the wrong stuff: prehospital dogma - cliff reid

The WRONG Stuff!Dogma in PH&RM

Cliff Reid Director of Training

Greater Sydney Area HEMS

SMACC FORCE Prehospital & Retrieval Pre-conference Workshop

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something held as an established opinion; a point of view or tenet put forth as authoritative without adequate grounds !

DOGMA

LYSIS a process of disintegration or dissolution

Prehospital RESEARCH !

HARDIS

ACUTE CRUSH INJURY

ACUTE CRUSH INJURYHYPERKALEMIATOURNIQUETS

ECG MONITORINGBICARBONATE

The patient has been buried for several hours with pressure on a limb. On admission he looks in good condition…. Signs of renal damage soon appear, and progress… The urine contains albumin and many dark brown or black granular casts… The blood urea and potassium, raised at an early stage, become progressively higher, and death occurs comparatively suddenly, frequently within a week Bywaters EG, Beall D.

Crush Injuries with Impairment of Renal FunctionBr Med J. 1941 Mar 22;1(4185):427–32.

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The patient has been buried for several hours with pressure on a limb. On admission he looks in good condition…. Signs of renal damage soon appear, and progress… The urine contains albumin and many dark brown or black granular casts… The blood urea and potassium, raised at an early stage, become progressively higher, and death occurs comparatively suddenly, frequently within a week Bywaters EG, Beall D.

Crush Injuries with Impairment of Renal FunctionBr Med J. 1941 Mar 22;1(4185):427–32.

“

”

The patient has been buried for several hours with pressure on a limb. On admission he looks in good condition…. Signs of renal damage soon appear, and progress… The urine contains albumin and many dark brown or black granular casts… The blood urea and potassium, raised at an early stage, become progressively higher, and death occurs comparatively suddenly, frequently within a week Bywaters EG, Beall D.

Crush Injuries with Impairment of Renal FunctionBr Med J. 1941 Mar 22;1(4185):427–32.

“

”

The patient has been buried for several hours with pressure on a limb. On admission he looks in good condition…. Signs of renal damage soon appear, and progress… The urine contains albumin and many dark brown or black granular casts… The blood urea and potassium, raised at an early stage, become progressively higher, and death occurs comparatively suddenly, frequently within a week Bywaters EG, Beall D.

Crush Injuries with Impairment of Renal FunctionBr Med J. 1941 Mar 22;1(4185):427–32.

“

”

The patient has been buried for several hours with pressure on a limb. On admission he looks in good condition…. Signs of renal damage soon appear, and progress… The urine contains albumin and many dark brown or black granular casts… The blood urea and potassium, raised at an early stage, become progressively higher, and death occurs comparatively suddenly, frequently within a week Bywaters EG, Beall D.

Crush Injuries with Impairment of Renal FunctionBr Med J. 1941 Mar 22;1(4185):427–32.

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”

not a

teaching is a “”

privilegeright

not a

teaching is a “”privilege

right

ACUTE CRUSH INJURYHYPERKALEMIATOURNIQUETS

ECG MONITORINGBICARBONATE

ACUTE CRUSH INJURYHYPERKALEMIA

Sever MS, Erek E, Vanholder R, Kantarci G, Yavuz M, Turkmen A, et alSerum potassium in the crush syndrome victims of the Marmara disaster.

Clin Nephrol. 2003 May;59(5):326–33.

one can speculate that many victims might have died due to hyperkalemia before reaching the hospitals.

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ACUTE CRUSH INJURYHYPERKALEMIA ?TOURNIQUETS

ACUTE CRUSH INJURYHYPERKALEMIATOURNIQUETS X

?

ACUTE CRUSH INJURYHYPERKALEMIATOURNIQUETS X

?

ECG MONITORING

ACUTE CRUSH INJURYHYPERKALEMIATOURNIQUETS

ECG MONITORINGBICARBONATE

XX

?

ACUTE CRUSH INJURYHYPERKALEMIATOURNIQUETS

ECG MONITORINGBICARBONATE

XX

?

X

DO NOT use a tourniquet for the first aid management of a crush injury Risk of deterioration so reassessment essential

DO NOT use a tourniquet for the first aid management of a crush injury Risk of deterioration so reassessment essential

iv fluids before releasing crushed body part (especially > 4 hrs) Consider tourniquet if not possible

DO NOT use a tourniquet for the first aid management of a crush injury Risk of deterioration so reassessment essential

iv fluids before releasing crushed body part (especially > 4 hrs) Consider tourniquet if not possible

Initial crystalloid bolus Reserve tourniquets for uncontrolled hemorrhage

aSPINAL IMMOBILIZATION

94/101 cervical CT imaging at $1,570 per scan No missed injuries Substantial costs and increased radiation exposure Hospital personnel should have confidence in pre-hospital decisions regarding CSI”

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Tello RR, Braude D, Fullerton L, Froman P.Outcome of Trauma Patients Immobilized by Emergency Department Staff, but Not by Emergency Medical Services Providers: A Quality Assurance Initiative.

Prehosp Emerg Care. 2014 Oct 2;18(4):544–9.

SCOOP & RUN VS STAY & PLAY

THE ONLY PREHOSPITAL FLUID OF BENEFIT IS GASOLINE

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Successful outcome after intravenous gasoline injection J Med Toxicol. Dec 2007; 3(4): 173–177. !

Suicide attempt by intravenous injection of gasoline: a case report J Emerg Med. 2010 Nov;39(5):618-22 !

Multi organ failure following intravenous gasoline for suicide: a case report Acta Med Iran. 2012;50(12):846-8

there was no significant association between time and mortality for any EMS interval ”

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there was no significant association between time and mortality for any EMS interval ”

“For haemodynamically stable undifferentiated trauma patients, increased on-scene time and total prehospital time does not increase mortality. !..focus should be on the type of care delivered and not on rapid transport. !”

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OXYGEN FOR STEMI

OXYGEN FOR STEMISupplemental oxygen therapy in patients with STEMI but without hypoxia may increase early myocardial injury and was associated with larger myocardial infarct size assessed at 6 months. ”

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Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, et al.Air Versus Oxygen in ST-Segment Elevation Myocardial Infarction

Circulation. 2015 May 22.

HEAD INJURY DOESN’T CAUSE HYPOTENSION

HEAD INJURY DOESN’T CAUSE HYPOTENSION

RR of hypotension from isolated head injury 2.5 (95% CI 2.0-3.2) !

RR for hemorrhagic injury 2.7 (95% CI, 2.1-3.5) !

in the 0- to 4-year-old group

The WRONG Stuff: Dogma in PH&RM

SMACC FORCE Prehospital & Retrieval Pre-conference Workshop

ACUTE CRUSH INJURY SPINE IMMOBILIZATION

SCOOP & RUN OXYGEN IN STEMI

HYPOTENSION & HEAD INJURY

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