Outcome of Trauma Patients Immobilized by Emergency Department Staff,but Not by Emergency Medical Services Providers: A Quality Assurance Initiative

Abstract

Background. Prehospital selective cervical spine immobilization (CSI) is a relatively new concept. In our emergency medical services (EMS) system, protocols for selective CSI are widely used; yet, some patients who are brought to the hospital without CSI undergo secondary immobilization and cervical spine imaging in the emergency department (ED). Immobilization in the ED, after a decision not to immobilize by EMS, suggests that either the prehospital assessment is not trusted or the patient has developed new symptoms over time. We undertook a quality assurance initiative to evaluate whether trauma patients brought to the ED without CSI, who then underwent secondary CSI and imaging in the ED, had injuries that were initially missed by EMS selective CSI protocol. Methods. This was a 36-month retrospective data analysis of blunt trauma patients transported directly from the field to the University of New Mexico Hospital level I trauma center by Albuquerque Ambulance Service (AAS) between March 2009 and February 2012. Inclusion criteria were age 18 years and older, transported by AAS without CSI, and cervical spinal imaging done in the ED. Patients were excluded if they were being transported between facilities, were prisoners, and/or refused CSI. A positive finding was defined as any acute abnormality identified by the attending radiologist on the final imaging report. Results. The study included 101 patients who met inclusion criteria. There were no significant missed injuries. Ninety-four of the 101 patients received cervical spinal CT imaging at an estimated cost of $1,570 per scan, not including physician charges. The remaining patients had plain film radiographic imaging. No patients had magnetic resonance imaging. Conclusions. In this retrospective quality assurance initiative, none of 101 patients who underwent secondary CSI and imaging in the ED had a missed acute cervical injury. No patients had any adverse effects or required treatment, yet these patients incurred substantial costs and increased radiation exposure. While our results suggest hospital personnel should have confidence in prehospital decisions regarding CSI, continued surveillance and a large-scale, prospective study are needed to confirm our findings.     

Paediatric and adolescent horse‐related injuries: Does the mechanism of injury justify a trauma response?

Objective: To identify the frequency, variety and disposition of horse‐related injury presentations to the ED and to use this information to evaluate the existing institutional trauma team activation criteria following horse‐related injuries. Methods: A retrospective case analysis was performed of all horse‐related injury presentations to the ED of Women's and Children's Hospital, Adelaide, Australia, in the 5 year period between January 1999 and December 2003. Results: A total of 186 children presented with horse‐related injuries during the 5 year study period. The median age of injury was 9 years (range 1–17 years), with 81% of presentations female and 60% of patients hospitalized. The mechanism of injury was divided into four groups: 148 falls (79%), 28 kicks (15%), 7 tramples (4%) and 5 bites (3%). There was one death. Seven presentations rated an Injury Severity Score >15, with full trauma team activation occurring for two of these presentations. Conclusion: Although horse‐related injury presentations are uncommon, severe injuries do occur. Patients presenting with severe horse‐related injuries do not always activate a full trauma team response based on current trauma team activation criteria. These severe injury presentations are supported by a limited trauma team response, which activates on the mechanism of injury. The effectiveness of this as a contingency system needs to be evaluated.     

Emergency department intubation of trauma patients with undiagnosed cervical spine injury

Objectives: Some trauma patients have an undiagnosed cervical spine injury but require immediate airway control. This paper reports an emergency department''s (ED) experience with these patients. In particular, is there a worse neurological outcome? Methods: A retrospective study over 6.5 years, based on prospectively collected data from the Royal Perth Hospital trauma registry. Patients with a cervical spine injury were identified and clinical data were abstracted. The primary outcome measure was evidence of exacerbation of cervical spine injury as a result of intubation by ED medical staff. Results: 308 patients (1.9%) of the 15 747 trauma patients were intubated by ED medical staff. Thirty seven (12%) were subsequently verified to have a cervical spine injury, of which 36 were managed with orotracheal intubation. Twenty five (69%) survived to have a meaningful post-intubation neurological examination. Fourteen (56%) of these 25 patients had an unstable cervical spine injury. Ninety per cent of all ED intubations were by ED medical staff. No worsening of neurological outcomes occurred. Conclusions: Every ninth trauma patient that this ED intubates has a cervical spine injury. Intubation by ED medical staff did not worsen neurological outcome. In the controlled setting of an ED staffed by senior practitioners, patients with undiagnosed cervical spine injury can be safely intubated.     

