Ace844

Hello Everyone, Since this has turned into an interesting debate, here's another study with a similar view point to throw in the mix... (Air Medical Journal Volume 25 @ Issue 4 , July-August 2006, Pages 165-169 doi:10.1016/j.amj.2006.04.002 Copyright © 2006 Air Medical Journal Associates Published by Mosby, Inc. Original Research Disagreement between transport team and ED staff regarding the prehospital assessment of air medically evacuated scene patients John P. Benner NREMT-Pa, b, Genevieve Brauning MDa, Mike Green RNc, Wendy Caldwell RNc, Matthew P. Borloz EMT-Ia, b and William J. Brady MDa, b, , aDepartment of Emergency Medicine, University of Virginia Health System, Charlottesville, VA bCharlottesville-Albemarle Rescue Squad, Charlottesville, VA cPegasus Aeromedical Flight Operations, Department of Emergency Medicine, University of Virginia Health System, Charlottesville, VA Available online 1 July 2006.) Original Research Disagreement between transport team and ED staff regarding the prehospital assessment of air medically evacuated scene patients John P. Benner NREMT-Pa, b, Genevieve Brauning MDa, Mike Green RNc, Wendy Caldwell RNc, Matthew P. Borloz EMT-Ia, b and William J. Brady MDa, b, , aDepartment of Emergency Medicine, University of Virginia Health System, Charlottesville, VA bCharlottesville-Albemarle Rescue Squad, Charlottesville, VA cPegasus Aeromedical Flight Operations, Department of Emergency Medicine, University of Virginia Health System, Charlottesville, VA Available online 1 July 2006. Abstract Study objective To determine the rate of disagreement in assessment of significant illness or injury between air medical transport team assessment and emergency department (ED) diagnosis in patients transferred from the scene of an incident to the ED. Methods Retrospective analysis was performed on 84 patients transported by medical flight teams from an accident scene to an ED. Results Results show transport team assessment concurred with ED diagnosis 96.7% of the time; most of the differences in assessment were overassessments by the transport team. Assessment differences occurred most often for abdominal injuries and least often for head injuries. Underassessment occurred most often for spinal cord injuries. Conclusions Despite the numerous difficulties involved in patient assessment, data show that the transport teams accurately evaluated patients in most instances. Disagreements in assessment of injury/illness most often were overassessments. Article Outline Introduction Methods Head Spine Chest/airway Abdomen Musculoskeletal Cardiovascular Discussion Conclusion References Introduction In 1967, the use of emergency air medical transport was extended from the Asian battlefields of Vietnam to the streets of the United States.1 Over the past 30 years, emergency air transport has evolved extensively from its military beginnings. Undeniably, the rotor- and fixed-wing aircraft have increasingly been supplied with advanced medical equipment and specialized personnel.2 and 3 These specialized practitioners, who are typically trained in critical care, have extensive experience in emergency medicine and operate under advanced medical protocols. Depending on the flight program, some of these protocols include such skills as rapid sequence intubation, pericardiocentesis, and thrombolysis of suspected acute myocardial infarction. Because of the advanced nature of these treatment options, use depends heavily on early recognition and accurate prehospital patient assessment. Accurate assessment by the transport team is vital in determining injuries/illness type and expediting treatment. Thus, patient assessment remains an integral yet challenging function of the medical transport team. Unfortunately, the circumstances of an emergency incident often limit time, space, light, and other factors needed for accurate evaluation.4 The absence of a controlled environment can hinder the accuracy of prehospital patient assessment and result in a diagnosis that disagrees with that of the emergency department (ED) staff. Only two previous studies have been published addressing the agreement of the flight team's patient assessment with the diagnosis of the ED staff; these studies rate the accuracy of the prehospital assessment at 89.4% and 75.2%.2 and 4 By comparing the transport team's assessment with that of the ED, we hope to gain insight into the areas in which flight personnel may benefit from additional education and clinical training. Methods The medical records of 84 patients transported from an incident location by medical helicopter to the University of Virginia Emergency Department were reviewed retrospectively. Patients transported by flight from another hospital were not included in the study. The University of Virginia ED is a Level 1 Trauma Center that serves approximately 60,000 patients a year. Transport team members consisted of either two flight nurses or a flight nurse and a flight paramedic. The average patient age was 38 years; 18 of the 84 patients (27.6%) were transported for medical problems, whereas 65 (72.4%) were transported for traumatic injury. Patient medical records were evaluated, noting the transport teams' assessment and the final ED diagnosis. Injuries were categorized into head, spine, chest/airway, abdomen, musculoskeletal system, and cardiovascular system (Figure 1). Any disagreement between the transport team's assessment and that of the ED was categorized as a difference. If the transport team indicated an actual or potential injury or illness that was not found by the ED, this difference was marked “overassessment,” whereas any injury/illness found by the ED and not noted by the transport team was marked “underassessment.” (12K) Figure 1. Data collection sheet for injury/illness classification by body system Eighty-four patients met entry criteria for air medical transport from an incident scene to the ED. The transport team's assessment agreed with the ED diagnosis in 96.7% of instances and differed 3.3% of the time (Table 1). Four injury/illness types were classified as head, two as chest/airway, and three as cardiovascular. Four injury/illness types were classified as musculoskeletal, one injury/illness was classified as spinal, and one as abdomen. Table 1. Frequency and Percentage of Overassessments and Underassessments by the Transport Team Head The flight crew assessed 336 potential injuries (84 for each of the potential head injuries in Figure 1): 311 injuries were noted as not present, and 25 were noted as present. ED final diagnosis confirmed the transport team's assessment in 331 occurrences (98.5%) and disagreed with assessment in five (1.5%). Of these five differences, one was an underassessment (0.3% of total occurrences) by the transport team and four were overassessments (1.2% of total occurrences). See Figure 2. (33K) Figure 2. Spine The transport team assessed 84 potential spinal cord injuries: 81 injuries were noted as not present, and three were noted as present. The ED's final diagnosis confirmed the crew's assessment in 81 occurrences (96.4%) and disagreed with assessment in three occurrences (3.6%). Of the three differences, all were underassessment by the transport team (Figure 3). (28K) Figure 3. Chest/airway The transport team assessed 168 potential chest/airway injuries: 124 injuries were noted as not present, and 44 were noted as present. ED diagnosis confirmed these assessments in 162 occurrences (96.4%) and disagreed in 6 (3.6%). Of the six differences, two were underassessments (1.5% of total