Neurologic outcomes following the introduction of a policy for using soft cervical collars in suspected traumatic cervical spine injury: A retrospective chart review.

OBJECTIVE: In trauma patients with potential cervical spine injury, immobilisation with a rigid cervical collar is widely recommended to prevent a secondary spinal cord injury. There is a lack of evidence for the effectiveness of this practice, but increasing evidence for complications from rigid collars. Soft foam collars may mitigate some of these issues and are used in our health service in place of rigid collars in selected patients at risk for traumatic cervical spine injury. The objective of the present study was to describe the neurological outcome of patients according to the cervical stabilisation technique used. METHODS: A multi-centre, retrospective, consecutive, case series of all patients assessed for a traumatic cervical spine injury from October 2017 to July 2018 was conducted. Data were obtained by a medical chart review. The primary outcome was the development of a new neurological deficit because of spinal cord injury while in hospital. RESULTS: Inter-rater reliability of data abstraction demonstrated very strong agreement (kappa 0.85, 95% confidence interval 0.80-0.90). Of 2036 patients, 1133 were managed in a soft collar. A new neurological deficit because of spinal cord injury developed in two patients managed in a rigid collar. One case managed in a soft collar was uncertain because of an incomplete baseline neurological examination. CONCLUSION: The use of soft foam cervical collars in patients at risk for a cervical spine injury does not appear to increase the risk for secondary spinal cord injury but larger prospective studies are required before a robust conclusion on safety can be claimed.

Conservative versus Interventional Treatment for Spontaneous Pneumothorax.

BACKGROUND: Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS: In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS: A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS: Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events. (Funded by the Emergency Medicine Foundation and others; PSP Australian New Zealand Clinical Trials Registry number, ACTRN12611000184976.).

Study protocol for a randomised controlled trial of invasive versus conservative management of primary spontaneous pneumothorax.

INTRODUCTION: Current management of primary spontaneous pneumothorax (PSP) is variable, with little evidence from randomised controlled trials to guide treatment. Guidelines emphasise intervention in many patients, which involves chest drain insertion, hospital admission and occasionally surgery. However, there is evidence that conservative management may be effective and safe, and it may also reduce the risk of recurrence. Significant questions remain regarding the optimal initial approach to the management of PSP. METHODS AND ANALYSIS: This multicentre, prospective, randomised, open label, parallel group, non-inferiority study will randomise 342 participants with a first large PSP to conservative or interventional management. To maintain allocation concealment, randomisation will be performed in real time by computer and stratified by study site. Conservative management will involve a period of observation prior to discharge, with intervention for worsening symptoms or physiological instability. Interventional treatment will involve insertion of a small bore drain. If drainage continues after 1 hour, the patient will be admitted. If drainage stops, the drain will be clamped for 4 hours. The patient will be discharged if the lung remains inflated. Otherwise, the patient will be admitted. The primary end point is the proportion of participants with complete lung re-expansion by 8 weeks. Secondary end points are as follows: days in hospital, persistent air leak, predefined complications and adverse events, time to resolution of symptoms, and pneumothorax recurrence during a follow-up period of at least 1 year. The study has 95% power to detect an absolute non-inferiority margin of 9%, assuming 99% successful expansion at 8 weeks in the invasive treatment arm. The primary analysis will be by intention to treat. ETHICS AND DISSEMINATION: Local ethics approval has been obtained for all sites. Study findings will be disseminated by publication in a high-impact international journal and presentation at major international Emergency Medicine and Respiratory meetings. TRIAL REGISTRATION NUMBER: ACTRN12611000184976; Pre-results.

ChIP: An early activation protocol for isolated blunt chest injury improves outcomes, a retrospective cohort study.

BACKGROUND: Blunt chest injuries not treated in a timely manner with sufficient analgesia, physiotherapy and respiratory support are associated with increased morbidity and mortality. The aim of the study was to determine the impact of a blunt chest injury early activation protocol (ChIP) on patient and hospital outcomes. METHODS: In this pre-post cohort study, the outcomes of patients with blunt chest injury who received ChIP were compared against those who did not. Data including injury severity, patient outcomes, hospital treatments and comorbidites were extracted from medical records. The primary outcome was pneumonia. Secondary outcomes evaluated health service delivery. Logistic and multiple regressions were used to adjust for potential confounding variables. RESULTS: 546 patients were included, 273 in the before-ChIP cohort and 273 in the after-ChIP cohort. The incidence of pneumonia following the introduction of ChIP was reduced by 4.8% (95% CI 0.5-9.2, p=0.03). In the after-ChIP cohort, more patients received a pain team review (32% vs. 13%, p<0.001), physiotherapy (93% vs. 86%, p=0.005) and trauma team review (95% vs. 39%, p<0.001). There was no difference in length of stay (p=0.50). CONCLUSIONS: ChIP improved the delivery of healthcare services and reduced the rate of pneumonia among patients with isolated chest trauma.

A Systematic Review and Meta-analysis of D-dimer as a Rule-out Test for Suspected Acute Aortic Dissection.

