Risk Factors for Wound Infection in Outpatients With Lower Extremity Burns.

BACKGROUND: We sought to evaluate risk factors for wound infection in patients with lower extremity (LE) burn. METHODS: Adults presenting with LE burn from January 2014 to July 2015 were included. Data regarding demographics, injury characteristics, and outcomes were obtained. The primary outcome was wound infection. Multivariate logistic regression analysis was performed to identify independent risk factors for wound infection. RESULTS: 317 patients were included with a mean age of 43 years and median total body surface area of .8%; 22 (7%) patients had a component of full-thickness (FT) burn; and 212 (67%) patients had below-the-knee (BTK) burn. The incidence of wound infection was 15%. The median time to infection was 5 days, and majority (61%) of the patients developed wound infection by day 5. Patients who developed wound infection were more likely to have an FT burn (22% vs. 5%, P < .001) and BTK burn (87% vs. 64%, P = .002), without a difference in other variables. Multivariate logistic regression analysis showed age (Odds ratio (OR) 1.02 and CI 1.00-1.04), presence of FT burn (OR 5.33 and CI 2.09-13.62), and BTK burn (OR 3.42 and CI 1.37-8.52) as independent risk factors for wound infection (area under the curve = .72). CONCLUSION: Age, presence of FT burn, and BTK burn are independent risk factors for wound infection in outpatients with LE burns.

Burn Wound Colonization, Infection, and Sepsis.

Background: Infection is a major cause of morbidity and mortality among burn patients, and it is important to understand the progression of wound colonization to wound infection to systemic sepsis. Methods: After a review of the literature we describe the clinical characteristics of burn wound colonization, infection, and sepsis, and conclude with best practices to decrease these complications. Results: Burn wounds are initially sterile after the thermal insult but become colonized by gram-positive organisms and subsequently by gram-negative organisms. Some populations are especially susceptible to initial or subsequent colonization by drug-resistant organisms. An increase in fungal colonization has been observed because of the widespread use of topical antibiotic agents. Male gender, older age, lower extremity burn, scald burn, full-thickness burn, delay in treatment, and pre-existing diabetes place patients at increased risk of infection. These infections range from cellulitis that requires systemic antibiotic agents, to invasive burn wound infection that requires prompt treatment with antibiotic agents and excision. Fungal wound infections pose a special challenge and cause substantial morbidity. Infection that leads to systemic sepsis is difficult to define in burn patients because of the body's compensatory hypermetabolic response to the burn injury. Potential sources of sepsis include wound infections and common nosocomial infections. The American Burn Association Sepsis criteria, defined in 2007, has demonstrated poor specificity for identifying sepsis and septic shock. The best approach to decrease wound infections is prevention. Practices that have been beneficial include isolation rooms, handwashing, appropriate wound care, early excision and grafting, antibiotic stewardship, and nutritional support. Conclusions: A burn patient remains at a substantial risk of wound infection despite advances in care. A burn care provider must understand the natural progression of colonization to infection to sepsis, and the multidisciplinary approach to wound care to limit the morbidity and mortality from these infectious.

Utility of Sequential Organ Failure Assessment score in predicting bacteremia in critically ill burn patients.

BACKGROUND: We evaluated whether qSOFA ≥2 and an increase in SOFA (ΔSOFA) ≥2 can help predict bacteremia in a critically ill burn population. METHODS: Patients age ≥15 and TBSA ≥15% admitted between 2009 and 2015 were included. All blood cultures were recorded, and positive and negative blood culture days were defined based on the culture results. SOFA and qSOFA scores were compared between positive and negative blood culture days. RESULTS: There were 50 patients in our study with a mean age of 47yrs and mean TBSA burn of 37%. Bacteremic patients had larger TBSA and full thickness burns, higher revised Baux score, and longer hospital LOS, without a difference in mortality, compared to non-bacteremic patients. There was no difference in qSOFA and SOFA scores between positive and negative blood culture days. A ΔSOFA ≥5 was highly specific for positive blood culture days. CONCLUSIONS: SOFA and qSOFA have limited ability to predict bacteremia in critically ill burn patients.

Outpatient burn management.

Most burn patients have injuries that may be treated on an outpatient basis. Newer silver-based dressings and improved medications for the treatment of pain and pruritus have led to further growth of outpatient care. The final barrier of distance from the burn center will decrease with the growth of telemedicine. It is incumbent for burn centers to develop outpatient guidelines to facilitate this growth of outpatient care.

Outcomes of outpatient management of pediatric burns.

