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Low Prevalence of C-spine Injuries in Low-level Falls Encourages Conservative Immobilization

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OVER-IMMOBILIZATION?
Boland LL, Satterlee PA, Jansen PR. Cervical spine fractures in elderly patients with hip fracture after low-level fall: An opportunity to refine prehospital spinal immobilization guidelines? Prehosp Disaster Med. 2014;29(1):96–99.

In April we covered the recommendation by the National Association of EMS Physicians (NAEMSP) suggesting that spinal immobilization be more conservative. Although much evidence was presented in the NAEMSP’s consensus of opinion, a new report from our home state of Minnesota may help finally put this argument to rest.

Methods: Members of the Minnesota Department of Health along with Dr. Paul Satterlee of Allina Health EMS retrospectively reviewed a full year of 2010–2011 ICD-10 diagnosis codes from the Minnesota Hospital Association’s billing information, searching for all patients with a diagnosis code of femur or pelvis fracture—indicating a hip fracture—excluding multiple data points from patients transferred between hospitals.

They then reviewed de-identified patient data to see how many of these patients suffered a cervical spine fracture after a low-level fall such as a trip from standing or falling from a wheelchair.

Results: Low-level fall with a femur or pelvis fracture was identified in 2,441 patients aged 65 or older. Of those, only 11 (0.01%) had cervical spine fractures, none of which were younger than 69, and nine of the 11 (82%) had associated symptoms including dementia, intoxication and head wounds. In elderly patients with a mechanism of injury other than falls, 28 of 1241 (0.02%) had C-spine fractures, accounting for only 2.3% prevalence.

Interestingly, this accounts for 64% of all elderly individuals with hip fractures, but low-level falls only accounted for 20% of hip fractures in those younger than 65.

Despite being a retrospective review, this brief article presents a good case for more conservative use of C-collars. Nearly all patients who had a concurrent C-spine fracture after a low-level fall also had a distracting injury. Although the case can be made that a hip fracture with pain is a distracting injury, the mechanism appears fairly minor per this report. Research is pointing more and more toward securing patients to a stretcher in a position of comfort rather than placing them in full immobilization.

BOTTOM LINE
What we know:Research is pointing away from the use of spinal immobilization in low-impact cases without distracting injuries.
What this study adds: The prevalence of C-spine injuries in low-level falls is quite low, and may support the conservative use of spinal immobilization.

STEMI FALSE-POSITIVES
Squire BT, Tamayo-Sarver JH, Rashi P, et al. Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Prehosp Emerg Care. 2014;18(1):1–8.

Review By Jeff Morgan, NREMT-P
This study reviewed the effects of prehospital cardiac catherization laboratories (CCL) in Los Angeles County from May 2008 through August 2009. This study took a retrospective look at a database that’s maintained in the county for patients diagnosed with ST elevation myocardial infarction (STEMI) who arrive at a STEMI receiving center (SRC) by ambulance either by prehospital personnel or an ED. This was compared to a group that had an ED echocardiogram-activated CCL within the first five minutes of arrival of ED. Once compared, the authors looked at false activation and the effect of prehospital activation on mortality.

The authors found that although door-to-balloon time was decreased by 14 minutes, the false positive activation of the CCL was 7.8% higher for prehospital providers. They weren’t able to show a decrease in patient mortality with earlier activation and concluded the costs may outweigh the benefits. They encouraged administration to look at the feasibility of continuing prehospital activation of the CCL.

Looking at the data, there were 1,010 CCL activations by EMS and 412 by EDs. Interestingly, prehospital CCL activation was determined only by the machine interpretation—at the time, none of the paramedics were trained in reading 12-lead ECGs. The authors recognized that other studies have shown that properly trained paramedics are equal to, and even slight better than, the ED at interpretation of the ECG in the presence of STEMI.1

Using mortality as an indicator for this type of treatment is a troubling comparison. It’s very easy to check and measure the results of CCL on mortality, but it doesn’t tell the whole story about the success of the procedure. Ejection fraction or some other measure of the myocardium would be a much better indicator of the success of the CCL. This is more difficult to measure, but capturing it would likely better show the true benefit of early CCL activation.

It appears additional research needs to be done. This study does, however, point out the need to make sure providers are properly interpreting their ECGs in the field and not just following the electronic interpretations that can lead to false activations. We would be interested to this study repeated with paramedics trained to properly read 12-lead ECGs and the results compared with the original study.

Jeff Morgan, NREMT-P, is a paramedic with Allina Health EMS and Dodge Center(Minn.) Ambulance.

Reference
1. Feldman JA, Brinsfield K, Bernard S, et al. Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: Results of an observational study. Am J Emerg Med. 2005;23(4):443–448.

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