Rapid Arterial Occlusion Evaluation Scale Agreement between Emergency Medical Services Technicians and Neurologists.

BACKGROUND: Rapid arterial occlusion evaluation (RACE) scale is a valid prehospital tool used to predict large vessel occlusion of major cerebral arteries in patients with suspected acute stroke. RACE scale administered by Emergency medicine services (EMS) technicians in the prehospital setting correlates well with NIH Stroke Scale score after patient arrival at a hospital. Despite this, the RACE scale is often characterized as too difficult for EMS technicians to accurately utilize. There are no data examining RACE scale accuracy in the prehospital setting comparing EMS technicians with neurologists. We sought to examine agreement between RACE scores calculated by EMS technicians and stroke neurologists in the prehospital setting during telestroke consultation. METHODS: Data for this observational cohort study were prospectively collected and retrospectively analyzed. EMS technicians in person and stroke specialized neurologists via televideo connection independently assessed suspected stroke patients and calculated RACE scores in the prehospital setting. We used a linearly weighted Cohen's kappa (kw) to estimate the extent of agreement for RACE score between EMS technicians and stroke neurologists. RESULTS: Thirty-one patients with stroke symptoms were independently examined and assessed with the RACE scale by EMS technicians and stroke neurologists in the prehospital setting. Exact agreement on the RACE score was found in 24 of 31 (77%) patients. We found very good agreement between EMS technicians and stroke neurologists, kw = .818 (95% CI, .677-.960), P< .001. CONCLUSIONS: EMS technicians provide reliable RACE assessments in patients with suspected stroke, with agreement similar to stroke specialized neurologists in the prehospital setting.

Characteristics and outcomes of trauma patients with ICU lengths of stay 30 days and greater: a seven-year retrospective study.

INTRODUCTION: Prolonged intensive care unit lengths of stay (ICU LOS) for critical illness can have acceptable mortality rates and quality of life despite significant costs. Only a few studies have specifically addressed prolonged ICU LOS after trauma. Our goals were to examine characteristics and outcomes of trauma patients with LOS >or= 30 days, predictors of prolonged stay and mortality. METHODS: All trauma ICU admissions over a seven-year period in a level 1 trauma center were analyzed. Admission characteristics, pre-existing conditions and acquired complications in the ICU were recorded. Logistic regression was used to identify independent predictors of prolonged LOS and predictors of mortality among those with prolonged LOS after univariate analyses. RESULTS: Of 4920 ICU admissions, 205 (4%) had ICU LOS >30 days. These patients were older and more severely injured. Age and injury severity score (ISS) were associated with prolonged LOS. After logistic regression analysis, sepsis, acute respiratory distress syndrome, and several infectious complications were important independent predictors of prolonged LOS. Within the group with ICU LOS >30 days, predictors of mortality were age, pre-existing renal disease as well as the development of renal failure requiring dialysis. Overall mortality was 12%. CONCLUSIONS: The majority of patients with ICU LOS >or= 30 days will survive their hospitalization. Infectious and pulmonary complications were predictors of prolonged stay. Further efforts targeting prevention of these complications are warranted.

Exclusion of cervical spine instability in patients with blunt trauma with normal multidetector CT (MDCT) and radiography.

The objective of the study was to determine if negative multidetector computed tomography (MDCT) and lateral radiography of the cervical spine effectively excludes patients with unstable cervical spine injuries. Over a period of 40 months, 6558 people were admitted to our trauma service with blunt injury and 447 (6.8%) were found to have cervical fractures. Fractures were identified by CT and/or lateral radiography. In order to rule out clinically significant instability in the absence of fracture, we identified nine patients who required any type of stabilization of the cervical spine including anterior fusion, posterior fusion and external orthosis. These patients also underwent MR of the cervical spine. Radiography, CT, and MR images and reports of these nine patients were reviewed. Nine patients without a fracture required cervical stabilization. These patients had the following abnormalities: disc herniation with canal stenosis in three, unilateral jumped facet in three, and various other soft tissue abnormalities in three, all of which were evident on CT or radiography. All nine patients had evidence for cervical spine injury or instability by MDCT. Normal MDCT and radiography appears adequate to 'clear' the cervical spine. We recommend that patients requiring cervical spine clearance undergo a complete MDCT and lateral radiograph of the cervical spine. If these studies are entirely normal, then the cervical spine may be cleared. If any abnormalities, including disc herniation, soft tissue swelling and bony malalignments are noted by radiography and/or MDCT, further studies, including MR, are indicated prior to clearance of the cervical spine.

