Coronavirus disease (COVID-2019) situation reports by WHO
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/
by Dr Ramon REYES MD
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Niveles de Alerta Antiterrorista en España. Nivel Actual 4 de 5.
Fuente Ministerio de Interior de España
sábado, 28 de marzo de 2020
Coronavirus disease (COVID-2019) situation reports by WHO
Coronavirus disease (COVID-2019) situation reports by WHO
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/
jueves, 26 de marzo de 2020
Recomendaciones para el manejo, prevención y control de COVID-19 en Unidades de Diálisis
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| Recomendaciones para el manejo, prevención y control de COVID-19 en Unidades de Diálisis |
DESCARGA
Todas nuestras publicaciones sobre Covid-19 en el enlace
Recuerda: Las #mascarillas quirúrgicas solo evitan que las gotas con virus salgan al exterior. "No están diseñadas para proteger de fuera hacia dentro, solo protegen de dentro hacia fuera", remarca el Dr. Lorenzo Armenteros. No sirven, por tanto, para protegerse del ambiente, pero son útiles para evitar la diseminación del virus, que este no salga.
Más información sobre los diferentes tipos de mascarillas que existen y sus utilidades ante el #COVID19
AVISO IMPORTANTE A NUESTROS USUARIOS
Este Blog va dirigido a profesionales de la salud y publico en general EMS Solutions International garantiza, en la medida en que puede hacerlo, que los contenidos recomendados y comentados en el portal, lo son por profesionales de la salud. Del mismo modo, los comentarios y valoraciones que cada elemento de información recibe por el resto de usuarios registrados –profesionales y no profesionales-, garantiza la idoneidad y pertinencia de cada contenido.
Es pues, la propia comunidad de usuarios quien certifica la fiabilidad de cada uno de los elementos de información, a través de una tarea continua de refinamiento y valoración por parte de los usuarios.
Si usted encuentra información que considera erronea, le invitamos a hacer efectivo su registro para poder avisar al resto de usuarios y contribuir a la mejora de dicha información.
El objetivo del proyecto es proporcionar información sanitaria de calidad a los individuos, de forma que dicha educación repercuta positivamente en su estado de salud y el de su entorno. De ningún modo los contenidos recomendados en EMS Solutions International están destinados a reemplazar una consulta reglada con un profesional de la salud.
Guía de recursos sobre Coronavirus by IntraMed
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| Guía de recursos sobre Coronavirus Agrupamos los contenidos de IntraMed realcionados con el brote de enfermedad COVID-19 debida al virus SARS-CoV-2 para facilitar su acceso a los colegas
Noticias médicas
• ¿Debería ser el historial de viajes el "quinto signo vital"?
La amenaza urgente de enfermedades transmisibles hace necesaria la recopilación del historial de viajes • COVID19: Se detecta transmisión local en contactos estrechos Hoy fueron confrmados diez (10) nuevos casos de COVID-19 • Persistencia del virus SARS-CoV-2 en aerosol y superficies Tasas de persistencia de HCoV-19 en comparación con SARS-CoV-1 • Transmisión del SARS-CoV-2 desde un contacto asintomático El hecho de que las personas asintomáticas sean fuentes potenciales de infección por 2019-nCoV puede justificar una reevaluación de la dinámica de transmisión del brote actual • Prevención de la propagación nosocomial del SARS-CoV-2 La detección de SARS-CoV-2 en muestras de pacientes, sus habitaciones y el calzado de un proveedor refuerza la necesidad de higiene de manos y la efectividad de la limpieza ambiental • La OMS declara el brote de coronavirus pandemia global "No cambia lo que está haciendo la OMS y lo que deberían hacer los países” • COVID-19: Nueva definición de "caso" Pautas para identificar pacientes con posible infección • Factores de riesgo de progresión de la neumonía en COVID-19 Análisis de los factores asociados con los resultados de la enfermedad en pacientes hospitalizados con enfermedad por coronavirus novedosa de 2019 • OMS Curso a Distancia: Nuevos virus respiratorios, incluido COVID-19 Una introducción general a los virus respiratorios emergentes, incluyendo el COVID-19 • Coronavirus: ¿Cómo preparar los ambientes de trabajo? Planifique, prepare y responda a la enfermedad por coronavirus 2019 • Cancelan el American College of Cardiology 2020 por el Coronavirus Las opciones virtuales y las presentaciones de premios se anunciarán en los próximos días • SARS influye en la respuesta a la epidemia de coronavirus COVID-19 La experiencia del Hospital General de Singapur que respondió al brote de SARS de 2003, incluida una lista exhaustiva de 43 consideraciones operativas terrestres para los departamentos de imágenes que actualmente reaccionan al COVID-19 • Coronavirus: Síntomas gastrointestinales y posible transmisión fecal Dos nuevos artículos de investigadores de China describen el impacto del coronavirus en el tracto digestivo • Coronavirus: los niños son tan susceptibles como los adultos Actualizaciones sobre la enfermedad respiratoria que ha infectado a decenas de miles de personas y ha matado a miles • Desvelan la puerta de entrada del coronavirus a las células humanas El hallazgo acerca la posibilidad de desarrollar anticuerpos para frenar la infección • Respondiendo a Covid-19: ¿una pandemia de una vez en un siglo? Un editorial de Bill Gates acerca del Coronavirus • Preocupación de la OMS por la expansión de COVID19 En conferencia de prensa, Tedros agregó que