Role of Flexion—Extension Radiographs in Blunt Pediatric Cervical Spine Injury

OBJECTIVE: To determine whether flexion-extension cervical spine radiography (FECSR) is abnormal in children who have sustained blunt cervical spine injury (CSI) when standard cervical spine radiography (SCSR) demonstrates no acute abnormalities. METHODS: This was a blinded radiographic review of 129 patients < or = 16 years of age evaluated at an academic pediatric trauma center during July 1990-March 1996. All patients had SCSR (anteroposterior/lateral views) and FECSR performed for a trauma-related event within seven days of injury. RESULTS: Of 46 patients without acute abnormalities on SCSR, one patient (with final clinical diagnosis of "no CSI") had acute abnormalities on FECSR (95% CI = 0.06% to 11.5%). Of 50 patients with isolated loss of lordosis on SCSR, no patient had acute abnormalities on FECSR (95% CI = 0% to 5.8%). The FECSR review revealed no acute abnormalities in 75 of 83 patients (90.4%) with suspicious findings for CSI viewed on SCSR (95% CI = 81.9% to 95.7%). Complications during FECSR were noted in one patient with transient paresthesias (0.8%) (95% CI = 0.02% to 4.2%). CONCLUSIONS: In children who underwent acute radiographic evaluation of blunt cervical spine trauma, FECSR was unlikely to be abnormal when no acute abnormality or isolated loss of lordosis was evident on SCSR. In a subset of patients with suspicious findings for occult CSI on SCSR, FECSR was useful in ruling out ligamentous instability in the acute, posttrauma setting.     

Potential adverse effects of spinal immobilization in children

Abstract Objective. The purpose of our study was to describe potential adverse effects associated with spinal immobilization following trauma among children. Methods. We conducted a prospective cohort study of children presenting to the emergency department (ED) for evaluation following trauma over a 13-month period. Children were eligible if they underwent spinal immobilization prior to physician evaluation or if they met the American College of Surgeons (ACS) guidelines for spinal immobilization but were not immobilized. We compared children who were immobilized with those who were not immobilized for self-reported pain, use of radiography to evaluate the cervical spine, ED length of stay, and ED disposition. We also report the characteristics of the cohort. Results. One hundred seventy-three spine-immobilized children and 112 children who met ACS criteria but were not immobilized were enrolled. There were differences between the two study groups, which included age, mechanism of injury, and proportion transported by emergency medical services. However, the comparison groups had comparable Pediatric Trauma Scores (PTSs) and Glasgow Coma Scale scores (GCSs). Immobilized children had a higher median pain score (3 versus 2) and were more likely to undergo cervical radiography (56.6% versus 13.4%) and be admitted to the hospital (41.6% versus 14.3%). The comparison groups had similar lengths of stay in the ED. Conclusion. Despite presenting with comparable PTSs and GCSs, children who underwent spinal immobilization following trauma had a higher degree of self-reported pain, and were much more likely to undergo radiographic cervical spine clearance and be admitted to the hospital than those who were not immobilized. Future studies are warranted to determine whether these differences are related to spinal immobilization or differences in the mechanisms of injury, injury patterns, or other variables.     

Evaluation of pediatric cervical spine injuries.

