Patient experience of spinal immobilisation after trauma

The relationship between acute pain and other types of suffering in pre-hospital trauma victims: An observational study

BACKGROUND

Acute pain is an important complaint reported by trauma victims, however, the relationship between it and other types of discomfort, such as discomfort caused by cold, discomfort caused by immobilization, and psychological distress such as fear, anxiety, and sadness is limitedly studied and documented.

AIM

To assess the relationship between acute trauma pain and other types of suffering in pre-hospital trauma victims.

METHODS

This is a prospective multicentre cohort study conducted in Immediate Life Support Ambulances in Portugal. All adult trauma victims with a mechanism of blunt and penetrating injuries, falls, road accidents and explosions, were included.

RESULTS

605 trauma victims were included, mainly male, with a mean age of 53.4 years. Before the intervention of the rescue teams, 90.5 % of the victims reported some level of pain, 39.0 % reported discomfort caused by cold, while 15.7 % felt fear, 8.4 % sadness, 49.8 % anxiety and 4.5 % apathy. Victims with high discomfort caused by cold tend to have higher pain levels. Significantly higher pain intensity were observed in victims with fear and anxiety. Univariate and multivariate analysis indicates that immobilization is associated with increased pain levels.

CONCLUSIONS

There is a statistically significant relationship between acute trauma pain, anxiety, fear, cold and immobilization.

Recent advances in lipid nanovesicles for targeted treatment of spinal cord injury

The effective regeneration and functional restoration of damaged spinal cord tissue have been a long-standing concern in regenerative medicine. Treatment of spinal cord injury (SCI) is challenging due to the obstruction of the blood-spinal cord barrier (BSCB), the lack of targeting of drugs, and the complex pathophysiology of injury sites. Lipid nanovesicles, including cell-derived nanovesicles and synthetic lipid nanovesicles, are highly biocompatible and can penetrate BSCB, and are therefore effective delivery systems for targeted treatment of SCI. We summarize the progress of lipid nanovesicles for the targeted treatment of SCI, discuss their advantages and challenges, and provide a perspective on the application of lipid nanovesicles for SCI treatment. Although most of the lipid nanovesicle-based therapy of SCI is still in preclinical studies, this low immunogenicity, low toxicity, and highly engineerable nanovesicles will hold great promise for future spinal cord injury treatments.

Cervical Collar Clearance in Obtunded Children Presenting Without a Known Traumatic Mechanism: Is Imaging Necessary?

BACKGROUND

Obtunded pediatric patients are often placed in cervical collars (c-collars) to protect their cervical spine (c-spine) while injury is being ruled out, even without a known traumatic injury. The goal of this study was to determine the necessity of c-collars in this population by determining the rate of c-spine injury among patients with suspected non-traumatic mechanisms of loss of consciousness.

METHODS

A single institution, ten-year retrospective chart review was conducted including all obtunded patients admitted to the Pediatric Intensive Care Unit without a known traumatic event. Patients were categorized into five groups based on etiology of obtundation: respiratory, cardiac, medical/metabolic, neurologic, and other. Comparisons were made between those placed in a c-collar and a control group who were not, using Wilcoxon rank sum test for continuous measures, and Chi-square or Fisher's exact test for categorical measures.

RESULTS

464 patients were included, of which 39 (8.41%) were placed in a c-collar. There was a significant difference in whether a patient was placed in a c-collar based on diagnosis category (p < 0.001). Those placed in a-c-collar were more likely to undergo imaging studies than the control group (p < 0.001). The overall incidence of c-spine injury in this patient population in our study was zero.

CONCLUSION

Cervical collar placement and radiographic evaluation is not necessary in obtunded pediatric patients who present without a known traumatic mechanism as the overall risk of injury is low. Consideration for collar placement should be given in cases when trauma cannot be definitively ruled out at initial evaluation.

LEVELS OF EVIDENCE

III.

Cervical immobilization in trauma patients: soft collars better than rigid collars? A systematic review and meta-analysis

INTRODUCTION

Rigid cervical spine following trauma immobilization is recommended to reduce neurological disability and provide spinal stability. Soft collars have been proposed as a good alternative because of the complications related to rigid collars. The purpose of this study was to perform a systematic review on soft and rigid collars in the prehospital management of cervical trauma.

METHOD

A systematic review was performed following the PRISMA guidelines. Search terms were (immobilization) AND (collar) AND ((neck) OR (cervical)) to evaluate the range of motion (ROM) and evidence of clinical outcome for soft and rigid collars.

RESULTS

A total of 18 studies met eligibility criteria including 2 clinical studies and 16 articles investigating the range of motion (ROM). Four hundred and ninety-six patients at a mean age of 32.5 years (SD 16.8) were included. Measurements were performed in a seated position in twelve studies. Eight articles reported the ROM without a collar, 7 with a soft collar, and 15 with a rigid collar. There was no significant difference in flexion/extension, bending and rotation following immobilization with soft collars compared to no collar. Rigid collars provided significantly higher stability compared to no collar (p < 0.005) and to soft collars in flexion/extension and rotation movements (p < 0.05). The retrospective clinical studies showed no significant differences in secondary spinal cord injuries for soft collar (0.5%) and for rigid collar (1.1%). One study, comparing immobilization without a collar compared to that with a rigid collar, found a significant difference in neurologic deficiency and supraclavicular nerve lesion.

CONCLUSION

Although rigid collars provide significant higher stability to no collar and to soft collars in flexion/ extension and rotation movements, clinical studies could not confirm a difference in neurological outcome.

LEVEL OF EVIDENCE

II, Systematic Review.

