- Email: [email protected]
Spinal immobilization after motor vehicle collision in patients who are ambulatory at the scene: Is it justified?
RESEARCH FORUM ABSTRACTS
i per 10.0O0 versus 7.6 per 10,000 at the non-mosh pit events (P<.05). At the mosh pit events, there was a rate of 18.5 of 10,00O [or injuries directly related to moshing activity. There was a higher rate of patients needing hospital transport at the mush pit events with a total transport rate at these events of 1.5 of 10,000 versus 0 2 per 10.000 for the non-mosh pit events (P<.05). The transport rate for patients injured in the mosh pit was 1.2 per 10,000. Of the injuries at the mosh pit events, 37% ,.,,'ere lacerations and musculoskeletal mechanisms versus 28.3% at the non-mosh pit events (P<.OS). Average temperature at the mosh pit events ,,,,-as 77.2 ~ F, whereas the average temperature at non-mosh pit events was 81.2~ Conclusion: Mass gatherings where mosh pits are present tend to ha`.'e an increase in medical incidents and injuries. There is also an increase in the number of patients requiring hospital transport. The increase in these injuries tend ro be lacerations and musculoskeletal in nature These increases can possibly o`.'erburden medical personnel responsible for these events if not properly prepared. Future event planning should take precautionary, or even restrictive measures to prepare for mosh pit activity.
256 s,,..,
Immobilization After Motor Vehicle Collision in Patients Who Are Ambulatory at the Scene: Is R Justified?
present ENIS mage criteria ,,,.'ere 41% 495% confidence interval [C1] 26% to 58%) and 83% (95% CI 76'5,, to 88%), respectively. Injuries in the 23 patients not identified by the present prehospital cntena included IAI (5), ICH (3), pneumothorax (l), abrnptio placentae (9), and pelvic fracture (4) Prehospital findings associated with the need for a trauma in the univanare analysis included third trimester of pregnancy (64% versus 46%), heart rate > 110 beats/min (44% versus 18%). prehospital complaint chest pain t31% versus 16%~. and history' of loss of consciousness (36% versus 11%). In the regression analysis, third trimester of pregnancy (P=.008), heart rate >1 l0 heats/min tP= 009), prehospita[ complaint of chest pain (P=.04). and histo D" of loss of consciousness (P<.0O 1) were all independently associated with the need for a trauma center. Conclusion: Most pregnant trauma patients admitted at this trauma center did not require a trauma center. Present prehospital mage criteria in our county, however, undertnaged more than half of the pregnant trauma patients with injuries best served at a trauma center Prehospital findings in the pregnant trauma patient independently associated v.lth an increased need for a trauma center include a heart rate >l I0 beats/min, complaints of chest pain, histo D' of loss of consciousness, and third trimester of pregnancy
Levy BM, Shubert RA, Phelan PK, Bennett MA, LanderCT, Mullen DA, Megargel RE, O'Connor RE/Christiana Care Health System, Newark, DE
258
Study objective: Emergency medical ser,.ices (EMS) protocols often require spinal immobilization for patients involved in motor vehicle collisions (MVCs) Protocols for the clinical clearance of cer','tcal spine injury" in the field have been tested, with vary'tug success. We conducted this study to determine whether patients v.'ho are noted to be ambulatory" at the scene has clinical beanng on cer`.-ical spine clearance. Methods: A prospective cohort of patients treated by EMS personnel with spinal immobilization, who were noted to be ambulatory- at the scene, were enrolled. All patients were transported to a Level I trauma center. Outcome measurements included age, use of passenger restraints, radiologic studies, diagnosis, and disposition. Statistical analysis included X2 and 95% confidence inter`.'als. Results: A total of 171 patients met enrollment criteria, with 112 (65%• using restraints. Mean age was 29 years. Restraint use was higher in those younger than 18 years than those older than 18 )'ears, although this difference was not significant. Radiologic studies ,,,,'ere as follo`.vs: cer`.'ical spine 64 (37%). lumbosacral spine 15 (9%), extremities 37 (22%), and head computed tomography 7 (4%) Differences in use of radiology with regards to passenger restraints were not significantly different Two patients were admitted to the hospital, 1 for an orthopedic injury', and the other for closed head injury'. A total of 109 patients were discharged from the emergency department with a diagnosis of cervical or lumbosacral strain; the remaining 60 had another diagnosis. None of the patients had spinal fracture or significant ligamemous injuries (0%, 1.7%). Conclusion: Patients who ambulate at the scene after MVCs are at low risk for spinal injury, and may not require spinal immobilization. Ambulatory" patients may represent an ideal subgroup to apply clinical clearance criteria in the field because of their low risk.
