The Wrong Stuff: Prehospital Dogma - Cliff Reid
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The Wrong Stuff: Prehospital Dogma Summary by: Cliff Reid The master of Dogmalysis himself, Cliff Reid, challenges current practices in prehospital and emergency medicine. Warning listeners to be skeptical, Cliff dissects the dogma of acute crush injuries and spinal immobilization. He also explores the false dichotomy of “scoop and run vs. stay and play”. Cliff reminds us that “not to challenge current practice is intellectually lazy”.
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The Wrong Stuff: Prehospital Dogma - Cliff Reid
- 1. The WRONG Stuff! Dogma in PH&RM Cliff Reid Director of Training Greater Sydney Area HEMS SMACC FORCE Prehospital & Retrieval Pre-conference Workshop
- 2. ! 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
- 6. ACUTE CRUSH INJURY HYPERKALEMIA TOURNIQUETS ECG MONITORING BICARBONATE
- 9. 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 Function Br Med J. 1941 Mar 22;1(4185):427–32. “ ”
- 10. 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 Function Br Med J. 1941 Mar 22;1(4185):427–32. “ ”
- 11. 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 Function Br Med J. 1941 Mar 22;1(4185):427–32. “ ”
- 12. 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 Function Br Med J. 1941 Mar 22;1(4185):427–32. “ ”
- 13. 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 Function Br Med J. 1941 Mar 22;1(4185):427–32. “ ”
- 14. not a teaching is a “ ” privilege right
- 15. not a teaching is a “ ”privilege right
- 17. ACUTE CRUSH INJURY HYPERKALEMIA TOURNIQUETS ECG MONITORING BICARBONATE
- 18. ACUTE CRUSH INJURY HYPERKALEMIA Sever MS, Erek E, Vanholder R, Kantarci G, Yavuz M, Turkmen A, et al Serum 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. “ ”
- 19. ACUTE CRUSH INJURY HYPERKALEMIA ? TOURNIQUETS
- 21. ACUTE CRUSH INJURY HYPERKALEMIA TOURNIQUETS X ? ECG MONITORING
- 23. ACUTE CRUSH INJURY HYPERKALEMIA TOURNIQUETS ECG MONITORING BICARBONATE X X ?
- 24. ACUTE CRUSH INJURY HYPERKALEMIA TOURNIQUETS ECG MONITORING BICARBONATE X X ? X
- 26. DO NOT use a tourniquet for the first aid management of a crush injury Risk of deterioration so reassessment essential
- 27. 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
- 28. 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
- 31. 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 ” “ 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.
- 32. SCOOP & RUN VS STAY & PLAY
- 36. THE ONLY PREHOSPITAL FLUID OF BENEFIT IS GASOLINE “ ”
- 37. 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
- 39. there was no significant association between time and mortality for any EMS interval ” “
- 40. 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. ! ” “
- 41. OXYGEN FOR STEMI
- 42. OXYGEN FOR STEMI Supplemental 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. ” “ 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.
- 43. HEAD INJURY DOESN’T CAUSE HYPOTENSION
- 44. 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
- 45. 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 resus.me/smaccchicagoREFERENCES AT: