American Journal of Emergency Medicine 38 (2020) 2049-2054

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American Journal of Emergency Medicine

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Correlation of history and physical examination with imaging in traumatic near-shore aquatic head and Spinal injury

Tucker Lurie, BS ^a,d, Bradford Schwartz, MD ^b,c, Daniel Najafali, BS ^d, Priyanka Gandhi, BS ^d,

Matthew Jackson, BS ^d, Quincy K. Tran, MD, PhD ^b,d,e,?

^a University of Maryland School of Medicine, 655 West Baltimore Street, Baltimore, MD 21201, USA

^b Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street; 6th Floor, Suite 200, Baltimore, MD 21201, USA

^c Department of Emergency Medicine, University of Maryland Capital Region Health, UM Prince George’s Hospital Center, 3001 Hospital Dr, Cheverly, MD 20785, USA

^d The Research Associate Program in Emergency Medicine & Critical Care, University of Maryland School of Medicine, Baltimore, MD; 22 South Greene Street, suite P1G01, Baltimore, MD 21201, USA

^e Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD; 22 South Greene Street, Baltimore, MD 21201, USA

a r t i c l e i n f o

Article history:

Received 9 April 2020

Received in revised form 15 June 2020 Accepted 24 June 2020

Keywords:

Beach activities

Near-shore aquatic activities Spinal injury

Imaging studies

history of present illness

a b s t r a c t

Objective: It remains unclear whether clinicians can rely on specific symptoms and signs to detect or exclude serious head and spinal injury sustained during near-shore aquatic activities. Our study investigated patients’ history of present illness (HPI) and physical examination (PE) for their utility in detecting serious head and spinal injury.

Methods: We conducted a multicenter retrospective comparative analysis of adult patients who were transported from the beach in Ocean City, Maryland, to three nearby emergency departments for possible spinal injury from 2006 through 2017. Patients suspected to have any spinal injury from beach activities were eligible. We excluded patients who could not verbalize their symptoms or with insufficient emergency department records. We compared components of each patient’s HPI and PE with radiologic evidence of spinal injury. We calculated sensitivity, specificity, and negative and positive Likelihood ratios .

Results: We analyzed 278 patients with suspected spinal injury. Midline spinal tenderness was associated with increased likelihood of thoracic (LR+ 2.6) and lumbar spinal fractures (LR+ 3.5). HPI complaints of paralysis (LR+ 13.9) and sensory loss (LR+ 5.8) had strong associations with spinal cord injuries. Weakness found through PE was also associated with spinal cord injury (LR+ 5.3).

Conclusions: We identified several components of the clinical evaluation that had clinically significant association with spinal injuries from beach-related trauma. While prospective studies are needed to confirm our observa- tions, clinicians may consider these high-risk features in patients with beach-related trauma and adjust testing and level of care appropriately.

(C) 2020

Introduction

Serious injury is rarely a consideration when a family plans a beach vacation. Nonetheless, hundreds of thousands of beach-related injuries are sustained each year [1]. Injury to the head and neck is of the greatest concern and has considerable socioeconomic impact. It is estimated that

Abbreviations: AGH, Atlantic General Hospital; LR, Likelihood ratio; LR-, Negative likelihood ratio; OCBP, Ocean City Beach Patrol; PRMC, Peninsula Regional Medical Center; LR+, Positive likelihood ratio; STC, R Adams Cowley Shock Trauma Center.

* Corresponding author at: 22 South Greene Street, Suite P1G01, Baltimore, MD 21201, USA.

E-mail addresses: [email protected] (T. Lurie), [email protected] (B. Schwartz), [email protected] (M. Jackson), [email protected] (Q.K. Tran).

a traumatic spinal cord injury will cost a patient between $1.1 million and $4.7 million over the course of their lifetime [2].

