Prehospital Emergency Care

ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20

Prehospital Predictors of Traumatic Spinal Cord

Injury in Victoria, Australia

Alaa O. Oteir BPT, PhD, Karen Smith BSc (Hons), PhD, Johannes Stoelwinder
MBBS, MD, James W. Middleton MBBS, PhD, Shelley Cox BSc (Hons), PhD, Lisa
N. Sharwood RN, BN, MPH, PhD & Paul A. Jennings BN, PhD

To cite this article: Alaa O. Oteir BPT, PhD, Karen Smith BSc (Hons), PhD, Johannes
Stoelwinder MBBS, MD, James W. Middleton MBBS, PhD, Shelley Cox BSc (Hons), PhD, Lisa
N. Sharwood RN, BN, MPH, PhD & Paul A. Jennings BN, PhD (2017): Prehospital Predictors
of Traumatic Spinal Cord Injury in Victoria, Australia, Prehospital Emergency Care, DOI:
10.1080/10903127.2017.1308608

To link to this article: http://dx.doi.org/10.1080/10903127.2017.1308608

Published online: 17 Apr 2017.

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PREHOSPITAL PREDICTORS OF TRAUMATIC SPINAL CORD INJURY IN VICTORIA,
AUSTRALIA
Alaa O. Oteir, BPT, PhD, Karen Smith, BSc (Hons), PhD, Johannes Stoelwinder, MBBS, MD,
James W. Middleton, MBBS, PhD, Shelley Cox, BSc (Hons), PhD,
Lisa N. Sharwood, RN, BN, MPH, PhD, Paul A. Jennings, BN, PhD
ABSTRACT
Objectives: To identify the predictors of traumatic spinal
cord injury (TSCI) and describe the differences between con-
firmed and potential TSCI cases in the prehospital setting.
Methods: A retrospective cohort study including all adult
patients over a six-year period (2007–12) with potential TSCI
who were attended and transported by Ambulance Victoria
(AV). We extracted potential TSCI cases from the AV data
warehouse and linked with the Victorian State Trauma Reg-
istry to compare with final hospital diagnosis. Results: We
included a total of 106,059 patients with potential TSCI in the
Received October 12, 2016 from Department of Community Emer-
gency Health and Paramedic Practice, Monash University, Mel-
bourne, Victoria, Australia (AO, KS, PJ); Paramedics Program,
Department of Allied Medical Sciences, Jordan University of Sci-
ence and Technology, Irbid, Jordan (AO); Research and Evaluation,
Ambulance Victoria, Melbourne, Victoria, Australia (KS, SC); Depart-
ment of Epidemiology and Preventive Medicine, Monash Univer-
sity, Melbourne, Victoria, Australia (KS, JS, SC, LS); Department of
Emergency Medicine, University of Western Australia, Perth, West-
ern Australia, Australia (KS); John Walsh Centre for Rehabilitation
Research, Kolling Institute, Northern Sydney Local Health District,
St Leonards and Sydney Medical School–Northern, The University
of Sydney, New South Wales, Australia (JM, LS); Ambulance Victo-
ria, Melbourne, Victoria, Australia (PJ); Emergency and Trauma Cen-
tre, The Alfred Hospital, Melbourne, Victoria, Australia (PJ); College
of Health and Biomedicine, Victoria University, Melbourne, Victoria,
Australia (PJ). Revision received March 4, 2017; accepted for publi-
cation March 7, 2017.
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
The VSTR is a Department of Health and Human Services, State Gov-
ernment of Victoria and Transport Accident Commission funded ini-
tiative. The Victorian State Trauma Outcomes Registry and Monitor-
ing Group, and the VSTR Steering Committee, are thanked for the
provision of VSTR data for this study.
A.O. Oteir, J. Stoelwinder, K. Smith, and P.A. Jennings conceived the
study. A.O. Oteir wrote the manuscript, and J. Stoelwinder, K. Smith,
S. Cox, L.N. Sharwood, J.W. Middleton, and P.A. Jennings critically
reviewed and edited the manuscript. All authors contributed to the
final review and approval of the manuscript.
Address correspondence to Alaa Oteir, Paramedics Program, Depart-
ment of Allied Medical Sciences, Jordan University of Science
and Technology, P.O. Box 3030, Irbid, 221100, Jordan. E-mail:
aooteir@just.edu.jo
© 2017 National Association of EMS Physicians
doi: 10.1080/10903127.2017.1308608
1
study, with 257 having a spinal cord injury confirmed at hos-
pital (0.2%). The median [First and third Quartiles] age of con-
firmed TSCI cases was 49 [32–69] years, with males compris-
ing 84.1%. Confirmed TSCI were mainly due to falls (44.8%)
and traffic incidents (40.5%). AV spinal care guidelines had a
sensitivity of 100% to detect confirmed TSCI. There were sev-
eral factors associated with a diagnosis of TSCI. These were
meeting AV Potential Major Trauma criteria, male gender,
presence of neurological deficit, presence of an altered state
of consciousness, high falls (> 3 meters), diving, or motor-
