher coordinated police response, large ambulance fleet) that could be integrated and expanded into a complete system of emergency care.
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Affiliation(s)
- Kavi Bhalla
- Public Health Sciences, University of Chicago Biological Sciences Division, Chicago, Illinois, USA
| | - Veena Sriram
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois, USA
| | | | - Richa Ahuja
- Indian Institute of Technology Delhi, New Delhi, Delhi, India
| | | | | | - Geetam Tiwari
- Indian Institute of Technology Delhi, New Delhi, Delhi, India
| | - Dinesh Mohan
- Indian Institute of Technology Delhi, New Delhi, Delhi, India
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Porter A, Difrancesca M, Slack S, Hudecek L, McIntosh SE. Improvised vs Standard Cervical Collar to Restrict Spine Movement in the Backcountry Environment. Wilderness Environ Med 2019; 30:412-416. [PMID: 31706730 DOI: 10.1016/j.wem.2019.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/13/2019] [Accepted: 07/30/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION To compare the effectiveness of a molded fleece jacket with that of a standard cervical collar at limiting movement of the cervical spine in 3 different directions. METHODS This is a prospective study using 24 healthy volunteers to measure cervical flexion/extension, rotation, and lateral flexion with both the fleece collar and the standard cervical collar. A hand-held goniometer was used for measurements. The results were then analyzed for the 3 independent movements using a noninferiority test. RESULTS The fleece collar was determined to be noninferior at limiting the designated motions. Comfort was greater while wearing the improvised fleece collar. CONCLUSIONS Our small study demonstrated that mountain travelers and rescuers may be able to use an improvised fleece jacket collar in place of a standard collar if spine trauma is suspected after a backcountry accident. Further research should examine different types of improvised collars, their ability to remain in place over extended evacuations, and when to apply collars to backcountry patients.
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Affiliation(s)
- Anne Porter
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | - Sean Slack
- Intermountain Medical Center, Murray, UT
| | - Laura Hudecek
- National Outdoor Leadership School Wilderness Medicine, Lander, WY
| | - Scott E McIntosh
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT.
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Yard J, Richman PB, Leeson B, Leeson K, Youngblood G, Guardiola J, Miller M. The Influence of Cervical Collar Immobilization on Optic Nerve Sheath Diameter. J Emerg Trauma Shock 2019; 12:141-144. [PMID: 31198282 PMCID: PMC6557047 DOI: 10.4103/jets.jets_80_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/22/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Prior research has revealed that cervical collars elevate intracranial pressure (ICP) in patients with traumatic brain injury. Two recent small studies evaluated the change in optic sheath nerve diameter (ONSD) measured by ultrasound as a proxy for ICP following cervical collar placement in healthy volunteers. OBJECTIVE We sought to validate the finding that ONSD measured by ultrasound increases after cervical collar placement within an independent data set. METHODS This was a prospective, crossover study involving volunteers. Participants were randomized to either have the ONSD measured first without a cervical collar or initially with a cervical collar. Two sonographers performed independent ONSD diameter measurements. Continuous data were analyzed by matched-paired t-tests. Alpha was set at 0.05. The primary outcome parameter was the overall mean difference between ONSD measurements with the cervical collar on and off. Multiple linear regression was performed to examine the relationship between variables and the primary outcome parameter. RESULTS There were 30 participants enrolled in the study. Overall mean ONSD for participants without the collar was 0.365 ± 0.071 cm and with the collar was 0.392 ± 0.081 cm. The mean change in ONSD for participants with and without the collar was 0.026 ± 0.064 cm (95% confidence interval of difference: 0.015-0.038; P < 0.001). Multiple regression analysis did not identify any variables associated with the variation in ONSD observed for collar versus noncollar. CONCLUSIONS We confirmed that ONSD does vary by a measurable amount with placement of a rigid cervical collar on healthy volunteers when assessed by ultrasound.
