Prehospital care of the injured: what's new

Radiographic cervical spine injury patterns in admitted blunt trauma patients with and without prehospital spinal motion restriction

Objectives

Selective prehospital cervical spine motion restriction (C-SMR) following blunt trauma has increasingly been used by emergency medical service (EMS) providers. We determined rates of prehospital C-SMR and concomitant radiographic injury patterns.

Methods

A retrospective trauma registry and chart review was conducted for all adult blunt trauma patients who were transported by EMS and hospitalized with radiographic cervical spine injuries from 2011 to 2019 at a level 1 trauma center.

Results

Of 658 admitted blunt trauma patients with confirmed cervical spine injury by imaging, 117 (17.8%) did not receive prehospital C-SMR. Patients without prehospital C-SMR were significantly older (76 vs 54 years), more often had low fall as mechanism of injury (59.8% vs 15.9%) and had lower Injury Severity Score (10 vs 17). Patients without C-SMR (Non-SMR) experienced the full array of cervical spine injury types and locations. While the non-SMR patients most often had dens fractures,C-SMR patients most often had C7 fractures; frequencies of fractures at the remaining vertebral levels were comparable. On MRI, cervical spinal cord (8.5% vs 19.6%) and ligamentous injuries (5.1% vs 12.6%) occurred less often in non-SMR patients. Approximately 8.5% of non-SMR patients and 20% of C-SMR patients required cervical spine surgery.

Conclusion

Patients without prehospital C-SMR demonstrate a broad array of cervical spine injuries. While the rates of certain cervical injuries are lower in prehospital non-SMR patients, they are not insignificant.

Level of evidence

Level III.

Should suspected cervical spinal cord injury be immobilised?: a systematic review

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.

The effect of different topical agents (silver sulfadiazine, povidone-iodine, and sodium chloride 0.9%) on burn injuries in rats

It was aimed to comparatively evaluate the effects of dressing methods with silver sulfadiazine, povidone-iodine, and saline which have a common use in routine practices for burn injuries. Twenty-eight Sprague Dawley adult female rats were used in this study. All the rats were divided into 4 groups: the control group, the povidone-iodine group, the saline group, and the silver sulfadiazine group. On each rat, a second degree burn which covered less than 10% of the body surface area was created under general anesthesia by a metal comb including four probes with 2 × 1 cm area. The control group did not have any treatment during the experiment. Povidone-iodine, saline, and silver sulfadiazine administrations were performed under ether anesthesia every day. On 0, 7th, 14th, and 21st days of the study, tissue samples were taken for histological analyses. The sections taken from the paraffin blocks were stained and avidin-biotin-peroxidase method was used for collagen immune-reactivity. In the light microscope analyses, number of inflammatory cells, vascularization, fibroblast proliferation, collagen formation and epithelialization were evaluated histologically in all groups and analysed statistically. The agents that we used for injury healing in the treatment groups did not show any significant better results in comparison with the control group. In conclusion, further studies with the use of sodium chloride, silver sulfadiazine, and povidone-iodine by creating deeper and/or larger burn injury models are needed in order to accept these agents in routine treatment.

The ebb and flow of fluid (as in resuscitation)

Since the early 1960's "resuscitation" following major trauma involved use of replacement crystalloid fluid/estimated blood loss in volumes of 3/1, in the ambulance, emergency room, operating room and surgical intensive care unit. During the past 20 years, MAJOR paradigm shifts have occurred in this concept. As a result hypotensive resuscitation with a view towards restriction of crystalloid, and prevention of complications has occurred. Improved results in both civilian and military environments have been reported. As a result there is new focus on trauma surgical involvement in all aspects of trauma patient management, focus on early aggressive surgical approaches (which may or may not involve an operation), and movement from crystalloid to blood, plasma, and platelet replacement therapy.

The prehospital management of suspected spinal cord injury: an update

INTRODUCTION

Spinal cord injury (SCI) is a serious condition that may lead to long-term disabilities placing financial and social burden on patients and their families, as well as their communities. Spinal immobilization has been considered the standard prehospital care for suspected SCI patients. However, there is a lack of consensus on its beneficial impact on patients' outcome.

OBJECTIVE

This paper reviews the current literature on the epidemiology of traumatic SCI and the practice of prehospital spinal immobilization.

DESIGN

A search of literature was undertaken utilizing the online databases Ovid Medline, PubMed, CINAHL, and the Cochrane Library. The search included English language publications from January 2000 through November 2012.

RESULTS

The reported annual incidence of SCI ranges from 12.7 to 52.2 per 1 million and occurs more commonly among males than females. Motor vehicle collisions (MVCs) are the major reported causes of traumatic SCI among young and middle-aged patients, and falls are the major reported causes among patients older than 55. There is little evidence regarding the relationship between prehospital spinal immobilization and patient neurological outcomes. However, early patient transfer (8-24 hours) to spinal care units and effective resuscitation have been demonstrated to lead to better neurological outcomes.