cycle or bicycle collisions. Conclusion: This study identified
several predictors of TSCI including meeting AV Potential
Major Trauma criteria, male gender, presence of neurologi-
cal deficit, presence of an altered state of consciousness, high
falls (> 3 meters), diving, or motorcycle or bicycle collisions.
Most of these predictors are included in NEXUS and/or CCR
criteria, however, Potential Major Trauma criteria have not
previously been linked to the presence of TSCI. Therefore,
Emergency Medical Systems are encouraged to integrate sim-
ilar Potential Major Trauma criteria into their guidelines and
protocols to further improve the provider’s accuracy in iden-
tifying TSCI and to be more selective in their spinal immobi-
lization, thereby reducing unwarranted adverse effects of this
practice. Key words: prehospital; paramedics; Emergency
Medical Systems; predictors; traumatic spinal cord injury;
TSCI; spinal immobilization
PREHOSPITAL EMERGENCY CARE 2017; Early Online:1–8
BACKGROUND AND RATIONALE
Traumatic spinal cord injury (TSCI) is a relatively rare
condition, comprising only 1% of traumatic injuries.1
However, paramedic ability to accurately diagnose
confirmed TSCI can play a significant role in influenc-
ing patient outcomes, and assists in the correct triage of
patients to receive the right care in the right place with-
out delay. Early and accurate recognition of potential
TSCI supports the decision of paramedics to preferen-
tially transport a patient directly to a major trauma ser-
vice (MTS) or specialist spinal center. Conversely, it also
has the potential to reduce inappropriate over-triage to
these centers.
Improving paramedic diagnostic ability may also
assist in reducing unnecessary spinal immobiliza-
tion and, therefore, avoiding related potential adverse
effects such as pain, discomfort, concealment of pene-
trating neck injuries. restriction of patients’ respiratory
2 PREHOSPITAL EMERGENCY CARE
capacity,2 and reduce unnecessary exposure to radio-
logical imaging.
While spinal immobilization criteria are increasingly
being used in the prehospital setting to improve the
detection of patients who progress to having a diagno-
sis of confirmed TSCI; they were originally designed
to identify low-risk patients and reduce the rate of
unwarranted spinal immobilization. Patients with a
low risk of having TSCI can be transported without
spinal immobilization,3,4 with growing evidence that
prehospital spinal immobilization is being overused
and may even be harmful to trauma patients.2,4–7
Emergency Medical Systems (EMS) such as Ambu-
lance Victoria use modified spinal immobilization
criteria; based on the Canadian C-spine Rules (CCR)
and Nexus criteria, to increase the sensitivity and
specificity of diagnosing TSCI cases. 8–13 As per AV
clinical practice guidelines, patients meeting AV
prehospital Potential Major Trauma criteria or AV
spinal immobilization criteria are considered at poten-
tial risk of having a TSCI and should receive prehospi-
tal spinal care, including spinal immobilization.14
We aimed to identify the predictors of confirmed
TSCI in patients identified as being at potential risk of
TSCI according to these criteria and describe the dif-
ferences between confirmed and potential at-risk cases
of TSCI in a prehospital setting. We hypothesize that
this may help improve the ability to accurately diag-
nose confirmed TSCI cases in the prehospital setting.
METHODS
Selection of Participants
This retrospective cohort study included all adult
patients potentially at-risk of TSCI managed and trans-
ported by Ambulance Victoria (AV) over a six-year
period, between 01 January 2007 and 31 December
2012. Relevant data items were extracted from the
Ambulance electronic patient care records, maintained
in the AV data warehouse. These variables included
demographic details, trauma aetiology, paramedic
assessment, management, prehospital times, transport
destination, and other event characteristics.
The group of patients considered at potential risk
of TSCI were defined as those meeting AV Potential
Major Trauma, met the AV spinal immobilization crite-
ria or had a predefined significant mechanism of injury
(MOI).14 AV Potential Major Trauma is a triage tool
used by paramedics to identify time critical patients
for transportation to an appropriate receiving hospi-
tal, preferably a hospital designated as a MTS or to
the highest level trauma designation within 45 minutes
transport time.
To be considered for inclusion in this study patients
