The Pre-Hospital Management of Suspected Spinal Cord Injury and its Association with Patient Outcomes

2017-02-06T00:28:55Z (GMT) by Ala'a O. Oteir
Traumatic spinal cord injury (TSCI) is relatively uncommon, but devastating and often leads to long-term disabilities. It affects the patient’s functioning, health and quality of life. Pre-hospital care may play a significant role in the reduction of secondary damage and further neurological deterioration, recovery and outcomes of patients following TSCI.
   
   Review of the literature identified a paucity of high-level evidence regarding the association between pre-hospital spinal immobilisation and patient neurological and functional outcomes. Therefore, the main aims of the thesis were to explore patient profiles of those who are at-risk of sustaining TSCI, identify the differences between at-risk and confirmed with TSCI and examine the differences between patients with TSCI who received pre-hospital spinal immobilisation and those who did not. All studies included adult trauma patients who were attended, managed and transported by Ambulance Victoria (AV) paramedics over a six-year period (2007 - 2012).
   
   The study of those at-risk to have sustained TSCI (potential TSCI) included 106,059 patients, with patient demographics and event characteristics of this cohort described. Falls and traffic-related incidents were the most common causes, with slightly more males (52.4%). The study also provided a clear definition of potential TSCI and baseline knowledge for future research.
   
   The potential TSCI dataset was then linked with the Victoria State Trauma Registry to identify patients with confirmed TSCI. This linkage identified 257 patients with confirmed TSCI (0.2%), mainly due to falls and traffic incidents. Patients had a median age of 49 years with males comprising 84.1% of the cohort. In addition, there were several independent indicators of confirmed TSCI including AV Pre-hospital Potential Major Trauma (PMT) criteria, male gender, the presence of neurological deficits, the presence of an altered conscious state, sustain a high fall (> 3 meters), diving accident and motorcycle and bicycle collisions.
   
   The non-immobilised TSCI patients were more likely to have sustained a low fall, be attended and managed by ALS paramedics and transported by road ambulances to a hospital other than a major trauma service or spinal care unit. The non-immobilised TSCI group also had worst long-term functional outcome scores compared to the immobilised TSCI group. The characteristics of TSCI patients who were not immobilised led to speculating that the non-immobilised group were not recognised or misdiagnosed by the pre-hospital care provider, which may have led to a different pathway of care compared to those immobilised. Outcome measurement at earlier stages of care should be validated and considered to examine the clinical effect of pre-hospital spinal immobilisation.
   
   This body of work provides empirical studies contributing to the knowledge gaps relating to describing TSCI from the pre-hospital perspectives, as well as the association between pre-hospital spinal immobilisation and patient outcomes following TSCI.  However, large prospective studies in this field are unlikely to be feasible and therefore we need to maximise the knowledge we can derive from observational studies such as those undertaken in this thesis. Meanwhile, hopefully, the findings in this thesis can improve pre-hospital spinal care leading to improved patient outcomes and decreased the burden of TSCI.