hay registros del nuevo coronavirus "en 28 países y 23 muertes" fuera de China • La OMS eleva el riesgo internacional del coronavirus a “muy alto” La Organización Mundial de la Salud ha elevado el riesgo internacional de propagación del coronavirus de “alto” a “muy alto” • Test positivos para Coronavirus en pacientes "recuperados" Los 4 pacientes fueron expuestos al nuevo coronavirus 2019 a través del trabajo como profesionales médicos • Coronavirus: ha matado a más personas que el SARS y el MERS El nuevo coronavirus que hasta ahora se ha extendido desde China a 26 países de todo el mundo no parece ser tan "mortal como otros coronavirus, incluidos el SARS y el MERS", dijo la Organización Mundial de la Salud • La OMS subestima la propagación del coronavirus De acuerdo con una revisión de estudios previos sobre la transmisibilidad del coronavirus realizado por investigadores de la Universidad de Umeå en Suecia • Coronavirus: existencias mundiales de equipos de protección se agotan La OMS advirtió de "interrupción severa" en el mercado de equipos de protección personal y dijo que las existencias mundiales eran "ahora insuficientes" para satisfacer la demanda • Coronavirus / OMS: medidas para combatir la "epidemia informativa" A fin de contrarrestar la ola de rumores y desinformación, la Organización Mundial de la Salud prevé elaborar mensajes para clarificar el panorama • Baricitinib como tratamiento potencial para el coronavirus 2019 Algunos compuestos probablemente sean efectivos, incluida la combinación de lopinavir más ritonavir contra el VIH • Datos clínicos y de tratamiento de casos de coronavirus en China El reporte incluye a 99 pacientes con nuevo coronavirus 2019 confirmado por laboratorio • Recomendaciones para equipos de salud Coronavirus 2019-nCoV Todo caso sospechoso constituye un evento de notificación obligatoria en el marco de la Ley 154651 y debe ser notificado en forma inmediata y completa al Sistema Nacional de Vigilancia de la Salud • Cómo prevenir el nuevo coronavirus Los expertos de la Escuela de Enfermería Johns Hopkins ofrecen ideas clave para los profesionales de la salud y los ciudadanos • OMS/OPS: Alerta Epidemiológica por nuevo Coronavirus La OPS / OMS monitorea de cerca la evolución epidemiológica de la situación y proporcionará orientación más detallada cuando esté disponible • Brote de neumonía en China vinculado a un nuevo coronavirus Un nuevo coronavirus parece ser el responsable del brote de neumonía en la ciudad de Wuhan, China, según la Organización Mundial de la Salud |
 | ¿Qué consejos preventivos debemos dar a las personas? La ciencia del comportamiento y la salud pública |
 | Consideraciones de salud mental durante el brote de COVID-19 Consideraciones desarrolladas por el Departamento de Salud Mental como apoyo para el bienestar psicológico durante el brote de COVID-19 |
 | Primera transmisión de persona a persona del coronavirus en EE. UU. De produjo entre dos personas con exposición prolongada sin protección mientras el primer paciente presentaba síntomas |
 | El impacto psicológico de la cuarentena y cómo reducirlo Una revisión de la evidencia disponible acerca de una medida imprescindible para controlar la pandemia |
 | Evolución y factores de riesgo de mortalidad por COVID-19 The Lancet: primer estudio identifica los factores de riesgo asociados con la muerte en adultos hospitalizados con nueva enfermedad por coronavirus en Wuhan |
 | SARS-CoV-2: una posible etiología de miocarditis fulminante La "tormenta de citoquinas" es el mecanismo central en la miocarditis fulminante que a menudo es mortal, especialmente en pacientes con disfunción severa de múltiples órganos |
 | Estudian fármacos para combatir la infección por coronavirus Evalúan la eficacia antiviral de cinco medicamentos aprobados por la FDA incluyendo: Ribavirina, Penciclovir, Nitazoxanida, Nafamostat y Cloroquina |
 | Coronavirus: Síntomas gastrointestinales y posible transmisión fecal Dos nuevos artículos de investigadores de China describen el impacto del coronavirus en el tracto digestivo |
 | Enfermedad por coronavirus 2019: ¿Cómo actuar? Considere la infección por covid-19 en cualquier persona con tos, fiebre o disnea que haya tenido contacto con un caso confirmado, o que haya regresado de un área de alto riesgo en los 14 días anteriores al inicio de los síntomas |
 | Coronavirus (2019-nCoV): evidencias para cuidados críticos Guía de recursos para UTI |
 | Guía para comprender el nuevo coronavirus 2019 Una revisión orientada al clínico para el reconocimiento y abordaje de casos sospechosos de COVID19 |
 | Nitazoxanida, un nuevo fármaco candidato para el tratamiento del coronavirus La nitazoxanida es un agente antiviral de amplio espectro que se encuentra en fase de desarrollo clínico para el tratamiento de la gripe y otras infecciones respiratorias virales |
 | Infecciones por coronavirus: más que solo el resfriado común El alcance y efecto final de este brote no está claro en la actualidad ya que la situación está evolucionando rápidamente |
HANTA VIRUS "VIRUS HANTA". ENFERMEDAD DEL SINDROME PULMONAR POR HANTAVIRUS
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| HANTAVIRUS "VIRUS HANTA" |
Información sobre los Hantavirus
Lo que Usted Debe Saber para Prevenir la Enfermedad del Síndrome Pulmonar por Hantavirus
(SPH o HPS por sus siglas en inglés)
Enlace:
CURSO
Bleeding Control for the Injured Course "Stop The Bleed" / Control de Sangrados para el Herido
Hantavirus
¿Qué son los hantavirus?
Los hantavirus son un tipo de virus que se encuentran en roedores en distintas partes del mundo.
