Scoop and Run

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
pseudoknot said:
I believe several clinical trials are underway or will be soon on therapeutic hypothermia for cardiac arrest in the field, including one at my school. It's a pretty exciting area, and there are a lot of details on how, when, and how much to cool that remain to be worked out. There's an interesting web site (not from my school) here:
http://www.med.upenn.edu/resuscitation/hypothermia/
Click to expand...
Logistically how do they do it? What are the criteria for a patient to be a candidate for it?
Members don't see this ad.
 
docB said:
Logistically how do they do it? What are the criteria for a patient to be a candidate for it?
Click to expand...
I believe they are going to be testing a new device that sprays aerosolized fluorocarbons in the sinuses and is supposed to be able to bring the brain to target temperature in under five minutes (if I remember correctly--this talk was a few months ago). Most other cooling methods take one or more hours, so in theory (& in lab animals) this could make a big difference. They would also carry cooled IV fluids on the ambulances.

I don't know the details of the protocol, but will try to find out. My guess is that it would have to be cardiac arrests witnessed by EMS at a minimum.
 
Members don't see this ad :)
Pseudoknot - My apologies if it has already been posted elsewhere, but do you have a link to the LAC+USC study you mentioned in your first few posts? This study was also referenced in my PHTLS class last year (much to the annoyance of the EMTs/medics in attendance) but I wasn't able to acquire the actual article. Thanks for your help.
 
I'm doing internal med right now, and I get the impression that permissive hypothermia will be the standard of care sometime within our careers. It pops up with enough regularity. I just found it again, in the ACP board review. Keep your eyes peeled.
 
howelljolly said:
I'm doing internal med right now, and I get the impression that permissive hypothermia will be the standard of care sometime within our careers. It pops up with enough regularity. I just found it again, in the ACP board review. Keep your eyes peeled.
Click to expand...

I hadn't heard the term "permissive hypothermia" before--was that a typo? It's an odd phrase since the hypothermia is usually actively induced. Anyway, I'm sure you're right, as it's already in the ACLS guidelines. My guess is that rapid cooling started in the field could make a bigger difference in preventing brain injury, and once that is worked out it should be widely adopted (albeit with the huge inertial time lag typical of medicine and EMS).
 
pseudoknot said:
I hadn't heard the term "permissive hypothermia" before--was that a typo? It's an odd phrase since the hypothermia is usually actively induced. Anyway, I'm sure you're right, as it's already in the ACLS guidelines. My guess is that rapid cooling started in the field could make a bigger difference in preventing brain injury, and once that is worked out it should be widely adopted (albeit with the huge inertial time lag typical of medicine and EMS).
Click to expand...


Yep... typo.... therapeutic hypothermia....
 
I completed the AHA 2010 guidelines instructor science update for BLS and ACLS last week. ACLS now has an entire module on post-resuscitation care (ROSC) in the adult patient. Induced hypothermia is now on the new post-resuscitation care algorithms and the AHA science journal "circulation" has a specific section on the concept of "induced hypothermia."

http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S768

Anecdotally, I have started to see even some of the small, outlying facilities in my area begin to employ induced hypothermia techniques following ROSC.
 
docB said:
Still doing research. Bumping this because it's the greatest thread ever on the EMS forum.
Click to expand...

Wow, this takes me back. I was about three months into my M1 year when I started this thread. So much has changed. And the largest local EMS agency here still does full spinal immobilization on GSWs. Sigh.
 
Members don't see this ad :)
pseudoknot said:
Wow, this takes me back. I was about three months into my M1 year when I started this thread. So much has changed. And the largest local EMS agency here still does full spinal immobilization on GSWs. Sigh.
Click to expand...

GSWs where? Anything other than isolated extremity penetrating trauma needs full spinal immobilization.
 
FiremedicMike said:
GSWs where? Anything other than isolated extremity penetrating trauma needs full spinal immobilization.
Click to expand...

No thanks. Full immobilization needs to go the way of the dinosaur in my opinion anyways. Several studies show it has no benefit and may even be harmful. Luckily I can clear and pretty much the only time I get the damn things out is to help move people who are dead weight (they are awesome for that).

