Backboard usage by EMS is an important part of patient safety. It keeps the patient from injuring themselves or others within the confines of the ambulance or helicopter. But too much of anything is bad, and this is true of backboards as well. As little as 2 hours on a board can lead to skin breakdown. The most common reason that patients are not taken off boards sooner is concern for spine fractures. But the reality is that the board is not necessary once the patient arrives in the ED. If the spine is broken and they are admitted as an inpatient, they will be on log roll precautions on a regular hospital bed and mattress! I recommend that hospitals develop a policy for getting all patients off backboards as quickly as possible. The most convenient time is during the logroll to examine the back during the ATLS evaluation. Note: do not do a rectal exam during the logroll because this will cause the patient to wiggle more than you would like while they are up on their side. The goal should be to get the backboard removed within 20 minutes of patient arrival. I recommend placing a slider board under them if they will be visiting diagnostic areas like CT scan. But as soon as all studies are finished, pull the slider board as this can cause skin problems as well. Ideally, board removal should be documented, and this whole process can become a PI project.
IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.
But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.
This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC). During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line closed, there could be.
Scoop and run vs stay and play are traditionally EMS concepts. Do I stay at the scene to perform invasive procedures, or do I perform the minimum I can and get to the nearest hospital?
For trauma patients time is the enemy and there is a different flavor of scoop and run vs stay and play. Do I take the patient to a nearby hospital that is not a high level trauma center to stay and play, or do I scoop and run to the nearest Level I or II center?
Admissions to a group of 8 trauma centers were analyzed over a 3 year period. A total of 1112 patients were studied. Patients were divided into two groups: those who were taken directly to a Level I trauma center (76%), and those who were transferred from another hospital (24%).
Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!
Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculate that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.
Bottom line: this is an interesting paper, but there are a number of flaws that prevent us from mandating that all trauma patients should go directly to the trauma center. The authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?
A lot of work needs to be done to add detail to this work. In the meantime, we have to trust our experienced prehospital providers to determine who really needs to go to the closest appropriate center, and what that really is.
Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.
Oral endotracheal intubation is the gold standard when a field airway is needed. However, they are not always possible due to protocol, training, patient anatomy or specific injuries. To allow airway support in these situations, a number of techniques and devices have been developed. The problem is, do we really know which one(s) are best?
To try to answer this question, a huge meta-analysis of all the English literature with information on success rates for these techniques was carried out. Over 2000 papers were identified, and they were narrowed down to 35 studies involving over 10,000 patients.
The success rates that they identified were as follows:
The Bottom Line: The King airway has the highest success rate of the alternative airway devices, although there was less data available and the effectiveness of ventilation has not been worked out yet. The best percutaneous rescue airway was the surgical crich.
Reference: A Meta-Analysis of Prehospital Airway Control Techniques Part II: Alternative Airway Devices and Cricothyrotomy Success Rates. Prehospital Emergency Care 14(4):515-530, Oct-Dec 2010.
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