The Impact of Prehospital Spinal Immobilization in Patients with Penetrating Spinal Injuries: A Systematic Review and Meta-Analysis

Penetrating injuries, such as gunshot or stab wounds, may cause spinal cord injuries and require prehospital spinal immobilization (PHSI) to stabilize the spine. However, the use of PHSI in penetrating spinal injuries remains controversial. This systematic review aimed to investigate the efficacy of prehospital PHSI in patients with penetrating trauma. We systematically searched Google Scholar, Medline (PubMed), The Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE between January 2000 and July 2021. All studies in English that assessed PHSI in patients (>16 years) with penetrating spinal injuries were included. Quality and risk of bias assessments were performed using the modified Newcastle-Ottawa scale. A narrative synthesis and a meta-analysis was conducted. Our search identified 928 studies but only 6 met our inclusion and exclusion criteria. All of the included studies were conducted in the US and the number of patients ranged from 156–75,567 over 3–9 study years. The majority of patients were gunshot or stab wounds. Three studies demonstrated an increased risk of mortality with spinal collars whilst the remaining three studies failed to show any benefits or the benefits remained unproven. All studies were retrospective studies with some risks of bias. This review highlights that the evidence from the literature on PHSI in penetrating trauma outweigh its benefits; thus, its use is discouraged in penetrating spinal trauma. However, further high-quality research is necessary to reach definitive conclusions and to possibly identify suitable alternatives to PHSI for penetrating spinal trauma.

European Resuscitation Council Guidelines 2021: First aid

The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.

Vacuum mattress or long spine board: which method of spinal stabilisation in trauma patients is more time consuming? A simulation study

BACKGROUND

Spinal stabilisation is recommended for prehospital trauma treatment. In Germany, vacuum mattresses are traditionally used for spinal stabilisation, whereas in anglo-american countries, long spine boards are preferred. While it is recommended that the on-scene time is as short as possible, even less than 10 minutes for unstable patients, spinal stabilisation is a time-consuming procedure. For this reason, the time needed for spinal stabilisation may prevent the on-scene time from being brief. The aim of this simulation study was to compare the time required for spinal stabilisation between a scoop stretcher in conjunction with a vacuum mattress and a long spine board.

METHODS

Medical personnel of different professions were asked to perform spinal immobilizations with both methods. A total of 172 volunteers were immobilized under ideal conditions as well as under realistic conditions. A vacuum mattress was used for 78 spinal stabilisations, and a long spinal board was used for 94. The duration of the procedures were measured by video analysis.

RESULTS

Under ideal conditions, spinal stabilisation on a vacuum mattress and a spine board required 254.4 s (95 % CI 235.6-273.2 s) and 83.4 s (95 % CI 77.5-89.3 s), respectively (p < 0.01). Under realistic conditions, the vacuum mattress and spine board required 358.3 s (95 % CI 316.0-400.6 s) and 112.6 s (95 % CI 102.6-122.6 s), respectively (p < 0.01).

CONCLUSIONS

Spinal stabilisation for trauma patients is significantly more time consuming on a vacuum mattress than on a long spine board. Considering that the prehospital time of EMS should not exceed 60 minutes and the on-scene time should not exceed 30 minutes or even 10 minutes if the patient is in extremis, based on our results, spinal stabilisation on a vacuum mattress may consume more than 20 % of the recommended on-scene time. In contrast, stabilisation on a spine board requires only one third of the time required for that on a vacuum mattress. We conclude that a long spine board may be feasible for spinal stabilisation for critical trauma patients with timesensitive life threatening ABCDE-problems to ensure the shortest possible on-scene time for prehospital trauma treatment, not least if a patient has to be rescued from an open or inaccessible terrain, especially that with uneven overgrown land.

A T2 Translational Science Modified Delphi Study: Spinal Motion Restriction in a Resource-Scarce Environment

INTRODUCTION

Emerging evidence is guiding changes in prehospital management of potential spinal injuries. The majority of settings related to current recommendations are in resource-rich environments (RREs), whereas there is a lack of guidance on the provision of spinal motion restriction (SMR) in resource-scarce environments (RSEs), such as: mass-casualty incidents (MCIs); low-middle income countries; complex humanitarian emergencies; conflict zones; and prolonged transport times. The application of Translational Science (TS) in the Disaster Medicine (DM) context was used to develop this study, leading to statements that can be used in the creation of evidence-based clinical guidelines (CGs).

OBJECTIVE

What is appropriate SMR in RSEs?

METHODS

The first round of this modified Delphi (mD) study was a structured focus group conducted at the World Association for Disaster and Emergency Medicine (WADEM) Congress in Brisbane Australia on May 9, 2019. The result of the focus group discussion of open-ended questions produced ten statements that were added to ten statements derived from Fischer (2018) to create the second mD round questionnaire.Academic researchers and educators, operational first responders, or first receivers of patients with suspected spinal injuries were identified to be mD experts. Experts rated their agreement with each statement on a seven-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤1.0. Statements that were in agreement reaching consensus were included in the final report; those that were not in agreement but reached consensus were removed from further consideration. Those not reaching consensus advanced to the third mD round.For subsequent rounds, experts were shown the mean response and their own response for each of the remaining statements and asked to reconsider their rating. As above, those that did not reach consensus advanced to the next round until consensus was reached for each statement.

RESULTS

Twenty-two experts agreed to participate with 19 completing the second mD round and 16 completing the third mD round. Eleven statements reached consensus. Nine statements did not reach consensus.

CONCLUSIONS

Experts reached consensus offering 11 statements to be incorporated into the creation of SMR CGs in RSEs. The nine statements that did not reach consensus can be further studied and potentially modified to determine if these can be considered in SMR CGs in RSEs.