Development of a new clinical decision rule for cervical CT to detect cervical spine injury in patients with head or neck trauma.

OBJECTIVE: Previous cervical spine imaging decision rules have been based on positive findings on plain X-ray and are limited by lack of specificity, age restrictions and complicated algorithms. We previously derived and validated a clinical decision rule (Rule 1) for detecting cervical spine injury (CSI) on CT in a single-centre study. This recommended CT for patients with (1) GCS score <14, (2) GCS 14-15 and posterior cervical tenderness or neurological deficit, (3) age ≥60 years and fall down stairs, or (4) age <60 and injured in a motorcycle collision or fallen from height. This study assessed the accuracy and reliability of this rule and refined the rule. METHODS: We conducted a prospective, dual-centre study at two Japanese EDs between August 2012 and March 2014. Patients with head or neck injury ≥16 years of age were included. Clinical data were collected from medical records. Imaging was at the discretion of the treating physician. CSI was diagnosed as a fracture or dislocation seen on CT; patients who were not imaged were followed for 14 days. We analysed the sensitivity and specificity of Rule 1 and refined it post hoc using recursive partitioning. RESULTS: 1192 patients were enrolled. 927 completed follow-up. Of these, 584 (63.0%) underwent CT imaging and 38 had CSI. Sensitivity and specificity of Rule 1 were 92.1% (95% CI 79.2% to 97.3%) and 58.6% (95% CI 55.4% to 61.9%). A second rule (Rule 2) was derived recommending CT for those with any of the following: GCS <14, cervical tenderness, neurological deficit or mechanism of injury (fall down stairs, motorcycle collision or fall from height) without age limits. Sensitivity and specificity were 100% (95% CI 90.8% to 100%) and 51.9% (95% CI 48.6% to 55.2%), respectively. CONCLUSIONS: Our initial CT decision rule had lower sensitivity than in our initial validation study. A refined decision rule based on GCS, neck tenderness, neurological deficit and mechanism of injury showed excellent sensitivity with a small loss of specificity. Rule 2 will now need validation in an independent cohort.

Outcomes and characteristics of non-immobilised, spine-injured trauma patients: a systematic review of prehospital selective immobilisation protocols.

OBJECTIVES: This review assesses prehospital selective immobilisation protocols across a range of outcomes, including neurological deterioration and characteristics of injured, non-immobilised patients. METHODS: Six electronic reference databases and eight grey literature sources were systematically searched. We included studies that enrolled acute trauma patients in the prehospital setting who were assessed for spine injury according to predefined clinical criteria and either immobilised or not. Data items included instances of neurological deterioration among patients with spine injuries, as well as available characteristics of those who were injured and not immobilised. Available data and study heterogeneity prevented meta-analyses. Bias was assessed for both individual studies and across studies by outcome. RESULTS: 604 unique articles were retrieved, of which 7 met inclusion criteria. There was moderate or high risk of bias across studies in all outcomes. Of 76 patients with spine injuries who were not immobilised, 72 had no neurological deficit that appeared after emergency medical services contact, and the remaining four were not followed. Within this group, there appears to be a trend towards elderly patients who suffered a thoracic or lumbar injury from a low-risk mechanism of injury. Among studies that report both the results of the protocol assessment and immobilisation status, there is variable correspondence between the two. CONCLUSIONS: Data limitations and study biases suggest caution when interpreting and applying the results of this review. Its findings are consistent with the conclusions of individual studies. The characteristics of injured, non-immobilised patients point to areas of future research to investigate apparent trends.

What is the purpose of log roll examination in the unconscious adult trauma patient during trauma reception?

BACKGROUND: During assessment after injury, the log roll examination, in particular palpation of the thoracolumbar spine, has low sensitivity for detecting spinal injury. The manoeuvre itself requires a pause during trauma resuscitation. The aim of this study was to assess the utility of the log roll examination in unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar spine injuries. METHODS: A retrospective cohort study was undertaken, reviewing the cases of unconscious (Glasgow Coma Scale (GCS) <9) and/or intubated major trauma (Injury Severity Scale (ISS) >12, abbreviated injury scale 2008) patients from the Alfred Trauma Registry, over a 2-year period from January 2011 to December 2012. Log roll examination findings, as documented in the medical record, were compared with CT reports. Out of the 624 screened records, 222 (35.6%) were excluded as the log roll or CT/MRI had not been performed. RESULTS: There were a total of 2028 major trauma presentations to the Alfred Hospital Emergency and Trauma Centre during the study period. Excluded cases comprised 147 patients who did not have a documented log roll, and 75 patients who did not have a CT or MRI. Of the 402 cases that met inclusion criteria, 35.3% had a thoracolumbar fracture, and the sensitivity of log roll examination was found to be 27.5%, with a specificity of 91%. The negative likelihood ratio for abnormalities on log roll was low (0.8). CONCLUSIONS: Examination of the back in unconscious trauma patients could be limited to visual inspection only to allow identification of penetrating wounds and other soft tissue injuries (including of the posterior scalp) and removal of foreign bodies, in patients planned for CT scans. The low sensitivity and poor negative likelihood ratio suggest that a normal log roll examination does not accurately predict the absence of bony injury to the thoracolumbar spine.

