- Email: [email protected]
Are Immobilization Backboards and C-Collars Needed for Patients who are Ambulatory at the Scene of a Motor Vehicle Accident?: The Occurrence of Spinal Injury
Research Forum Abstracts cases of these sudden unexpected infant deaths (SUID) are caused by suffocation. If resuscitative efforts are uniformly unsuccessful, declaring death at the scene may be a more efficient use of resources and benefit officials trying to determine cause of death. Study Objective: To determine outcome of out-of-hospital cardiac arrests in infants with initial rhythm of asystole. Methods: Charts from all infants (age ¼ <1yr), who were evaluated at a large tertiary urban teaching hospital (120,000 total visits/yr, 22000 pediatric visits/yr) with the chief complaint of cardiac arrest (pulseless and apnic determined by first health care personnel) from 1999-2012 were reviewed. Data collected (using Utstein criteria) included if arrest was witnessed vs. un-witnessed, initial cardiac rhythm, disposition from ED, disposition from hospital (if admitted), age, sex, and circumstances of how the baby was found. Trauma, drowning and emergent birth related deaths were excluded. Analysis planned was Fischer’s Exact; however, as there were no survivors, binomial analysis performed assuming next victim would be resuscitated. This provided a lower limit to confidence interval for mortality estimation. Results: Of the 90 infants presenting with asystole, 0 survived to hospital discharge. The mortality in this small series was 100%. If the 91st victim arriving in asystole was successfully resuscitated, the mortality rate confidence interval would be 96.76%-100%. Additional analysis revealed that 20% (18/90) of the infants were found in sleeping with a family member. Conclusions: Due to the small numbers, this study is ongoing. However, in this small series, there were no survivors in infants suffering out-of-hospital cardiac arrest with initial rhythm as asystole. Declaring these deaths at the scene would allow for appropriate investigations, and more efficient use of EMS and ED resources. Issues regarding the family’s acceptance of pronouncement of death at the scene may represent an additional challenge. Additionally, efforts at limiting family members sleeping with infants may have a substantial effect on infant mortality.
399
Are Immobilization Backboards and C-Collars Needed for Patients who are Ambulatory at the Scene of a Motor Vehicle Accident?: The Occurrence of Spinal Injury
Loza A, McCoy E, Puckett J, Penalosa P/UC Irvine, Orange, CA
Background: The acute management of potential spinal injuries in motor vehicle accident (MVA) patients is undergoing an extreme reassessment. Although there is no sufficient evidence to support guidelines for immobilization of trauma patients, the current recommendation is to place all MVA patients who have the potential of spinal injury on backboards and rigid cervical collars. Spinal immobilization in all MVA patients may lead to over utilization of resources in the out-of-hospital care setting and in the emergency department. Ambulation status in patients at the scene of the MVA may help to determine the need for immobilization. Study Objective: The purpose of this study is to compare the occurrence of spinal injury in patients who are ambulatory (AB) vs. non-ambulatory (NAB) at the scene of an MVA. Methods: This is a prospective study conducted over a 3-month period from January to March 2013 at the University of California, Irvine, a Level 1 Urban Trauma Center. Patients who were 18 years old and older who presented to the emergency department for an MVA were eligible for the study. Children and pregnant females were excluded from the study. Out-of-hospital data was obtained by trauma nurses, research assistants, and residents at the time of patient arrival directly from the paramedics. A standardized data collection sheet was used to document data. Hospital course and patient outcomes were cross referenced to the trauma registry from the surgery department. Spinal injury was defined as vertebral fracture, vertebral dislocation, spinal cord injury, spinal cord syndrome and spinal cord injury without radiographic abnormality (SCIWORA). Significant spinal injury was defined as any surgical intervention needed or physical disability caused as a result of acute spinal injury. Data is presented in percentages and confidence intervals. Results: A total of 165 patients were analyzed. The median age was 35 years old. In total, 47% were males and 53% were females. Overall, 40% (67) of patients were NAB, while 60% (98) were AB. 9% (15) of the total patients had spinal injuries. Among the AB patients, 5% (CI 1.7-11.5%) had spinal injuries
S144 Annals of Emergency Medicine
and all were vertebral fractures. From the NAB patients, 15% (CI 7.4- 25.7%) had spinal injury, which consisted of vertebral fractures and 1 spinal cord injury. P¼0.03. There were no significant spinal injuries in the AB spinal injury group. In the NAB spinal injury group, there were 2 significant injuries which required surgeries. Conclusions: In this study, we found a significant lower occurrence of spinal injury in patients who were ambulatory at the scene of an MVA, versus those who were non-ambulatory. There were no significant spinal injuries in the ambulatory group. Positive ambulation status may be protective of spinal injuries and may be used as a out-of-hospital assessment tool for spinal immobilization. This study is limited by a small data set and lack of standardized radiographic studies for detecting spinal injury. These results are preliminary and part of a larger ongoing study. Further studies should seek to validate this preliminary study.
