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Kishawi SK, Adomshick VJ, Halkiadakis PN, Wilson K, Petitt JC, Brown LR, Claridge JA, Ho VP. Development of Imaging Criteria for Geriatric Blunt Trauma Patients. J Surg Res 2023; 283:879-888. [PMID: 36915016 DOI: 10.1016/j.jss.2022.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Current decision tools to guide trauma computed tomography (CT) imaging were not validated for use in older patients. We hypothesized that specific clinical variables would be predictive of injury and could be used to guide imaging in this population to minimize risk of missed injury. METHODS Blunt trauma patients aged 65 y and more admitted to a Level 1 trauma center intensive care unit from January 2018 to November 2020 were reviewed for histories, physical examination findings, and demographic information known at the time of presentation. Injuries were defined using the patient's final abbreviated injury score codes, obtained from the trauma registry. Abbreviated injury score codes were categorized by corresponding CT body region: Head, Face, Chest, C-Spine, Abdomen/Pelvis, or T/L-Spine. Variable groupings strongly predictive of injury were tested to identify models with high sensitivity and a negative predictive value. RESULTS We included 608 patients. Median age was 77 y (interquartile range, 70-84.5) and 55% were male. Ground-level fall was the most common injury mechanism. The most commonly injured CT body regions were Head (52%) and Chest (42%). Variable groupings predictive of injury were identified in all body regions. We identified models with 97.8% sensitivity for Head and 98.8% for Face injuries. Sensitivities more than 90% were reached for all except C-Spine and Abdomen/Pelvis. CONCLUSIONS Decision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.
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Affiliation(s)
- Sami K Kishawi
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Victoria J Adomshick
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Penelope N Halkiadakis
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Keira Wilson
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Jordan C Petitt
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Laura R Brown
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeffrey A Claridge
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio; Case Western Reserve University, Department of Population and Quantitative Health Sciences, Cleveland, Ohio.
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McCallum J, Eagles D, Ouyang Y, Ende JV, Vaillancourt C, Fehlmann C, Shorr R, Taljaard M, Stiell I. Cervical spine injuries in adults ≥ 65 years after low-level falls - A systematic review and meta-analysis. Am J Emerg Med 2023; 67:144-155. [PMID: 36893628 DOI: 10.1016/j.ajem.2023.02.008] [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: 10/05/2022] [Revised: 01/10/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Adults ≥ 65 are at risk of cervical spine (C-spine) injury, even after low-level falls. The objectives of this systematic review were to determine the prevalence of C-spine injury in this population and explore the association of unreliable clinical exam with C-spine injury. METHODS We conducted this systematic review according to PRISMA guidelines. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic reviews to include studies reporting on C-spine injury in adults ≥ 65 years after low-level falls. Two reviewers independently screened articles, abstracted data, and assessed bias. Discrepancies were resolved by a third reviewer. A meta-analysis was performed to estimate overall prevalence and the pooled odds ratio for the association between C-spine injury and an unreliable clinical exam. RESULTS The search identified 2044citations, 138 full texts were screened, and 21 studies were included in the systematic review. C-spine injury prevalence in adults ≥ 65 years after low-level falls was 3.8% (95% CI: 2.8-5.3). The odds of c-spine injury in those with altered level of consciousness (aLOC) v/s not aLOC was 1.21 (0.90-1.63) and in those with GCS < 15 v/s GCS 15 was 1.62 (0.37-6.98). Studies were at a low-risk of bias, although some had low recruitment and significant loss to follow-up. CONCLUSIONS Adults ≥ 65 years are at risk of cervical spine injury after low-level falls. More research is needed to determine whether there is an association between cervical spine injury and GCS < 15 or altered level of consciousness.
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Affiliation(s)
- Jessica McCallum
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Debra Eagles
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
| | - Yongdong Ouyang
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Jamie Vander Ende
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
| | - Christian Vaillancourt
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
| | - Christophe Fehlmann
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva CH-1211, Switzerland.
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Ian Stiell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
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Lau L, Ajzenberg H, Haas B, Wong CL. Trauma in the Aging Population. Emerg Med Clin North Am 2023; 41:183-203. [DOI: 10.1016/j.emc.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Williams JR, Muesch AJ, Svenson JE, Clegg AW, Patterson BW, Ward MA. Utility of bedside assessment to evaluate for cervical-spine fracture post ground-level fall for patients 65 years and older. Am J Emerg Med 2022; 53:208-214. [DOI: 10.1016/j.ajem.2022.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 10/19/2022] Open
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Bérubé M, Moore L, Tardif PA, Berry G, Belzile É, Lesieur M, Paquet J. Low-value injury care in the adult orthopaedic trauma population: A systematic review. Int J Clin Pract 2021; 75:e15009. [PMID: 34816530 DOI: 10.1111/ijcp.15009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/19/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices. METHODS We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes. RESULTS Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. CONCLUSION In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Pierre-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
| | - Gregory Berry
- Division of Orthopaedic Surgery, McGill University Health Center, Montréal, Québec, Canada
| | - Étienne Belzile
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Martin Lesieur
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Jérôme Paquet
- Division of Neurosurgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
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Santos Júnior H, Giacon-Arruda BCC, Larrosa S, Andrade ARD, Teston EF, Ferreira Júnior MA. Extrication techniques of entrapped car crash victims: a scoping review. Rev Esc Enferm USP 2021; 55:e20210064. [PMID: 34807225 DOI: 10.1590/1980-220x-reeusp-2021-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 09/30/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to summarize the extrication techniques of entrapped car crash victims with potential spinal injury. METHOD a literature review study, of scoping review type, using the MEDLINE/PubMed, CINAHL, Scopus, Science Direct, Web of Science, Cochrane Library and gray literature data sources, without time frame, with studies that addressed extricating techniques extrication of entrapped car crash victims. RESULTS a total of 33 studies were included that enabled identifying and summarizing the different types of extrication and respective devices for extrication of entrapped car crash victims, indicated according to injury assessment and the victim's clinical condition. All pointed to the need for techniques to maintain neutral alignment and prevent spine twists. CONCLUSION this study indicated that injury assessment with an emphasis on the victim's clinical condition provides a coherent decision-making regarding the technique and device to be used. However, carrying out other comparative studies between existing techniques may help in the decision-making process more assertively.
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Affiliation(s)
- Hamilton Santos Júnior
- Universidade Federal de Mato Grosso do Sul, Instituto Integrado de Saúde, Programa de Pós-Graduação em Enfermagem, Campo Grande, MS, Brazil
| | | | - Sarah Larrosa
- Universidade Federal de Mato Grosso do Sul, Instituto Integrado de Saúde, Curso de Enfermagem, Campo Grande, MS, Brazil
| | - André Rodrigues de Andrade
- Corpo de Bombeiros Militar do Distrito Federal, Grupamento de Atendimento de Emergência Pré-Hospitalar, Brasília, DF, Brazil
| | - Elen Ferraz Teston
- Universidade Federal de Mato Grosso do Sul, Instituto Integrado de Saúde, Programa de Pós-Graduação em Enfermagem, Campo Grande, MS, Brazil
| | - Marcos Antonio Ferreira Júnior
- Universidade Federal de Mato Grosso do Sul, Instituto Integrado de Saúde, Programa de Pós-Graduação em Enfermagem, Campo Grande, MS, Brazil
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Cushing CH, Holmes JF, Tyler KR. Cervical Spine Injuries in Older Patients with Falls Found on Magnetic Resonance Imaging After Computed Tomography. West J Emerg Med 2021; 22:1190-1195. [PMID: 34546897 PMCID: PMC8463044 DOI: 10.5811/westjem.2021.5.51844] [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: 01/22/2021] [Accepted: 05/05/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction In this study we aimed to determine the rate of traumatic abnormalities on cervical spine magnetic resonance imaging (MRI) after a normal cervical spine computed tomography (CT) in older patients with ground-level falls. We hypothesized that MRI is low yield following a normal physical examination and normal CT after a ground-level fall. Methods This was a retrospective cohort study of patients 65 years and older evaluated with a cervical spine MRI following a ground-level fall. Inclusion criteria included age 65 years and older, ground-level fall, normal cervical spine CT followed by a cervical spine MRI. We abstracted data following accepted methodologic guidelines. Patients with any focal neurological finding were considered to have an abnormal neurological examination. Imaging studies were considered to be abnormal if there was a report of an acute traumatic injury. The primary outcome was a traumatic abnormality identified on MRI. We described data with simple descriptive statistics. Results Eighty-seven patients with a median age of 74 (interquartile range [IQR] 69, 83]) years had an MRI following a normal cervical spine CT. Median emergency department length of stay was 8.2 hours (IQR 5.3, 13.5). Sixty-four (73.6%) patients had a normal neurological examination on arrival; eight of these patients (12.5% (95% confidence interval [CI], 5.6–23.2%) had an abnormal cervical spine MRI. Twenty-three patients (26.4%) had an abnormal neurological examination on arrival; two of these patients (8.7%, 95% CI, 1.1–28%) had an abnormal cervical spine MRI. Overall, 10 patients (11.5%) had an abnormal cervical spine MRI. One patient underwent operative intervention due to an unstable injury. Of the remaining nine patients with acute findings on cervical spine MRI, there were no other unstable injuries; two patients were managed with cervical orthosis, and seven patients had no additional management. Conclusion In this study of older patients with ground-level falls and normal, atraumatic, cervical spine CT, a small portion had traumatic abnormalities on MRI, with few requiring further intervention. Further study is required to identify criteria to determine when MRI should be performed in older patients after a ground-level fall.
