Hong Rick, Meenan Molly, Prince Erin, Murphy Ronald, Tambussi Caitlin, Rohrbach Rick, Baumann Brigitte M
Cooper University Hospital, Cooper Medical School of Rowan University, Department of Emergency Medicine, Camden, New Jersey.
West J Emerg Med. 2014 Jul;15(4):471-9. doi: 10.5811/westjem.2014.2.19244.
We wanted to compare 3 existing emergency medical services (EMS) immobilization protocols: the Prehospital Trauma Life Support (PHTLS, mechanism-based); the Domeier protocol (parallels the National Emergency X-Radiography Utilization Study [NEXUS] criteria); and the Hankins' criteria (immobilization for patients <12 or >65 years, those with altered consciousness, focal neurologic deficit, distracting injury, or midline or paraspinal tenderness).To determine the proportion of patients who would require cervical immobilization per protocol and the number of missed cervical spine injuries, had each protocol been followed with 100% compliance.
This was a cross-sectional study of patients ≥18 years transported by EMS post-traumatic mechanism to an inner city emergency department. Demographic and clinical/historical data obtained by physicians were recorded prior to radiologic imaging. Medical record review ascertained cervical spine injuries. Both physicians and EMS were blinded to the objective of the study.
Of 498 participants, 58% were male and mean age was 48 years. The following participants would have required cervical spine immobilization based on the respective protocol: PHTLS, 95.4% (95% CI: 93.1-96.9%); Domeier, 68.7% (95% CI: 64.5-72.6%); Hankins, 81.5% (95% CI: 77.9-84.7%). There were 18 cervical spine injuries: 12 vertebral fractures, 2 subluxations/dislocations and 4 spinal cord injuries. Compliance with each of the 3 protocols would have led to appropriate cervical spine immobilization of all injured patients. In practice, 2 injuries were missed when the PHTLS criteria were mis-applied.
Although physician-determined presence of cervical spine immobilization criteria cannot be generalized to the findings obtained by EMS personnel, our findings suggest that the mechanism-based PHTLS criteria may result in unnecessary cervical spine immobilization without apparent benefit to injured patients. PHTLS criteria may also be more difficult to implement due to the subjective interpretation of the severity of the mechanism, leading to non-compliance and missed injury.
我们想要比较三种现有的紧急医疗服务（EMS）固定方案：院前创伤生命支持（PHTLS，基于机制）；多迈尔方案（与国家紧急X线摄影应用研究[NEXUS]标准类似）；以及汉金斯标准（为年龄小于12岁或大于65岁、意识改变、有局灶性神经功能缺损、有分散性损伤、或中线或椎旁压痛的患者进行固定）。为了确定按照每个方案需要进行颈椎固定的患者比例以及漏诊颈椎损伤的数量，假设每个方案都能100%依从执行。
这是一项横断面研究，研究对象为年龄≥18岁、因创伤机制由EMS转运至市中心急诊科的患者。医生在进行放射学成像之前记录所获取的人口统计学和临床/病史数据。通过查阅病历确定颈椎损伤情况。医生和EMS人员均对研究目的不知情。
498名参与者中，58%为男性，平均年龄为48岁。根据各自方案，以下参与者需要进行颈椎固定：PHTLS方案，95.4%（95%置信区间：93. = = 1 - 96.9%）；多迈尔方案，68.7%（95%置信区间：64.5 - 72.6%）；汉金斯标准，81.5%（95%置信区间：77.9 - 84.7%）。共有18例颈椎损伤：12例椎体骨折、2例半脱位/脱位和4例脊髓损伤。若依从这三种方案中的每一种，均可对所有受伤患者进行适当的颈椎固定。在实际操作中，当PHTLS标准应用错误时，漏诊了2例损伤。
尽管医生确定的颈椎固定标准情况不能推广至EMS人员所获得的结果，但我们的研究结果表明，基于机制的PHTLS标准可能会导致不必要的颈椎固定，而对受伤患者并无明显益处。由于对机制严重程度的主观解读，PHTLS标准可能也更难实施，从而导致不依从和漏诊损伤。