To compare historical features, clinical examination findings, and radiographic results among pediatric patients with cervical spine injury (CSI), a retrospective review of patients who were diagnosed with CSI was undertaken. Two main groups were identified: radiographically evident cervical spine injury (RESCI), and spinal cord injury without radiographic abnormality (SCIWORA). Demographic, historical, clinical, and radiographic information was obtained from patients' charts and analyzed to determine factors associated with CSI and to determine the efficacy of the various radiographic views. Seventy-two children, ages from 1 month to 15 years (median age, 9 yrs), were included in the study. Sports-related injuries were the most common. Forty patients had RESCI and 32 had SCIWORA. Forty-nine (80%) of all the patients had abnormal findings on neck examination, and six (16%) of the RECSI group had abnormal neurological findings. Lateral radiographs had a sensitivity for CSI of 79%; a three-view radiographic series had a sensitivity of 94%. All patients with CSI who were clinically asymptomatic had both a high-risk injury mechanism and a distracting injury. CSI should be suspected in any child with abnormal findings on neck or neurological examination. A minimum of three radiographic cervical spine views should be obtained in the evaluation of CSI in children. Even in the face of a three-view series, CSI should be suspected in patients with an abnormal neck or neurological exam, high-risk mechanism of injury, or distracting injury.     

A paediatric trauma study of scooter injuries

Objective: To investigate the incidence and describe the nature of non‐motorized scooter related injuries in children presenting to the ED. Setting: Paediatric ED of a metropolitan tertiary referral hospital. Methods: A prospective observational study of patients aged under 19 years presenting with injuries sustained while using a non‐motorized scooter. Clinicians recorded the data in the patient record. Main outcome measures: type of injury sustained; period of experience on the scooter; the use of protective gear; the presence of adult supervision; the place of accident; and the patient outcome. Results: Sixty‐two eligible patients were recruited over an 18 month period. The incidence of scooter‐ related injuries was 1.3% of all paediatric trauma presentations. There was a fall in scooter injury presentations over the study period; however, this was not statistically significant. The most common injury sustained using a scooter was an upper limb fracture (41.9%). Closed head injury comprised 8.1% of all scooter related injuries. The majority of patients were not wearing protective gear and were unsupervised at the time of their accident. Most patients (79%) were managed in the ED and discharged. Conclusions: There has been no significant change in scooter injury presentations over the two summer periods of 2000 and 2001. Children presenting to the ED with a scooter related injury tend to be primary school aged, which may have implications on scooter design, age recommendations and safety guidelines.     

Potential Adverse Effects of Spinal Immobilization in Children

Abstract

Objective. The purpose of our study was to describe potential adverse effects associated with spinal immobilization following trauma among children. Methods. We conducted a prospective cohort study of children presenting to the emergency department (ED) for evaluation following trauma over a 13-month period. Children were eligible if they underwent spinal immobilization prior to physician evaluation or if they met the American College of Surgeons (ACS) guidelines for spinal immobilization but were not immobilized. We compared children who were immobilized with those who were not immobilized for self-reported pain, use of radiography to evaluate the cervical spine, ED length of stay, and ED disposition. We also report the characteristics of the cohort. Results. One hundred seventy-three spine-immobilized children and 112 children who met ACS criteria but were not immobilized were enrolled. There were differences between the two study groups, which included age, mechanism of injury, and proportion transported by emergency medical services. However, the comparison groups had comparable Pediatric Trauma Scores (PTSs) and Glasgow Coma Scale scores (GCSs). Immobilized children had a higher median pain score (3 versus 2) and were more likely to undergo cervical radiography (56.6% versus 13.4%) and be admitted to the hospital (41.6% versus 14.3%). The comparison groups had similar lengths of stay in the ED. Conclusion. Despite presenting with comparable PTSs and GCSs, children who underwent spinal immobilization following trauma had a higher degree of self-reported pain, and were much more likely to undergo radiographic cervical spine clearance and be admitted to the hospital than those who were not immobilized. Future studies are warranted to determine whether these differences are related to spinal immobilization or differences in the mechanisms of injury, injury patterns, or other variables.     

