Vehicle rollover as an indicator of mechanism of injury was investigated in a study examining accident databases and the medical literature. Only 2.4% of crashes involved rollovers but they accounted for one third of occupant deaths.
Some facts on vehicle rollover from the article:
Rollover is defined as a vehicle overturned by at least one quarter turn (at least onto its side).
Some rollovers involve many quarter turns and the final resting position may be on the vehicle’s side, roof, or back on its wheels.
Factors that cause a vehicle to roll over include trajectory (i.e., turning vs. straight), vehicle type, and speed (precrash velocity may be the most predictive factor)
The Canadian C-Spine rule – a decision instrument designed to clinically rule out important cervical spine injuries in alert patients – was successfully and safely applied by Canadian paramedics in a study of 1949 patients. Any misinterpretation erred on the side of safety.
This important work could ultimately result in less stress, discomfort, and wasting of ambulance resources and time for this large subgroup of pre-hospital patients. The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics Ann Emerg Med. 2009 Nov;54(5):663-671
After intubation it is critical to securely fasten the tracheal tube so it does not dislodge during transfer. Dedicated devices are available for this although mostly cloth tape is used.
Different knots have been compared although not found be significantly different in terms of security1. One favoured knot, which is easy to learn and to teach, is the lark’s head (also called cow’s hitch)2.
The tape is folded in half so there is a loop at one end and two free ends at the other. The loop is wrapped around the tube and the two free ends are fed through the loop, and then taped around the patient’s head. It has been suggested that this results in the tape gripping the tube over the widest possible area, thereby reducing the potential for slippage and displacement.
Easy! larks head knot
1.The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes BMC Emerg Med. 2006 May 24;6:7 Open Access
2. A knotty problem resolved Anaesthesia. 2007 Jun;62(6):637
A prospective study of 746 children sedated in the emergency department with iv or im ketamine revealed 2.1% may have experienced ’emergence delirium’ although the authors concede this was difficult to define. In contrast, 291 (38%) reported pleasant altered perceptions. Follow up revealed at least one nightmare in the following weeks in 3.4% of patients, which may be well under the rate reported in the normal unsedated paediatric population. What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation? Emerg Med Australas. 2009 Aug;21(4):315-22
Finally a well designed blinded randomised controlled trial on this subject. 0.3 mg/kg etomidate was compared with 2mg/kg ketamine for RSI in 655 patients requiring emergency intubation in the pre-hospital, emergency department, or intensive care unit environments. No difference was observed in intubation conditions or the primary endpoint of maximum SOFA score in the first three days, although the etomidate group had a higher rate of adrenal insufficiency as defined by response to an ACTH test. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009 Jul 25;374(9686):293-300
Plasma levels of adrenaline and noradrenaline increased signficantly in patients with acute coronary syndrome during ambulance transportation – a finding in keeping with studies on normal volunteers. I wonder how much more of an effect helicopter retrieval might have? Emergency ambulance transport induces stress in patients with acute coronary syndrome Emerg Med J. 2009 Jul;26(7):524-8.
Ketamine lowered ICP in brain-injured kids
Ventilated children between the ages of 1 and 16 with traumatic brain injury and elevated intracranial pressure (ICP) were given ketamine and effect on cerebral perfusion pressure (CPP) and ICP was measured. Ketamine decreased ICP while maintaining blood pressure and CPP.
These results refute the notion that ketamine increases ICP. The authors conclude: “Ketamine is a safe and effective drug for patients with traumatic brain injury and intracranial hypertension, and it can possibly be used safely in trauma emergency situations” Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension J Neurosurg Pediatr. 2009 Jul;4(1):40-6 (Full text)
Smaller self-inflating bags produce greater guideline consistent ventilation in simulated cardiopulmonary resuscitation
A comparison between two sizes of self-inflating resuscitation bags revealed improved adherence to resuscitation guidelines with the smaller bag. Student paramedics were more likely to produce suboptimal tidal volumes and ventilation rates with a 1500ml bag than a 1000ml bag during simulated ventilation of an artificial lung model.
BMC Emerg Med. 2009 Feb 20;9:4 http://www.ncbi.nlm.nih.gov/pubmed/19228432
Full text at http://www.biomedcentral.com/1471-227X/9/4
The physician-led pre-hospital service London HEMS examined its penetrating trauma caseload between 1991 and 2006. Overall, stabbings rose annually by 23.2% and shootings by 11.0%. Is the prevalence of deliberate penetrating trauma increasing in London? Experiences of an urban pre-hospital trauma service
Injury. 2009 May;40(5):560-3 http://www.ncbi.nlm.nih.gov/pubmed/19232594