CONCLUSION

This review reaffirms the need for further research to validate the advantages, disadvantages, and the effects of spinal immobilization on patients' neurological outcomes.

Utilisation of a Level 1 Trauma Centre in KwaZulu-Natal: appropriateness of referral determines trauma patient access

BACKGROUND

Appropriate referral of major trauma patients to an accredited Level 1 Trauma facility is associated with improved outcome. A new Level 1 Trauma Centre was opened at Inkosi Albert Luthuli Central Hospital in March 2007. This study sought to audit the referral pattern of external consults to the trauma unit and ascertain whether the unit was receiving appropriate referrals and has adequate capacity.

METHODS

An audit was performed of the referral proformas used in the unit to record admission decisions and of the computerised trauma database. The audit examined referral source (scene vs. interhospital), regional distribution, and final decision regarding admission of the injured patients. The study was approved by the UKZN Ethics Committee (BE207/09 and 011/010).

RESULTS

Of the 1,212 external consults, 540 were accepted for admission while the rest were not accepted for various reasons. These included 206 cases where no bed was available, 233 did not meet admission criteria (minor injury or futile situation), and 115 were for subspecialty management of a single-system injury. Finally, 115 were initially refused pending stabilisation for transfer at a regional facility. Twenty-six percent of the cases were referrals from the scene, with an acceptance rate of 96 %. Most patients (59 %) were from the local eThekwini region.

CONCLUSION

Major multiorgan system trauma remains a significant public health burden in KwaZulu-Natal. A Level 1 Trauma Service is used appropriately in most circumstances. However, the additional need for more hospital facilities that provide such services across the whole province to enable effective geographical coverage for those trauma patients requiring such specialised trauma care is essential.

Should suspected cervical spinal cord injuries be immobilised? A systematic review protocol

BACKGROUND

Cervical spinal cord injuries may result in life-threatening situations and long-term disability. Prehospital spinal immobilisation is the standard of care for patients with potential spinal cord injury (SCI). It aims to prepare patients for transport, achieve neutral spinal alignment, and reduce movement and secondary injuries in potentially unstable spines. However, there is a lack of evidence on its clinical benefits and its overall effect on patient outcomes.

OBJECTIVES

To identify the reported outcomes following immobilisation of suspected cervical SCI, to compare the effects of spinal immobilisation versus no immobilisation on the reported outcomes, and to provide recommendations for prehospital cervical immobilisation.

DESIGN/METHODS

A search of the literature will be conducted using relevant online databases. This will include all types of human studies that were published in English from the earliest record available to the first week of October 2013. One author will conduct the search and two independent authors will screen the titles and the abstracts identified by the search and critically appraise the selected papers. A third author will be available to resolve any disagreement. The findings will be reported according to Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Critical appraisal as well as the level and the strength of evidence will follow the National Health and Medical Research Council (NHMRC) guidelines.

DISCUSSION

Evidence-based practices should be pursued to further improve the prehospital care for suspected cervical SCI. This systematic review will contribute to the body of knowledge regarding the spinal immobilisation effects on the SCI patient's outcomes.

Prehospital lactated ringer's solution treatment and survival in out-of-hospital cardiac arrest: a prospective cohort analysis

BACKGROUND

No studies have evaluated whether administering intravenous lactated Ringer's (LR) solution to patients with out-of-hospital cardiac arrest (OHCA) improves their outcomes, to our knowledge. Therefore, we examined the association between prehospital use of LR solution and patients' return of spontaneous circulation (ROSC), 1-month survival, and neurological or physical outcomes at 1 month after the event.

METHODS AND FINDINGS

We conducted a prospective, non-randomized, observational study using national data of all patients with OHCA from 2005 through 2009 in Japan. We performed a propensity analysis and examined the association between prehospital use of LR solution and short- and long-term survival. The study patients were ≥18 years of age, had an OHCA before arrival of EMS personnel, were treated by EMS personnel, and were then transported to hospitals. A total of 531,854 patients with OHCA met the inclusion criteria. Among propensity-matched patients, compared with those who did not receive pre-hospital intravenous fluids, prehospital use of LR solution was associated with an increased likelihood of ROSC before hospital arrival (odds ratio [OR] adjusted for all covariates [95% CI] = 1.239 [1.146-1.339] [p<0.001], but with a reduced likelihood of 1-month survival with minimal neurological or physical impairment (cerebral performance category 1 or 2, OR adjusted for all covariates [95% CI] = 0.764 [0.589-0.992] [p = 0.04]; and overall performance category 1 or 2, OR adjusted for all covariates [95% CI] = 0.746 [0.573-0.971] [p = 0.03]). There was no association between prehospital use of LR solution and 1-month survival (OR adjusted for all covariates [95% CI] = 0.960 [0.854-1.078]).

