Prehospital Immobilization Research Articles

Lack of Association between Cervical Spine Injuries and Prehospital Immobilization: From Tradition to Evidence.

Background: Cervical spine (C-spine) trauma usually results from blunt injuries and is traditionally managed by prehospital spinal immobilization using a cervical collar. We sought to examine if prehospital C-spine immobilization is associated with actual C-spine injuries and what factors are associated with the decision to immobilize the C-spine. Methods: We retrospectively analyzed blunt trauma patients treated by Israeli Defense Force (IDF) medical teams from 2015 to 2020. Children, penetrating injuries, and non-threatening injuries were excluded. Demographic data, injury characteristics, and prehospital information were collected from the IDF Trauma Registry's electronic medical records and merged with corresponding hospital data from the Israeli National Trauma Registry. Results: Overall, 220 patients were included, with a mean age of 32 and a predominance of male patients (78%). Most injuries were due to motor vehicle collisions (77%). In total, 40% of the patients received a cervical collar. C-spine injuries were present in 8%, of which 50% were immobilized with a cervical collar. There were no significant differences in the incidences of C-spine injuries or disability outcomes with or without collar immobilization. The use of a collar was significantly associated with backboard immobilization (OR = 14.5, p < 0.001) and oxygen use (OR = 2.5, p = 0.032). Conclusions: Prehospital C-spine immobilization was not associated with C-spine injury or neurological disability incidences. C-spine immobilization by medical providers may be influenced by factors other than the suspected presence of a C-spine injury, such as the use of a backboard. Clear clinical guidelines for inexperienced medical providers are called for.

887 A Review of the Management of Paediatric Spinal Injuries in Low- and Middle-Income Countries

Abstract Aim Paediatric spinal cord injuries (SCI), particularly in the low-and middle-income countries (LMICs), present a pressing global health concern. There is a lack of dedicated research protocols for managing these injuries. To address this, we conducted a review to characterise the methods of management strategies of paediatric SCI in LMICs and drew comparisons with established protocols in high-income countries (HICs). Method MEDLINE, Cochrane library, and Global Index Medicus were searched from database inception to August 1, 2023. Studies reporting the management of paediatric SCI from LMICs were included. Randomised control trials and cohort studies reporting the management of Paediatric SCI from HICs were included. Pooled statistics were calculated using measures of central tendency and spread. Results A total of 685 studies were identified, of which 5 were included from LMICs. A total of 286 patients in the LMIC setting were included in our review with age of participants ranging from 0 to 18 years. The number of patients receiving prehospital immobilisation was characterised in one study (n= 6/36; 17%). Patients transported to the hospital by ambulance was characterised in only one study (n= 18/44; 41%). In the studies reporting the data, most patients underwent surgery (n=151/250; 60.4%). Patients receiving methylprednisolone or long-term management data was not present in any of the included studies. Conclusions There is a paucity of studies reporting the management of paediatric SCI in LMICs. There is insufficient data for accurate comparison and analysis. This study calls for more research to develop international guidelines that inform clinical practice.

A multicenter cohort study on the association between prehospital immobilization and functional outcome of patients following spinal injury in Asia

Prehospital spinal immobilization is a widely used procedure in the emergency medical service (EMS) system worldwide, while the incidence of patients with spinal injury (SI) is relatively low, and unnecessary prehospital spinal immobilization is associated with patient complications. This study aimed to determine the association between prehospital spine immobilization and favorable functional outcomes at hospital discharge among trauma patients with SI. We conducted a retrospective cohort study using the Pan-Asia Trauma Outcomes Study (PATOS) registry data from January 1, 2016, to November 30, 2018. A total of 759 patients with SI were enrolled from 43,752 trauma patients in the PATOS registry during the study period. The subjects had a median age of 58 years (Q1–Q3, 41–72), and 438 (57.7%) patients had prehospital spine immobilization. Overall, prehospital spinal immobilization was not associated with favorable functional outcomes at discharge in multivariable logistic regression (aOR 1.06; 95% CI 0.62–1.81, p = 0.826). However, in the subgroup of cervical SI, prehospital spinal immobilization was associated with favorable functional outcomes at discharge (aOR 3.14; 95% CI 1.04–9.50; p = 0.043). Therefore, we suggest that paramedics should be more careful when determining the presence of a cervical SI and should apply full spine immobilization if possible.