Implementation of a dual cervical spine and blunt cerebrovascular injury assessment pathway for pediatric trauma patients

Background:Pediatric cervical spine (CSI) and blunt cerebrovascular injuries (BCVI) are challenging to evaluate as they are rare but carry high morbidity and mortality. CT scans are the traditional imaging modality to evaluate for CSI/BCVI, but involve radiation exposure and potential future increased risk of malignancy. Therefore, we present results from the implementation of a combined CSI/BCVI pediatric trauma clinical pathway to aid clinicians in their decision-making.Methods:We conducted a 2-year retrospective cohort study analyzing data pre and post implementation of the combined CSI/BCVI pathway. Data was obtained from a level 1 pediatric trauma center and included blunt trauma patients under the age of 14. We evaluated the use of cervical spine computed tomography (CT), CT angiography, and plain radiographs, as well as missed injuries and provider pathway adherence.Results:We included 358 patients: 209 pre-pathway and 149 post-pathway implementation. Patient mean age was 8.9 years and 61% were male (61% males). There were no significant differences in GCS, AIS, and ISS between pre and post pathway groups. Post pathway implementation saw reduced use of cervical spine CT, although this was not clinically significant (33% vs 31%, p = 0.74). However, cervical spine radiography use increased (9% vs 16%, p = 0.03), and there was also an increase in screening for BCVI injuries with higher use of CTA (5% vs 7%, p = 0.52). A total of 12 CSI and 3 BCVI were identified with no missed injuries. Provider adherence to the pathway was modest (54%).ConclusionImplementation of a combined CSI/BCVI clinical pathway for pediatric trauma patients increased screening radiography and did not miss any injuries. However, CT use did not significantly decrease and provider adherence was modest, supporting the need for further implementation analysis and larger studies to validate the pathway's sensitivity and specificity for CSI/BCVI.     

Performance of the New South Wales Ambulance Service major trauma transport protocol (T1) at an inner city trauma centre

Objective: To evaluate the performance of a newly implemented prehospital trauma triage (T1) protocol in New South Wales for patients transported to an inner city major trauma centre. Methods: An observational study was conducted over 1 year. Prehospital data and injury characteristics were collected prospectively for all hospital trauma team activations and injury presentations transported by Ambulance Service of New South Wales. Univariate comparison of T1‐ and non‐T1‐transported patients was performed and sensitivity, specificity, overtriage and undertriage rates were calculated. The outcomes studied were Injury Severity Score >15 and major outcome (composite of in‐hospital death and/or transferred from the ED to operating theatre or intensive care unit). Factors associated with undertriage were determined with univariate analysis. Results: A total of 2664 ambulance arrivals for trauma were studied with 767(29%) transported on the T1 protocol. T1‐transported patients were associated with more severe injury (23% vs 6%, P < 0.001) and major outcomes (30% vs 10%, P < 0.001) compared with non‐T1‐transported patients. The sensitivity of the T1 protocol for severe injury was 63% with a positive predictive value of 23%. The undertriage and overtriage rates for severe injury were 12% and 77%, respectively. Undertriaged patients were elderly with falls as the predominant mechanism of injury. Conclusion: The sensitivity and undertriage rates associated with the T1 protocol indicate the ongoing need for secondary triage at designated trauma centres and refinement of the protocol to include age as a criterion.     

Evaluation of the acute cervical spine: a management algorithm. (Department of Surgery, University of Kentucky, Lexington, KY) J Trauma 2000;49:450–456.