must have met one or more of the following criteria:
2017 EARLY ONLINE
1. Met AV “Potential Major Trauma Criteria,” which
includes: aberrant vital signs (systolic blood
pressure (SBP) <90 mmHg, pulse rate (PR)
>124, respiratory rate (RR) <12 or >24 and/or
GCS<15), prespecified anatomical injuries or a
prespecified mechanism of injury with a ‘modifier’
(age>55 years, pregnancy and/or comorbidities).14
2. Any patient considered by the attending
paramedics to have a potential TSCI as evidenced
by documentation of “suspected SCI” or “SCI” or
deliberate transport of a patient to a SCI unit.14
3. Any patient involved in a significant MOI, which
includes: high-speed motor vehicle collisions
(>60 km/h), ejection from vehicle, motorcycle or
bicycle collisions (>30 km/h), vehicle rollover,
pedestrian impact, explosion, prolonged extrica-
tion, high falls (>3 m), or struck on head by a
falling object (>3 m).13
4. Any patient where spinal immobilization inter-
ventions were applied, or who should have been
immobilized according to the AV spinal immobi-
lization criteria.
AV spinal immobilization criteria are based on a com-
bination of the CCR and Nexus criteria. They include
all patients who experienced a significant MOI and had
any of the following findings14 :
r Older than 55 years
r A comorbidity including muscular weakness and/or
a bone disease
r Unconsciousness or altered conscious state (Glasgow
Coma Score (GCS) < 15)
r Drug or alcohol affected
r Significant distracting injury
r Neurological deficit including paralysis and
paresthesia
r Spinal pain and/or tenderness
Patients were excluded from this study if they died at
the scene, were less than 16 years old, received an inter-
facility transport only, or had a non-traumatic aetiology
of their spinal disease. Cases with insufficient prehos-
pital data were also excluded.
We identified patients with confirmed TSCI diag-
nosed during their hospital admission by linking AV
study data with the Victorian State Trauma Registry
(VSTR) using unique patient identification numbers.
The TSCI as spinal cord injury with an Abbreviated
Injury Scale (AIS) > 3 with or without other injuries.15
The VSTR also includes information regarding hospi-
tal diagnoses and procedures. Variables extracted from
VSTR included discharge diagnosis, level of injury,
abbreviated injury scale (AIS), maximum AIS sever-
ity score in each body region, and injury severity score
(ISS).
A. Oteir et al. PREHOSPITAL PREDICTORS OF TSCI
FIGURE 1. Inclusion flowchart.
Setting
Ambulance Victoria provides emergency medical ser-
vices to the state of Victoria, Australia. Victoria’s pop-
ulation is approximately 5.7 million people in an
area of 227,000 square kilometers.16 It operates as a
two-tiered emergency medical response system, which
includes advanced life support paramedics and mobile
intensive care ambulance paramedics. Mobile intensive
care ambulance paramedics are trained to perform a
wider range of airway management procedures, such
as endotracheal intubation, and provide an increased
number of medications.13,17
Statistical Analysis
We summarized continuous data as medians and first
and third quartiles [Q1, Q3] and groups compared
using the Mann-Whitney U test. We presented categor-
ical data as proportions and 95% confidence intervals
and compared groups using chi-square or Fisher’s
exact tests. All reported p-values are two-sided and
FIGURE 2. Annual incidence of Traumatic Spinal Cord Injuries (TSCI) per million population.
3
a value less than 0.05 is regarded as statistically sig-
nificant. To identify the independent predictors of
confirmed TSCI, we conducted a univariate logistic
analysis followed by a multivariate logistic regression
model using stepwise forward variable selection. We
specified a p-value of 0.05 for addition to the model,
whereas we specified p = 0.1 for removal from the
model. Factors that were insufficiently reported for
inclusion in the final model comprised comorbidities
and distracting injuries. We assessed model perfor-
mance using the area under the receiver operator
characteristic curve (ROC) and assessed a calibration
of the model using Hosmer-Lemeshow statistic. We
undertook all statistical analysis using STATA (version
12.1 Stata Corporation, College Station, TX, USA).
Ethical Approval
This study gained ethical approval on July 19, 2013
from Monash University Human Research Ethics Com-
mittee (MUHREC; project number 2013000883).
4 PREHOSPITAL EMERGENCY CARE 2017 EARLY ONLINE