occurrences) and four were overassessments (1.8% of total occurrences). See Figure 4. (30K) Figure 4. Abdomen The transport team assessed 84 potential abdominal injuries: 70 injuries were noted as not present, and 14 were noted as present. ED diagnosis confirmed the crew's assessment in 78 occurrences (92.9%) and disagreed with the assessment in six occurrences (7.1%). Of the six differences, two were underassessments (2.4% of total occurrences) and four were overassessments (4.7% of total occurrences). See Figure 5. (29K) Figure 5. Musculoskeletal The transport team assessed 336 potential musculoskeletal injuries: 312 were noted as not present, and 24 were noted as present. ED diagnosis confirmed the crew's assessment in 317 occurrences (94.4%) and disagreed with 19 (5.6%). Of the 19 differences, seven were underassessment (2.1% of total occurrences) and 12 were overassessment (3.5% of total occurrences). See Figure 6. (30K) Figure 6. Cardiovascular The transport team assessed 252 potential cardiovascular problems: 143 were noted as not present, and 109 were noted as present. ED diagnosis confirmed the crew's assessment in 247 occurrences (98.2%) and disagreed with the assessment in five occurrences (1.8%). Of the five differences, one was an underassessment (0.4% of total occurrences) and four were overassessments (1.6% of total occurrences). See Figure 7. (30K) Figure 7. Discussion These data indicate that flight personnel's assessment agreed with that of the ED staff 96.7% of the time. The existing previous studies showed that transport team assessments concurred with the ED diagnosis 75.2% and 89.4% of the time.2 and 4 Overassessment of the patient by the transport team occurred in 27 cases (1.9%), and underassessment occurred in 18 cases (1.3%). Because it is the responsibility of the transport team to determine potential or possible injuries without confirmation, overassessments by the transport team are expected. Though disagreement between the transport team and ED is never desired, in most cases it is better that the transport team overassess the patient, ensuring that more precautions are taken than necessary. However, overassessments could result in an unnecessary therapy (medical or procedural), leading to higher costs. In the instance of underassessment, overlooked injuries will go untreated throughout transport and in the hospital until recognized by ED staff. Furthermore, underassessment denies forewarning to the ED staff, who prepare for a patient based on the transport team's pre-arrival radio report. One previous study indicated that disagreement between assessments was most frequent in abdominal injuries and least frequent for head injuries.4 Our study shows the same results but with different divisions between overassessment and underassessment. Abdominal injuries showed the greatest percentage of disagreements (7.1%): four of the six disagreements were overassessments. This may be caused by the transport team's tendency to base assessment of possible injuries on the mechanism of injury. Underassessments may be attributed to the delayed presentation of certain symptoms such as abdominal distension. Musculoskeletal injuries accounted for the second greatest percentage of disagreements (5.6%). A disproportionate number of overassessments occurred in musculoskeletal injuries, 9 of 27 total overassessments were attributed to musculoskeletal injuries. These overassessments may simply be precautionary; that is, because the transport team did not have the help of x-ray equipment, they indicated potential injuries without confirmation of their presence. Most overassessed musculoskeletal injuries were closed long bone fractures. Spinal cord injuries were the third greatest cause of disagreements in assessment. This statistic is surprising because flight personnel, by protocol, use spinal precautions and immobilization for all trauma patients. Perhaps these precautions were always taken but the transport team thought spinal injuries were not present. Another possibility could arise from poor neurological assessment or a patient's altered mental status before the use of paralytics to secure a patient's airway; after the administration of these drugs, a complete neurological examination is impossible. If the severity of a patient's condition necessitated definitive airway intervention immediately on transport team arrival, any further examinations might be considered underassessments if deficits were present. The remaining areas (head, cardiovascular, and chest/airway) show the lowest occurrences of disagreements, though all have some instances in both underassessments and overassessments. The conditions under which transport teams operate may account for the differences between their assessment and that of the ED. The transport team is subject to the constraints of limited time, minimal space, poor scene lighting, few diagnostic tools, and many other practical concerns that prevent a complete survey. Though quick arrival time may benefit the patient, it does not always support the complete assessment. Often, indications of injury may not be apparent early in the presentation because they have not yet had sufficient time to develop (eg, abdominal distension). An important diagnostic tool is often the patient's complaint of pain; however, for patients with multiple and major injuries, such as a fractured bone, the pain may be overshadowed by more severe injuries. This is also true for patients with an altered mental status; it is quite possible for injuries to be overlooked because of the patient's inability to complain. Conclusion Despite the apparent difficulties involved in accurately assessing the patient, data show that the transport teams overcame these obstacles and performed accurate assessments in most instances. Furthermore, the transport teams reviewed for this study were significantly more accurate in patient assessment than those reviewed in previous studies. Though their accuracy was high, areas of possible improvement exist. Because spinal cord injuries had the highest incidence of underassessment, it may be beneficial for the transport team to be more cautious in evaluating mechanism of injury and possible spinal cord damage. In addition, a quick and accurate determination of a patient's baseline neurological status can be helpful for secondary assessments later in the flight. Because of the nature of and the potential for severe outcomes, the greatest precautions must be taken for these injuries. Certainly, the most successful plan for improving the care and accuracy of assessment by the transport team will include continued evaluation and increased training in problem areas. References 1 S Roberts, C Bailey and JR Vandermade et al., Medicopter: an airborne intensive care unit, Ann Surg 172 (1970), pp. 325–333. Abstract-MEDLINE 2 HC Cleveland and JA Miller, An air emergency service: the extension of the emergency department, Top Emerg Med 1 (1980), pp. 47–54. Abstract-MEDLINE | Abstract-EMBASE 3 HC Cleveland, DB Bigelow, D Dracon and F Dusty, A civilian air emergency service: A report of its development, technical aspects, and experience, J Trauma 16 (1976), pp. 452–463. Abstract-MEDLINE | Abstract-EMBASE 4 P Campbell, Comparison of flight nurses' prehospital assessments and emergency physicians' ED assessments of trauma patients, J Emerg Nurs 13 (1987), pp. 219–222. Abstract-MEDLINE Address for correspondence: William J. Brady, MD, PO Box 800699, Department of Emergency Medicine, University of Virginia Health System, Charlottesville, VA 22908