Practice patterns after implementation of a selective spinal immobilization protocol in a regional trauma system.

Universal spinal immobilization has been the standard of prehospital trauma care since the 1960s. Selective immobilization has been shown to be safe and effective for emergency medical services use, but it is unclear whether such protocols reduce unnecessary and potentially harmful immobilization practices. This study evaluated the impact of a selective spinal immobilization protocol on practice patterns in a regional trauma system. All encounters for traumatic injury in the Tidewater Emergency Medical Services region from 2010 to 2016 were extracted from the Virginia Pre-Hospital Information Bridge. An interrupted time series analysis was used to assess practice change after system-wide protocol implementation in 2013. Intravenous access was used as a nonequivalent outcome measure in the absence of an appropriate control group. A total of 63,981 encounters were analyzed. At baseline, 16.7% of patients underwent full immobilization. The preprotocol slope was slightly positive (0.2% per month; 95% confidence interval, 0.1-0.2%). Slope and level changes after protocol implementation did not differ from those observed for intravenous access (-0.4% vs. -0.4% per month [ p = 0.4917] and -1.6% vs. -1.1% [ p = 0.1202], respectively). Cervical spinal immobilization became more common over the postimplementation period (0.1% per month; 95% confidence interval, 0.1-0.1%). Rates of immobilization for isolated penetrating trauma remained unchanged. Implementation of a selective spinal immobilization protocol did not reduce prehospital immobilization rates in a regional trauma system. Given the entrenched nature of immobilization practices, more intensive education and training strategies are needed. Efforts should prioritize eliminating immobilization for isolated penetrating trauma given its association with increased mortality. Therapeutic/Care Management; Level IV.

Occupational-Seasonal Spine and Other Orthopaedic Injuries due to Fall from Java Plum Tree

Background: Falling from a Java Plum (Jamun) tree is one of the primary causes of Spine and other extremity fractures during the Monsoon season (when it is harvested) in Pakistan. Objective: To assess the distribution of patients with different facture types presented with the history of fall from Jamun tree during Monsoon season. Study Design: Retrospective study Place and Duration of Study: Department of Orthopaedics &amp; Spine Surgery, Ghurki Trust Teaching Hospital, Lahore 1st May 2020 to 31st August 2020, Methodology: Forty two male patients age ranged from 12-55 years of age were enrolled. Information was obtained from the hospital’s trauma registry, and medical records were retrospectively reviewed for data about the type of fractures, occupational status, pre-hospital immobilization, time of presentation, and the time between fall and management and length of hospital stay were reviewed. Results: The average age of the patient was 34.6 years. Twenty four (57.14%) had spine fractures and 18 (42.8%) suffered other axial and skeletal fractures. Nearly three-fourths needed surgical intervention. In contrast, 26.1 % were managed conservatively. Conclusion: During monsoon season, we received 4.6% of extra patients with different injuries following fall from Jamun tree. In most cases, young men from lower socio-economic status suffer from varying degrees of disability and experience financial problems. Keywords: Fall, Java Plum, Mass awareness, Occupational-seasonal injury, Spine fractures

Effect of Nighttime on Prehospital Care and Outcomes of Road Traffic Injuries in Asia: A Cross-Sectional Study of Data from the Pan-Asian Trauma Outcomes Study (PATOS)