Table 1. Differences between confirmed TSCI and potential TSCI.

∗
Confirmed TSCI No TSCI p- value
Characteristic n = 257 (n, (%)) n = 105,802 (n, (%))

Age (Median years [Q1, Q3]) 50 [33, 69] 51 [29, 78] 0.3
Sex <0.001
Male 216 (84.05) 55,345 (52.3)
Female 41 (16.95) 50,457 (47.7)
Case nature <0.001
Low falls (<3m) 87 (33.9) 47,260 (44.7)
High falls (ࣙ3m) 28 (10.9) 2,335 (2.2)
MVC 47 (18.3) 27,672 (26.2)
Motorcycle collisions 31 (12.1) 5,810 (5.5)
Bicycle collisions 19 (7.4) 4,480 (4.2)
Pedestrian collisions 7 (2.7) 3,410 (3.2)
Diving 11 (4.3) 85 (0.1)
†
Violence 9 (3.5) 7,089 (6.7)
‡
Sporting 9 (3.5) 4,483 (4.2)
§
Other 9 (3.5) 3,178 (3.0)
Injury pattern 0.001
Blunt 246 (95.7) 104, 472 (98.7)
Penetrating 11 (4.3) 1, 274 (1.2)
Both – 56 (0.1)
Level of injury –
Cervical 184 (71.6) –
Thoracic 56 (21.8) –
Lumbosacral 17 (6.6) –
Highest level treating paramedic <0.001
MICA 58 (22.6) 6,057 (5.7)
ALS 199 (77.4) 99,745 (94.3)
Transport Mode <0.001
Air 39 (15.2) 967 (0.9)
Road 218 (84.8) 104,835 (99)
Initial destination <0.001
MTS 194 (75.5) 31,533 (29.8)
Specialized spinal center 9 (3.5) 4,637 (4.4)
Other destinations 54 (21.0) 68,196 (64.3)
Unknown 0.0 1,436 (1.4)
Spinal immobilization 0.09
Yes 225 (87.6) 88,448 (83.6)
No 32 (12.5) 17,354 (16.4)
Reported as suspected TSCI <0.001
Yes 113 (44.0) 2,732 (2.6)
No 144 (56.0) 103,070 (97.4)

Q1, Q3: Firs and third quartiles; TSCI: Traumatic spinal cord injury; MICA: Mobile Intensive Care Ambulance; ALS: Advanced Life Support; MTS: major trauma
service, MVC: Motor Vehicle Collision; 3m: three meters.
∗
Chi-square, Mann-Whitney U test or Fisher’s exact test.
†
including stabbing and shooting incidents.
‡
Includes Australian Rules football, horse riding and other sports.
§
Others include struck by an object, industrial, recreational, and farm related incidents.

