Clinical Clearance of Cervical Spinal Injuries by Emergency Nurses

OBJECTIVES: To determine the interrater reliability between emergency nurses and emergency physicians on defined criteria for clinically clearing the cervical spine in blunt trauma patients. METHODS: Blunt trauma patients, 12 years or older, arriving with cervical spinal precautions were prospectively enrolled as a convenience sample. Each member of the emergency physician-nurse pair completed a questionnaire with regard to five criteria for clinically clearing the cervical spine for each patient. Interrater reliability was determined by calculating the kappa statistics for the individual and combined criteria. RESULTS: Physicians and nurses agreed on the presence or absence of the combined criteria in 175 of 211 patients (82.9%; kappa, 0.65). Agreements on individual criteria were as follows: 1) intoxication--203 patients (96.2%; kappa, 0.82); 2) altered consciousness--197 patients (93.4%; kappa, 0.60); 3) neck pain--185 patients (87.7%; kappa, 0.75); 4) distracting injury--160 patients (75.8%; kappa, 0.36); and 5) neurologic deficit--198 patients (93.8%; kappa, 0.45). If disagreements in which the physician would clinically clear the patient but the nurse would not were considered as agreements, then overall agreement would be 198 of 211 patients (93.8%; kappa, 0.88). On the assumption that nurses would assess patients prior to physicians, they would have cleared 35% of the patients before the physicians. However, they would have ordered 12% more radiographs and unsafely clinically cleared 5% of the patients. CONCLUSIONS: The interrater reliability for the combined cervical spinal injury criteria between emergency nurses and physicians was good to excellent. However, with the training given in this study, nurses would order more radiographs than physicians and would unsafely clinically clear cervical spines in some patients.     

Identification of Intra-abdominal Injuries in Children Hospitalized Following Blunt Torso Trauma

OBJECTIVE: To determine the utility of the ED physical examination and laboratory analysis in screening hospitalized pediatric blunt trauma patients for intra-abdominal injuries (IAIs). METHODS: The authors reviewed the records of all patients aged <15 years who sustained blunt traumatic injury and were admitted to a Level 1 trauma center over a four-year period. Patients were considered high-risk for IAI if they had any of the following at ED presentation: decreased level of consciousness (GCS < 15), abdominal pain, tenderness on abdominal examination, or gross hematuria. Patients without any of these findings were considered moderate risk for LAI. The authors compared moderate-risk patients with and without IAIs with regard to physical examination and laboratory findings obtained in the ED. RESULTS: Of 1,040 children with blunt trauma, 559 (54%) were high-risk and 481 (46%) were moderate-risk for IAI. 126 (23%) of the high-risk and 22 (4.6%) of the moderate-risk patients had IAIs. Among moderate-risk patients with and without IAIs, those with IAIs were more likely to have abdominal abrasions (5/22 vs 34/459, p = 0.008), an abnormal chest examination (11/22 vs 86/457, p = 0.01), higher mean serum concentrations of aspartate aminotransferase (AST) (604 U/L vs 77 U/L, p < 0.001) and alanine aminotransferase (ALT) (276 U/L vs 39 U/L, p = 0.002), higher mean white blood cell (WBC) counts (16.3 K/mm3 vs 12.8 K/mm3, p < 0.001), and a higher prevalence of >5 RBCs/hpf on urinalysis (7/22 vs 54/427, p = 0.02). There was no significant difference (p > 0.05) between moderate-risk patients with and without IAIs in initial serum concentrations of amylase, initial hematocrit, drop in hematocrit >5 percentage points in the ED, or initial serum bicarbonate concentrations. CONCLUSION: In children hospitalized for blunt torso trauma who are at moderate risk for IAI, ED findings of abdominal abrasions, an abnormal chest examination, and microscopic hematuria as well as elevated levels of AST and ALT, and elevated WBC count are associated with IAI.     