400
Despite Self-Reported Comfort in Managing Syncope Patients in the Out-of-Hospital Setting, Most EMS Providers have Significant Knowledge Deficits in the Definition, Etiology, and Management of Syncope
Long B, Cabanas J, Hess E, Serrano L/Mayo Clinic College of Medicine, Rochester, MN; Office of the Medical Director Austin/Travis County EMS System, Austin, TX
Background: Emergency medical services (EMS) personnel provide the first line of care for patients with syncope, performing an initial assessment, to determine immediate needs and to establish a treatment plan, as well as gathering details of the history of present illness from the patient, scene, and eyewitnesses. Study Objective: To assess the knowledge and attitudes of out-of-hospital providers in the recognition, management, and risk stratification of patients who present with syncope. Methods: We performed a multi-center cross-sectional study with IRB approval. A 23-item survey was administered via email to out-of-hospital providers in Minnesota, Wisconsin, and Austin, TX. The survey evaluated provider understanding of the definition, etiology, management, and risk stratification of syncope. Pilot testing was performed on a different cohort prior to implementation. We compared responses according to prior training in syncope, comfort level, certification level, and nursing training using Kruskal-Wallis, T-test, Chi-square, and Fisher exact test. Results: A total of 285 completed surveys were received after email invitations to 639 out-of-hospital providers (45% response rate). Two hundred twenty-four were male (79.4%), 249 were paramedics (90.2%), 22 (8.1%) had nursing training, and 193 (69.5%) had worked in EMS more than 10 years. One hundred fifty eight (56.8%) providers received training on syncope and 271 (95%) felt comfortable to very comfortable assessing and managing patients with syncope. Only 158 (55.4%) providers were able to correctly define syncope and 79 (27.7%) were able to correctly identify the cause of syncope. Providers who received prior training felt more comfortable evaluating patients than those without [73 (46.2%) vs. 43 (35.8%), p¼ 0.0305]. There were no differences in percentage of correct answers related to syncope evaluation, management, and risk stratification [67.7 (SD 12.5) vs. 67.4 (SD 13.2)] in those who had syncope training vs. those who did not. Providers who felt very comfortable with their training and experience evaluating patients with syncope had a higher percent of correct answers than those who felt somewhat comfortable/comfortable and somewhat uncomfortable/ uncomfortable [71.3 (SD10.8) vs. 65.2 (13.3) vs. 58.6 (14.3), p< 0.0001]. Providers with the certification level of paramedic had a higher percentage of correct answers than those with lower certification levels [68.9 (SD 11.9) vs. 55.3 (9.4), p<0.0001]. There were no differences in correct answers in providers who had nursing training [67.6 (SD12.9) vs. 65.9 (12.0), p¼ 0.5643] vs. those who did not. Conclusions: Certified paramedics had greater knowledge of the definition, etiology, and management of syncope compared to EMS providers with other training backgrounds. Although nearly all respondents reported feeling comfortable managing patients with syncope, only half were able to correctly define it and less than one third correctly classified syncope etiology. Most EMS providers require additional experience, education, and training in syncope to ensure competent management of these patients.
