ACEP’s New Policy on Spinal Precautions

The American College of Emergency Physicians (ACEP) just released “EMS Management of Patients with Potential Spinal Injury“.

Bottom line:

Spinal motion restriction should be considered for patients who meet validated indications such as the NEXUS criteria or Canadian C-Spine rules.

Backboards should not be used as a therapeutic intervention or as a precautionary measure either inside or outside the hospital or for inter-facility transfers.  Spinal immobilization should not be used for patients with penetrating trauma without evidence of spinal injury.

EMS medical directors should assure EMS providers are properly educated on assessing risk for spinal injury and neurologic assessment, as well as on performing patient movement in a manner that limits additional spinal movement in patients with potential spinal injury.  Patient movement and transfer practices should be coordinated with receiving facility personnel.

Go check it out here.

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Out-of-hospital Cardiac Arrest Intubations May Hurt Patients

The study done in the Jan 2013 JAMA shows that patients suffering from out-of-hospital cardiac arrest who were intubated in the field had a less favorable neurologic outcome than those getting bag-valve-mask ventilation.

One possible reason for this is the time taken for intubation may take away from uninterrupted cardiac compressions…and we know that uninterrupted compressions is the key to improving survival in out-of-hospital cardiac arrest.

 

JAMA OHCA intubation

Shortcutting Pediatric Resuscitation

Doing complex calculations under maximal stress can be a recipe for problems. Learn to take shortcuts to prevent errors in judgement and calculation.

Research on the counting system here.

Book review for On Combat by David Grossman: http://emcrit.org/podcasts/emcrit-book-club-on-combat-by-grossman/

Download a PDF of dosage shortcuts here.

New Tech in EMS: 2014

Here is a presentation on new and upcoming things in the EMS world.

Spinal Immobilization

So, do we have to put every trauma patient into a collar and on a backboard? Probably not, but the practice is go ingrained in our EMS culture that it happens with high frequency.

There was a landmark article in the New England Journal of Medicine by Jerome Hoffman in 2000 that looked at 34,000 patients to develop a rule set for clinical clearance of the cervical spine. The absence of the following criteria place the patient into a low probability of injury and did not require imaging:

  1. the absence of tenderness at the posterior midline of the cervical spine
  2. the absence of a focal neurologic deficit
  3. a normal level of alertness
  4. no evidence of intoxication
  5. absence of clinically apparent pain that might distract the patient from the pain of a cervical-spine injury

If the above patients did not require any form of imaging, then those same patients would not require spinal immobilization.

The topic of reviewing and reconsidering how we handle prehospital spinal immobilization is rising and there are several recent articles challenging the status quo.

In the March edition of JEMS, there was an article entitled “Research Suggests Time for Change in Prehospital Spinal Immobilization“. EMSWorld has the following articles: “Evidence Against Backboards“, and “Does Spinal Immobilization Help Patients“.

According to Dr. Bledsoe’s review of the literature, he states that there is no evidence that backboards immobilize the spine, backboards can cause pain, make airway management more difficult, impair respirations, and place the patient at risk of aspiration. Additionally, there is no evidence that backboards improve patient outcomes. Dr. Bledsoe is similarly critical of cervical collar usage.

BOTTOM LINE:

  1. The application of NEXUS or Canadian C-Spine criteria to prehospital patients can identify those that do not need a C-collar.
  2. Understand that there is no significant evidence that the use of backboards improves patient outcomes, and we should work to reduce their usage.

 

 

Resources

JEMS-Spinal-Immobilization

Canadian-C-Spine-Rule

Example-Spine-Assessment-Protocol

SERTAC-Spine-Assessment

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Damage Control Resuscitation

Trauma lessons learned during the Afghanistan and Iraqi wars lead the military to release Joint Theater Trauma System Clinical Practice Guideline discussing elements of Damage Control Resuscitation. Those elements along with the use of tourniquets lead to the creation of the following EMS Draft Protocol.

EMS Protocol Draft

Damage Control Resuscitation

7 August 2013

Purpose:

Based on knowledge gained from the military regarding trauma resuscitation, there is new evidence advancing the initial care and resuscitation of patients suffering from significant hemorrhage. This protocol is an update and replacement of the current approach to trauma patient resuscitation.

The use of large volume crystalloid infusion is known to decrease the ability of patients to form clots and therefore should be limited to patients who are rapidly deteriorating despite other interventions.

 

INDICATIONS:

This protocol is indicated for use in all trauma patients, appearing to be at least 16 years of age, with ongoing significant hemorrhage (SBP < 90 mmHg and/or heart rate > 110 bpm), or who are considered to be at risk of significant hemorrhage.

HEMORRHAGE CONTROL:

In patients with evidence of significant hemorrhage:

  • Apply tourniquets to extremities as indicated
  • Use firm, continuous direct pressure to site of continuing bleeding
  • Application of hemostatic gauze (e.g. Trauma Gauze) as indicated

PERMISSABLE HYPOTENTION:

Limit the infusion of crytalloids in patients with SBP > 90 mmHg.

Give 250-500 mL boluses of crystalloid every 10 minutes:

  • Hypotensive patients (SBP < 90 or absent radial pulse)
  • Patients with isolated head trauma (necessitating a higher blood pressure to maintain cerebral perfusion pressure)

TRANEXAMIC ACID (TXA):

Patients meeting the above indications AND are within 3 hours of injury:

  • 1 gram TXA in 100 mL infused over 10 minutes

Use with caution in patients with past history of DVT/PE or hypercoaguable condition.

ALERT RECEIVING FACILITY:

If time permits, notify the receiving facility that the patient will likely meet Massive Transfusion Protocol criteria.

Resources:

(1) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23–32.

(2) Tranexamic acid decreases mortality following wartime injury: the Military Application of Tranexamic acid in Trauma Emergency Resuscitation Study (MATTERS) MAJ Jonathan J. Morrison, MB ChB, MRCS, RAMC(V), LT COL (sel) Joseph J. Dubose, MD, USAF MC, COL Todd E. Rasmussen, MD, USAF MC, SURG CAPT Mark Midwinter, BMedSci, MD FRCS RN. Arch Surg. 2012; 147:113-119.

(3) Joint Theater Trauma System Clinical Practice Guideline. Damage Control Resuscitation At Level IIb/III Treatment Facilities. July 2012.

Additional Resources:

http://emcrit.org/podcasts/tranexamic-acid-trauma/

Damage_Control_Resuscitation_17_Jul_12 

damage control resuscitation

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