Blunt Splenic Injuries in the Adolescent Trauma Population: The Role of Angiography and Embolization

Background: Splenic artery embolization (SAE) improves non-operative splenic salvage rates in adults, but its utility and safety in the pediatric population is less well defined. Objective: Because adolescent trauma patients are often triaged to adult trauma centers, we were interested in evaluating SAE in this particular population. We hypothesize that angiography and embolization is a safe and effective adjunct to non-operative management in the adolescent population. Methods: A retrospective review of all patients aged 13-17 years admitted to our Level I Trauma Center with blunt splenic injury from 1997-2005 was performed. We reviewed patient demographics, operative reports, admission, and follow-up abdominal computed tomography (ACT) results, angiographic reports, and patient outcomes. Results: A total of 97 patients were reviewed. Eighteen patients underwent immediate surgery, and 79 of the remaining patients had planned non-operative management. Of those participating in non-operative management, 35/79 (44%) were initially observed and 44/79 (56%) underwent initial angiography, 23/44 having embolization. Patients in the embolization group had an overall high grade of injury (American Association for the Surgery of Trauma mean grade 3.3, SD 0.6). The overall splenic salvage rate was 96% (76/79) in the non-operative management group; 100% splenic salvage was seen in the observational group; 100% salvage was also seen in patients with negative angiography, and 87% salvage (20/23) in the splenic artery embolization group. Conclusion: Splenic artery embolization may be a valuable adjunct in adolescent blunt splenic injury, especially in higher grade injuries or with evidence of splenic vascular injury on ACT.     

The Significance of Out-of-hospital Hypotension in Blunt Trauma Patients

Objective: To determine the significance of a low out-of-hospital systolic blood pressure (SBP) reading in blunt trauma patients who have a normal SBP upon ED arrival.
Methods: A retrospective case-control study compared admitted blunt trauma patients who were hypotensive (SBP ≤90 mm Hg) in the field and normotensive in the ED (group 1) with those who were normotensive both in the field and in the ED (group 2). The groups were compared for mortality, intensive care unit (ICU) admission, injury severity scale (ISS) score, need for transfusion in the ED, incidence of intra-abdominal injury, and incidence of pelvic or femur fracture.
Results: Each group consisted of 52 patients. The groups were similar with respect to age, gender, and initial ED SBP. The group 1 patients had a higher mortality (10 vs 1, p = 0.008), a higher number of ICU admissions (28 vs 12, p = 0.001), more pelvic or femur fractures (16 vs 7, p = 0.03), and a higher ISS score (19.0 vs 10.5, p = 0.01). Although not significant, group 1 also had higher incidences of intra-abdominal injury (10 vs 3, p = 0.07) and transfusion (8 vs 2, p = 0.09).
Conclusion: The injured patients who were hypotensive in the out-of-hospital setting but normotensive upon ED arrival were more severely injured and had more potential for blood loss than were the patients who were normotensive both in the out-of-hospital setting and in the ED. Out-of-hospital hypotension may be a clinical predictor of severe injury, even in the face of normal ED SBP. Prospective studies are indicated to validate this hypothesis.     

Laryngeal Injury and Pneumomediastinum Due to Minor Blunt Neck Trauma: Case Report

Background

Serious isolated laryngeal injuries are uncommon in children.

Clinical Sobriety Assessment by Emergency Physicians in Blunt Trauma Patients with Acute Alcohol Exposure

Background: Alcohol use increases injury risk and severity. However, few studies have evaluated the ability of emergency physicians (EPs) to accurately determine sobriety. Objectives: To determine the predictive value of clinical sobriety assessment by EPs in blunt trauma patients with acute alcohol use. Materials and Methods: Blunt trauma patients, aged 18–65 years with suspected acute alcohol use, were prospectively enrolled in the study. EPs assessed study subjects before sample collection for blood alcohol level (BAL) and urine drug screen measurement. Alcohol exposure was considered significant if BAL was ≥ 80 mg/dL. Sobriety (non-significant alcohol exposure) was defined as a BAL < 80 mg/dL. EP sobriety assessment was compared to measured BAL and predictive values were calculated. Agreement on significance of alcohol exposure occurred if EP-estimated BAL > 80 mg/dL agreed with measured BAL > 80 mg/dL, or estimated BAL < 80 mg/dL agreed with measured BAL < 80 mg/dL. Chi-squared analysis was used to compare the proportion of correct physician assessments among patients with sobriety and those with significant alcohol exposure. Results: Of 158 enrolled subjects, 153 completed clinical assessment. EP assessment had a predictive value of 83% (95% confidence interval [CI] 77–90%) for significant alcohol exposure and 69% (95% CI 60–78%) for sobriety. Agreement on the significance of alcohol exposure was 82% (125/153; 95% CI 76–88%). EPs identified 32% (11/34; 95% CI 17–48%) of sober patients, but identified 96% (114/119; 95% CI 92–99%) of patients with significant alcohol exposure. EP assessment was significantly less accurate in identifying sober patients (p < 0.01). Conclusions: Emergency physicians identified significant recent alcohol exposure in blunt trauma patients 96% of the time. However, clinical assessment by EPs in blunt trauma patients with recent alcohol use had only moderate predictive value for significant alcohol exposure. Sober patients were frequently misidentified as having significant alcohol exposure.     

