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I.Was Concerned to Read the Paper Injured 302 Letters to the Editor Centre in collaboration with the British extrication from a vehicle, the patient can be Study) for providing information from the Association for Accident and Emergency J Accid Emerg Med: first published as 10.1136/emj.13.4.302-b on 1 July 1996. Downloaded from Medicine, June 1995. extricated with support to the whole spine study. This database, compiled from clinical 3 Underhill TJ, Greene MK, Dove AF. A safely from virtually any vehicle accident. The notes, reveals that of the 658 patients with a comparison of the efficacy of gastric lavage, board's construction, specifically designed trauma score greater than 15, only 51 ipecacuanha and activated charcoal in the and emergency management of paracetamol with a slippery surface to slide patients from patients were recorded as trapped overdose. Arch Emerg Med 1990;7:148-54. the wreck, has a major advantage in requiring extrication (personal communica- prehospital care as an extrication device. This tion). is not possible with a vacuum mattress or If thought necessary, a single ambulance The authors reply scoop types of stretcher or, in fact, any other crew could transfer a patient from a spinal type of stretcher available. board simply by use of a scoop stretcher We are grateful for the opportunity to The patient on extrication is immediately placed between the patient and the board and respond to these comments regarding our immobilised with head and neck restraint and then lowered onto a vacuum mattress. This, paper. four body straps and transferred to an however, would be time consuming and With regard to the suggestion that we ambulance trolley. The patient is then probably not warranted; it would add time to implied gastric lavage to be an inappropriate transported on the board during the short the evacuation of the casualty. measure in scenarios 1 and 2, we must stress transfer to hospital, where, again, the As covered in our paper, the spinal board that the intention of our paper was to provoke advantage of being on a board is obvious. In is not an ideal surface The spine is not flat! debate (successfully it would appear) rather the case of a multiple injury patient, rapid The neck is extended on the board'; it causes than to suggest management guidelines. transfer from an ambulance to hospital trolley patients without spinal injury pain and The paper by Underhill et al (reference 3 is essential and this is facilitated by rapid discomfort; it causes pressure sores in those above) showed paracetamol levels falling by a transfer on the spine board, again with a patients with (often irreversible) spinal mean of 39.3% over the two hours following patient fully immobilised. The hospital staff, injury, who may stay on the board until they lavage. This does not demonstrate causality, once appraised of the mechanism of injury arrive at a spinal centre. Patients are left on particularly in the absence of an adequate and apparent injuries to the patient, can the board longer than necessary due to control group. The paper also demonstrated decide whether to maintain the patient on the caution about causing or extending an injury. a mean fall in serum paracetamol levels of board or transfer them with an appropriate This is usually until a radiological series is 40.7% following administration of ipecacuana spinal lift to a vacuum mattress. performed. These x rays may also be needed and of 52-5% over the same two hour period If a vacuum mattress were available on all because of pain caused by lying on a board, following administration ofactivated charcoal. front line ambulances, a single ambulance which cannot be differentiated from The difference between results for lavage and crew would not be able to transfer a patient, significant trauma.2 We do not think that in ipecacuana was not significant. The fall in once extricated from a wreckage, from a spine most settings rapid removal from the board paracetamol levels following charcoal was sig- board to a vacuum mattress. The vacuum takes place, and many casualty departments nificantly greater than both other forms of mattress, therefore, although an ideal A&E own boards to continue this type of spinal treatment. The paper concludes that "acti- department and secondary transfer tool, has immobilisation. vated charcoal was more effective at limiting a number of practical limitations in its Although we do not expect change in absorption of paracetamol following overdose prehospital use as a primary stretcher. The practice from our paper we wish to highlight than either gastric lavage or ipecacuana spine board certainly does have its the above points and agree with Dr Carney's induced emesis". The authors also comment limitations, with pressure area problems if suggestion that spinal boards should only be that gastric lavage is not a risk-free procedure. patients are left on the board for long periods used for the short periods of transfer to The new guidelines for the management of of time, but its value as an extrication device, hospital from the scene of the accident. paracetamol poisoning recommend lavage or enabling extrication with in-line spinal charcoal rather than lavage with charcoal as immobilisation for transfer to hospital, P W MAIN M E LOVELL the optimal treatment within two hours of cannot be overemphasised. 208 (Merseyside) Field Hospital, RAMC(V) ingestion (reference 2 above). This paper clearly emphasises the potential Chavasse House; Sarum Road; Liverpool; L25 2XP hazards of a spine board to a patient, with http://emj.bmj.com/ I GREAVES defined spinal column injury, but one must S GOODACRE 1 Schringer DL, Larmon B, LeGassick T, P GROUT remember that the majority of patients are Blinman T. Spinal immobilisation on a flat Accident and Emergency Department, placed on a board with only suspected injury, board: does it result in a neutral position of St _ames's University Hospital, because of their injury pattern or injury the cervical spine. Ann Emerg Med 1991; Beckett St, Leeds, LS9 7TF 20:878-81. mechanism that puts the spine at risk. The 2 Chan D, Goldberg R, Tascone A, Harmon S, safe extrication of a patient from the wreckage Chan L. The effect of spinal immobilisation is almost certainly of more importance to the on healthy volunteers. Ann Emerg Med integrity of a damaged spinal column than a 1 994;23:48-5 1. smaller risk of pressure area problems in the on October 2, 2021 by guest. Protected copyright. short transfer time to hospital. C J CARNEY Director of Operations Support surfaces Staffordshire Ambulance Service NHS Trust EDITOR,-I.was concerned to read the paper 1 Main PW, Lovell ME. A review ofseven support surfaces with emphasis on their protection of by P W Main and M E Lovell entitled "A the spinally injured. J7 Accid Emerg Med Fast tracking patients with a proximal review of seven support surfaces with 1996;13:34-7. femoral fracture emphasis on their protection of the spinally injured".1 The authors reply EDITOR,-Ryan et al are right to highlight the I would not in any way doubt their findings need for improvement in the management of on the pressure problems related to the use Thank you for the opportunity to answer Dr patients with proximal femoral fractures in of long spinal boards. Unfortunately, Camey's points. We would value any debate accident and emergency departments in the however, they seem to have missed the whole of this most important subject. United Kingdom' but even with the fast point of the use of spine boards in the We disagree that the long spinal board's tracking system in place, over 75% of their prehospital care of critically injured patients. main and most used function is in the patients waited two hours or more in the Although the spine board may provide a extrication setting, involving motor vehicle A&E department before transfer. Conse- surface for in-line immobilisation of the trauma. The spinal board will be used for any quently, we feel that the system does not fully spine, its primary function is in the road patient when spinal injury is suspected, address the real priorities for treatment of traffic accident setting, where it is used to including motorcycle accidents, falls from such patients. We define these priorities as (a) extricate patients from vehicles and for their heights, pedestrian RTAs, diving accidents, the urgent provision ofeffective analgesia and subsequent transportation to hospital. etc. We wonder what percentage of calls that splintage, (b) prompt imaging and other The spine board is the only tool that can an ambulance crew attends and where a investigations to allow for a plan of action, be used to slide a patient with a serious injury spinal board is used are for extrication. We (c) the primary prevention of common com- from a vehicle with safe in-line minimal suspect that it is few. It would be helpful if plications such as pressure sores, and (d) immobilisation of the spine and retain that such information were collected, since no clear and frequent communication with the immobilisation on route to hospital. With the direct figures are available. We are grateful to patient (and carers) about the likely timescale use of a board for both rearwvard and side Mr DA Boot (Mersey Trauma Outcome of transfer to a ward, surgery and postoper-.
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