RESULTS Demographic and Event Characteristics

During the study period, we identified a total of 114,579
patients with traumatic injuries. Of these, a total of
106,059 (92.6%) were included in the study as “at-risk”
patients with potential TSCI based on the defined cri-
teria, mechanism of injury, and signs/symptoms or
paramedic suspicion. The final study cohort included
257 (0.2%) patients who were confirmed to have a
TSCI during their hospital admission. Figure 1 shows
the patient inclusion flowchart. These TSCI had a
varying annual incidence rate over the study period
(Figure 2).
Patients included in this study were adult (aged
between 16 and 107 years) and predominately male
(n = 55,561; 52.4%). Table 1 compares the major causes
of confirmed (n = 257) versus potential at-risk (n =
105,802) cases of TSCI. Falls (44.7%; 95% CI: 38.6, 50.9)
and traffic incidents (40.5%; 95% CI: 34.4, 46.5) were the
most common causes of confirmed TSCI. The median
[Q1–Q3] age was 49 [32–69] years, with males compris-
ing 84.1% (95% CI: 79.5, 88.6) of TSCI. Low falls com-
posed 33.9% (95% CI: 28.0, 39.7) of the confirmed TSCI
group.
A. Oteir et al. PREHOSPITAL PREDICTORS OF TSCI
Table 2. Initial vital signs.
Confirmed TSCI
Vital signs Median[Q1, Q3]
Initial systolic blood pressure 120 [90,140]
Initial pulse rate
Initial GCS
Initial respiratory rate
GCS: Glasgow coma scale; Q1, Q3: Firs and third quartiles.
∗
counts: systolic n = 104212; respiratory rate n = 104490; GCS = 104633, pulse rate = 104566.
†
all n = 242 patients except SBP n = 240.
Overall, TSCI in the cervical region comprised 71.6%
(95 CI: 66.0, 77.1) of confirmed TSCI cases, followed
by thoracic injuries (21.8%, 95% CI: 16.7, 26.9). While
isolated TSCI comprised 35.4% (95% CI: 29.5, 41.3),
multiple injuries including a TSCI with at least two
injured body regions according to AIS codes (face,
head/neck, chest, abdomen, extremities, and/or exter-
nal) comprised 37.7% (95% CI: 31.8, 43.7) of confirmed
TSCI. The remaining 26.9 included face, head/neck,
chest, abdomen, extremities or external injuries. The
overall median injury severity score (ISS) was 25
[Q1–Q3: 17–34].
Confirmed TSCI were more likely to be male and
have experienced high falls (i.e., falls>3m), motorcycle
collisions, bicycle collisions, or diving incidence than
the potential TSCI group (p < 0.001). In addition, a
higher proportion of confirmed TSCI patients were
suspected by the treating paramedics, treated by
mobile intensive care ambulance paramedics, received
air transport, and were transported directly to a MTS
(p < 0.001).
Initial systolic blood pressure and pulse rate were
lower in the confirmed TSCI group as assessed by treat-
ing paramedics at the scene; however, this was not clin-
ically significant (Table 2).13
Patients with confirmed TSCI were much more likely