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Affiliation(s)
- Joseph Yard
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Peter B. Richman
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Ben Leeson
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Kimberly Leeson
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Guy Youngblood
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
| | - Jose Guardiola
- Texas A&M University-Corpus Christi, Corpus Christi, TX, USA
| | - Michael Miller
- CHRISTUS Health/Texas A&M Residency in Emergency Medicine, Corpus Christi, TX, USA
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Prehospital care of spinal injuries: a historical quest for reasoning and evidence. 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 2018; 27:2999-3006. [PMID: 30220041 DOI: 10.1007/s00586-018-5762-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/08/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE The practice of prehospital immobilization is coming under increasing scrutiny. Unravelling the historical sequence of prehospital immobilization might shed more light on this matter and help resolve the situation. Main purpose of this review is to provide an overview of the development and reasoning behind the implementation of prehospital spine immobilization. METHODS An extensive search throughout historical literature and recent evidence based studies was conducted. RESULTS The history of treating spinal injuries dates back to prehistoric times. Descriptions of prehospital spinal immobilization are more recent and span two distinct periods. First documentation of its use comes from the early 19th century, when prehospital trauma care was introduced on the battlefields of the Napoleonic wars. The advent of radiology gradually helped to clarify the underlying pathology. In recent decades, adoption of advanced trauma life support has elevated in-hospital trauma-care to an high standard. Practice of in-hospital spine immobilization in case of suspected injury has also been implemented as standard-care in prehospital setting. Evidence for and against prehospital immobilization is equally divided in recent evidence-based studies. In addition, recent studies have shown negative side-effects of immobilisation in penetrating injuries. CONCLUSION Although widely implementation of spinal immobilization to prevent spinal cord injury in both penetrating and blunt injury, it cannot be explained historically. Furthermore, there is no high-level scientific evidence to support or reject immobilisation in blunt injury. Since evidence in favour and against prehospital immobilization is equally divided, the present situation appears to have reached something of a deadlock. These slides can be retrieved under Electronic Supplementary Material.
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Phaily A, Khan M. Is our current method of cervical spine control doing more harm than good? TRAUMA-ENGLAND 2018. [DOI: 10.1177/1460408618777773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg 2018; 84:736-744. [DOI: 10.1097/ta.0000000000001764] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Fedor PJ, Burns B, Lauria M, Richmond C. Major Trauma Outside a Trauma Center: Prehospital, Emergency Department, and Retrieval Considerations. Emerg Med Clin North Am 2017; 36:203-218. [PMID: 29132578 DOI: 10.1016/j.emc.2017.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Care of the critically injured begins well before the patient arrives at a large academic trauma center. It is important to understand the continuum of care from the point of injury in the prehospital environment, through the local hospital and retrieval, until arrival at a trauma center capable of definitive care. This article highlights the important aspects of trauma assessment and management outside of tertiary or quaternary care hospitals. Key elements of each phase of care are reviewed, including management pearls and institutional strategies to facilitate effective and efficient treatment of trauma patients from the point of injury forward.
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Affiliation(s)
- Preston J Fedor
- Department of Emergency Medicine, Division of Prehospital, Austere and Disaster Medicine, University of New Mexico, 1 University of New Mexico, MSC11 6025, Albuquerque, NM 87131-0001, USA.
| | - Brian Burns
- Greater Sydney Area HEMS, NSW Ambulance, NSW 2200, Australia; Sydney University, Sydney, NSW, Australia
| | - Michael Lauria
- Dartmouth-Hitchcock Advanced Response Team (DHART), Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Clare Richmond
- Greater Sydney Area HEMS, NSW Ambulance, NSW 2200, Australia; Royal Prince Alfred Hospital, Sydney, Australia
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Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: a guide to evaluation and management. Ann R Coll Surg Engl 2017. [PMID: 29046084 DOI: 10.1308/rcsann.2017.0191] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction Penetrating neck injury is a relatively uncommon trauma presentation with the potential for significant morbidity and possible mortality. There are no international consensus guidelines on penetrating neck injury management and published reviews tend to focus on traditional zonal approaches. Recent improvements in imaging modalities have altered the way in which penetrating neck injuries are now best approached with a more conservative stance. A literature review was completed to provide clinicians with a current practice guideline for evaluation and management of penetrating neck injuries. Methods A comprehensive MEDLINE (PubMed) literature search was conducted using the search terms 'penetrating neck injury', 'penetrating neck trauma', 'management', 'guidelines' and approach. All articles in English were considered. Articles with only limited relevance to the review were subsequently discarded. All other articles which had clear relevance concerning the epidemiology, clinical features and surgical management of penetrating neck injuries were included. Results After initial resuscitation with Advanced Trauma Life Support principles, penetrating neck injury management depends on whether the patient is stable or unstable on clinical evaluation. Patients whose condition is unstable should undergo immediate operative exploration. Patients whose condition is stable who lack hard signs should undergo multidetector helical computed tomography with angiography for evaluation of the injury, regardless of the zone of injury. Conclusions The 'no zonal approach' to penetrating neck trauma is a selective approach with superior patient outcomes in comparison with traditional management principles. We present an evidence-based, algorithmic and practical guide for clinicians to use when assessing and managing penetrating neck injury.
