1
|
Breindahl N, Bierens JLM, Wiberg S, Barcala-Furelos R, Maschmann C. Prehospital guidelines on in-water traumatic spinal injuries for lifeguards and prehospital emergency medical services: an international Delphi consensus study. Scand J Trauma Resusc Emerg Med 2024; 32:76. [PMID: 39180135 PMCID: PMC11344453 DOI: 10.1186/s13049-024-01249-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 08/16/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Trauma guidelines on spinal motion restriction (SMR) have changed drastically in recent years. An international group of experts explored whether consensus could be reached and if guidelines on SMR performed by trained lifeguards and prehospital EMS following in-water traumatic spinal cord injury (TSCI) should also be changed. METHODS An international three-round Delphi process was conducted from October 2022 to November 2023. In Delphi round one, brainstorming resulted in an exhaustive list of recommendations for handling patients with suspected in-water TSCI. The list was also used to construct a preliminary flowchart for in-water SMR. In Delphi round two, three levels of agreement for each recommendation and the flowchart were established. Recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three; recommendations with moderate consensus (75-85% agreement) underwent major revisions in two consecutive phases; and recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2. RESULTS Twenty-four experts participated in Delphi round one. The response rates for Delphi rounds two and three were 92% and 88%, respectively. The study resulted in 25 recommendations and one flowchart with four flowchart paths; 24 recommendations received strong consensus (≥ 85%), and one recommendation received moderate consensus (81%). Each of the four paths in the flowchart received strong consensus (90-95%). The integral flowchart received strong consensus (93%). CONCLUSIONS This study produced expert consensus on 25 recommendations and a flowchart on handling patients with suspected in-water TSCI by trained lifeguards and prehospital EMS. These results provide clear and simple guidelines on SMR, which can standardise training and guidelines on SMR performed by trained lifeguards or prehospital EMS.
Collapse
Affiliation(s)
- Niklas Breindahl
- Prehospital Center Region Zealand, Ringstedgade 61, 13, 4700, Næstved, Denmark.
- Department of Neonatal and Pediatric Intensive Care, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
- International Life Saving Federation, Leuven, Belgium.
- International Drowning Researchers' Alliance, Kuna, ID, USA.
| | - Joost L M Bierens
- International Life Saving Federation, Leuven, Belgium
- International Drowning Researchers' Alliance, Kuna, ID, USA
- Extreme Environments Laboratory, School of Sport, Health and Exercise Science, University of Portsmouth, Portsmouth, UK
| | - Sebastian Wiberg
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Roberto Barcala-Furelos
- International Life Saving Federation, Leuven, Belgium
- International Drowning Researchers' Alliance, Kuna, ID, USA
- REMOSS Research Group, Faculty of Education and Sports Sciences, Universidade de Vigo, Pontevedra, Spain
| | - Christian Maschmann
- Department of Emergency Medicine NFZ, Cantonal Hospital St. Gallen, Gallen, Switzerland
| |
Collapse
|
2
|
Martin C, Spies V. [Gunshot Wounds and Penetrating Injuries]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:253-263. [PMID: 37044109 DOI: 10.1055/a-1734-7221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
The acute medical care in Germany after gunshot and stab wounds in the pre-hospital and in-hospital setting is a rarity in an international comparison. The resulting lack of routine in the acute care of critically injured people after penetrating trauma should therefore be countered with regular theoretical and practical training. In addition to standardized care algorithms for the care of severely injured people, knowledge of kinetics and wound ballistics is required for focused treatment. The article focuses mainly on the early treatment phase.
