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Adam Thompson, EMT-P
A place for the emergency clinician to procrastinate, discriminate, evaluate, emulate, & educate.
Compliance with documentation of ETCO2 was poor.
Since the completion of the study, training and education on the use of capnography interpretation and documentation have been emphasized by the group of supervising EMS medical directors, and continuous-waveform capnography is now incorporated into the airway management protocol.
Our finding that EMS providers reported only 70% of attempted intubations suggests that self-reported rates of intubation may underestimate the number of intubation attempts and therefore overestimate success rates.
"Intitial evaluation of the trauma patient begins with the primary survey, part of which is the complete exposure of the patient ((An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department, By Swaminatha V. Mahadevan, Gus. M. Garmel, Published by Cambridge University Press, 20057, page 102)). Failure to completely expose the patient may result in missing a serious traumatic injury ((Id. at 102))."
"Exposure is obtained by completely undressing the patient. Patients must be fully undressed to allow a complete evaluation. ((Manual of emergency medicine, By Jon L. Jenkins, G. Richard Braen
Edition: 5, Published by Lippincott Williams & Wilkins, 2004, page 33))"
"The final part of the primary survey involves a quick scan of the patient's body to note any other potentially life threatening injuries. In general, this requires removal of the patient's clothes...Injuries cannot be treated unless they are identified." ((Trauma By Ernest Eugene Moore, David V. Feliciano, Kenneth L. Mattox page 115.))
Proper and consistent placement of the precordial leads is essential for obtaining accurate ECG tracings. ((Sensible analysis of the 12-lead ECG By Kathryn Monica Lewis, Kathleen A. Handal. Published by Cengage Learning, 2000, page 12.))
Correct placement is important because the 12-lead ECGs are compared with previous ECGs. For the comparison to be reliable for identifying existing problems or highlighting the appearance of new problems, the electrodes must be placed consistently. ((NANCY CAROLINES EMERGENCY CARE IN THE STREETS By AUTOR NAO LOCALIZADO, Nancy L Caroline Published by Jones & Bartlett Publishers, 2007, page 27.65.))
When performing 12-lead ECGs on female patients, place the electrodes for leads V3 through V6 under rather than on the breast. ((Prehospital 12-Lead ECG: What You Should Know, http://www.physio-control.com/uploadedFiles/learning/clinical-topics/Prehospital%2012-Lead%20ECG%20What%20You%20Should%20Know%203009852-000.pdf))
"It's a dream job for a sexual predator," said Greg Kafoury, a Portland, Ore., lawyer who represents three women who were groped by a paramedic. "Everything is there: Women who are incapacitated, so they're hugely distracted. Medical cover to put your hands in places where, in any other context, a predator would be immediately recognized as such."
Fear of failure to identify cervical spine injury has led to extremely liberal use of radiography in patients with blunt trauma and remotely possible neck injury. A number of previous retrospective and small prospective studies have tried to address the question of whether any clinical criteria can identify patients, from among this group, at sufficiently low risk that cervical spine radiography is unnecessary. The National Emergency X-Radiography Utilization Study (NEXUS) is a very large, federally supported, multicenter, prospective study designed to define the sensitivity, for detecting significant cervical spine injury, of criteria previously shown to have high negative predictive value. Done at 23 different emergency departments across the United States and projected to enroll more than 20 times as many patients with cervical spine injury than any previous study, NEXUS should be able to answer definitively questions about the validity and reliability of clinical criteria used as a preliminary screen for cervical spine injury.
According to the NEXUS Low-Risk Criteria, cervical spine radiography is indicated for trauma patients unless they exhibit ALL of the following criteria:
1. No posterior midline cervical spine tenderness
and
2. No evidence of intoxication
and
3. Normal level of alertness
and
4. No focal neurological deficit
and
5. No painful distracting injuries
Explanations:
These are for purposes of clarity only. There are not precise
definitions for the individual NEXUS Criteria, which are subject
to interpretation by individual physicians.
- Midline posterior bony cervical spine tenderness is present if the patient complains of pain on palpation of the posterior midline neck from the nuchal ridge to the prominence of the first thoracic vertebra, or if the patient evinces pain with direct palpation of any cervical spinous process.
- Patients should be considered intoxicated if they have either of the following: a) a recent history by the patient or an observer of intoxication or intoxicating ingestion; or b) evidence of intoxication on physical examination such as odor of alcohol, slurred speech, ataxia, dysmetria or other cerebellar findings, or any behavior consistent with intoxication. Patients may also be considered to be intoxicated if tests of bodily secretions are positive for drugs (including but not limited to alcohol) that affect level of alertness.
- An altered level of alertness can include any of the following: a) Glasgow Coma Scale score of 14 or less; b) disorientation to person, place, time, or events; c) inability to remember 3 objects at 5 minutes; d) delayed or inappropriate response to external stimuli; or, e) other.
- Any focal neurologic complaint (by history) or finding (on motor or sensory
examination).- No precise definition for distracting painful injury is possible. This includes any condition thought by the clinician to be producing pain sufficient to distract the patient from a second (neck) injury. Examples may include, but are not limited to: a) any long bone fracture; b) a visceral injury requiring surgical consultation; c) a large laceration, degloving injury, or crush injury; d) large burns: or e) any other injury producing acute functional impairment. Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries.
