Curr Opin Crit Care. 2002 Dec;8(6):566-70.
Spinal immobilization in trauma patients: is it really necessary?
The acute management of potential spinal injuries in trauma patients is undergoing radical reassessment. Until recently, it was mandatory that nearly all trauma patients be immobilized with a back board, hard cervical collar, head restraints, and body strapping until the spine could be cleared radiologically. This practice is still recommended by many references. It is now clear that this policy subjects most patients to expensive, painful, and potentially harmful treatment for little, if any, benefit. Low-risk patients can be safely cleared clinically, even by individuals who are not physicians. Patients at high risk for spinal instability should be removed from the hard surface to avoid tissue ischemia. Understanding the rationale for these changes requires knowledge of mechanisms of injury, physiology, and biomechanics as they apply to spinal injuries.
JAMA. 2002 Dec 18;288(23):3035-8.
- Comment on:
- JAMA. 2002 Dec 18;288(23):3008-13.
Resuscitation after cardiac arrest: a 3-phase time-sensitive model.
Department of Medicine, Johns Hopkins University, Baltimore, Md, USA.
Acad Emerg Med. 2001 Jul;8(7):758-60.
The golden hour: scientific fact or medical "urban legend"?
The term "golden hour" is commonly used to characterize the urgent need for the care of trauma patients. This term implies that morbidity and mortality are affected if care is not instituted within the first hour after injury. This concept justifies much of our current trauma system. However, definitive references are generally not provided when this concept is discussed. It remains unclear whether objective data exist. This article discusses a detailed literature and historical record search for support of the "golden hour" concept. None is identified.
Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.Moore C, Woollard M.
OBJECTIVE: To investigate whether 10% dextrose given in 5 g (50 ml) aliquots is more effective than 50% dextrose given in 5 g (10 ml) aliquots in the treatment of out of hospital hypoglycaemia. DESIGN: Randomised controlled trial. SETTING: Out of hospital patients attended by paramedics from a large UK ambulance service. PARTICIPANTS: 51 unresponsive adult patients with blood glucose levels < or = 4 mmol/l. INTERVENTION: 5 g (50 ml) intravenous aliquots of 10% dextrose or 5 g (10 ml) intravenous aliquots of 50% dextrose to a maximum dose of 25 g. MAIN OUTCOME MEASURES: To compare for each dextrose concentration the time to achieve a Glasgow Coma Scale (GCS) score of 15, and the dose required to obtain a blood glucose level of > or = 4.5 mmol/l. RESULTS: There were no statistically significant differences between the groups with regard to age or sex, median pretreatment GCS, pretreatment blood glucose level, or proportion of patients with insulin dependent diabetes. Following treatment, there were no statistically significant differences in median time to recovery (8 minutes), median post-treatment GCS, or number of subjects experiencing a further hypoglycaemic episode within 24 hours (four per group). The median total dose of dextrose administered was significantly less with the 10% concentration (10% = 10 g, 50% = 25 g, p < 0.001) and median post-treatment blood sugar levels were also significantly lower (10% = 6.2 mmol/l and 50% = 9.4 mmol/l, p = 0.003). There were no reports of extravasation injuries in either group. CONCLUSIONS: Dextrose 10% delivered in 5 g (50 ml) aliquots is administered in smaller doses than dextrose 50% delivered in 5 g/10 ml aliquots, resulting in lower post-treatment blood glucose levels. We therefore recommend it as the intravenous treatment of choice for adult hypoglycaemia.
PMID: 15983093 [PubMed - indexed for MEDLINE]
Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest.Ong ME, Tan EH, Ng FS, Panchalingham A, Lim SH, Manning PG, Ong VY, Lim SH, Yap S, Tham LP, Ng KS, Venkataraman A; Cardiac Arrest and Resuscitation Epidemiology Study Group.
