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Tavender E, Eapen N, Wang J, Rausa VC, Babl FE, Phillips N. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev 2024; 3:CD011686. [PMID: 38517085 PMCID: PMC10958760 DOI: 10.1002/14651858.cd011686.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.
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Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Nitaa Eapen
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Vanessa C Rausa
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Australia
- Biomechanics and Spine Research Group, Centre for Children's Health Research, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Australia
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Hawkins SC, Williams J, Bennett BL, Islas A, Quinn R. Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection: 2024 Update. Wilderness Environ Med 2024; 35:78S-93S. [PMID: 38379496 DOI: 10.1177/10806032241227232] [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] [Indexed: 02/22/2024]
Abstract
The Wilderness Medical Society reconvened an expert panel to update best practice guidelines for spinal cord protection during trauma management. This panel, with membership updated in 2023, was charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in wilderness environments. Recommendations are made regarding several parameters related to spinal cord protection. These recommendations are graded based on the quality of supporting evidence and balance the benefits and risks/burdens for each parameter according to American College of Chest Physicians methodology. Key recommendations include the concept that interventions should be goal-oriented (spinal cord/column protection in the context of overall patient and provider safety) rather than technique-oriented (immobilization). An evidence-based, goal-oriented approach excludes the immobilization of suspected spinal injuries via rigid collars or backboards.
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Affiliation(s)
- Seth C Hawkins
- Department of Emergency Medicine, Wake Forest University, Winston-Salem, NC
| | - Jason Williams
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Arthur Islas
- Department of Family and Community Medicine, University of Nevada, Reno School of Medicine, Reno, NV
| | - Robert Quinn
- Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX
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Baratloo A, Ahmadzadeh K, Forouzanfar MM, Yousefifard M, Farhang Ranjbar M, Hashemi B, Aghili SH. NEXUS vs. Canadian C-Spine Rule (CCR) in Predicting Cervical Spine Injuries; a Systematic Review and Meta-analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e66. [PMID: 37840870 PMCID: PMC10568954 DOI: 10.22037/aaem.v11i1.2143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Introduction Clinical decision tools have been shown to reduce imaging rates for clearance of suspected cervical spine injury (CSI). This review provides more comprehensive evidence on the diagnostic capabilities of National Emergency X-Radiography Utilization Study (NEXUS) and Canadian C-spine rule (CCR) in this regard. Method A systematic review of the current literature was performed on studies published until Jan 26th, 2023, in databases of Medline, Scopus, Web of Science, and Embase, investigating the performance of NEXUS and CCR in blunt trauma patients. QUADAS-2 and GRADE guidelines were used to assess the quality and certainty of evidence. All analyses were performed using the STATA 14.0 statistical analysis software. Results 35 articles comprising 70000 patients for NEXUS and 33000 patients for CCR were included in this review. NEXUS and CCR were evaluated to have a sensitivity of 0.94 (95% confidence interval (CI): 0.88 to 0.98) and 1.00 (95% CI: 0.98 to 1.00) in the detection of any CSI and 0.95 (95% CI: 0.89 to 0.98) and 1.00 (95% CI: 0.95 to 1.00) in the detection of clinically important CSI. The area under the curve (AUC) of NEXUS and CCR was 0.85 and 0.97 for any CSI and 0.78 (95% CI: 0.74 to 0.81) and 0.94 (95% CI: 0.91 to 0.96) for clinically important CSI. Conclusion Our study demonstrates that both NEXUS and CCR can be used in ruling out patients with low risk of CSI, and CCR was shown to have superior performance. Even though these tools have low specificity, their application can still greatly reduce the number of radiographic imaging performed in emergency departments.
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Affiliation(s)
- Alireza Baratloo
- Research Center for Trauma in Police Operations, Directorate of Health, Rescue & Treatment, Police Headquarter, Tehran, Iran
| | - Koohyar Ahmadzadeh
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehdi Forouzanfar
- Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mehri Farhang Ranjbar
- Research Center for Trauma in Police Operations, Directorate of Health, Rescue & Treatment, Police Headquarter, Tehran, Iran
| | - Behrooz Hashemi
- Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Hadi Aghili
- Research Center for Trauma in Police Operations, Directorate of Health, Rescue & Treatment, Police Headquarter, Tehran, Iran
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Abstract
BACKGROUND Clinical prediction models should be validated before implementation in clinical practice. But is favorable performance at internal validation or one external validation sufficient to claim that a prediction model works well in the intended clinical context? MAIN BODY We argue to the contrary because (1) patient populations vary, (2) measurement procedures vary, and (3) populations and measurements change over time. Hence, we have to expect heterogeneity in model performance between locations and settings, and across time. It follows that prediction models are never truly validated. This does not imply that validation is not important. Rather, the current focus on developing new models should shift to a focus on more extensive, well-conducted, and well-reported validation studies of promising models. CONCLUSION Principled validation strategies are needed to understand and quantify heterogeneity, monitor performance over time, and update prediction models when appropriate. Such strategies will help to ensure that prediction models stay up-to-date and safe to support clinical decision-making.
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McCallum J, Eagles D, Ouyang Y, Ende JV, Vaillancourt C, Fehlmann C, Shorr R, Taljaard M, Stiell I. Cervical spine injuries in adults ≥ 65 years after low-level falls - A systematic review and meta-analysis. Am J Emerg Med 2023; 67:144-155. [PMID: 36893628 DOI: 10.1016/j.ajem.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/10/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Adults ≥ 65 are at risk of cervical spine (C-spine) injury, even after low-level falls. The objectives of this systematic review were to determine the prevalence of C-spine injury in this population and explore the association of unreliable clinical exam with C-spine injury. METHODS We conducted this systematic review according to PRISMA guidelines. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic reviews to include studies reporting on C-spine injury in adults ≥ 65 years after low-level falls. Two reviewers independently screened articles, abstracted data, and assessed bias. Discrepancies were resolved by a third reviewer. A meta-analysis was performed to estimate overall prevalence and the pooled odds ratio for the association between C-spine injury and an unreliable clinical exam. RESULTS The search identified 2044citations, 138 full texts were screened, and 21 studies were included in the systematic review. C-spine injury prevalence in adults ≥ 65 years after low-level falls was 3.8% (95% CI: 2.8-5.3). The odds of c-spine injury in those with altered level of consciousness (aLOC) v/s not aLOC was 1.21 (0.90-1.63) and in those with GCS < 15 v/s GCS 15 was 1.62 (0.37-6.98). Studies were at a low-risk of bias, although some had low recruitment and significant loss to follow-up. CONCLUSIONS Adults ≥ 65 years are at risk of cervical spine injury after low-level falls. More research is needed to determine whether there is an association between cervical spine injury and GCS < 15 or altered level of consciousness.
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Affiliation(s)
- Jessica McCallum
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Debra Eagles
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
| | - Yongdong Ouyang
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Jamie Vander Ende
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
| | - Christian Vaillancourt
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
| | - Christophe Fehlmann
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva CH-1211, Switzerland.
