What do your protocols say about spinal immobilization for penetrating trauma?

[craig]

I can not see the points that anyone is making with regards to the question that started this post.

is this a bash kiwi exercise (I in for that......lol) but in reality what he can say at time is correct

the first post with the bracketed comment about A/NZ evidence based practice was a little out of line, thats how things progress

we all know of things we do that work but have NEVER been proven. so evedence based practice covers this abnomile.

I fail to see why a person that has been shot/ stabbed/ poked/ slapped/ prodded/ stuck required to be immobolised to a hard board with straps and head boxed if there is no evedence of spinal involvment

for the record, our protocol for penetrating trauma is as follows;

PENETRATING TRAUMA PROTOCOL T8

1. PROTOCOL F2 - including primary assessment (ABCDE)

2. ARREST HAEMORRHAGE

3. DO NOT REMOVE AN IMPALED OBJECT

* transport the patient with the object in situ. Occasionally, the protruding end of the object has to be cut off to allow easier transportation

* The only exception is an intra-cardiac object in a patient with cardiac arrest requiring external cardiac compressions if ressustation is commenced

4. Treat HYPOVOLAEMIA if present to the presence of a radial pulse

5. PAIN MANAGEMENT

6. TREAT SPECIFIC INJURIES

7. URGENT TRANSPORT is essential for all penetrating trauma excluding injuries to the hands and feet

8. Regular repeat and documnet ABCD physical examinations and physiological observations in order to identify trends in clinical deterioration

Mininise scene time and treat en-route. Do not give fliuds for penetrating trauma to the torso if the total times from call booked to arrival at hospital is likely to be less than 30 minutes

approved by Medical Director

maintained by Clinical Services

Revised Janurary 2012

[BEorP]

I can not see the points that anyone is making with regards to the question that started this post.

is this a bash kiwi exercise (I in for that......lol) but in reality what he can say at time is correct

the first post with the bracketed comment about A/NZ evidence based practice was a little out of line, thats how things progress

we all know of things we do that work but have NEVER been proven. so evedence based practice covers this abnomile.

I fail to see why a person that has been shot/ stabbed/ poked/ slapped/ prodded/ stuck required to be immobolised to a hard board with straps and head boxed if there is no evedence of spinal involvment

Thanks for your comments. I think that you may have taken my Aus/NZ comment a bit differently than I intended. My intent in the thread was to find out if there are places that still routinely do spinal immobilization for penetrating trauma, and obviously you guys would have moved beyond that. I don't mean to stifle the discussion, but there really is no question as to what is best for the patients (clearly there should be no routine spinal immobilization for penetrating trauma). Despite this, it still happens some places (whether written into the protocols explicitly or simply as the accepted practice) so I am just curious how prevalent it is and where it still happens.

[island emt]

3. DO NOT REMOVE AN IMPALED OBJECT

* transport the patient with the object in situ. Occasionally, the protruding end of the object has to be cut off to allow easier transportation

* The only exception is an intra-cardiac object in a patient with cardiac arrest requiring external cardiac compressions if ressustation is commenced."

Now the question begs to be asked: If you have a traumatic arrest due to penetrating trauma to the heart, WHY would you even try resuscitation ?????

BEOP: Our protocols have the leeway for us to determine how to package and transport any & all patients.

We have a evidence based selective spinal immobilization protocol. based of of over a decade of use from the original wilderness medicine protocol, on through the nexus study.

It has been tweaked a little over time but still pretty much what came out of woods 15 years ago.

[emtdennis]

Thanks, but would you also do spinal immobilization for penetrating trauma?

I should have known better to think that I could type a typo-free post sans glasses!

I would not do a spinal immobilization, no need for it where the spine is not compromised.

[Richard B the EMT]

OK, I'll be one of the first to admit I'm not usually involved with the research end of our business and that the only constant is change. As always, note one of my "mantras": "Follow your local protocols, as mine might be different from yours".

Current protocols might even have me LSB a suspected Shaken Baby Syndrome patient. Past protocols allowed application of Medical Anti Shock Trousers/Pneumatic Anti Shock Garments, until modifications were instituted following Brian Watkins dying from complications to a penetrating chest wound (stabbed in the chest during a mugging) caused by the application of the MAST.

Massive bleeding from extremities used to be treated by tourniquet. Protocols changed to use them in cases between "loss of limb versus loss of life", Now, protocols are again changing, as to when to use them.