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Affiliation(s)
- Corinne H Cushing
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - James F Holmes
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - Katren R Tyler
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
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Disproportionate Use in Minor Trauma Is Driving Emergency Department Cervical Spine Imaging: An Injury Severity Score-Based Analysis. J Am Coll Radiol 2021; 18:1532-1539. [PMID: 34339664 DOI: 10.1016/j.jacr.2021.07.006] [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] [Received: 04/18/2021] [Revised: 06/23/2021] [Accepted: 07/01/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Clinical practice guidelines intended to reduce unnecessary cervical spine imaging have yielded mixed results. We aimed to assess evolving emergency department (ED) cervical spine imaging utilization in patients with trauma by injury severity. METHODS Using 2009 to 2018 IBM MarketScan Commercial Databases, we identified ED trauma encounters, associated cervical spine imaging, and related diagnosis codes. We classified encounters by injury severity (minor, intermediate, major) using an International Classification of Disease code-derived Injury Severity Score algorithm and studied evolving imaging utilization using multivariable Poisson regression models. RESULTS Of all 11,346,684 ED visits for trauma, 7,753,914 (68.3%), 3,524,250 (31.1%), and 68,520 (0.6%) involved minor, intermediate, and major injuries, respectively. Overall cervical spine imaging increased 5.7% annually (incidence rate ratio [IRR] 1.057, P < .001) with radiography decreasing 2.7% annually (IRR 0.973, P < .001) and CT increasing 10.5% annually (IRR 1.105, P < .001). Radiography utilization remained unchanged for minor injuries (IRR 0.994, P = .14) but decreased for intermediate (IRR 0.928 versus minor, P < .001) and major (IRR 0.931 versus minor, P < .001) injuries. Increases in CT utilization were greatest for minor injuries (IRR 1.109, P < .001) with smaller increases in intermediate (IRR 0.960 versus minor, P < .001) and major (IRR 0.987 versus minor, P = .022) injuries. CONCLUSIONS Recent increases in cervical spine imaging in commercially insured patients with trauma seen in the ED have been largely related to increases in CT for patients with only minor injuries, in whom imaging utilization has been historically low. Further study is necessary to assess appropriateness, implications on costs and population radiation dose, and factors influencing ordering decision making.