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Ian Stiell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
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Implementation of the Modified Canadian C-Spine Rule by Paramedics. Ann Emerg Med 2023; 81:187-196. [PMID: 36328852 DOI: 10.1016/j.annemergmed.2022.08.441] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/26/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE The Canadian C-spine rule was modified and validated for use by the paramedics in a multicenter study where patients were assessed with the Canadian C-spine rule yet all transported with immobilization. This study evaluated the clinical impact of the modified Canadian C-spine rule when implemented by paramedics. METHODS This single-center prospective cohort implementation study took place in Ottawa, Canada (from 2011 to 2015). Advanced and primary care paramedics were trained to use the modified Canadian C-spine rule, collect data on a standardized study form, and selectively transport eligible patients without immobilization. We evaluated all consecutive low-risk adult patients (Glasgow Coma Scale [GCS] 15, stable vital signs) at risk for a neck injury. We followed all patients without initial radiologic evaluation for 30 days. Analyses included descriptive statistics with 95% confidence intervals (CI), sensitivity, specificity, and kappa coefficients. RESULTS The 4,034 enrolled patients had a mean age of 43 (range 16 to 99), and 53.4% were female. Motor vehicle collisions were the most common mechanism of injury (55.1%), followed by falls (23.9%). There were 11 clinically important injuries. The paramedics classified these injuries with a sensitivity of 90.9% (95% CI, 58.7 to 99.8) and specificity of 66.5% (95% CI, 65.1 to 68.0). There was no adverse event or resulting spinal cord injury. The kappa agreement between paramedics and investigators was 0.94. A total of 2,583 (64.0%) immobilizations were avoided using the modified Canadian C-spine rule. CONCLUSION Paramedics could accurately apply the modified Canadian C-spine rule to low-risk trauma patients and significantly reduce the need for spinal immobilization during transport. This resulted in no adverse event or any spinal cord injury.
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Geduld C, Muller H, Saunders CJ. Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: A scoping review. Afr J Emerg Med 2022; 12:393-405. [PMID: 36187075 PMCID: PMC9489745 DOI: 10.1016/j.afjem.2022.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 12/01/2022] Open
Abstract
There is a need for a patient-centred approach to the prehospital spinal management approach, which considers the associated risks, available personnel and limited resources. There is limited evidence supporting the use of the NEXUS and CCR decision tools in the prehospital setting. Prehospital spinal motion restriction decision tools should focus on reducing unnecessary spinal motion restriction and its associated adverse effects Developing a decision tool with more context-specific prehospital instructions for selective spinal motion restriction is of value.
Introduction The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners. Method We performed a focused scoping review of published literature on the prehospital use of clinical c-spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis. Results Following screening, forty-two articles were included in this scoping review. No studies conducted specifically in low resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting. Conclusion This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety, and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation, and a lack of context-specific evidence. These may provide important considerations for future guideline development.
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Affiliation(s)
- Charlene Geduld
- Division of Emergency Medicine, University of Cape Town, F51 Old Main Building, Groote Schuur Hospital, Observatory, South Africa
- Emergency Medical Care, Department of Clinical Science, Central University of Technology, Emergency Medical Care Building, 1 President Brand Street, Bloemfontein, South Africa
- Corresponding authors.
| | - Henra Muller
- Radiography, Department of Clinical Sciences, Central University of Technology, Prosperitas Building, 1 President Brand Street, Bloemfontein, South Africa
| | - Colleen J. Saunders
- Division of Emergency Medicine, University of Cape Town, F51 Old Main Building, Groote Schuur Hospital, Observatory, South Africa
- Corresponding authors.
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Leonardo F, Galindo GFDC, Pagamisse OST, Rodrigues JMDS. ALGORITHMS FOR CLINICAL ASSESSMENT OF THE CERVICAL SPINE IN PATIENTS WITH SEVERE TRAUMA: A MIXED-METHOD ANALYZIS. COLUNA/COLUMNA 2021. [DOI: 10.1590/s1808-185120212002242209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: Cervical trauma is an important cause of morbidity and mortality, affecting 2% of patients admitted to emergency units. Therefore, this study aims to compare the use of two clinical cervical spine evaluation algorithms, the Canadian C-Spine Rule (CCR) and the National Emergency X-radiography Utilization Study (NEXUS). Methods: A descriptive study of the use of the two algorithms by medical residents in the initial assessment of severely traumatized patients admitted to the regional emergency unit was conducted. The evaluation of the indication for imaging tests and the positive predictive value of the algorithms were the parameters analyzed. Finally, the residents answered a questionnaire evaluating the applicability, degree of confidence and advantages of both flowcharts. Results: There was no significant difference between the number of indications for imaging or their predictive values. In the analysis of the questionnaires, the CCR proved to be more reliable and the NEXUS more applicable, and the positive and negative points of applying each of them were highlighted. Conclusion: It is concluded that the two methods are similar in detecting injuries and optimizing the use of imaging exams, being equally indicated to evaluate cervical trauma. However, the technical specifics of each must be taken into account when deciding which to use. Level of evidence IV; Descriptive Study.
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Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Kuppermann N, Lerner EB, Leonard JC. Prehospital Factors Associated With Cervical Spine Injury in Pediatric Blunt Trauma Patients. Acad Emerg Med 2021; 28:553-561. [PMID: 33217762 DOI: 10.1111/acem.14176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND The risk for cervical spine injury (CSI) must be assessed in children who sustain blunt trauma. The Pediatric Emergency Care Applied Research Network (PECARN) retrospectively derived CSI model identifies CSI risk in children based on emergency department (ED) provider observations. The objective of this pilot study was to determine the univariate association of emergency medical services (EMS) provider-observed historical, mechanistic, and physical examination factors with CSI in injured children. Secondarily, we assessed the performance of the previously identified eight PECARN CSI risk factors (PECARN model) based exclusively on EMS provider observation. METHODS We conducted a four-center, prospective observational study of children 0 to 17 years old who were transported by EMS after blunt trauma and underwent spinal motion restriction or trauma team activation in the ED. In the ED, EMS providers recorded their observations for a priori determined CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks and test characteristics for the PECARN model based solely on EMS provider observations. RESULTS Of 1,372 enrolled children, 25 (1.8%) had CSIs. Of the a priori determined CSI risk factors, seven factors had bivariable associations with CSIs: axial load, altered mental status, signs of basilar skull fracture, substantial torso injury, substantial thoracic injury, respiratory distress, and decreased oxygen saturation. The PECARN model (high-risk motor vehicle collision, diving mechanism, predisposing condition, neck pain, decreased neck mobility, altered mental status, neurologic deficits, and/or substantial torso injury) exhibited the following test characteristics when based on EMS provider observations: sensitivity = 96.0% (95% confidence interval [CI] = 88.3% to 100.0%); negative predictive value = 99.8% (95% CI = 99.4% to 100.0%); specificity = 38.5% (95% CI = 35.9% to 41.1%); and positive predictive value = 2.8% (95% CI = 1.7% to 3.9%). CONCLUSION EMS providers can identify risk factors associated with CSI in injured children who experience blunt trauma. These risk factors may be considered for inclusion in a pediatric CSI decision rule specific to the prehospital setting.