The literature surrounding pediatric burns has focused on inpatient management. The goal of this study is to characterize the population of burned children treated as outpatients and assess outcomes validating this method of burn care. A retrospective review of 953 patients treated the burn clinic and burn unit of a tertiary care center. Patient age, burn etiology, burn characteristics, burn mechanism, and referral pattern were recorded. The type of wound care and incidence of outcomes including subsequent hospital admission, infection, scarring, and surgery served as the primary outcome data. Eight hundred and thirty children were treated as outpatients with a mean time of 1.8 days for the evaluation of burn injury in our clinic. Scalds accounted for 53% of the burn mechanism, with burns to the hand/wrist being the most frequent area involved. The mean percentage of TBSA was 1.4% for the outpatient cohort and 8% for the inpatient cohort. Burns in the outpatient cohort healed with a mean time of 13.4 days. In the outpatient cohort, nine (1%) patients had subsequent admissions and three (0.4%) patients had concern for infection. Eight patients from the outpatient cohort were treated with excision and grafting. The vast majority of pediatric burns are small, although they may often involve more critical areas such as the face and hand. Outpatient wound care is an effective treatment strategy which results in low rates of complications and should become the standard of care for children with appropriate burn size and home support.

Recurrent toxic epidermal necrolysis secondary to iopromide contrast.

We present the case report of a patient with three episodes of Stevens-Johnson syndrome/toxic epidermal necrolysis attributed to the monomeric, nonionic, intravenous contrast iopromide. All three episodes required inpatient management, with the last two episodes being referred to the burn unit. Recurrence was the result of misattribution of an antibiotic as the inciting agent in the first two episodes.

The Interplay of Preference, Familiarity and Psychophysical Properties in Defining Relaxation Music.

BACKGROUND: The stress response has been well documented in past music therapy literature. However, hypometabolism, or the relaxation response, has received much less attention. Music therapists have long utilized various music-assisted relaxation techniques with both live and recorded music to elicit such a response. The ongoing proliferations of relaxation music through commercial media and the dire lack of evidence to support such claims warrant attention from healthcare professionals and music therapists. OBJECTIVE: The purpose of these 3 studies was to investigate the correlational relationships between 12 psychophysical properties of music, preference, familiarity, and degree of perceived relaxation in music. METHODS: Fourteen music therapists recommended and analyzed 30 selections of relaxation music. A group of 80 healthy adults then rated their familiarity, preference, and degree of perceived relaxation in the music. RESULTS: The analysis provided a detailed description of the intrinsic properties in music that were perceived to be relaxing by listeners. These properties included tempo, mode, harmonic, rhythmic, instrumental, and melodic complexities, timbre, vocalization/lyrics, pitch range, dynamic variations, and contour. In addition, music preference was highly correlated with listeners' perception of relaxation in music for both music therapists and healthy adults. The correlation between familiarity and degree of relaxation reached significance in the healthy adult group. CONCLUSIONS: Results from this study provided an in-depth operational definition of the intrinsic parameters in relaxation music and also highlighted the importance of preference and familiarity in eliciting the relaxation response.

Takotsubo cardiomyopathy after minor burn injury.

The relationship between severe emotional stress and subsequent acute cardiac dysfunction has been anecdotally noted for decades. In fact, cases of "death by fright" have been described since ancient times, and a growing body of evidence suggests that this phenomenon is due to an acute catecholamine-induced cardiomyopathy. The authors present a case of Takotsubo cardiomyopathy complicating a minor burn injury that occurred during an operating room fire. Two PEA arrests occurred immediately after injury, and an intra-aortic balloon pump was required due to hemodynamic instability. The diagnosis was confirmed by echocardiogram and cardiac catherization. This condition is often unrecognized as a cause of hemodynamic instability and may be more common after burn injury than we presently recognize.

Risk factors for ophthalmic complications in patients with burns.

A retrospective study of patients admitted to MetroHealth Medical Center was performed to identify the risk factors for short- and long-term ophthalmologic complications related to burn injury. From 2000 to 2007, the authors identified 293 patients with the inclusion criteria of facial burns, TBSA ≥20%, or smoke inhalation injury. Seventy (24%) developed ocular complications, and 16 (11%) developed long-term complications. Statistically significant risk factors identified for short-term complications were burn size, chemical burns, depth of facial burns, initial Glasgow Coma Scale, and need for mechanical ventilation/sedation. Risk factors for long-term complications included wound infection with Pseudomonas or Acinetobacter, third-degree burn size, hours to ophthalmology evaluation, LOS, time on mechanical ventilation, and need for STSG. In addition to facial burns, the requirement of mechanical ventilation, prolonged sedation, and presence of infection with Pseudomonas or Acinetobacter increase the risk of injury to the eye after burn injury, and these patients may benefit from serial eye examinations for early identification of ocular complications.