Collapse
|
3
|
Häske D, Blumenstock G, Hossfeld B, Wölfl C, Schweigkofler U, Stock JP. The Immo Traffic Light System as a Decision-Making Tool for Prehospital Spinal Immobilization. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:753-758. [PMID: 35978468 PMCID: PMC9853232 DOI: 10.3238/arztebl.m2022.0291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 01/24/2022] [Accepted: 07/21/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Spinal injuries are difficult injuries to assess yet can be associated with significant neurological damage. To avoid secondary damage, immobilization is considered state of the art trauma care. The indication for spinal immobilization must be assessed, however, for potential complications as well as its advantages and disadvantages. METHODS This systematic review addressing the question of the correct indication for spinal immobilization in trauma patients was compiled on the basis of our previously published analysis of possible predictors from the Trauma Registry of the German Society for Trauma Surgery. A Delphi procedure was then used to develop suggestions for action regarding immobilization based on the results of this review. RESULTS The search of the literature yielded 576 publications. The 24 publications included in the qualitative analysis report of 2 228 076 patients. A decision tool for spinal immobilization in prehospital trauma care was developed (Immo traffic light system) based on the results of the Delphi procedure. According to this system, severely injured patients with blunt trauma, severe traumatic brain injury, peripheral neurological symptoms, or spinal pain requiring treatment should be immobilized. Patients with a statistically increased risk of spinal injury as a result of the four cardinal features (fall >3m, severe trunk injury, supra clavicular injury, seniority [age >65 years]) should only have their spinal motion restricted after weighing up the pros and cons. Isolated penetrating trunk injuries should not be immobilized. CONCLUSION High-quality studies demonstrating the benefit of prehospital spinal immobilization are still lacking. Decision tools such as the Immo traffic light system can help weigh up the pros and cons of immobilization.
Collapse
Affiliation(s)
- David Häske
- Center for Public Health and Health Services Research, University Hospital of Tübingen, and German Red Cross Emergency Services Reutlingen,*Center for Public Health and Health Services Research University Hospital of Tübingen Osianderstr. 5 72076 Tübingen, Germany
| | - Gunnar Blumenstock
- Institute of Clinical Epidemiology and Applied Biometry, University Hospital of Tübingen
| | - Björn Hossfeld
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Federal Armed Forces Hospital of Ulm
| | - Christoph Wölfl
- Department for Orthopedic Surgery, Trauma and Sports Traumatology – Hand and Plastic Surgery, Musculoskeletal Center Neuwied, Marienhaus Hospital Neuwied
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Trauma Center, Frankfurt am Main
| | - Jan-Philipp Stock
- Department for Anesthesiology, Intensive Care Medicine, Emergency Medicine, Pain Therapy and Palliative Care, am Steinenberg Hospital, Reutlingen: Jan-Philipp Stock
| |
Collapse
|
4
|
Habermehl N, Minich NM, Malay S, Mahran A, Kim G. Pediatric Thoracolumbar Spinal Injuries in United States Trauma Centers. Pediatr Emerg Care 2022; 38:e876-e880. [PMID: 33848099 DOI: 10.1097/pec.0000000000002427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Injuries are the leading cause of morbidity and mortality in children ages 1 to 18 years. There are limited studies about pediatric thoracolumbar (TL) spinal injuries; the purpose of this study was to characterize TL spinal injuries among pediatric patients evaluated in US trauma centers. METHODS This was a retrospective cohort study of the National Trauma Data Bank. Patients aged 1 to 18 years with a thoracic or lumbar spinal injury sustained by blunt trauma during calendar years 2011 through 2016 were included. Cervical spinal injuries, death before arrival, or penetrating trauma were excluded. The data was abstracted, and missing data was addressed by imputations. Data was analyzed using descriptive statistics and multinomial logistic regressions. RESULTS A total of 20,062 patients were included in the study. Thoracolumbar spinal injuries were more commonly sustained by 16- to 17-year-olds (45.7%), boys (56.6%), and White (74.8%). The injuries were often from a motor vehicle collision (MVC) (55.2%) and resulted in a bone injury (82.3%). Mechanism of injury and age were significant in predicting injury type. A fall was more likely than MVC to result in disc injury (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.24-2.33), strain injury (OR, 1.18; 95% CI, 1.05-1.34), or cord injury (OR, 1.27; 95% CI, 1.12-1.45). Younger children were more likely than adolescents to present with disc injury (OR, 2.79; 95% CI, 1.75-4.45), cord injury (OR, 1.46; 95% CI, 1.18-1.81), or strain injury (OR, 1.37; 95% CI, 1.09-1.72). CONCLUSIONS To our knowledge, this is the largest pediatric TL spinal study. Clinicians should consider TL spinal injuries when adolescents present after an MVC, and specifically, TL spinal cord injuries when young children present after a fall. Additionally, pediatric TL spinal injury prevention should highlight motor vehicle and fall safety.