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Engelbart J, Zhou P, Johnson J, Lilienthal M, Zhou Y, Ten-Eyck P, Galet C, Skeete D. Geriatric clinical screening tool for cervical spine injury after ground-level falls. Emerg Med J 2021; 39:301-307. [PMID: 34108196 DOI: 10.1136/emermed-2020-210693] [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: 09/19/2020] [Accepted: 05/28/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND A consistent approach to cervical spine injury (CSI) clearance for patients 65 and older remains a challenge. Clinical clearance algorithms like the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have variable accuracy and the Canadian C-spine rule excludes older patients. Routine CT of the cervical spine is performed to rule out CSI but at an increased cost and low yield. Herein, we aimed to identify predictive clinical variables to selectively screen older patients for CSI. METHODS The University of Iowa's trauma registry was interrogated to retrospectively identify all patients 65 years and older who presented with trauma from a ground-level fall from January 2012 to July 2017. The relationship between predictive variables (demographics, NEXUS criteria and distracting injuries) and presence of CSI was examined using the generalised linear modelling (GLM) framework. A training set was used to build the statistical models to identify clinical variables that can be used to predict CSI and a validation set was used to assess the reliability and consistency of the model coefficients estimated from the training set. RESULTS Overall, 2312 patients ≥65 admitted for ground-level falls were identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best predictive model for CSI included midline tenderness, focal neurological deficit and signs of trauma to the head/face, with midline tenderness highly predictive of CSI (OR=22.961 (15.178-34.737); p<0.001). The negative predictive value (NPV) for this model was 95.1% (93.9%-96.3%). In the absence of midline tenderness, the best model included focal neurological deficit (OR=2.601 (1.340-5.049); p=0.005) and signs of trauma to the head/face (OR=3.024 (1.898-4.815); p<0.001). The NPV was 94.3% (93.1%-95.5%). CONCLUSION Midline tenderness, focal neurological deficit and signs of trauma to the head/face were significant in this older population. The absence of all three variables indicates lower likelihood of CSI for patients≥65. Future observational studies are warranted to prospectively validate this model.
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Affiliation(s)
- Jacklyn Engelbart
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Peige Zhou
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Jenna Johnson
- Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Michele Lilienthal
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Yunshu Zhou
- Institute for Clinical and Translational Science, Biostatistics, Epidemiology, and Research Design Core, The University of Iowa, Iowa City, Iowa, USA
| | - Patrick Ten-Eyck
- Institute for Clinical and Translational Science, Biostatistics, Epidemiology, and Research Design Core, The University of Iowa, Iowa City, Iowa, USA
| | - Colette Galet
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Dionne Skeete
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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Lesko K, Deasy C. Low falls causing major injury: a retrospective study. Ir J Med Sci 2020; 189:1435-1443. [PMID: 32185749 DOI: 10.1007/s11845-020-02212-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Falling from a height of under 2 m (low fall) is the most common mechanism of injury causing major trauma in Ireland. This presentation encompasses a wide patient cohort, from paediatric sport injuries to elderly falls. AIMS Our aim is to characterise major trauma resulting from a low fall, and its various sub-populations, to identify preventative strategies and care pathways to improve outcomes for patients. METHODS The Trauma Audit and Research Network (TARN) which is used to provide Major Trauma Audit was used to retrospectively identify patients presenting to the Cork University Hospital Emergency Department with trauma resulting from a low fall from January 2015 to June 2018. RESULTS The database returned 1066 qualifying cases (49.3% of cases in the time period), with a mean age of 67.3 years (SD = 21) and a median age of 71.3 years (IQR = 23); 44% were male. 'Mechanical falls' accounted for n = 513 (48%) of low-fall injuries, followed by 'stationary falls' n = 265 (25%). Injuries occurred most often at home n = 515 (48%), followed by public places n = 208 (19.5%). The most severely injured body region was the limbs n = 526 (49.3%), followed by the head n = 253 (23.7%). A number of patients with Glasgow Outcome Scores of 4 (moderate disability) and 5 (good recovery) were n = 488 (45.8%) and n = 390 (36.6%). CONCLUSIONS Low falls occur in patients over 55 years of age; many do not return to independent living. Wait times to initial assessment, length of hospital stay and mortality increase with age. Mechanical falls at home are the most common cause of low-fall major trauma.
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Affiliation(s)
- Kathryn Lesko
- School of Medicine, University College Cork, Cork, Ireland.
