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Chary AN, Suh M, Ordoñez E, Cameron-Comasco L, Ahmad S, Zirulnik A, Hardi A, Landry A, Ramont V, Obi T, Weaver EH, Carpenter CR. A scoping review of geriatric emergency medicine research transparency in diversity, equity, and inclusion reporting. J Am Geriatr Soc 2024. [PMID: 38994587 DOI: 10.1111/jgs.19052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/09/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION The intersection of ageism and racism is underexplored in geriatric emergency medicine (GEM) research. METHODS We performed a scoping review of research published between January 2016 and December 2021. We included original emergency department-based research focused on falls, delirium/dementia, medication safety, and elder abuse. We excluded manuscripts that did not include (1) original research data pertaining to the four core topics, (2) older adults, (3) subjects from the United States, and (4) for which full text publication could not be obtained. The primary objective was to qualitatively describe reporting about older adults' social identities in GEM research. Secondary objectives were to describe (1) the extent of inclusion of minoritized older adults in GEM research, (2) GEM research about health equity, and (3) feasible approaches to improve the status quo of GEM research reporting. RESULTS After duplicates were removed, 3277 citations remained and 883 full-text articles were reviewed, of which 222 met inclusion criteria. Four findings emerged. First, race and ethnicity reporting was inconsistent. Second, research rarely provided a rationale for an age threshold used to define geriatric patients. Third, GEM research more commonly reported sex than gender. Fourth, research commonly excluded older adults with cognitive impairment and speakers of non-English primary languages. CONCLUSION Meaningful assessment of GEM research inclusivity is limited by inconsistent reporting of sociodemographic characteristics, specifically race and ethnicity. Reporting of sociodemographic characteristics should be standardized across different study designs. Strategies are needed to include in GEM research older adults with cognitive impairment and non-English primary languages.
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Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Michelle Suh
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois, USA
| | - Edgardo Ordoñez
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Lauren Cameron-Comasco
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oaks, Michigan, USA
| | - Surriya Ahmad
- Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, New York, USA
| | - Alexander Zirulnik
- Department of Emergency Medicine, Massachusetts General Brigham, Boston, Massachusetts, USA
| | - Angela Hardi
- Olin Medical Library, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alden Landry
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vivian Ramont
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Tracey Obi
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
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Lundy ME, Zhang B, Ditillo M. Management of the Geriatric Trauma Patient. Surg Clin North Am 2024; 104:423-436. [PMID: 38453311 DOI: 10.1016/j.suc.2023.09.010] [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: 03/09/2024]
Abstract
With a rapidly aging worldwide population, the care of geriatric trauma patients will be at the forefront of every career in Trauma and Acute Care Surgery. The unique intersection of advanced age, comorbidities, frailty, and physiologic changes presents a challenge in the care of elderly injured patients. It is well established that increasing age is associated with higher mortality and worse outcomes after injury, but it is also clear that there is room for improvement in the management of this special patient population.
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Affiliation(s)
- Megan Elizabeth Lundy
- University of Arizona Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, 1501 North Campbell Avenue, Tucson, AZ 85724, USA. https://twitter.com/MLundyMD
| | - Bo Zhang
- University of Arizona Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, 1501 North Campbell Avenue, Tucson, AZ 85724, USA. https://twitter.com/bo_zhang1
| | - Michael Ditillo
- University of Arizona Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, 1501 North Campbell Avenue, Tucson, AZ 85724, USA.
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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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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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Cowley A, Nelson M, Hall C, Goodwin S, Kumar DS, Moore F. Recommendation for changes to the guidelines of trauma patients with potential spinal injury within a regional UK ambulance trust. Br Paramed J 2022; 7:59-67. [PMID: 36531802 PMCID: PMC9730189 DOI: 10.29045/14784726.2022.12.7.3.59] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Spinal assessment and immobilisation has been a topic of debate for many years where, despite an emerging evidence base and the delivery of new guidance overseas, little has changed within UK pre-hospital practice. Since 2018, South East Coast Ambulance Service NHS Foundation Trust has spent time working with local trauma networks and expertise from within the region and international colleagues to develop a set of C-spine assessment and immobilisation guidelines that reflect the current best available international evidence and significant changes in international pre-hospital practice from settings such as Scandinavia and Australasia. METHODS A specialist group was commissioned to review the topic of pre-hospital spinal immobilisation and explore potential for evidence-based improvement. In conjunction with local trauma networks, subject matter experts and a thorough review of recent literature, a series of recommendations were made in order to improve spinal care within the authoring trust. RESULTS Seven recommendations were made, and an updated set of guidelines produced. These included the removal of semi-rigid collars from pre-hospital spinal immobilisation; the creation of two tiers of patients to ensure that the high-risk and low-risk populations are considered separately and an accompanying decision tool to safeguard both cohorts; an increased emphasis on the risk of spinal injury in the frail and older patient; an emphasis on spinal motion restriction rather than rigid immobilisation; an increased emphasis on self-extrication; and the use of a marker for emergency departments. SUMMARY An updated set of guidance has been produced using a combination of specialist and expert opinion alongside a literature review with close involvement of key stakeholders, both public and professional. The new guidance helps to ensure a patient-centred approach where each person is considered an individual with their risk of injury and management measures tailored to their specific needs.