Trauma registry data validation: building objectivity.

The process of developing, implementing, and refining a registry data validation system is integral to optimal trauma registry operations. Describing registrar skill and proficiency in a manner that was once subjective can be replaced with objective assessment through the use of concrete rating guidelines and examples. The ability to standardize the evaluation of each registry abstract becomes the foundation for analyzing the overall accuracy of registry data. Key to the process is incorporating the validation rating tool as part of the data abstract. If properly implemented, the methodology described becomes a practical means for accuracy reporting, peer benchmarking, orientation and training, and performance management.

Detection of cervical spine injuries in alert, asymptomatic geriatric blunt trauma patients: who benefits from radiologic imaging?

There are differing recommendations in the literature regarding cervical spine imaging in alert, asymptomatic geriatric patients. Previous studies also have not used computed tomography routinely. Given that cervical radiographs may miss up to 60 per cent of fractures, the incidence of cervical spine injuries in this population and its implications for clinical management are unclear. We conducted a retrospective study of blunt trauma patients 65 years and older who were alert, asymptomatic, hemodynamically stable, and had normal neurologic examinations. For inclusion, patients were required to have undergone computed tomography and plain radiographs. The presence and anatomic location of potentially distracting injuries or pain were recorded. Two hundred seventy-four patients were included, with a mean age of 76 +/- 10 years. The main mechanisms of injury were falls (51%) and motor vehicle crashes (41%). Nine of 274 (3%) patients had cervical spine injuries. The presence of potentially distracting injuries above the clavicles was associated with cervical injury when compared with patients with distracting injuries in other anatomic locations or no distracting injuries (8/115 vs 1/159, P = 0.03). There was no association of cervical spine injury with age greater or less than 75 years or with mechanism of injury. The overall incidence of cervical spine injury in the alert, asymptomatic geriatric population is low. The risk is increased with a potentially distracting injury above the clavicles. Patients with distracting injuries in other anatomic locations or no distracting injuries may not need routine cervical imaging.

Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion.

BACKGROUND: Traumatic brain injury (TBI) can be compounded by physiologic derangements that produce secondary brain injury. The purpose of this study is to elucidate the frequency with which physiologic factors that are associated with secondary brain injury occur in patients with severe closed head injuries and to determine the impact of these factors on outcome. METHODS: The records of 81 adult blunt trauma patients with Glasgow Coma Scale scores < or = 8 and transport times < 2 hours to a Level I trauma center were retrospectively reviewed searching for the following 11 secondary brain injury factors (SBIFs) in the first 24 hours postinjury: hypotension, hypoxia, hypercapnia, hypocapnia, hypothermia, hyperthermia, metabolic acidosis, seizures, coagulopathy, hyperglycemia, and intracranial hypertension. We recorded the worst SBIF during six time periods: hours 1, 2, 3, 4, 5 to 14, and 16 to 24. Occurrence of each SBIF was then correlated with outcome. RESULTS: Hypocapnia, hypotension, and acidosis occurred more frequently than other SBIFs (60-80%). Hypotension, hyperglycemia, and hypothermia were associated with increased mortality rate. Patients with episodes of hypocapnia, acidosis, and hypoxia had significantly longer intensive care unit length of stay (LOS). These three SBIFs and hyperglycemia related to longer hospital LOS as well. Hypotension and acidosis were associated with discharge to a rehabilitation facility rather than home. Finally, multivariate regression analysis revealed that hypotension, hypothermia, and Abbreviated Injury Scale score of the head were independently related to mortality, whereas other SBIFs, age, Injury Severity Score, and Glasgow Coma Scale score were not. Metabolic acidosis and hypoxia were related to longer intensive care unit and hospital LOS. CONCLUSION: Our early management of head-injured patients stresses avoidance and correction of SBIFs at all costs. Nonetheless, SBIFs occur frequently in the first 24 hours after traumatic brain injury. Six of the 11 factors studied are associated with significantly worse outcomes. Hypotension and hypothermia are independently related to mortality. Because these SBIFs are potentially preventable, protocols could be developed to decrease their frequency.