Female perineal injuries in children and adolescents presenting to a paediatric emergency department.

This retrospective case series determined documentation quality and likelihood of safeguarding issues in girls  aged 0-15 years with perineal and genital injuries presenting to a paediatric emergency department (ED). During the period between 2002 and 2010, cases were identified and clinical information was recorded. Cases were cross-referenced against the hospital's safeguarding unit's records up to 2011. In total, 181 case notes were available for review with 76.2% of patients discharged home from the ED. Fewer than 50% of case notes contained clear anatomical description of the injuries. In 51 (28.2%) cases, child safeguarding issues were considered, with specific referrals made to safeguarding services in 20 of these (11.0%). Only one case involved subsequent child safeguarding proceedings. Clear documentation of injury patterns by medical staff was poor, but medical and nursing staff should not be anxious about dealing with this cohort of patients as they are no different from other incidental injuries needing diligent levels of child safeguarding awareness.

Improvement in institutional protocols leads to decreased mortality in patients with haemodynamically unstable pelvic fractures.

BACKGROUND: The mortality rate in patients with haemodynamically unstable pelvic fractures is as high as 40-60%. In recent years, angioembolisation and pelvic packing have been introduced as part of a multimodality treatment for these patients. Protocol-driven management has been shown to improve outcomes. PATIENTS AND METHODS: This is a Level III retrospective cohort study of patients suffering from unstable pelvic fractures from 1 January 1996 to 30 September 2011. The aim of the study was to review our results, particularly in terms of mortality through the evolution of three phases of treatment protocols: preangiography, angiography and pelvic packing. RESULTS: The overall 30-day mortality rate for all patients was 47.2%, with a rate of 63.5% in the preangiography phase, 42.1% in the angiography phase and 30.6% in the pelvic packing phase. Multivariate logistic regression analysis identified the use of retroperitoneal packing as a significant independent predictive factor for 24 h mortality. CONCLUSIONS: Our results showed an improvement in patient survival with sequential protocols over the study period, during which we incorporated a multidisciplinary approach to managing these complicated pelvic fractures. The results strongly suggest that retroperitoneal packing should be highly recommended for bleeding subsequent to pelvic fracture, in addition to other modalities of treatment.

The 'Necksafe' head articulation control system: a novel cervical immobilisation device.

INTRODUCTION: The early application of a semirigid disposable cervical collar following trauma is considered a routine practice. The aim of these devices is to immobilise the cervical spine and minimise the risk of additional neurological damage. However, these collars provide only partial immobilisation, are uncomfortable and are associated with a number of complications. Our team designed and tested a novel cervical immobilisation device that aims to improve immobilisation with reduced complications: the 'Necksafe'. METHODS: Human volunteers were recruited and consented to test the novel Necksafe device in comparison with a conventional collar (the AMBU Perfit ACE) in a range of evaluations. These included assessments of the cervical range of movement (CROM) that occurred during scripted movements of the head and neck, and the effect of the new and conventional devices on jugular vein dimensions, assessed using ultrasound scanning. RESULTS: CROM analysis showed that, under standardised testing conditions, the Necksafe device offers cervical immobilisation that is at least equivalent to a conventional collar, and is superior in the planes of extension, lateral flexion and rotation. Ultrasound examination of the jugular veins was inconclusive and did not reveal any differences in jugular venous diameter or flow. Qualitative feedback from ambulance paramedics was highly supportive of the new design, suggesting that it is more comfortable, easier to fit, less confining and better tolerated than a conventional collar, with improved immobilisation effectiveness. CONCLUSIONS: The results of quantitative and qualitative testing are highly supportive of the new Necksafe design, with improved cervical immobilisation, comfort and access to the airway.

Mortality and morbidity after high-dose methylprednisolone treatment in patients with acute cervical spinal cord injury: a propensity-matched analysis using a nationwide administrative database.

