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Fri Mar 13 13:15:53 GMT 2009

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An inappropriately ("loosly") applied collar is an invitation to
medicolegal scrutiny and regret.  The general recommendations of this
study and its references are to a) make efforts to clear the spine ASAP,
and b) remove or reposition the collars in patients with clinically
significant and refractory rises in ICP (and significantly: none of them
encourage that cervical immobilization be half-assed).

First, this is not particularly provocative news, least of all to anyone
with passing familiarity with bedside trauma care.  There's probably no
literature which discourages doubling an elastic around your pinkie
finger; but most of us would agree based on principal, if not
rudimentary experience.

Second, these patients are, by any reasonable expectation, comatose.
They do not require much in the way of stabilization beyond maybe a
couple of towel rolls and conspicuous signage saying, "LOG ROLL ONLY."
If you're trusting a loose collar to "remind" providers of an uncleared
neck, be aware that it may just as easily fool the same providers into
thinking that the spine is somehow protected from carelessness.

Third, although I admit that I'm unfamiliar with the "Spieth" product,
the reference works seem restricted to cheap, rescue-type collars
(StifNecks and Phillies).  These do not represent the standard of care
much past the prehospital phase.  One wonders whether the same results
are to be found with better fitted and padded models like the Miami-J.
If nothing else, this is simply another among countless excellent
reasons to conclude the prehospital phase as promptly as possible.

Pret Bjorn, RN
Bangor, ME USA

	-----Original Message-----
	From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Sherry, Scott :LPH
Trauma
	Sent: Thursday, March 12, 2009 1:47 PM
	To: Trauma &amp; Critical Care mailing list
	Subject: RE: Prehospital pelvic compression

	1.	Ho AM, Fung KY, Joynt GM, Karmakar MK, Peng Z. Rigid
cervical collar and intracranial pressure of patients with severe head
injury. Journal of Trauma-Injury Infection & Critical Care
2002;53(6):1185-8. 

	I havent read it. may be a good start...
	one of our stratigies is to make sure the collar is placed
loosly on a paitent with refractory elevated icps. 
	suppine positioning also can increase icps as well. we try to
get reverse trendelenberg 30 dg. and tl clearance asap. not sure what
difference no collar would have prehosp if you are still keeping pt
flat...just needs to be loose enough to allow venous drainage. 

________________________________

	From: trauma-list-bounces at trauma.org on behalf of Patzalek,
Wayne
	Sent: Thu 3/12/2009 5:58 AM
	To: Trauma &amp; Critical Care mailing list
	Subject: RE: Prehospital pelvic compression

	I would be interested in references to CID devices increasing
ICP.

	Respectfully,

	Wayne Patzalek
	Instructional Coordinator, Paramedicine
	School of Health Sciences
	College of the North Atlantic
	1 Prince Philip Dr
	St. John's, NL A1C 5P7

	ph 709.758.7682
	fax 709.758.7634
	-----Original Message-----
	From: Dr Timothy Hardcastle
[mailto:dr.tchardcastle at absamail.co.za]
	Sent: March 11, 2009 3:01 PM
	To: Trauma &amp; Critical Care mailing list
	Subject: Re: Prehospital pelvic compression

	Karim

	Agree with your sentiments. As for collars, we know they
increase ICP. I
	am aware of Ambulance services and trauma systems that no longer
use them
	- replaced with headblocks and spidder harness

	Tim
	Dr T C Hardcastle
	M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
	Principal Specialist Trauma Surgeon /
	Honorary Lecturer University of KwaZulu-Natal Dept Surgery
	Deputy Director - IALCH Trauma Service
	Durban - South Africa
	> Let's be clear what we're talking about here.  Are we talking
about
	> pelvic belts in general or the T-POD binder?
	>
	> Pelvic belts are an ideal prehospital device.  They provide
fracture
	> splintage during the phases where there is the most movement
(and
	> potential clot disruption). They should be placed to protect &
	> stabilize a suspected pelvic injury, just like any splint -
and as a
	> protective device just like the C-collar.  Like any splint
they will
	> reduce bleeding from bone ends and some venous bleeding.
(They will
	> never control significant arterial bleeding).   (Tim -
following your
	> logic about exposure then cervical spine collars should not be
placed
	> pre-hospital).
	>
	> The belts are there to stablize - not to "close-down" a
pelvis.  As
	> such they can be placed on any pelvic fracture (before the
fracture
	> pattern is known). They should not be applied by two gorillas
leaning
	> on the pelvis, but just snugly over the greater trochanters.
	>
	> I personally don't see any reason for placing them over
clothes.
	> These should be cut off and then the belt placed.  BUT if they
are on
	> over clothes then take it off, cut the clothes off and then
put it
	> back on!!
	>
	> I've never liked the T-POD.  It's too big, too
over-engineered, too
	> inflexible and doesn't allow easy access for laparotomy/angio.
Like
	> Tim says a simple belt like the Pelvigrip or SAM sling is
ideal.
	>
	> As for no data - it's true there is little specific data
related to
	> the belts (but about as much as there is for any type of
splintage).
	> BUT there is data recently from protocolised care of bleeding
pelvic
	> fractures that includes using the pelvic belt as part of the
	> management algorithm.
	>
	> Karim
	>
	> 2009/3/10 Dr Timothy Hardcastle
<dr.tchardcastle at absamail.co.za>:
	>> Johan
	>>
	>> Good reason to change practice - they should NOT be used
pre-hospital:
	>> The
	>> pelvic binder is only useful for open-book fractures (AP
compression
	>> type), more for patient support than anything else (I agree
with
	>> Norman's
	>> comments).
	>>
	>> Good practice of ATLS is to do an EXPOSURE with ENVIRONMENTAL
control -
	>> neither is possible with the binder. If they want to use
something, the
	>> Pelvigrip type device, with velcro straps for easy
removal/adjustment is
	>> a
	>> better option. Also re-usable (made of neoprene)
	>>
	>> How fast do you get your trauma-CT. If less than 30 minutes -
fine,
	>> otherwise get the pelvic mobile film in the ER.
	>>
	>> Regards
	>> Tim
	>>
	>> Dr T C Hardcastle
	>> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
	>> Principal Specialist Trauma Surgeon /
	>> Honorary Lecturer University of KwaZulu-Natal Dept Surgery
	>> Deputy Director - IALCH Trauma Service
	>> Durban - South Africa
	>>>
	>>> Hello!
	>>> I have a question to all of you regarding the use of
prehospital pelvic
	>>> binders. I work at a small hospital where we dont have
access to x-ray
	>>> of
	>>> the pelvis in the traumaroom. Currently the prehospital
personel
	>>> applies
	>>> the TPOD (pelvic binder) in the prehospital setting whenever
they
	>>> suspects
	>>> a pelvic fracture. The TPOD is often placed before removing
the
	>>> patients
	>>> cloths. This approach interferes the examination of the
patient in the
	>>> traumaroom because when the pelvic divice is applied
prehospital every
	>>> one
	>>> is afraid of removing it with the fear of bleeding. Since we
dont have
	>>> acces to plain x-ray in the traumaroom we often leave the
TPOD until
	>>> the
	>>> trauma-ct is done and we have  pictures. The tpod also makes
it
	>>> difficult
	>>> to remove the patients clothes and sometimes makes it
impossible to
	>>> make a
	>>> good examination of the lower back, perineum/rectum. How
would yo
	>>> approach
	>>> this matter?
	>>>
	>>> Johan
	>>>
	>>>
	>>>
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	>>
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C-collars and ICP (was RE: Prehospital pelvic compression)