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42 MARCH 2015 | EMSWORLD.com Myth #5: Patient Extrication with the KED Prevents Spine Movement The myth explained: Following major motor vehicle collisions, prehospital providers are taught that a patient should remain still within the vehicle and allow properly trained rescuers to control their movements to remove the patient from their vehicle and place them on a long backboard. Prehospital providers are taught several techniques, ranging from rapid extrication to applica- tion of a Kendrick Extrication Device (KED). We're literally taught the patients may kill themselves if they move on their own with an unrecognized spine injury. The Evidence In 20 09, Jeffer y Shafer and Rosanne Naunheim teamed up to compare the differ- ences in spine motion when patients remove themselves from a severely damaged vehicle compared to when the patient is removed with assistance from prehospital profes- sionals. Using motion tracking cameras and strategically placed sensors on their volunteer patients, these authors performed four tests: self-extrication with and without a cervical collar, and extrication by rescu- ers directly onto a long spineboard, and via KED. In each test the spine motion was recorded for both the overall change from start to finish as well as the range of motion. Self-extrication without a cervical collar produced an average change of 8.7 degrees of motion (standard deviation 11.9⁰) in the cervical spine with a range of motion over 31⁰; the application of a cervical collar reduced the overall change to 1.4⁰ (SD 4⁰) with a range of motion of 6.4⁰. Standard extrication onto a longboard produced an average of 1⁰ (SD 4.5⁰); however, the range of motion was 26.6⁰, and when a KED was used to assist with extrication the patient's mean overall change was 2⁰ (SD 2.3⁰) with a range of motion of 31.1⁰! Based on this study the authors conclud- ed patient manipulation to apply a KED and slide them onto a longboard directly from a vehicle causes more spine motion than does applying a cervical collar and allowing the patient to extricate themselves and walk to a stretcher. 15 A similar study was repeated by jack Engsberg and his colleagues and pub- lished in the Journal of Emergency Medicine in 2013. These researchers found the appli- cation of a KED during the extrication pro- cess causes more spine motion than assisted extrication directly onto a spineboard and compared to a patient self-extricating after a cervical collar is applied. 16 The Bottom Line The KED increases spinal column motion during the extrication process; alternative methods of extrication need to be consid- ered and explored. Myth #6: Never Remove a Dressing from a Bleeding Wound; When It Bleeds Through Just Add on More Dressings! The myth explained: Every major first aid resource says to apply a dressing on any uncontrolled hemorrhage, and if it soaks with blood to add more dressings on top of the original but not remove the blood- soaked dressing. The claim is removal of the original dressing may disrupt clots that are forming, causing the patient to continue to bleed. The Evidence To start addressing this myth it's important to understand the basics of hemostasis, the process through which clots form. When an injury to a blood vessel occurs, colla- gen and von Willebrand factors (vWF) are exposed and promote platelets to attach to the wounded surface. As platelet aggrega- tion occurs, a plug develops which stops the bleeding. Platelet aggregation occurs along human tissue. Once a platelet plug occurs and hemorrhage stops, a fibrin mesh begins to form that stabilizes the clot and strengthens it. When a dressing is applied to a wound, the goal is to stop the bleeding. This is suc - cessfully completed 95% of the time with well-aimed direct pressure directly into the injured tissue. The key to well-aimed direct pressure is to apply adequate pressure into the injured tissue and on the injured vessel. When pressure is applied generally around the wound there is typically inad- equate pressure to stop the hemorrhage. Well-aimed direct pressure means target- ing the pressure directly into the hemor- rhaging tissue. There is not one clinical trial that dem- onstrates removing a blood-soaked dress- ing will cause clot removal or cause the clotting process to start over. When large bulky dressings are applied over hemor- rhage sites it becomes very difficult to apply well-aimed direct pressure into the wound and as a result more generalized pressure around the injury occurs. At this point, the dressing becomes a source for collecting the lost blood and is actually doing very little to control hemorrhage. Dressings that quickly become saturated with blood are an indication adequate pres- sure has not been applied to the bleeding site. Simply adding more dressings on top of the injury will do little more than absorb more blood; it will not help control bleeding or support clot formation. When a dressing becomes soaked with blood, remove it and apply better aimed pressure with a clean dressing. In 2014, the American College of Surgeons released a position paper on prehospital hemorrhage management strategies. In this paper they identify that well-aimed direct pressure is likely to control hemorrhage in most instances. When hemorrhage can- not be controlled with well-aimed direct pressure, they recommend the next step be tourniquet placement for extremity injuries. In instances when a tourniquet cannot be © Jones and Bar tlet t Learning. Photographed by Kimberly Pot vin. CONTINUING EDUCATION