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Affiliation(s)
- Alan Cowley
- South East Coast Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0002-3093-4395
| | - Magnus Nelson
- South East Coast Ambulance Service NHS Foundation Trust
| | - Claire Hall
- South East Coast Ambulance Service NHS Foundation Trust
| | - Simon Goodwin
- South East Coast Ambulance Service NHS Foundation Trust
| | | | - Fionna Moore
- South East Coast Ambulance Service NHS Foundation Trust
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Williams JR, Muesch AJ, Svenson JE, Clegg AW, Patterson BW, Ward MA. Utility of bedside assessment to evaluate for cervical-spine fracture post ground-level fall for patients 65 years and older. Am J Emerg Med 2022; 53:208-214. [DOI: 10.1016/j.ajem.2022.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 10/19/2022] Open
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Bérubé M, Moore L, Tardif PA, Berry G, Belzile É, Lesieur M, Paquet J. Low-value injury care in the adult orthopaedic trauma population: A systematic review. Int J Clin Pract 2021; 75:e15009. [PMID: 34816530 DOI: 10.1111/ijcp.15009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/19/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices. METHODS We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes. RESULTS Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. CONCLUSION In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Pierre-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
| | - Gregory Berry
- Division of Orthopaedic Surgery, McGill University Health Center, Montréal, Québec, Canada
| | - Étienne Belzile
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Martin Lesieur
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Jérôme Paquet
- Division of Neurosurgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
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Cushing CH, Holmes JF, Tyler KR. Cervical Spine Injuries in Older Patients with Falls Found on Magnetic Resonance Imaging After Computed Tomography. West J Emerg Med 2021; 22:1190-1195. [PMID: 34546897 PMCID: PMC8463044 DOI: 10.5811/westjem.2021.5.51844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/26/2021] [Accepted: 05/05/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION In this study we aimed to determine the rate of traumatic abnormalities on cervical spine magnetic resonance imaging (MRI) after a normal cervical spine computed tomography (CT) in older patients with ground-level falls. We hypothesized that MRI is low yield following a normal physical examination and normal CT after a ground-level fall. METHODS This was a retrospective cohort study of patients 65 years and older evaluated with a cervical spine MRI following a ground-level fall. Inclusion criteria included age 65 years and older, ground-level fall, normal cervical spine CT followed by a cervical spine MRI. We abstracted data following accepted methodologic guidelines. Patients with any focal neurological finding were considered to have an abnormal neurological examination. Imaging studies were considered to be abnormal if there was a report of an acute traumatic injury. The primary outcome was a traumatic abnormality identified on MRI. We described data with simple descriptive statistics. RESULTS Eighty-seven patients with a median age of 74 (interquartile range [IQR] 69, 83]) years had an MRI following a normal cervical spine CT. Median emergency department length of stay was 8.2 hours (IQR 5.3, 13.5). Sixty-four (73.6%) patients had a normal neurological examination on arrival; eight of these patients (12.5% (95% confidence interval [CI], 5.6-23.2%) had an abnormal cervical spine MRI. Twenty-three patients (26.4%) had an abnormal neurological examination on arrival; two of these patients (8.7%, 95% CI, 1.1-28%) had an abnormal cervical spine MRI. Overall, 10 patients (11.5%) had an abnormal cervical spine MRI. One patient underwent operative intervention due to an unstable injury. Of the remaining nine patients with acute findings on cervical spine MRI, there were no other unstable injuries; two patients were managed with cervical orthosis, and seven patients had no additional management. CONCLUSION In this study of older patients with ground-level falls and normal, atraumatic, cervical spine CT, a small portion had traumatic abnormalities on MRI, with few requiring further intervention. Further study is required to identify criteria to determine when MRI should be performed in older patients after a ground-level fall.
