Controversies in rescue Tony Smith, Medical Director, St John

Controversies in rescue Cervical spine immobilisation The golden hour Crush injury Tourniquets Questions

Cervical spine immobilisation A controversial area for sometime We teach our personnel to clear the cervical spine clinically if: Patient is awake, alert and cooperative No neck or upper back pain to palpation, in particular no midline bony tenderness Normal peripheral motor power and sensation No significant distracting injuries These are mechanism and age independent Many patients are able to be cleared clinically

Cervical spine immobilisation We teach that the role of firm cervical collar is controversial May cause more harm than good We teach not to use tape We teach not to transport on hard boards, unless very short duration We take a pragmatic approach to the use of head blocks We take a pragmatic approach to the uncooperative patient Goal is to minimise movement

Cervical spine immobilisation Our previous approach was relatively liberal in terms of not placing a firm cervical collar But still resulted in a significant number of ‘low risk’ patients receiving a firm cervical collar More neck pain More radiation to clear the cervical spine More agitation Raised intra-cranial pressure Impaired breathing Pressure areas Possible that a firm cervical collar may cause more harm

Why we decided to change In 2015 ILCOR changed their advice in the first aid section “We no longer recommend the routine use of a firm cervical collar” Firm cervical collars may cause more harm than good Note: there was no new evidence Resulted in a number of people changing their approach For example Queensland Ambulance Service Many were just looking for a reasonable consensus to make a change Included ambulance sector in NZ

How we decided to change Ambulance sector working group produced a draft procedure Significantly reducing the role of the firm cervical collar Circulated widely for comment College of Emergency Medicine College of Intensive Care Medicine College of Surgeons Major Trauma Networks Spinal Cord Impairment Governance Committee Spinal Society Emergency Department staff via unit Managers/Charge Nurses Large amount of feedback Overwhelmingly in favour of change Some feedback that we weren't going far enough

A new procedure

A new procedure

A new procedure

A new procedure

Our experience so far Early days Lanyards only went on the vehicles in April/May Training finishing at the end of July Clinical practice takes time to change Always lags behind procedures and guidelines Will be reviewed at the end of 2018

The golden hour A concept developed by Adams Cowley in the 1980s Shock Trauma Center in Baltimore Concept became a mantra Patients with major trauma arriving in hospital within sixty minutes have a greater chance of survival

The golden hour Unfortunately not true… What they did show Key issue Multiple databases showed no direct correlation between survival rates and time to arrival in hospital What they did show Direct correlation between survival rates and time to arrival in the most appropriate hospital Key issue No point in a patient with major trauma going to a hospital that cannot meet their treatment needs

The golden hour What this means in practice Policies in place for most Take the patient to the right hospital whenever feasible, even if further away than the closest hospital If going to another hospital minimise the time delay to reaching the right hospital Policies in place for most Staging in New Zealand

Crush injury Severe crush injury is rare Mortality rates are high A small group of patients deteriorate rapidly when the weight is released Sometimes called crush syndrome Actually release syndrome Cause is controversial

Crush injury and release syndrome Amount of injury proportional Weight of the object, amount of body crushed, duration of crush Damaged and ischaemic muscle Release of toxins, including myoglobin and potassium The weight can act as a tourniquet Systemic toxin release when weight released

Crush injury and release syndrome General guide: more than a limb for more than an hour Release the weight as soon as possible Time is crucial Prepare for release syndrome Apply tourniquet/s if possible Gain IV access and load with IV fluid Administer calcium and bicarbonate Consider administering glucose and insulin Blood likely to be useful Coordinated approach and good communication Should release of the weight be deliberately delayed?

Tourniquets Have always been controversial Can be life saving Will cause limb ischaemia Can cause nerve damage Can make bleeding worse Significant use in WW1 and WW2 Later years not supported

Tourniquets Newer designs overcome many disadvantages Clear evidence during recent wars that they save lives Most ambulance services have introduced them Including to first responders

Tourniquets Newer designs overcome many disadvantages Clear evidence during recent wars that they save lives Most ambulance services have introduced them Including to first responders

Tourniquets

Case example Van vs truck, trapped Major injuries to legs that were obviously bleeding Bilateral tourniquets applied by first responders prior to ambulance arrival Prolonged extrication

Summary Cervical spine immobilisation The golden hour Crush injury Changing, role of firm cervical collar is reducing The golden hour Doesn't really exist Important to go to the right hospital Crush injury Release syndrome is rare but real Preparation for and treatment of release syndrome saves lives Tourniquets Clearly have a role Save lives in the hands of first responders

Questions