Collapse
Affiliation(s)
- Nikita Habermehl
- From the Division of Pediatric Emergency Medicine, Rainbow Babies & Children's Hospital
| | - Nori Mercuri Minich
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sindhoosha Malay
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Amr Mahran
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
| | | |
Collapse
|
5
|
Evidenzbasierte Empfehlung aus Dänemark zur Wirbelsäulenimmobilisation beim erwachsenen Traumapatienten. Notf Rett Med 2020. [DOI: 10.1007/s10049-020-00717-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
6
|
Hill GP, Dean T, Muller A, Martin AP, Sigal AP, Fernandez FB, Ong AW. Noncontiguous Spine Injury: Is the Risk Increased in Low-Energy Falls? Am Surg 2020; 87:1989-1991. [PMID: 32683943 DOI: 10.1177/0003134820934414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Georgia P Hill
- Division of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, PA, USA.,6556 Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Tameka Dean
- 6556 Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Alison Muller
- Division of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, PA, USA
| | - Anthony P Martin
- Division of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, PA, USA
| | - Adam P Sigal
- 35355 Department of Emergency Medicine, Reading Hospital, Reading, PA, USA
| | - Forrest B Fernandez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, PA, USA
| | - Adrian W Ong
- Division of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, PA, USA
| |
Collapse
|
7
|
Maschmann C, Jeppesen E, Rubin MA, Barfod C. New clinical guidelines on the spinal stabilisation of adult trauma patients - consensus and evidence based. Scand J Trauma Resusc Emerg Med 2019; 27:77. [PMID: 31426850 PMCID: PMC6700785 DOI: 10.1186/s13049-019-0655-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/06/2019] [Indexed: 12/13/2022] Open
Abstract
Traumatic spinal cord injury is a relatively rare injury in Denmark but may result in serious neurological consequences. For decades, prehospital spinal stabilisation with a rigid cervical collar and a hard backboard has been considered to be the most appropriate procedure to prevent secondary spinal cord injuries during patient transportation. However, the procedure has been questioned in recent years, due to the lack of high-quality studies supporting its efficacy. A national interdisciplinary task force was therefore established to provide updated clinical guidelines on prehospital procedures for spinal stabilisation of adult trauma patients in Denmark. The guidelines are based on a systematic review of the literature and grading of the evidence, in addition to a standardised consensus process.This process yielded five main recommendations:A strong recommendation against spinal stabilisation of patients with isolated penetrating trauma; a weak recommendation against the prehospital use of a rigid cervical collar and a hard backboard for ABCDE-stable patients; and a weak recommendation for the use of a vacuum mattress for patient transportation. Finally, our group recommends the use of our clinical algorithm to ensure good clinical practice.