OBJECTIVE: To examine the magnitude of the adverse impact of high-dose methylprednisolone treatment in patients with acute cervical spinal cord injury (SCI). METHODS: We examined the abstracted data from the Japanese Diagnosis Procedure Combination database, and included patients with ICD-10 code S141 who were admitted on an emergency basis between 1 July and 31 December in 2007-2009. The investigation evaluated the patients' sex, age, comorbidities, Japan Coma Scale, hospital volume and the amount of methylprednisolone administered. One-to-one propensity-score matching between high-dose methylprednisolone group (>5000 mg) and control group was performed to compare the rates of in-hospital death and major complications (sepsis; pneumonia; urinary tract infection; gastrointestinal ulcer/bleeding; and pulmonary embolism). RESULTS: We identified 3508 cervical SCI patients (2652 men and 856 women; mean age, 60.8 ± 18.7 years) including 824 (23.5%) patients who received high-dose methylprednisolone. A propensity-matched analysis with 824 pairs of patients showed a significant increase in the occurrence of gastrointestinal ulcer/bleeding (68/812 vs 31/812; p<0.001) in the high-dose methylprednisolone group. Overall, the high-dose methylprednisolone group demonstrated a significantly higher risk of complications (144/812 vs 96/812;OR, 1.66; 95% CI 1.23 to 2.24; p=0.001) than the control group. There was no significant difference in in-hospital mortality between the high-dose methylprednisolone group and the control group (p=0.884). CONCLUSIONS: Patients receiving high-dose methylprednisolone had a significantly increased risk of major complications, in particular, gastrointestinal ulcer/bleeding. However, high-dose methylprednisolone treatment was not associated with any increase in mortality.

Cervical spine clearance in the elderly: do elderly patients get a bad deal?

OBJECTIVE: To investigate whether elderly patients, presenting following trauma and requiring immobilisation and imaging of the cervical spine, require increased use of CT and spend longer immobilised when compared to the younger population. METHODS: A retrospective chart review was undertaken of 35 adults aged 18-65 years, and 32 adults over 65 years, requiring cervical spine imaging following trauma. RESULTS: 1 of the 35 younger patients, and 16 of the 32 elderly patients, underwent CT. Elderly patients spent 1:05 h longer immobilised (p<0.005). CONCLUSIONS: Half of the elderly patients underwent CT, and they were immobilised for significantly longer than younger patients. Measures should be adopted to facilitate early diagnosis and mitigate complications of prolonged immobilisation in elderly patients with neck trauma.

Role of routine pelvic radiography in initial evaluation of stable, high-energy, blunt trauma patients.

BACKGROUND: Pelvic fractures are among the most devastating traumatic injuries accompanied by high morbidity and mortality rate leading to catastrophic outcomes and haemodynamic consequences. Although Advanced Trauma Life Support (ATLS) recommends performing pelvic radiography in all major blunt trauma patients, several lines of evidence recommend that it can be limited to those blunt trauma patients who are haemodynamically unstable or have positive pelvic physical examination. Thus, we performed this study in order to evaluate the efficacy of routine pelvic radiography in haemodynamically stable, high-energy, blunt trauma patients. METHODS: This was a prospective cross-sectional study including all the haemodynamically stable, high-energy, blunt trauma patients with negative pelvic physical examination referring to our trauma centre during a 5-month period (May-September 2010). Pelvic radiographies were performed and reviewed for abnormalities. In those who had negative pelvic physical examination and the radiography was not revealing enough, CT imaging was requested and reviewed. RESULTS: During the study period, 1679 high-energy blunt trauma patients referred to our centre out of which 389 were haemodynamically stable and had negative pelvic physical examination. Pelvic radiography was found to be normal in all the patients except one (0.25%) who had pelvic fracture. Only three patients required CT imaging out of which two (0.5%) were found to be normal. CONCLUSIONS: Pelvic radiography could be eliminated from the primary survey protocol of the patients with high-energy blunt trauma who are haemodynamically stable and have negative pelvic physical examination.

A re-conceptualisation of acute spinal care.

The emergency care of patients who may have spinal injuries has become highly ritualised. There is little scientific support for many of the recommended interventions and there is evidence that at least some methods now used in the field and emergency department are harmful. Since prospective clinical trials are not likely to resolve these issues I propose a reconceptualisation of spinal trauma to allow a more rational approach to treatment. To do this I analyse the basic physics, biomechanics and physiology involved. I then develop a list of recommended treatment variations that are more in keeping with the actual causes of post impact neurological deterioration than are current methods. Discarding the fundamentally flawed emphasis on decreasing post injury motion and concentrating on efforts to minimise energy deposition to the injured site, while minimising treatment delays, can simplify and streamline care without subjecting patients to procedures that are not useful and potentially harmful. Specific treatments that are irrational and which can be safely discarded include the use of backboards for transportation, cervical collar use except in specific injury types, immobilisation of ambulatory patients on backboards, prolonged attempts to stabilise the spine during extrication, mechanical immobilisation of uncooperative or seizing patients and forceful in line stabilisation during airway management.