Here, here, and here.
 
FiremedicMike said:
GSWs where? Anything other than isolated extremity penetrating trauma needs full spinal immobilization.
Click to expand...

Not if you want your patient to live. The NNT for this in penetrating trauma is about 1100, number needed to harm is about 65. I'm too tired to find the reference but it's out there and if no one else can dig it up I'll post it after my ICU rotation is over.

The bottom line is that it's very rare for GSWs to cause neurologic injury unless the person was obviously shot in the spine, and even then the damage is pretty much done and immobilization isn't going to do any good. On the other hand it takes valuable scene time from these patients who need to go to the OR.

edit: akinsje posted the paper I was thinking of and others above, but his links won't work outside his school. Here they are:

http://www.ncbi.nlm.nih.gov/pubmed/20065766
J Trauma. 2010 Jan;68(1):115-20; discussion 120-1.
Spine immobilization in penetrating trauma: more harm than good?
In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine immobilization. Overall mortality was 8.1%. Unadjusted mortality was twice as high in spine-immobilized patients (14.7% vs. 7.2%, p < 0.001). The odds ratio of death for spine-immobilized patients was 2.06 (95% CI: 1.35-3.13) compared with nonimmobilized patients. Subset analysis showed consistent trends in all populations. Only 30 (0.01%) patients had incomplete spinal cord injury and underwent operative spine fixation. The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.

CONCLUSIONS:
Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma.


http://www.ncbi.nlm.nih.gov/pubmed/19820585

J Trauma. 2009 Oct;67(4):774-8.
Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso.
RESULTS: Three hundred fifty-seven subjects from SMH and 75,210 from NTDB were included. A total of 9.2% of SMH subjects and 4.3% of NTDB subjects had spine injury, with 51.5% of SMH subjects and 32.3% of NTDB subjects having SCI. No SMH subject had an unstable spine fracture requiring surgical stabilization without complete neurologic injury. No subjects with SCI improved or worsened, and none developed a new deficit. Twenty-six NTDB subjects (0.03%) had spine fractures requiring stabilization in the absence of SCI. Emergent intubation was required in 40.6% of SMH subjects and 33.8% of NTDB subjects. Emergent surgical intervention was required in 54.5% of SMH subjects and 43% of NTDB subjects.

CONCLUSIONS:
Our data suggest that the benefit of PHSI in patients with torso GSW remains unproven, despite a potential to interfere with emergent care in this patient population. Large prospective studies are needed to clarify the role of PHSI after torso GSW.


http://www.ncbi.nlm.nih.gov/pubmed/9523928

Acad Emerg Med. 1998 Mar;5(3):214-9.
Out-of-hospital spinal immobilization: its effect on neurologic injury.
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 <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.
 
FiremedicMike said:
GSWs where? Anything other than isolated extremity penetrating trauma needs full spinal immobilization.
Click to expand...

Unfortunately, as already stated, spending time on a long board, especially prolonged amounts of time are associated with outcomes that are less than optimal. Even more concerning is the fact that this information is not all that new, yet it still continues to be common practice among many EMS services.
 
Alright, here's my take.

I fully agree with the idea that most of the time, full spinal immobilization is overkill. I am rather lenient on low impact scenarios like minor car crashes and falls. I also accept that many times, penetrating injury will not result in a spinal cord injury. The idea that I'm not willing to accept is that penetrating injuries never result in spinal cord injuries. I'm not willing to gamble my career on a situation where there is a potential for spinal cord injury, especially when full spinal immobilization is the accepted standard of care (and has been for decades).
 
Last edited:
FiremedicMike said:
Alright, here's my take.

I fully agree with the idea that most of the time, full spinal immobilization is overkill. I am rather lenient on low impact scenarios like minor car crashes and falls. I also accept that many times, penetrating injury will not result in a spinal cord injury. The idea that I'm not willing to accept is that penetrating injuries never result in spinal cord injuries. I'm not willing to gamble my career on a situation where there is a potential for spinal cord injury, especially when full spinal immobilization is the accepted standard of care (and has been for decades).
Click to expand...