Collapse
Affiliation(s)
- Christian Maschmann
- Emergency Department, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Department of Anesthesiology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Emergency Medical Services Copenhagen, University Copenhagen, Copenhagen, Denmark
| | - Elisabeth Jeppesen
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Health Science, University of Stavanger, Stavanger, Norway
| | - Monika Afzali Rubin
- Cochrane Anesthesia & Cochrane Critical and Emergency Care Group, Copenhagen, Denmark
- Department of Anesthesiology, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - Charlotte Barfod
- Emergency Medical Services Copenhagen, University Copenhagen, Copenhagen, Denmark
| |
Collapse
|
8
|
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]
|
9
|
Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging. J Emerg Med 2018; 56:153-165. [PMID: 30598296 DOI: 10.1016/j.jemermed.2018.10.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 10/16/2018] [Accepted: 10/25/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging. OBJECTIVE Our aim was to quantify the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients. METHODS A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2 × 2 tables, were duplicates, were not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios. RESULTS In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1-152.2; I2 = 94%; p < 0.001) and negative likelihood ratio (-LR) = 0.43 (95% CI 0.32-0.59; I2 = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1-467.9; I2 = 87%; p < 0.001) and -LR = 0.04 (95% CI 0.02-0.08; I2 = 23%; p = 0.26). CONCLUSIONS CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.
Collapse
|
10
|
Lam C, Chen PL, Kang JH, Cheng KF, Chen RJ, Hung KS. Risk factors for 14-day rehospitalization following trauma with new traumatic spinal cord injury diagnosis: A 10-year nationwide study in Taiwan. PLoS One 2017; 12:e0184253. [PMID: 28863195 PMCID: PMC5581159 DOI: 10.1371/journal.pone.0184253] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 08/21/2017] [Indexed: 11/24/2022] Open
Abstract
Objectives Fourteen-day rehospitalization with new traumatic spinal cord injury (tSCI) diagnosis is used as an indicator for the diagnostic quality of the first hospitalization. In this nationwide population-based cohort study, we identified risk factors for this indicator. Methods We conducted a nested case–control study by using the data of patients who received a first hospitalization for trauma between 2001 and 2011. The data were retrieved from Taiwan’s National Health Insurance Research Database. Variables including demographic and trauma characteristics were compared between patients diagnosed with tSCI at the first hospitalization and those receiving a 14-day rehospitalization with new tSCI diagnosis. Results Of the 23 617 tSCI patients, 997 had 14-day rehospitalization with new tSCI diagnosis (incidence rate, 4.22%). The risk of 14-day rehospitalization with new tSCI diagnosis was significantly lower in patients with severe (injury severity score [ISS] = 16–24; odds ratio [OR], 0.17; 95% confidence interval [CI], 0.13–0.21) and profound (ISS > 24; OR, 0.11; 95% CI, 0.07–0.18) injuries. Interhospital transfer (OR, 8.20; 95% CI, 6.48–10.38) was a significant risk factor, along with injuries at the thoracic (OR, 1.62; 95% CI, 1.21–2.18), lumbar (OR, 1.30; 95% CI, 1.02–1.65), and multiple (OR, 3.23; 95% CI, 1.86–5.61) levels. Brain (OR, 2.82), chest (OR, 2.99), and abdominal (OR, 2.74) injuries were also identified as risk factors. In addition, the risk was higher in patients treated at the orthopedic department (OR, 2.26; 95% CI, 1.78–2.87) and those of other surgical disciplines (OR, 1.89; 95% CI, 1.57–2.28) than in those treated at the neurosurgery department. Conclusions Delayed tSCI diagnoses are not uncommon, particularly among trauma patients with ISSs < 16 or those who are transferred from lower-level hospitals. Further validation and implementation of evidence-based decision rules is essential for improving the diagnostic quality of traumatic thoracolumbar SCI.
