Femur fractures should not be considered distracting injuries for cervical spine assessment

Dahlquist, Robert T.; Fischer, Peter; Desai, Harsh; Rogers, Alan R.; Christmas, A. Britton; Gibbs, Michael; Sing, Ronald F.

doi:10.1016/j.ajem.2015.08.009

Cited by 9 publications

(4 citation statements)

References 22 publications

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“…Konstantinides et al [30] concluded that only the upper chest injuries may be significant enough to decrease the sensitivity of the physical examination of the cervical spine in alert and non-intoxicated patients blunt trauma patients. Furthermore, Dahlquist et al [31] showed, that femur fractures should not be considered as distracting injuries for cervical spine assessment. Clinical examination is a sensitive screening method for thoracolumbar spine clearance in patients with distracting injuries [32].…”

Section: Discussionmentioning

confidence: 99%

The characteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study

Oosterwold

Sagel²,

Grunsven³

et al. 2016

Eur J Trauma Emerg Surg

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BackgroundPre-hospital spinal immobilisation by emergency medical services (EMS) staff is currently the standard of care in cases of suspected spinal column injuries. There is, however, a lack of data on the characteristics of patients who received spinal immobilisation during the pre-hospital phase and on the adverse effects of immobilisation. The objectives of this study were threefold. First, we determined the pre-hospital characteristics of blunt trauma patients with suspected spinal column injuries who were immobilised by EMS staff. Second, we assessed the choices made by EMS staff regarding spinal immobilisation techniques and reasons for immobilisation. Third, we researched the possible adverse effects of immobilisation.DesignA retrospective observational study in a cohort of blunt trauma patients.Study methodData of blunt trauma patients with suspected spinal column injuries were collected from one EMS organisation between January 2008 and January 2013. Coded data and free text notes were analysed.ResultsA total of 1082 patients were included in this study. Spinal immobilisation was applied in 96.3 % of the patients based on valid pre-hospital criteria. In 2.1 % of the patients immobilisation was not based on valid criteria. Data of 1.6 % patients were missing. Main reasons for spinal immobilisation were posterior midline spinal tenderness (37.2 % of patients) and painful distracting injuries (13.5 % of patients). Spinal cord injury (SCI) was suspected in 5.7 % of the patients with posterior midline spinal tenderness. A total of 15.8 % patients were immobilised using non-standard methods. The reason for departure from the standard method was explained for 3 % of these patients. Reported adverse effects included pain (n = 10, 0.9 %,); shortness of breath (n = 3, 0.3 %); combativeness or anxiety (n = 6, 0.6 %); and worsening of pain when supine (n = 1, 0.1 %).Conclusion/recommendationSpinal immobilisation was applied in 96.3 % of all included patients based on pre-hospital criteria. We found that consensus among EMS staff on how to interpret the criterion ‘distracting injury’ was lacking. Furthermore, the adverse effects of spinal immobilisation were incompletely documented in pre-hospital care reports. To provide validated information on potential symptoms of SCI, a uniform EMS scoring system for motoric assessment should be developed.

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Section: Discussionmentioning

confidence: 99%

The characteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study

Oosterwold

Sagel²,

Grunsven³

et al. 2016

Eur J Trauma Emerg Surg

View full text Add to dashboard Cite

show abstract

“…9 It is impossible to rule out intoxication clinically and di cult to differentiate between intoxication symptoms, concussions, or critical neurological injuries, 9,35 and studies indicate that distracting injuries do not disturb the sensitivity of a spine examination. [36][37][38] During the Delphi process, some issues enriched the understanding of what makes in-water TSCI special.…”

Section: Discussionmentioning

confidence: 99%

“…Distracting injuries do not disturb the sensitivity of a spine examination. [36][37][38] Current guidelines on spinal motion restriction of trauma patients recommend treating trauma patients with distracting injuries in the same way as all other trauma patients. 9 86% R24: It is recommended to treat patients with language barriers in the same way as patients without language barriers suspected of in-water traumatic spinal cord injury.…”

Section: %mentioning

confidence: 99%

Prehospital guidelines on in-water traumatic spinal injuries for lifeguards and prehospital Emergency Medical Services: an international Delphi consensus study