En los EE.UU., las infecciones por hantavirus humano fueron identificadas por primera vez en el suroeste, en 1993. En años recientes, se han presentado casos esporádicos en varios estados del este, incluyendo Nueva York. Unos estudios han demostrado que los ratones se encuentran frecuentemente infectados y parecen ser la fuente de infección.
¿La enfermedad es común en los seres humanos?
No. Las infecciones humanas por hantavirus son raras. Se pueden presentar casos esporádicos o aislados en el país, en mayor cantidad en regiones con alta cantidad de polvo, lo que favorece la transmisión del virus.
¿Cómo se contagia este virus?
Son portadores del virus los roedores, tales como los ratones, encontrados en toda América del Norte. Los roedores infectados eliminan el virus vivo en la saliva, la materia fecal y la orina. Los seres humanos adquieren la infección al inhalar partículas microscópicas de la orina o material fecal de roedores, que contienen el virus. No se cree que las picaduras de insectos y animales domésticos tengan un papel en la transmisión del Hantavirus.
¿Pueden las personas infectarse entre sí?
No existen pruebas de la transmisión entre personas en los Estados Unidos. No hay casos de trabajadores de la salud que hayan sido infectados al atender a personas infectadas.
¿Cuáles son sus síntomas?
Los síntomas típicos incluyen fiebre alta, dolores musculares, tos y dolor de cabeza. Después de varios días, los problemas respiratorios empeoran rápidamente. Los pulmones pueden llenarse de líquido y las víctimas pueden morir por insuficiencia respiratoria o shock.
¿Cuánto tiempo después de la exposición aparecen los síntomas?
Típicamente entre dos y cuatro semanas, pudiendo ser de algunos días hasta dos meses.
¿Existe tratamiento?
No existe un tratamiento específico para el Hantavirus. Los médicos han estado administrando ribavarin, un medicamento antiviral, de manera experimental, a las personas que sospechen que sean víctimas de la enfermedad.
¿La enfermedad es siempre fatal?
No. Hace mucho tiempo, alrededor de la mitad de las personas infectadas moría, pero el diagnóstico y tratamiento de apoyo rápidos han mejorado el índice de supervivencia.
¿Cuál es la mejor manera de evitar la exposición al hantavirus?
Evite el contacto con materia fecal u orina de roedores. Para reducir la exposición al Hantavirus en el hogar, evite o elimine las infestaciones de roedores. Si los roedores están en la casa, consulte a un exterminador o al departamento de salud local para obtener información adicional acerca de la eliminación y el control de roedores. Si se utilizan trampas para eliminar los roedores, se deben colocar en un recipiente vació, como un cartón de leche puesto de costado o sobre un periódico, para evitar el contacto con material potencialmente infeccioso. La trampa, la caja o el periódico ya utilizados al igual que roedor deben lavarse bien con una solución desinfectante para uso doméstico (consiste en detergente y 1½ tazas de blanqueador por cada galón de agua) y luego deben ser colocados en bolsas de basura dobles para ser desechados. Lávese las manos con agua y jabón después de haber completado el proceso anterior. Después de haber eliminado los roedores de un edificio, usted debe eliminar los elementos que los atraen (fuentes de alimentos almacenados de manera inadecuada, basura, etc.). Se deben tomar medidas a prueba de roedores para evitar su entrada.
¿Qué se debe hacer para limpiar la materia fecal de los roedores?
Las viviendas con grandes cantidades de materia fecal de roedores deben ventilarse antes de volver a ocupar el edificio.
Es importante evitar que las partículas de materia fecal de los roedores invadan el aire donde puedan ser inhaladas. Los residuos se deben empapar con una solución desinfectante de uso doméstico (detergente y 1½ tazas de blanqueador por cada galón de agua) para reducir el polvo en el aire. Una botella pulverizadora vieja que produzca un aerosol fino es ideal para aplicar la solución.
Luego, se deben limpiar los detritos con guantes y se deben colocar en bolsas de plástico dobles para ser desechadas, junto con todo el material de limpieza utilizado, tal como toallas de papel, etc. No use aspiradoras ni barra con escoba, ya que creará polvo en el aire. El uso de guantes, máscaras contra el polvo, ropa de manga larga y gafas protectoras puede ayudar a evitar la exposición personal. Lávese las manos con agua y jabón después de haber completado el proceso anterior.
¿Dónde puedo obtener más información?
Si usted está gravemente enfermo(a) y tiene fiebre alta, consulte a un médico o diríjase a la sala de emergencias local de inmediato. Para obtener información general, llame al departamento de salud local o estatal.
Recursos principales
Enlaces externos
Los CDC no se responsabilizan por información obtenida fuera de www.cdc.gov:
- Hantavirus
- MedlinePlus
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| HANTAVIRUS "VIRUS HANTA" |
Todas nuestras publicaciones sobre Covid-19 en el enlace
CURSO
GEOLOCALIZACION Desfibriladores
Republica Dominicana
martes, 24 de marzo de 2020
Time for Change in Prehospital Spinal Immobilization,Suggests a Research
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| Time for Change in Prehospital Spinal Immobilization,Suggests a Research |
Articulo obsoleto
Te recomiendo leer en el enlace
http://emssolutionsint.blogspot.com/2016/09/es-necesario-inmovilizar-todos-los.html
Te recomiendo leer en el enlace
http://emssolutionsint.blogspot.com/2016/09/es-necesario-inmovilizar-todos-los.html
Jim Morrissey, MA, EMT-P | From the March 2013 Issue | Tuesday, March 19, 2013
Prehospital spinal immobilization has long been held as the standard of care for victims of blunt or penetrating trauma who have experienced a mechanism of injury (MOI) forceful enough to possibly damage the spinal column. The majority of EMS textbooks stress that any significant MOI, regardless of signs and symptoms of spine injury, requires full-body immobilization, which is typically defined as a cervical collar being applied and the patient being secured to a backboard with head stabilizers in place.
