To collar or not to collar. Views of pre-hospital emergency care providers on immobilisation without cervical collars: a focus group study.

BACKGROUND: Spinal cord injury (SCI) is a rare event, with high numbers of patients unnecessarily immobilised with no potential benefit based on limited evidence from the 1950s and 1960s. Contemporary opinion now challenges the notion that traditional immobilisation prevents movement and protects the spine. Current literature suggests that these methods which include semi-rigid collars can potentially cause more movement of the spine and harm the patient. The purpose of this study was to explore the views and perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar. METHODS: Focus groups were used to allow individuals to discuss and comment on a new method of immobilisation which omits the semi-rigid collar and to capture the thoughts, feelings and experiences of participants. Thematic analysis of the coded transcriptions was used to identify emerging themes. RESULTS: Three focus groups were conducted with 15 participants in each. Participants were all exposed to patients sustaining trauma within their professional roles. Six intertwined themes emerged from the analysis: communication, conflict, education/training, empowerment, risk and the patient. Woven between these themes are the complex interactions that bring together the inter-professional relationships with other emergency services and hospital staff, the patient, the public and pre-hospital care providers. DISCUSSION: Existing immobilisation practices are being challenged, with clinicians empowered to tailor practice to meet specific patient needs. There is limited empirical evidence to support current immobilisation practices. Contemporary literature suggests current practices may potentially cause harm. New pragmatic immobilisation practices are gradually being adopted by some pre-hospital care providers. CONCLUSION: This study explored the perspectives of pre-hospital care providers on immobilising patients without the use of a semi-rigid collar for potential SCI. The consensus of the participants supports a pragmatic approach to managing potential SCI that provides safe, high-quality patient-centred care.

Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol.

INTRODUCTION: As the number of patients sustaining hip fractures increases, interventions aimed at improving patient comfort and reducing complication burden acquire increased importance. Frailty, cognitive impairment, and difficulty in assessing pain control characterize this population. In order to inform future care, a review of pain assessment and the use of preoperative intravenous paracetamol (IVP) is presented. MATERIALS AND METHODS: Systematic review of preoperative IVP administration in patients presenting with a hip fracture. RESULTS: Intravenous paracetamol is effective in the early management of pain control in the hip fracture population. There is a considerable decrease in use of breakthrough pain medications when compared with other pain relief modalities. Additionally, IVP reduces the incidence of opioid-induced complications, reduces length of stay, and lowers mean pain scores. Another significant finding of this study is the poor administration of all analgesics to patients with hip fracture with up to 72% receiving no prehospital analgesia. DISCUSSION: The potential benefits of IVP as routine in the early management of hip fracture-related pain are clear. Studies of direct comparison between analgesia regimes to inform optimum bundles of analgesic care are sparse. This study highlights the need for properly constructed pathway-driven comparator studies of contemporary analgesia regimes, with IVP as a central feature to optimize pain control and minimize analgesia-related morbidity in this vulnerable population.

The growing challenge of major trauma in older people: a role for comprehensive geriatric assessment?

In this commentary article, we describe the impact that an ageing population is having on the nature of major trauma seen in emergency departments. The proportion of major trauma victims who are older people is rapidly increasing and a fall from standing is now the most common mechanism of injury in major trauma. Potential barriers to effective care of this patient group are highlighted, including: a lack of consensus regarding triage criteria; potentially misleading physiological parameters within triage criteria; non-linear patient presentations and diagnostic nihilism. We argue that the complex ongoing care and rehabilitation needs of older patients with major trauma may be best met through Comprehensive Geriatric Assessment (CGA). Furthermore, the use of frailty screening tools may facilitate more informed early decision-making in relation to treatment interventions in older trauma victims. We call for geriatric medicine and emergency medicine departments to collaborate-equipping urgent care staff with the basic competencies necessary to initiate CGA should be a priority, and geriatricians have a key role to play in delivery of such educational interventions.