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Fri Aug 17 16:09:11 BST 2007

This is a scenario that is expected to be addressed in all EMS provider training and practice will vary dependent upon the national / local policy regarding 'risk of injury' assessment through to use of spinal protective devices provided / request for additional personnel etc. Having reviewed so many of these, the fundamental difference in programmes is the autonomy which the individual care provider is allowed to exercise (as opposed to a 'blind obedience' with policy) at a given incident. 

*         What constitutes 'significant' accident history

*         What constitutes 'significant clinical symptoms'

*         What constitutes 'controlled evacuation'

*         What constitutes 'scoop and run'

*         What constitutes 'duck and drag under cover'

*         Patient presenting with 'significant accident history' and with 'significant clinical symptoms'

*         Patient presenting with 'significant accident history' but without 'significant clinical symptoms'

*         Patient presenting with 'significant clinical symptoms' irrespective of accident history

*         Patient in whom application of spinal protective device(s) is contraindicated

*         Guidance for managing penetration injuries (especially where object protruding)

*         Pregnant casualties with 'suspicious history or symptoms'

*         Patient who refuses or resists the 'indicated' application of spinal protective device(s)

*         Patient in ambulance without spinal protection devices in place who deteriorates/develops new spinal pain/neurological change

*         How to work with ED staff who whip patient off spinal board upon arrival without any consideration for the rationale, time and effort the EMS provider took to 'protect' the patient from scene

The cost of a single non-ventilated tetraplegic to the combined health/welfare/national economy budget is estimated as upwards of £500,000 sterling per annum ~ $1,000,000

UK/US concur ~10% of spinal/spinal cord injuries occur/detected after admission to ED

Commonest error is 'failure to appreciate mechanism of injury'

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of trauma at emergencyunit.com
Sent: 17 August 2007 10:02
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Question for the prehospital experts

Hey, autumn (fall to my US colleagues) can't be far off! I smell old

chestnuts roasting once more. 

Let's have some statistics. 98% of people imaged when attending EDs with

post-traumatic neck pain don't have fractures (study presented at ICEM in

Vancouver, but I never found where it was published). Of those that do, some

80% (my guess) have a fracture that is not threatening the cord. 5% will

have a completed spinal cord injury - and so 15% will have an unstable

fracture that may move and damage the cord. In figures, three people in a

thousand have a cord at risk. I said this is a guess, but after many years

doing this it feels right. There may be one more with a SCIWORA; soft tissue

injury (usually the posterior ligament) that puts the cord at risk. My

friend Keith Porter says he has never seen a person in a rear end shunt with

a neck fracture. I have seen one, which was imaged and the abnormality

missed (someone didn't take big ear studs off) but the patient came to no

harm.

So we are undoubtedly immobilising and imaging people unnecessarily.

However, I dealt with a high-speed head on collision a couple of months ago

with a patient who refused a collar. She was a retired doctor. She had a

painful knee injury. She was held whilst being extricated and during

transfer to hospital - not because anything was suspected but because she

wouldn't tolerate anything else. She had a hangman's fracture.

Thus you only need one scare story  like these two which are true quite

reasonably to give prehospital teams great concerns about not immobilising a

neck. There is a good paper in the EMJ recently where crews were given an

algorithm to clear the neck and achieved a spectacular 87% roadside

discharge rate.

http://emj.bmj.com/cgi/content/abstract/24/7/501?maxtoshow=&HITS=10&hits=10&

RESULTFORMAT=&author1=crouch&fulltext=neck&andorexactfulltext=and&searchid=1

&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

Sorry about the long URL - here's a redirector. http://tinyurl.com/2tlws6

-----Original Message-----

From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]

On Behalf Of Mathias Kalkum

Sent: 17 August 2007 09:15

To: Trauma &amp; Critical Care mailing list

Subject: Re: Question for the prehospital experts

Lorick and others,

> - snip - understand that there exists, but I have been unable to find, 

> a study in Germany which compared NO immobilization with FULL 

> immobilization (including use of NMB) by MD staffed ambulances in 

> different parts of the country.  I am told by a USN corpsmen who saw 

> the data at a class in Germany that there was NO difference in 

> outcome.  Anyone know of this study?  Did it have enough resolving 

> power to mean anything?

- snip -

personally I have seen at least 3 (three) broken dens injuries only detected

in hospital or after (sic!) discharge of hospital, each of them without

paralysis. All of them have been addressed after a time of 1 to 3 weeks

after the injury. This underlines my skepticism against inflexible and

strict immobilization by protocol rather than supporting it. However, one

should remember that in Germany we make liberal use of vacuum mattresses,

and spineboards are very rare to find. Though I could not find the paper you

have mentioned, I found a very skeptical paper against protocol driven

immobilization which produced some literature. You might want to check it

out here: http://www.aerzteblatt.de/v4/archiv/lit.asp?id=42481

Cheers!

Mathias

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Question for the prehospital experts