Current spinal board usage in emergency departments across the UK

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

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

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

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

Evidence-based practice: best imaging practice in musculoskeletal disorders

As musculoskeletal disorders are a common cause of emergency department visits in the United States, it is vital for nurses and nurse practitioners to understand the decision rules for ordering imaging tests when triaging patients with musculoskeletal complaints. Proper knowledge and command of selecting the most appropriate imaging for these frequent emergency department presentations will help reduce costs, decrease ionizing radiation exposure, and increase patient throughput. This article reviews the current evidence-based literature for musculoskeletal imaging in the emergency department and discusses the epidemiology, etiology, management, and prevention of the most common musculoskeletal disorders.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

Spinal cord injury management and rehabilitation: highlights and shortcomings from the 2005 earthquake in Pakistan

Recent natural disasters have highlighted the lack of planning for rehabilitation and disability management in emergencies. A review of our experience with spinal cord injury (SCI) after the Pakistan earthquake of 2005, plus a review of other literature about SCI after natural disasters, shows that large numbers of people will incur SCIs in such disasters. The epidemiology of SCI after earthquakes has not been well studied and may vary with location, severity of the disaster, available resources, the expertise of the health care providers, and cultural issues. A lack of preparedness means that evacuation protocols, clinician training, dedicated acute management and rehabilitation facilities, specialist equipment, and supplies are not in place. The dearth of rehabilitation medicine specialists in developing regions further complicates the issue, as does the lack of national spinal cord registries. In our 3 makeshift SCI units, however, which are staffed by specialists and residents in rehabilitation medicine, there were no deaths, few complications, and a successful discharge for most patients. Technical concerns include air evacuation, early spinal fixation, aggressive management to optimize bowel and bladder care, and provision of appropriate skin care. Discharge planning requires substantial external support because SCI victims must often return to devastated communities and face changed vocational and social possibilities. Successful rehabilitation of victims of the Pakistan earthquake has important implications. The experience suggests that dedicated SCI centers are essential after a natural disaster. Furthermore, government and aid agency disaster planners are advised to consult with rehabilitation specialists experienced in SCI medicine in planning for the inevitable large number of people who will have disabilities after a natural disaster.

A repeat audit of spinal board usage in the emergency department

An audit of spinal board usage in 2002 was repeated [Malik MHA, Lovell ME. Current spinal board usage in emergency departments across the UK. Int J Care Injured 2003;34:327-9]. It is acknowledged that this device should be used for extrication and transport, with usual removal after the primary survey. This repeat audit was carried out to try and discover whether there have been changes regarding the use of spinal boards since its publication. We found improvements have been made in some areas including the removal of patients from boards with 21% now removing patients immediately (5% previously) and 58% removing patients following clearance on the lumbar and thoracic spine by a senior clinician after log roll (52% previously). In 2006, 21% (43% previously) are still leaving patients on spinal boards routinely until radiological evidence provides clearance, 45% will place patients on boards after their arrival even if they were not on one in pre-hospital management (48% previously) and the number of boards the department owns, remained similar. In house audits of usage remained largely unchanged at 22%. We recommend ongoing departmental review of practice.

Reduced time on the spinal board-effects of guidelines and education for emergency department staff

AIM

Prehospital spinal immobilisation is usually accomplished with a spinal board. Prolonged immobilisation on spinal boards in the emergency department (ED) can be detrimental. This study aimed to reduce the time spent by patients on spinal boards using a staff education program.

METHODS

Observational study in a trauma centre ED seeing 180,000ED attendances per year. The length of time immobilised on spinal board was recorded by the trauma nurse coordinator. Guidelines on removal of spinal boards were issued after recording period 1 (January-June 2001) and reinforced several times. The post-training period (period 2) extended from May to October 2003. Medians were compared using Mann-Whitney U-test (non-parametric data); chi-square test was used for categorical data.

RESULTS

There were 122 eligible patients in period 1 and 104 eligible patients in period 2. Median time to removal from the spinal board was reduced by 18.5 min from 50 to 31.5 min (Mann-Whitney U-test, p<0.0001, 95% CI for difference in medians 13-29 min). In period 1, 44 of 122 patients (36%) were removed from the spinal board before leaving the ED, compared to 78 of 104 patients (75%) in period 2 (p<0.0001, chi-square test).

CONCLUSION

The introduction of guidelines, reinforced by ED staff education, can significantly reduce the time patients spend on spinal boards after trauma and can increase the proportion of patients who can be removed from the board before leaving the ED.