scholarly journals PL03: Implementation of the Canadian C-Spine Rule by paramedics: a safety evaluation

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S26-S27 ◽  
Author(s):  
C. Vaillancourt ◽  
M. Charette ◽  
J.E. Sinclair ◽  
J. Maloney ◽  
R. Dionne ◽  
...  
Keyword(s):  
Motor Vehicle ◽  
Eligible Patient ◽  
Vital Signs ◽  
Low Risk ◽  
Spine Injury ◽  
Trauma Patients ◽  
Risk Criteria ◽  
Radiologic Evaluation ◽  
Kappa Agreement ◽  
The Impact

Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.

scholarly journals P136: What happens to bypassed trauma patients meeting Field Trauma Triage standards?

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S113-S113
Author(s):  
M. Austin ◽  
J. Sinclair ◽  
S. Leduc ◽  
S. Duncan ◽  
J. Rouleau ◽  
...  
Keyword(s):  
Orthopedic Surgery ◽  
Motor Vehicle ◽  
Vital Signs ◽  
Trauma Patients ◽  
Level Of Consciousness ◽  
Control And Prevention ◽  
Ct Head ◽  
Trauma Triage ◽  
Record Review ◽  
The Impact

Introduction: Prehospital field trauma triage (FTT) standards were reviewed and revised in 2014 based on the recommendations of the Centers for Disease Control and Prevention. The FTT standard allows a hospital bypass and direct transport, within 30 min, to a lead trauma hospital (LTH). Our objectives were to assess the impact of the newly introduced prehospital FTT standard and to describe the emergency department (ED) management and outcomes of patients that had bypassed closer hospitals. Methods: We conducted a 12-month multi-centred health record review of paramedic and ED records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness (physiologic), step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as urgent that met FTT standard, regardless of transport time. We developed and piloted a data collection tool and obtained consensus on all definitions. The primary outcome was the rate of appropriate triage to a LTH which was defined as: ISS ≥12, admitted to intensive care unit (ICU), non-orthopedic surgery, or death. We have reported descriptive statistics. Results: 570 patients were included: mean age 48.8, male 68.9%, falls 29.6%, motor vehicle collisions 20.2%, stab wounds 10.5%, transported to a LTH 76.5% (n = 436). 72.2% (n = 315) of patients transported to a LTH had bypassed a closer hospital and 126/306 (41.2%) of those were determined to be an appropriate triage to LTH (9 patients had missing outcomes). ED management included: CT head/cervical spine 69.9%, ultrasound 53.6%, xray 51.6%, intubation 15.0%, sedation 11.1%, tranexamic acid 9.8%, blood transfusion 8.2%, fracture reduction 6.9%, tube thoracostomy 5.9%. Outcomes included: ISS ≥ 12 32.7%, admitted to ICU 15.0%, non-orthopedic surgery 11.1%, death 8.8%. Others included: admission to hospital 57.5%, mean LOS 12.8 days, orthopedic surgery 16.3% and discharged from ED 37.3%. Conclusion: Despite a high number of admissions, the majority of trauma patients bypassed to a LTH were considered over-triaged, with a low number of ED procedures and non-orthopedic surgeries. Continued work is needed to appropriately identify patients requiring transport to a LTH.

scholarly journals Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial

10.2196/16966 ◽  
2020 ◽  
Vol 9 (6) ◽  
pp. e16966
Author(s):  
Christian Vaillancourt ◽  
Manya Charette ◽  
Monica Taljaard ◽  
Kednapa Thavorn ◽  
Elizabeth Hall ◽  
...  
Keyword(s):  
Health Economic Evaluation ◽  
Total Duration ◽  
Improve Patient Care ◽  
Low Risk ◽  
Spine Injury ◽  
Trauma Patients ◽  
X Rays ◽  
Stepped Wedge ◽  
Cord Injury ◽  
Cluster Randomized

Background Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. Objective This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. Methods We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. Results Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. Conclusions We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). Trial Registration ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. International Registered Report Identifier (IRRID) DERR1-10.2196/16966

scholarly journals P008: Evaluation of outcomes after implementation of a provincial prehospital bypass standard for trauma patients – an Eastern Ontario experience

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S65-S66
Author(s):  
M. Austin ◽  
J. Sinclair ◽  
S. Leduc ◽  
S. Duncan ◽  
J. Rouleau ◽  
...  
Keyword(s):  
Injury Severity ◽  
Univariate Analysis ◽  
Vital Signs ◽  
Trauma Centre ◽  
Trauma Patients ◽  
Level Of Consciousness ◽  
Orthopedic Operation ◽  
Eastern Ontario ◽  
Record Review ◽  
The Impact