The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: a prospective randomized crossover trial.

The purpose of this study was to explore the efficacy of two music therapy protocols on pain, anxiety, and muscle tension levels during dressing changes in burn patients. Twenty-nine inpatients participated in this prospective, crossover randomized controlled trial. On two consecutive days, patients were randomized to receive music therapy services either on the first or second day of the study. On control days, they received no music. On music days, patients practiced music-based imagery (MBI), a form of music-assisted relaxation with patient-specific mental imagery before and after dressing changes. Also, on music days during dressing changes, the patients engaged in music alternate engagement (MAE), which consisted of active participation in music making. The dependent variables were the patients' subjective ratings of their pain and anxiety levels and the research nurse's objective ratings of their muscle tension levels. Two sets of data were collected before, three sets during, and another two sets after dressing changes. The results showed significant decrease in pain levels before (P < .025), during (P < .05), and after (P < .025) dressing changes on days the patients received music therapy in contrast to control days. Music therapy was also associated with a decrease in anxiety and muscle tension levels during the dressing changes (P < .05) followed by a reduction in muscle tension levels after dressing changes (P < .025). Music therapy significantly decreases the acute procedural pain, anxiety, and muscle tension levels associated with daily burn care.

Trauma team activation can be tailored by prehospital criteria.

A two phase prospective study was carried out at a regional Level I trauma center over 1 year. Phase I involved collecting observational data to determine which trauma criteria could potentially be used to identify patients that could be evaluated by a lower level trauma activation (category-3). A category-3 involved a smaller response team with priority access to imaging. Phase II involved implementing this third tier activation system and prospectively evaluating the outcomes related to resources and patient care. A total of 3104 patients were evaluated with 2076 patients in phase I and 1037 in phase II. Three commonly identified activation criteria out of the 36 studied were not associated with admission. These criteria were pedestrian struck by vehicle, high speed vehicular crash, and Glasgow Coma Score 12-14. These criteria were then used as triggers for a category-3 activation in phase II. Comparisons of patients with these three identified criteria between phase I and II demonstrated that significantly fewer patients were admitted, charges were reduced, emergency department times were similar, and less man-power hours were needed in phase II. The utilization of a third tiered activation system resulted in a decrease utilization of many resources without sacrificing patient care.

The "fever workup" and respiratory culture practice in critically ill trauma patients.

PURPOSE: Fever and leukocytosis (FAL) in critically ill patients often triggers a "workup" that includes a respiratory secretion culture (RCx). We evaluated our respiratory culture practice associated with FAL. We hypothesized that FAL would be associated with a RCx, but would not be associated with a positive culture or treating a respiratory infection in critically injured patients during their first 14 intensive care unit (ICU) days. MATERIALS AND METHODS: An 18-month retrospective analysis was performed on consecutive ICU trauma patients admitted for 2 days or more to a level I trauma center. Data collected included demographics, injuries, RCxs (bronchoalveolar lavage or tracheal aspirate), maximum daily temperature, and a daily leukocyte count during the first 14 ICU days. RESULTS: A total of 510 patients with a mean age of 49 and injury severity score of 19 were evaluated for a total of 3839 patient-days. Two hundred eleven patients had 489 RCxs obtained (2.4 RCxs/patient); 94 (19%) were obtained on consecutive days. Obtaining a RCx was associated with fever (relative risk, 4.8; 95% confidence interval, 4.1-5.8) and the combination of FAL (relative risk, 2.6; 95% confidence interval, 2.2-3.1), but not leukocytosis alone. Fever, leukocytosis, or FAL did not predict a positive RCx. One hundred twenty-eight patients were treated for a respiratory infection. Treatment of respiratory infections was contrary to the RCx results 24% of the time. The sensitivity and specificity of a positive RCx being associated with respiratory infection were 97% and 46%, respectively. CONCLUSIONS: Fever and leukocytosis were associated with the decision to obtain RCxs but were not associated with positive RCxs in our ICU practice. Respiratory secretion culture results had a low specificity and did not consistently impact treatment decisions. Factors other than fever and leukocytosis alone should influence the decision to obtain RCxs during the first 14 days in the ICU after trauma.