Collapse
Affiliation(s)
- Carlos Lam
- Emergency Department, Department of Emergency and Critical Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ping-Ling Chen
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Jiunn-Horng Kang
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuang-Fu Cheng
- Biostatistics Center, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Ray-Jade Chen
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
- * E-mail: (RJC); (KSH)
| | - Kuo-Sheng Hung
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
- Department of Neurosurgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- * E-mail: (RJC); (KSH)
| |
Collapse
|
11
|
Oosterwold JT, Sagel DC, van Grunsven PM, Holla M, de Man-van Ginkel J, Berben S. The characteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study. Eur J Trauma Emerg Surg 2017; 43:513-524. [PMID: 27277072 PMCID: PMC5533828 DOI: 10.1007/s00068-016-0688-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 05/28/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pre-hospital spinal immobilisation by emergency medical services (EMS) staff is currently the standard of care in cases of suspected spinal column injuries. There is, however, a lack of data on the characteristics of patients who received spinal immobilisation during the pre-hospital phase and on the adverse effects of immobilisation. The objectives of this study were threefold. First, we determined the pre-hospital characteristics of blunt trauma patients with suspected spinal column injuries who were immobilised by EMS staff. Second, we assessed the choices made by EMS staff regarding spinal immobilisation techniques and reasons for immobilisation. Third, we researched the possible adverse effects of immobilisation. DESIGN A retrospective observational study in a cohort of blunt trauma patients. STUDY METHOD Data of blunt trauma patients with suspected spinal column injuries were collected from one EMS organisation between January 2008 and January 2013. Coded data and free text notes were analysed. RESULTS A total of 1082 patients were included in this study. Spinal immobilisation was applied in 96.3 % of the patients based on valid pre-hospital criteria. In 2.1 % of the patients immobilisation was not based on valid criteria. Data of 1.6 % patients were missing. Main reasons for spinal immobilisation were posterior midline spinal tenderness (37.2 % of patients) and painful distracting injuries (13.5 % of patients). Spinal cord injury (SCI) was suspected in 5.7 % of the patients with posterior midline spinal tenderness. A total of 15.8 % patients were immobilised using non-standard methods. The reason for departure from the standard method was explained for 3 % of these patients. Reported adverse effects included pain (n = 10, 0.9 %,); shortness of breath (n = 3, 0.3 %); combativeness or anxiety (n = 6, 0.6 %); and worsening of pain when supine (n = 1, 0.1 %). CONCLUSION/RECOMMENDATION Spinal immobilisation was applied in 96.3 % of all included patients based on pre-hospital criteria. We found that consensus among EMS staff on how to interpret the criterion 'distracting injury' was lacking. Furthermore, the adverse effects of spinal immobilisation were incompletely documented in pre-hospital care reports. To provide validated information on potential symptoms of SCI, a uniform EMS scoring system for motoric assessment should be developed.
Collapse
Affiliation(s)
- J T Oosterwold
- School of Nursing and Health, University Medical Centre Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
- Ambulance Department, University Medical Centre Groningen, Roden, The Netherlands.
| | - D C Sagel
- Ambulance Department, University Medical Centre Groningen, Roden, The Netherlands
| | - P M van Grunsven
- Ambulance Emergency Medical Service Gelderland-Zuid, Nijmegen, The Netherlands
| | - M Holla
- Department of Orthopaedic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J de Man-van Ginkel
- Department of Rehabilitation, Nursing Science and Sports, University Medical Centre Utrecht, Utrecht, The Netherlands
- Faculty of Medicine, Clinical Health Sciences, Utrecht University, Utrecht, The Netherlands
| | - S Berben
- Eastern Regional Emergency Healthcare Network & IQ Scientific Centre for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Critical and Emergency Care, Knowledge Centre of Sustainable Healthcare, HAN University of Applied Sciences, Nijmegen, The Netherlands
| |
Collapse
|
12
|
Clinical Judgment Is Not Reliable for Reducing Whole-body Computed Tomography Scanning after Isolated High-energy Blunt Trauma. Anesthesiology 2017; 126:1116-1124. [DOI: 10.1097/aln.0000000000001617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Background
The purpose of this study was to test the diagnostic performance of clinical judgment for the prediction of a significant injury with whole-body computed tomography scanning after high-energy trauma.