STUDY OBJECTIVE: The aim of this systematic review and meta-analysis is to determine the diagnostic accuracy of D-dimer as a rule-out test for acute aortic dissection. Previous meta-analyses have had methodological problems with conflicting conclusions, and new diagnostic accuracy studies have been published since. METHODS: All prospective cross-sectional analytic studies of D-dimer as a diagnostic test for acute aortic dissection were included where diagnosis was confirmed by an accepted reference standard. Studies were identified with MEDLINE, EMBASE, Medion, Google Scholar, Web of Science, and bibliographies of relevant articles and previous systematic reviews. Two reviewers independently screened articles for inclusion, assessed study quality, and extracted data. RESULTS: Abstracts from 800 articles were reviewed, yielding 30 potentially relevant studies that were reviewed in full text. Five studies met all eligibility criteria. Data from 4 studies (1,557 participants) that used a D-dimer cutoff of 0.50 µg/mL were pooled to estimate sensitivity, specificity, and positive and negative likelihood ratios. Overall, sensitivity and negative likelihood ratio were 98.0% (95% confidence interval [CI] 96.3% to 99.1%) and 0.05 (95% CI 0.03 to 0.09), respectively. These measurements had little statistical heterogeneity. Specificity (41.9%; 95% CI 39.0% to 44.9%) and positive likelihood ratio (2.11; 95% CI 1.46 to 3.05) showed significant statistical heterogeneity. When applied to a low-risk population as defined by the American Heart Association (prevalence 6%), the posttest probability for acute aortic dissection was 0.3%. CONCLUSION: This meta-analysis suggests that a negative D-dimer result may be useful to help rule out acute aortic dissection in low-risk patients.

Improvement in emergency department length of stay using a nurse-led 'emergency journey coordinator': a before/after study.

OBJECTIVE: Australian EDs are required to conform to the National Emergency Access Target (NEAT): patients must depart within 4 h of arrival. The study's aim was to determine if a nursing role called the 'Emergency Journey Coordinator' (EJC) improved NEAT through resolving delays in patient processing. METHODS: The proportion of patients achieving NEAT before and after the EJC role started were compared with adjustment for confounding variables. All data were obtained from the ED computer management system. RESULTS: There were 23 848 patients over a 128 day period before and 20 884 over a 115 day period after the introduction of the EJC role. The proportion of patients meeting NEAT after the EJC role started was 64.4% compared with 59.6% before, an absolute improvement of 4.9% (95% confidence interval [CI] 4.0-5.8, P < 0.001). This benefit persisted after controlling for confounding effects. For patients admitted NEAT was 38.1% after the EJC role started compared with 32.5% before, an absolute improvement of 5.6% (95% CI 4.1-7.1, P < 0.001). For patients discharged, NEAT was 80.2% after the EJC role started compared with 74.6% before, an absolute improvement of 5.6% (95% CI 4.7-6.6, P < 0.001). Mean ED occupancy decreased from 34.3 patients before to 32.4 after, a decrease of 2.0 patients (95% CI 1.2-2.8, P < 0.001). There was no clinically important difference in the proportion of patient who did not wait to be seen or in ambulance transfer of care time. CONCLUSION: NEAT targets were improved in the ED of a tertiary referral hospital after the introduction of the EJC role.

Validation of a method to assess range of motion of the cervical spine using a tape measure.

OBJECTIVE: The purposes of this study were to validate a tape measure method for measuring cervical spine range of motion compared with a universal goniometer in all planes of motion and to derive equations to convert a linear measurement to an angular distance. METHODS: Participants were healthy volunteers. Measurements of flexion/extension, rotation, and lateral flexion were made with the universal goniometer and tape measure, in the neutral position, extreme of motion, and 2 positions between. Measurements from the 2 techniques were compared with Pearson correlation coefficient and simple linear regression to determine R(2), the regression coefficient and the regression equation. Reliability was assessed using the intraclass correlation coefficient. RESULTS: There were 40 participants with a mean age of 30.5 (SD, 9.1) years. Goniometer measurements had good to excellent correlation with both absolute and percentage change in tape measurement (correlation coefficients, 0.74-0.94 and 0.75-0.91, respectively). Correlation was highest for flexion and extension, lowest for rotation and lateral flexion. The amount of variability in the data explained by the linear regression models (R(2)) varied from 55% to 89%. Intraclass correlation coefficient ranged from 0.44 to 0.69 and 0.38 to 0.59 for intrarater and interrater reliability, respectively. Reliability was greatest for flexion and extension, lowest for rotation and lateral flexion. CONCLUSION: This study demonstrated that tape measurements correlated well with a universal goniometer. The tape measure may be useful for measuring cervical spine range of motion where availability, simplicity, and low cost are important considerations such as with conduct of research or patient management.

Factors associated with failure to follow up with a general practitioner after discharge from the emergency department.

OBJECTIVES: To identify factors associated with failure to follow up with a general practitioner (GP) after discharge from the ED or emergency medicine unit (EMU). METHODS: This prospective cohort study enrolled adult patients discharged from the ED who were requested to see their GP to complete their medical care. Participants were contacted by phone after 2 weeks to determine GP follow-up status. Variables associated with failure to follow up were determined using multivariate logistic regression. RESULTS: Of 247 participants enrolled, 217 had complete outcome data. After controlling for the confounding effect of other variables, four variables remained significantly associated with follow-up status. Compared with participants who did follow up, those who failed to follow up were less likely to have an EMU admission (OR 0.46, 95% CI 0.22-0.93, P < 0.03), a regular GP (OR 0.16, 95% CI 0.08-0.35, P < 0.001), health insurance (OR 0.41, 95% CI 0.20-0.82, P < 0.01) or awareness of the reason why they were supposed to follow up (OR 0.25, 95% CI 0.11-0.54, P < 0.001). The most common reason for failure to follow up (65%) was that the participant did not consider it necessary. CONCLUSION: Participants who were aware of the reason for follow up with a GP, who were admitted to EMU, had health insurance or had a regular GP were more likely to comply with follow-up advice. This highlights that good patient communication is important for successful follow up, and that alternative avenues for completion of management need to be explored for patients without health insurance or a regular GP.