The Impact of a Cervical Collar on Intracranial Pressure in Traumatic Brain Injury Patients: A Systematic Review and Meta-Analysis

Purpose: Although the use of a cervical collar in the prehospital setting is recommended to prevent secondary spinal cord injuries and ensure spinal immobilization, it is not known what effects this has on raising intracranial pressure (ICP) in traumatic brain injury (TBI) patients. In the absence of studies measuring ICP in the prehospital setting, the aim of this study was to systematically review the data related to ICP changes measured after presentation at the hospital in patients who had arrived wearing cervical collars. Methods: We searched Medline (PubMed), Embase, CINAHL, and Google Scholar for studies that investigated in-hospital ICP changes in TBI patients arriving at the hospital wearing collars. Titles, abstracts, and full texts were then searched for inclusion in the study. A narrative synthesis, as well as a meta-analysis, was performed. Results: Of the 1006 studies identified, only three met the inclusion/exclusion criteria. The quality of the three included studies was moderate and the risk of bias was low. All three studies used the Laerdal Stifneck collar, but all studies showed an increase in ICP after application of the collar. A further three studies that measured ICP but did not fit the systematic search were also included due to low patient numbers. A meta-analysis of the pooled data confirmed a significant increase in ICP, although between the four studies, only 77 patients were included. The meta-analysis also confirmed that after removal of the collar, there was a significant decrease in ICP. Conclusions: Our study suggests that the use of a cervical collar increases ICP in TBI and head injury patients, which may have detrimental effects. However, due to the extremely low sample size from all six studies, caution must be exercised when interpreting these data. Thus, further high-quality research is necessary to unequivocally clarify whether cervical collars should be used in patients with TBI.

Paramedic adult pain assessment: pilot study

Background: An inability to assess pain may lead to poor or incorrect treatment. However, pain is often poorly assessed in the prehospital setting. Objective: This study aimed to determine the inter-rater reliability of the Wong-Baker FACES Pain Rating Scale in the prehospital setting in Qatar with five adult standardised patients. Methods: This prospective, quantitative pilot study gathered primary data using survey questionnaires. Five members of staff played the roles of standardised adult patients presenting with differing reference levels of pain. Thirty-five paramedics assessed and recorded the pain intensity score of these five patients using the Wong-Baker FACES Pain Rating Scale. Each participant was exposed to the same five patients and the same range of facial expressions in a random order. Results: The paramedics recorded the pain score of the five patients based on their observations of their facial expressions, often unexpectedly comparing these to the FACES tool. Overall, the inter-rater reliability as determined through Fleiss' kappa indicated only a poor-to-slight agreement of the allocated pain scores against the reference standards. There was a wide grouping of the pain score levels around the reference standard; most of the allocations were 1 to 2 pain score levels away from the reference standard, although not in a normal distribution, with some of the higher reference pain levels receiving lower scores and vice versa. Sensitivity was poor to very poor throughout. Conclusion: The inter-rater reliability of the participant sample when using the Wong-Baker FACES Pain Rating Scale to determine pain levels of five standardised patients was poor because the tool was surprisingly not used appropriately by most clinicians. This could be attributed to various factors including the multinational population, language barriers, a lack of familiarisation with the Wong-Baker FACES Pain Rating Scale and other environmental factors.

Development of machine learning model for predicting hospitalization in the prehospital setting

Background: Studies have developed models for predicting patient outcomes for successful risk stratification in the prehospital setting. However, these models generally require many predictors to achieve high prediction ability, resulting in a bar for implementing models in the real clinical setting. Objective: We aimed to develop a simple and implementable machine learning model using automatically-collected data (age, sex, vital signs) to predict patient outcomes during transportation in comparison with National Early Warning Score (NEWS). Methods: This is a retrospective cohort study using data from the ED of three tertiary care hospitals in Japan from April 2017 to March 2020. We included adult patients (aged over 18 years) who were transported to the ED of participating hospitals. We excluded patients with trauma/injury, cardiac arrest, transferred from other hospitals, patients with missing vital signs data, or having data of obvious outliers. The predictors were patient age, sex, mental status evaluated with Japan Coma Scale, systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, and oxygen saturation. The primary outcome was hospitalization. We developed a model using XGBoost. Results: During the study period, 3528 visits transported by emergency medical services were eligible. The median NEWS was 4.0, and 2081 patients were hospitalized. The discrimination ability of the newly developed model was 0.70 (95%CI 0.67-0.73), which was better than those of NEWS 0.64 (95%CI 0.61-0.68). The newly developed models performance measures (e.g., sensitivity, specificity) were comparable with NEWS. Conclusions: Our newly developed machine learning model using routinely available data has moderate prediction ability and was better than NEWS.

Agreement between Prehospital and Final Diagnosis in Patients with Acute Allergic Reactions: A Cross-Sectional Study

Introduction: Acute allergic reactions are usually first encountered in the prehospital setting and account for about 0.3% to 0.8% of prehospital runs in different countries. Right, and rapid recognition and treatment are necessary to decrease mortality and morbidity, especially in severe critical cases. This study evaluates the accuracy of prehospital care providers’ diagnosis in patients with acute allergic reactions in comparison with final (discharge) diagnosis as the gold standard. Methods: Patients who were transported to 2 urban referral hospitals between 2008 and 2014 under the dispatch code of “acute allergic reaction” were included in the study, retrospectively. Demographic data, etiology of an allergic reaction, clinical presentations, vital signs stability, and need for epinephrine injection were evaluated. The prehospital care providers’ diagnosis (documented on-call report) was compared with the final diagnosis (documented on discharge summary form). Results: A total of 300 patients were included in the study. In 55 (18.3%) cases the prehospital care providers’ and final diagnoses were different. Diagnoses were similar in 245 (81.6%) patients. Kappa coefficient was calculated as 0.621which shows a moderate-to-substantial agreement between prehospital and final diagnoses. Fifteen patients (5%) were discharged from the hospital with a diagnosis of anaphylaxis and only 4 cases (26.6%) were diagnosed in the prehospital setting. Conclusion: Although the overall agreement between prehospital and final diagnosis of acute allergic reactions calculated in this study was good, the accuracy of diagnosing the anaphylaxis (as the most critical allergic reaction with a potential fatality) was less than optimal.