(Air Medical Journal Volume 25 @ Issue 4 , July-August 2006, Pages 144-148 Pediatric Perspective Current practice in pediatric immobilization—an editorial Christopher Wagner RN, CFRN, EMT-P1 and Paul Mazurek RN, BSN, CCRN, CEN, EMT-P1 Available online 1 July 2006.) As a member of the editorial board of Air Medical Journal, as well as the pediatric section editor, I have the unique opportunity to be afforded a forum in which to discuss areas of practice that are controversial and, in many cases, heatedly debated. A current focus of debate is the appropriate prehospital and transport spinal immobilization of the pediatric patient. Perhaps no other commonly performed treatment is more poorly researched or clouded by practitioners' long-held anecdotal and a priori clinical experiences. In this article I discuss what I think are the strengths and weaknesses of current practice in the immobilization of children and attempt to find a scientifically based common ground that allows transport programs to provide more safe and consistent care. The principal obstacle in changing current practice is the fact that the vast majority of children cared for and immobilized do not have spinal fractures or neurological injury.1 and 2 Safer cars, increased seat belt and helmet use, and organized early age safety education have all combined to decrease these injuries. This hampers changes in practice because many clinicians do not see complications from their current immobilization techniques. Simply put, poor or inadequate immobilization is not a problem in the uninjured child. The rarity of these injuries, coupled with their morbidity, make proper spinal immobilization vitally important. As stated, common clinical goals are an appropriate starting point in approaching the standardization of pediatric spinal immobilization. Goals of spinal immobilization The universally agreed-on goal of spinal immobilization is the prevention of neurological injury by pathological movement of injured vertebrae or vertebral components.3, 4, 5, 6, 7 and 8 What is less clear is what population requires this protection. Current triage protocols focus on a combination of assessment of the patient's mechanism of injury (MOI) and neurological/mental status. Fortunately, prehospital and transport clinical decision making have some absolutes. A pediatric trauma patient who is unconscious, has an altered mental status (from injury or intoxicants), has a neurological deficit, or has spinal pain on initial examination requires spinal immobilization.3, 7, 8, 9, 10 and 11 If a trauma patient does not meet these criteria, the decision to immobilize is based on the patient's MOI. MOIs that predispose patients to spinal cord injury are listed in Table 1. Any child with a significant MOI and a distracting injury (ie, an obviously fractured extremity) requires spinal immobilization. Table 1. Mechanisms of Injuries Predisposing Children to Spinal Injury Data from Sanders MJ, McKenna K.7 Literature has begun to challenge the need to immobilize any patient not meeting these criteria. Domeier et al10 and 11 demonstrated in a large multicenter trial that the triage application of the criteria just outlined captured the vast majority of spinal injuries. The difficulty in extrapolating the adult literature to pediatric patient care is the questioned reliability of the child to contribute to the caregiver's assessment. Obviously the preverbal child will not be able to assist, and many believe children younger than 12 years may be equally unreliable. Because of these factors, the child younger than 12 with a significant MOI should be provided with spinal immobilization (with medical control guidance) until radiographic or a more complete medical examination can be completed. Any discussion on the benefits of spinal immobilization needs to be balanced with an understanding of potential complications that may be encountered. Spinal immobilization is uncomfortable, requires time to apply (which may delay transport), may impair ventilation, and has the potential to increase the risk of aspiration.12, 13, 14 and 15 Prolonged use may cause skin breakdown on points of pressure. These issues make the prudent application of spinal immobilization important in both preventing iatrogenic morbidity and providing safe and efficient transport. Proper spinal immobilization of the injured child for transport should include the following: 1. A rigid, appropriately sized cervical collar. A well-placed collar should position the spine in a neutral position and control flexion and extension. 2. A hard backboard that supports the entire spine should be applied. Padding of the board will be necessary to provide neutral alignment in children and improve patient comfort without compromising cervical spine stability.6, 7 and 8 3. Lateral support (with commercial blocks, sandbags, or towel rolls) should be applied to the head to prevent rotation of the cervical spine as well as lateral bending. It also must provide support should the board need to be turned in the event of emesis. 4. Straps should be applied to the backboard to immobilize the patient (at the head, shoulders, pelvis, and knees) and protect spine stability when moving or turning the patient. 5. Tape or a strap also should be applied to the forehead to assist in keeping the head down in the anxious, agitated, or combative child. The use of tape or a strap across the chin is more controversial. Aggressive use of chin restraint often leads to unwanted cervical extension and may further inhibit mouth opening in the event of emesis. An appropriately sized cervical collar should prevent neck flexion, and a forehead strap in most cases should keep the child positioned. The benefit of chin restraint must always be weighed against possible complications. 6. The immobilization device should preferably not interfere with subsequent radiologic examination. 