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Affiliation(s)
- J L Nowicki
- ENT Head and Neck Surgery, Flinders Medical Centre and Flinders University , South Australia , Australia
| | - B Stew
- ENT Head and Neck Surgery, Flinders Medical Centre and Flinders University , South Australia , Australia
| | - E Ooi
- ENT Head and Neck Surgery, Flinders Medical Centre and Flinders University , South Australia , Australia.,Department of Surgery, Flinders University , South Australia , Australia
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Stanton D, Hardcastle T, Muhlbauer D, van Zyl D. Cervical collars and immobilisation: A South African best practice recommendation. Afr J Emerg Med 2017; 7:4-8. [PMID: 30456099 PMCID: PMC6234176 DOI: 10.1016/j.afjem.2017.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/22/2016] [Accepted: 01/10/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The consequences of spinal injury as a result of trauma can be devastating. Spinal immobilisation using hard trauma boards and rigid cervical collars has traditionally been the standard response to suspected spinal injury patients even though the risk may be extremely low. Recently, adverse events due to the method of immobilisation have challenged the need for motion restriction in all trauma patients. International guidelines have been published for protection of the spine during transport and this article brings those guidelines into the South African context. RECOMMENDATIONS Trauma patients need to be properly assessed using both an approved list of high and low risk factors, as well as a thorough examination. They should then be managed accordingly. Internationally validated assessment strategies have been developed, and should be used as part of the patient assessment. The method of motion restriction should be selected to suit the situation. The use of a vacuum mattress is the preferable technique, with the use of a trauma board being the least desirable. CONCLUSION The need for motion restriction in suspected spinal injury should be properly evaluated and appropriate action taken. Not all trauma patients require spinal motion restriction.
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Affiliation(s)
- D. Stanton
- Netcare Education, Faculty of Emergency and Critical Care, South Africa
| | - T. Hardcastle
- University of Kwazulu Natal, Trauma Surgery Training Unit, Inkosi Albert Luthuli Central Hospital Trauma Service and Trauma ICU, South Africa
| | - D. Muhlbauer
- Department of Emergency Medical Care and Rescue, Durban University of Technology, South Africa
| | - D. van Zyl
- Life Flora Hospital Advanced Life Support Unit, South Africa
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Clemency BM, Bart JA, Malhotra A, Klun T, Campanella V, Lindstrom HA. Patients Immobilized with a Long Spine Board Rarely Have Unstable Thoracolumbar Injuries. PREHOSP EMERG CARE 2016; 20:266-72. [DOI: 10.3109/10903127.2015.1086845] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Oto B, Corey DJ, Oswald J, Sifford D, Walsh B. Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature. Acad Emerg Med 2015; 22:1200-12. [PMID: 26394232 DOI: 10.1111/acem.12765] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/25/2015] [Accepted: 05/29/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The objectives were to review published reports of secondary neurologic deterioration in the early stages of care after blunt spinal trauma and describe its nature, context, and associated risk factors. METHODS The authors searched the MEDLINE, EMBASE, and CINAHL databases for English-language studies. Cases were included meeting the criteria age 16 years or older, nonpenetrating trauma, and experiencing neurologic deterioration during prehospital or emergency department (ED) care prior to definitive management (e.g., discharge, spinal clearance by computed tomography, admission to an inpatient service, or surgical intervention). Results were qualitatively analyzed for characteristics and themes. RESULTS Forty-one qualifying cases were identified from 12 papers. In 30 cases, the new deficits were apparently spontaneous and were not detected until routine reassessment. In 12 cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, "unintentional manipulation," falling in or near the ED, and forced collar application in patients with ankylosing spondylitis. Thirteen cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study. CONCLUSIONS Published reports of early secondary neurologic deterioration after blunt spinal trauma are exceptionally rare and generally poorly documented. High-risk features may include altered mental status and ankylosing spondylitis. It is unclear how often events are linked with spontaneous patient movement and whether such events are preventable.