Emergency Management of Blunt Testicular Trauma

Objective: Severe blunt testicular trauma is an infrequently reported consequence of injury, yet it is associated with significant sequelae. This case series evaluates the characteristics of patients with severe blunt testicular trauma, assesses the role of ultrasonography in their management, and offers an evaluation algorithm for use by both emergency and urology personnel.
Methods: A retrospective review was conducted of ten patients who had severe blunt testicular injuries referred for urologic evaluation over a seven-year period at a level 1 trauma center. Attention was focused on ultrasonographic results, operative findings, and testicular salvage rates.
Results: With the exception of two motorcycle crash victims, patients presented in a delayed fashion (mean 3.5 days; range 1–5 days). Most (6/10) patients had true testicular rupture, all were explored urgently, and there was a 100% testicular salvage rate. Of the eight patients who had preoperative ultrasonographic examination, two were reported to show testicular rupture, but on exploration only one in fact had a tunica albuginea tear. Six patients had ultrasonographic examinations that revealed nonspecific abnormalities but failed to show testicular rupture; three had testicular rupture.
Conclusions: Ultrasonography cannot be relied on to accurately diagnose rupture of the testis in high-risk patients. However, testicular rupture is universally associated with an abnormal ultrasonography scan, albeit commonly yielding nonspecific findings. A high level of suspicion is mandatory with high-energy transfer mechanisms. Since a significant delay in presentation is not unusual, early exploration is warranted in the setting of high risk and provides an excellent chance of testicular salvage. Injuries associated with normal testicular ultrasonography may be managed conservatively.     

Performance of the Pediatric Glasgow Coma Scale in Children with Blunt Head Trauma

Objectives: To compare the accuracy of a pediatric Glasgow Coma Scale (GCS) score in preverbal children with blunt head trauma with the standard GCS score in older children. Methods: The authors prospectively enrolled children younger than 18 years with blunt head trauma. Patients were divided into cohorts of those 2 years and younger and those older than 2 years. The authors assigned a pediatric GCS score to the younger cohort and the standard GCS score to the older cohort. Outcomes were 1) traumatic brain injury (TBI) on computed tomography (CT) scan or 2) TBI in need of acute intervention. The authors created and compared receiver operating characteristic (ROC) curves between the age cohorts for the association of GCS scores and TBI. Results: The authors enrolled 2,043 children, and 327 were 2 years and younger. Among these 327, 15 (7.7%; 95% confidence interval [CI] = 4.4% to 12.4%) of 194 who underwent imaging with CT had TBI visible and nine (2.8%; 95% CI = 1.3% to 5.2%) had TBI needing acute intervention. In children older than 2 years, 83 (7.7%; 95% CI = 6.2% to 9.5%) of the 1,077 who underwent imaging with CT had TBI visible and 96 (5.6%; 95% CI = 4.6% to 6.8%) had TBI needing acute intervention. For the pediatric GCS in children 2 years and younger, the area under the ROC curve was 0.72 (95% CI = 0.56 to 0.87) for TBI on CT scan and 0.97 (95% CI = 0.94 to 1.00) for TBI needing acute intervention. For the standard GCS in older children, the area under the ROC curve was 0.82 (95% CI = 0.76 to 0.87) for TBI on CT scan and 0.87 (95% CI = 0.83 to 0.92) for TBI needing acute intervention. Conclusions: This pediatric GCS for children 2 years and younger compares favorably with the standard GCS in the evaluation of children with blunt head trauma. The pediatric GCS is particularly accurate in evaluating preverbal children with blunt head trauma with regard to the need for acute intervention.     

