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… 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

15. 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

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 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

25. Questions