A retrospective review was initiated of all trauma patients evaluated in a Level I trauma center the year before and after implementation of a new cervical spine protocol to determine the incidence of missed cervical injuries. An additional 6 months were reviewed to detect any missed injuries late in the study period. During the 2‐year study period, 4,460 patients presented to the emergency room with some form of cervical spine precautions. Blunt trauma comprised 90% of the study population. According to the protocol, approximately 45% required further cervical radiographs after presentation. In the preprotocol year, 77 of 2,217 (3.4%) patients were diagnosed with cervical spine injuries, 16 of 77 (21%) with multiple level injuries, and 25 of 77 (32%) with neurologic compromise. Three of 2,217 patient had missed cervical spine injuries on their initial evaluations. In the postprotocol year, 84 of 2,243 (3.4%) patients had cervical injuries, 25 of 84 (30%) with multiple levels of injuries and 28 of 84 (28%) with neurologic compromise. No patient evaluated during the protocol year was missed. All statistics between the two groups were not significant. Conclude the current protocol by risk stratifying patients on presentation is effective in assessing patients for cervical spine injuries. Comment by Gabor B. Racz, M.D. This is a retrospective review from a Level I trauma center a year before and after implantation of a cervical spine injury protocol. The comparison of outcomes before and after the protocol was rather similar in that the diagnosis of cervical spine injury in 77 of 2,217 patients, or 3.4% and 84 of 2,243 had cervical injuries again 3.4%. Prior to the initiation of the protocol, the first year had three cervical spine injuries missed, which were diagnosed later secondary to continued neck pain on reevaluation. There were no missed cases after the protocol. The evaluation and examination go hand in hand. More emphasis is placed on the clinical exam and plain multiple view x‐ray films and adherence to limiting the rigid collar to 6 h switching over to soft collar and developing more of a confidence in the clinical exam rather than to concentrate on the more expensive and time consuming radiological diagnostic procedures. The cervical algorithm does work and it is impressive that there were no missed injuries. It is recommended that physicians working in a Level I trauma center should go and review the algorithm in detail. The recommended practice is to rely on plain films first if there is persistent pain flexion and extension films and involvement of appropriate consultants in these patients who must be assumed to have cervical spine injury.     

Tram‐related trauma in Melbourne,Victoria

Objectives: To establish the incidence and pattern of injuries in patients presenting to hospital with tram‐related injuries. Methods: Data on tram‐related injury pertaining to 2001–2008 calendar years were extracted from three datasets: the population‐based Victorian State Trauma Registry for major trauma cases, the Victorian Emergency Minimum Dataset for ED presentations and the National Coroners' Information System for deaths. Incidence rates adjusted for the population of Melbourne, and trends in the incidence of tram‐related ED presentations and major trauma cases, were analysed and presented as incidence rate ratios (IRR). Results: There were 1769 patients who presented to ED after trauma related to trams in Melbourne during the study period. Of these, 107 patients had injuries classified as major trauma. There was a significant increase in the rate of ED presentations (IRR 1.03, P= 0.010) with falls (46%) the most commonly reported mechanism. Most falls occurred inside the trams. There was also a significant increase in the incidence rates of major trauma cases (IRR 1.12, P= 0.006) with pedestrians accounting for most major trauma cases. Conclusions: Most cases of trauma related to trams have minor injuries and are discharged following ED management. Primary prevention of falls in trams and the separation of pedestrians from trams are key areas requiring immediate improvement. In the face of increasing trauma associated with trams, continuing safety surveillance and targeted public safety messages are important to sustain trams as safe and effective mode of transport.     

New Immobilization Guidelines Change EMS Critical Thinking in Older Adults With Spine Trauma

Objective: The impact of immobilization techniques on older adult trauma patients with spinal injury has rarely been studied. Our advisory group implemented a change in the immobilization protocol used by emergency medical services (EMS) professionals across a region encompassing 9 trauma centers and 24 EMS agencies in a Rocky Mountain state using a decentralized process on July 1, 2014. We sought to determine whether implementing the protocol would alter immobilization methods and affect patient outcomes among adults ≥60 years with a cervical spine injury. Methods: This was a 4-year retrospective study of patients ≥60 years with a cervical spine injury (fracture or cord). Immobilization techniques used by EMS professionals, patient demographics, injury characteristics, and in-hospital outcomes were compared before (1/1/12–6/30/14) and after (7/1/14–12/31/15) implementation of the Spinal Precautions Protocol using bivariate and multivariate analyses. Results: Of 15,063 adult trauma patients admitted to nine trauma centers, 7,737 (51%) were ≥60 years. Of those, 237 patients had cervical spine injury and were included in the study; 123 (51.9%) and 114 (48.1%) were transported before and after protocol implementation, respectively. There was a significant shift in the immobilization methods used after protocol implementation, with less full immobilization (59.4% to 28.1%, p < 0.001) and an increase in the use of both a cervical collar only (8.9% to 27.2%, p < 0.001) and not using any immobilization device (15.5% to 31.6%, p = 0.003) after protocol implementation. While the proportion of patients who only received a cervical collar increased after implementing the Spinal Precautions Protocol, the overall proportion of patients who received a cervical collar alone or in combination with other immobilization techniques decreased (72.4% to 56.1%, p = 0.01). The presence of a neurological deficit (6.5% vs. 5.3, p = 0.69) was similar before and after protocol implementation; in-hospital mortality (adjusted odds ratio = 0.56, 95% confidence interval: 0.24–1.30, p = 0.18) was similar post–protocol implementation after adjusting for injury severity. Conclusions: There were no differences in neurologic deficit or patient disposition in the older adult patient with cervical spine trauma despite changes in spinal restriction protocols and resulting differences in immobilization devices.     

Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients

INTRODUCTION: The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutaneous tracheostomy. OBJECTIVE: To determine the necessity of cervical spine clearance and neck extension in trauma patients receiving percutaneous tracheostomy. DESIGN: Prospective analysis of case series from August 1, 1995 to August 31, 1998. SETTING: A university-based Level I trauma center. PATIENTS: A total of 88 consecutive trauma patients receiving percutaneous tracheostomy. Patients were divided into two groups based on the radiographic or clinical status of their cervical spine: cleared and noncleared. RESULTS: The overall success and complication rate were 99% (87/88) and 11% (10/88), respectively. There were no procedure-related deaths. The cleared group consisted of 60 patients; three patients in this group who had "bull" or "thick" necks did not have full neck extension during percutaneous tracheostomy. The noncleared group consisted of 28 patients, 13 of which had known cervical spine fractures; 27 noncleared patients were maintained in the neutral position (no extension) during percutaneous tracheostomy, whereas one patient with low suspicion of spinal injury was partially extended. Of the 13 patients with cervical spine fractures, six patients had been stabilized with a halo or operative fixation, and seven patients were stabilized with a cervical collar at the time of percutaneous tracheostomy. The success rate was 100% (60/60) for the cleared group compared with 96% (27/28) for the noncleared group (p > .05). The complication rate was 13% (8/60) for the cleared group compared with 7.1% (2/28) for the noncleared group (p > .05). We had a 100% success rate and no complications in the seven patients with cervical spine injury who were stabilized with a cervical collar. No patient had spinal cord injury caused by percutaneous tracheostomy. CONCLUSION: Percutaneous tracheostomy can be safely performed in trauma patients without cervical spine clearance and neck extension, including patients with stabilized cervical spine or spinal cord injury.     

Epidemiology of Thoracolumbar Spine Injury in Blunt Trauma

OBJECTIVE: To evaluate the prevalence, distribution, and demographics of thoracolumbar (TL) spine injuries following blunt trauma. METHODS: Prospective, cross-sectional study of a consecutive sample of all blunt trauma patients presenting initially to the emergency department (ED) of a Level 1 trauma center and undergoing thoracic and/or lumbar spine radiography from August 1997 to November 1998. The age, sex, and mechanism of injury of each patient as well as location and type of spine injury were recorded for those patients with vertebral fractures, dislocations, or subluxations. RESULTS: Two thousand four hundred four blunt trauma patients were enrolled. Vertebral injuries were identified in 152 individuals (6.3%, 95% CI = 5.4% to 7.4%). Two hundred sixty distinct anatomic levels of injury were identified in these 152 individuals. Of these 260 injuries, 42 (16.2%) occurred at L1, 38 (14.6%) at L2, 29 (11.1%) at L3, and 27 (10.4%) at T12, making these the most commonly injured vertebrae. Injuries were most common (34 patients) in those aged 30-39 years and were least common (12 patients) in those under 18 years. Compression fractures (52%) were the most common injury in the thoracic spine, while transverse process fractures (48%) were the most common injuries in the lumbar spine. CONCLUSIONS: The prevalence of TL injuries in ED blunt trauma patients undergoing TL radiographs is 6.3%. The most commonly injured area of the TL spine is the thoracolumbar junction.     

