Cervical spine fractures in elderly patients with hip fracture after low-level fall: an opportunity to refine prehospital spinal immobilization guidelines?

BACKGROUND: Conventional prehospital spine-assessment approaches based on low index of suspicion and mechanism of injury (MOI) result in the liberal application of spinal immobilization in trauma patients. A painful distracting injury (DI), such as a suspected hip fracture, historically has been a sufficient condition for immobilization, even in an elderly patient who suffers a simple fall from standing and exhibits no other risk factors for spinal injury. Because the elderly are at increased risk of hip fracture from low-level falls, and are also particularly susceptible to the discomfort and morbidity associated with immobilization, the prevalence of cervical spine (c-spine) fracture in this patient population was examined. METHODS: Hospital billing records were used to identify all cases of traumatic femur fracture in Minnesota (USA) in 2010-2011. Concurrent diagnosis and external cause codes were used to estimate the prevalence of c-spine fracture by age and MOI. RESULTS: Among 1,394 patients with femur fracture, 23 (1.7%) had a c-spine fracture. When the MOI was a fall from standing or sitting height and the patient age was ≥ 65, the prevalence dropped to 0.4% (2/565). The prevalence was similar when the definition of hip fracture additionally included pelvis fractures (0.5%; 11/2,441). Eight of the 11 patients with c-spine fracture had diagnosis codes indicative of criteria other than the DI that likely would have resulted in immobilization (eg, head injury and compromised mental status). CONCLUSIONS: C-spine fracture is extremely rare in elderly patients who sustain hip fracture as a result of a low-level fall, and appears to be accompanied frequently by other known predictors of spinal injury besides DI. More research is needed to determine whether conservative use of spinal immobilization may be warranted in elderly patients with hip fracture after low-level falls when the only criteria for immobilization is the distracting hip injury.

Reproducibility of impedance cardiography parameters in outpatients with clinically stable coronary artery disease.

BACKGROUND: Impedance cardiography (ICG) is a noninvasive method of determining hemodynamic parameters. It is clinically important to determine whether any change in ICG parameters occur due to changes in disease status or therapeutic interventions, or due to normal hemodynamic and technology variability. The objective of this study was to establish the intra- and inter-day reproducibility of ICG in a stable population with coronary artery disease (CAD). METHODS: A prospective, time series design was used. The study group consisted of 96 clinically stable CAD patients in an outpatient cardiac rehabilitation program. Measurements of ICG hemodynamic parameters were obtained at four points in time: after 5 and 10 min of rest on the first day and after 5 and 10 min of rest on a second day, 1 week later. RESULTS: There were small but significant intra-day changes between the 5- and 10-min hemodynamic measures. Mean absolute percent changes in intra-day hemodynamic measures were <8%. High intra-day correlation was observed, ranging from 0.85 for mean arterial pressure to 0.99 for thoracic fluid content. There were expectedly larger inter-day hemodynamic variation of up to 18% and lower inter-day correlation for all ICG parameters ranging from 0.66 to 0.88. CONCLUSIONS: Impedance cardiography measurements demonstrate both intra- and inter-day reproducibility within clinically acceptable ranges in a clinically stable population of CAD patients. The expected ranges of variation can be used to gauge whether a patient's hemodynamic status has changed because of disease or intervention.