This approach to patient immobilization has been accepted and implemented as the standard of care for decades with little scientific evidence justifying the practice.1–3 In addition, scant data shows that immobilization in the field has a positive effect on neurological outcomes in patients with blunt or penetrating trauma.1,4–6 In fact, several studies and articles show that spine immobilization may cause more harm than good in a select sub-set of trauma patients.5–7
Many experts question the current practice of prehospital spinal immobilization.1,2,4–15 There are now some guidelines, textbooks and an increasing number of EMS agencies that support a progressive, evidence-based approach in an effort to lessen unnecessary spinal immobilizations in the field.
It’s problematic to use MOI alone as the key indicator for prehospital spinal immobilization. In addition, the harmful sequelae and potential dangers of spine immobilization need to be considered in any field protocol. We need to examine appropriate spine injury assessment guidelines and algorithms that allow for the selective immobilization of injured patients.
We also should review immobilization devices and techniques that are more appropriate for patients who do require immobilization, or better termed, spinal motion restriction (SMR), by EMS providers.
Outdated Indicators?
It typically takes several years for EMS textbooks to catch up with new evidence and then additional time for the EMS instructional community to modify curricula and change current practice. For example, definitions of mechanisms that require spinal immobilization found in most EMS textbooks are outdated and problematic. Such indicators for potential spine injury as fall, damage to the vehicle, injury above the clavicle and mechanism of injury involving motion, are not particularly helpful when determining the best course of action in the field.
It typically takes several years for EMS textbooks to catch up with new evidence and then additional time for the EMS instructional community to modify curricula and change current practice. For example, definitions of mechanisms that require spinal immobilization found in most EMS textbooks are outdated and problematic. Such indicators for potential spine injury as fall, damage to the vehicle, injury above the clavicle and mechanism of injury involving motion, are not particularly helpful when determining the best course of action in the field.
Especially troubling has been the lack of emphasis on the assessment of the patient before making a decision about immobilization. Historically, more emphasis has been placed on what happened to the vehicle or the best guess on how far someone may have fallen, instead of what actually happened to the person.
It isn’t the fall that causes injury; it’s the sudden stop at the end. The more sudden the stop, the more likely an injury results, especially if the kinetic energy was transmitted to the head and/or neck.
The physical condition of the patient must also be considered. A young, athletic person is able to withstand more forces than an elderly patient. So the spectrum of potential injuries is best determined through a detailed history and physical exam.
Vehicle damage has long been considered a strong indicator of potential spine injury, yet improvements in vehicular design and construction should change the way we look at vehicle damage. Vehicle technology and passenger protection is far superior to what it has been, particularly since the 70’s when EMS textbooks began advocating back boarding of patients in vehicles with significant damage.
Vehicle damage zones are now inherently built into newer vehicles, designed to absorb and dissipate the kinetic energy of a collision, and keep the passenger cabin relatively isolated and protected.16 An experienced paramedic once said, “The cake box might be crumpled, but the cake can be fine.”
Some textbooks accurately address this issue. Even as far back as 1990, the American Academy of Orthopaedic Surgeons addressed emergency medical responders in an extended-care environment, stating, “Patients with a positive mechanism of injury, without signs and symptoms, and with a normal pain response may be treated without full spine immobilization, if approved by your medical control physician.”17
Emergency medical personnel who work in extended-care, tactical, combat and wilderness environments have long realized the need to safely and accurately assess and clear patients regarding spinal injuries.18,19
New guidelines from Prehospital Trauma Life Support and the National Association of EMS Physicians have diminished the emphasis on immobilizing victims of penetrating trauma without neurologic deficits.20
In the setting of drowning, the 2010 evidence-based guidelines from the American Heart Association state that “Routine c-spine immobilization is a Class III (potentially harmful) unless clear trauma is evident in the history or exam, because it may unnecessarily delay or impede ventilations."21
Precautionary Immobilization
It isn’t surprising that the term and practice of “precautionary immobilization” has developed. It’s estimated that at least five million patients are immobilized in the prehospital environment in the U.S. each year. Most have no complaints of neck or back pain or other evidence of spine injury.3,11,12(See Photo 2.)
It isn’t surprising that the term and practice of “precautionary immobilization” has developed. It’s estimated that at least five million patients are immobilized in the prehospital environment in the U.S. each year. Most have no complaints of neck or back pain or other evidence of spine injury.3,11,12(See Photo 2.)
EMS personnel historically have neither been given the tools nor the authority to make informed decisions about objectively determining the need for prehospital spinal immobilization. This may be because the emergency medical community thought immobilization was always safe, conservative and always in the best interest of the patient. However, evidence now shows that, in some cases, spinal immobilization may not be in the patient’s best interest.1–3,7,8,10–13
Some prehospital care providers will admit that they often immobilize patients without evidence of spine injury because they want to avoid being questioned on arrival at the emergency department (ED). This dynamic can (and must) change with education and outreach.
Backboard-Based Immobilization
In addition to patient discomfort and anxiety associated with backboard-based immobilization, there are several potentially significant consequences. Standard immobilization requires the patient’s body to conform to a flat, hard surface. In addition, EMS secures a cervical collar around the patient’s neck and uses tape to secure the patient’s head to the board.