Bishop P. Davis E/University of RochesterMedical Center. Rochester,NY
257 ,r.um."'""'"Patients~
Prehospita, Triage Criteria |or Pregnant B I n .
Evaluationof EMD Priority Coding and Dispositionof Patients
Stud)" objectives The mage of nonurgent patients who call 911 to alternative care sites, using Emergency Medical Dispatch (EMD)-coded calls, alpha (nonurgent) is often a popular idea. However, no stud)" has demonstrated an accurate method of achieving this goal. The purpose of this stud)" ',','as to evaluate the accuracy of EMD compared with emergency medical services (EMS) disposition of 911 calls. Methods: This is a retrospective comparison of EMD code `.'ersus emergency medical technician {.EMT) disposition requests for EMS in an urban en`.lronment of 225.000 population from January" 1 to Februa D" 6, 1998 Dispositions for these calls were di'.'ided into 9 categories dependent on seriousness of complaint (advanced life support IALSI versus basic life support [BLSI versus nontranspon) and mode of transport to hospital tlighls and sirens xersus regular) Cross-tabulation technique was used to compare ENID code (A, B. C. D, or other) with disposition Overtriage was determined as an EMD code for C or D that had a disposition as BLS (graded according to increase of level of seriousness't, and undertriage as A or B that had a disposition as ALS Green versus red refers to whether the patient was transported using lights and sirens. Results: A total of 3,784 calls were included in the study The Table charts the destination of the calls. Detailed analysis of alpha calls requinng ALS (7.28%) was undertaken to determine those specific EMD codes as problem areas Seventy-nine of 686 "A" calls were upgraded to ALS, with 3 of these identified as life4hreatening (ALS red). Five ENID codes had a _>33% instance of being upgraded to ALS. If all of these alpha calls were upgraded to a "B"-Ievel call, the "A'" response would have a 96% accuracy for not requiring A Le, and a 9 9 8 % accuracy that the person is not ha`.'ing a life-threatening emergency. Conclusion: ENID alpha coding ".vith modification may be an accurate method of determining calls not requinng ALS Further stud) is needed to determine whether these calls will be appropnate for alternative destination
GoodwinHC, Wisner DH, HolmesOF/Universityof California-Davis MedicalCenter. Sacramento,CA Study objectives: (1) To test the reliability of current emergency medical services (EMS) trauma protoco]s for appropriate triage of pregnant blunt trauma patients, and (2) to identify prehospital signs and symptoms that may predict the need for a trauma center in these patients. Methods: We reviewed the medical records of all pregnant blunt trauma patients admitted to an urban Level 1 trauma center over a 5-year period. Before data analysis. the need for a trauma center was defined as follows: ICU admission, operative therapy within initia[ 24 hours, intra-abdominal injury (IA[), intracranial hemorrhage rICH), spinal injuw, pneumothorax, uterine rupture, abruptio placentae, pelx-ic fracture, or patient death. The abstractor ,,','as blinded to these criteria during chart rex-Jew The sensitivity and specificity of this county's present prehospital triage criteria were determined. Categorical data were analyzed using Fisher's exact test. Variables associated with a need for a trauma center in the univanahle analysis (/:%-.05) were entered into a backward elimination regression analysis. Results: Two hundred forty-four patients met study criteria Thmy (12%) had incomplete EMS and/or hospital charts and were excluded. Thirty-nine (18%') of the patients met criteria for requiring a trauma center The sensitivuy and specificity of the
OCTOBER 1999, PART 2
34:4
ANNALS OF EMERGENCY MEDICINE
Table, abstract 258. Coding Disposition
Alpha
1 ALS Red 2 ALS Green 3 BLSRed 4 BLSGreen 5 Nontransport 6 Canceled
3 76 0 790 153 35
700A
9 No patient 10 Other Total
Bravo Charlie Delta 9 51 0 405 111 121
13 230 0 529 94 55
51 234 1 343 90 40
Other
Sum
6 14 0 83 17 42
82 604 1 2,151 465 293
1
6
0
11
0
18
19 8 1,086
63 3 770
15 3 939
34 3 807
19 3 184
150 20 3,784
S 67
i per 10.0O0 versus 7.6 per 10,000 at the non-mosh pit events (P<.05). At the mosh pit events, there was a rate of 18.5 of 10,00O [or injuries directly related to moshing activity. There was a higher rate of patients needing hospital transport at the mush pit events with a total transport rate at these events of 1.5 of 10,000 versus 0 2 per 10.000 for the non-mosh pit events (P<.05). The transport rate for patients injured in the mosh pit was 1.2 per 10,000. Of the injuries at the mosh pit events, 37% ,.,,'ere lacerations and musculoskeletal mechanisms versus 28.3% at the non-mosh pit events (P<.OS). Average temperature at the mosh pit events ,,,,-as 77.2 ~ F, whereas the average temperature at non-mosh pit events was 81.2~ Conclusion: Mass gatherings where mosh pits are present tend to ha`.'e an increase in medical incidents and injuries. There is also an increase in the number of patients requiring hospital transport. The increase in these injuries tend ro be lacerations and musculoskeletal in nature These increases can possibly o`.'erburden medical personnel responsible for these events if not properly prepared. Future event planning should take precautionary, or even restrictive measures to prepare for mosh pit activity.