Methods
The authors conducted an observational prospective study in a single level-I trauma center. Adult patients were included if they had an isolated high-energy injury. Senior trauma leaders were asked to make a clinical judgment regarding the likelihood of a significant injury before performance of a whole-body computed tomography scan. Clinical judgments were recorded using a probability diagnosis scale. The primary endpoint was the diagnosis of a serious-to-critical lesion on the whole-body computed tomography scan. Diagnostic performance was assessed using receiver operating characteristic analysis.
Results
Of the 354 included patients, 127 patients (36%) had at least one injury classified as abbreviated injury score greater than or equal to 3. The area under the receiver operating characteristic curve of the clinical judgment to predict a serious-to-critical lesion was 0.70 (95% CI, 0.64 to 0.75%). The sensitivity of the clinical judgment was 82% (95% CI, 74 to 88%), and the specificity was 49% (95% CI, 42 to 55%). No patient with a strict negative clinical examination had a severe lesion (n = 19 patients). The sensitivity of the clinical examination was 100% (95% CI, 97 to 100%) and its specificity was 8% (95% CI, 5 to 13%).
Conclusions
Clinical judgment alone is not sufficient to reduce whole-body computed tomography scan use. In patients with a strictly normal physical examination, whole-body computed tomography scanning might be avoided, but this result deserves additional study in larger and more diverse populations of trauma patients.
Collapse
|
13
|
Carter AW, Jacups SP, Ackland HM, Wright A, Lawson A, Armit D, Mooney R. Spinal clearance practices at a regional Australian hospital: A window to major trauma management performance outside metropolitan trauma centres. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2017. [DOI: 10.5339/jemtac.2017.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Prevention of secondary spinal injury via spinal protection measures is a standard component of trauma management, and a high-quality spinal clearance process is imperative in achieving this aim. To evaluate the current practice with a view to achieving best practice, we sought to examine the spinal clearance process and outcomes at a regional Australian referral hospital, which services a large geographical catchment area. Methods: A retrospective review of medical records of all patients with major trauma who presented to an Australian regional hospital during 2014 was conducted. The primary outcome measure was missed or delayed diagnosis of spinal injury. Secondary outcome measures included compliance with internationally accepted spinal clearance process measures, timing and choice of appropriate imaging modalities, rates of spinal injury and documentation of spinal clearance. Results: Of the 112 patients with major trauma who met the study eligibility criteria and were discharged from hospital during the study period from 1 January to 31 December 2014, 11 spinal injuries were missed or delayed in diagnosis. The injuries occurred in 3.6% of patients and all were thoracolumbar spine (TLS) injuries. The predominant reasons for missed or delayed diagnosis were reduced sensitivity of plain X-ray compared with computed tomography for spinal injury screening and incomplete full spinal imaging to detect non-contiguous fractures. Conclusion: Evidence-based clinical decision rules are imperative in ascertaining the need for imaging in the TLS and would be enhanced by an internationally recognised definition of clinical significance based on injury morphology rather than clinician management decision alone. In addition, regional hospitals may have limited capacity to achieve spinal clearance, and other trauma quality assurance standards commensurate with national and international benchmarks without the valuable performance feedback provided by state trauma registries, as is currently the case in Queensland.
Collapse
Affiliation(s)
- Angus W. Carter
- 1Intensive Care Department, Cairns Hospital, Queensland, Australia
| | - Susan P. Jacups
- 1Intensive Care Department, Cairns Hospital, Queensland, Australia
- 2The Cairns Institute, James Cook University, Cairns, Queensland, Australia
| | - Helen M. Ackland
- 3Intensive Care Department, The Alfred Hospital, Melbourne, Australia
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 5Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Wright
- 6Department of Anaesthesia and Perioperative Medicine, Cairns Hospital, Queensland, Australia
| | - Amy Lawson
- 7Department of Surgery, Cairns Hospital, Queensland, Australia
| | - Drew Armit
- 8Department of Orthopaedic Surgery, Cairns Hospital, Queensland, Australia
| | - Richard Mooney
- 9Department of Emergency Medicine, Cairns Hospital, Queensland, Australia
| |
Collapse
|