急性颈髓损伤并发低钠血症的护理干预

目的探讨急性颈髓损伤并发低钠血症的护理干预措施。方法回顾性分析11例急性颈髓损伤并发低钠血症患者的护理干预,包括重点监测血钠、尿量和尿钠的改变,观察患者意识状态和生命体征变化,注意早期饮食、饮水的干预,重视高热护理、心理干预,实施正确的补液、补钠和抗利尿治疗等。结果10例患者血钠均逐渐恢复正常,症状好转出院;1例患者自行出院。结论早期发现和正确及时诊断急性颈髓损伤后并发低钠血症十分重要,给予恰当的治疗及护理于预对于纠正低钠血症、改善患者的预后尤为关键。     

Positive FAST Without Hemoperitoneum Due to Fluid Resuscitation in Blunt Trauma

Background

The focused assessment with sonography in trauma (FAST) examination is an important screening tool in the evaluation of blunt trauma patients.

Objectives

To describe a case of a hemodynamically unstable polytrauma patient with positive FAST due to fluid resuscitation after blunt trauma.

Case Report

We describe a case of a hemodynamically unstable polytrauma patient who underwent massive volume resuscitation prior to transfer from a community hospital to a trauma center. On arrival at the receiving institution, the FAST examination was positive for free intraperitoneal fluid, but no hemoperitoneum or significant intra-abdominal injuries were found during laparotomy. In this case, it is postulated that transudative intraperitoneal fluid secondary to massive volume resuscitation resulted in a positive FAST examination.

Conclusion

This case highlights potential issues specific to resuscitated trauma patients with prolonged transport times. Further study is likely needed to assess what changes, if any, should be made in algorithms to address the effect of prior resuscitative efforts on the test characteristics of the FAST examination.     

Iatrogenic Spinal Cord Injury in a Trauma Patient with Ankylosing Spondylitis

Background: The recommended practice for over 30 years has been to routinely immobilize patients with unstable cervical spinal injuries using cervical spinal collars. It is shown that patients with Ankylosing spondylitis (AS) are four times more likely to suffer a spinal fracture compared to the general population and have an eleven-fold greater risk of spinal cord injury. Current protocols of spinal immobilization were responsible for secondary neurologic deterioration in some of these patients. Objective: To describe an iatrogenic injury resulting from the use of a rigid spinal board and advocate for the use of alternative immobilization methods or no immobilization at all. Case: We present our case here of a 68-year-old male with a history of AS. The patient was ambulatory on scene after a low speed car accident, but immobilized with a rigid backboard by paramedics. He developed back pain and paraplegia suddenly when the backboard was lifted for transport to the hospital. A CT scan revealed an extension fraction of T10 to T11 with involvement of the posterior column. Emergency spinal fusion was performed. Patient died of complications in the hospital. Conclusion: This case shows that spinal immobilization should be avoided in cases of ambulatory patients without a clear indication. Alternative transport methods such as vacuum mattresses should be considered when spinal immobilization is indicated, especially for patients with predispositions to spinal injury, particularly AS, to maintain the natural alignment of the spinal curvature.     

颈髓损伤并发心律失常分析

目的探讨颈髓损伤患者的心律失常及发病机理。方法回顾性分析61例颈髓损伤患者的心律失常发生情况。结果窦性心动过缓的总发生率为26.2%;病程3个月内窦性心动过缓的发生率（52.4%）高于病程＞3个月发生率（12.5%）;C₅以上损伤者窦性心动过缓发病率（46.2%）高于C_6-8者（11.4%）。结论急性期窦性心动过缓的发生率为52.4%,但急性期以后心律失常发生风险仍然很大,应持续监测。     

颈段脊髓损伤患者肺功能分析

目的探讨颈段脊髓损伤（SCI）患者肺功能变化的特点及影响因素.方法回顾性分析48例颈段SCI患者的肺功能资料,分析肺活量（VC）、最大通气量（MVV）、1秒钟最大呼气量（FEV1）、75%肺活量用力呼气流速比（V75）的预测百分比与ASIA感觉评分和运动评分的相关性,然后分别以VC、MVV、FEV1、V75的实测值为自变量进行多元线性回归分析.结果颈段SCI患者肺功能指标中VC、MVV、FEV1、V75的预测百分比均明显下降,表现为限制性通气功能障碍;相关分析显示,VC、FEV1、V75的预测百分比均与ASIA运动评分呈正相关,与感觉评分无相关性;在分别以VC、MVV、FEV1、V75实测值为自变量的4个多元线性回归方程中,身高均以保护因素出现于其中的3个方程中,体重为保护因素出现于另外1个方程中;与SCI有关的ASIA运动评分、感觉评分和病程等指标中只有运动评分出现于以MVV、FEV1、V75实测值为自变量的多元线性回归方程中,感觉评分和病程未出现于任何一个多元线性回归方程中.结论除身高和体重外,ASIA运动评分是影响颈段SCI患者肺功能的主要因素.     