256 s,,..,
Immobilization After Motor Vehicle Collision in Patients Who Are Ambulatory at the Scene: Is R Justified?
present ENIS mage criteria ,,,.'ere 41% 495% confidence interval [C1] 26% to 58%) and 83% (95% CI 76'5,, to 88%), respectively. Injuries in the 23 patients not identified by the present prehospital cntena included IAI (5), ICH (3), pneumothorax (l), abrnptio placentae (9), and pelvic fracture (4) Prehospital findings associated with the need for a trauma in the univanare analysis included third trimester of pregnancy (64% versus 46%), heart rate > 110 beats/min (44% versus 18%). prehospital complaint chest pain t31% versus 16%~. and history' of loss of consciousness (36% versus 11%). In the regression analysis, third trimester of pregnancy (P=.008), heart rate >1 l0 heats/min tP= 009), prehospita[ complaint of chest pain (P=.04). and histo D" of loss of consciousness (P<.0O 1) were all independently associated with the need for a trauma center. Conclusion: Most pregnant trauma patients admitted at this trauma center did not require a trauma center. Present prehospital mage criteria in our county, however, undertnaged more than half of the pregnant trauma patients with injuries best served at a trauma center Prehospital findings in the pregnant trauma patient independently associated v.lth an increased need for a trauma center include a heart rate >l I0 beats/min, complaints of chest pain, histo D' of loss of consciousness, and third trimester of pregnancy
Levy BM, Shubert RA, Phelan PK, Bennett MA, LanderCT, Mullen DA, Megargel RE, O'Connor RE/Christiana Care Health System, Newark, DE
258
Study objective: Emergency medical ser,.ices (EMS) protocols often require spinal immobilization for patients involved in motor vehicle collisions (MVCs) Protocols for the clinical clearance of cer','tcal spine injury" in the field have been tested, with vary'tug success. We conducted this study to determine whether patients v.'ho are noted to be ambulatory" at the scene has clinical beanng on cer`.-ical spine clearance. Methods: A prospective cohort of patients treated by EMS personnel with spinal immobilization, who were noted to be ambulatory- at the scene, were enrolled. All patients were transported to a Level I trauma center. Outcome measurements included age, use of passenger restraints, radiologic studies, diagnosis, and disposition. Statistical analysis included X2 and 95% confidence inter`.'als. Results: A total of 171 patients met enrollment criteria, with 112 (65%• using restraints. Mean age was 29 years. Restraint use was higher in those younger than 18 years than those older than 18 )'ears, although this difference was not significant. Radiologic studies ,,,,'ere as follo`.vs: cer`.'ical spine 64 (37%). lumbosacral spine 15 (9%), extremities 37 (22%), and head computed tomography 7 (4%) Differences in use of radiology with regards to passenger restraints were not significantly different Two patients were admitted to the hospital, 1 for an orthopedic injury', and the other for closed head injury'. A total of 109 patients were discharged from the emergency department with a diagnosis of cervical or lumbosacral strain; the remaining 60 had another diagnosis. None of the patients had spinal fracture or significant ligamemous injuries (0%, 1.7%). Conclusion: Patients who ambulate at the scene after MVCs are at low risk for spinal injury, and may not require spinal immobilization. Ambulatory" patients may represent an ideal subgroup to apply clinical clearance criteria in the field because of their low risk.