Introduction: Trauma and injury play a significant role in the population's burden of disease. Limited research exists evaluating the role of trauma bypass protocols. The objective of this study was to assess the impact and effectiveness of a newly introduced prehospital field trauma triage (FTT) standard, allowing paramedics to bypass a closer hospital and directly transport to a trauma centre (TC) provided transport times were within 30 minutes. Methods: We conducted a 12-month multi-centred health record review of paramedic call reports and emergency department health records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness, step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as an urgent transport to hospital, that met one of the 4 steps of the FTT standard and would allow for a bypass consideration. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions. The primary outcome was the rate of appropriate triage to a TC, defined as any of the following: injury severity score ≥12, admitted to an intensive care unit, underwent non-orthopedic operation, or death. We report descriptive and univariate analysis where appropriate. Results: 570 adult patients were included with the following characteristics: mean age 48.8, male 68.9%, attended by Advanced Care Paramedic 71.8%, mechanisms of injury: MVC 20.2%, falls 29.6%, stab wounds 10.5%, median initial GCS 14, mean initial BP 132, prehospital fluid administered 26.8%, prehospital intubation 3.5%, transported to a TC 74.6%. Of those transported to a TC, 308 (72.5%) had bypassed a closer hospital prior to TC arrival. Of those that bypassed a closer hospital, 136 (44.2%) were determined to be “appropriate triage to TC”. Bypassed patients more often met the step 1 or step 2 of the standard (186, 66.9%) compared to the step 3 or step 4 (122, 39.6%). An appropriate triage to TC occurred in 104 (55.9%) patients who had met step 1 or 2 and 32 (26.2%) patients meeting step 3 or 4 of the FTT standard. Conclusion: The FTT standard can identify patients who should be bypassed and transported to a TC. However, this is at a cost of potentially burdening the system with poor sensitivity. More work is needed to develop a FTT standard that will assist paramedics in appropriately identifying patients who require a trauma centre.

scholarly journals Comparative analysis of the frequency and the severity of diagnosed lesions between pedestrians struck by motor vehicles and other blunt trauma mechanisms victims

2015 ◽  
Vol 42 (4) ◽  
pp. 253-258 ◽  
Author(s):  
JOSÉ GUSTAVO PARREIRA ◽  
RAFAEL KRIEGER MARTINS ◽  
JULIO SLONGO ◽  
JACQUELINE A. GIANNINI PERLINGEIRO ◽  
SILVIA CRISTINE SOLDÁ ◽  
...  
Keyword(s):  
Blunt Trauma ◽  
Motor Vehicle ◽  
Flail Chest ◽  
Vital Signs ◽  
Motor Vehicles ◽  
Trauma Patients ◽  
Arterial Blood ◽  
Group A ◽  
Extremity Injuries ◽  
Mechanism Of Trauma

ABSTRACTObjective:to compare the frequency and the severity of diagnosed injuries between pedestrians struck by motor vehicles and victims of other blunt trauma mechanisms.Methods:retrospective analysis of data from the Trauma Registry, including adult blunt trauma patients admitted from 2008 to 2010. We reviewed the mechanism of trauma, vital signs on admission and the injuries identified. Severity stratification was carried using RTS, AIS-90, ISS e TRISS. Patients were assigned into group A (pedestrians struck by motor vehicle) or B (victims of other mechanisms of blunt trauma). Variables were compared between groups. We considered p<0.05 as significant.Results:a total of 5785 cases were included, and 1217 (21,0%) of which were in group A. Pedestrians struck by vehicles presented (p<0.05) higher mean age, mean heart rate upon admission, mean ISS and mean AIS in head, thorax, abdomen and extremities, as well as lower mean Glasgow coma scale, arterial blood pressure upon admission, RTS and TRISS. They also had a higher frequency of epidural hematomas, subdural hematomas, subarachnoid hemorrhage, brain swelling, cerebral contusions, costal fractures, pneumothorax, flail chest, pulmonary contusions, as well as pelvic, superior limbs and inferior limbs fractures.Conclusion:pedestrian struck by vehicles sustained intracranial, thoracic, abdominal and extremity injuries more frequently than victims of other blunt trauma mechanism as a group. They also presented worse physiologic and anatomic severity of the trauma.

Detection of Cervical Spine Injuries in Alert, Asymptomatic Geriatric Blunt Trauma Patients: Who Benefits from Radiologic Imaging?

2006 ◽  
Vol 72 (9) ◽  
pp. 773-777 ◽  
Author(s):  
Adrian W. Ong ◽  
Aurelio Rodriguez ◽  
Robert Kelly ◽  
Vicente Cortes ◽  
Jack Protetch ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Cervical Spine ◽  
Blunt Trauma ◽  
Cervical Spine Injury ◽  
Motor Vehicle ◽  
Spine Injury ◽  
Trauma Patients ◽  
Cervical Spine Injuries ◽  
Spine Injuries ◽  
Anatomic Locations