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Affiliation(s)
- Lorin R. Browne
- From the Department of Pediatrics and Emergency Medicine Medical College of Wisconsin Milwaukee WIUSA
| | - Fahd A. Ahmad
- the Department of Pediatrics Washington University School of Medicine in St. Louis St. Louis MOUSA
| | - Hamilton Schwartz
- Department of Pediatrics Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Michael Wallendorf
- Department of Biostatistics Washington University School of Medicine in St. Louis St. Louis MOUSA
| | - Nathan Kuppermann
- the Department of Emergency Medicine and Pediatrics University of California Davis School of Medicine Sacramento CAUSA
| | - E. Brooke Lerner
- Department of Emergency Medicine University at Buffalo Buffalo NYUSA
| | - Julie C. Leonard
- Department of Pediatrics Nationwide Children’s Hospital and The Ohio State University College of Medicine Columbus OHUSA
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Evaluating the paramedic application of the prehospital Canadian C-Spine Rule in sport-related injuries. CAN J EMERG MED 2021; 23:356-364. [PMID: 33721288 DOI: 10.1007/s43678-021-00086-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 12/23/2020] [Indexed: 10/21/2022]
Abstract
OBJECTIVES We sought to compare the ability of the prehospital Canadian C-Spine Rule to selectively recommend immobilization in sport-related versus non-sport-related injuries and describe sport-related mechanisms of injury. METHODS We reviewed data from the prospective paramedic Canadian C-Spine Rule validation and implementation studies in 7 Canadian cities. A trained reviewer further categorized sport-related mechanisms of injury collaboratively with a sport medicine physician using a pilot-tested standardized form. We compared the Canadian C-Spine Rule's recommendation to immobilize sport-related versus non-sport-related patients using Chi-square and relative risk statistics with 95% confidence intervals. RESULTS There were 201 sport-related patients among the 5,978 included. Sport-related injured patients were younger (mean age 36.2 vs. 42.4) and more predominantly male (60.5% vs. 46.8%) than non-sport-related patients. Paramedics did not miss any C-Spine injury when using the Canadian C-Spine Rule. C-Spine injury rates were similar between sport (2/201; 1.0%) and non-sport-injured patients (47/5,777; 0.8%). The Canadian C-Spine Rule recommended immobilization equally between groups (46.4% vs. 42.5%; RR 1.09 95%CI 0.93-1.28), most commonly resulting from a dangerous mechanism among sport-injured (68.7% vs. 54.5%; RR 1.26 95%CI 1.08-1.47). The most common dangerous mechanism responsible for immobilization in sport was axial load. CONCLUSION Although equal proportions of sport and non-sport-related injuries were immobilized, a dangerous mechanism was most often responsible for immobilization in sport-related cases. These findings do not address the potential impact of using the Canadian C-Spine Rule to evaluate collegiate or pro athletes assessed by sport medicine physicians. It does support using the Canadian C-Spine Rule as a tool in sport-injured patients assessed by paramedics.
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Zileli M, Osorio-Fonseca E, Konovalov N, Cardenas-Jalabe C, Kaprovoy S, Mlyavykh S, Pogosyan A. Early Management of Cervical Spine Trauma: WFNS Spine Committee Recommendations. Neurospine 2021; 17:710-722. [PMID: 33401852 PMCID: PMC7788428 DOI: 10.14245/ns.2040282.141] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/06/2020] [Indexed: 12/12/2022] Open
Abstract
Epidemiology, prevention, early management of cervical spine trauma and it's reduction are the objectives of this review paper. A PubMed and MEDLINE search between 2009 and 2019 were conducted using keywords. Case reports, experimental studies, papers other than English language and and unrelated studies were excluded. Up-to-date information on epidemiology of spine trauma, prevention, early emergency management, transportation, and closed reduction were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Global incidence of traumatic spinal injury is higher in low- and middle-income countries. The most frequent reasons are road traffic accidents and falls. The incidence from low falls in the elderly are increasing in high-income countries due to ageing populations. Prevention needs legislative, engineering, educational, and social efforts that need common efforts of all society. Emergency care of the trauma patient, transportation, and in-hospital acute management should be planned by implementing detailed protocols to prevent further damage to the spinal cord. This review summarizes the WFNS Spine Committee recommendations on epidemiology, prevention, and early management of cervical spine injuries.
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Affiliation(s)
- Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
| | | | - Nikolay Konovalov
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | | | - Stanislav Kaprovoy
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | - Sergey Mlyavykh
- Trauma and Orthopedics Institute, Privolzhsky Research Medical University, Nizhniy Novgorod, Russian Federation
| | - Artur Pogosyan
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
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12
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Vaillancourt C, Charette M, Taljaard M, Thavorn K, Hall E, McLeod B, Fergusson D, Brehaut J, Graham I, Calder L, Ramsay T, Tugwell P, Kelly P, Cheskes S, Saskin R, Plint A, Osmond M, Macarthur C, Straus S, Rochon P, Prud'homme D, Dahrouge S, Marlin S, Stiell IG. Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial. JMIR Res Protoc 2020; 9:e16966. [PMID: 32348267 PMCID: PMC7296410 DOI: 10.2196/16966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/23/2019] [Accepted: 12/31/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. OBJECTIVE This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. METHODS We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. RESULTS Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. CONCLUSIONS We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). TRIAL REGISTRATION ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/16966.
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Affiliation(s)
- Christian Vaillancourt
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | | | - Elizabeth Hall
- Patient Representative, Owner-Hall Consulting, Director-Helping Hands for India, Kanata, ON, Canada
| | - Brent McLeod
- Paramedic Representative, Hamilton Paramedic Service, Hamilton, ON, Canada
| | | | - Jamie Brehaut
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian Graham
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lisa Calder
- Medical Care Analytics, Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Tugwell
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Kelly
- Ottawa Paramedic Service, Ottawa, ON, Canada
| | - Sheldon Cheskes
- Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Amy Plint
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Martin Osmond
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | | | - Sharon Straus
- Knowledge Translation Program, St. Michael's Hospital, Toronto, ON, Canada
| | - Paula Rochon
- Women's College Research Institute, Toronto, ON, Canada
| | | | | | | | - Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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13
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Qamar SR, Evans D, Gibney B, Redmond CE, Nasir MU, Wong K, Nicolaou S. Emergent Comprehensive Imaging of the Major Trauma Patient: A New Paradigm for Improved Clinical Decision-Making. Can Assoc Radiol J 2020; 72:293-310. [PMID: 32268772 DOI: 10.1177/0846537120914247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Modern advances in the medical imaging layered onto sophisticated trauma resuscitation strategies in highly organized regionalized trauma systems have created a paradigm shift in the management of severely injured patients. Although immediate exploratory surgery to identify and control life-threatening injuries still has its place, accelerated image acquisition and interpretation procedures now make it rare for trauma surgeons in major centers to venture into damage control surgery unaided by computed tomography (CT) or other imaging, particularly in cases of blunt trauma. Indeed, because of the high incidence of clinically occult injuries associated with major mechanism trauma, and even lower energy trauma in frail or elderly patients, CT imaging has become as invaluable as physical examination, if not more so, in critical decision-making in support of optimal outcomes. In particular, whole-body computed tomography (WBCT) completed promptly after initial assessment of a major trauma provides a quick, comprehensive survey of injuries that enables better surgical planning, obviates the need for multiple subsequent studies, and permits specialized reconstructions when needed. For those at risk for problematic occult injury after modest trauma, WBCT facilitates safer discharge planning and simplified follow-up. Through standardized guidelines, streamlined protocols, synoptic reporting, accessible web-based platforms, and active collaboration with clinicians, radiologists dedicated to trauma and emergency imaging enable clearer understanding of complex injuries in high-risk patients which leads to superior clinical decision-making. Whereas dated dogma has long warned that the CT scanner is the last place to take a challenging trauma patient, modern practice suggests that, more often than not, early comprehensive imaging can be done safely and efficiently and is in the patient's best interest. This article outlines how the role of diagnostic imaging for major trauma has evolved considerably in recent years.
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Affiliation(s)
- Sadia Raheez Qamar
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - David Evans
- Department of Surgery, 8167Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Gibney
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Ciaran E Redmond
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Muhammad Umer Nasir
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Kenneth Wong
- Department of Radiology, 71511Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Savvas Nicolaou
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
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14
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Hawkins SC, Williams J, Bennett BL, Islas A, Kayser DW, Quinn R. Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection. Wilderness Environ Med 2019; 30:S87-S99. [DOI: 10.1016/j.wem.2019.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/25/2019] [Accepted: 08/01/2019] [Indexed: 11/30/2022]
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15
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Ellis MJ, Russell K. The Potential of Telemedicine to Improve Pediatric Concussion Care in Rural and Remote Communities in Canada. Front Neurol 2019; 10:840. [PMID: 31428043 PMCID: PMC6688625 DOI: 10.3389/fneur.2019.00840] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 07/19/2019] [Indexed: 12/15/2022] Open
Abstract
Concussion is a form of mild traumatic brain injury that affects thousands of Canadian children and adolescents annually. Despite national efforts to harmonize the recognition and management of pediatric concussion in Canada, timely access to primary and specialized care following this injury remains a challenge for many patients especially those who live in rural and remote communities. To address similar challenges facing patients with stroke and other neurological disorders, physicians have begun to leverage advances in telemedicine to improve the delivery of specialized neurological care to those living in medically underserved regions. Preliminary studies suggest that telemedicine may be a safe and cost-effective approach to assist in the medical care of select patients with acute concussion and persistent post-concussion symptoms. Here we provide an overview of telemedicine, teleneurology, the principles of concussion assessment and management, as well as the current state of concussion care in Canada. Utilizing preliminary evidence from studies of telemedicine in concussion and experience from comprehensive systems of care for stroke, we outline steps that must be taken to evaluate the potential of telemedicine-based concussion networks to improve the care of pediatric concussion patients living in underserved rural and remote communities in Canada.
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Affiliation(s)
- Michael J Ellis
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.,Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada.,Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada.,Pan Am Concussion Program, Winnipeg, MB, Canada
| | - Kelly Russell
- Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
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16
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Kroeker J, Keith J, Carruthers H, Hanna C, Qureshi N, Calic M, Kaye M, Solow M, Coey J, Sulaiman S. Investigating the time‐lapsed effects of rigid cervical collars on the dimensions of the internal jugular vein. Clin Anat 2019; 32:196-200. [DOI: 10.1002/ca.23264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 07/27/2018] [Accepted: 08/07/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Jenna Kroeker
- Keith B. Taylor Global Scholars Program at Northumbria UniversitySt. George's International School of Medicine Newcastle‐upon‐Tyne NE1 8ST UK
| | - Jay Keith
- Keith B. Taylor Global Scholars Program at Northumbria UniversitySt. George's International School of Medicine Newcastle‐upon‐Tyne NE1 8ST UK
| | - Hailey Carruthers
- Keith B. Taylor Global Scholars Program at Northumbria UniversitySt. George's International School of Medicine Newcastle‐upon‐Tyne NE1 8ST UK
| | - Cherry Hanna
- Keith B. Taylor Global Scholars Program at Northumbria UniversitySt. George's International School of Medicine Newcastle‐upon‐Tyne NE1 8ST UK
| | - Natasha Qureshi
- Keith B. Taylor Global Scholars Program at Northumbria UniversitySt. George's International School of Medicine Newcastle‐upon‐Tyne NE1 8ST UK
| | - Masa Calic
- Keith B. Taylor Global Scholars Program at Northumbria UniversitySt. George's International School of Medicine Newcastle‐upon‐Tyne NE1 8ST UK
| | - Meagan Kaye
- Keith B. Taylor Global Scholars Program at Northumbria UniversitySt. George's International School of Medicine Newcastle‐upon‐Tyne NE1 8ST UK
| | - Marissa Solow
- Keith B. Taylor Global Scholars Program at Northumbria UniversitySt. George's International School of Medicine Newcastle‐upon‐Tyne NE1 8ST UK
| | - James Coey
- Keith B. Taylor Global Scholars Program at Northumbria UniversitySt. George's International School of Medicine Newcastle‐upon‐Tyne NE1 8ST UK
- Department of AnatomySt. George's University Grenada West Indies
| | - Sara Sulaiman
- Department of Applied SciencesNorthumbria University Newcastle‐upon‐Tyne NE1 8ST UK
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17
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Ellis MJ, Bauman S, Cowle S, Fuselli P, Tator CH. Primary care management of concussion in Canada. Paediatr Child Health 2019; 24:137-142. [PMID: 31110450 DOI: 10.1093/pch/pxy171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/13/2018] [Indexed: 11/14/2022] Open
Abstract
Concussion has emerged as an important public health issue affecting thousands of Canadians annually. Health care providers including paediatricians, family and emergency medicine physicians, nurses, and nurse practitioners are commonly tasked with the responsibility of providing primary care to patients with acute concussion and those with persistent post-concussion symptoms. In July 2017, Parachute, in collaboration with the Public Health Agency of Canada and Sport Canada released the Canadian Guideline on Concussion in Sport that outlines a standardized and evidence-based approach to the recognition, diagnosis, and management of youth and adults with suspected concussion. In this report, we provide a brief overview of the important roles of primary care providers in the medical assessment, management, and prevention of concussion as outlined in this national best practice guideline.
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Affiliation(s)
- Michael J Ellis
- Department of Surgery and Pediatrics and Child Health, Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba.,Pan Am Concussion Program, Winnipeg, Manitoba, Canada
| | - Shannon Bauman
- Department of Surgery and Department of Family Medicine, Royal Victoria Regional Health Care Centre, Barrie, Ontario.,Department of Community and Family Medicine, University of Toronto, Toronto, Ontario.,Concussion North, Barrie, Ontario
| | | | | | - Charles H Tator
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario.,Canadian Concussion Centre, Toronto Western Hospital, Toronto, Ontario
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18
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Ellis MJ, Leddy J, Cordingley D, Willer B. A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes. Front Neurol 2018; 9:1115. [PMID: 30619068 PMCID: PMC6306465 DOI: 10.3389/fneur.2018.01115] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/05/2018] [Indexed: 12/29/2022] Open
Abstract
Sport-related concussion is an important condition that can affect collegiate and professional athletes. Expert consensus guidelines currently suggest that all athletes who sustain acute concussion be managed with a conservative approach consisting of relative rest and gradual resumption of school and sport activities with active intervention reserved for those with persistent post-concussion symptoms lasting >10-14 days for adults. Unfortunately, these recommendations place little emphasis on the rapid physical deconditioning that occurs in athletes within days of exercise cessation or the pathophysiological processes responsible for acute concussion symptoms that can be successfully targeted by evidence-based rehabilitation strategies. Based on our evolving approach to patients with persistent post-concussion symptoms, we now present an updated physiological approach to the initial medical assessment, rehabilitation, and multi-disciplinary management of collegiate and professional athletes with acute concussion. Utilizing the results of a careful clinical history, comprehensive physical examination and graded aerobic exercise testing, we outline how team physicians, and athletic training staff can partner with multi-disciplinary experts in traumatic brain injury to develop individually tailored rehabilitation programs that target the main physiological causes of acute concussion symptoms (autonomic nervous system dysfunction/exercise intolerance, vestibulo-ocular dysfunction, and cervical spine dysfunction) while maintaining the athlete's physical fitness during the recovery period. Considerations for multi-disciplinary medical clearance of collegiate and professional athletes as well as the application of this approach to non-elite athletes are also discussed.
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Affiliation(s)
- Michael J. Ellis
- Section of Neurosurgery, Department of Surgery, Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, Canada North Concussion Network, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Concussion Program, Winnipeg, MB, Canada
| | - John Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Buffalo, NY, United States
| | - Dean Cordingley
- Pan Am Concussion Program, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada
| | - Barry Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, United States
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19
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20
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Stiell IG, Clement CM, Lowe M, Sheehan C, Miller J, Armstrong S, Bailey B, Posselwhite K, Langlais J, Ruddy K, Thorne S, Armstrong A, Dain C, Perry JJ, Vaillancourt C. A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses. Ann Emerg Med 2018; 72:333-341. [DOI: 10.1016/j.annemergmed.2018.03.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 02/27/2018] [Accepted: 03/23/2018] [Indexed: 11/29/2022]
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21
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Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T. Review article: Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series). Emerg Med Australas 2018; 30:754-772. [PMID: 30168261 DOI: 10.1111/1742-6723.13131] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/14/2018] [Accepted: 06/10/2018] [Indexed: 12/13/2022]
Abstract
Neck pain and whiplash injuries are a common presentation to the ED, and a frequent cause of disability globally. This rapid review investigated best practice for the assessment and management of musculoskeletal neck pain in the ED. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years addressing acute neck pain assessment, management or prognosis in the ED were included. Data extraction was conducted, followed by quality appraisal to rate levels of evidence where possible. The search revealed 2080 articles, of which 51 were included (n = 22 primary articles, n = 13 systematic reviews and n = 16 guidelines). Consistent evidence was found to support the use of 'red flags' to screen for serious pathologies, judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance. Clinicians may also consider applying risk-stratification methods, such as using a clinical prediction rule, to guide patient discharge and referral plans; however, the evidence is still emerging in this population. This rapid review provides clinicians managing neck pain in the ED a summary of the best available evidence to enhance quality of care and optimise patient outcomes.
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Affiliation(s)
- Kirsten Strudwick
- Emergency Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia.,Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia.,School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Megan McPhee
- Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Anthony Bell
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Melinda Martin-Khan
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Trevor Russell
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
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22
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Fontaine G, Forgione M, Lusignan F, Lanoue MA, Drouin S. Cervical Spine Collar Removal by Emergency Room Nurses: A Quality Improvement Project. J Emerg Nurs 2018; 44:228-235. [DOI: 10.1016/j.jen.2017.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/24/2017] [Accepted: 07/29/2017] [Indexed: 11/30/2022]
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23
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Bier JD, Scholten-Peeters WGM, Staal JB, Pool J, van Tulder MW, Beekman E, Knoop J, Meerhoff G, Verhagen AP. Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain. Phys Ther 2018; 98:162-171. [PMID: 29228289 DOI: 10.1093/ptj/pzx118] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/30/2017] [Indexed: 02/07/2023]
Abstract
The Royal Dutch Society for Physical Therapy (KNGF) issued a clinical practice guideline for physical therapists that addresses the assessment and treatment of patients with nonspecific neck pain, including cervical radiculopathy, in Dutch primary care. Recommendations were based on a review of published systematic reviews.During the intake, the patient is screened for serious pathologies and corresponding patterns. Patients with cervical radiculopathy can be included or excluded through corresponding signs and symptoms and possibly diagnostic tests (Spurling test, traction/distraction test, and Upper Limb Tension Test). History taking is done to gather information about patients' limitations, course of pain, and prognostic factors (eg, coping style) and answers to health-related questions.In case of a normal recovery (treatment profile A), management should be hands-off, and patients should receive advice from the physical therapist and possibly some simple exercises to supplement "acting as usual."In case of a delayed/deviant recovery (treatment profile B), the physical therapist is advised to use, in addition to the recommendations for treatment profile A, forms of mobilization and/or manipulation in combination with exercise therapy. Other interventions may also be considered. The physical therapist is advised not to use dry needling, low-level laser, electrotherapy, ultrasound, traction, and/or a cervical collar.In case of a delayed/deviant recovery with clear and/or dominant psychosocial prognostic factors (treatment profile C), these factors should first be addressed by the physical therapist, when possible, or the patient should be referred to a specialist, when necessary.In case of neck pain grade III (treatment profile D), the therapy resembles that for profile B, but the use of a cervical collar for pain reduction may be considered. The advice is to use it sparingly: only for a short period per day and only for a few weeks.
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Affiliation(s)
- Jasper D Bier
- Department of General Practice, Erasmus University of Rotterdam, Rotterdam, PO Box 2040, 3000CA Rotterdam, the Netherlands
| | - Wendy G M Scholten-Peeters
- Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, The Netherlands
| | - J Bart Staal
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, the Netherlands, and Research Group for Musculoskeletal Rehabilitation, HAN University of Applied Sciences, Nijmegen, the Netherlands
| | - Jan Pool
- Institute of Human Movement Studies, Department of Lifestyle and Health, HU University of Applied Sciences, Utrecht, the Netherlands
| | - Maurits W van Tulder
- Faculty of Earth and Life Sciences, Institute of Health Sciences, VU University Amsterdam, the Netherlands
| | - Emmylou Beekman
- The Research Centre for Autonomy and Participation for Persons With a Chronic Illness, Zuyd University of Applied Sciences, Heerlen, the Netherlands
| | - Jesper Knoop
- The Research Centre for Autonomy and Participation for Persons With a Chronic Illness, Zuyd University of Applied Sciences
| | - Guus Meerhoff
- The Research Centre for Autonomy and Participation for Persons With a Chronic Illness, Zuyd University of Applied Sciences
| | - Arianne P Verhagen
- Department of General Practice, Erasmus University of Rotterdam, Rotterdam, the Netherlands
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Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, Schep NWL, van Rijn RR. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database Syst Rev 2017; 12:CD011686. [PMID: 29215711 PMCID: PMC6486014 DOI: 10.1002/14651858.cd011686.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population. OBJECTIVES To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma. SEARCH METHODS We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility. SELECTION CRITERIA We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy. MAIN RESULTS Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity. AUTHORS' CONCLUSIONS There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.
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Affiliation(s)
- Annelie Slaar
- WestfriesgasthuisDepartment of RadiologyMaelsonstraat 3HoornNoord HollandNetherlands1624 NP
| | - M M Fockens
- University of AmsterdamAcademic Medical CenterAmsterdamNetherlands
| | - Junfeng Wang
- Academic Medical CenterDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mario Maas
- Academic Medical CenterDepartment of RadiologyUniversity of AmsterdamMeibergdreefAmsterdamNetherlands
| | - David J Wilson
- St Lukes HospitalDepartment of RadiologyLatimer RoadHeadingtonOxfordUKOX3 7PF
| | - J Carel Goslings
- Academic Medical CenterTrauma Unit, Department of SurgeryMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Niels WL Schep
- Academic Medical CenterDepartment of Surgery/Trauma UnitMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Rick R van Rijn
- Academic Medical Center AmsterdamDepartment of RadiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Browne LR, Schwartz H, Ahmad FA, Wallendorf M, Kuppermann N, Lerner EB, Leonard JC. Interobserver Agreement in Pediatric Cervical Spine Injury Assessment Between Prehospital and Emergency Department Providers. Acad Emerg Med 2017; 24:1501-1510. [PMID: 28921731 DOI: 10.1111/acem.13312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/25/2017] [Accepted: 09/11/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Investigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency medical services (EMS) providers can use these tools to appropriately determine the need for spinal motion restrictions and make field disposition decisions. OBJECTIVES The objective was to determine the interobserver agreement between EMS and emergency department (ED) providers for CSI risk assessment variables and overall gestalt for CSI in children after blunt trauma. METHODS This was a planned, substudy of a four-site, prospective cohort of children < 18 years transported by EMS to pediatric EDs for evaluation of CSI after blunt trauma. Inclusion criteria were trauma team activation and/or EMS-initiated spinal motion restriction. Exclusion criteria were penetrating trauma, transfer to another facility for definitive care, state custody, or substantial language barrier. For each eligible child, the transporting EMS provider and treating ED provider independently recorded their clinical assessment for CSI. This included mechanism of injury and patient history and physical examination findings. We assessed each paired variable for interobserver agreement between EMS and ED provider using kappa (κ) analysis. We considered variables with κ lower confidence interval values ≥0.4 to have moderate or better agreement. RESULTS We obtained 1,372 paired observations for 29 variables. After finding prevalence and observer bias were adjusted for, all variables achieved moderate to better agreement including eight variables previously shown to be independently associated with CSI in children: diving mechanism, high-risk motor vehicle collision, altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, and predisposing medical condition. EMS and ED providers, however, showed less than moderate agreement for their overall gestalt for CSI in children. Of note, both EMS and ED providers did not assess for neck pain, inability to move the neck, and/or cervical spine tenderness in more than 10% of study patients. CONCLUSIONS Emergency medical services and ED providers achieved at least moderate agreement in the assessment of CSI risk factors in children after blunt trauma. However, EMS and ED providers did not achieve moderate agreement on gestalt for CSI and some risk factors went unassessed by providers. These findings support the development of a pediatric CSI risk assessment tool for EMS and ED providers to reduce interventions for those children at very low risk for CSIs while still identifying all children with injury.
