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Heterogeneous emergency department management of published recommendation defined hypotension in patients with acute traumatic spinal cord injury: A multi‐centre overview
Author(s) -
Sharwood Lisa N,
Joseph Anthony,
Guo Cici,
Flower Oliver,
Ball Jonathon,
Middleton James W
Publication year - 2019
Publication title -
emergency medicine australasia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.602
H-Index - 52
eISSN - 1742-6723
pISSN - 1742-6731
DOI - 10.1111/1742-6723.13290
Subject(s) - medicine , emergency department , guideline , spinal cord injury , observational study , anesthesia , blood pressure , emergency medicine , mean arterial pressure , prospective cohort study , spinal cord , heart rate , pathology , psychiatry
Objective Evidence‐based management for patients with acute traumatic spinal cord injury (TSCI) in the ED has a critical impact on long‐term outcomes. Acute hypotension post‐injury may compromise spinal cord perfusion and extend neurological damage. Published guidelines recommend mean arterial blood pressure (BP) maintenance between 85 and 90 mmHg for 7 days post‐injury; the extent to which this is followed in Australia is unknown. Methods Prospective observational study of patients ≥16 years with TSCI, treated at 48 hospitals across two Australian states. Mean arterial BPs were recorded in the Ambulance, and ED arrival and discharge. Patients’ medical records documented treatment provided (intravenous fluids, vasopressors or both) for BP augmentation. Hypotension was defined as mean arterial BP <85 mmHg, per the American Association of Neurological Surgeons guidelines. Results The 208 patients with TSCI in the present study were more likely to receive BP augmentation if they experienced direct transport to a Spinal Cord Service hospital (OR 5.57, 95% CI 2.32–10.11), had a cervical level injury (OR 2.32, 95% CI 1.01–5.5) or were hypotensive on ED arrival (OR 2.42, 95% CI 1.34–4.39). Of the 112 patients who were hypotensive, 71 (63.4%) received treatment for this; however, the majority (76%) remained hypotensive on discharge. Conclusion Hypotensive patients’ post‐TSCI experienced heterogeneous ED care discordant with published guidelines; varying by hospital type. Specialist care and more severe injury increased likelihood of guideline adherence. Lack of adherence may influence patient outcomes. Level 1 evidence is needed along with consistent guideline implementation and clinician training to likely improve TSCI management and outcomes.