Prehospital care - scoop and run or stay and play?

Improved training and expertise has enabled emergency medical personnel to provide advanced levels of care at the scene of trauma. While this could be expected to improve the outcome from major injury, current data does not support this. Indeed, prehospital interventions beyond the BLS level have not been shown to be effective and in many cases have proven to be detrimental to patient outcome. It is better to "scoop and run" than "stay and play". Current data relates to the urban environment where transport times to trauma centres are short and where it appears better to simply rapidly transport the patient to hospital than attempt major interventions at the scene. There may be more need for advanced techniques in the rural environment or where transport times are prolonged and certainly a need for more studies into subsets of patients who may benefit from interventions in the field.

Falls from height: spine, spine, spine!

BACKGROUND: Falls from a height are a major cause of morbidity and hospital cost. Spinal injury is frequently associated with falls from height, but reliable predictive factors have not been identified. Diagnostic evaluation of the spine is complex and debated. Our objective was to characterize spinal injury after falls from height and identify predictive factors of spinal injuries. STUDY DESIGN: Medical records of patients with falls from height>10 feet admitted in a Level I trauma center during a period of 66 months were reviewed. Univariate and multivariate analyses were performed to identify independent risk factors of spinal injuries. RESULTS: Of 414 patients, 127 (31%) suffered 277 spinal injuries. Multiple spinal injuries at different levels were found in 62 (49%) patients; in 19 (15%) spinal injuries were at noncontinuous levels. The only independent predictor of spinal injury was alcohol intoxication (odds ratio=3.305; 95% CI, 1.75-6.242; p<0.001) but the number of intoxicated patients was low and the predictive ability weak. Level of falls from height did not correlate with likelihood of spinal injury. Twenty-four of 107 (22%) patients with spinal injuries and a reliable clinical examination had no symptoms related to the spine; all but 2 had distracting injuries. CONCLUSIONS: Spinal injury is frequent among survivors of falls from height>10 feet. Because of the absence of reliable predictors of spinal injury, the possibility of multiple noncontinuous fractures, and the presence of distracting injuries clouding the clinical presentation, aggressive evaluation of the entire spine is warranted.

Routine repeat head CT for minimal head injury is unnecessary.

BACKGROUND: Patients with MHI and a positive head computed tomography (CT) scan frequently have a routine repeat head CT (RRHCT) to identify possible evolution of the head injury requiring intervention. RRHCT is ordered based on the premise that significant injury progression may take place in the absence of clinical deterioration. METHODS: In a Level I urban trauma center with a policy of RRHCT, we reviewed the records of 692 consecutive trauma patients with Glasgow Coma Scale scores of 13-15 and a head CT (October 2004 through October 2005). The need for medical or surgical neurologic intervention after RRHCT was recorded. Patients with a worse and unchanged RRHCT were compared, and independent predictors of a worse RRHCT were identified by stepwise logistic regression. RESULTS: There were 179 patients with MHI and RRHCT ordered. Of them, 37 (21%) showed signs of injury evolution on RRHCT and 7 (4%) required intervention. All 7 had clinical deterioration preceding RRHCT. In no patient without clinical deterioration did RRHCT prompt a change in management. A Glasgow Coma Scale score less than 15 (13 or 14), age higher than 65 years, multiple traumatic lesions found on first head CT, and interval shorter than 90 minutes from arrival to first head CT predicted independently a worse RRHCT. CONCLUSIONS: RRHCT is unnecessary in patients with MHI. Clinical examination identifies accurately the few who will show significant evolution and require intervention.

Emergency department abdominal computed tomography for nontraumatic abdominal pain: optimizing utilization.

OBJECTIVES: To identify predictors of positive computed tomographic (CT) yield and to measure the impact of CT yield on the disposition of patients referred for computed tomography after presenting to an emergency department with nontraumatic abdominal pain. MATERIALS AND METHODS: Computed tomographic reports, laboratory data, and emergency department and hospital records were retrospectively analyzed in 604 consecutive patients undergoing CT examinations. Computed tomographic yield was correlated to age, gender, leukocyte count, specified precomputed-tomography clinical diagnosis, and patient disposition. RESULTS: Forty-eight percent of CT scans (298 of 621) had positive results. Computed tomographic results were positive in 76% of children (13 of 17) and 47% of adults (285 of 604) (P < .03) and in 45% of female patients (155 of 343) and 51% of male patients (143 of 278) (P < .2). Fifty-two percent of CT scans (223 of 426) with and 38% (75 of 195) without specified precomputed-tomography clinical diagnoses had positive results (P < .01). Fifty-eight percent of CT scans (161 of 278) with elevated and 40% of CT scans (135 of 336) with normal patient leukocyte counts had positive results (P < .001). Sixty-seven percent of patients (171 of 256) admitted and 35% of patients (127 of 365) discharged had positive CT results (P < .001). Computed tomography revealed unsuspected diagnoses in 27% of patients (165 of 621). Thirteen percent of patients (12 of 93) without any clinical predictors for positive CT yield were admitted after positive CT results. Thirty-eight percent of patients (104 of 273) with clinically suspected diagnoses requiring admission were discharged after negative CT results. CONCLUSION: Clinical indicators of positive CT yield include pediatric age, leukocytosis, and a specified precomputed-tomography diagnosis. Positive CT results are a predictor for hospital admission. In one quarter of cases, computed tomography identifies clinically unsuspected diagnoses and thereby adds information important for patient management, even after clinical evaluation.

Hyperventilation in traumatic brain injury patients: inconsistency between consensus guidelines and clinical practice.

BACKGROUND: This study assessed patients with traumatic brain injury (TBI) to determine whether prehospital and community hospital providers employed hyperventilation therapy inconsistent with consensus recommendation against its routine use. METHODS: This prospective analysis of 37 intubated TBI patients without herniation, undergoing helicopter transport to an urban Level I center, entailed flight crews' noting of assisted ventilation rate (AVR) and end-tidal carbon dioxide (ETCO2) upon their arrival at trauma scenes or community hospitals. A priori-set levels of AVR and ETCO2 were used to assess frequency of guideline-inconsistent hyperventilation, and Fisher's exact and Kruskal-Wallis tests assessed association between guideline-inconsistent hyperventilation and manual vs. mechanical ventilation mode. RESULTS: Inappropriately high AVR and low ETCO2 were seen in 60% and 70% of patients, respectively. Manual ventilation was associated with guideline-inconsistent hyperventilation assessed by AVR (p = 0.038) and ETCO2 (p = 0.022). CONCLUSION: Prehospital and community hospital hyperventilation practices are not consistent with consensus recommendations for limitation of hyperventilation therapy.

EMS Agenda for the Future: Where We Are Where We Want to Be.

During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the "EMS Agenda for the Future." Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are Integration of Health Services, EMS Research, Legislation and Regulation, System Finance, Human Resources, Medical Direction, Education Systems, Public Education, Prevention, Public Access, Communication Systems, Clinical Care, Information Systems, and Evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care. [Delbridge TR, Bailey B, Chew JL Jr, Conn AKT, Krakeel JJ, Manz D, Miller DR, O'Malley PJ, Ryan SD, Spaite DW, Stewart RD, Suter RE, Wilson EM: EMS agenda for the future: Where we are … where we want to be. Ann Emerg Med February 1998;31:251-263.].