Nobody's going to yell at you for following your protocols. (Well, except for that CPR with NRM in place deal DocB mentioned in another thread.) When it comes down to a lot of issues like this, when you're working on the front lines, the decision's already been made about what's appropriate by your medical director. Much as we try to practice evidence-based or science-based medicine, lawsuit-based medicine is the current standard of care, and it's an uphill battle to change that. All you can do is lobby your medical director if you want to see things change.

I have, in the past, used a long board more for the transfer convenience from ground to cart than as an actual immobilization device in some kinds of trauma. Our ER docs were pretty fast to take people off the board when we hit the ED, so the bedsore problem wasn't much of an issue.

It was only in the major trauma situations (isolated chest injury with bad vitals) with the surgery team leading the show that we really got grilled about immobilization; but I think that was a few years ago. They stuck to the ATLS script, so if that hasn't changed since then, neither has their care.
 
I presented my point with a bit too much of an emphasis on the protocol and standard of care. I do see value in spinal immobilization to penetrating chest/abd trauma. I cannot look at a penetrating injury and tell with any certainty that there is or is not a spinal cord injury associated with that injury. Regardless of whether or not the damage is already done, if someone does have a spinal cord injury, I'd prefer they not move around and potentially make it worse.

Isolated chest trauma with bad vitals, you betcha that guy could have a spinal cord injury, and I'm not going to roll the dice and take the chance that he's not. I'm not sure why the surgical team crawled up in you for that, do they really think the 3 minutes it took you to immobilize the patient would have made any difference in the long run? 3 minutes is the difference between driving lights and sirens during rush hour traffic compared to 0300..

On that note, the original response I typed had pointed out that the 3 minutes (which to be honest is a stretch, it really doesn't take long to slap on a collar and roll someone onto a backboard) taken to immobilize is not an exclusive time period where all efforts are being focused on immobilization. Personally I am continuing my initial/ongoing assessment and formulating my plan. Others are in the back of the truck getting stuff ready, and others are thumb wrestling over who's driving us to the hospital.
 
The inherent problem with the above listed studies, as well as similar studies which tend to show "higher mortality rates with EMS intervention" is that they don't compare apples to apples. You aren't looking at identical patients with identical injuries, identical past medical histories, and identical mitigating factors, then having one transported with full spinal immobilization and one without. All you have is a chunk of patients with unspecified penetrating chest trauma, some of them were backboarded, some where not.

As an alternative perspective to that study, I would presume that the group of patients who were not backboarded did not present nearly as poorly as the group that was backboarded. It's been my experience that patients with penetrating chest trauma look quite a bit worse when the injuries are more significant (obviously). These patients, who were backboarded because they presented to EMS in poor condition, likely had more significant internal injuries and a higher likelihood of death than the group that was not. In the end, I find it somewhat rash and irresponsible to correlate their death with full spinal immobilization.

I actually find the figure of 1 in 1000 to be quite a bit higher than I expected (I expected around 1/10:000+) and to be honest that only furthers my point. Can you honestly look at a patient and tell me that you aren't that 1 in 1000? I'm not going to stake their long term well being on the theory of saving 3 minutes. I am in a bit of a rush to get to the store or I would search deeper for the total number of penetrating chest/abd injuries over the last 10 years, but I would imagine based on the 1/1000 figure you listed, there are likely several thousand people over that period of time who can attribute their spinal cord well-being to full-spinal immobilization. That's really all the evidence I need.
 
FiremedicMike said:
The inherent problem with the above listed studies, as well as similar studies which tend to show "higher mortality rates with EMS intervention" is that they don't compare apples to apples. You aren't looking at identical patients with identical injuries, identical past medical histories, and identical mitigating factors, then having one transported with full spinal immobilization and one without. All you have is a chunk of patients with unspecified penetrating chest trauma, some of them were backboarded, some where not.

As an alternative perspective to that study, I would presume that the group of patients who were not backboarded did not present nearly as poorly as the group that was backboarded. It's been my experience that patients with penetrating chest trauma look quite a bit worse when the injuries are more significant (obviously). These patients, who were backboarded because they presented to EMS in poor condition, likely had more significant internal injuries and a higher likelihood of death than the group that was not. In the end, I find it somewhat rash and irresponsible to correlate their death with full spinal immobilization.