to meet both AV Potential Major Trauma and spinal
immobilization criteria than patients at potential risk
of TSCI (79.4% versus 46.7%, p < 0.001) (Table 3). All
the confirmed TSCI group (100%) met at least one cri-
terion of spinal immobilization and/or AV Potential
Major Trauma criteria.
Table 4 summarizes the factors associated with
confirmed TSCI. Univariate analyses revealed
nine factors with a statistically significant positive
Table 3. Comparison between confirmed and no TSCI based on potential major trauma and spinal immobilization.
∗
Criteria
Potential Major Trauma and spinal immobilization
Potential Major Trauma only
∗
Spinal immobilization only
Did not meet Potential Major Trauma or Spinal immobilization
TSCI: Traumatic spinal cord injury.
∗
Ie. without a modifying mechanism of injury.
†
Fisher’s exact test.
5
† ∗
No TSCI p-value
Median[Q1, Q3]
130 [120,150] <0.001
80 [65, 90] 84 [76, 96] <0.001
15 [14, 15] 15 [15, 15] <0.001
16 [16, 20] 16 [16, 20] 0.5
association with the presence of confirmed TSCI.
Three factors were identified as negatively associ-
ated with confirmed TSCI. Eight factors remained
significant in the multivariate model.
Patients meeting AV Potential Major Trauma crite-
ria, being male, have an altered level of consciousness
and present with a neurological deficit have greater
odds of sustaining a confirmed TSCI when compared
to those who did not. Moreover, significant MOI such
falls from higher than three meters, diving, and motor-
bike or bicycle collision were also found to be inde-
pendent predictors of TSCI in this study. Model fit was
good with an area under ROC of 0.81 (95% CI: 0.78,
0.84) with Hosmer-Lemeshow statistic of 0.51.
Spinal Immobilization
The overall immobilization rate was 83.6% (95% CI;
83.4–83.8). Patients confirmed to have TSCI had a sim-
ilar rate of immobilization compared to the potential
group at-risk of TSCI (87.6% vs. 83.6%, p = 0.09).
Median [Q1–Q3] scene time was 22 minutes [15–
30]. Overall, spinal immobilization increased median
scene time by four minutes (p < 0.001) compared to
those who did not receive spinal immobilization. More-
over, confirmed TSCI had a longer median [Q1–Q3]
scene time of 31 minutes [Q1–Q3: 23–43] compared to
potential TSCI (22 [15–30], p < 0.001). Among those
confirmed to have TSCI, patients who received spinal
immobilization had a longer median scene time com-
pared to those who did not receive spinal immobiliza-
tion (32 [24–44] vs. 23 [16–34], p = 0.004). In the poten-
tial group at-risk of having TSCI, spinal immobilization
increased median scene time by four minutes (18 [12–
25] vs. 22 [16–31], p < 0.001).
†
Confirmed TSCI No TSCI p-value
n = 257 n = 105,802
204 (79.4) 49,388 (46.7) <0.001
19 (7.4) 2,177 (2.1)
34 (13.2) 44,080 (41.7)
0.0 10,157 (9.6)
6 PREHOSPITAL EMERGENCY CARE 2017 EARLY ONLINE