7. The immobilization should allow access to the patient for assessment and treatment. An important and often overlooked facet of spinal immobilization in children, especially during transport, is that when correctly applied, it allows caregivers access to the patient without the need to alter or compromise the immobilization. Correctly applied spinal immobilization also should not need to be reinforced or changed on arrival to the emergency department. With this in mind, a discussion of current techniques and their relative strengths and shortcomings can be examined. The long board/short board The long/short spinal board is often overlooked in the immobilization of children. It is an excellent tool for many reasons. Nearly every prehospital provider has one readily available. Straps and tape are easily applied. Its size allows total patient access when the child is placed supine, and most are radiographically neutral. This board is also easily secured to ambulance or aircraft stretchers, increasing transport safety. The single daunting factor in the use of the spinal board is the appropriate use of padding to place the cervical spine in a neutral position (and to fill lateral space in the infant or small child). Children up to approximately 8 years old have a proportionally larger head than body. This will cause neck flexion in the unsupported child. Thoracic support (with blankets or padding) is used to prevent cervical spine flexion. In addition, padding will increase patient comfort as well as ameliorate some conductive heat loss from the patient's skin contacting the cooler surface of the board.6 Figure 1 demonstrates the cervical flexion caused by occipital prominence in children of various ages. (92K) Figure 1. Cervical flexion caused by occipital prominence in children of various ages. Another option that has gained increasing acceptance, especially in relation to spinal immobilization of the pediatric patient, is the use of vacuum splints. Such a device, when used in conjunction with a rigid board, may address the previously discussed issues of padding for patient comfort and support. The long/short board is easily turned in the event of emesis and is familiar to all emergency departments. Boards with metal components should be avoided when possible to prevent interference with radiologic examination. The infant/toddler car seat This form of immobilization, although commonly used and taught, may be the method with the most potential complications. The car seat is an excellent tool during extrication as it allows for rapid removal of the child from the vehicle. Once removed from the vehicle, it is an extremely unreliable method of spinal immobilization. If the child is left upright in the seat, it demands that the potentially injured cervical spine support the weight of the head, a condition that we demand of no other trauma patient. An upright position also requires the thoracic and lumbar spine to support the weight of the body. If the car seat is placed in a supine position, the flexed lower extremities may apply pressure to the abdomen, potentially embarrassing respiratory effort in an age group that predominately uses their abdominal muscles to support respirations. Applying a cervical collar and placing posterior padding in a seated child requires extensive patient movement and has the potential to aggravate injuries. Access to the patient is often limited, and the child will need to be re-immobilized on arrival to the emergency department to allow for radiologic/physical examination. I believe that the groups best suited for rapid and appropriate spinal immobilization are prehospital and transport crews. It is always in the best interest of children to have care provided by the most qualified caregiver. Recognizing this, it is important that paramedics and transport crews are taught and encouraged to properly remove a child from a car seat and provide effective spinal immobilization. I recognize the resistance to this well-entrenched practice. It is important to recall that clinical practice should be directed toward the appropriate treatment of the suspected but rare injury rather than to procedures presumed to be more expeditious. The Kendrick extrication device The Kendrick extrication device (KED) is another commonly used immobilization device that may present more potential complications than most providers acknowledge. Markenson et al.4 advocate the routine use of the KED for all pediatric patients, championing its availability, familiarity, and adaptability. The KED has significant limitations that I believe make it applicable in only a small number of injured children. As previously discussed, the knees of traumatically injured patients must be supported to prevent undue stress on the lumbar spine (a common site of pediatric spine injury). Allowing lower extremities to freely move or permitting the weight of the lower extremities to fall below the level of the pelvis places undue stress on the potentially injured thoracic/lumbar spine. These same considerations demand that adult patients be placed on a long board after extrication with the KED.7, 8, 13 and 16 Interestingly, Markenson et al.4 endorse the need for lower extremity support but offer illustrations of a child immobilized in a KED without fully supported lower extremities. Figure 2 illustrates this limitation of the KED with a volunteer 8-year-old. Additionally, the flexible nature of the KED, which makes it so helpful in extrication, restricts its usefulness in immobilization. Extremely small children do not have enough thoracic width to prevent lateral compression of the KED should it be needed to be turned in the event of emesis. (158K) Figure 2. Lack of lower extremity support with a Kendrick extrication device. When turned on its side, the posterior surface of the KED may distort (bow out), compromising spinal immobilization. This limitation is illustrated in Figure 3. A small child immobilized in the KED requires not only posterior padding for neutral spine positioning but also lateral padding to fill space not occupied by the child (as is required on long/short backboards). This space may be filled by folding the edges of the KED or with towel or blankets. The diversity of size in the pediatric patient makes this practice time consuming and indiscriminate. Padding and rolling the edge of the KED may obscure the patient, hampering reassessment. Should access to the patient be required in transport, removal of this padding or lateral support may impair immobilization. Although I concur that the KED is readily available and certainly familiar, its limitations in all but a small percentage of children may outweigh its benefits. (75K) Figure 3. Distorted posterior surface of the Kendrick extrication device. Age-appropriate cervical spine stabilization The characteristics of the developing pediatric cervical spine necessitate appropriate immobilization. The underdeveloped supporting muscles, loose ligament structure, partially ossified vertebrae, and instability of the atlantooccipital joint increase the child's risk of serious cervical injury as a result of significant mechanism of injury.5 A properly fitting cervical collar is an important first step in adequate spinal immobilization. A properly sized pediatric cervical collar must take into account several key anatomical differences. One of the most obvious differences is the child's larger head-to-torso ratio. This, combined with the increased range of motion seen in the pediatric cervical spine, may compromise the spine's ability to be maintained in a neutral position.16 The relative difference in neck length between the adult and child is another important consideration when immobilizing the pediatric cervical spine. The more acute angle between the occiput and shoulders, smaller chin-to-chest distance, and