| | - Conor Deasy
- School of Medicine, University College Cork, Cork, Ireland
- Cork University Hospital, Cork, Ireland
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Nakanishi T, Mitra B, Ackland H, O'Reilly G, Cameron P. Time in Collars and Collar-Related Complications in Older Patients. World Neurosurg 2019; 129:e478-e484. [PMID: 31150857 DOI: 10.1016/j.wneu.2019.05.187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/20/2019] [Accepted: 05/22/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Cervical spine immobilization, including cervical collars, has been recommended in most trauma guidelines. However, cervical spine immobilization can be associated with harm, and an increasing body of evidence has demonstrated associated complications. We hypothesized that older trauma patients placed in cervical collars for >24 hours were at greater risk of developing collar-related complications compared with those placed in cervical collars for ≤24 hours. METHODS We conducted a retrospective cohort study of injured patients without a fracture of the cervical vertebrae, aged ≥65 years, who had been placed in a cervical collar during the period from January 1, 2015 to December 31, 2015. The primary outcome was the composite of the in-hospital development of nosocomial pneumonia and collar-related pressure ulcers. RESULTS A total of 1154 patients had been treated with cervical collars during the study period, and 61 (5.1%) had developed collar-related complications. Male sex, a lower initial Glasgow Coma Scale score, a history of congestive heart failure, a history of chronic obstructive pulmonary disease or asthma, operative management, and longer hospital and intensive care unit lengths of stay demonstrated a univariable association with collar-related complications (P < 0.10), in addition to a duration in the collar for >24 hours. An independent association was found between collar duration >24 hours and the outcome of interest (adjusted odds ratio, 2.50; 95% confidence interval, 1.16-5.39; P = 0.02). CONCLUSIONS Among older patients without a cervical vertebral fracture, duration of cervical collar use for >24 hours was associated with the development of collar-related complications. We recommend attention to early collar clearance for older trauma patients.
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Affiliation(s)
- Taizo Nakanishi
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan.
| | - Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Helen Ackland
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gerard O'Reilly
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Characteristics and Management of Emergency Department Patients Presenting with C2 Cervical Spine Fractures. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4301051. [PMID: 31223616 PMCID: PMC6541942 DOI: 10.1155/2019/4301051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/12/2019] [Accepted: 04/28/2019] [Indexed: 11/17/2022]
Abstract
Background C2 cervical fractures account for approximately 18% of cervical spine injuries. Few studies have examined patients presenting to an emergency department (ED) with this injury relative to demographics, injury mechanism, and hospital course. Objectives To compare multiple variables of ED patients presenting with these types of injuries. Methods In this retrospective cohort study, data were obtained from the Trauma Registry of an academic trauma referral center from January 1, 2011, to December 31, 2015. Patients who presented with a C2 fracture were identified. Information regarding the patient's gender, age, mechanism of injury, associated injuries, if a procedure was required, disposition, and mortality was extracted. Comparative analyses were conducted between cases over or under age 60. Results Between January 1, 2011, to December 31, 2015, a total of 139 patients with C2 fractures were identified. Most patients were 60 years or older (79%). Of those, 62% were female, and falls were the most common mechanism (78%). Of those under 60, 50% were female and motor vehicle crashes (MVCs) were the most common mechanism (71%). Odontoid fractures comprised 84% of C2 fractures. Only 6% had an associated spinal cord injury. Less than one-third of patients required operative intervention for their spinal injuries, and intervention was more common in older patients. Following admission, 19% of patients required placement into a nursing home or skilled nursing facility. Conclusions C2 fractures are more common in older adults and usually resulted from falls. Odontoid fractures are most common. Most C2 fractures do not result in neurologic injury, and only a third were treated surgically. However, several patients were unable to return to their homes following their injury.
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Beckmann NM, West OC, Nunez D, Kirsch CF, Aulino JM, Broder JS, Cassidy RC, Czuczman GJ, Demertzis JL, Johnson MM, Motamedi K, Reitman C, Shah LM, Than K, Ying-Kou Yung E, Beaman FD, Kransdorf MJ, Bykowski J. ACR Appropriateness Criteria® Suspected Spine Trauma. J Am Coll Radiol 2019; 16:S264-S285. [DOI: 10.1016/j.jacr.2019.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
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Clinical Outcome and Management for Geriatric Traumatic Injury: Analysis of 2688 Cases in the Emergency Department of a Teaching Hospital in Taiwan. J Clin Med 2018; 7:jcm7090255. [PMID: 30181469 PMCID: PMC6162823 DOI: 10.3390/jcm7090255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/23/2018] [Accepted: 09/03/2018] [Indexed: 01/06/2023] Open
Abstract
Geriatric traumatic injuries in emergency departments are frequent and associated with higher mortality rates and catastrophic functional outcomes. Several prediction scores have been established to manage traumatic patients, including the shock index (SI), revised trauma score (RTS), injury severity score (ISS), trauma injury severity score (TRISS), and new injury severity score (NISS). However, it was necessary to investigate the effectiveness and efficiency of care for the geriatric traumatic population. In addition, image studies such as computed tomography and magnetic resonance imaging play an important role in early diagnosis and timely intervention. However, few studies focus on this aspect. The association between the benefit of carrying out more image studies and clinical outcomes remains unclear. In this study, we included a total of 2688 traumatic patients and analyzed the clinical outcomes and predicting factors in terms of geriatric trauma via pre-hospital and in-hospital analysis. Our evaluation revealed that a shock index ≥1 may be not a strong predictor of geriatric trauma due to the poor physical response in the aging population. This should be modified in geriatric patients. Other systems, like RTS, ISS, TRISS, and NISS, were significant in terms of predicting the clinical outcome.
