Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging.

BACKGROUND: Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a "Spinal Immobilization" protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new "Spinal Motion Restriction" protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging. METHODS: This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January-June 2015 and January-June 2016. RESULTS: There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p < 0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02). CONCLUSION: A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.

Sufficient catheter length for pneumothorax needle decompression: a meta-analysis.

INTRODUCTION: Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis. METHODS: A meta-analysis of existing studies was conducted. A Medline search was performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall thickness, and a standard deviation or confidence interval. A PubMed search was performed in a similar fashion. Sample size, mean chest wall thickness, and standard deviation were found or calculated for each study. Data were combined to create a pooled dataset. Normal distribution of data was assumed. Procedural success was defined as catheter length being equal to or greater than the chest wall thickness. RESULTS: The Medline and PubMed searches yielded 773 unique studies; all study abstracts were reviewed for possible inclusion. Eighteen papers were identified for full manuscript review. Thirteen studies met all inclusion criteria and were included in the analysis. Pooled sample statistics were: n=2,558; mean=4.19 cm; and SD=1.37 cm. Minimum catheter length needed for success at the 95th percentile for chest wall size was found to be 6.44 cm. DISCUSSION: A catheter of at least 6.44 cm in length would be required to ensure that 95% of the patients in this pooled sample would have penetration of the pleural space at the site of needle decompression, and therefore, a successful procedure. These findings represent Level III evidence.

Parenteral midazolam is superior to diazepam for treatment of prehospital seizures.

INTRODUCTION: Diazepam and midazolam are commonly used by paramedics to treat seizures. A period of drug scarcity was used as an opportunity to compare their effectiveness in treating prehospital seizures. METHODS: A retrospective chart review of a single, large, commercial agency during a 29-month period was performed. The period included alternating shortages of both medications. Ambulances were stocked with either diazepam or midazolam based on availability of the drugs. Adult patients who received at least 1 parenteral dose of diazepam or midazolam for treatment of seizures were included. The regional prehospital protocol recommended 5 mg intravenous (IV) diazepam, 5 mg intramuscular (IM) diazepam, 5 mg IM midazolam, or 2.5 mg IV midazolam. Medication effectiveness was compared with respect to the primary end point: cessation of seizure without repeat seizure during the prehospital encounter. RESULTS: A total of 440 study subjects received 577 administrations of diazepam or midazolam and met the study criteria. The subjects were 52% male, with a mean age of 48 (range 18-94) years. A total of 237 subjects received 329 doses of diazepam, 64 (27%) were treated with first-dose IM. A total of 203 subjects received 248 doses of midazolam; 71 (35%) were treated with first-dose IM. Seizure stopped and did not recur in 49% of subjects after parenteral diazepam and 65% of subjects after parenteral midazolam (p = 0.002). Diazepam and midazolam exhibited similar first dose success for IV administration (58 vs. 62%; p = 0.294). Age, gender, seizure history, hypoglycemia, the presence of trauma, time to first administration, prehospital contact time, and frequency of IM administration were similar between groups. CONCLUSION: For parenteral administration, midazolam demonstrated superior first-dose seizure suppression. This study demonstrates how periods of drug scarcity can be utilized to study prehospital medication effectiveness.