higher fulcrum of flexion seen especially in the infant and toddler age groups must be taken into account.17 Attempting to stabilize the cervical spine while failing to account for these significant differences can jeopardize appropriate airway alignment and thus the child's ability to breathe and ventilate. The properly fitting pediatric cervical collar should provide appropriate occipital support, maintain adequate cervical spine and airway alignment, and provide sufficient lateral support.7, 8 and 16 The patient's chin should not overlap or sink into the chin well of the cervical collar. Again, the diversity of patient size can make placing an appropriately sized cervical collar a daunting task. In the absence of an available properly fitting cervical collar, acceptable practice is to immobilize the child's spine to a rigid backboard in the standard fashion and using towel rolls (lateral support) and tapes or straps to stabilize the cervical spine.7 and 8 If a cervical collar is not used chin support (by tape or strap) is required to control flexion. When providing cervical support with lateral support/towel rolls, it is imperative to prevent pressure on the anterior neck, which may impede ventilation, respirations, or circulation. A commercially available collar that takes into account the unique anatomical differences of the pediatric cervical spine is the Miami Jr (Jerome Medical, Moorestown, NJ) cervical collar (Figure 4). With four different sizes available, this product line includes the infant to preteen age range. Replaceable and washable padded inserts increase comfort. This is particularly important when the child will be in the collar for extended periods (typically 6 hours or more).17 (141K) Figure 4. Miami Jr cervical collar. Commercial devices Most immobilization devices commonly available have some shortcomings. Recognizing this, several companies have produced pediatric-specific immobilization devices, eliminating many of the limitations of techniques previously discussed. They are adaptable to most children too small for adult devices and are easily secured for patient transport. The largest drawback to commercial devices is the initial cost. Budgetary constraints in programs that rarely care for children may make the purchase of these devices impractical. A device should be selected based on the previously stated criteria for proper pediatric spinal immobilization. Of particular interest is a line of products developed by the Ferno Corporation. The Pedi-Pac (Calgary, Alberta) is simplistic, compact, functional, and most importantly provides access to the patient (Figure 5). Please note that the same company that manufactures the KED board recognizes the need for age-appropriate immobilization not addressed by the adult extrication device. (20K) Figure 5. The Pedi-Pac. Particular to the infant age group is the Medkids (Ferno, Wilmington, OH) baby board. The device easily fastens to most stretchers and litter systems and helps maintain spinal column alignment with a self-contained pneumatic positioning device. It accommodates the wide range of thoracic elevation requirements without any extra padding and also provides easy access to the patient (Figure 6). (16K) Figure 6. Medkids Baby Board. Conclusion The spinal immobilization of children is challenging, often requiring ingenuity and improvisation to properly provide care. Keeping in mind the requirements for spinal immobilization, many options are available to transport crews. The limitations of current practices need to be recognized. Educating prehospital and transport crews on the proper extrication and immobilization of children is vitally important. The use of pediatric-specific commercial devices should be evaluated because they offer transport crews the fewest clinical limitations. Coordination with local medical control in developing policies for pediatric spinal immobilization is also important in this process. References 1 MJ Hamilton and ST Myles, Pediatric spinal injury; Review of 174 hospital admissions, J Neurosurg 77 (1992), pp. 700–704. Abstract-EMBASE | Abstract-MEDLINE 2 MJ Hamilton and ST Myles, Pediatric spinal injuries: review of 61 deaths, J Neurosurg 77 (1992), pp. 705–708. Abstract-EMBASE | Abstract-MEDLINE 3 M Domeier, Indications for pre-hospital spinal immobilization, Prehosp Emerg Care 3 (1999), pp. 251–253. 4 D Markenson, G Foltin and M Tunik et al., The Kendrick extrication device used for pediatric spinal immobilization, Prehosp Emerg Care 3 (1999), pp. 66–69. Abstract-MEDLINE | Abstract-EMBASE 5 JA Nemeth, Case study: a new approach to stabilization of the cervical spine in infants. The Academy Today: Am Acad Orthotists ProsthetistsAvailable at http:/www.oandp.org/academytoday/2005apr/4.asp. 6 M Nypaver and D Treolar, Neutral cervical spine positioning in children, Ann Emerg Med 23 (1994), pp. 208–211. Abstract-EMBASE | Abstract-MEDLINE 7 In: MJ Sanders and K Mckenna, Editors, Mosby's Paramedic Textbook (2nd ed.), Mosby Publishing, St. Louis (2001). 8 US Department of Transportation. EMT basic: national standard curriculum. Washington, DC: National Highway Traffic Safety Administration. 9 RM Domeier, RW Evans, RA Swor, EJ Rivera-Rivera and SM Frederiksen, Prehospital clinical findings associated with spinal injury, Prehosp Emerg Care 1 (1997), pp. 11–15. Abstract-MEDLINE 10 RM Domeier, RW Evans, RA Swor, EJ Rivera-Rivera and SM Frederiksen, Prospective validation of out of hospital spinal clearance criteria: A preliminary report, Acad Emerg Med 4 (1997), pp. 643–646. Abstract-EMBASE | Abstract-MEDLINE 11 RM Domeier, RW Evans and RA Swor et al., The reliability of prehospital clinical evaluation for potential spinal injury is not affected by mechanism of injury, Prehosp Emerg Care 3 (1999), pp. 332–337. Abstract-EMBASE | Abstract-MEDLINE 12 D Bauer and R Kowalski, Effect of spinal immobilization devices on pulmonary function in the healthy nonsmoking man, Ann Emerg Med 17 (1988), pp. 915–918. Abstract 13 D Bauer and R Kowalski, The effect of spinal immobilization on healthy volunteers, Ann Emerg Med 23 (1994), pp. 48–51. 14 D Chan, RM Goldberg, J Mason and L Chan, Backboard versus mattress splint immobilization a comparison of symptoms generated, J Emerg Med 14 (1996), pp. 293–298. SummaryPlus | Full Text + Links | PDF (3266 K) 15 M Walsh, T Grant and S Mickey, Lung function compromised by spinal immobilization, Ann Emerg Med 19 (1990), pp. 615–616. Abstract 16 In: JE Tintinalli, GD Kelen and JS Stapczynski, Editors, Emergency Medicine: A Comprehensive Study Guide (6th ed.), McGraw-Hill Professional, New York (2003), pp. 1546–1547. 17 Jerome MedicalAvailable at http://www.jeromemedical.com/html/miami_jr.html. 1 Christopher Wagner, RN, CFRN, EMT-P, and Paul Mazurek, RN, BSN, CCRN, CEN, EMT-P, are flight nurse specialists with Survival Flight at the University of Michigan in Ann Arbor.