Near-shore aquatic activities (e.g. surfing, bodysurfing, boogie boarding/bodyboarding, diving) are low speed but high risk, with head and neck injuries making up 34%-53% of total traumatic near- shore aquatic injuries [3-5]. The prototypical patient is often a young or middle-aged male [3-9]. Forced hyperextension [6-8] and a board striking the face [4,5,10] are the most common mechanisms of injury to the neck and head, respectively. Expeditious transport to a medical center with neurosurgical capability is crucial for patients with spinal cord injuries, as delayed transport is associated with reduced improve- ment of neurological status and worse functional outcome [11]. Thus, early identification of patients at high risk of spinal injury would allow Prehospital personnel and emergency medicine clinicians to more effec- tively triage those patients and order appropriate imaging studies.

https://doi.org/10.1016/j.ajem.2020.06.091

0735-6757/(C) 2020

Previous studies on near-shore aquatic injuries have largely identi- fied risk factors in patients with known craniospinal injuries after these patients had already been admitted to neurosurgical services [4- 10,12]. However, the utility of those risk factors, patients’ chief com- plaints, or physical examination (PE) findings in determining patterns of injury among patients with suspected near-shore aquatic injuries re- mains unknown.

The goal of our study was to assess the correlation of patients’ chief complaints and certain PE findings with radiologic evidence of spinal in- jury. Our study utilized data from the beach patrol and individual pa- tient records to identify high-risk components of the history of present illness (HPI) and PE from patients who arrived at the emergency department (ED) with suspected traumatic spinal injuries sustained on the shore.

Methods

Study setting

This was a Multicenter retrospective study of all adult patients (age 18 and over) transported from the beach in Ocean City, Maryland, to EDs for suspected spinal injuries.

The Ocean City Beach Patrol (OCBP) maintains incident reports each summer on all suspected injuries, from sprained ankles to suspected traumatic spinal injury. We were granted access to OCBP’s database, which contained data from 2006 through 2017. When patients sustain injuries at the beach, the majority are transported to three hospital sites:

• • • Atlantic General Hospital (AGH), a non-trauma ED 13 km (km) from the Ocean City Beach
    • Peninsula Regional Medical Center (PRMC), a level II trauma center 50 km from the beach
    • R Adams Cowley Shock Trauma Center (STC), a level I regional trauma center 230 km from the beach (170 km via helicopter)

  Selection of participants

  We identified all adult patients in the OCBP database with suspected traumatic spinal injuries. We then cross-referenced the OCBP data to patient records at AGH, PRMC, and STC to find and follow the course of these patients’ examination and diagnosis.

  We excluded patients unable to verbalize symptoms (e.g. arriving in cardiac arrest or comatose) because we were interested in assessing components of their self-reported HPI. We also excluded patients:

  • • • Not transported for treatment
      • Transported to a site other than the three named
      • With missing ED medical records or records indicating no suspicion for spinal injuries.

  The study was approved by the institutional review boards at STC and PRMC, and the ethics committee at AGH. With these approvals in place, we received permission to access patients’ medical records at each hospital.

  Data collection

  We used a standardized Microsoft Access database as our data col- lection tool. Data was collected by one researcher and confirmed by an independent researcher to maintain Interrater agreement of at least 90%. Any disagreement was adjudicated by discussion between the researchers.

  We collected patient data from multiple sources: the OCBP database, emergency medical services records, and receiving hospitals’ ED re- cords. Collected data included: age, gender, race, type of aquatic activity,

  date of injury, pertinent HPI and PE findings, type and results of imaging studies, and disposition from each hospital. However, we did not exam- ine patients’ management and outcomes as they were not the primary focus of our study.

  Outcome measures

  Primary

  Correlation of patients’ chief complaints and PE findings with any spinal injury–defined as any bony spinal fracture or spinal cord injury

  –seen on radiograph (XR), computed tomography (CT), or magnetic resonance imaging (MRI).

  Secondary

  • Correlation of patients’ chief complaints and PE findings with spinal cord injury, defined as MRI-detected:
    • Compression
    • Edema
    • Contusion
    • Hemorrhage
  • Correlation of HPI complaint of loss of consciousness (LOC) with any head injury, defined as CT-detected:
    • Skull fracture
    • Intraparenchymal bleeding
    • Subdural or epidural hematoma

• Evaluation of high-risk components of HPI and PE

  We compared PE findings of midline spinal tenderness with diagno- sis of spinal fracture as seen on XR or CT scan of the spine. We also com- pared HPI complaints of paresthesia, weakness, paralysis, sensory loss, and pain, and PE findings of weakness and decreased sensation with di- agnosis of spinal cord injury as seen on MRI. The frequency of patient- reported LOC was compared to any Intracranial injury as seen on head CT scans.