Table 4. Factors associated with confirmed TSCI. trauma service and/or have an air transport (all p-
values < 0.05). Immobilized patients were also more
Odds Ratios (95% CI)
Factor Unadjusted OR Adjusted OR likely to be involved in high falls incidents or traffic
related collisions including motor vehicle, motorcycle,
Met AV Potential Major or bicycle collisions (p = 0.002).
Trauma criteria
No Ref –
There were no differences in patient demograph-
Yes 6.9 (4.8, 9.9) 5.9 (4.1, 8.5) ics, level or completeness of TSCI, and injury sever-
Sex ity scores between the immobilized and the non-
Female Ref – immobilized patients (all p-values ࣙ 0.1).
Male 4.8 (3.4, 6.7) 4.0 (2.9, 5.7)
Age (years) 1.0 (0.99, 1.0)
∗ More than half of the non-immobilized patients had
Met spinal immobilization a low fall (18/32, 56.3%), with the majority being older
criteria
∗
than 55 years (14/32, 43.8%). Low falls were defined
Neurological Deficit as falls from stairs, less than 3 meters high and/or at
No Ref –
Yes 2.6 (2.0, 3.4) 2.5 (1.9, 3. 3)
ground level due to slip or trip.
ASC (GCS < 15)
No Ref –
Yes 1.8 (1.4, 2.3) 1.7 (1.3, 2.2) DISCUSSION
Spinal pain/tenderness
No Ref –
TSCI is a relatively rare, but devastating injury. Less
∗
Yes 0.9 (0.7, 1.2) than 1% (0.2%) of a very large cohort of patients who
Distracting injury
†
were at risk or suspected to have sustained a TSCI were
No Ref –
∗
diagnosed with the injury in this cohort. This study
Yes 0.7 (0.5, 0.9) demonstrated that the demographic and event factors
Alcohol or drug affected
No Ref –
predictive of TSCI in the prehospital setting include:
Yes 0.7 (0.5, 1.0)
∗ meeting AV Potential Major Trauma criteria, male gen-
Comorbidity
†
der, presence of an altered state of consciousness, the
No Ref – presence of any neurological deficit and four specific
∗
Yes 0.5 (0.4, 0.7) mechanisms of injury including high falls (>3 meters),
Age>55 years
diving, motorcycle collisions and bicycle collisions.
No Ref –
Yes 0.9 (0.7, 1.1)
∗ Some of these factors have been recognized in pre-
Case nature vious studies to be associated with the likelihood of
Low falls Ref – TSCI.8–12,18 Meeting AV Potential Major Trauma crite-
High falls (>3m) 6.5 (4.2, 10.0) 3.2 (2.1, 4.8)
∗ ria has not previously been linked to the presence of
MVC 0.9 (0.6, 1.3)
Motorcycle collisions 2.9 (1.4, 3.8) 1.9 (1.3, 2.8) TSCI, however in this study, we found it to be a strong
Bicycle collisions 2.3 (1.4, 3.8) 1.8 (1.3, 3.0) independent predictor of TSCI from a cohort of patients
∗
Pedestrian collisions 1.1 (0.5, 2.4) at risk, validating the utility of the guidelines. This is
Diving 70.3 (36.3, 136.3) 41.7 (21.2, 82.2) likley due to parmedics and/or spinal care guidelines
‡
Violence 0.7 (0.3, 1.4) 0.4 (0.2, 0.8) ability to diagnose TSCI cases, as reporting suspected
§ ∗
Sporting 1.1 (0.5, 2.1)
║ ∗
TSCI (44% of TSCI) is a criterion of AV Potential Major
Others 1.5 (0.8, 3.1) Trauma criteria.
Pattern of injury
Blunt Ref – The commonly applied NEXUS criteria; a decision
∗
Penetrating trauma 3.7 (2.0, 6.7) rule where patients who meet the criteria are consid-
ered to be at low risk of TSCI and can be transported
AV: Ambulance Victoria; TSCI: Traumatic spinal cord injury; ASC: altered state
of consciousness (GCS < 15); CGS: Glasgow coma scale; 3m: 3 meters; MVC: without spinal immobilization, is comprised of five
Motor Vehicle Collision. different factors including altered level of conscious-
∗
Neurological deficit: change or loss of motor and/or sensory function as ness, neurological deficit, alcohol or drug intoxication,
reported in the electronic patient care reports.
†
poorly documented in ePCRs, were not included in the model. pain or tenderness in the cervical spine and distract-
‡
including stabbing and shooting incidents. ing injuries.8–10 In our cohort of patients at risk of TSCI,
§
Include struck horse riding, Australian football and other types of sports. only the presence of neurological deficit and an altered
║
includes struck by an object, industrial and farm related incidents.
state of consciousness were independent predictors.
The CCR was designed to identify patients requir-
ing cervical imaging and was validated for alert and
Immobilized vs. Non-immobilized TSCI
hemodynamically stable patients.11,12 Five factors in
In the confirmed TSCI and compared to patients our model were found to be somewhat consistent with
who did not receive spinal immobilization, spinally those included in this rule, and these were the pres-