STUDY OBJECTIVE: The benefit of epinephrine in cardiac arrest is controversial and has not been conclusively shown in any human clinical study. We seek to assess the effect of introducing intravenous epinephrine on the survival outcomes of out-of-hospital cardiac arrest patients in an emergency medical services (EMS) system that previously did not use intravenous medications. METHODS: This observational, prospective, before-after clinical study constitutes phase II of the Cardiac Arrest and Resuscitation Epidemiology project. Included were all patients who are older than 8 years, with nontraumatic out-of-hospital cardiac arrest conveyed by the national emergency ambulance service. The comparison between the 2 intervention groups for survival to discharge was made with logistic regression and expressed in terms of the odds ratio (OR) and the corresponding 95% confidence interval (CI). RESULTS: From October 1, 2002, to October 14, 2004, 1,296 patients were enrolled into the study, with 615 in the pre-epinephrine and 681 in the epinephrine phase. Demographic and EMS characteristics were similar in both groups. Forty-four percent of patients received intravenous epinephrine in the epinephrine phase. There was no significant difference in survival to discharge (pre-epinephrine 1.0%; epinephrine 1.6%; OR 1.7 [95% CI 0.6 to 4.5]; adjusted for rhythm OR 2.0 [95% CI 0.7 to 5.5]); return of circulation (pre-epinephrine 17.9%; epinephrine 15.7%; OR 0.9 [95% CI 0.6 to 1.2]), or survival to admission (pre-epinephrine 7.5%; epinephrine 7.5%; OR 1.0 [95% CI 0.7 to 1.5]). There was a minimal increase in scene time in the epinephrine phase (10.3 minutes versus 10.7 minutes; 95% CI of difference 0.02 to 0.94 minutes). CONCLUSION: We were unable to establish a significant survival benefit with the introduction of intravenous epinephrine to an EMS system. More research is needed to determine the effectiveness of drugs such as epinephrine in resuscitation.
PMID: 17509730 [PubMed - indexed for MEDLINE]
The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system.Shatney CH, Homan SJ, Sherck JP, Ho CC.
Department of Surgery, Stanford University School of Medicine and Santa Clara Valley Medical Center, San Jose, California 95128, USA.
BACKGROUND: Continuing controversy surrounding the value of scene helicopter evacuation of urban trauma victims led to the present study. METHODS: A retrospective review was performed of all patients brought to our trauma center from the injury scene by helicopter from 1990 to 2001. RESULTS: The study included 947 consecutive patients, 911 with blunt trauma and 36 with penetrating injuries. The mean Injury Severity Score (ISS) was 8.9. Fifteen patients died in the emergency department, 312 patients (33.5%) were discharged home from the emergency department (mean ISS, 2.7), and 620 patients were hospitalized (mean ISS, 11.4). Three hundred thirty-nine of the hospitalized patients (54.7%) had an ISS < or = 9; 148 patients had an ISS > or = 16. Eighty-four patients (8.9%) required early operation, mostly for open extremity fractures; only 17 patients (1.8%) underwent surgery for immediately life-threatening injuries. For 54.7% of the patients, the helicopter was judged to be clearly faster than would have been possible by ground transport. In 140 additional patients (14.8%) with prolonged scene time, the helicopter was probably faster than ground ambulance. Considering faster transport time and either the need for early operation or hospitalization with an ISS > or = 9 as advantageous, a maximum of 22.8% of the study population possibly benefited from helicopter transport. CONCLUSION: The helicopter is used excessively for scene transport of trauma victims in our metropolitan trauma system. New criteria should be developed for helicopter deployment in the urban trauma environment.
PMID: 12435928 [PubMed - indexed for MEDLINE]
Occupational fatalities in emergency medical services: a hidden crisis.Maguire BJ, Hunting KL, Smith GS, Levick NR.