Introduction: Emergency response to a road traffic injury (RTI) plays a crucial role in patient survival, and the quality of the emergency response should be consistent regardless of the time of day. The aim of this study was to investigate prehospital care and survival outcomes compared between emergency response to RTI during the day and emergency response to RTI at night in Asia. Method: This cross-sectional study used data from the Pan-Asian Trauma Outcome Study (PATOS) that was conducted during 2015-2018. We included RTI patients who were transported to the emergency department (ED) by ground ambulance. That group was then categorized according to the time that the ambulance arrived on-scene. On-scene arrival during 8:00 am to 7:59 pm was defined as the daytime group, and arrival during 8:00 pm to 7:59 am was defined as the nighttime group. Multiple logistic regression was employed to identify factors associated with nighttime prehospital interventions and survival outcomes after adjustment for age, alcohol consumption, and injury severity score (ISS). Results: The final analysis included 20,105 RTI patients. Of those, 12,043 (60%) accidents occurred during the daytime, and 8,062 (40%) occurred at night. RTI patients at night were younger (mean age: 35.7 ± 17.3 vs. 39.5 ± 20.7; p < 0.001), had more alcohol consumption (15.0% vs. 4.2%; p < 0.001), and had more severe injuries (mean ISS: 6.5 ± 7.5 vs. 5.8 ± 7.0; p < 0.001) compared to the daytime group. The nighttime group had increased prehospital immobilization (adjusted odds ratio [aOR]: 1.22, 95% confidence interval [CI]: 1.14-1.31) and more prehospital intravenous (IV) access (aOR 1.36, 95%CI: 1.22-1.51). There was no significant difference in either basic or advanced airway management between the daytime and nighttime groups. The nighttime group had decreased survival in the ED (aOR: 0.80, 95%CI: 0.65-0.98); however, nighttime on-scene arrival did not impact survival to discharge (aOR: 1.10, 95%CI: 0.91-1.33). Conclusion: In the PATOS community, RTI patients that sustained their injuries at night received significantly more prehospital immobilization and IV access, and they had significantly decreased survival in the ED. The results of this study can be used to develop and enhance strategies to improve the care and outcomes of nighttime RTI in Asia.

Pre-Hospital Immobilisation for Neck of Femur Fractures in Australia - a Break in the Evidence

Neck of femur (NOF) fractures present a significant challenge for healthcare systems and are associated with major complications and high mortality. Hospital clinical pathways aim to improve care and optimise outcomes for individuals sustaining NOF fractures; however, these pathways exclude the pre-hospital management of suspected NOF fractures. Therefore, there remains a lack of evidenced-based standardisation for pre-hospital management. To date, research into pre-hospital management of NOF fractures has mostly focussed on pain relief, with very little research examining immobilisation techniques. This is despite immobilisation offering great clinical benefit for other long bone fractures. Unlike hospital clinical pathways that undergo annual reports and reviews, pre-hospital guidelines for NOF fracture immobilisation have received little attention in the past decade. Given advances in research-informed practice for pre-hospital management of other fractures, it seems timely and pertinent to examine current clinical practice guidelines for NOF fractures, focusing on the appropriateness of current immobilisation techniques.

LO57: Pain associated with investigations and procedural interventions commonly administered in the emergency department in older adults: a prospective cohort study

Introduction: Acute pain is frequent among patients visiting the emergency department (ED). In addition to the acute discomfort, pain has been linked to adverse events and poorest outcomes in older adults. However, pain is frequently overlooked by emergency clinicians, particularly in older adults. Advanced age has been linked to poor recognition and under treatment of pain. The contribution of ED investigations and procedures to the patient's pain is unknown. This study aims to determine the intensity of the pain induced by the investigations and procedures commonly performed in the ED. Methods: In two EDs, a convenience sample of older adults (≥ 65 years old) with at least two investigations or procedures performed during their ED visit were eligible. Patients were excluded if they were hemodynamically unstable, in palliative care or not oriented in time and space. The pain intensity was assessed at bedside by a research assistant for the following investigations or procedures: blood sampling, intravenous catheter, electrocardiogram, X-rays, computed tomography, beside ultrasound, urinary catheter, cervical collar and prehospital immobilization mattress. The predetermined sample size was 50 pain assessment per investigation or procedure. The pain intensity was assessed using a numerous rating scale (NRS) ranging from 0 (no pain) to 10 (most severe pain), for each investigation or procedure received. NRS results are presented using median (med) and interquartile range (IQR) and classified as followed: no pain (0), mild pain (1-3), moderate pain (4-6) and severe pain (7-10). Results: Between June 2018 and December 2019, 494 patients were screened of which 318 were finally included (exclusion: not oriented (n = 113), refusal (n = 27), palliative care (n = 34), other reasons (n = 12)). The mean age of included patients was 77.8 years old (standard deviation = 8.0), 54.4% were female and 78.6% were living in the community. Only 15 patients (4.7%) were known to have cognitive impairment or dementia and 23 patients (7.2%) were on regular or PRN opioid medication at home. The expected sample size of at least 50 pain score assessment per investigation or procedure was obtained for all interventions with the exception of urinary catheter (n = 23) and immobilization mattress (n = 35). For the other investigations or procedures, the number of pain assessment ranged between 51 (cervical collar) and 231 (blood sampling). All investigations and procedures were associated with a median pain score of 0 with the exception of blood sampling (n = 231, med NRS 1 (IQR 0;3)), intravenous catheter (n = 241, med NRS 1 (IQR 0;4)), urinary catheter (n = 23, med NRS 4 (IQR 1;6)), cervical collar (n = 51, med NRS 5 (IQR 0;8)) immobilisation mattress (n = 35, med NRS 3 (IQR 0;8)). Moderate or severe pain (NRS 4-10) was infrequently reported following most investigations or procedures with the exception of urinary catheter (60.8%), cervical collar (54.9%) and immobilization mattress (48.5%). Cervical collar induced severe pain in 41.8% of the patients. Conclusion: Most investigations and procedures commonly administered in the ED to older adults are associated with no pain or low intensity of pain. Severe pain is also infrequently induced by these interventions for most older adults. However, urinary catheter, cervical collar and immobilization mattress are associated with a higher intensity of pain and more than 40% of patients suffering from severe pain following the application of cervical collar. Considering the potential adverse effects of pain and the lack of evidence-based data to support the use of some interventions such as the cervical collar, the decision to use these interventions should be carefully weighted and could include a shared-decision making process. The generalizability of those findings to older adults with cognitive impairment is unknown. Future studies should focus on circumstances in which these procedures are beneficial to the patient to limit the unnecessary pain associated with their use.