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Affiliation(s)
- Lorin R. Browne
- Department of Pediatrics and Emergency Medicine; Medical College of Wisconsin (LRB, EBL); Madison WI
| | - Hamilton Schwartz
- Department of Pediatrics; University of Cincinnati College of Medicine (HS); Cincinnati OH
| | - Fahd A. Ahmad
- Department Pediatrics; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Michael Wallendorf
- Department of Biostatistics; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics; University of California Davis School of Medicine; Sacramento CA
| | - E. Brooke Lerner
- Department of Pediatrics and Emergency Medicine; Medical College of Wisconsin (LRB, EBL); Madison WI
| | - Julie C. Leonard
- Nationwide Children's Hospital and The Ohio State University College of Medicine; Columbus OH
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Validity and reliability of clinical prediction rules used to screen for cervical spine injury in alert low-risk patients with blunt trauma to the neck: part 2. A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1219-1233. [DOI: 10.1007/s00586-017-5301-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 08/22/2017] [Accepted: 09/14/2017] [Indexed: 10/18/2022]
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Elliott JM, Courtney DM. Clinician's Commentary on Belot et al. 1. Physiother Can 2017; 69:290-291. [PMID: 30371682 DOI: 10.3138/ptc.2016-32-cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- James M Elliott
- Professor, Faculty of Health Sciences, The University of Sydney and Northern Sydney Local Health District, St Leonards, Sydney, NSW, Australia; Adjunct Professor, Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA;
| | - D Mark Courtney
- Associate Professor, Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL;
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Belot M, Hoens AM, Kennedy C, Li LC. Does Every Patient Require Imaging after Cervical Spine Trauma? A Knowledge Translation Project to Support Evidence-Informed Practice for Physiotherapists. Physiother Can 2017; 69:280-289. [PMID: 30369695 DOI: 10.3138/ptc.2016-32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: This article evaluates, describes, and addresses a gap in British Columbia physiotherapists' knowledge of the decision making required for the diagnostic imaging of patients after traumatic neck injury. Method: An online survey of orthopaedic physiotherapists in British Columbia was undertaken to explore their awareness of, knowledge of, and attitudes toward the Canadian Cervical Spine Rule (C-Spine Rule) and decision making regarding the need for diagnostic imaging in managing patients with traumatic neck injury. The survey included questions about managing clinical scenarios; respondents' awareness, knowledge, and use of a specific clinical decision rule-the C-Spine Rule-and any perceived barriers to using clinical practice guidelines in general and the C-Spine Rule in specific. The survey also included questions about the facilitators of and barriers to using the C-Spine Rule. These data were used to guide development of a tool kit to facilitate use of the rule. Results: Of 889 physiotherapists, 467 (52.5%) completed the survey. Given a scenario in which imaging was indicated according to the C-Spine Rule, 95.2% of the respondents correctly recommended imaging. However, in a scenario in which imaging was not indicated, 42.7% incorrectly recommended it. The barriers to using the guidelines included their perceived rigidity, role limitation, and reliance on clinical judgment. The results indicated a need for, and guided development of, resources to facilitate the use of the C-Spine Rule by British Columbia physiotherapists. Conclusions: We identified a gap in the knowledge of British Columbia physiotherapists in identifying which patients were most likely to require imaging after sustaining a traumatic neck injury. We developed a tool kit to address these barriers. British Columbia physiotherapists have accessed this resource extensively. Evaluating its impact on clinical practice, although desirable, was not feasible.
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Affiliation(s)
| | - Alison M Hoens
- Department of Physical Therapy, University of British Columbia
| | | | - Linda C Li
- Department of Physical Therapy, University of British Columbia.,Arthritis Research Canada, Richmond, British Columbia
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Abstract
AbstractObjectives: To summarize the clinical characteristics and outcomes of pediatric sports-related concussion (SRC) patients who were evaluated and managed at a multidisciplinary pediatric concussion program and examine the healthcare resources and personnel required to meet the needs of this patient population. Methods: We conducted a retrospective review of all pediatric SRC patients referred to the Pan Am Concussion Program from September 1st, 2013 to May 25th, 2015. Initial assessments and diagnoses were carried out by a single neurosurgeon. Return-to-Play decision-making was carried out by the multidisciplinary team. Results: 604 patients, including 423 pediatric SRC patients were evaluated at the Pan Am Concussion Program during the study period. The mean age of study patients was 14.30 years (SD: 2.32, range 7-19 years); 252 (59.57%) were males. Hockey (182; 43.03%) and soccer (60; 14.18%) were the most commonly played sports at the time of injury. Overall, 294 (69.50%) of SRC patients met the clinical criteria for concussion recovery, while 75 (17.73%) were lost to follow-up, and 53 (12.53%) remained in active treatment at the end of the study period. The median duration of symptoms among the 261 acute SRC patients with complete follow-up was 23 days (IQR: 15, 36). Overall, 25.30% of pediatric SRC patients underwent at least one diagnostic imaging test and 32.62% received referral to another member of our multidisciplinary clinical team. Conclusion: Comprehensive care of pediatric SRC patients requires access to appropriate diagnostic resources and the multidisciplinary collaboration of experts with national and provincially-recognized training in TBI.
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Ellis MJ, Leddy J, Willer B. Multi-Disciplinary Management of Athletes with Post-Concussion Syndrome: An Evolving Pathophysiological Approach. Front Neurol 2016; 7:136. [PMID: 27605923 PMCID: PMC4995355 DOI: 10.3389/fneur.2016.00136] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/08/2016] [Indexed: 01/03/2023] Open
Abstract
Historically, patients with sports-related concussion (SRC) have been managed in a uniform fashion consisting mostly of prescribed physical and cognitive rest with the expectation that all symptoms will spontaneously resolve with time. Although this approach will result in successful return to school and sports activities in the majority of athletes, an important proportion will develop persistent concussion symptoms characteristic of post-concussion syndrome (PCS). Recent advances in exercise science, neuroimaging, and clinical research suggest that the clinical manifestations of PCS are mediated by unique pathophysiological processes that can be identified by features of the clinical history and physical examination as well as the use of graded aerobic treadmill testing. Athletes who develop PCS represent a unique population whose care must be individualized and must incorporate a rehabilitative strategy that promotes enhanced recovery of concussion-related symptoms while preventing physical deconditioning. In this review, we present our evolving evidence-based approach to evaluation and management of athletes with PCS that aims to identify the pathophysiological mechanisms mediating persistent concussion symptoms and guides the initiation of individually tailored rehabilitation programs that target these processes. In addition, we outline the important qualified roles that multi-disciplinary healthcare professionals can play in the management of this patient population, and discuss where future research efforts must be focused to further evaluate this evolving pathophysiological approach.