I actually find the figure of 1 in 1000 to be quite a bit higher than I expected (I expected around 1/10:000+) and to be honest that only furthers my point. Can you honestly look at a patient and tell me that you aren't that 1 in 1000? I'm not going to stake their long term well being on the theory of saving 3 minutes. I am in a bit of a rush to get to the store or I would search deeper for the total number of penetrating chest/abd injuries over the last 10 years, but I would imagine based on the 1/1000 figure you listed, there are likely several thousand people over that period of time who can attribute their spinal cord well-being to full-spinal immobilization. That's really all the evidence I need.
Click to expand...

Assuming full spinal immobilisation would have prevented additional problems and/or exacerbations of the underlying injury and assuming spinal immobilisation did not cause other problems...
 
My problem with your argument is that it comes from a perspective that full immobilization is a good thing, i.e. missing that 1 in 1000 will cause them a bad outcome, but the research just doesn't show that. It shows no difference in outcomes (even for those found to have an injury) or increased morbidity/mortality.
 
atkinsje said:
My problem with your argument is that it comes from a perspective that full immobilization is a good thing, i.e. missing that 1 in 1000 will cause them a bad outcome, but the research just doesn't show that. It shows no difference in outcomes (even for those found to have an injury) or increased morbidity/mortality.
Click to expand...

You really believe anyone with an incomplete spinal cord injury should NOT be placed into full spinal immobilization?
 
pseudoknot said:
Absolutely. Show me any evidence that it's a helpful intervention even for unstable injuries.

The collar, maybe. The rest is a rain dance.
Click to expand...

On a side note, I didn't say it was a cervical spine injury <shrug>

Look I'm not trying to be argumentative or confrontational, but I've yet to see (and likely won't, due to the nature of medicine) anything that definitively says that full spinal immobilization is harmful, but we should be able to assume it's helpful in the scenario of a partial spinal injury.

I find the studies you listed, and the ones like them, to be lacking. To grossly simplify these types of studies, we'll do this

Patient A has a penetrating chest injury and was placed in full spinal immobilization before transport, Patient A died
Patient B has a penetrating chest injury and was not placed in full spinal immobilization before transport, Patient B survived

Conclusion - full spinal immobilization was harmful for patient A

likewise,

Patient A had a gunshot wound and was transported by EMS to the hospital and died
Patient B had a gunshot wound and was transported by private auto, Patient B survived

Conclusion - transport by EMS was detrimental to patient A.

Certainly you can see the fault to these studies when they become simplified?


Again, I'm really enjoying this debate, and I'm not trying to argue just to argue.
 
Do not oversimplify your conclusions then. Many of the good studies do not in fact say that immobilisation was "absolutely" harmful. Often you will see works such as "associated with increased mortality and so on..." Also, you need to look into the data a bit further and you will often find that the statistics are often adjusted and take many factors into consideration. You can also get a better feel for the data if it has been generally reproduced in other studies, has been peer reviewed and you have a decent understanding of basic statistics such as N versus n, confidence intervals, standard deviations and so on. The conclusions are rarely as simple as you stated.
 
I actually do understand basic statistics, although I never learned of an N vs n, mind explaining?
 
Ah, ok we're on the same page again.. Sorry stats was 6 months ago and I've forgotten some of it..
 
FiremedicMike said:
I actually find the figure of 1 in 1000 to be quite a bit higher than I expected (I expected around 1/10:000+) and to be honest that only furthers my point. Can you honestly look at a patient and tell me that you aren't that 1 in 1000?
Click to expand...
I think the point being made by others here is that in the other 999 people you are causing needless harm and in the 1/1000 you probably aren't changing the outcome with full spinal immobilization anyway. It's an issue of weighing the risks against the benefits.
 
You must log in or register to reply here.
Next unread thread

Similar threads

leviathan
Scoop and run in your area
Replies
2
Views
1K
TarHeelEMT
TarHeelEMT
Top