CJEM Articles: André Lavoie

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  • Evaluation of the Prehospital Index, presence of high-velocity impact and judgment of emergency medical technicians as criteria for trauma triage
    March 2010 12 2
    André Lavoie, Lynne Moore, Marcel Émond, Moishe Liberman, Stéphanie Camden

    Objective: We sought to evaluate the performance of the Prehos pital Index (PHI), the high velocity impact (HVI) criterion and emergency medical technician (EMT) judgment for the prehospital triage of injured patients.

    Methods: The study population included all prehospital trauma patients transported by an emergency medical service to 2 level I trauma centres for adults. All prehospital run sheets were linked to trauma registry data. The main outcome was severe trauma, defined as death within 72 hours, admission to the intensive care unit within 24 hours or an Injury Severity Score greater than 15. We assessed sensitivity, specificity and rates of overtriage.

    Results: Of 16 805 patients in the study population, 1113 (6.62%) had severe trauma. The combination of all 3 triage criteria (PHI score ≥ 4, HVI presence and EMT judgment) performed best for identifying patients with severe trauma, with a sensitivity of 74.2% but with an overtriage rate of 85.1%. Alone, EMT judgment had the highest sensitivity and a PHI score of 4 or greater had the low est rate of overtriage.

    Conclusion: Although the combination of PHI score, HVI pres ence and EMT judgment offers the highest sensitivity for the iden tification of patients that could benefit from direct transport to a level I trauma centre, overall sensitivity remains low and over triage is high. More research is required to improve prehospital triage.

  • Refinement of the Quebec decision rule for radiography in shoulder dislocation
    January 2009 11 1
    André Lavoie, Lynne Moore, Marcel Émond, Natalie Le Sage

    Objective: We prospectively derived a clinical decision rule to guide pre- and postreduction radiography for emergency department (ED) patients with anterior glenohumeral dislocation.

    Methods: This prospective cohort derivation study took place at 4 university-affiliated EDs over a 3-year period and enrolled consenting patients with anterior glenohumeral dislocation who were 18 years of age or older. We compared patients with a clinically important fracture-dislocation with those who had an uncomplicated dislocation to provide the clinical decision rule components using recursive partitioning. The final rule involved age, mechanism, prior dislocation and humeral ecchymosis.

    Results: A total of 222 patients were included in the study. Forty (18.0%) had clinically important fracture-dislocation. A clinical decision rule using 4 factors reached a sensitivity of 100% (95% confidence interval [CI] 89.4%-100%), a specificity of 34.2% (95% CI 27.7%-41.2%), a negative predictive value of 99.2% (95% CI 92.8%-99.9%) and a negative likelihood ratio of 0.04 (95% CI 0.002-0.27). Patients younger than 40 years are at high risk for clinically important fracture- dislocation only if the mechanism of injury involves substantial force (i.e., a fall greater than their own height, a sport injury, an assault or a motor vehicle collision). Patients 40 years of age or older are at high risk only in the presence of humeral ecchymosis or after their first dislocation. Projected use of the rule would reduce the absolute number of prereduction radiographs by 27.9% and of postreduction by 81.9%.

    Conclusion: The Quebec shoulder dislocation rule for patients with acute anterior glenohumeral dislocation holds promise to reduce unnecessary imaging, pending validation.