  Statistical analysis

  We first used descriptive data to compare characteristics of patients with and without any spinal injury. Continuous data were expressed as mean and standard deviation (SD) or median and interquartile range (IQR), as appropriate. The t-test or Mann-Whitney test were used to an- alyze groups’ means or median as appropriate. Categorical data was compared using the Fisher exact test or Pearson chi-square test as ap- propriate. Statistical analyses with two-tailed p value <.05 were consid- ered clinically significant.

  Sensitivity, specificity, positive and negative predictive values (PPV

  and NPV), positive and negative likelihood ratios (LR+ and LR-) and their associated confidence intervals (CI) were calculated. LR+ > 2.0 and LR- < 0.5 were considered clinically significant. Statistical analysis was performed using SAS Studio version 3.8 (SAS Institute Inc.).

  Results

  We identified 640 patients from the Ocean City Beach Patrol data- base and included 278 eligible patients in our final analysis (Fig. 1).A comparative analysis of patient characteristics is presented in Table 1. Most patients were male, aged 35-54, and nonresidents of Ocean City. Spinal cord injury patients had higher rates of diving, complaints of pain, paresthesia, or weakness, and PE findings of weakness or decreased sensation.

  

  Patients transported to AGH, PRMC, or STC (n = 442)

  Excluded patients transported anywhere but

  AGH, PRMC, or STC

  (n = 3)

  Patients transported for treatment (n = 445)

  Excluded patients not transported for treatment (n = 195)

  All adult patients in OCBP database with suspected spinal injury

  (N = 640)

  Fig. 1. Patient selection. Abbreviations: AGH, Atlantic General Hospital; ED, emergency department; OCBP, Ocean City Beach Patrol; PRMC, Peninsula Regional Medical Center; STC, R Adams Cowley Shock Trauma Center. a. 2 patients eloped, 1 was transported via family members, 1 patient was injured away from the shore, 1 patient was incorrectly listed as an adult by OCBP and found to be a minor upon chart review, and 1 patient had a duplicate encounter.

  Patients included in analysis n = 278

  Excluded patients: Missing ED record (n = 146)

  In cardiac arrest/comatose (n = 6)

  With ED record indicating no spinal evaluation (n = 6) Other (n = 6)a

  Table 1

  Comparative analysis of patients with suspected near-shore spinal injury.

  Variables	All	No injury (A)	Bony spinal fracture (B)	Spinal cord injury (C)	p-values A vs Ba	p-values A vs Ca
  Number of patientsb	278	176	48	41	N/A	N/A
  Age in years, mean (SD)	42 (14)	39 (13)	49 (12)	46 (15)	N/A	N/A
  Age in years, n (%)
  18-34	87 (31)	71 (40)	6 (13)	9 (22)	< 0.0001	0.005
  35-54	137 (49)	84 (48)	27 (56)	19 (46)
  55-75	54 (19)	21 (12)	15 (31)	13 (32)
  Gender, n (%) Male	215 (77)	123 (70)	43 (90)	39 (95)	0.005	0.0005
  Female	63 (23)	53 (30)	5 (10)	2 (5)
  Race, n (%)
  White	239 (86)	146 (83)	42 (88)	38 (93)	0.51	0.15
  Non-white	39 (14)	30 (17)	6 (13)	3 (7)
  Activity at injury, n (%)

  Bodysurfing	118 (42)	70 (40)	21 (44)	21 (51)	0.62	0.22
  Boogie boarding	90 (32)	58 (33)	17 (35)	8 (20)	0.73	0.13
  Diving	14 (5)	3 (2)	3 (6)	8 (20)	0.11	< 0.0001
  Swimming	21 (8)	17 (10)	2 (4)	2 (5)	0.38	0.54
  Otherc	35 (13)	28 (16)	5 (10)	2 (5)	0.49	0.08

