Controversies in rescue Tony Smith, Medical Director, St John

1. Controversies in rescue Tony Smith, Medical Director, St John

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. A new procedure

9. A new procedure

10. A new procedure

11. A new procedure

12. 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

13. 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

14. The golden hour • Unfortunately not true… • 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

15. The golden hour • What this means in practice • 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

16. 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

17. 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

18. 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?

19. 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

20. 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

21. 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

22. Tourniquets

23. 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

24. Summary • Cervical spine immobilisation • 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

25. Questions