immobilized patients were more likely to meet AV ence of neurological deficit and high-risk mechanisms
Potential Major Trauma triage criteria, sustain a blunt of injury including high falls, diving, motorcycle colli-
trauma, have chest injuries, be transported to a major sions and pedestrian collisions.
A. Oteir et al. PREHOSPITAL PREDICTORS OF TSCI
A few studies have reported on the diagnosis of
TSCI based on the use of CCR or Nexus criteria, with
sensitivities ranging between 87% and 99%.10,12,19 In
our study, meeting AV Potential Major Trauma or
spinal immobilization criteria (AV spinal care guide-
lines) identified all confirmed cases of TSCI (100%).
Furthermore, assessment for aberrant vital signs is an
important component of AV Potential Major Trauma
criteria. The presence of a systolic blood pressure
< 90 mmHg, pulse rate>124, respiratory rate < 12
or >24 and/or GCS<15 may be associated with con-
firmed TSCI. Although the results revealed a statisti-
cally significant difference in median (Q1 - Q3) initial
vital signs (SBP and PR), these differences were not
clinically significant.
Whilst the aim of the study was not to describe
the use of spinal immobilization for this cohort, the
study findings did confirm that spinal immobilization
increases scene time.2,12,20 Previous studies have shown
spinal immobilization to have been overly used among
some trauma patients.3,4,21
Only two patients in 1000 went on to have a con-
firmed TSCI, yet the vast majority of these patients
(87.6%) were immobilized.2 Similar to our findings,
a previous study reported that 49% of the non-
immobilized patients were elderly fallers (15/31,
out of 255 TSCI cases with complete prehospital
reports).22 The low-risk mechanism of injury as well
as the absence of neurological deficits may have con-
tributed to misdiagnosing these patient by the treat-
ing paramedics hence they did not apply spinal immo-
bilization. Therefore, prehospital care professionals
should maintain a high index of suspicion when deal-
ing with elderly fallers.22
It is important to identify prehospital factors which
independently predict the likelihood of TSCI, to sup-
port EMS providers in determining those at greatest
risk of TSCI. Improved sensitivity and specificity of
clinical decision support tools will aid in triage and
management of trauma patients at risk of TSCI, while
reducing the over-triage and indiscriminate applica-
tion of cervical collars and immobilization techniques.
This retrospective study relied on the available
data derived from the electronic patient care reports
recorded by paramedics who operate in a challenging
prehospital environment. As a result, some valid cases
may have been misreported (errors of omission or accu-
racy) and/or underreported (misclassification) of the
potential or ‘at risk’ cohort. A strength of this study was
the direct linkage with state trauma registry data which
allowed the complete ascertainment of all patients who
were ultimately reported to have sustained a TSCI.
The findings of this study would equally apply to
similar EMS settings and adult populations. When con-
sidering the generalizability of the results of this study,
it must be noted that AV uses a well-developed trauma
triage and spinal immobilization guidelines, and that
7
paramedics are well educated and experienced in the
prehospital assessment and management of trauma
including trauma triage and spinal care.
CONCLUSION
Early and accurate recognition of potential TSCI by
prehospital care providers can significantly influence
patients triage and improve their outcomes. This study
identified different several easily detectable factors that
were associated with confirmed TSCI including; AV
Potential Major Trauma criteria, male gender, altered
state of consciousness, presence of neurological deficit,
high falls, diving, and motorbike and bicycle collisions.
Although NEXUS and/or CCR criteria include the
majority of these factors within their criteria, we found
that AV Potential Major Trauma criteria were predic-
tive of confirmed TSCI which have not previously been
linked to the presence of TSCI. Therefore, Emergency
Medical Systems are encouraged to integrate similar
Potential Major Trauma criteria into their guidelines
and protocols to further improve the provider’s accu-
racy in identifying TSCI and to be more selective in
their spinal immobilization, thereby reducing unwar-
ranted adverse effects of this practice.
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