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Affiliation(s)
| | - Domenic John Corey
- Northeastern University; Boston MA
- Cataldo Ambulance Service, Inc.; Somerville MA
| | | | | | - Brooks Walsh
- Department of Emergency Medicine; Bridgeport Hospital; Bridgeport CT
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Oteir AO, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised?: a systematic review. Injury 2015; 46:528-35. [PMID: 25624270 DOI: 10.1016/j.injury.2014.12.032] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 12/21/2014] [Accepted: 12/30/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Spinal cord injuries occur worldwide; often being life-threatening with devastating long term impacts on functioning, independence, health, and quality of life. OBJECTIVES Systematic review of the literature to determine the efficacy of cervical spinal immobilisation (vs no immobilisation) in patients with suspected cervical spinal cord injury (CSCI); and to provide recommendations for prehospital spinal immobilisation. METHODS Searches were conducted of the Cochrane library, CINAHL, EMBASE, Pubmed, Scopus, Web of science, Google scholar, and OvidSP (MEDLINE, PsycINFO, and DARE) databases. Studies were included if they were relevant to the research question, published in English, based in the prehospital setting, and included adult patients with traumatic injury. RESULTS The search identified 1471 citations, of which eight observational studies of variable quality were included. Four studies were retrospective cohorts, three were case series and one a case report. Cervical collar application was reported in penetrating trauma to be associated with unadjusted increased risk of mortality in two studies [(OR, 8.82; 95% CI, 1.09-194; p=0.038) & (OR, 2.06; 95% CI, 1.35-3.13)], concealment of neck injuries in one study and increased scene time in another study. While, in blunt trauma, one study indicated that immobilisation might be associated with worsened neurological outcome (OR, 2.03; 95% CI, 1.03-3.99; p=0.04, unadjusted). We did not attempt to combine study results due to significant heterogeneity of study design and outcome measures. CONCLUSION There is a lack of high-level evidence on the effect of prehospital cervical spine immobilisation on patient outcomes. There is a clear need for large prospective studies to determine the clinical benefit of prehospital spinal immobilisation as well as to identify the subgroup of patients most likely to benefit.
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Affiliation(s)
- Ala'a O Oteir
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne, Victoria, Australia.
| | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Johannes U Stoelwinder
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - James Middleton
- Rehabilitation Studies Unit, Sydney Medical School-Northern, The University of Sydney, New South Wales, Australia
| | - Paul A Jennings
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne, Victoria, Australia; Ambulance Victoria, Melbourne, Victoria, Australia
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Quinn RH, Williams J, Bennett BL, Stiller G, Islas AA, McCord S. Wilderness Medical Society Practice Guidelines for Spine Immobilization in the Austere Environment: 2014 Update. Wilderness Environ Med 2014; 25:S105-17. [DOI: 10.1016/j.wem.2014.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 05/22/2014] [Accepted: 05/25/2014] [Indexed: 01/21/2023]
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Beaty N, Slavin J, Diaz C, Zeleznick K, Ibrahimi D, Sansur CA. Cervical spine injury from gunshot wounds. J Neurosurg Spine 2014; 21:442-9. [PMID: 24926931 DOI: 10.3171/2014.5.spine13522] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Gunshot wounds (GSWs) to the cervical spine have been examined in a limited number of case series, and operative management of this traumatic disease has been sparsely discussed. The current literature supports and the authors hypothesize that patients without neurological deficit need neither surgical fusion nor decompression. Patients with GSWs and neurological deficits, however, pose a greater management challenge. The authors have compiled the experience of the R Adams Cowley Shock Trauma Center in Baltimore, Maryland, over the past 12 years, creating the largest series of such injuries, with a total number of 40 civilian patients needing neurosurgical evaluation. The current analysis examines presenting bone injury, surgical indication, presenting neurological examination, and neurological outcome. In this study, the authors characterize the incidence, severity, and recovery potential of