Injuries significantly associated with thoracic spine fractures: A case–control study

Objective: To determine injuries significantly associated with traumatic thoracic spine (T‐spine) fractures Methods: This was a case–control study undertaken in an adult trauma centre. Cases were patients admitted with a traumatic T‐spine fracture between January 1999 and August 2007. Each case had two controls matched for sex, age (±5 years) and injury severity classification (major/minor). Data were collected from patient medical records and the trauma service database. Multivariate logistic regression was used to determine injuries significantly associated with T‐spine fracture. Results: Two hundred and sixty‐one cases and 512 controls were enrolled. In both groups, mean age was 41 years and 70% of patients were male. Univariate analysis revealed a range of injuries that were significantly more common among the cases, especially cervical and lumbar spine injuries, sternal/scapular/clavicular/rib fractures, pneumo/haemothorax and pulmonary contusions (P < 0.01). Skull fractures and lower limb injuries were significantly more common among the controls (P < 0.01). Logistic regression analysis revealed that only cervical and lumbar spine injuries and rib fractures were positively associated with T‐spine fracture (P < 0.001). Skull fractures and lower limb injuries were negatively associated with T‐spine injury (P < 0.001). Conclusion: Cervical and lumbar spine injuries and rib fractures are significantly associated with T‐spine fracture. The presence of these injuries should raise suspicion of concomitant T‐spine injury.     

The Epidemiology of Emergency Department Trauma Discharges in the United States

Objective

Injury‐related morbidity and mortality is an important emergency medicine and public health challenge in the United States. Here we describe the epidemiology of traumatic injury presenting to U.S. emergency departments (EDs), define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries.

Methods

We conducted a secondary retrospective, repeated cross‐sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all‐payer ED survey database in the United States. Main outcomes and measures were survey‐adjusted counts, proportions, means, and rates with associated standard errors (SEs) and 95% confidence intervals. We plotted annual age‐stratified ED discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level I or II trauma center care with injury fatality using a multivariable survey‐adjusted logistic regression analysis that controlled for age, sex, injury severity, comorbid diagnoses, and teaching hospital status.

Results

There were 181,194,431 (SE = 4,234) traumatic injury discharges from U.S. EDs between 2006 and 2012. There was a mean year‐to‐year decrease of 143 (95% CI = –184.3 to –68.5) visits per 100,000 U.S. population during the study period. The all‐age, all‐cause case‐fatality rate for traumatic injuries across U.S. EDs during the study period was 0.17% (SE = 0.001%). The case‐fatality rate for the most severely injured averaged 4.8% (SE = 0.001%), and severely injured patients were nearly four times as likely to be seen in Level I or II trauma centers (relative risk = 3.9 [95% CI = 3.7 to 4.1]). The unadjusted risk ratio, based on group counts, for the association of Level I or II trauma centers with mortality was risk ratio = 4.9 (95% CI = 4.5 to 5.3); however, after sex, age, injury severity, and comorbidities were accounted for, Level I or II trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 [95% CI = 0.79 to 1.18]). There were notable changes at the extremes of age in types and causes of ED discharges for traumatic injury between 2009 and 2012. Age‐stratified rates of diagnoses of traumatic brain injury increased 29.5% (SE = 2.6%) for adults older than 85 and increased 44.9% (SE = 1.3%) for children younger than 18. Firearm‐related injuries increased 31.7% (SE = 0.2%) in children 5 years and younger. The total inflation‐adjusted cost of ED injury care in the United States between 2006 and 2012 was $99.75 billion (SE = $0.03 billion).

Conclusions

Emergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the United States. Level I or II trauma centers remain a bulwark against the tide of severe trauma in the United States, but the types and causes of traumatic injury in the United States are changing in consequential ways, particularly at the extremes of age, with traumatic brain injuries and firearm‐related trauma presenting increased challenges.     

Evaluation of neck discomfort, neck tenderness, and neurologic deficits as indicators for radiography in blunt trauma victims.