Low Yield of Paired Head and Cervical Spine Computed Tomography in Blunt Trauma Evaluation

Background

With increased computed tomography (CT) utilization, clinicians may simultaneously order head and neck CT scans, even when injury is suspected only in one region.

Intracranial Pathology in Elders with Blunt Head Trauma

Objectives: To examine presentations and prevalence of head injury among elder victims of blunt trauma and to estimate the prevalence of occult injuries associated with a normal level of consciousness, absence of neurologic deficit, and no evidence of significant skull fracture.
Methods: The study population consisted of all patients aged 65 years or older enrolled in the National Emergency X-Radiography Utilization Study (NEXUS) II head injury cohort. The authors assessed the prevalence and patterns of intracranial injuries among this cohort and compared the prevalence of specific presenting signs and symptoms among injured and uninjured patients. An occult injury subcohort was also constructed, and injury prevalence was examined among this group.
Results: A total of 1,934 elder patients were identified among the 13,326 subjects in NEXUS II (14.5%). Significant intracranial injury, defined as an injury that typically requires procedural intervention or is associated with persistent neurologic impairment or long-term disability, was found in 178 elder patients (9.2%; 95% confidence interval = 8.0% to 10.6%) as compared with 697 individuals among 11,392 younger patients (6.1%; 95% confidence interval = 5.7% to 6.6%). Focal neurologic deficits were present in 55.8% of elder patients with injury. Prevalence of specific injuries among elder and younger patients, respectively, included the following: subdural hematoma, 4.4% and 2.4%; contusion, 4.0% and 3.2%; epidural hematoma, 0.5% and 1.0%; and depressed skull fracture, 0.2% and 0.5%. Forty-two elder patients (2.2%) had an occult injury, compared with only 92 younger patients (0.8%).
Conclusions: Elder patients with head trauma are at higher risk of developing a significant intracranial injury, including subdural and epidural hematoma. An occult presentation is also more common in elders.     

急性颈髓损伤后低钠血症37例临床分析

目的:探讨急性颈髓损伤后低钠血症的治疗.方法:回顾性分析2008年1月-2010年12月收治的急性颈髓损伤后低钠血症患者37例的临床资料.结果:血钠在120-130 mmol/L的32例经补盐和限制水摄入量治疗2-3周后低钠症状改善;血钠<120 mmol/L的5例,治疗6-8周后恢复正常2例,死亡3例.结论:颈髓损伤后低钠血症发生率与损伤程度密切相关,及早发现并补充钠盐和控制液体量是有效的治疗方法;能量支持及维持胶体渗透压能提高疗效.     

Best Practice in Diagnostic Imaging after Blunt Force Trauma Injury to the Cervical Spine: A Systematic Review

IntroductionThe aim of this study was to investigate best practice in evidence-based clinical examinations to determine the diagnostic efficacy of plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) of a cervical spine injury after blunt force trauma.MethodsA systematic review of recent literature was performed, with the intention of analysing only original research articles focusing on at least two imaging modalities or clinical decision guidelines in relation to blunt force trauma injuries involving the cervical spine. The search used the following databases: ProQuest Central, ScienceDirect, and Scopus. A total of 18 studies were identified as suitable for review; these were further supported by relevant secondary studies.ResultsIt was found that the National Emergency X-Radiology Utilization Study and the Canadian C-Spine Rule are both highly sensitive methods for screening patients after cervical spine injuries. CT was shown to have a higher validity than plain radiography and MRI for the detection of a bony cervical spine injury. MRI is recommended for obtunded or unevaluable patients with suspected neurologic deficit.ConclusionsOverall, the literature appears to suggest that individuals with a suspected high risk of injury after examination using clinical decision rules should undergo a cervical CT examination. For patients who are found to have a low risk of injury after clinical decision guidelines, good-quality plain radiography is recommended as sufficient.