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Affiliation(s)
- Corinne H Cushing
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - James F Holmes
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - Katren R Tyler
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
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Benchetrit S, Blackham J, Braude P, Halliday R, Shipway D, Williams A, Carlton E. Emergency management of older people with cervical spine injuries: an expert practice review. Emerg Med J 2021; 39:331-336. [PMID: 34344732 DOI: 10.1136/emermed-2020-211002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/26/2021] [Indexed: 11/03/2022]
Abstract
Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.
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Affiliation(s)
| | | | - Philip Braude
- Department of Medicine for Older People, Southmead Hospital, Bristol, UK
| | - Ruth Halliday
- Trauma & Orthopaedic Research Team, Southmead Hospital, Bristol, UK
| | - David Shipway
- Department of Medicine for Older People, Southmead Hospital, Bristol, UK
| | - Adam Williams
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
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Engelbart J, Zhou P, Johnson J, Lilienthal M, Zhou Y, Ten-Eyck P, Galet C, Skeete D. Geriatric clinical screening tool for cervical spine injury after ground-level falls. Emerg Med J 2021; 39:301-307. [PMID: 34108196 DOI: 10.1136/emermed-2020-210693] [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: 09/19/2020] [Accepted: 05/28/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND A consistent approach to cervical spine injury (CSI) clearance for patients 65 and older remains a challenge. Clinical clearance algorithms like the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have variable accuracy and the Canadian C-spine rule excludes older patients. Routine CT of the cervical spine is performed to rule out CSI but at an increased cost and low yield. Herein, we aimed to identify predictive clinical variables to selectively screen older patients for CSI. METHODS The University of Iowa's trauma registry was interrogated to retrospectively identify all patients 65 years and older who presented with trauma from a ground-level fall from January 2012 to July 2017. The relationship between predictive variables (demographics, NEXUS criteria and distracting injuries) and presence of CSI was examined using the generalised linear modelling (GLM) framework. A training set was used to build the statistical models to identify clinical variables that can be used to predict CSI and a validation set was used to assess the reliability and consistency of the model coefficients estimated from the training set. RESULTS Overall, 2312 patients ≥65 admitted for ground-level falls were identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best predictive model for CSI included midline tenderness, focal neurological deficit and signs of trauma to the head/face, with midline tenderness highly predictive of CSI (OR=22.961 (15.178-34.737); p<0.001). The negative predictive value (NPV) for this model was 95.1% (93.9%-96.3%). In the absence of midline tenderness, the best model included focal neurological deficit (OR=2.601 (1.340-5.049); p=0.005) and signs of trauma to the head/face (OR=3.024 (1.898-4.815); p<0.001). The NPV was 94.3% (93.1%-95.5%). CONCLUSION Midline tenderness, focal neurological deficit and signs of trauma to the head/face were significant in this older population. The absence of all three variables indicates lower likelihood of CSI for patients≥65. Future observational studies are warranted to prospectively validate this model.
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Affiliation(s)
- Jacklyn Engelbart
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Peige Zhou
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Jenna Johnson
- Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Michele Lilienthal
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Yunshu Zhou
- Institute for Clinical and Translational Science, Biostatistics, Epidemiology, and Research Design Core, The University of Iowa, Iowa City, Iowa, USA
| | - Patrick Ten-Eyck
- Institute for Clinical and Translational Science, Biostatistics, Epidemiology, and Research Design Core, The University of Iowa, Iowa City, Iowa, USA
| | - Colette Galet
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Dionne Skeete
- Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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Liang T, Roseman E, Gao M, Sinert R. The Utility of the Focused Assessment With Sonography in Trauma Examination in Pediatric Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis. Pediatr Emerg Care 2021; 37:108-118. [PMID: 30870341 DOI: 10.1097/pec.0000000000001755] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the utility of the Point of Care Ultrasound (POCUS) Focused Assessment with Sonography for Trauma (FAST) examination for diagnosis of intra-abdominal injury (IAI) in children presenting with blunt abdominal trauma. METHODS We searched medical literature from January 1966 to March 2018 in PubMed, EMBASE, and Web of Science. Prospective studies of POCUS FAST examinations in diagnosing IAI in pediatric trauma were included. Sensitivity, specificity, and likelihood ratios (LR) were calculated using a random-effects model (95% confidence interval). Study quality and bias risk were assessed, and test-treatment threshold estimates were performed. RESULTS Eight prospective studies were included encompassing 2135 patients with a weighted prevalence of IAI of 13.5%. Studies had variable quality, with most at risk for partial and differential verification bias. The results from POCUS FAST examinations for IAI showed a pooled sensitivity of 35%, specificity of 96%, LR+ of 10.84, and LR- of 0.64. A positive POCUS FAST posttest probability for IAI (63%) exceeds the upper limit (57%) of our test-treatment threshold model for computed tomography of the abdomen with contrast. A negative POCUS FAST posttest probability for IAI (9%) does not cross the lower limit (0.23%) of our test-treatment threshold model. CONCLUSIONS In a hemodynamically stable child presenting with blunt abdominal trauma, a positive POCUS FAST examination result means that IAI is likely, but a negative examination result alone cannot preclude further diagnostic workup for IAI. The need for computed tomography scan may be obviated in a subset of low-risk pediatric blunt abdominal trauma patients presenting with a Glasgow Coma Scale of 14 to 15, a normal abdominal examination result, and a negative POCUS FAST result.