Seventeen of 480 adult blunt trauma victims who sustained cervical spine injuries (CSI) were studied prospectively. In reliable patients, complaints of neck discomfort and tenderness demonstrated sensitivities of 86% and 79%, respectively, for CSI. A positive physical examination, defined as neurologic deficits, or cervical region discomfort or tenderness was noted in 13 of 14 reliable individuals sustaining CSI (sensitivity 93%, specificity 16%, positive predictive value 3.3%, negative predictive value 98.7%). Lack of absolute sensitivity of these studied clinical parameters, either singly or in concert, for CSI suggests that eliminating cervical spine radiography on the basis of the absence of neck discomfort, tenderness, or neurological deficits in reliable blunt trauma victims could result in missed CSI. An enormous prospective data base will be required to definitively address the sensitivity of all clinical parameters currently employed to determine the need for cervical spine radiography in reliable blunt trauma victims.     

Guardian Availability in Children Evaluated in the Emergency Department for Blunt Head Trauma

Background: Enrolling children in research studies in the emergency department (ED) is typically dependent on the presence of a guardian to provide written informed consent. Objectives: The objectives were to determine the rate of guardian availability during the initial ED evaluation of children with nontrivial blunt head trauma, to identify the reasons why a guardian is unavailable, and to compare clinical factors in patients with and without a guardian present during initial ED evaluation. Methods: This was a prospective study of children (<18 years of age) presenting to a single Level 1 trauma center after nontrivial blunt head trauma over a 10‐month period. Physicians documented patient history and physical examination findings onto a structured data form after initial evaluation. The data form contained data points regarding the presence or absence of the patient’s guardian during the initial ED evaluation. For those children for whom the guardian was not available during the initial ED evaluation, the physicians completing the data forms documented the reasons for the absence. Results: The authors enrolled 602 patients, of whom 271 (45%, 95% confidence interval [CI] = 41% to 49%) did not have a guardian available during the initial ED evaluation. In these 271 patients, 261 had reasons documented for lack of guardian availability, 43 of whom had multiple reasons. The most common of these was that the guardian did not ride in the ambulance (51%). Those patients without a guardian available were more likely to be older (mean age, 11.4 years vs. 7.6 years; p < 0.001), be victims of a motor vehicle collision (MVC; 130/268 [49%] vs. 35/328 [11%]; p < 0.001), have a Glasgow Coma Scale (GCS) score <14 (21/269 [7.8%] vs. 11/331 [3.3%]; p = 0.02), and undergo cranial computed tomography (CT) scanning (224/271 [83%] vs. 213/331 [64%]; p < 0.001). Multivariate analysis identified similar independent risk factors for lack of guardian presence. Conclusions: Nearly one‐half of children with nontrivial blunt head trauma evaluated in the ED may not have a guardian available during their initial ED evaluation. Patients whose guardians are not available at the time of initial ED evaluation are older and have more severe mechanisms of injury and more serious head trauma. ED research studies of pediatric trauma patients that require written informed consent from a guardian at the time of initial ED evaluation and treatment may have difficulty enrolling targeted sample size numbers and will likely be limited by enrollment bias.     

Clinical outcomes of magnetic resonance imaging in blunt cervical trauma

Objectives: To determine whether MRI of the cervical spine resulted in a change in management of patients with blunt trauma and normal plain X‐ray (XR)/CT of the cervical spine. Methods: An explicit chart review was conducted of patients seen at a Level 1 trauma centre over a 1 year period. Clinical details were extracted from the charts of patients with blunt trauma who had a normal plain XR and CT scan of the cervical spine and who underwent cervical spine MRI. A comparison of clinical details was made between those with a normal/abnormal MRI secondary to the acute injury. Results: One hundred and thirty‐four patients met entry criteria. Discharge non‐operative management of the cervical spine was associated with a change in management by the MRI result (P < 0.0001) where MRI of the cervical spine occurred a median of 3 days (interquartile range 0–4.5, range 0–137) after the injury. The MRI occurred before discharge 90% of the time in both groups. Operative management occurred in three patients and was delayed until after first outpatient review in two patients. Conclusions: An abnormal MRI after normal plain XR and CT cervical spine studies resulted in a change in non‐operative management at discharge. Early MRI resulted in one patient receiving surgery before discharge. No unstable injuries were detected by MRI that were not evident on plain XR or CT cervical spine.