There are differing recommendations in the literature regarding cervical spine imaging in alert, asymptomatic geriatric patients. Previous studies also have not used computed tomography routinely. Given that cervical radiographs may miss up to 60 per cent of fractures, the incidence of cervical spine injuries in this population and its implications for clinical management are unclear. We conducted a retrospective study of blunt trauma patients 65 years and older who were alert, asymptomatic, hemodynamically stable, and had normal neurologic examinations. For inclusion, patients were required to have undergone computed tomography and plain radiographs. The presence and anatomic location of potentially distracting injuries or pain were recorded. Two hundred seventy-four patients were included, with a mean age of 76 ± 10 years. The main mechanisms of injury were falls (51%) and motor vehicle crashes (41%). Nine of 274 (3%) patients had cervical spine injuries. The presence of potentially distracting injuries above the clavicles was associated with cervical injury when compared with patients with distracting injuries in other anatomic locations or no distracting injuries (8/115 vs 1/159, P = 0.03). There was no association of cervical spine injury with age greater or less than 75 years or with mechanism of injury. The overall incidence of cervical spine injury in the alert, asymptomatic geriatric population is low. The risk is increased with a potentially distracting injury above the clavicles. Patients with distracting injuries in other anatomic locations or no distracting injuries may not need routine cervical imaging.

scholarly journals Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial (Preprint)

2019 ◽  
Author(s):  
Christian Vaillancourt ◽  
Manya Charette ◽  
Monica Taljaard ◽  
Kednapa Thavorn ◽  
Elizabeth Hall ◽  
...  
Keyword(s):  
Health Economic Evaluation ◽  
Total Duration ◽  
Improve Patient Care ◽  
Low Risk ◽  
Spine Injury ◽  
Trauma Patients ◽  
X Rays ◽  
Stepped Wedge ◽  
Cord Injury ◽  
Cluster Randomized

BACKGROUND Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. OBJECTIVE This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. METHODS We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. RESULTS Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. CONCLUSIONS We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). CLINICALTRIAL ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/16966

131 Characterizing atlanto-occipital dissociation and its association with pediatric traumatic cardiac arrest: A descriptive case series

2021 ◽  
Vol 26 (Supplement_1) ◽  
pp. e92-e93
Author(s):  
Dayae Jeong ◽  
Gabrielle Freire ◽  
Suzanne Beno
Keyword(s):  
Cardiac Arrest ◽  
Motor Vehicle ◽  
Prehospital Care ◽  
Pediatric Trauma ◽  
Case Series ◽  
Spine Injury ◽  
Trauma Patients ◽  
X Ray ◽  
Traumatic Cardiac Arrest ◽  
Mild Disability

Abstract Primary Subject area Emergency Medicine - Paediatric Background Atlanto-occipital dislocation (AOD) is a type of cervical spine injury (CSI) that is commonly fatal or associated with severe neurologic consequences. Although rare, AOD is now more commonly recognized in children as improved prehospital care allows for more patients to reach trauma centres and undergo definitive imaging. Patients with AOD often present with cardiorespiratory instability and prompt diagnosis is crucial. However, diagnosis may be delayed due to variation in imaging practices and lack of literature on this topic. Objectives Primary objective: Describe the demographic characteristics, clinical presentation, and long-term outcomes of children with AOD, compared to other upper CSI. Secondary objective: Describe the frequency of AOD and other upper CSI in pediatric traumatic cardiac arrest (PTCA) and the utility of a lateral c-spine radiograph in this setting. Design/Methods This was a retrospective, single-centre case series of all pediatric trauma patients age &lt; 16 years diagnosed with upper CSI seen at a tertiary pediatric trauma centre from 2000-2020. Patients were included if they had evidence of bony or ligamentous injury from C0-2. The diagnosis of upper CSI was ascertained on autopsy, when available, then cross-sectional imaging, then plain radiographs, when the other modalities were unavailable. Data was obtained from manual chart review and analyzed using descriptive statistics. Results Thirty-six patients were excluded for not meeting upper CSI criteria. Of 93 patients with upper CSI, 24 had AOD: 14 (15%) complete and 10 (11%) incomplete (Table 1). The mechanism of injury was motor-vehicle-collision in 23 (96%) of these patients, and a fall in one (4%). All patients with complete AOD presented in PTCA and only one (7%) survived. Of seven patients with AOD who received a lateral c-spine x-ray during resuscitation, 5 (71%) had identifiable injuries. In contrast, of the 10 patients with incomplete AOD, only 1 (10%) presented in arrest and none died. Only one patient received an x-ray during resuscitation, which showed the injury but went undetected, and 100% of final diagnoses were made through CT. The majority of incomplete AOD patients were managed non-operatively and had minimal to mild disability. Conclusion In our study population, complete AOD was highly fatal with all patients presenting in PTCA. In contrast, incomplete AOD carried a more favorable prognosis with 100% survival and minimal-mild disability. If there is suspicion for AOD, a lateral c-spine XR in the trauma bay can aid in early diagnosis, guiding neurosurgical management and/or goals of care discussions.

Low-Risk Criteria for Pelvic Radiography in Pediatric Blunt Trauma Patients

2011 ◽  
Vol 27 (2) ◽  
pp. 92-96 ◽  
Author(s):  
Andrew T. Wong ◽  
KeriAnne B. Brady ◽  
Allison M. Caldwell ◽  
Nathan M. Graber ◽  
David H. Rubin ◽  
...  
Keyword(s):  
Blunt Trauma ◽  
Low Risk ◽  
Trauma Patients ◽  
Risk Criteria ◽  
Pelvic Radiography
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