  Chief complaint(s) at HPI, n (%)^d

  Pain	203 (73)	151 (86)	36 (75)	12 (29)	0.08	< 0.0001
  Paresthesia	81 (29)	29 (16)	14 (29)	28 (68)	0.06	< 0.0001
  Weakness or paralysis	39 (14)	8 (5)	6 (13)	21 (51)	0.08	< 0.0001
  LOC	25 (9)	16 (9)	4 (8)	4 (10)	0.99	0.99
  PE findings, n (%) Weakness
  Normal strength	228 (82)	164 (93)	39 (81)	17 (41)	0.02	< 0.0001
  Any weakness	50 (18)	12 (7)	9 (19)	24 (59)
  Sensation
  Normal	241 (87)	167 (95)	40 (83)	15 (37)	0.01	< 0.0001
  Any decrease	37 (13)	9 (5)	8 (17)	26 (63)
  Midline spinal tenderness, n (%)	69 (25)	41 (23)	18 (38)	8 (20)	0.06	0.68

  Abbreviations: HPI, history of present illness; LOC, loss of consciousness; N/A, not applicable; PE, physical examination; SD, standard deviation.

  ^a Bold values indicate statistically significant findings.

  ^b 13 patients with injuries to spinal ligaments were not included in the analysis.

  ^c Includes patients who were rafting, walking in or out of the water, swimming along the shore, standing, or wading in the water.

  ^d Patients may have more than one chief complaint.

  Utility of midline spinal tenderness in detecting spinal fracture

  Imaging modality	Sensitivity, %		Specificity, %		PPV, %		NPV, %		aLR+		aLR-
  	(95% CI)		(95% CI)		(95% CI)		(95% CI)		(95% CI)		(95% CI)
  XR
  C-spine	33		78		20		88		1.52		0.85
  	(6.66-60.01)		(68.59-87.57)		(2.47-37.53)		(79.71-95.68)		(0.61, 3.78)		(0.56, 1.30)
  T-spine	43		65		21		83		1.21		0.89
  	(6.20-79.52)		(47.67-81.36)		(0.00-42.92)		(68.42-98.24)		(0.45, 3.21)		(0.44, 1.77)
  L-spine	50		81		25		93		2.58		0.62
  	(1.00-99.00)		(66.74-94.55)		(0.00-55.01)		(82.71-100)		(0.77, 8.71)		(0.23, 1.68)
  CT
  C-spine	35		79		35		79		1.68		0.82
  	(21.89-48.95)		(72.47-85.43)		(21.37-48.02)		(73.03-85.91)		(1.03, 2.75)		(0.65, 1.02)
  T-spine	75		79		38		95		3.52		0.32
  	(44.99-100.00)		(67.02-90.42)		(13.78-61.22)		(87.95-100)		(1.79, 6.96)		(0.10, 1.06)
  L-spine	25		80		11		92		1.28		0.93
  	(0.00-67.43)		(68.36-92.62)		(0.00-31.64)		(82.64-100)		(0.21, 7.81)		(0.52, 1.67)

  Abbreviations: C-spine, cervical spine; CT, computed tomography; L-spine, lumbar spine; LR-, negative likelihood ratio; NPV, negative predictive value; LR+, positive likelihood ratio; PPV, positive predictive value; T-spine, thoracic spine; XR, radiograph.

  ^a Bold values indicate clinically significant findings.

  Presence of spinal fracture based on midline spinal tenderness

  The PE finding of midline spinal tenderness was compared to the presence of spinal fracture on XR and CT (Table 2). On XR lumbar spine, spinal tenderness had a LR+ of 2.6 for detecting lumbar fracture but was non-significant at the cervical and thoracic levels. On CT tho- racic spine, tenderness had a LR+ of 3.5 and a LR- of 0.3 for detecting spinal fracture but was non-significant at the cervical and lumbar levels. Tenderness at any spinal level resulted in a NPV of 83%-93% on XR and 79%-95% on CT.

  Presence of spinal cord injury based on HPI complaints and PE findings

  HPI complaints of paresthesia, paralysis, weakness, sensory loss, and pain, and PE findings of weakness and decreased sensation were com- pared to the detection of spinal cord injury on MRI (Table 3). We found 4 of 5 HPI complaints and both PE findings to be clinically signif- icant. Patients’ reports of paralysis had the highest association with spi- nal cord injury (LR+ 13.9), followed by their reports of sensory loss (LR

  + 5.8), weakness (LR+ 4.0), and paresthesia (LR+ 3.1). PE findings of weakness and decreased sensation were significant at LR+ of 5.3 and

  3.8 respectively. LR- (0.5) was also significant with PE finding of weakness.