STUDY OBJECTIVE: We estimate the occupational fatality rate among emergency medical services (EMS) personnel in the United States. METHODS: We undertook descriptive epidemiology of occupational fatalities among EMS providers. Analysis was conducted by using data from 3 independent fatality databases: the Census of Fatal Occupational Injuries (1992 to 1997), the National EMS Memorial Service (1992 to 1997), and the National Highway Traffic Safety Administration's Fatality Analysis Reporting System (1994 to 1997). These rates were compared with the occupational fatality rates of police and firefighters and with the rate of all employed persons in the United States. RESULTS: The Census of Fatal Occupational Injuries database documented 91 EMS provider occupational fatalities. The National EMS Memorial Service database contained 70 fatalities, and the Fatality Analysis Reporting System identified 8 ground-transportation EMS occupational fatalities. There was also wide variation in fatality counts by cause of injury. Using the highest cause-specific count from each of the databases, we estimate that there were at least 67 ground transportation-related fatalities, 19 air ambulance crash fatalities, 13 deaths resulting from cardiovascular incidents, 10 homicides, and 5 other causes, resulting in 114 EMS worker fatalities during these 6 years. We estimated a rate of 12.7 fatalities per 100,000 EMS workers annually, which compares with 14.2 for police, 16.5 for firefighters, and a national average of 5.0 during the same time period. CONCLUSION: This study identifies an occupational fatality rate for EMS workers that exceeds that of the general population and is comparable with that of other emergency public service workers.PMID: 12447340 [PubMed - indexed for MEDLINE
The ideal tool for decorators: a novel use for disposable laryngoscope blades.Green RJ, Pierce JM.
Southampton General Hospital, Southampton SO16 6YD.PMID: 17185714 [PubMed - indexed for MEDLINE
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.Smith GC, Pell JP.
OBJECTIVES: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. Design Systematic review of randomised controlled trials. DATA SOURCES: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists. STUDY SELECTION: Studies showing the effects of using a parachute during free fall. MAIN OUTCOME MEASURE: Death or major trauma, defined as an injury severity score > 15. RESULTS: We were unable to identify any randomised controlled trials of parachute intervention. CONCLUSIONS: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.PMID: 16602356 [PubMed
Study of the Therapeutic Effects of Intercessory Prayer (STEP) in cardiac bypass patients: a multicenter randomized trial of uncertainty and certainty of receiving intercessory prayer.Benson H, Dusek JA, Sherwood JB, Lam P, Bethea CF, Carpenter W, Levitsky S, Hill PC, Clem DW Jr, Jain MK, Drumel D, Kopecky SL, Mueller PS, Marek D, Rollins S, Hibberd PL.
BACKGROUND: Intercessory prayer is widely believed to influence recovery from illness, but claims of benefits are not supported by well-controlled clinical trials. Prior studies have not addressed whether prayer itself or knowledge/certainty that prayer is being provided may influence outcome. We evaluated whether (1) receiving intercessory prayer or (2) being certain of receiving intercessory prayer was associated with uncomplicated recovery after coronary artery bypass graft (CABG) surgery. METHODS: Patients at 6 US hospitals were randomly assigned to 1 of 3 groups: 604 received intercessory prayer after being informed that they may or may not receive prayer; 597 did not receive intercessory prayer also after being informed that they may or may not receive prayer; and 601 received intercessory prayer after being informed they would receive prayer. Intercessory prayer was provided for 14 days, starting the night before CABG. The primary outcome was presence of any complication within 30 days of CABG. Secondary outcomes were any major event and mortality. RESULTS: In the 2 groups uncertain about receiving intercessory prayer, complications occurred in 52% (315/604) of patients who received intercessory prayer versus 51% (304/597) of those who did not (relative risk 1.02, 95% CI 0.92-1.15). Complications occurred in 59% (352/601) of patients certain of receiving intercessory prayer compared with the 52% (315/604) of those uncertain of receiving intercessory prayer (relative risk 1.14, 95% CI 1.02-1.28). Major events and 30-day mortality were similar across the 3 groups. CONCLUSIONS: Intercessory prayer itself had no effect on complication-free recovery from CABG, but certainty of receiving intercessory prayer was associated with a higher incidence of complications.
PMID: 16569567 [PubMed - indexed for MEDLINE]