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Kim C, Sartin R, Dissanaike S. Is a "Pan-Scan" Indicated in the Older Patient with a Ground Level Fall? Am Surg 2018; 84:1480-1483. [PMID: 30268180 DOI: 10.1177/000313481808400954] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Routine full-body CT "pan-scan" use in older patients after ground level falls (GLFs) is of questionable benefit. Retrospective review of new diagnosis & changes in management in patients >55 years with Glasgow Coma Scale of 15 after a GLF who received a pan-scan (routine head, cervical spine/neck, chest abdomen, and pelvis CT). Head CT results were considered separately; results described in the following paragraph pertains to cervical spine/neck, chest, abdomen, and pelvis CT. One hundred and fifty-two patients received pan-scans; 96 (63%) had new findings. Thirty-five (23%) resulted in a minor change and three (2%) in a major change in management, defined as a procedural intervention. This included tube thoracostomy in one patient and cervical spine surgery in two. A further eight patients required the use of a cervical collar. In all patients requiring intervention, there were clinical signs present that should have led to directed CT scan of area of concern. Routine pan-scans in stable, alert older patients after a GLF result in new findings in most patients, with primarily nonprocedural interventions for these additional findings.
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Beckmann NM, Cai C, Spence SC, Prasarn ML, Clark West O. Is elevated body mass index protective against cervical spine injury in adults? Emerg Radiol 2018; 25:415-424. [PMID: 29603036 DOI: 10.1007/s10140-018-1602-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 03/23/2018] [Indexed: 01/01/2023]
Abstract
PURPOSE Correlate body mass index (BMI) with incidence and type of cervical spine injury seen on CT in adult patients presenting with blunt trauma. MATERIALS AND METHODS Retrospective chart review of all adult blunt trauma patients who had a cervical spine CT performed at our level 1 trauma center during an approximately 3-year period. RESULTS A statistically significant (p = 0.01) difference in cervical spine injury incidence was present between different BMI groups. Cervical spine injury incidence was 7.7% for underweight (BMI ≤ 18) patients, 7.1% for normal weight (BMI 18-25) patients, 6.2% for overweight/obese (BMI 25-35) patients, and 4.7% for morbidly obese (BMI > 35) patients. Using BMI > 18-25 as a reference group, females with BMI > 25-35 had an adjusted odds ratio (aOR) of 0.56 (CI 0.41-0.75) and females with BMI > 35 had an aOR of 0.42 (CI 0.26-0.70). Males with a BMI ≤ 18 had an aOR of 2.20 (CI 1.12-4.32) and males with BMI > 35 had an aOR of 0.66 (CI 0.46-0.95). A particularly low incidence of cervical spine injury was observed in patients older than 65 in the obese group with a cervical spine injury rate of only 1.4% in this patient population. No statistical significant difference was seen in injury morphology across the BMI groups. CONCLUSION An inverse relationship exists between BMI and the overall incidence of cervical spine injury. This protective effect appears to be influenced by gender with elevated BMI having lower relative odds of cervical spine injury in women than in men. A particularly low rate of cervical spine injury was identified in obese patients over the age of 65. Routine imaging of all elderly, obese trauma patients with low energy mechanism of injury may not be warranted.