  Presence of head or spinal injury based on LOC

  Almost 9% (25/278) of patients in this study who were alert and ori- ented enough to provide HPI reported LOC. CT head was ordered in 163 patients, of which 3 had intracranial injury and 2 reported LOC. Patients’ HPI complaints of LOC were compared to the development of head in- jury, any spinal injury, and spinal cord injury specifically (Table 4). Patient-reported LOC had a LR+ of 5.6, LR- of 0.4, and a NPV of 99% (95% CI 98%-100%) for head injury but was not clinically useful for de- tecting a spinal fracture or spinal cord injury.

  Discussion

  This study investigated the correlation of HPI and PE findings with diagnosis in patients identified by a beach patrol as at high risk for near-shore spinal injury and transported to an ED. We were able to identify several components of the clinical evaluation that are predictive of either spinal fractures or spinal cord injuries.

  Table 3

  Utility of HPI and PE components in detecting spinal cord injury.

  Clinical finding	Sensitivity, %		Specificity, %		PPV, %		NPV, %		LR + a		LR-a
  	(95% CI)		(95% CI)		(95% CI)		(95% CI)		(95% CI)		(95% CI)
  HPI Paresthesia	68		78		35		93		3.05		0.41
  	(54.05-82.54)		(72.33-82.94)		(24.21-44.92)		(89.93-96.87)		(2.23, 4.19)		(0.26, 0.64)
  Paralysis	29		98		71		89		13.87		0.72
  	(15.34-43.20)		(96.06-99.72)		(48.93-92.25)		(85.08-92.70)		(5.16, 37.30)		(0.59, 0.88)
  Weakness	22		95		41		88		4.00		0.83
  	(9.28-34.62)		(91.62-97.41)		(20.36-61.45)		(83.45-91.55)		(0.46, 8.74)		(0.83, 0.97)
  Sensory loss	5		99		50		86		5.81		0.96
  	(0.00-11.47)		(97.99-100.00)		(1.00-99.00)		(81.63-89.90)		(0.84, 40.10)		(0.89, 1.03)
  Pain	29		19		6		61		0.36		3.64
  PE	(15.34-43.20)		(14.37-24.44)		(2.67-9.16)		(50.31-72.35)		(0.22, 0.59)		(2.63, 5.05)
  Weakness	59		89		48		93		5.34		0.47
  	(43.46-73.62)		(85.05-93.01)		(34.15-61.85)		(89.13-95.95)		(3.42, 8.33)		(0.32, 0.67)
  Decreased sensation	37		90		39		89		3.77		0.70
  	(21.84-51.33)		(86.53-94.06)		(23.93-55.01)		(85.23-93.10)		(2.16, 6.60)		(0.55, 0.89)

  Abbreviations: HPI, history of present illness; LR-, negative likelihood ratio; LR+, positive likelihood ratio; NPV, negative predictive value; PE, physical examination; PPV, positive predic- tive value.

  ^a Bold values indicate clinically significant findings.

  Table 4

  Utility of LOC in detecting head, spinal cord, or any spinal injury.

  Injury	Sensitivity, %		Specificity, %		PPV, %		NPV, %		LR + a		LR-a
  	(95% CI)		(95% CI)		(95% CI)		(95% CI)		(95% CI)		(95% CI)
  Head	67		88		10		99		5.62		0.38
  	(13.32-100.00)		(83.11-93.14)		(0.00-22.08)		(97.92-100)		(2.27, 13.88)		(0.08, 1.88)
  Spinal cord	10		91		16		85		1.10		0.99
  	(0.67-18.84)		(87.52-94.76)		(1.63-30.37)		(81.02-89.73)		(0.40, 3.04)		(0.89, 1.10)
  Any spinal	10		91		38		63		1.08		0.99
  	(4.03-15.57)		(86.66-95.16)		(19.76-57.16)		(57.55-69.44)		(0.51, 2.29)		(0.92, 1.07)

  Abbreviations: LOC, loss of consciousness; LR-, negative likelihood ratio; LR+, positive likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.

  ^a Bold values indicate clinically significant findings.

  Consistent with prior studies [13,14], midline spinal tenderness was not an effective way to screen for spinal fractures in our patient popula- tion. However, with significant LR+ at thoracic and lumbar levels, and moderate to strong NPV at all levels, the presence or absence of midline spinal tenderness spinal tenderness was a useful PE finding to adjust in- dices of suspicion of spinal fracture.