Breindahl,

Bierens,

Wiberg

et al. 2024

Preprint

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Background Trauma guidelines on spinal motion restriction (SMR) have changed drastically in recent years. An international group of experts explored whether consensus could be reached and if guidelines on SMR performed by trained lifeguards and prehospital EMS following in-water traumatic spinal cord injury (TSCI) should also be changed. Methods An international three-round Delphi process was conducted from October 2022 to November 2023. In Delphi round one, brainstorming resulted in an exhaustive list of recommendations for handling patients with suspected in-water TSCI. The list was also used to construct a preliminary flowchart for in-water SMR. In Delphi round two, three levels of agreement for each recommendation and the flowchart were established. Recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three; recommendations with moderate consensus (75–85% agreement) underwent major revisions in two consecutive phases; and recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2. Results Twenty-four experts participated in Delphi round one. The response rates for Delphi rounds two and three were 92% and 88%, respectively. The study resulted in 25 recommendations and one flowchart with four flowchart paths; 24 recommendations received strong consensus (≥ 85%), and one recommendation received moderate consensus (81%). Each of the four paths in the flowchart received strong consensus (90–95%). The integral flowchart received strong consensus (93%). Conclusions This study produced expert consensus on 25 recommendations and a flowchart on handling patients with suspected in-water TSCI by trained lifeguards and prehospital EMS. These results provide clear and simple guidelines on SMR, which can standardise training and guidelines on SMR performed by trained lifeguards or prehospital EMS.

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“…9,10 It is discussed, if the criteria "distracting injury" leads to unnecessary immobilization, due to the lack of clear evidence about the kind of injury, that should be considered as distracting. 11,12 Considering the recent guidelines including the 2016 German trauma guideline, 1,2,13 as well as the EMS local standard operating procedures (SOP) 14 a spinal immobilization is required if any of the criteria above applies, if none of the criteria applies an immobilization is not required. The NEXUS-criteria and the Canadian C-Spine rule are explicitly cited in both the German guideline and the local SOP.…”

Section: Introductionmentioning

confidence: 99%

Immobilization in Emergency Medical Service – Are CSR and NEXUS-Criteria Considered? A Matched-Pairs Analysis Between Trauma Patients Treated by Onsite EMS Physicians and Patients Treated by Tele-EMS Physicians

Hofstetter¹,

Schröder²,

Beckers³

et al. 2023

OAEM

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Background:The NEXUS-low-risk criteria (NEXUS) and Canadian C-spine rule (CSR) are clinical decision tools used for the prehospital spinal clearance in trauma patients, intending to prevent over-as well as under immobilization. Since 2014, a holistic telemedicine system is part of the emergency medical service (EMS) in Aachen (Germany). This study aims to examine whether the decisions to immobilize or not by EMS-and tele-EMS physicians are based on NEXUS and the CSR, as well as the guideline adherence concerning the choice of immobilization device. Methods: A single-site retrospective chart review was undertaken. Inclusion criteria were EMS physician and tele-EMS physician protocols with traumatic diagnoses. Matched pairs were formed, using age, sex and working diagnoses as matching criteria. The primary outcome parameters were the criteria documented as well as the immobilization device used. The evaluation of the decision to immobilize based on the criteria documented was defined as secondary outcome parameter. Results: Of a total of 247 patients, 34% (n = 84) were immobilized in the EMS physician group and 32.79% (n = 81) in the tele-EMS physician group. In both groups, less than 7% NEXUS or CSR criteria were documented completely. The decision to immobilize or not was appropriately implemented in 127 (51%) in the EMS-physician and in 135 (54, 66%) in the tele-EMS physician group. Immobilization without indication was performed significantly more often by tele-EMS physicians (6.88% vs 2.02%). A significantly better guideline adherence was found in the tele-EMS physician group, preferring the vacuum mattress (25, 1% vs 8.9%) over the spineboard. Conclusion:It could be shown that NEXUS and CSR are not applied regularly, and if so, mostly inconsistently with incomplete documentation by both EMS-and tele-EMS physicians. Regarding the choice of the immobilization device a higher guideline adherence was shown among the tele-EMS physicians.

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Femur fractures should not be considered distracting injuries for cervical spine assessment

Cited by 9 publications

References 22 publications

The characteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study

The characteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study

Prehospital guidelines on in-water traumatic spinal injuries for lifeguards and prehospital Emergency Medical Services: an international Delphi consensus study

Immobilization in Emergency Medical Service – Are CSR and NEXUS-Criteria Considered? A Matched-Pairs Analysis Between Trauma Patients Treated by Onsite EMS Physicians and Patients Treated by Tele-EMS Physicians

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