Bishop P. Davis E/University of RochesterMedical Center. Rochester,NY
257 ,r.um."'""'"Patients~
Prehospita, Triage Criteria |or Pregnant B I n .
Evaluationof EMD Priority Coding and Dispositionof Patients
Stud)" objectives The mage of nonurgent patients who call 911 to alternative care sites, using Emergency Medical Dispatch (EMD)-coded calls, alpha (nonurgent) is often a popular idea. However, no stud)" has demonstrated an accurate method of achieving this goal. The purpose of this stud)" ',','as to evaluate the accuracy of EMD compared with emergency medical services (EMS) disposition of 911 calls. Methods: This is a retrospective comparison of EMD code `.'ersus emergency medical technician {.EMT) disposition requests for EMS in an urban en`.lronment of 225.000 population from January" 1 to Februa D" 6, 1998 Dispositions for these calls were di'.'ided into 9 categories dependent on seriousness of complaint (advanced life support IALSI versus basic life support [BLSI versus nontranspon) and mode of transport to hospital tlighls and sirens xersus regular) Cross-tabulation technique was used to compare ENID code (A, B. C. D, or other) with disposition Overtriage was determined as an EMD code for C or D that had a disposition as BLS (graded according to increase of level of seriousness't, and undertriage as A or B that had a disposition as ALS Green versus red refers to whether the patient was transported using lights and sirens. Results: A total of 3,784 calls were included in the study The Table charts the destination of the calls. Detailed analysis of alpha calls requinng ALS (7.28%) was undertaken to determine those specific EMD codes as problem areas Seventy-nine of 686 "A" calls were upgraded to ALS, with 3 of these identified as life4hreatening (ALS red). Five ENID codes had a _>33% instance of being upgraded to ALS. If all of these alpha calls were upgraded to a "B"-Ievel call, the "A'" response would have a 96% accuracy for not requiring A Le, and a 9 9 8 % accuracy that the person is not ha`.'ing a life-threatening emergency. Conclusion: ENID alpha coding ".vith modification may be an accurate method of determining calls not requinng ALS Further stud) is needed to determine whether these calls will be appropnate for alternative destination
GoodwinHC, Wisner DH, HolmesOF/Universityof California-Davis MedicalCenter. Sacramento,CA Study objectives: (1) To test the reliability of current emergency medical services (EMS) trauma protoco]s for appropriate triage of pregnant blunt trauma patients, and (2) to identify prehospital signs and symptoms that may predict the need for a trauma center in these patients. Methods: We reviewed the medical records of all pregnant blunt trauma patients admitted to an urban Level 1 trauma center over a 5-year period. Before data analysis. the need for a trauma center was defined as follows: ICU admission, operative therapy within initia[ 24 hours, intra-abdominal injury (IA[), intracranial hemorrhage rICH), spinal injuw, pneumothorax, uterine rupture, abruptio placentae, pelx-ic fracture, or patient death. The abstractor ,,','as blinded to these criteria during chart rex-Jew The sensitivity and specificity of this county's present prehospital triage criteria were determined. Categorical data were analyzed using Fisher's exact test. Variables associated with a need for a trauma center in the univanahle analysis (/:%-.05) were entered into a backward elimination regression analysis. Results: Two hundred forty-four patients met study criteria Thmy (12%) had incomplete EMS and/or hospital charts and were excluded. Thirty-nine (18%') of the patients met criteria for requiring a trauma center The sensitivuy and specificity of the
OCTOBER 1999, PART 2
34:4
ANNALS OF EMERGENCY MEDICINE
Table, abstract 258. Coding Disposition
Alpha
1 ALS Red 2 ALS Green 3 BLSRed 4 BLSGreen 5 Nontransport 6 Canceled
3 76 0 790 153 35
700A
9 No patient 10 Other Total
Bravo Charlie Delta 9 51 0 405 111 121
13 230 0 529 94 55
51 234 1 343 90 40
Other
Sum
6 14 0 83 17 42
82 604 1 2,151 465 293
1
6
0
11
0
18
19 8 1,086
63 3 770
15 3 939
34 3 807
19 3 184
150 20 3,784
S 67