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Affiliation(s)
- Michael J Ellis
- Pan Am Concussion Program, Section of Neurosurgery, Department of Surgery, Pediatrics and Child Health, University of Manitoba, Children's Hospital Research Institute of Manitoba, Canada North Concussion Network , Winnipeg, MB , Canada
| | - John Leddy
- UBMD Department of Orthopaedics and Sports Medicine, State University of New York at Buffalo Jacobs School of Medicine and Biomedical Sciences , Buffalo, NY , USA
| | - Barry Willer
- Department of Psychiatry, State University of New York at Buffalo Jacobs School of Medicine and Biomedical Sciences , Buffalo, NY , USA
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Saragiotto BT, Michaleff ZA. The Canadian C-Spine Rule. J Physiother 2016; 62:170. [PMID: 27161303 DOI: 10.1016/j.jphys.2016.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 02/22/2016] [Accepted: 04/06/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- Bruno Tirotti Saragiotto
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Zoe A Michaleff
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia; Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
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Smith N, Curtis K. Can emergency nurses safely and accurately remove cervical spine collars in low risk adult trauma patients: An integrative review. ACTA ACUST UNITED AC 2016; 19:63-74. [PMID: 27005407 DOI: 10.1016/j.aenj.2016.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/22/2016] [Accepted: 01/24/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Well validated clinical decision rules exist to facilitate the safe removal of collars in the alert, orientated, low risk adult trauma patient, however this practice is traditionally conducted by medical staff. The aim of this review is to synthesise current evidence to determine the efficacy of emergency nurses in safely and accurately removing cervical spine collars using cervical spine rules, in alert, orientated, low risk trauma adult patients. METHODS A multi-method search strategy was used to find primary research studies followed by a rigorous screening and quality appraisal process. Data from included articles were extracted, grouped and synthesised. RESULTS Nine quantitative research articles resulted in four key findings: the inter-rater reliability between nurses and doctors clearing the cervical spine was high (kappa range (0.61-0.80)); nurses can safely implement the cervical spine clinical decision rule; use of a cervical spine clinical decision rule decreases the time patients are immobilised and; nurses felt confident applying a cervical spine clinical decision rule. CONCLUSION Appropriately trained emergency nurses can safely apply cervical spine rules to alert, orientated, low risk adult trauma patients. Implementation of nurses clearing cervical spines should include training and ongoing monitoring.
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Affiliation(s)
- Nicola Smith
- Sydney Nursing School, The University of Sydney, 88 Mallett Street, Camperdown, Sydney, NSW 2050, Australia; Emergency Department, St. Vincents Public Hospital, 390 Victoria Street, Darlinghurst, Sydney 2010, Australia.
| | - Kate Curtis
- Sydney Nursing School, The University of Sydney, 88 Mallett Street, Camperdown, Sydney, NSW 2050, Australia; Trauma Service, St George Hospital, Gray St, Kogarah 2217, Australia
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Clement CM, Stiell IG, Lowe MA, Brehaut JC, Calder LA, Vaillancourt C, Perry JJ. Facilitators and barriers to application of the Canadian C-spine rule by emergency department triage nurses. Int Emerg Nurs 2016; 27:24-30. [PMID: 26796288 DOI: 10.1016/j.ienj.2015.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We recently conducted a multicentre implementation study on the use of the Canadian C-Spine Rule (CCR) by emergency department (ED) nurses to clear the c-spine in alert and stable trauma patients (n = 4506). The objective of this study was to conduct a survey of nurses, physicians, and administrators to evaluate their views on the facilitators and barriers to the implementation of the CCR. METHODS We conducted both a paper-based and an electronic survey of the three different ED hospital staff groups of nine large teaching hospitals in Ontario, including six regional trauma centres. The content of this survey was informed by a qualitative evaluation of the opinions of the study nurses who had participated in the validation study. RESULTS 57.5% (281/489) ED triage nurses, 50.2% ED physicians, and 82.8% of administrators responded. Nurse responses most often showed support from manager/educators and teamwork between physicians, nurses, and managers as being important facilitators to the use of the CCR. Physician responses most often identified the importance of a nurse leader/champion/educator, and presence of strong physician leaders. Administrator responses indicated the importance of nurse educators/champions, nurse engagement, and educational support. Barriers indicated by all three groups included busy department, lack of physician support, and lack of nursing support. CONCLUSIONS Bringing about change in clinical practice is complex. Strong leadership, effective communication, and senior physician buy-in appear to be very important. Identification of system-specific barriers and facilitators are important components of successful knowledge translation.
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Affiliation(s)
- Catherine M Clement
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Ian G Stiell
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Maureen A Lowe
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jamie C Brehaut
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lisa A Calder
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Christian Vaillancourt
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada
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Finnerty NM, Rodriguez RM, Carpenter CR, Sun BC, Theyyunni N, Ohle R, Dodd KW, Schoenfeld EM, Elm KD, Kline JA, Holmes JF, Kuppermann N. Clinical Decision Rules for Diagnostic Imaging in the Emergency Department: A Research Agenda. Acad Emerg Med 2015; 22:1406-16. [PMID: 26567885 DOI: 10.1111/acem.12828] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 07/13/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Major gaps persist in the development, validation, and implementation of clinical decision rules (CDRs) for diagnostic imaging. OBJECTIVES The objective of this working group and article was to generate a consensus-based research agenda for the development and implementation of CDRs for diagnostic imaging in the emergency department (ED). METHODS The authors followed consensus methodology, as outlined by the journal Academic Emergency Medicine (AEM), combining literature review, electronic surveys, telephonic communications, and a modified nominal group technique. Final discussions occurred in person at the 2015 AEM consensus conference. RESULTS A research agenda was developed, prioritizing the following questions: 1) what are the optimal methods to justify the derivation and validation of diagnostic imaging CDRs, 2) what level of evidence is required before disseminating CDRs for widespread implementation, 3) what defines a successful CDR, 4) how should investigators best compare CDRs to clinical judgment, and 5) what disease states are amenable (and highest priority) to development of CDRs for diagnostic imaging in the ED? CONCLUSIONS The concepts discussed herein demonstrate the need for further research on CDR development and implementation regarding diagnostic imaging in the ED. Addressing this research agenda should have direct applicability to patients, clinicians, and health care systems.