Fever and leukocytosis in critically ill trauma patients: it is not the blood.

The diagnosis of bacteremia in critically ill patients is classically based on fever and/or leukocytosis. The objectives of this study were to determine 1) if our intensive care unit obtains blood cultures based on fever and/or leukocytosis over the initial 14 days of hospitalization after trauma; and 2) the efficacy of this diagnostic workup. An 18-month retrospective cohort analysis was performed on consecutively admitted trauma patients. Data collected included demographics, injuries, and the first 14 days maximal daily temperature, leukocyte count, and results of blood and catheter tip cultures. Fever was defined as a maximum daily temperature of 38.5 degrees C or greater and leukocytosis as a leukocyte count 12,000/mm3 or greater of blood. Five hundred ten patients were evaluated for a total of 3,839 patient-days. The mean age and injury severity score were 49 +/- 1 years and 19 +/- 1, respectively. Four hundred twenty-five blood culture episodes were obtained and 25 (6%) bacteremias were identified in 23 patients (5%). A significant association was found between obtaining blood cultures in patients with fever (relative risk [RR], 7.7), leukocytosis (RR, 1.3), and fever + leukocytosis (RR, 3.2). However, no significant association was found between these clinical signs and the diagnosis of bacteremia. In fact, fever alone was inversely associated with bacteremia. Our intensive care unit follows the common "fever workup" practice and obtains blood cultures based on the presence of fever and leukocytosis. However, fever and leukocytosis were not associated with bacteremia, suggesting inefficiency and that other factors are more important after trauma.

Who is monitoring your infections: shouldn't you be?

BACKGROUND: In the era of pay for performance and outcome comparisons among institutions, it is imperative to have reliable and accurate surveillance methodology for monitoring infectious complications. The current monitoring standard often involves a combination of prospective and retrospective analysis by trained infection control (IC) teams. We have developed a medical informatics application, the Surgical Intensive Care-Infection Registry (SIC-IR), to assist with infection surveillance. The objectives of this study were to: (1) Evaluate for differences in data gathered between the current IC practices and SIC-IR; and (2) determine which method has the best sensitivity and specificity for identifying ventilator-associated pneumonia (VAP). METHODS: A prospective analysis was conducted in two surgical and trauma intensive care units (STICU) at a level I trauma center (Unit 1: 8 months, Unit 2: 4 months). Data were collected simultaneously by the SIC-IR system at the point of patient care and by IC utilizing multiple administrative and clinical modalities. Data collected by both systems included patient days, ventilator days, central line days, number of VAPs, and number of catheter-related blood steam infections (CR-BSIs). Both VAPs and CR-BSIs were classified using the definitions of the U.S. Centers for Disease Control and Prevention. The VAPs were analyzed individually, and true infections were defined by a physician panel blinded to methodology of surveillance. Using these true infections as a reference standard, sensitivity and specificity for both SIC-IR and IC were determined. RESULTS: A total of 769 patients were evaluated by both surveillance systems. There were statistical differences between the median number of patient days/month and ventilator-days/month when IC was compared with SIC-IR. There was no difference in the rates of CR-BSI/1,000 central line days per month. However, VAP rates were significantly different for the two surveillance methodologies (SIC-IR: 14.8/1,000 ventilator days, IC: 8.4/1,000 ventilator days; p = 0.008). The physician panel identified 40 patients (5%) who had 43 VAPs. The SIC-IR identified 39 and IC documented 22 of the 40 patients with VAP. The SIC-IR had a sensitivity and specificity of 97% and 100%, respectively, for identifying VAP and for IC, a sensitivity of 56% and a specificity of 99%. CONCLUSIONS: Utilizing SIC-IR at the point of patient care by a multidisciplinary STICU team offers more accurate infection surveillance with high sensitivity and specificity. This monitoring can be accomplished without additional resources and engages the physicians treating the patient.

Therapeutic anticoagulation in the trauma patient: is it safe?