In addition to patient discomfort and anxiety associated with backboard-based immobilization, there are several potentially significant consequences. Standard immobilization requires the patient’s body to conform to a flat, hard surface. In addition, EMS secures a cervical collar around the patient’s neck and uses tape to secure the patient’s head to the board.
This practice often increases patient anxiety and has the potential to aggravate underlying injuries. Standard spinal immobilization techniques can also take away the patient’s ability to effectively protect their own airway thus significantly increasing the risk of aspiration.3–6,11,13
Patient vomiting, bleeding, airway drainage and swelling are common problems associated with trauma patients. Even with one EMS provider dedicated to the management of the airway and patient suction, it cannot be assumed that a suction catheter can handle the job when significant bleeding and/or vomiting is presented.
The continued spinal stability of a patient who is turned on their side to facilitate airway drainage and control is also questionable. Patients typically experience a significant shift in body weight and distribution, causing more movement to the spine than the immobilization process was intended to prevent.
In a comprehensive review published in Prehospital and Disaster Medicine, healthy volunteers who were immobilized on a backboard were found to be “significantly more likely to complain of pain when compared with immobilization on a vacuum mattress.” Adverse effects of backboard-based immobilization documented in this study include increased ventilatory effort, pain and discomfort.
In addition to pressure injury, the backboard may also be the cause of pain—even in otherwise healthy volunteers. The resultant posterior surface/back pain of immobilized patients has been documented to result in unnecessary radiographs and potential clinical ambiguity regarding the cause of the pain.3,22 There’s an increased cost associated with some of these complications.
It has been documented that supine patient immobilization results in a 15–20% reduction in respiratory capacity, and that respiratory effectiveness is markedly reduced by the strapping systems typically used.3,9,13 Patients are often either strapped securely, thus having diminished respiratory capacity, or loosely secured, facilitating easier breathing. Neither scenario is ideal.
The challenge is exacerbated in obese patients, the elderly and patients with such underlying diseases as congestive heart failure, COPD, asthma and pneumonia.
Done properly, immobilization in the field takes time and multiple personnel. Time delay to the ED or trauma center arrival has been cited as a significant problem for critical trauma victims. Several studies have looked at the risk vs. benefit of prehospital immobilization, with several authors and researchers questioning the value of current practices.1,2,7,8,11,15
Studies have also shown limited or no benefit of prehospital immobilization of penetrating trauma patients. (See photos on pages 32 and 33.) Unnecessary immobilization of this subset of trauma patients can result in prolonged on-scene time and delayed transport to definitive care, which may increase morbidity and mortality.4–6,14,18,23–25
Several studies show that cervical collars by themselves aren’t without risk or significant consequences.4,26–28 One study concludes that cervical collars frequently increase intracranial pressure and may be particularly harmful if used on head-injured patients.26
Another researcher observed that cervical collars “can result in abnormal distraction within the upper cervical spine in the presence of severe injury.”28 In addition, cervical collars hide areas of the head and neck, resulting in the increased possibility of missing injuries or evolving problems, such as swelling, hematoma and tracheal deviation.27,28
In addition, the longer a patient is immobilized, the more likely that cutaneous pressure ulcers will develop, most notably in the occipital, sacral or heel areas.9,12,22,29,30 This is especially true in elderly, unconscious and neurologically impaired patients.
This problem may be significantly reduced with padding or use of a vacuum mattress. Unfortunately, the vast majority of the patients who are immobilized don’t get padding in voids or areas of significant body weight/pressure or a vacuum mattress that distributes beads/padding in voids and uneven body surface areas.
The Penetrating Trauma Patient
As referenced earlier, there is a growing body of evidence that suggests penetrating trauma victims shouldn’t be routinely immobilized. Immobilization has been associated with higher mortality in patients with penetrating trauma.4–6,14,23–25
As referenced earlier, there is a growing body of evidence that suggests penetrating trauma victims shouldn’t be routinely immobilized. Immobilization has been associated with higher mortality in patients with penetrating trauma.4–6,14,23–25
Independent studies show that whether the penetrating trauma is to the head, neck or torso, immobilization is unnecessary, interferes with and delays emergent care, and should be seriously reconsidered as the standard of care.4–6,14,23
A Journal of Trauma article concluded, “Indirect spinal injury does not occur in patients with gunshot wounds to the head.” The authors state, “Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.”14
Another retrospective study showed similar concerns about the use of a cervical collar with patients who have penetrating injuries to the neck. This study suggests that avoiding the collar should be the rule, and that a provider who chooses to apply a cervical collar should have good justification. The authors also suggest that frequent examination of the underlying structures and tissue is warranted if a cervical collar is used.4
A comprehensive retrospective analysis of gunshot injuries to the torso found that immobilization was of little or no benefit, even if an unstable spine fracture was present. The authors argue that airway management, including intubation, is far more complicated and problematic with prehospital spinal immobilization in place.5,6
In fact, failed airway management was reported to be the second-leading error preceding death of trauma patients, accounting for 16% of mortality in one study. This study also highlights the potential delay to definitive surgical treatment and the lack of neurologic improvement after gunshot injury to the spinal cord, suggesting that prehospital spinal immobilization is unjustified.5,6
Proper Spine Injury Assessment
For many trauma patients, a vetted field assessment criterion that focuses on the assessment of the patient rather than the mechanism of injury would obviate unwarranted immobilization.3,11,31
For many trauma patients, a vetted field assessment criterion that focuses on the assessment of the patient rather than the mechanism of injury would obviate unwarranted immobilization.3,11,31
Many emergency medicine specialists believe an accurate, reliable, simple-to-perform spinal injury assessment could reduce spine immobilizations drastically. Thankfully, there is a trend in this direction across the nation.