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Affiliation(s)
- Nathan M. Finnerty
- Department of Emergency Medicine; The Ohio State University College of Medicine; Columbus OH
| | - Robert M. Rodriguez
- Department of Emergency Medicine; University of California San Francisco School of Medicine; San Francisco CA
| | - Christopher R. Carpenter
- Department of Emergency Medicine; Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Benjamin C. Sun
- Department of Emergency Medicine; Oregon Health & Science University; Portland OR
| | - Nik Theyyunni
- Department of Emergency Medicine; University of Michigan Medical School; Ann Arbor MI
| | - Robert Ohle
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Kenneth W. Dodd
- Department of Emergency Medicine; Hennepin County Medical Center; Minneapolis MN
- Department of Internal Medicine; Hennepin County Medical Center; Minneapolis MN
| | - Elizabeth M. Schoenfeld
- Department of Emergency Medicine; Baystate Medical Center; Tufts University School of Medicine; Springfield MA
| | - Kendra D. Elm
- Department of Emergency Medicine; University of Minnesota Medical School; Minneapolis MN
| | - Jeffrey A. Kline
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - James F. Holmes
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
| | - Nathan Kuppermann
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
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Rossettini G, Rondoni A, Testa M. Application of the Canadian C-Spine Rule during early clinical evaluation of a patient presenting in primary care with a C2 fracture following a motor vehicle collision: A case report. INT J OSTEOPATH MED 2015. [DOI: 10.1016/j.ijosm.2015.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Stein SC, Attiah MA. Clinical Prediction and Decision Rules in Neurosurgery. Neurosurgery 2015; 77:149-55; discussion 156. [DOI: 10.1227/neu.0000000000000818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Quinn RH, Williams J, Bennett BL, Stiller G, Islas AA, McCord S. Wilderness Medical Society Practice Guidelines for Spine Immobilization in the Austere Environment: 2014 Update. Wilderness Environ Med 2014; 25:S105-17. [DOI: 10.1016/j.wem.2014.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 05/22/2014] [Accepted: 05/25/2014] [Indexed: 01/21/2023]
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Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma 2014; 31:531-40. [PMID: 23962031 PMCID: PMC3949434 DOI: 10.1089/neu.2013.3094] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.
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Affiliation(s)
- Terje Sundstrøm
- 1 Department of Biomedicine, University of Bergen , Bergen, Norway
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Wilderness Medical Society practice guidelines for spine immobilization in the austere environment. Wilderness Environ Med 2013; 24:241-52. [PMID: 23827829 DOI: 10.1016/j.wem.2013.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 03/03/2013] [Accepted: 03/07/2013] [Indexed: 11/22/2022]
Abstract
In an effort to produce best-practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several factors related to spinal immobilization. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each factor according to the methodology stipulated by the American College of Chest Physicians. A treatment algorithm based on the guidelines is presented.
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Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CWC. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ 2012; 184:E867-76. [PMID: 23048086 PMCID: PMC3494329 DOI: 10.1503/cmaj.120675] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is uncertainty about the optimal approach to screen for clinically important cervical spine (C-spine) injury following blunt trauma. We conducted a systematic review to investigate the diagnostic accuracy of the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) criteria, 2 rules that are available to assist emergency physicians to assess the need for cervical spine imaging. METHODS We identified studies by an electronic search of CINAHL, Embase and MEDLINE. We included articles that reported on a cohort of patients who experienced blunt trauma and for whom clinically important cervical spine injury detectable by diagnostic imaging was the differential diagnosis; evaluated the diagnostic accuracy of the Canadian C-spine rule or NEXUS or both; and used an adequate reference standard. We assessed the methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies criteria. We used the extracted data to calculate sensitivity, specificity, likelihood ratios and post-test probabilities. RESULTS We included 15 studies of modest methodologic quality. For the Canadian C-spine rule, sensitivity ranged from 0.90 to 1.00 and specificity ranged from 0.01 to 0.77. For NEXUS, sensitivity ranged from 0.83 to 1.00 and specificity ranged from 0.02 to 0.46. One study directly compared the accuracy of these 2 rules using the same cohort and found that the Canadian C-spine rule had better accuracy. For both rules, a negative test was more informative for reducing the probability of a clinically important cervical spine injury. INTERPRETATION Based on studies with modest methodologic quality and only one direct comparison, we found that the Canadian C-spine rule appears to have better diagnostic accuracy than the NEXUS criteria. Future studies need to follow rigorous methodologic procedures to ensure that the findings are as free of bias as possible.
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Abstract
PURPOSE OF REVIEW We present data from recently conducted research regarding the diagnosis of blunt cervical spine injury (CSI) in children. RECENT FINDINGS Research in the prehospital setting to evaluate the need for cervical spine immobilization in children, regardless of clinical findings or mechanism of injury, suggests that low-risk prediction rules may be safely utilized by prehospital providers, although more data is needed. Their size, developing skeleton and unique anatomy leave children vulnerable to particular injury patterns, namely cephalad bony fractures and ligamentous and spinal cord injuries without radiographic abnormality. Low-risk clinical prediction rules have been developed but need to be further validated. For those children at higher risk of CSI, diagnostic imaging strategies are evolving, with computed tomography and MRI becoming more prominent. SUMMARY Evidence in the management of children with CSI has expanded in recent years, but further large prospective studies are needed. We present a review of some recent developments influencing clinical practice.
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Vaillancourt C, Charette M, Kasaboski A, Maloney J, Wells GA, Stiell IG. Evaluation of the safety of C-spine clearance by paramedics: design and methodology. BMC Emerg Med 2011; 11:1. [PMID: 21284880 PMCID: PMC3040719 DOI: 10.1186/1471-227x-11-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 02/01/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Canadian Emergency Medical Services annually transport 1.3 million patients with potential neck injuries to local emergency departments. Less than 1% of those patients have a c-spine fracture and even less (0.5%) have a spinal cord injury. Most injuries occur before the arrival of paramedics, not during transport to the hospital, yet most patients are transported in ambulances immobilized. They stay fully immobilized until a bed is available, or until physician assessment and/or X-rays are complete. The prolonged immobilization is often unnecessary and adds to the burden of already overtaxed emergency medical services systems and crowded emergency departments. METHODS/DESIGN The goal of this study is to evaluate the safety and potential impact of an active strategy that allows paramedics to assess very low-risk trauma patients using a validated clinical decision rule, the Canadian C-Spine Rule, in order to determine the need for immobilization during transport to the emergency department.This cohort study will be conducted in Ottawa, Canada with one emergency medical service. Paramedics with this service participated in an earlier validation study of the Canadian C-Spine Rule. Three thousand consecutive, alert, stable adult trauma patients with a potential c-spine injury will be enrolled in the study and evaluated using the Canadian C-Spine Rule to determine the need for immobilization. The outcomes that will be assessed include measures of safety (numbers of missed fractures and serious adverse outcomes), measures of clinical impact (proportion of patients transported without immobilization, key time intervals) and performance of the Rule. DISCUSSION Approximately 40% of all very low-risk trauma patients could be transported safely, without c-spine immobilization, if paramedics were empowered to make clinical decisions using the Canadian C-Spine Rule. This safety study is an essential step before allowing all paramedics across Canada to selectively immobilize trauma victims before transport. Once safety and potential impact are established, we intend to implement a multi-centre study to study actual impact.
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Affiliation(s)
- Christian Vaillancourt
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital - Civic Campus, 1053 Carling Avenue, Room F-658, Ottawa, ON, K1Y 4E9, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Regional Paramedic Program of Eastern Ontario, Ottawa, ON, Canada
| | - Manya Charette
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital - Civic Campus, 1053 Carling Avenue, Room F-658, Ottawa, ON, K1Y 4E9, Canada
| | - Ann Kasaboski
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital - Civic Campus, 1053 Carling Avenue, Room F-658, Ottawa, ON, K1Y 4E9, Canada
| | - Justin Maloney
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Regional Paramedic Program of Eastern Ontario, Ottawa, ON, Canada
| | - George A Wells
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital - Civic Campus, 1053 Carling Avenue, Room F-658, Ottawa, ON, K1Y 4E9, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ian G Stiell
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital - Civic Campus, 1053 Carling Avenue, Room F-658, Ottawa, ON, K1Y 4E9, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
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