PURPOSE: Trauma patients who require therapeutic anticoagulation pose a difficult treatment problem. The purpose of this study was to determine: (1) the incidence of complications using therapeutic anticoagulation in trauma patients, and (2) if any patient factors are associated with these complications. METHODS: An 18-month retrospective review was performed on trauma patients >or= 15 years old who received therapeutic anticoagulation using unfractionated heparin (UH) and/or fractionated heparin (FH). Forty different pre-treatment and treatment patient characteristics were recorded. Complications of anticoagulation were documented and defined as any unanticipated discontinuation of the anticoagulant for bleeding or other adverse events. RESULTS: One-hundred-fourteen trauma patients were initiated on therapeutic anticoagulation. The most common indication for anticoagulation was deep venous thrombosis (46%). Twenty-four patients (21%) had at least 1 anticoagulation complication. The most common complication was a sudden drop in hemoglobin concentration requiring blood transfusion (11 patients). Five patients died (4%), 3 of whom had significant hemorrhage attributed to anticoagulation. Bivariate followed by logistic regression analysis identified chronic obstructive pulmonary disease (OR = 9.2, 95%CI = 1.5-54.7), UH use (OR = 3.8, 95%CI = 1.1-13.0), and lower initial platelet count (OR = 1.004, 95%CI = 1.000-1.008) as being associated with complications. Patients receiving UH vs. FH differed in several characteristics including laboratory values and anticoagulation indications. CONCLUSION: Trauma patients have a significant complication rate related to anticoagulation therapy, and predicting which patients will develop a complication remains unclear. Prospective studies are needed to determine which treatment regimen, if any, is appropriate to safely anticoagulate this high risk population.

Validation of Surgical Intensive Care-Infection Registry: a medical informatics system for intensive care unit research, quality of care improvement, and daily patient care.

BACKGROUND: We developed a prototype electronic clinical information system called the Surgical Intensive Care-Infection Registry (SIC-IR) to prospectively study infectious complications and monitor quality of care improvement programs in the surgical and trauma intensive care unit. The objective of this study was to validate SIC-IR as a successful health information technology with an accurate clinical data repository. STUDY DESIGN: Using the DeLone and McLean Model of Information Systems Success as a framework, we evaluated SIC-IR in a 3-month prospective crossover study of physician use in one of our two surgical and trauma intensive care units (SIC-IR unit versus non SIC-IR unit). Three simultaneous research methodologies were used: a user survey study, a pair of time-motion studies, and an accuracy study of SIC-IR's clinical data repository. RESULTS: The SIC-IR user survey results were positive for system reliability, graphic user interface, efficiency, and overall benefit to patient care. There was a significant decrease in prerounding time of nearly 4 minutes per patient on the SIC-IR unit compared with the non SIC-IR unit. The SIC-IR documentation and data archiving was accurate 74% to 100% of the time depending on the data entry method used. This accuracy was significantly improved compared with normal hand-written documentation on the non SIC-IR unit. CONCLUSIONS: SIC-IR proved to be a useful application both at individual user and organizational levels and will serve as an accurate tool to conduct prospective research and monitor quality of care improvement programs.

Fever and leukocytosis in critically ill trauma patients: it's not the urine.

BACKGROUND: Infectious complications are a major cause of morbidity and mortality in critically ill trauma patients. Therefore, fever and leukocytosis often trigger an extensive laboratory workup that includes a urine culture (UCx). The purposes of this study were to: 1) Define the current practice for obtaining UCxs in trauma patients admitted to the surgical and trauma intensive care unit (STICU); and 2) determine if there is an association between fever or leukocytosis and urinary tract infections (UTIs) during the initial 14 hospital days. METHODS: An 18-month retrospective cohort analysis was performed on consecutive trauma patients admitted for at least two days to the STICU at a level I trauma center. Data collected included demographics, injuries, and daily maximal temperature (T(max)), leukocyte count, and UCx results for the first 14 days. Fever and leukocytosis were defined as T(max) > or =38.5 degrees C and leukocyte count > or =12,000/mm(3), respectively. Urinary tract infections were diagnosed with a positive UCx (> or =10(5) organisms/mL of urine). RESULTS: Five hundred ten patients were evaluated for a total of 3,839 patient-days. Their mean age and Injury Severity Score were 49 +/- 1 years and 19 +/- 1 points, respectively. Seventy-two percent were men, and 91% had sustained blunt injuries. Four hundred seven UCxs were obtained; 42 patients (8%) had 60 UTIs. The cohort had an indwelling urinary catheter for 97% of the patient-days, yielding an infection density of 16 UTIs/1,000 urinary catheter-days. There was a significant association between obtaining a UCx and fever and between fever and leukocytosis (both, p < 0.001), but no association of UTI with fever, leukocytosis, or the combination of fever and leukocytosis. Analysis using temperature and leukocyte count as continuous variables identified no temperature or leukocyte range associated with UTIs. Independent risk factors for UTI calculated by logistic regression were female sex, older age, low Injury Severity Score, and no antibiotics within 24 h before the UCx was obtained. CONCLUSIONS: The practice of obtaining a UCx from the STICU trauma patient was related to fever and fever with leukocytosis. However, neither fever nor leukocytosis nor both were associated with UTIs. These data suggest that there is an unnecessary emphasis on UTI as a source of fever and leukocytosis in injured patients during their first 14 STICU days. Our results suggest that the paradigm for evaluating UTI as a cause of fever needs to be reevaluated in critically ill trauma patients.