  HPI complaints and PE findings correlated well with spinal cord in- jury. Surprisingly, HPI correlated more strongly with spinal cord injury than did PE findings. Prior studies have noted that neurological inju- ries can be subtle, and sometimes subjective history from the patient may give the only initial clues [8,15,16]. Although weakness on PE (LR+ 5.3) more strongly correlated with spinal cord injury than did patients’ complaints of weakness (LR+ 4.0), the correlation was not as strong as with patients’ complaints of paralysis (LR+ 13.9). Addi- tionally, decreased sensation on PE (LR+ 3.8) was not as good a pre- dictor of spinal cord injury as patients’ complaints of sensory loss (LR+ 5.8). Therefore, our study affirms that patients’ chief complaints should influence clinicians’ indices of suspicion when diagnosing pa- tients with suspected spinal injuries from near-shore aquatic activities.

  Loss of consciousness (LOC) was a useful finding in assessing for head injury in our study. Although reported in over 8% of cases, only three of 163 patients who received head CT scans were found to have head injuries. This relatively high frequency of LOC with low incidence of head injury may be attributable to the multiple ways that near-shore aquatic trauma differs from other traumatic mechanisms. Panic and hypoxia can occur while a patient is underwater, and the diving reflex may result in tran- sient bradycardia. All three conditions likely cause LOC to occur more frequently in aquatic vs. other injuries [17,18]. This suggests providers can reduce potentially unnecessary head CTs of patients sustaining aquatic blunt trauma–in accordance with current choosing wisely guidelines from the American College of Emer- gency Physicians [19]–by determining if LOC was present.

  Limitations

  The retrospective nature of this study relied on the integrity of the AGH, PRMC, and STC databases. However, almost a third of charts were unavailable, in part because AGH destroys its records 10 years after the initial patient encounter. Since near shore spinal injuries might not be common and AGH is known to be the location of transport for most patient, we decided to include as many eligible patients as pos- sible. Therefore, we did not exclude AGH nor limit the study period to within 10 years. Furthermore, our study also relied on clinicians’ docu- mentation, which has been shown to be inadequate in critically ill pa- tients [20]. We also excluded patients who could not verbalize their symptoms, but these patients may have been at higher risk for spinal in- juries. This study focused on adults, while patients under 18 made up al- most a quarter of patients transported for suspected spinal injury during the study period. Further studies should consider evaluating pediatric patients and their corresponding injuries.

  Conclusion

  Our study identified a few HPI complaints and PE findings that cor- relate with near-shore aquatic head and spinal injury. Patients’ HPI complaint of paralysis, and PE findings of weakness and decreased sen- sation correlated with spinal cord injury. HPI of maintaining conscious- ness during injury suggests the absence of clinically significant head trauma. Due to our study’s exploratory nature, further prospective stud- ies are needed to confirm our observations. Clinicians may consider these High-risk factors to appropriately expedite care and refine testing and resource utilization for patients who sustain near-shore aquatic injuries.

  CRediT authorship contribution statement

  Tucker Lurie: Conceptualization, Writing – original draft, Writing – review & editing. Bradford Schwartz: Conceptualization, Writing – orig- inal draft, Writing – review & editing. Daniel Najafali: Writing – review & editing. Priyanka Gandhi: Writing – review & editing. Matthew Jack- son: Writing – review & editing. Quincy K. Tran: Conceptualization, Writing – original draft, Writing – review & editing.

  Acknowledgements

  We thank Ms. Stephanie Cason at Peninsula Regional Medical Center and Ms. Shannon Gandee at Atlantic General Hospital for their assis- tance in completion of this study. Deborah M. Stein, ELS, provided lan- guage and technical editing of the manuscript.

  Funding source

  This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

  Presentation

  The data was presented in part at the American College of Emer- gency Physician’s Research Forum in October 2019, Denver, Colorado.

  References

  1. United States Lifesaving Association. 2018 National lifesaving statistics, http:// arc.usla.org/Statistics/current.asp?Statistics=Current; 2018 [accessed 6 April

     2020].