Prehospital care of spinal injuries: a historical quest for reasoning and evidence.

The practice of prehospital immobilization is coming under increasing scrutiny. Unravelling the historical sequence of prehospital immobilization might shed more light on this matter and help resolve the situation. Main purpose of this review is to provide an overview of the development and reasoning behind the implementation of prehospital spine immobilization. An extensive search throughout historical literature and recent evidence based studies was conducted. The history of treating spinal injuries dates back to prehistoric times. Descriptions of prehospital spinal immobilization are more recent and span two distinct periods. First documentation of its use comes from the early 19th century, when prehospital trauma care was introduced on the battlefields of the Napoleonic wars. The advent of radiology gradually helped to clarify the underlying pathology. In recent decades, adoption of advanced trauma life support has elevated in-hospital trauma-care to an high standard. Practice of in-hospital spine immobilization in case of suspected injury has also been implemented as standard-care in prehospital setting. Evidence for and against prehospital immobilization is equally divided in recent evidence-based studies. In addition, recent studies have shown negative side-effects of immobilisation in penetrating injuries. Although widely implementation of spinal immobilization to prevent spinal cord injury in both penetrating and blunt injury, it cannot be explained historically. Furthermore, there is no high-level scientific evidence to support or reject immobilisation in blunt injury. Since evidence in favour and against prehospital immobilization is equally divided, the present situation appears to have reached something of a deadlock. These slides can be retrieved under Electronic Supplementary Material.

Review of existing measurement tools to assess spinal motion during prehospital immobilization.

The quantification of spinal movement to investigate the efficacy of prehospital immobilization devices and techniques remains difficult. Therefore, we aim to systematically review the literature on reported measurement tools applicable within this research field. A keyword literature search of relevant articles was performed using the database of PubMed including international literature published in English between January 2010 and December 2015. Only studies describing methods applicable to estimate spinal movement during prehospital immobilization were included. Six measurement tools were found that have either been used (goniometer/inclinometer, imaging modalities, electromagnetic systems, and optoelectronic systems) or have the potential to be used (inertial measurement units and a combination of strain gauge technology and accelerometers) in this research field. Novel devices can assess spinal motion during prehospital care including extrication, application of immobilization devices, and transportation from the site of the accident to the final destination, and therefore can be considered for usage.

Efficacy of prehospital spine and limb immobilization in multiple trauma patients.