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Affiliation(s)
- Nicholas M Beckmann
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA.
| | - Chunyan Cai
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
- Biostatistics/Epidemiology/Research/Design Core, Center for Clinical and Translational Sciences, The University of Texas Health Science Center at Houston, 6410 Fannin, UTPB 1100.08, Houston, TX, 77030, USA
| | - Susanna C Spence
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA
| | - Mark L Prasarn
- Department of Orthopedic Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX, 77030, USA
| | - O Clark West
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA
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Thesleff T, Niskakangas T, Luoto T, Iverson GL, Öhman J, Ronkainen A. Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from 1987 to 2010. Spine J 2018; 18:430-438. [PMID: 28822822 DOI: 10.1016/j.spinee.2017.08.231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/17/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Fall-induced injuries in patients are increasing in number, and they often lead to serious consequences, such as cervical spine injuries (CSI). CSI diagnostics remain a challenge despite improved radiological services. PURPOSE Our aim is to define the incidence and risk factors for diagnostic errors among patients who died following a CSI. STUDY DESIGN/SETTING A retrospective death certificate-based study of the whole population of Finland was carried out. PATIENT SAMPLE We identified 2,041 patients whose death was, according to the death certificate, either directly or indirectly caused by a CSI. OUTCOME MEASURES Demographics, injury- and death-related data, and adverse event (AE)-related data were the outcome measures. METHODS All death certificates between the years 1987 and 2010 from Statistics Finland that identified a CSI as a cause death were reviewed to identify preventable AEs with the emphasis on diagnostic errors. RESULTS Of the 2,041 patients with CSI-related deaths, 36.5% (n=744) survived at least until the next day. Errors in CSI diagnostics were found in 13.8% (n=103) of those who died later than the day of injury. Those with diagnostic errors were significantly older (median age 79.4 years, 95% confidence interval 75.9-80.1 vs. 74.9, 95% confidence interval 70.2-72.9, p<.001) and the mechanism of injury was significantly more often a fall (86.4%, n=89 vs. 69.7%, n=447, p=.002) compared with those who did not have a diagnostic error. The incidence of diagnostic errors increased slightly during the 24-year study period. CONCLUSIONS Cervical spine injury diagnostics remain difficult despite improved radiological services. The majority of the patients subjected to diagnostic errors are fragile elderly people with reduced physical capacity. In our analysis, preventable AEs and diagnostic errors were most commonly associated with ground-level falls.
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Affiliation(s)
- Tuomo Thesleff
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland.
| | - Tero Niskakangas
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Teemu Luoto
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Center for Health and Rehabilitation Research, 79/96 Thirteenth Street, Charlestown Navy Yard, Charlestown, MA, 02129, Massachusetts, USA
| | - Juha Öhman
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
| | - Antti Ronkainen
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, FI-33521, Tampere, Finland
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Jambhekar A, Lindborg R, Chan V, Fulginiti A, Fahoum B, Rucinski J. Over the hill and falling down: Can the NEXUS criteria be applied to the elderly? Int J Surg 2018; 49:56-59. [DOI: 10.1016/j.ijsu.2017.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/19/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
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Paykin G, O'Reilly G, Ackland H, Mitra B. Review article: NEXUS criteria to rule out cervical spine injury among older patients: A systematic review. Emerg Med Australas 2017; 30:450-455. [DOI: 10.1111/1742-6723.12880] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/15/2017] [Accepted: 09/09/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Gabriel Paykin
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Gerard O'Reilly
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Helen Ackland
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Intensive Care Department; The Alfred; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
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Lindborg R, Jambhekar A, Chan V, Laskey D, Rucinski J, Fahoum B. Distracting injury defined: does an isolated hip fracture constitute a distracting injury for clearance of the cervical spine? Emerg Radiol 2017; 25:35-39. [PMID: 28936568 DOI: 10.1007/s10140-017-1555-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/15/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES As the population within the USA ages, the number of hip fractures seen yearly in the emergency department is expected to rise. According to the NEXUS criteria, many of these patients receive computerized tomographic scan (CT) evaluation of the cervical spine because a hip fracture may constitute a distracting injury. The objective of this study is to determine if an isolated hip fracture constitutes a distracting injury which requires imaging of the cervical spine. METHODS Data were prospectively collected on 158 trauma patients with isolated hip fractures between April 1, 2015 and March 9, 2016. Patient demographics were analyzed and compared to the National Emergency X-Radiography Utilization Study (NEXUS). RESULTS Patients with isolated hip fractures were predominantly elderly, on average 78.6 +/- 15.9 years old, and 94.3% of these injuries occurred after a fall from standing. Only one patient also had a cervical spine fracture which was not clinically significant. When compared to the established rate of cervical spine injury of 2.4%, the absolute risk reduction (ARR) was 0.35% (95% CI, - 1.06 to 1.75%) and the number needed to treat (NNT) was 290. CONCLUSION In the case of an elderly patient with an isolated hip fracture and no cervical midline tenderness, cervical spine imaging may be reserved for those who have other NEXUS criteria for further workup.