Isolated cervical spine fractures in the elderly: a deadly injury.

BACKGROUND: Traumatic injury in the elderly is an increasing problem and studies have shown that elderly patients (>/=65 years old) with cervical spine fractures and spinal cord injury (SCI) carry a mortality rate of 21% to 30%. However, little has been described with regard to outcomes for elderly patients with isolated cervical spine fractures (ICSF). HYPOTHESIS: Outcomes for elderly patients with ICSF will be similar to elderly patients with cervical fractures and associated traumatic injuries (ATI) or SCI. METHODS: A 9-year retrospective analysis was performed on all patients >/=65 years old admitted to a level I trauma center with any cervical spine fracture. Primary outcomes were defined as favorable (discharge to home or rehabilitation hospital) or unfavorable (death, discharge to a long-term acute care facility, or a skilled nursing facility). ICSF was defined as those fractures without ATI or SCI. Long-term mortality data were gathered using the Social Security Death Index. RESULTS: A total of 177 patients with mean age of 78 +/- 1 and Injury Severity Score of 17 +/- 1 were evaluated. Fifty-six percent were men and falls were the most common mechanism (62%). An unfavorable outcome was seen in 56% of the study population with a mortality rate of 25%. ATIs were seen in 57% of the population and 22% had SCI. Patients with SCI had a significantly higher mortality compared with patients without SCI (38% vs. 22%, p = 0.032). However, there was no difference in unfavorable outcomes. Patients with ICSF had no differences in unfavorable outcomes compared with patients with SCI or ATI. Long-term survival analysis after discharge (mean = 2.8 years) demonstrated that patients with a favorable outcome had a significantly improved survival compared with patients with unfavorable outcomes (p < 0.001). CONCLUSION: ICSFs were associated with an unfavorable outcome in the elderly population regardless of ATI or SCI. These unfavorable outcomes were also associated with long-term mortality. Strategies to reduce morbidity and mortality in this devastating injury will be essential to improve outcomes and maximize resource utilization.

Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma?

BACKGROUND: The optimal method of clearing the cervical spine (CS) in obtunded blunt trauma patients (OBTPs) remains unclear. Computed tomography (CT) identifies most injuries but may fail to detect ligamentous and spinal cord injuries. Magnetic resonance (MR) imaging has been widely used to exclude these. The purpose of this study was to evaluate whether CT of the CS (CT-CS) alone is adequate to clear the CS in OBTPs. Our hypothesis was that MR imaging of the CS (MR-CS) does not contribute relevant information and is not necessary in this patient population. METHODS: A prospective evaluation of OBTPs with a CT-CS negative for acute trauma and an MR-CS obtained for clearance was performed at a Level I trauma center between July 1, 2004, and June 30, 2006. Data gathered included demographics, results of CT-CS and MR-CS, timing of MR-CS, Glasgow Coma Scale score at time of MR-CS, adverse events occurring while obtaining MR-CS, and cervical collar complications. RESULTS: One hundred and fifteen patients were identified. There were 90 male patients. The mean age was 43.9 years +/- 1.9 years, mean Injury Severity Score was 24.4 +/- 1.0, and mean length of stay was 23.4 days +/- 1.2 days. The MR-CS was performed on hospital day 7.5 +/- 0.6 and the mean Glasgow Coma Scale score at the time of MR-CS was 8.3 +/- 0.3. Six MR-CS (5.2%) subsequently identified acute injuries. Findings included microtrabecular injuries, intraspinous ligament injuries, a cord signal abnormality, and a cervical epidural hematoma. None of these findings changed management and none required continued cervical collar usage. Six cervical collar complications were identified (5.2%). No adverse events related to transport or obtaining MR-CS occurred. Eliminating MR-CS would have decreased health care costs by over $250,000 during this period. CONCLUSIONS: MR-CS may be unnecessary in the OBTP if the CT-CS is negative. Elimination of MR-CS in this population will lead to earlier removal of cervical collars, decreased cervical collar complications, protection of the patient from exposure to potential risks inherent to obtaining this study, and decreased health care costs.