Sticking our neck out: is magnetic resonance imaging needed to clear an obtunded patient's cervical spine?

BACKGROUND: Evaluating the cervical spine in the obtunded trauma patient is a subject fraught with controversy. Some authors assert that a negative computed tomography (CT) scan is sufficient. Others argue that CT alone misses occult unstable injuries, and magnetic resonance imaging (MRI) will alter treatment. This study examines the data in an urban, county trauma center to determine if a negative cervical spine CT scan is sufficient to clear the obtunded trauma patient. METHODS: Records of all consecutive patients admitted to a level 1 trauma center from January 2000 to December 2011 were retrospectively analyzed. Patients directly admitted to the intensive care unit with a Glasgow Coma Scale score ≤13, contemporaneous CT and MRI, and a negative CT reading were included. The results of the cervical spine MRI were analyzed. RESULTS: A total of 309 patients had both CT and MRI, 107 (35%) of whom had negative CTs. Mean time between CT and MRI was 16 d. Of those patients, seven (7%) had positive acute traumatic findings on MRI. Findings included ligamentous injury, subluxation, and fracture. However, only two of these patients required surgical intervention. None had unstable injuries. CONCLUSIONS: In the obtunded trauma patient with a negative cervical spine CT, obtaining an MRI does not appear to significantly alter management, and no unstable injuries were missed on CT scan. This should be taken into consideration given the current efforts at cost-containment in the health care system. It is one of the larger studies published to date.

Examining triage patterns of inhalation injury and toxic epidermal necrolysis-Stevens Johnson syndrome.

The American Burn Association recommends that patients with toxic epidermal necrolysis-Stevens Johnson syndrome (TEN-SJS) or burn inhalation injuries would benefit from admission or transfer to a burn center (BC). This study examines to what extent those criteria are observed within a regional burn network. Hospital discharge data from 2000 to 2010 was obtained for all hospitals within the South Florida regional burn network. Patients with International Classification of Disease-9th revision discharge diagnoses for TEN-SJS or burn inhalation injury and their triage destination were compared using burn triage referral criteria to determine whether the patients were triaged differently from American Burn Association recommendations. Two hundred ninety-nine TEN-SJS and 131 inhalation injuries were admitted to all South Florida hospitals. Only 25 (8.4%) of TEN-SJS and 27 (21%) of inhalation injuries were admitted to the BC. BC patients had greater length of stay (TEN-SJS 22 vs 10 days; inhalation 13 vs 7) and were more likely to be funded by charity or be self-paid (TEN-SJS 24 vs 9.5%, P = .025; inhalation 44 vs 14%, P < .001), but less likely to hold some form of private or government insurance (TEN-SJS 72 vs 88%, P = .02; inhalation 48 vs 81%, P = .006). TEN-SJS BC patients were more frequently discharged home for self-care (76 vs 50%, P = .006). Non-BC patients were more often discharged to other healthcare facilities (28 vs 0% TEN-SJS, 20 vs 7.4% inhalation). Inappropriate triage may occur in more than 3 out of 4 of the TEN-SJS and inhalation injury patients within our burn network. Unfamiliarity with triage criteria, patient insurance status, and overcoding may play a role. Further studies should fully characterize the problem and implement education or incentives to encourage more appropriate triage.

Exploring trauma recidivism in an elderly cohort.

PURPOSE: As the population ages, trauma in the elderly is an increasingly recognized source of elderly morbidity. However, previous reviews on the topic provide only broad recommendations. The purpose of this study was to examine the elderly recidivist cohort at an urban trauma center for mechanisms of repeat injury. METHODS: The trauma registry at a major urban trauma center was queried to identify all patients aged 65 and older admitted from 1991-2010. Recidivist admissions were compared to nonrecidivist admissions. Demographics, mechanism of injury, injury location, length of stay, and mortality data were collected. Recidivists' mechanism of injury was compared with their initial mechanism of injury. Descriptive statistics, Student t-test, and a z-rank test of proportions were applied with significance set to P ≤ 0.05. RESULTS: Between 1991 and 2010, 6476 patients aged 65+ were admitted, of which 79 (1.22%) were recidivists. Of these, 64 patients were aged 65 and older for both admissions. Most often, recidivists were male (70% versus 60%) and injured in penetrating trauma (17% versus 7.5%, P = 0.045). Recidivists trended towards more frequent injuries in bicycle collisions (3% versus 1.9%) and all-terrain vehicle (ATV)/motorcycle crashes (6.3% versus 1.7%), but were less likely to be hit by cars (49% versus 36%, P = 0.034). At least two thirds of recidivist patients injured in falls, ATV/motorcycle accidents, and stabbings had previously been injured by the same mechanism. CONCLUSIONS: The overall recidivism rate in the elderly population is low. Nevertheless, recidivists were more susceptible to penetrating trauma, ATV/motorcycle collisions, and possibly bicycle accidents. These findings can help design counseling initiatives and injury prevention programs that target specific elderly trauma patients.

Pediatric trauma recidivism in an urban cohort.

BACKGROUND: Recidivism is a well-known problem in adult trauma patients. Trauma recidivists are a population that warrants further intervention to prevent future trauma. Among pediatric patients, the recidivism rate, demographics, mechanism, and mortality are unknown. We hypothesized that specific groups of pediatric trauma recidivists could be identified for targeted prevention efforts. METHODS: All pediatric trauma patients admitted to a level 1 pediatric trauma center in an urban county hospital between 1991 and 2010 were reviewed. Age, sex, Glasgow Coma Scale, injury location, injury cause, disposition, length of stay, and mortality were collected and compared between nonrecidivist and recidivist cohorts. RESULTS: The recidivism rate among patients aged 0-19 y was 1.5% compared with 0.9% in those aged 0-16 y. Recidivists were more likely males (P < 0.001) suffering from penetrating injuries. They were less frequently injured in motor vehicle collisions. Two of every three recidivist gunshot wound (GSW) victims were injured by a GSW on their prior admission. CONCLUSIONS: The pediatric recidivism rate in our population is small. Nevertheless, recidivists are more than twice as likely to be injured by penetrating trauma, especially GSWs. Targeted screening and counseling in this demographic may be helpful in reducing youth trauma recidivism.