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Baker M, Jaeger C, Hafley C, Waymack J. Appropriate CT cervical spine utilisation in the emergency department. BMJ Open Qual 2020; 9:bmjoq-2019-000844. [PMID: 33028655 PMCID: PMC7542617 DOI: 10.1136/bmjoq-2019-000844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 07/30/2020] [Accepted: 09/18/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction Over 40 000 CT scans are performed in our emergency department (ED) annually and utilisation is over 80% capacity. Improving medical appropriateness of CT scans may reduce total number of scans, time, cost and radiation exposure. Methods Lean Six Sigma methodology was used to improve the process. A National Emergency X-Radiography Utilisation Study (NEXUS)-based PowerForm was implemented in the electronic health record and providers were educated on the criteria. Results The rate of potentially medically inappropriate CT C-spine scans decreased from 45% (19/42) to 22% (90/403) (two-proportion test, p=0.002). After the intervention, there was no longer a difference between midlevel providers and physicians in the rate of medically inappropriate orders (19% vs 22%) (two-proportion test, p=0.850) compared with that before the intervention (56% vs 31%) (two-proportion test, p<0.01). Overall rates of CT C-spine scans ordered decreased from 69.3 to 62.6/week (t-test, p=0.019). Conclusion A validated clinical decision-making tool implemented into the medical record can improve quality of care. This study lays a foundation for other imaging studies with validated support tools with similar potential improvements.
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Affiliation(s)
- Mark Baker
- Department of Emergency Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Cassie Jaeger
- Department of Operations Improvement, Memorial Health System, Springfield, Illinois, USA
| | - Carol Hafley
- Midwest Healthcare Quality Alliance, Memorial Health System, Springfield, Illinois, USA
| | - James Waymack
- Department of Emergency Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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Sacino A, Rosenblatt K. Early Management of Acute Spinal Cord Injury-Part I: Initial Injury to Surgery. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2019; 6:213-221. [PMID: 34012997 DOI: 10.1055/s-0039-1694688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Acute spinal cord injury is a devastating event associated with substantial morbidity worldwide. The pathophysiology of spinal cord injury involves the initial mechanical trauma and the subsequent inflammatory response, which may worsen the severity of neurologic dysfunction. Interventions have been studied to reduce the extent of primary injury to the spinal cord through preventive measures and to mitigate secondary insult through early specialized care. Management, therefore, is multifold, interdisciplinary, and begins immediately at the time of injury. It includes the trauma triage, acute management of the circulatory and respiratory systems, and definitive treatment, mainly with surgical decompression and stabilization.
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Affiliation(s)
- Amanda Sacino
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Kathryn Rosenblatt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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14
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Coggins A, Ebrahimi N, Kemp U, O'Shea K, Fusi M, Murphy M. A prospective evaluation of cervical spine immobilisation in low-risk trauma patients at a tertiary Emergency Department. Australas Emerg Care 2019; 22:69-75. [PMID: 31053486 DOI: 10.1016/j.auec.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/03/2019] [Accepted: 04/03/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND In the Emergency Department cervical spine immobilisation precautions are frequently used. There is controversy in regard to the balance of risks and benefits of routine immobilisation in conscious patients. METHODS A prospective multi-methods evaluation in a tertiary trauma referral centre. The objectives were to investigate current practices and rate of concordance with established international guidelines. A provider survey focused on current knowledge, skills and attitudes and was disseminated to nurses, doctors and paramedics treating trauma patients. Additionally, clinical data were collected on a cohort of immobilised trauma patients. Demographic data were analysed using SPSS and content analysis was completed by manifest coding. RESULTS The response rate to the survey was 85.2%. Interdisciplinary providers included nurses (n=46), doctors (n=68) and paramedics (n=41). Content analysis revealed a range of themes for improving care. Themes identified included improved application of guidelines, tailored use of equipment in low-risk patients, improved access to radiology results, and staff education. The series of five case vignettes provided to participants revealed a high level of variance in intended approaches to immobilisation. In the cohort of trauma patients (n=54), the median age was 54 years and the most common mechanism of injury was falls (40.7%). Median time spent with immobilisation was 325min. Adherence to a recognised decision tool was 35/54 (64.8%). Precautions were initiated by paramedics in 42/54 (77.8%). CONCLUSIONS Despite widespread dissemination of guidelines, observed approaches to patient immobilisation appear to be highly variable in this trauma centre. Reducing variation for low-risk patients is likely to improve the patient journey and minimise the risk of prolonged immobilisation. Further assessment of the causes of variation could define goals for targeted translational change.
