Jeffrey S. Guy

Are five-view plain films of the cervical spine unreliable? A prospective evaluation in blunt trauma patients with altered mental status.

OBJECTIVES Clearing the cervical spine in a time-sensitive fashion is difficult. We hypothesized that admission computed tomographic scan of the occiput to T1 (CTS) with multiplanar reformatted images will replace five-view (odontoid, anteroposterior, lateral, and oblique) plain films of the cervical spine (CSX) in the initial evaluation of blunt trauma patients with altered mental status. METHODS Between January and July 2001, all patients aged 16 years or older with altered mental status undergoing both CTS and CSX were prospectively entered into the study group. Attending physician interpretation defined the presence of cervical spine injury. Unstable fractures were defined as requiring surgical or halo stabilization. RESULTS One thousand six patients met study criteria. One hundred sixteen patients had 172 cervical spine injuries (CSIs) (fracture and subluxation). CSX missed 90 of 172 (52.3%) CSIs in 65 of 172 (56.0%) patients. Anatomically, CSX failed to identify 14 of 15 occipital fractures (93.3%), 17 of 36 (47.2%) C1-3 fractures, and 59 of 121 (48.8%) C4-T1 CSIs. CSX failed to identify 5 of 29 (17.2%) patients with unstable CSIs. CTS failed to diagnose 3 of 172 (1.7%) CSIs that were stable (spinous process fractures at C6-7). Two patients exhibited spinal cord injury without radiologic abnormality missed by both modalities. CTS had a sensitivity of 97.4%, a specificity of 100%, a prevalence of 11.5%, a positive predictive value of 100%, and a negative predictive value of 99.7%. CSX had a sensitivity of 44.0%, a specificity of 100%, a prevalence of 11.5%, a positive predictive value of 100%, and a negative predictive value of 93.2%. CONCLUSION CTS outperformed five-view CSX in a group of patients with altered mental status or distracting injuries. Five-view CSX failed to diagnose 52.3% of cervical spine fractures identified by CTS. Five-view CSX failed to diagnose five patients with unstable cervical fractures and failed to identify 93.3% of patients with occipital condyle fractures.

The impact of a normoglycemic management protocol on clinical outcomes in the trauma intensive care unit.

BACKGROUND The purpose of this study was to determine if protocol-driven normoglycemic management in trauma patients affected glucose control, ventilator-associated pneumonia, surgical-site infection, and inpatient mortality. METHODS A prospective, consecutive-series, historically controlled study design evaluated protocol-driven normoglycemic management among trauma patients at Vanderbilt University Medical Center. Those mechanically ventilated > or =24 hours and > or =15 years of age were included. A glycemic-control protocol required insulin infusion therapy for glucose >110 mg/dL. Control patients included those who met criteria, were admitted the year preceding protocol implementation, and had hyperglycemia treated at the physicians discretion. RESULTS Eight hundred eighteen patients met study criteria; 383 were managed without protocol; 435 underwent protocol. The protocol group had lower glucose levels 7 of 14 days measured. After admission, both groups had mean daily glucose levels <150 mg/dL. No difference in pneumonia (31.6% vs 34.5%; p = .413), surgical infection (5.0% vs 5.7%; p = .645) or mortality (12.3% vs 13.1%; p = .722) occurred between groups. If one episode of blood glucose level was > or =150 mg/dL (n = 638; 78.0%), outcomes were worse: higher daily glucose levels for 14 days after admission (p < .001), pneumonia rates (35.9% vs 23.3%; p = .002), and mortality (14.6% vs 6.1%; p = .002). One or more days of glucose > or =150 mg/dL had a 2- to 3-fold increase in the odds of death. Protocol use in these patients was not associated with outcome improvement. CONCLUSIONS Protocol-driven management decreased glucose levels 7 of 14 days after admission without outcome change. One or more glucose levels > or =150 mg/dL were associated with worse outcome.

Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee.

Spine immobilization in trauma patients suspected of having a spinal injury has been a cornerstone of prehospital treatment for decades. Current practices are based on the belief that a patient with an injured spinal column can deteriorate neurologically without immobilization. Most treatment protocols do not differentiate between blunt and penetrating mechanisms of injury. Current Emergency Medical Service (EMS) protocols for spinal immobilization of penetrating trauma are based on historic practices rather than scientific merits. Although blunt spinal column injuries will occasionally produce unstable vertebral injuries, which may result in subsequent neurologic propagation if not managed appropriately in the field, this has not been demonstrated to be the case with penetrating trauma.1 Patients with penetrating trauma have different management priorities than those with blunt mechanisms. In patients with penetrating wounds of the head and neck, cervical collars hinder provider assessment of the neck for evolving injuries, tissue edema, subcutaneous emphysema, hematoma development or expansion, and tracheal deviation— with many of these injuries often identified only after removal of the cervical collar.2,3 Airway management is a significant issue in the penetrating trauma population who have had their cervical spine immobilized by prehospital personnel. Endotracheal intubation is more difficult in patients with cervical immobilization.4 More attempts at intubation occur in patients with cervical spine immobilization than occur without, and there is a higher incidence of esophageal intubation and tube dislodgement in this group.5 In the case of penetrating injuries, delays in transport prolong the time before patients receive the prompt surgical care needed to arrest hemorrhage. Even with experienced prehospital providers, spine immobilization is time consuming. The time required for experienced emergency medical technicians to properly immobilize a cervical spine has been reported to be 5.64 minutes ( 1.49 minutes).6 This scene delay can be catastrophic for a patient with penetrating trauma requiring urgent surgical intervention for airway compromise or hemorrhage. Studies have demonstrated that cervical collars increase intracranial pressure in patients with head injuries.7–9 The mechanism for this rise in intracranial pressure is unknown but has been postulated to be due to jugular venous compression by the cervical collar.10 Finally, no study has demonstrated that penetrating trauma can produce an unstable spine injury. Progression of spinal cord injury has not been demonstrated to occur following penetrating trauma, which has a different mechanism of injury from blunt trauma. The PreHospital Trauma Life Support (PHTLS) program is a national and international educational effort sponsored jointly by the National Association of Emergency Medical Technicians and the American College of Surgeons Committee on Trauma. The Executive Committee of PHTLS is comprised of surgeons, emergency physicians, and paramedics. The mission of PHTLS is to further the knowledge of prehospital providers of all levels in the management of victims of trauma. To that end, PHTLS publishes textbooks and offers educational courses for prehospital providers at both basic and advanced levels of training. The PHTLS program was modeled after the American College of Surgeons Committee on Trauma Advanced Trauma Life Support course for physicians.