It would depend on what my assessment came up with, and how the pt presented. How reliable was that 1st B/P? What were the next 3? So with blood loss of that magnatude with a pt with this hx, you're gonna say, BLS, sayianarai?? I'm surprised to hear that from someone fo your ESM educational stature... ACE

"Dust," That was aweful kind and generous of you to say that. Are you sure you didn't get hit in the head by a trowel recently in the sandbox??? Where's that fire and brimstone your famous for? I'm confused.... :wink: ACE844

Thanks AK, glad you finally approve :wink: 8) ANY ONE ELSE ALSO NOTICE THE LACK OF ANY MENTION OF TOCO USE OR ACCEL-DECELL CONSIDERATION HERE AS WELL?!?!?!??! HMMMM :roll:

Yeah, what he said... I'll be in the corner now.. I was thinking maybe AML at first...

I'm actually surprised there was even a question in this case..!!!

"systemlord," Ok, Lets try this another way... Here's what 'E-medicine.com says; (http://www.emedicine.com/med/topic633.htm @ Eclampsia Last Updated: October 5, 2005 Rate this Article Email to a Colleague Get CME/CE for article Synonyms and related keywords: seizures in pregnancy, toxemia of pregnancy, coma in pregnancy, preeclampsia, cerebral vasospasm, focal ischemia, hypertensive encephalopathy AUTHOR INFORMATION Section 1 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Author: Stephanie R Fugate, DO, Consulting Staff, Department of Obstetrics and Gynecology, Woodbridge Family Health Clinic Coauthor(s): Gregory E Chow, MD, Fellow in Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Washington School of Medicine Stephanie R Fugate, DO, is a member of the following medical societies: American College of Obstetricians and Gynecologists Editor(s): Bruce A Meyer, MD, Chief, Department of Obstetrics and Gynecology, UMass Memorial Health Care System, Chair, Professor, Department of Obstetrics and Gynecology, University of Massachusetts Medical School; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Antonio V Sison, MD, FACOG, Program Director, Department of Obstetrics and Gynecology, Robert Wood Johnson University Hospital Hamilton; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; and Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University; Chief, Division of Reproductive Genetics, Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern Memorial Hospital) ***{Note, their are some big guns in OB medicine who authored this... One MIGHT TAKE THAT INTO CONSIDERATION}*** [/font:c9f44e0bf2] Eclampsia Background: Eclampsia is defined as seizure activity or coma unrelated to other cerebral conditions in an obstetrical patient with preeclampsia. While most cases present in the third trimester of pregnancy or within the first 48 hours following delivery, rare cases have been reported prior to 20 weeks' gestation or as late as 23 days postpartum. Eclampsia has also been described without prior development of preeclampsia. Pathophysiology: Many investigators have proposed genetic, immunologic, endocrinologic, nutritional, and even infectious agents as the cause for preeclampsia/eclampsia. Despite extensive research, no definitive cause has been identified. Presumably, the placenta and fetal membranes play a role in the development of preeclampsia because of the prompt resolution of the disease following delivery. A common pathway thought to be associated with the development of preeclampsia is utero-placental ischemia. Uteroplacental ischemia is postulated to predispose to the production and release of biochemical mediators that enter the maternal circulation, causing widespread endothelial dysfunction and generalized arteriolar constriction and vasospasm. Preeclampsia/eclampsia creates a functional derangement of multiple organ systems, such as the central nervous system and the hematologic, hepatic, renal, and cardiovascular systems. The severity depends on medical or obstetric factors. Systemic derangements in eclampsia include the following: Cardiovascular Generalized vasospasm Increased peripheral vascular resistance Increased left ventricular stroke work index Decreased central venous pressure Decreased pulmonary wedge pressure Hematologic Decreased plasma volume Increased blood viscosity Hemoconcentration Coagulopathy Renal Decreased glomerular filtration rate Decreased renal plasma flow Decreased uric acid clearance Hepatic Periportal necrosis Hepatocellular damage Subcapsular hematoma Central nervous system Cerebral edema Cerebral hemorrhage Frequency: In the US: Approximately 5% of pregnancies are complicated by preeclampsia. Of these patients, 0.5-2% progress to eclampsia. The incidence is increased in women of low socioeconomic status, extremes of age, and primigravid state. Both preeclampsia and eclampsia account for significant maternal and fetal morbidity and mortality. Mortality/Morbidity: Eclampsia accounts for approximately 50,000 maternal deaths worldwide annually. In the United States, the maternal mortality rate from eclampsia has been reduced with early diagnosis and aggressive management and is currently less than 1%. The fetal mortality rate from eclampsia has also decreased but still remains at approximately 12%. Maternal complications of eclampsia may include permanent CNS damage from recurrent seizures or intracranial bleeds, renal insufficiency, and death. Causes of neonatal death include prematurity, placental infarcts, intrauterine growth retardation, abruptio placentae, and fetal hypoxia. Race: Racial predilection is unclear. A higher incidence of this condition may exist in African Americans. Sex: Only females are affected. Age: Preeclampsia/eclampsia affects women of all ages, but the frequency is increased in nulliparous women younger than 20 years. Women older than 40 years with preeclampsia have 4 times the incidence of seizures compared to women in their third decade of life. Other risk factors include the following: Nulliparity and age older than 35 years Preexisting hypertension or renal disease Poor prenatal care Strong family history of preeclampsia/eclampsia Systemic lupus erythematous Obstetric conditions associated with an abundance of chorionic villi (eg, twin gestations, molar pregnancies, triploidy, nonimmune hydrops fetalis) Medical Care: Eclamptic convulsions are life-threatening emergencies and require the