CONCLUSION

In Japanese patients experiencing OHCA, the prehospital use of LR solution was independently associated with a decreased likelihood of a good functional outcome 1 month after the event, but with an increased likelihood of ROSC before hospital arrival. Prehospital use of LR solution was not associated with 1-month survival. Further study is necessary to verify these findings. Please see later in the article for the Editors' Summary.

Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on survival of trauma victims

BACKGROUND

The Prehospital Trauma Life Support (PHTLS) course has been widely implemented and approximately half a million prehospital caregivers in over 50 countries have taken this course. Still, the effect on injury outcome remains to be established. The objective of this study was to investigate the association between PHTLS training of ambulance crew members and the mortality in trauma patients.

METHODS

A population-based observational study of 2830 injured patients, who either died or were hospitalized for more than 24 h, was performed during gradual implementation of PHTLS in Uppsala County in Sweden between 1998 and 2004. Prehospital patient records were linked to hospital-discharge records, cause-of-death records, and information on PHTLS training and the educational level of ambulance crews. The main outcome measure was death, on scene or in hospital.

RESULTS

Adjusting for multiple potential confounders, PHTLS training appeared to be associated with a reduction in mortality, but the precision of this estimate was poor (odds ratio, 0.71; 95% confidence interval, 0.42-1.19). The mortality risk was 4.7% (36/763) without PHTLS training and 4.5% (94/2067) with PHTLS training. The predicted absolute risk reduction is estimated to correspond to 0.5 lives saved annually per 100,000 population with PHTLS fully implemented.

CONCLUSIONS

PHTLS training of ambulance crew members may be associated with reduced mortality in trauma patients, but the precision in this estimate was low due to the overall low mortality. While there may be a relative risk reduction, the predicted absolute risk reduction in this population was low.

Resuscitation with hypertonic saline-dextran reduces serum biomarker levels and correlates with outcome in severe traumatic brain injury patients

In the treatment of severe traumatic brain injury (TBI), the choice of fluid and osmotherapy is important. There are practical and theoretical advantages to the use of hypertonic saline. S100B, neuron-specific enolase (NSE), and myelin-basic protein (MBP) are commonly assessed biomarkers of brain injury with potential utility as diagnostic and prognostic indicators of outcome after TBI, but they have not previously been studied in the context of fluid resuscitation. This randomized controlled trial compared serum concentrations of S100B, NSE, and MBP in adult severe TBI patients resuscitated with 250 mL of 7.5% hypertonic saline plus 6% dextran70 (HSD; n = 31) versus 0.9% normal saline (NS; n = 33), and examined their relationship with neurological outcome at discharge. Blood samples drawn on admission (<or=3 h post-injury), and at 12, 24, and 48 h post-resuscitation were assayed by ELISA for the selected biomarkers. Serial comparisons of biomarker concentrations were made by ANOVA, and relationships between biomarkers and outcome were assessed by multiple regression. On admission, mean (+/-SEM) S100B and NSE concentrations were increased 60-fold (0.73 +/- 0.08 microg/L) and sevenfold (37.0 +/- 4.8 microg/L), respectively, in patients resuscitated with NS, compared to controls (0.01 +/- 0.01 and 6.2 +/- 0.6, respectively). Compared with NS resuscitation, S100B and NSE were twofold and threefold lower in HSD-treated patients and normalized within 12 h. MBP levels were not significantly different from controls in either treatment arm until 48 h post-resuscitation, when a delayed increase (0.58 +/- 0.29 microg/L) was observed in NS-treated patients. Biomarkers were elevated in the patient group showing an unfavorable outcome. HSD-resuscitated patients with favorable outcomes exhibited the lowest serum S100B and NSE concentrations, while maximal levels were found in NS-treated patients with unfavorable outcomes. The lowest biomarker levels were seen in survivors resuscitated with HSD, while maximal levels were in NS-resuscitated patients with fatal outcome. Pre-hospital resuscitation with HSD is associated with a reduction in serum S100B, NSE, and MBP concentrations, which are correlated with better outcome after severe TBI.

Pro/con debate: is the scoop and run approach the best approach to trauma services organization?

You are asked to be involved in organizing a trauma service for a major urban center. You are asked to make a decision on whether the services general approach to trauma in the city (which does have a well-established trauma center) will be scoop and run (minimal resuscitation at the scene with a goal to getting the patient to a trauma center as quickly as possible) or on-the-scene resuscitation with transfer following some degree of stabilization.