The idea of “clearing” a patient of spinal injury in the field has been, and continues to be debated. However, there are prehospital spine assessment protocols that safely and accurately allow EMTs and paramedics to omit prehospital spinal immobilization in certain patients.
Some EMS experts prefer the term “selective immobilization” to “clearing” the c-spine, but the end result is the same. The end result is the reduction of the incidence of unwarranted spinal immobilizations.
For example, the Maine spine injury assessment guidelines, developed by Peter Goth, MD, in the 1990s, have been shown to be accurate and safe.10,31,32 Several states and EMS systems around the nation use this, or a similar protocol, to help decrease the number of trauma patients being subjected to prehospital spinal immobilization.
The origin of this type of spinal assessment was initially intended to help ED physicians clinically decide if they can safely clear patients from prehospital spinal immobilization and reduce or eliminate unnecessary radiographic studies. It has been shown that the proper clinical exam and history is more accurate at predicting spine injuries than X-ray review.10,32–35
The spine injury assessment guidelines that have been adopted by multiple prehospital systems are based on the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria. Each has similar parameters, requiring that the patient be awake, alert, conversant and without significant distracting injury or intoxication.
In addition, the guidelines further state that the physical exam should reveal no pain or tenderness to the posterior neck and back and the neurologic exam must find normal motor and sensory function in the extremities.10,18,31,33–35
Studies show that prehospital care providers can safely apply spine injury assessment criteria and not miss any clinically
significant spine injuries.10,31,32 Although these guidelines are available, training and practice is needed to become proficient at using these criteria.
significant spine injuries.10,31,32 Although these guidelines are available, training and practice is needed to become proficient at using these criteria.
Alameda County (Calif.) EMS has revised its spine injury assessment protocol to accurately reflect the current literature and research. (See Figure 1, p. 38). Its goals in 2012 were to reduce unnecessary immobilization, and use treatment modalities in the best interest of and provide the most comfort to the patient. In some cases, this meant forgoing prehospital spinal immobilization to expedite transport to a trauma center.
However, long-established norms are hard to break, and extensive training was required to make this new policy successful. EMS schools, fire departments and other EMS providers, as well as emergency department staff, needed to be exposed to the literature and trained in the new protocol.
Initial training and outreach has been well received and the early indicators have shown a significant reduction in spine immobilizations. The end result is:
>> A better understanding of the need for expeditious care under specific circumstances, in particular, the need to move rapidly when penetrating trauma is present;
>> All involved are empowered to break the paradigm of “board them all” as a result of understanding the importance of proper spinal/neurological assessment and assessment parameters that allow crews to assess for serious spinal indications and perform selective immobilization. We did the same process decades ago when we adopted rapid removal techniques for patients in lieu of spending precious minutes placing splints and half backboards on critical patients. Little or no untoward results occurred with that change in procedure;
>> More attention to patient comfort and pain instead of routine placement of trauma patients on a hard, uncomfortable platform that often put them in anatomically-incorrect positions for extended time periods, made patients unnecessarily claustrophobic lying supine and immobile and exacerbation of respiratory distress in patients due to the supine position, strap placement, and existing conditions such as CHF, COPD or morbid obesity; and
>> The ability to deploy and maximize the usage of alternative immobilization and transfer devices and stretchers such as vacuum mattresses, scoop or CombiCarriers and flexible stretchers such as Ferno and SKED stretchers and others that feature lateral patient support slats and multiple handles for convenient movement and transfer of patients. Many of these devices are better suited to patient movement in tight spaces and crew body mechanics when carrying and transferring patients down stairways and other difficult environments.
>> A better understanding of the need for expeditious care under specific circumstances, in particular, the need to move rapidly when penetrating trauma is present;
>> All involved are empowered to break the paradigm of “board them all” as a result of understanding the importance of proper spinal/neurological assessment and assessment parameters that allow crews to assess for serious spinal indications and perform selective immobilization. We did the same process decades ago when we adopted rapid removal techniques for patients in lieu of spending precious minutes placing splints and half backboards on critical patients. Little or no untoward results occurred with that change in procedure;
>> More attention to patient comfort and pain instead of routine placement of trauma patients on a hard, uncomfortable platform that often put them in anatomically-incorrect positions for extended time periods, made patients unnecessarily claustrophobic lying supine and immobile and exacerbation of respiratory distress in patients due to the supine position, strap placement, and existing conditions such as CHF, COPD or morbid obesity; and
>> The ability to deploy and maximize the usage of alternative immobilization and transfer devices and stretchers such as vacuum mattresses, scoop or CombiCarriers and flexible stretchers such as Ferno and SKED stretchers and others that feature lateral patient support slats and multiple handles for convenient movement and transfer of patients. Many of these devices are better suited to patient movement in tight spaces and crew body mechanics when carrying and transferring patients down stairways and other difficult environments.