proper treatment to decrease maternal morbidity and mortality. Presentation: If the patient develops convulsions at home, she usually is brought to the hospital in a comatose (ie, postictal) condition. These patients should be cared for by a team of qualified physicians (preferably obstetricians) and nurses. Patients should undergo continuous intensive monitoring. They should be placed in a monitored labor room with minimal noise and external stimuli. Initial management: As with any seizure, the initial management is to clear the airway and administer adequate oxygenation. The patient should be positioned in the left lateral position to help improve uterine blood flow and obstruction of the vena cava by the gravid uterus. The patient should be protected against maternal injury during the seizure, ie, the guardrails should be up on the bed, a padded tongue blade is placed between the teeth, and secretions are suctioned from the patient's mouth. Intravenous access: After the seizure has ended, a 16- to 18-gauge intravenous line should be obtained for drawing specimens for laboratory studies and administering fluids. Intravenous fluids should be limited to isotonic solutions to replace urine output and about 700 mL/d to replace insensible losses. Control of the seizure: Do not attempt to shorten or abolish the initial seizure. A syringe containing 2-4 g of magnesium sulfate should be the only anticonvulsant at the bedside. Magnesium sulfate is administered intramuscularly or intravenously to decrease and prevent further convulsions. Laboratory workup: A complete blood count, chemistry panel, and liver function tests should be conducted. A urinalysis should be sent to evaluate for proteinuria, and a 24-hour urine collection for protein should be initiated. Hypertension control: Record blood pressure every 10 minutes. Control blood pressure (diastolic 90-100 mm Hg) with administration of antihypertensive medications (ie, hydralazine, labetalol). Monitoring: Carefully monitor the neurologic status, urine output, respirations, and fetal status for all patients. An indwelling Foley catheter should be placed in the bladder to help collect and record urine output. Invasive monitoring: Pulmonary artery pressure monitoring may be necessary for accurate fluid management in eclamptic patients. This is particularly important in patients who have evidence of pulmonary edema or oliguria/anuria. Assessment of medical condition: Once the seizure is controlled and the patient has regained consciousness, the general medical condition is assessed. Induction of labor may be initiated when the patient is stable. Delivery Delivery is the treatment for eclampsia after proper stabilization. If the patient is undelivered, no attempt should be made to deliver the infant either vaginally or by cesarean delivery until the acute phase of the seizure or coma has passed. The mode of delivery should be based on obstetric indications but should be chosen with an awareness of the fact that vaginal delivery is preferable from a maternal standpoint. In the absence of fetal malpresentation or fetal distress, oxytocin should be initiated to induce labor in the following situations: At 30 weeks' gestation or greater, irrespective of the cervical dilation or effacement Prior to 30 weeks' gestation with a favorable cervix Patients with an unfavorable cervix with a gestational age of 30 weeks or less, once stabilized, should be delivered electively by cesarean delivery. This approach is preferred because pregnancies prior to 30 weeks' gestation with eclampsia have a higher risk of complications intrapartum. Intrapartum complications include the following: Fetal growth retardation (30%) Fetal distress (30%) Abruption (23%) Fetal monitoring Fetal heart rate and intensity of the contractions should be monitored closely. Fetal bradycardia is a common finding following the eclamptic seizure and has been reported to last from 30 seconds to 9 minutes. The interval from the onset of the seizure to the fall in the fetal heart rate is typically 5 minutes. Transitory fetal tachycardia may occur following the bradycardia. During the recovery phase, the fetal heart rate tracing may reveal a loss of beat-to-beat variability and late decelerations. The mechanism for the fetal tracing abnormalities is most likely due to a decrease in uterine blood flow caused by the intense vasospasm and uterine hyperactivity during the convulsion. If the fetal heart tracing does not improve following a seizure, other conditions should be considered. Growth restricted and preterm fetuses may take longer to recover following a seizure. Consider placental abruption if uterine hyperactivity remains and fetal bradycardia persists. Surgical Care: Patients with eclampsia may need to be delivered immediately by cesarean delivery, depending on the maternal and fetal condition. Stabilize the patient before initiating cesarean delivery during the acute phase because delivery may aggravate oliguria and other manifestations of the disease.The anesthesiologist should be informed of the maternal condition and may be helpful if endotracheal intubation or an operative delivery is necessary. For nonemergent cesarean delivery, epidural anesthesia is preferred and can be induced in a steplike fashion, being careful not to cause maternal hypotension. The use of spinal anesthesia is controversial because of the possibility of extreme sympathetectomy, resulting in maternal hypotension and uteroplacental insufficiency. Consultations: An experienced obstetrician should be consulted immediately. Consider consultation with a maternal-fetal medicine specialist, with transport to a tertiary care site after stabilization if it is in the fetal or maternal best interest. In the event of prematurity or fetal compromise, a pediatrician or neonatologist should be consulted. Diet: Patients with eclampsia should have nothing by mouth until medically stabilized. During a seizure, maintaining the patient's airway and being careful to help avoid aspiration of stomach contents is important. Activity: Strict bedrest Left lateral hip roll to help improve uterine blood flow to the fetus HOPE THIS HELPS, ACE844

Tech guessed it with "MADE" being the answer, if your a Vince Vaughn fan you should check this movie out as it's classic!!