Background:Injuries are a major cause of mortality and disability worldwide and are estimated to become the third leading cause of death by 2020. Most traffic deaths occur during the prehospital phase; consequently, prehospital trauma care has received considerable attention during the past decade. However, there is no study on the prehospital immobilization of spine and limbs in patients with multiple trauma in Iran.Objectives:This study aimed to investigate the epidemiology of trauma and the quality of limb and spine immobilization in patients with multiple trauma transferred to Shahid Beheshti Medical Center via emergency medical services (EMS).Patients and Methods:This cross-sectional study was conducted in 2013. The study population consisted of all patients with multiple trauma who had been transferred by EMS to the Central Trauma Department of the Shahid Beheshti Medical Center, Kashan, Iran. The study used a checklist and we recruited a convenience sample of 400 patients with multiple trauma. Data were described by using frequency tables, central tendency measures, and variability indices. Moreover, we analyzed data using SPSS.Results:The study sample consisted of 301 (75.2%) males and 99 (24.8%) females. The most common mechanism of trauma was traffic injuries (87.25%). Motorcyclists constituted 52.25% of the road traffic injuries victims. Overall, the quality of immobilization was at an undesirable level in 95.8% of patients with spine and limbs injuries. A significant association was observed between the quality of spine and limbs immobilization and the EMS workers’ education level (P = 0.005).Conclusions:The quality of spine and limb immobilizations was undesirable in more than 90% of cases. Due to the importance of good spine and limb immobilization in patients with multiple trauma, prehospital EMS technicians should be retrained for proper immobilization in patients suspected of spine or limb injuries. Developing evidence-based protocols and strengthening the regulatory and supervisory system to improve quality of prehospital emergency care in patients with multiple trauma is recommended.

Complications from pre-hospital immobilisation

This case report involves a 67-year-old-woman involved in a motor vehicle collision with an isolated complaint of minor hip pain. Pre-hospital personnel responding in the traditional manner quickly immobilized the patient in a cervical collar and long spine board in preparation for transport to a trauma centre. The patient developed progressively worsening respiratory distress while en route to the Emergency Department after immobilization. For unknown reasons, the patient's underlying medical conditions and deterioration were not recognized despite worsening vital signs and continued complaints of shortness of breath. She ultimately required intubation and admission to the Intensive Care Unit likely as a result of unnecessary immobilization. There is little evidence to show that routine spinal immobilization in the pre-hospital environment improves outcomes regardless of whether there is a true spinal injury or not. However, spinal immobilization has been found to cause pain, tissue injury, anxiety and decreased pulmonary function. This case report demonstrates the important role that pre-hospital providers have in deciding whether or not to immobilize a patient and that the consequences of unnecessary immobilization can be life-threatening.

A Retrospective Study of Five Clinical Criteria and One Age Criterion for Selective Prehospital Spinal Immobilization.

Full spinal immobilization of blunt trauma victims is a widely accepted prehospital measure, applied in order to prevent (further) damage to the spinal cord. However, looking at the marginal evidence that exists for the effectiveness of spinal immobilization, and the growing evidence for the negative effects following immobilization, a more selective protocol might be able to reduce possible morbidity and mortality as good as the present prehospital immobilization protocol. In a retrospective study, the sensitivity of a selective prehospital immobilization protocol that adds an age criterion to five clinical spine clearance criteria is examined. Based on ICD-9 codes, all patients admitted to the trauma center diagnosed with spinal fractures with or without spinal damage were identified. The sensitivity of the combination of five clinical criteria (reduced awareness, evidence of intoxication, neurological deficit, pain of the spine on palpation, (significant) distracting injury) and an age criterion (65 years or older at time of accident) was determined. If one or more criteria were positive, standard full immobilization would be indicated. The other patients would not have been immobilized. A total of 238 blunt trauma victims primarily admitted to the trauma center were included for this study. Median age of the included patients was 39 years (range 5-98), with 32.8% female. A total of 236 had at least one positive criterion (sensitivity 99.2%). The two missed patients were male, 40 and 41 years old. Radiology showed a small fissure in the arch of C2, and a transverse process fracture of L3, respectively. Both patients were discharged the next day without complications or medical interventions. In this retrospective study, a selective protocol based on clinical criteria instead of trauma mechanism showed 99.2% sensitivity for spinal fractures with or without spinal cord damage. Based on this study and the current controversy surrounding spinal immobilization, a prospective study should be considered to evaluate the five clinical criteria and one age criterion in the prehospital setting.

Spinal Injuries

The pre-hospital care of patients with suspected spinal injuries involves early immobilisation of the whole spine and the institution of measures to prevent secondary injury from hypoxia, hypoperfusion or further...