Of course, crews have to take special caution when dealing with and managing high-risk patients, including pediatric patients, the elderly and those with such degenerative bone disorders as osteoporosis. Field personnel need to be conservative while evaluating these patients and should provide spinal motion restriction when in doubt.33,34
Unconventional Options
Even with appropriate application of spine injury assessment guidelines, some patients still require some degree of prehospital spinal motion restriction. Vacuum mattresses and other break-away and flexible stretchers have been used successfully throughout Europe for years. They score well in several critical areas, including patient comfort, secure immobilization, insulation, lack of pressure sore development and, in the case of some vacuum device configurations, allow crews to utilize them without a cervical collar.12,29,30
Even with appropriate application of spine injury assessment guidelines, some patients still require some degree of prehospital spinal motion restriction. Vacuum mattresses and other break-away and flexible stretchers have been used successfully throughout Europe for years. They score well in several critical areas, including patient comfort, secure immobilization, insulation, lack of pressure sore development and, in the case of some vacuum device configurations, allow crews to utilize them without a cervical collar.12,29,30
When considering adding vacuum mattresses, vacuum stretchers or other immobilization devices to your arsenal, keep in mind that they don’t require more effort or training than using backboards. Vacuum mattresses can also effectively pad voids, distribute weight evenly and immobilize patients on their side because the device can be “molded” around the patient to best package them safely. (See photos on page 36.)
However, keep in mind that backboards still have a place, especially to restrain or slide a patient out of an extrication mess. There is also nothing that precludes you from utilizing a combination of devices such as a backboard or scoop-type stretcher to remove a patient and transfer them to a more moldable or comfortable secure surface such as a vacuum mattresses. Many systems use this combination or deploy vacuum mattresses in conjunction with flexible stretchers. (See photo, top of page 36.)
Another emerging school of thought questions the need for traditional prehospital spinal immobilization at all—even for patients who have positive evidence of a spinal column or spinal cord injury. One group of researchers who compared various extrication tools and methods found that allowing a patient to self-extricate from a vehicle with a cervical collar alone caused less movement of the spine than the use of cervical collar, KED extrication device and standard extrication techniques.36 This triggers a series of questions that are beyond the scope of this article. Groups such as the National Association of EMS Physicians and the U.S. Metropolitan Municipalities Medical Directors and Global Affiliates Consortium are carefully discussing these options and revisions to our traditional approaches to neck and spine immobilization
Conclusion
It’s appropriate for emergency personnel to immobilize certain trauma patients. However, many other trauma patients are unnecessarily immobilized by EMS. Spinal immobilization isn’t always a benign intervention. It can result in increased scene time, delay of delivery to definitive care, problematic airway management, increased patient pain or dyspnea, and unnecessary radiographic testing.
It’s appropriate for emergency personnel to immobilize certain trauma patients. However, many other trauma patients are unnecessarily immobilized by EMS. Spinal immobilization isn’t always a benign intervention. It can result in increased scene time, delay of delivery to definitive care, problematic airway management, increased patient pain or dyspnea, and unnecessary radiographic testing.
Many trauma patients can be safely and accurately assessed and treated without immobilization if they meet all criteria in prehospital spinal assessment guidelines. Extensive initial training and ongoing review is necessary for an effective selective immobilization protocol.
Science, research and multiple validated articles have changed the way EMS practices. If good patient care is the goal, it’s time that prehospital spinal immobilization be critically examined.
From www.jems.com
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References
1. Hauswald M, Ong G, Tandberg D, et al. Out-of-hospital spinal immobilization: Its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214–219.
2. Baez AA, Schiebel N. Evidence-based emergency medicine/systematic review abstract. Is routine spinal immobilization an effective intervention for trauma patients? Ann Emerg Med. 2006;47(1):110–112.
3. Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehosp Disaster Med. 2005;20(1):47–53.
4. Barkana Y, Stein M, Scope A, et al. Prehospital stabilization of the cervical spine for penetrating injuries of the neck: Is it necessary? Injury. 2000;31(5):305–309.
5. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma. 2010;68(1):115–120; discussion 120–121.
6. Brown JB, Bankey PE, Sangosanya AT, et al. Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso. J Trauma. 2009;67(4):774–778.
7. Smith JP, Bodai BI, Hill AS, et al. Prehospital stabilization of critically injured patients: A failed concept. J Trauma. 1985;25(1):65–70.
8. Seamon MJ, Fisher CA, Gaughan J, et al. Prehospital procedures before emergency department thoracotomy: ‘Scoop and run’ saves lives. J Trauma. 2007;63(1):113–120.
9. Chan D, Goldberg R, Tascone A, et al. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48–51.
10. Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med. 2005;46(2):123–131.
11. Kwan I, Burns F. Spinal immobilization for trauma patients (Cochrane Review). Cochrane Review; 2009; 11 http://summaries.cochrane.org/CD002803/spinal-immobilisation-for-trauma-....
12. McHugh TP, Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998;5(3):278–280.
13. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999;3(4):347–352.
14. Kaups KL, Davis JW. Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. J Trauma. 1998;44(5):865–867.
15. Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. Sept. 8, 2012. [Epub ahead of print].
16. Centers for Disease Control and Prevention (Sept. 6, 2012). Guidelines for Field Triage of Injured Patients. 2011; Retrieved from www.cdc.gov/Fieldtriage. Accessed Sept. 24, 2012, 2012.
17. Worsing R. Basic Rescue and Emergency Care. First Edition. Ed: American Academy of Orthopaedic Surgeons, Park Ridge, IL; 1990; 253 .
18. Goth P. Spine Injury, Clinical Criteria for Assessment and Management. Augusta, ME: Medical Care Development Publishing; 1994.
19. Morrissey J. Field Guide of Wilderness Medicine and Rescue. Third Edition Ed: Wilderness Medical Associates, Portland, ME; 2000; 30-33.
20. Stuke LE, Pons PT, Guy JS, et al. Prehospital spine immobilization for penetrating trauma: Review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011;71(3):763–769; discussion 769–770.
21. Berg RA, Hemphill R, Abella BS, et al. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S685–S705.
22. March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002;6(4):421–424.
23. Kennedy FR, Gonzalez P, Beitler A, et al. Incidence of cervical spine injury in patients with gunshot wounds to the head. South Med J. 1994;87(6):621–623.