     National Spinal Cord Injury Statistical Center. Spinal Cord Injury (SCI): Facts and fig- ures at a glance, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5102286/pdf/ yscm-39-493.pdf; 2016 [accessed 6 April 2020].

  2. Nathanson A, Haynes P, Galanis D. Surfing injuries. Am J Emerg Med. 2002;20(3): 155-60.
  3. Allen RH, Eiseman B, Straehley CJ, Orloff BG. Surfing injuries at Waikiki. JAMA. 1977; 237(7):668-70.
  4. Hay CSM, Barton S, Sulkin T. Recreational surfing injuries in Cornwall. United Kingdom Wilderness Environ Med. 2009;20(4):335-8. https://doi.org/10.1580/ 1080-6032-020.004.0335.
  5. Omori K, Kondo A, Oode Y, Itoi A, Sakuraba K, Yanagawa Y. Analysis of patients with bodyboarding injuries transported by physician-staffed emergency helicopter. J Emerg Trauma Shock. 2015;8(1):39-42. https://doi.org/10.4103/0974-2700. 145416.
  6. Robles LA. Cervical spine injuries in ocean bathers: wave-related accidents. Neuro- surgery. 2006;58(5):920-3. https://doi.org/10.1227/01.NEU.0000209941.18102.35.
  7. Chang SKY, Tominaga GT, Wong JH, Weldon EJ, Kaan KT. Risk factors for water sports-related cervical spine injuries. J Trauma. 2006;60(5):1041-6. https://doi. org/10.1097/01.ta.0000218256.39295.8f.
  8. Cheng CLY, Wolf AL, Mirvis S, Robinson WL. Body surfing accidents resulting in cer- vical spinal injuries. Spine (Phila Pa 1976). 1992;17(3):257-60. https://doi.org/10. 1097/00007632-199203000-00002.
  9. Dimmick S, Brazier D, Wilson P, Anderson SE. Injuries of the spine sustained whilst surfboard riding. Emerg Radiol. 2013;20(1):25-31. https://doi.org/10.1007/s10140- 012-1089-1.
  10. Lee DY, Park YJ, Song SY, Hwang SC, Kim KT, Kim DH. The importance of early sur- gical decompression for Acute traumatic spinal cord injury. Clin Orthop Surg. 2018;10(4):448-54. https://doi.org/10.4055/cios.2018.10.4.448.
  11. Scher A. Bodysurfing injuries of the spinal cord. S Afr Med J. 1995;85(10):1022-4.
  12. Inaba K, Nosanov L, Menaker J, Bosarge P, Williams L, Turay D, et al. Prospective der- ivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: an American Association for the Surgery of Trauma multi-institutional trials

      group study. J Trauma Acute Care Surg. 2015;78(3):459-67. https://doi.org/10. 1097/TA.0000000000000560.

      Duane T, Dechert T, Wolfe L, Aboutanos M, Malhotra AIR. Clinical examination and its reliability in identifying cervical spine fractures. J Trauma Acute Care Surg. 2007;62(6):1405-10.

  13. Scher A. Cervical spinal cord injury without evidence of fracture or dislocation. S Afr Med J. 1976;50:962-5.
  14. Pope JV, Edlow JA. Avoiding misdiagnosis in patients with neurological emergencies. Emerg Med Int. 2012;949275. https://doi.org/10.1155/2012/949275.
  15. Nuckton TJ, Chandra R, Heye KD, Lauritzen SK, Magocsy M. Near-syncope after swimming in cold water. Case Rep Int. 2016;5:18-21.
  16. Godek D, Freeman AM. Physiology, diving reflex. http://www.ncbi.nlm.nih.gov/ pubmed/30855833;; 2019.
  17. American College of Emergency Physicians. Choosing Wisely: Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insig- nificant trauma and a normal neurological evaluation, https://www. choosingwisely.org/clinician-lists/acep-avoid-head-ct-for-asymptomatic-adults- with-syncope/; 2017 [accessed 6 April 2020].
  18. Rose M, Newton C, Boulam B, Bogne N, Ketchum A, Shah U, et al. Assessing adequacy of emergency provider documentation among Interhospital transferred patients with acute aortic dissection. World J Emerg Med. 2019;10(2):94-100. https://doi. org/10.5847/wjem.j.1920-8642.2019.02.005.