Quick Exam Detects Spinal Injuries in Gunshot Victims

Norra MacReady

March 29, 2010

March 29, 2010 (Anaheim, California) — A simple clinical examination is highly reliable at identifying gunshot victims who require aggressive treatment or who are risk of lasting neurological deficits, David Ibrahim, a second-year student at the Keck School of Medicine, University of Southern California (USC) in Los Angeles, reported here at the American Medical Student Association 60th Annual Convention.

Mr. Ibrahim and his coinvestigators at USC prospectively studied 282 patients admitted with penetrating injuries to a level I trauma center between March and September 2008. Each patient was evaluated by a senior resident or attending surgeon and then followed through their hospital course for all spinal injury diagnoses, imaging studies, and any immobilization, stabilization, or surgical procedures.

Of the 282 patients, 143 (50.7%) had a gunshot wound (GSW), 12 (8.4%) sustained a spinal injury, and 4 (33.3%) had permanent disabilities.

GSWs to the head and neck were most likely to result in a spinal injury (21.1%); followed by multiple shots to the head, neck, and torso (12.5%); and to shots the torso alone (9.4%). The remaining 139 patients had stab wounds, with no spinal injuries.

The clinical examination — evaluating spinal pain, tenderness to palpation, deformity, and neurologic symptoms — was performed on 112 of the GSW patients; the other 31 unable to undergo evaluation. The overall sensitivity, specificity, and negative and positive predictive values (NPV and PPV) of the examination were 66.7%, 89.6%, 95.2%, and 46.2%, respectively. In cases of clinically significant injuries, which the researchers defined as "injuries requiring surgical intervention, cervical or thoracic spine orthosis, or cord transections," sensitivity, specificity, and NPV, and PPV were 100%, 87.5%, 87.5%, and 30.8%, respectively.

"I was surprised by the high sensitivity of the examination," said Mr. Ibrahim. "There has never been a formal study of the value of the examination — it has just been the doctrine that this is what you do when trauma patients come in. But no one had ever looked at the sensitivity and the specificity of the exam before."

Previous studies on stab wound victims have shown that knives are more limited in the depth of their penetration and the extent of the damage they can do, which might explain why none of the stab wound patients in this study sustained any spinal injuries, Mr. Ibrahim told Medscape Med Students. Whatever the reason, "it's agreed upon in the literature that stab wounds generally don't produce spinal injuries."

Prehospital immobilization of the spine would not have helped any of the patients in this study, he noted. Other investigators have found that "the delay in hospitalization required for the paramedics to stabilize these patients is associated with a higher mortality rate, as opposed to just scooping them up and taking them to the [emergency department]." Also, he said, given the high sensitivity of the clinical examination, stabilization in the field probably would not have changed any prognoses.

A simple examination like this could help accelerate the definitive management of these patients without always requiring them to undergo imaging studies, he said. "In this day and age of rising healthcare costs, there's a significant implication not only in minimizing the radiation that patients might be exposed to in imaging studies, but also in making the most efficient use of resources, whether it be of time or equipment."

The study's main limitation was its small size. "We'd have to do a larger study to confirm these findings. It might also be interesting to look at the incidence of spinal injuries in patients who were stabilized in the field, compared with in the [emergency department]."

Patients coming to emergency departments in small local hospitals would be the most likely beneficiaries of these findings, said emergency physician Harry Severance, MD, a ballistics expert and professor and director of resource development at the University of Tennessee College of Medicine, in Chattanooga, who was not involved in this study. "At a level I trauma center, they'll scan you anyway because they do everything according to protocols, and right now imaging is the best thing we've got."

But, added Dr. Severance, "in small community hospitals, which are most of the hospitals in this country, where they may not have the equipment available or someone experienced at interpreting the findings in the middle of the night, a bedside evaluation like this would help."

American Medical Student Association (AMSA) 60th Annual Convention: Abstract 26: Presented March 11, 2010.

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