24. Chong CL, Ware DN, Harris JH, Jr. Is cervical spine imaging indicated in gunshot wounds to the cranium? J Trauma. 1998;44(3):501–502.
25. Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma. 1989;29(3):332–337.
26. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996;27(9):647–649.
27. Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intracranial pressure. Am J Emerg Med. 1999;17(2):135–137.
28. Ben-Galim P, Dreiangel N, Mattox KL, et al. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010;69(2):447–450.
29. Cordell WH, Hollingsworth JC, Olinger ML, et al. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995;26(1):31–36.
30. Luscombe MD, Williams JL. Comparison of a long spinal board and vacuum mattress for spinal immobilisation. Emerg Med J. 2003;20(5):476–478.
31. Muhr MD, Seabrook DL, Wittwer LK. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehosp Emerg Care. 1999;3(1):1–6.
32. Domeier RM, Evans RW, Swor RA, et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehosp Emerg Care. 1999;3(4):332–337.
33. Stroh G, Braude D. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med. 2001;37(6):609–615.
34. Barry TB, McNamara RM. Clinical decision rules and cervical spine injury in an elderly patient: a word of caution. J Emerg Med. 2005;29(4):433–436.
35. Burton JH, Dunn MG, Harmon NR, et al. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006;61(1):161–167.
36. Shafer JS, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009;10(2):74–78.
2. Baez AA, Schiebel N. Evidence-based emergency medicine/systematic review abstract. Is routine spinal immobilization an effective intervention for trauma patients? Ann Emerg Med. 2006;47(1):110–112.
3. Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehosp Disaster Med. 2005;20(1):47–53.
4. Barkana Y, Stein M, Scope A, et al. Prehospital stabilization of the cervical spine for penetrating injuries of the neck: Is it necessary? Injury. 2000;31(5):305–309.
5. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma. 2010;68(1):115–120; discussion 120–121.
6. Brown JB, Bankey PE, Sangosanya AT, et al. Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso. J Trauma. 2009;67(4):774–778.
7. Smith JP, Bodai BI, Hill AS, et al. Prehospital stabilization of critically injured patients: A failed concept. J Trauma. 1985;25(1):65–70.
8. Seamon MJ, Fisher CA, Gaughan J, et al. Prehospital procedures before emergency department thoracotomy: ‘Scoop and run’ saves lives. J Trauma. 2007;63(1):113–120.
9. Chan D, Goldberg R, Tascone A, et al. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48–51.
10. Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med. 2005;46(2):123–131.
11. Kwan I, Burns F. Spinal immobilization for trauma patients (Cochrane Review). Cochrane Review; 2009; 11 http://summaries.cochrane.org/CD002803/spinal-immobilisation-for-trauma-....
12. McHugh TP, Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998;5(3):278–280.
13. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999;3(4):347–352.
14. Kaups KL, Davis JW. Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. J Trauma. 1998;44(5):865–867.
15. Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. Sept. 8, 2012. [Epub ahead of print].
16. Centers for Disease Control and Prevention (Sept. 6, 2012). Guidelines for Field Triage of Injured Patients. 2011; Retrieved from www.cdc.gov/Fieldtriage. Accessed Sept. 24, 2012, 2012.
17. Worsing R. Basic Rescue and Emergency Care. First Edition. Ed: American Academy of Orthopaedic Surgeons, Park Ridge, IL; 1990; 253 .
18. Goth P. Spine Injury, Clinical Criteria for Assessment and Management. Augusta, ME: Medical Care Development Publishing; 1994.
19. Morrissey J. Field Guide of Wilderness Medicine and Rescue. Third Edition Ed: Wilderness Medical Associates, Portland, ME; 2000; 30-33.
20. Stuke LE, Pons PT, Guy JS, et al. Prehospital spine immobilization for penetrating trauma: Review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011;71(3):763–769; discussion 769–770.
21. Berg RA, Hemphill R, Abella BS, et al. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S685–S705.
22. March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002;6(4):421–424.
23. Kennedy FR, Gonzalez P, Beitler A, et al. Incidence of cervical spine injury in patients with gunshot wounds to the head. South Med J. 1994;87(6):621–623.
24. Chong CL, Ware DN, Harris JH, Jr. Is cervical spine imaging indicated in gunshot wounds to the cranium? J Trauma. 1998;44(3):501–502.
25. Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma. 1989;29(3):332–337.
26. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996;27(9):647–649.
27. Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intracranial pressure. Am J Emerg Med. 1999;17(2):135–137.
28. Ben-Galim P, Dreiangel N, Mattox KL, et al. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010;69(2):447–450.
29. Cordell WH, Hollingsworth JC, Olinger ML, et al. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995;26(1):31–36.
30. Luscombe MD, Williams JL. Comparison of a long spinal board and vacuum mattress for spinal immobilisation. Emerg Med J. 2003;20(5):476–478.
31. Muhr MD, Seabrook DL, Wittwer LK. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehosp Emerg Care. 1999;3(1):1–6.
32. Domeier RM, Evans RW, Swor RA, et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehosp Emerg Care. 1999;3(4):332–337.
33. Stroh G, Braude D. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med. 2001;37(6):609–615.
34. Barry TB, McNamara RM. Clinical decision rules and cervical spine injury in an elderly patient: a word of caution. J Emerg Med. 2005;29(4):433–436.
35. Burton JH, Dunn MG, Harmon NR, et al. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006;61(1):161–167.
36. Shafer JS, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009;10(2):74–78.
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