cervical GSWs. The rate of unstable fractures requiring surgical intervention is documented. A detailed discussion of surgical indications with a treatment algorithm for cervical instability is offered. METHODS A total of 144 cervical GSWs were retrospectively reviewed. Of these injuries, 40 had documented neurological deficits. No neurosurgical consultation was requested for patients without deficit. Epidemiological and clinical information was collected on patients with neurological deficit, including age, sex, timing, indication, type of surgery, initial examination after resuscitation, follow-up examination, and imaging data. RESULTS Twenty-eight patients (70%) presented with complete neurological deficits and 12 patients (30%) presented with incomplete injuries. Fourteen (35%) of the 40 patients underwent neurosurgical intervention. Twelve patients (30%) required intervention for cervical instability. Seven patients required internal fixation involving 4 anterior fusions, 2 posterior fusions, and 1 combined approach. Five patients were managed with halo immobilization. Two patients underwent decompression alone for neurological deterioration and persistent compressive injury, both of whom experienced marked neurological recovery. Follow-up was obtained in 92% of cases. Three patients undergoing stabilization converted at least 1 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade and the remaining operative cases experienced small ASIA motor score improvement. Eighteen patients underwent inpatient MRI. No patient suffered complications or neurological deterioration related to retained metal. Three of 28 patients presenting with AIS Grade A improved to Grade B. For those 12 patients with incomplete injury, 1 improved from AIS Grade C to D, and 3 improved from Grade D to E. CONCLUSIONS Spinal cord injury from GSWs often results in severe neurological deficits. In this series, 30% of these patients with deficits required intervention for instability. This is the first series that thoroughly documents AIS improvement in this patient population. Adherence to the proposed treatment algorithm may optimize neurological outcome and spine stability.
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Affiliation(s)
- Narlin Beaty
- Department of Neurosurgery, University of Maryland; and
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Garcia A, Liu TH, Victorino GP. Cost-utility analysis of prehospital spine immobilization recommendations for penetrating trauma. J Trauma Acute Care Surg 2014; 76:534-41. [PMID: 24458063 DOI: 10.1097/ta.0b013e3182aafe50] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The American College of Surgeons' Committee on Trauma's recent prehospital trauma life support recommendations against prehospital spine immobilization (PHSI) after penetrating trauma are based on a low incidence of unstable spine injuries after penetrating injuries. However, given the chronic and costly nature of devastating spine injuries, the cost-utility of PHSI is unclear. Our hypothesis was that the cost-utility of PHSI in penetrating trauma precludes routine use of this prevention strategy. METHODS A Markov model based cost-utility analysis was performed from a society perspective of a hypothetical cohort of 20-year-old males presenting with penetrating trauma and transported to a US hospital. The analysis compared PHSI with observation alone. The probabilities of spine injuries, costs (US 2010 dollars), and utility of the two groups were derived from published studies and public data. Incremental effectiveness was measured in quality-adjusted life-years. Subset analyses of isolated head and neck injuries as well as sensitivity analyses were performed to assess the strength of the recommendations. RESULTS Only 0.2% of penetrating trauma produced unstable spine injury, and only 7.4% of the patients with unstable spine injury who underwent spine stabilization had neurologic improvement. The total lifetime per-patient cost was $930,446 for the PHSI group versus $929,883 for the nonimmobilization group, with no difference in overall quality-adjusted life-years. Subset analysis demonstrated that PHSI for patients with isolated head or neck injuries provided equivocal benefit over nonimmobilization. CONCLUSION PHSI was not cost-effective for patients with torso or extremity penetrating trauma. Despite increased incidence of unstable spine injures produced by penetrating head or neck injuries, the cost-benefit of PHSI in these patients is equivocal, and further studies may be needed before omitting PHSI in patients with penetrating head and neck injuries. LEVEL OF EVIDENCE Economic and value-based evaluation, level II.
