Cervical spine fractures in elderly patients with hip fracture after low-level fall: an opportunity to refine prehospital spinal immobilization guidelines?

Re-contact rates with a UK ambulance service following paramedic referral to a falls prevention service for those aged ≥ 65 years: a retrospective cohort study

Background

Falls in older populations constitute a large proportion of the workload for UK ambulance services, and cost the NHS over £2.3 billion per year. A large proportion of older fallers are not conveyed to an emergency department (ED), representing a vulnerable group of patients. New pathways have been developed for paramedics to refer this group directly to falls prevention services.

Objectives

This study aimed to investigate the re-contact rates and characteristics of service users aged ≥ 65 years who fell and were referred to a falls prevention service by paramedics, and to describe the characteristics of those who re-contacted the ambulance service after referral.

Methods

A retrospective cross-sectional cohort study was carried out in the geographical area covered by the South Eastern division of the Northern Ireland Ambulance Service (NIAS) between 1 July and 30 September 2017. The primary outcome was the rate of subsequent contacts with the ambulance service following referral.

Results

There were 1079 incidents of falls in service users aged ≥ 65 years. A referral rate of 7% (n = 75) was reported, constituting the study cohort. Re-contact rates were 37.3% (n = 28) within 1 month and 70.7% (n = 53) within 6 months. Women and those exposed to a 'long lie' were more likely to re-contact, while those with cognitive impairment appeared particularly vulnerable to falls and repeat falls. Repeat falls were common. Documentation by attending clinicians was generally poor.

Conclusion

Future research should investigate the efficacy of paramedic referral to falls prevention services. Interventions targeted at reducing long lies and investigating optimal interventions for those with cognitive impairments should also be explored. Improving clinical documentation will facilitate future research.

Advanced mobile prehospital nursing care for elderly people post-trauma: integrative review

OBJECTIVE

to identify scientific evidences available on the literature on nursing interventions on advanced mobile prehospital care for elderly people post-trauma.

METHOD

an integrative review of literature on the databases PubMed, CINAHL, and LILACS, from 2012 to 2017.

RESULTS

a sample composed by 26 studies, grouped into six thematic categories: circulation with hemorrhage control (n=11); dysfunction, neurological state (n=7); airway with protection of the cervical spine (n=3); secondary evaluation (n=3); ventilation and breathing (n=1), and environment exposition/control (n=1).

CONCLUSION

Despite having identified nursing interventions, there was no description of specific nursing interventions related to advanced mobile prehospital care for elderly people post-trauma.

Distracting injury defined: does an isolated hip fracture constitute a distracting injury for clearance of the cervical spine?

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.

The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury

The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.

Cervical spine fractures in elderly patients with hip fracture after low-level fall: an opportunity to refine prehospital spinal immobilization guidelines?

BACKGROUND

Conventional prehospital spine-assessment approaches based on low index of suspicion and mechanism of injury (MOI) result in the liberal application of spinal immobilization in trauma patients. A painful distracting injury (DI), such as a suspected hip fracture, historically has been a sufficient condition for immobilization, even in an elderly patient who suffers a simple fall from standing and exhibits no other risk factors for spinal injury. Because the elderly are at increased risk of hip fracture from low-level falls, and are also particularly susceptible to the discomfort and morbidity associated with immobilization, the prevalence of cervical spine (c-spine) fracture in this patient population was examined.

METHODS

Hospital billing records were used to identify all cases of traumatic femur fracture in Minnesota (USA) in 2010-2011. Concurrent diagnosis and external cause codes were used to estimate the prevalence of c-spine fracture by age and MOI.

RESULTS

Among 1,394 patients with femur fracture, 23 (1.7%) had a c-spine fracture. When the MOI was a fall from standing or sitting height and the patient age was ≥ 65, the prevalence dropped to 0.4% (2/565). The prevalence was similar when the definition of hip fracture additionally included pelvis fractures (0.5%; 11/2,441). Eight of the 11 patients with c-spine fracture had diagnosis codes indicative of criteria other than the DI that likely would have resulted in immobilization (eg, head injury and compromised mental status).

CONCLUSIONS

C-spine fracture is extremely rare in elderly patients who sustain hip fracture as a result of a low-level fall, and appears to be accompanied frequently by other known predictors of spinal injury besides DI. More research is needed to determine whether conservative use of spinal immobilization may be warranted in elderly patients with hip fracture after low-level falls when the only criteria for immobilization is the distracting hip injury.