Management of patients with cervical spine trauma in the emergency department: a systematic critical appraisal of guidelines with a view to developing standardized strategies for clinical practice

Several guidelines on the evaluation of patients with suspected cervical spine trauma in the Emergency Department (ED) exist. High heterogeneity between different guidelines has been reported. Aim of this study was to find areas of agreement and disagreement between guidelines, to identify topics in which further research is needed and to provide an evidence-based cervical spine trauma algorithm for ED physicians. The three most relevant guidelines published on cervical spine trauma in the last 10 years were selected screening websites of the main scientific societies and through the comparison of a normalized Google Scholar and SCOPUS citation index. We compared the selected guidelines through seven a-priori defined questions. In case of disagreement between the guidelines or if the quality of evidence appeared low, evidence from published systematic reviews on the topic was added to build an evidence-based algorithm for approach to spinal trauma in the ED. The three selected guidelines were: NICE 2016, Eastern Association for the Surgery of Trauma 2009 and American Association of Neurological Surgeons and Congress of Neurological Surgeons 2013. We found complete agreement on one question, partial agreement for one questions, no agreement for two questions, while agreement was not assessable for 3 questions. The agreement between different guidelines and the evidence on which recommendations are based is low. An attempt to build an evidence-based algorithm has been made. More studies are needed on many topics.

Vascularized tendon graft to the central slip using a finger fillet flap

Burn boutonniere deformity (BBD) treatment remains a challenge in reconstructive surgery. Severe hand defects after burn/trauma may be reconstructed with nonsalvageable or amputated tissue. The fillet flap (FF) is generally used as “spare parts” in the trauma algorithm for mangled extremities. This case study examines the use of a FF with concurrent repair of the adjacent finger extensor tendon with the amputated finger flexor tendon after burn injury. The goal is to provide adequate tissue coverage using a finger FF while concurrently reconstructing the central slip of the extensor tendon with the transposed flexor tendon from an adjacent nonfunctional digit. After reconstruction, no subluxation of the extensor tendon occurred with manipulation. Despite prolonged rehabilitation due to injuries, the surgical site healed appropriately. Single-stage FF reconstruction with vascularized tendon grafts should be considered in selected patients with BBD. This novel idea can be applied to the management of traumatized extremities.

Defining criteria to choose appropriate destination hospital for trauma patients: Piacenza Local Health Authority’s Piacenza trauma algorithm protocol

Ambulance crew’s choosing of appropriate destination hospital for trauma patients can affect survival and morbidity outcomes. Aim of the present study is to devise a decision-making algorithm in order to allow the best choice of destination hospital for trauma patients and to apply it on an electronic device able to facilitate the decision made by ambulance staff. The method used was analysis of literature data, context and workload with a retrospective observational study. A comparison between the destination hospitals actually chosen and those that could have been chosen with the <em>Piacenza trauma algorithm</em> has been applied. The data shows a 9.5% (P&gt;0.10) more advantageous change in appropriateness in the choice of medical facility and a 1.4% increase in admissions to the Emergency Department of the provincial hospital. The creation and use of a medical protocol and its consequent installation on an electronic device (tablet) that can be shared over a computer platform could help medical staff make appropriate pre-hospital choices as regards the destination hospital for trauma patients.