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Affiliation(s)
- Arturo Garcia
- From the Alameda County Medical Center, University of California, San Francisco-East Bay, Oakland, CA
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Wilderness Medical Society practice guidelines for spine immobilization in the austere environment. Wilderness Environ Med 2013; 24:241-52. [PMID: 23827829 DOI: 10.1016/j.wem.2013.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 03/03/2013] [Accepted: 03/07/2013] [Indexed: 11/22/2022]
Abstract
In an effort to produce best-practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several factors related to spinal immobilization. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each factor according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented.
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Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee. ACTA ACUST UNITED AC 2012; 71:763-9; discussion 769-70. [PMID: 21909006 DOI: 10.1097/ta.0b013e3182255cb9] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Clinical examination is highly sensitive for detecting clinically significant spinal injuries after gunshot wounds. ACTA ACUST UNITED AC 2012; 71:523-7. [PMID: 21537203 DOI: 10.1097/ta.0b013e318216f467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal method for spinal evaluation after penetrating trauma is currently unknown. The goal of this study was to determine the sensitivity and specificity of a standardized clinical examination for the detection of spinal injuries after penetrating trauma. METHODS After Institutional Review Board approval, all evaluable penetrating trauma patients aged 15 years or more admitted to the Los Angeles County + University of Southern California Medical Center were prospectively evaluated for spinal pain, tenderness to palpation, deformity, and neurologic deficit. RESULTS During the 6-month study period, 282 patients were admitted after sustaining a penetrating injury; 143 (50.7%) as a result of gunshot wound (GSW) and 139 (49.3%) as a result of stab wound (SW). None of the patients sustaining a SW had a spinal injury. Of the 112 evaluable GSW patients, 9 sustained an injury: 6 with a true-positive and 3 with a false-negative clinical examination. The overall sensitivity, specificity, positive predictive value, and negative predictive value were 66.7%, 89.6%, 46.2% and 95.2%, respectively. For clinically significant injuries requiring surgical intervention, cervical or thoracolumbar spine orthosis, or cord transections, however, the sensitivity of clinical examination was 100.0%, specificity 87.5%, positive predictive value 30.8%, and negative predictive value 87.5%. CONCLUSION Clinically significant spinal injury, although rare after SWs, is not uncommon after GSWs. A structured clinical examination of the spine in evaluable patients who have sustained a GSW is highly reliable for identifying those with clinically significant injuries.
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Burgess CA, Dale OT, Almeyda R, Corbridge RJ. An evidence based review of the assessment and management of penetrating neck trauma. Clin Otolaryngol 2012; 37:44-52. [PMID: 22152036 DOI: 10.1111/j.1749-4486.2011.02422.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although relatively uncommon, penetrating neck trauma has the potential for serious morbidity and an estimated mortality of up to 6%. The assessment and management of patients who have sustained a penetrating neck injury has historically been an issue surrounded by significant controversy. OBJECTIVES OF REVIEW: To assess recent evidence relating to the assessment and management of penetrating neck trauma, highlighting areas of controversy with an overall aim of formulating clinical guidelines according to a care pathway format. TYPE OF REVIEW Structured, non-systematic review of recent medical literature. SEARCH STRATEGY An electronic literature search was performed in May 2011. The Medline database was searched using the Medical Subject Headings terms 'neck injuries' and 'wounds, penetrating' in conjunction with the terms 'assessment' or 'management'. Embase was searched with the terms 'penetrating trauma' and 'neck injury', also in conjunction with the terms 'assessment' and 'management'. Results were limited to articles published in English from 1990 to the present day. EVALUATION METHOD Abstracts were reviewed by the first three authors to select full-text articles for further critical appraisal. The references and citation links of these articles were hand-searched to identify further articles of relevance. RESULTS 147 relevant articles were identified by the electronic literature search, comprising case series, case reports and reviews. 33 were initially selected for further evaluation. CONCLUSIONS Although controversy continues to surround the management of penetrating neck trauma, the role of selective non-operative management and the utility of CT angiography to investigate potential vascular injuries appears to be increasingly accepted.
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Affiliation(s)
- C A Burgess
- Department of ENT Surgery, The Royal Berkshire Hospital, Reading, UK.
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