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Affiliation(s)
- Ryan Lindborg
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA.
| | - Amani Jambhekar
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
| | - Vincent Chan
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
| | - Daniel Laskey
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
| | - James Rucinski
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
| | - Bashar Fahoum
- Department of Surgery, New York Presbyterian Brooklyn Methodist Hospital, 506 Sixth Street, Brooklyn, NY, 11215, USA
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Paykin G, O'Reilly G, Ackland HM, Mitra B. The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients. Injury 2017; 48:1020-1024. [PMID: 28274471 DOI: 10.1016/j.injury.2017.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 02/15/2017] [Accepted: 02/18/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVE The National Emergency X-Radiography Utilization Study (NEXUS) criteria are used to assess the need for imaging to evaluate cervical spine integrity after injury. The aim of this study was to assess the sensitivity of the NEXUS criteria in older blunt trauma patients. METHODS Patients aged 65 years or older presenting between 1st July 2010 and 30th June 2014 and diagnosed with cervical spine fractures were identified from the institutional trauma registry. Clinical examination findings were extracted from electronic medical records. Data on the NEXUS criteria were collected and sensitivity of the rule to exclude a fracture was calculated. RESULTS Over the study period 231,018 patients presented to The Alfred Emergency & Trauma Centre, of whom 14,340 met the institutional trauma registry inclusion criteria and 4035 were aged ≥65years old. Among these, 468 patients were diagnosed with cervical spine fractures, of whom 21 were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% [95% CI: 92.1%-96.7%] on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% [95% CI: 93.2%-97.2%]. CONCLUSION Compared with the general adult blunt trauma population, the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. We therefore suggest that liberal imaging be considered for older patients regardless of history or examination findings and that the addition of an age criterion to the NEXUS criteria be investigated in future studies.
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Affiliation(s)
- Gabriel Paykin
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia; Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Gerard O'Reilly
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia; Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Helen M Ackland
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia; Intensive Care Department, The Alfred Hospital, Melbourne, Australia
| | - Biswadev Mitra
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia; Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.
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Cervical spine evaluation in the bluntly injured patient. Int J Surg 2016; 33:246-250. [PMID: 26827890 DOI: 10.1016/j.ijsu.2016.01.086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 12/29/2015] [Accepted: 01/24/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cervical spine injuries causing spinal cord trauma are rare in blunt trauma yet lead to devastating morbidity and mortality when they occur. There exists considerable debate in the literature about the best way for clinicians to proceed in ruling out cervical spine injuries in alert or obtunded blunt trauma patients. METHODS We reviewed the current literature and practice management guidelines to generate clinical recommendations for the detection and clearance of cervical spine injuries in the blunt trauma patient. RESULTS The NEXUS and Canadian C-Spine Rules are clinical tools to guide in the clearance of the cervical spine of patients who have sustained low risk trauma and who are pain free, with the Canadian C-Spine Rules having superior sensitivity and specificity. In the alert, high risk patient with pain (or without, if over the age of 65 years), follow up imaging is required. The best imaging modality to use is Computerized Tomography (CT) of the cervical spine. In the obtunded trauma patient, CT clearance of c-spine injury is adequate, unless there is soft tissue injury or any non-bony abnormalities detected. At such point, definitive clearance may be obtained with Magnetic Resonance Imaging (MRI). CONCLUSIONS It is imperative to assume cervical spine injury in the blunt trauma patient. Clinical decision rules for cervical clearance may be used in low risk patients, avoiding imaging. High risk patients require imaging in the form of CT scan of the cervical spine.
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