However, the use of tourniquets is heavy in the military, but civilian usage usually follows military discoveries. I'll have to wait until NY State DoH first authorizes Pilot Programs, and my agency is involved in that pilot program.

I would love not having to apply the LSB to as many current types of MOI as I do, or use a "scoop" instead of an LSB, However, I follow protocols, until the new protocols are implemented, then, I follow protocols.I admit I may think outside the box, but cannot act until the powers that be, change the box for me.

Edited for spelling corrections

Edited July 11, 2012 by Richard B the EMT

[craig]

Now the question begs to be asked: If you have a traumatic arrest due to penetrating trauma to the heart, WHY would you even try resuscitation ?????

the Question could also be "Why WOULDN'T you?".................isnt hypovolaemia a reversible casue of death? can we amend that is some way, until definitve care is given (surgery) that is why it is an URGENT transport situation.......beside, how often will this happen.............

[island emt]

Craig: Not picking on you personally.

But in a traumatic arrest with penetrating or impaled through the heart, unless you happen to be in the trauma center parking lot and the thoracic surgical team is waiting & ready to go, then the odds of survivability are not going to be good .

Survivability from traumatic arrest is very low.

Yes we can replace fluids, but how many services carry whole blood ? Packed cells Ever tried to do chest compressions on a GSW to the heart? All you get is a fountain of blood with every compression.replacing all that lost blood with colloids is not going to change the inevitable outcome.

yes we can pack the wound, but you still need to fix the penetration and thats one thing thats not in anyones protocol to my knowledge.

[craig]

^{Craig: Not picking on you personally.}

^{But in a traumatic arrest with penetrating or impaled through the heart, unless you happen to be in the trauma center parking lot and the thoracic surgical team is waiting & ready to go, then the odds of survivability are not going to be good .}

^{Survivability from traumatic arrest is very low.}

^{Yes we can replace fluids, but how many services carry whole blood ? Packed cells Ever tried to do chest compressions on a GSW to the heart? All you get is a fountain of blood with every compression.replacing all that lost blood with colloids is not going to change the inevitable outcome.}

^{yes we can pack the wound, but you still need to fix the penetration and thats one thing thats not in anyones protocol to my knowledge.}

^{all true, but does not the patient deserve the best chance of survival? do we attempt to sustain life or just do nothing?...... what happens if the patient has been stabbed in the heart and the object is the thing plugging the wound before they goe in to CA...they were alive when you started treatment on them, do you just now stop?}

^{What to do you tell the parents of a 12 yo shooting victim, that their child was only seconds ago alive but now they have arrested,,stiff luck they are now dead......makes a mockery of everything we attempt to teach the public about early access defib and CPR then dont it....}

^{I agree, unless i in in the corridore outside the OT, the outcome is not high, but that is not a reason for NOT attempting some sort of resusitation.}

[island emt]

Yes you can do a make you feel good show and pat yourself on the back, BUT in the end it was a useless attempt at trying to reverse a fatal injury.

A case in point : high speed motor vehicle crash. When I arrived on scene there were folks trying to do CPR on the driver. I made everyone stop and look at the scene. The drivers brain matter was all over the house into which he had crash landed.

They felt good because they could say " We did everything possible?

In reality they abused a corpse and screwed up a crime scene.

edit to add

Injuries incompatible with life is a term that needs to be thought about..

Edited July 12, 2012 by island emt

[BushyFromOz]

Yes you can do a make you feel good show and pat yourself on the back, BUT in the end it was a useless attempt at trying to reverse a fatal injury.

A case in point : high speed motor vehicle crash. When I arrived on scene there were folks trying to do CPR on the driver. I made everyone stop and look at the scene. The drivers brain matter was all over the house into which he had crash landed.

They felt good because they could say " We did everything possible?

In reality they abused a corpse and screwed up a crime scene.

edit to add

Injuries incompatible with life is a term that needs to be thought about..

Not all injuries with high mortality are incompaitble with life.

In this case exsanguination, PEA, cardiac tamponade or any other aetilogy you can come up with that involves penetrating thoracic trauma is not unmanagable, and not all penetrating trauma is going to skewer your ticker, or obliterate your left ventricle

Your making a lot of assumptions about underlying tissue/organ damage that you most likely can't see.

The example of your MCA and brain matter everywhere is not a real apples to apples comparison

just sayin

Edited July 13, 2012 by BushyFromOz