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Affiliation(s)
- Andrew Coggins
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia.
| | - Nargus Ebrahimi
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
| | - Ursula Kemp
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
| | - Kelly O'Shea
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
| | | | - Margaret Murphy
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
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Beckmann NM, West OC, Nunez D, Kirsch CF, Aulino JM, Broder JS, Cassidy RC, Czuczman GJ, Demertzis JL, Johnson MM, Motamedi K, Reitman C, Shah LM, Than K, Ying-Kou Yung E, Beaman FD, Kransdorf MJ, Bykowski J. ACR Appropriateness Criteria® Suspected Spine Trauma. J Am Coll Radiol 2019; 16:S264-S285. [DOI: 10.1016/j.jacr.2019.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
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16
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Jambhekar A, Lindborg R, Chan V, Fulginiti A, Fahoum B, Rucinski J. Over the hill and falling down: Can the NEXUS criteria be applied to the elderly? Int J Surg 2018; 49:56-59. [DOI: 10.1016/j.ijsu.2017.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/19/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
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17
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Paykin G, O'Reilly G, Ackland H, Mitra B. Review article: NEXUS criteria to rule out cervical spine injury among older patients: A systematic review. Emerg Med Australas 2017; 30:450-455. [DOI: 10.1111/1742-6723.12880] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/15/2017] [Accepted: 09/09/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Gabriel Paykin
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Gerard O'Reilly
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Helen Ackland
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Intensive Care Department; The Alfred; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
- National Trauma Research Institute; Monash University; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
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Lau BPH, Hey HWD, Lau ETC, Nee PY, Tan KA, Tan WT. The utility of magnetic resonance imaging in addition to computed tomography scans in the evaluation of cervical spine injuries: a study of obtunded blunt trauma patients. 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; 27:1028-1033. [PMID: 28993912 DOI: 10.1007/s00586-017-5317-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 08/03/2017] [Accepted: 09/26/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Bernard Puang Huh Lau
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore
| | - Hwee Weng Dennis Hey
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore.
| | - Eugene Tze-Chun Lau
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore
| | - Pei Yi Nee
- Division of Family Medicine, National University Hospital, Singapore, Singapore
| | - Kimberly-Anne Tan
- University Orthopaedic, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 11, Singapore, 119228, Singapore
| | - Wah Tze Tan
- Department of Anaesthesia, Ng Teng Fong General Hospital, Singapore, Singapore
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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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20
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Hunter A, McGreevy J, Linden J. Pathologic C-spine fracture with low risk mechanism and normal physical exam. Am J Emerg Med 2017; 35:1383.e1-1383.e2. [PMID: 28554588 DOI: 10.1016/j.ajem.2017.05.038] [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: 04/17/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022] Open
Abstract
Cervical spinal fracture is a rare, but potentially disabling complication of trauma to the neck. Clinicians often rely on clinical decision rules and guidelines to decide whether or not imaging is necessary when a patient presents with neck pain. Validated clinical guidelines include the Canadian C-Spine Rule and the Nexus criteria. Studies suggest that the risks of a pathologic fracture from a simple rear end collision are negligible. We present a case of an individual who presented to an emergency department (ED) after a low speed motor vehicle collision complaining of lateral neck pain and had multiple subsequent visits for the same complaint with negative exam findings. Ultimately, he was found to have a severely pathologic cervical spine fracture with notable cord compression. Our objective is to discuss the necessity to incorporate clinical decision rules with physician gestalt and the need to take into account co-morbidities of a patient presenting after a minor MVC.
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Affiliation(s)
- Andrew Hunter
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, United States.
| | - Jolion McGreevy
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, United States.
| | - Judith Linden
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, United States.
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