An additional Maine EMS 2002 Spine Assessment Protocol departure from the NEXUS investigation is the direction to immobilize patients for a complaint of neck pain as well as any tenderness present in the prehospital spine assessment. This change is purposefully meant to provide an added level of concern for spine injury by increasing the “sensitivity” of the spine assessment protocol. This direction should also serve as a means for decreasing the disagreement potential between providers’ (both in and out of the hospital) assessment of individual patients.
While the NEXUS investigation applies solely to the cervical spine, large scale clinical trials evaluating clinical decision rules for thoracic, lumbar, or sacral spine injuries have yet to be performed. As a consequence, care of the entire spine generally follows cervical spine assessment and treatment principles.
The prehospital assessment of tenderness should include, but not be limited to, the palpation of the posterior midline spine. While NEXUS has emphasized the sole importance of posterior, midline spine tenderness in cervical spine assessment, the Maine EMS 2002 Spine Assessment Protocol includes consideration of any areas of spine tenderness as a means for immobilization. This decision represents another adaptation of the NEXUS rules in an attempt to improve the instrument’s sensitivity for any spine injury as well as decreasing medical provider disagreement potential.
Standards: There is insufficient evidence to support treatment standards.
Guidelines: There is insufficient evidence to support treatment guidelines.
Options:
- It is suggested that all trauma patients with a cervical spinal column injury or with a mechanism of injury having the potential to cause cervical spinal injury should be immobilized at the scene and during transport using one of several available methods.
- A combination of a rigid cervical collar and supportive blocks on a backboard with straps is very effective in limiting motion of the cervical spine and is recommended. The longstanding practice of attempted cervical spinal immobilization using sandbags and tape alone is not recommended.
The chief concern during the initial management of patients with potential cervical spinal injuries is that neurologic function may be impaired due to pathologic motion of the injured vertebrae. It is estimated that 3% to 25% of spinal cord injuries occur after the initial traumatic insult, either during transit or early in the course of management.
Where is the proof that spinal immobilization even works?-Rogue Medic
Recently, the use of spinal immobilization for all trauma patients, particularly those with a low likelihood of traumatic cervical spinal injury has been questioned. It is unlikely that all patients rescued from the scene of an accident or site of traumatic injury require spinal immobilization.
OBJECTIVE: To examine the effect of emergency immobilization on neurologic outcome of patients who have blunt traumatic spinal injuries. METHODS: A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did. The 2 hospitals were comparable in physician training and clinical resources. Neurologic injuries were assigned to 2 categories, disabling or not disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as explanatory variables. RESULTS: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a less than 2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34). CONCLUSION: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.
OBJECTIVE: To determine whether EMS providers can accurately apply the clinical criteria for clearing cervical spines in trauma patients. METHODS: EMS providers completed a data form based on their initial assessments of all adult trauma patients for whom the mechanism of injury indicated immobilization. Data collected included the presence or absence of: neck pain/tenderness; altered mental status; history of loss of consciousness; drug/alcohol use; neurologic deficit; and other painful/distracting injury. After transport to the ED, emergency physicians (EPs) completed an identical data form based on their assessments. Immobilization was considered to be indicated if any one of the six criteria was present. The EPs and EMS providers were blinded to each other's assessments. Agreement between the EP and EMS assessments was analyzed using the kappa statistic. RESULTS: Five-hundred seventy-three patients were included in the study. The EP and EMS assessments matched in 78.7% (n = 451) of the cases. There were 44 (7.7%) patients for whom EP assessment indicated immobilization, but the EMS assessment did not. The kappa for the individual components of the assessments ranged from 0.35 to 0.81, with the kappa for the decision to immobilize being 0.48. The EMS providers' assessments were generally more conservative than the EPs'. CONCLUSION: EMS and EP assessments to rule out cervical spinal injury have moderate to substantial agreement. However, the authors recommend that systems allowing EMS providers to decide whether to immobilize patients should follow those patients closely to ensure appropriate care and to provide immediate feedback to the EMS providers.
OBJECTIVE: To determine whether paramedics can safely use a spinal clearance algorithm to reduce unnecessary spinal immobilization (SI) in the out-of-hospital setting. METHODS: Paramedics were instructed in the use of a spinal clearance algorithm that prompted assessment of the trauma patient's 1) level of consciousness, 2) drug and/or alcohol use, 3) loss of consciousness during the event, 4) presence of spinal pain/tenderness, 5) presence of neurologic deficit, 6) concomitant serious injury, or 7) presence of pain with range of motion. The algorithm indicated that if any of the above were present, the patient should receive full SI, and if all of the above were negative, then SI could be withheld. Paramedics completed a tracking form that included the above and followed the patient to the emergency department (ED). Data were then gathered to determine the presence of spinal fracture, neurologic deficit, or a combination of the two. To compare the trends for SI, a retrospective medical incident report (MIR) review was conducted from the previous year. MIRs were selected based on the same criteria as those used for study inclusion. RESULTS: Two hundred eighty-one patients were included in the study, with 65% (n = 183) of them receiving SI. Two hundred ninety-three MIRs were included in the retrospective sample, with SI being provided 95% (n = 288) of the time. Comparison of these samples shows a 33% reduction in utilization of SI (95% confidence interval: 27.2%- 38.8%). CONCLUSION: An out-of-hospital spinal clearance algorithm administered by paramedics can reduce SI by one-third. Any application of a spinal clearance algorithm should be accompanied by rigorous medical supervision.