I'm not sure what you mean, although well said and great points "tech," and good morninng and You have south of the border approval:: I wonder how someone who states they researched eclampsia and learned about the pathgenesis of this Dx, and then again say 'IT'S NOT A REAL EMERGENCY'?!?!?!!? Perhaps they were hoping to Anyhow, I hope that this individual continues to learn and I would say more, except [marq=up:e3871161a5]OUCH![/marq:e3871161a5] I am told.... ACE844

I thought I had posted this question yesterday; but it seems to have mysteriously disappeared. So I will ask again. When was the last time this pt voided and or had a BM?

I think this is the part where either some serious back pedaling happens or better yet, perhaps we should ask this question. How much backpeddaling could a back pedaler do if a backpeddlar were facing backwards on his uni-cycle!?!?!? 8) :shock:

I personally think that BiPAP should be useed in lieu of CPAP pre-hospital and that it is more effective in these cases. ACE

The Revised Trauma score is great for some patients I have also been known to use the TRISS, or APACHE scores as well. Hope this helps, ACE844

This is one of those times where I wish the "DITCH DOCTOR, and some of the other more famous personalities" would come on back and RE-EDUCATE this individual in the manner for which they so obviously need to be. This is either arrogance of the worst kind (that which is held up on a house of ignorance) or a desperate cry for education, and further training. Out Here, ACE844

ALS

Also in addition to the last statement i just made I will say this. We have been able to 'debate' many hotbutton issues here long before you came without them degenerating into flame fests. We can 'discuss' many things in opposing with opposing views passionately because that is part of what makes us good at what we do. That being said, those threads weren't started with the sole intention of initiating trouble! Well said everyoen else above!!! Food for thought, ACE844

When was the last time this persion voided in all capacities?

Just out curiosity... What's the prehospital M&M in your system?

Anytime ,

Are you intentionally trying to cause trouble!?!?!?!? This is the SECOND TIME I have asked you this?!?!?!!? Your just asking for this....

"Mike," Have you tried doing the insertion with the baloon partially inflated? I had a similar issue and found this helped allieveate the problem. Hope this Helps, ACE844

"azcep," This is slightly : That's so You don't even know it!! :wink: 8) :shock: [marq=down:e573d105a2]NICELY DONE!!![[/marq:e573d105a2] :::

Outstanding reccommedations "AZCEP," here's one more to add to the list for those of you who are students and or have to participate in rounds or just want to learn more about EBM. This book should be used in conjunction with the Hardcover version of Emergency medicine by the same authors! http://www.amazon.com/gp/product/007141024...7478449?ie=UTF8 Emergency Medicine: Just the Facts, 2/e (Just the Facts) (Paperback) by O. John Ma, David M. Cline, Judith E. Tintinalli, Gabor D. Kelen, J. Stephan Stapczynski "Through the year 2003, the American Board of Emergency Medicine (ABEM) administered three written exams each year: the Certification Exam, the Recertification Exam, and the..." (more) Explore: Books on Related Topics | Concordance | Text Stats | SIPs | CAPs Browse: Front Cover | Copyright | Table of Contents | Excerpt | Index | Back Cover | Surprise Me! Editorial Reviews Book Description The best study guide for emergency medicine board exams! This rapid, comprehensive review of emergency medicine succinctly covers all the information needed for emergency medicine board exam success or as a clinical refresher. Featuring a bulleted format, this valuable guide includes only the most important facts as well as test-taking tips and strategies. Referenced to the new edition Tintinalli's Emergency Medicine, 6/e. ENDORSED BY THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS From the Back Cover ***** "Great quick review for emergency medicine in-training exams / boards exams. One could read this text in two weeks just before the exam and retain the most relevant information. Highly recommended." —Online review of the first edition "...a very enjoyable book to read. The amount of material in each chapter is good, with just the key facts included and the fluff removed. The concise and consistent format makes it easy and quick to read." —Doody Review Services on first edition THINK OF IT AS A HIGH-YIELD TINTINALLI! Distilling the most critical information from the #1 text in emergency medicine, JUST THE FACTS is the perfect tool to prepare for in-service or licensing exams, re-certification, CME, or for use as a clinical refresher. Its highly efficient format conveniently condenses and simplifies only the most important content, for maximum yield and comprehension. *Endorsed by the American College of Emergency Physicians *Effectively condenses Tintinalli's Emergency Medicine, 6/e, for a concise, yet comprehensive review *Standardized, bulleted format stresses key points of epidemiology, pathophysiology, clinical features, diagnosis and differential, and ED care and disposition *Highlights and summarizes key concepts, to assure quick absorption of the material and reinforce your understanding of even the most difficult topics *Chapters are logically organized to help focus your study and provide quick access to subjects Also available: Ma et al: Emergency Medicine Manual, 6/e Promes: Emergency Medicine CME & Board Review, 3/e Tintinalli et al: Emergency Medicine, 6/e See all Editorial Reviews -------------------------------------------------------------------------------- Product Details Paperback: 624 pages Publisher: McGraw-Hill Professional; 2 edition (May 20, 2004) Language: English ISBN: 0071410244 Product Dimensions: 10.9 x 8.5 x 1.0 inches Shipping Weight: 3.02 pounds (View shipping rates and policies) Average Customer Review: based on 1 review. (Write a review.) Amazon.com Sales Rank: #15,838 in Books (See Top Sellers in Books) Yesterday: #53,529 in Books (Publishers and authors: improve your sales) Would you like to update product info or give feedback on images? (We'll ask you to sign in so we can get back to you) 7/10 stars

Now before the thread police get crankyand try anything reflexive.... We are all here to help and are willing to help you learn. That being said, you will find that most posters here also expect you to take an active role in your own education, and such. That is why I posted what I did.... I hope that you will utilize the wonderful resource that is this site to its full potential, and if you have questions, ask away.. But only after having doen a full and comprehensive search of course!!! :wink: :shock: 8) These things take time, and many of us were woefully unprepared for the realities of this profession as well. So good luck... and happy posting Out here, ACE844