Volume 62, no. 4s : October 2013
399
Are Immobilization Backboards and C-Collars Needed for Patients who are Ambulatory at the Scene of a Motor Vehicle Accident?: The Occurrence of Spinal Injury
Loza A, McCoy E, Puckett J, Penalosa P/UC Irvine, Orange, CA
Background: The acute management of potential spinal injuries in motor vehicle accident (MVA) patients is undergoing an extreme reassessment. Although there is no sufficient evidence to support guidelines for immobilization of trauma patients, the current recommendation is to place all MVA patients who have the potential of spinal injury on backboards and rigid cervical collars. Spinal immobilization in all MVA patients may lead to over utilization of resources in the out-of-hospital care setting and in the emergency department. Ambulation status in patients at the scene of the MVA may help to determine the need for immobilization. Study Objective: The purpose of this study is to compare the occurrence of spinal injury in patients who are ambulatory (AB) vs. non-ambulatory (NAB) at the scene of an MVA. Methods: This is a prospective study conducted over a 3-month period from January to March 2013 at the University of California, Irvine, a Level 1 Urban Trauma Center. Patients who were 18 years old and older who presented to the emergency department for an MVA were eligible for the study. Children and pregnant females were excluded from the study. Out-of-hospital data was obtained by trauma nurses, research assistants, and residents at the time of patient arrival directly from the paramedics. A standardized data collection sheet was used to document data. Hospital course and patient outcomes were cross referenced to the trauma registry from the surgery department. Spinal injury was defined as vertebral fracture, vertebral dislocation, spinal cord injury, spinal cord syndrome and spinal cord injury without radiographic abnormality (SCIWORA). Significant spinal injury was defined as any surgical intervention needed or physical disability caused as a result of acute spinal injury. Data is presented in percentages and confidence intervals. Results: A total of 165 patients were analyzed. The median age was 35 years old. In total, 47% were males and 53% were females. Overall, 40% (67) of patients were NAB, while 60% (98) were AB. 9% (15) of the total patients had spinal injuries. Among the AB patients, 5% (CI 1.7-11.5%) had spinal injuries
S144 Annals of Emergency Medicine
and all were vertebral fractures. From the NAB patients, 15% (CI 7.4- 25.7%) had spinal injury, which consisted of vertebral fractures and 1 spinal cord injury. P¼0.03. There were no significant spinal injuries in the AB spinal injury group. In the NAB spinal injury group, there were 2 significant injuries which required surgeries. Conclusions: In this study, we found a significant lower occurrence of spinal injury in patients who were ambulatory at the scene of an MVA, versus those who were non-ambulatory. There were no significant spinal injuries in the ambulatory group. Positive ambulation status may be protective of spinal injuries and may be used as a out-of-hospital assessment tool for spinal immobilization. This study is limited by a small data set and lack of standardized radiographic studies for detecting spinal injury. These results are preliminary and part of a larger ongoing study. Further studies should seek to validate this preliminary study.
400
Despite Self-Reported Comfort in Managing Syncope Patients in the Out-of-Hospital Setting, Most EMS Providers have Significant Knowledge Deficits in the Definition, Etiology, and Management of Syncope
Long B, Cabanas J, Hess E, Serrano L/Mayo Clinic College of Medicine, Rochester, MN; Office of the Medical Director Austin/Travis County EMS System, Austin, TX
Background: Emergency medical services (EMS) personnel provide the first line of care for patients with syncope, performing an initial assessment, to determine immediate needs and to establish a treatment plan, as well as gathering details of the history of present illness from the patient, scene, and eyewitnesses. Study Objective: To assess the knowledge and attitudes of out-of-hospital providers in the recognition, management, and risk stratification of patients who present with syncope. Methods: We performed a multi-center cross-sectional study with IRB approval. A 23-item survey was administered via email to out-of-hospital providers in Minnesota, Wisconsin, and Austin, TX. The survey evaluated provider understanding of the definition, etiology, management, and risk stratification of syncope. Pilot testing was performed on a different cohort prior to implementation. We compared responses according to prior training in syncope, comfort level, certification level, and nursing training using Kruskal-Wallis, T-test, Chi-square, and Fisher exact test. Results: A total of 285 completed surveys were received after email invitations to 639 out-of-hospital providers (45% response rate). Two hundred twenty-four were male (79.4%), 249 were paramedics (90.2%), 22 (8.1%) had nursing training, and 193 (69.5%) had worked in EMS more than 10 years. One hundred fifty eight (56.8%) providers received training on syncope and 271 (95%) felt comfortable to very comfortable assessing and managing patients with syncope. Only 158 (55.4%) providers were able to correctly define syncope and 79 (27.7%) were able to correctly identify the cause of syncope. Providers who received prior training felt more comfortable evaluating patients than those without [73 (46.2%) vs. 43 (35.8%), p¼ 0.0305]. There were no differences in percentage of correct answers related to syncope evaluation, management, and risk stratification [67.7 (SD 12.5) vs. 67.4 (SD 13.2)] in those who had syncope training vs. those who did not. Providers who felt very comfortable with their training and experience evaluating patients with syncope had a higher percent of correct answers than those who felt somewhat comfortable/comfortable and somewhat uncomfortable/ uncomfortable [71.3 (SD10.8) vs. 65.2 (13.3) vs. 58.6 (14.3), p< 0.0001]. Providers with the certification level of paramedic had a higher percentage of correct answers than those with lower certification levels [68.9 (SD 11.9) vs. 55.3 (9.4), p<0.0001]. There were no differences in correct answers in providers who had nursing training [67.6 (SD12.9) vs. 65.9 (12.0), p¼ 0.5643] vs. those who did not. Conclusions: Certified paramedics had greater knowledge of the definition, etiology, and management of syncope compared to EMS providers with other training backgrounds. Although nearly all respondents reported feeling comfortable managing patients with syncope, only half were able to correctly define it and less than one third correctly classified syncope etiology. Most EMS providers require additional experience, education, and training in syncope to ensure competent management of these patients.
Volume 62, no. 4s : October 2013