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Medical Studies

I have enclosed the following studies and articles to help providers understand the need for the Turley Backboard pad. This information should help your department or agency see just how much of a difference the Turley Backboard Pad can make to patients.  It will also educate providers on the most current trends in best helping the patients that we take care of.

Evidence Based Practice
Evidence based practice is a "total process beginning with knowing what clinical question to ask, how to find the best practice, and how to critically appraise the evidence for validity and applicability to the particular care situation..  The best evidence then must be applied by a clinician with expertise in considering the patient's unique values and needs.  The final aspect of the process is evaluation of the effectiveness of care and continual improvement of the process." (DePalma, 2000)

Iatrogenic
"Any adverse mental or physical condition induced in a patient by effects of treatment by a physician or provider.  Term implies that such effects could have been avoided by proper or judicious care on the part of the provider."   (Taber's Cyclopedic Medical Dictionary Edition 17)

Use of the Turley Backboard Pad for patient comfort
Pre-hospital spinal immobilization is one of the most frequently performed procedures for trauma patients in the field.  Approximately five million patients in the United States receive spinal immobilization every year.  Despite the widespread use, the clinical benefits of pre hospital spinal immobilization have been questioned. Spinal immobilization is not a benign procedure.  The adverse effects of spinal immobilization have been well documented… (and/or produce skin ulcerations)… In addition, the studies described here suggest that spinal immobilization in patients with suspected spinal injury who are conscious, might reposition themselves to relieve the discomfort caused by ischemia. 

Theoretically, this repositioning could worsen any existing spinal injury.  Patients who are unable to move or feel pain due to trauma  can be at risk for soft tissue injuries… Controlled trials to compare different  immobilization strategies on trauma patients need to be considered in order to establish an evidence base for the practice of pre-hospital spinal immobilization ( Effects of Pre hospital Spinal Immobilization: A Systematic Review of Randomized Trials on Healthy Subjects).  (http://pdm.medicine.wisc.edu   Pre hospital and Disaster Medicine, author  Irene Kwan, MSc;1 Frances Bunn, MSc 2,  January - February 2005)

"Increasing the amount of padding on a backboard decreased the amount of ischemic pain caused by immobilization.   (Pre hospital Emergency Care 2000;4:250-252   www.sciencedirect.com)

This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness...Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness. PREHOSPITAL EMERGENCY CARE 2002;6:421-424

"Conclusion:  This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness, the authors recommend that initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients.  Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations.  (Pre hospital Emergency Care  2002;6:421-424   www.sciencedirect.com)

"Conclusion:  The spinal board should be removed in all patients soon after arrival in accident and emergency departments, ideally after the primary survey and resuscitation phases."  (www.pubmedcentral.nih.gov/articalerender.fcgi?artid=1725508   Emergency Medical Journal 2001 by David Vickery)

Pressure Sores
"I believe many problems start in the E.R.," she says, "For example, patients should be cleared from the backboards within 20 minutes."  (Barbara Braden, RN, PhD, FAAN, developer of the Braden Scale for Predicting Pressure Soar Risk,   http://include.nurse.com/apps/pbcs.dll/article?AID=/20080505/NATIONAL01/80503001)

"Pressure sore development is multi-factorial with localized mechanical pressure being the integral component-"where there is no pressure, there is no sore"...the rate of pressure sore necrosis is directly related to the level of applied pressure and to time."   (The Use of spinal board after the pre-hospital phase of trauma management.  by D. Vickery www.emjonline.com)

"Pressure is a common cause of structural damage to a muscle and its peripheral nerve supply.  There is a definite time-pressure relationship in the development of pressure sores.  Skin can tolerate minute pressure indefinitely, but great pressure for a short time is disruptive.  Microscopic tissue changes secondary to local ischemia occur in less than 30 minutes.  Pressure interferes with arteriolar and capillary blood flow...Pressure necrosis can begin from within the tissue over a bony prominence, where the body weight is greatest per square inch."
(Critical Care Nursing, A Holistic Approach: Seventh Edition: pages 733-734)

"Presently, treatment of pressure sores in the United States is estimated to cost in excess of $1 billion annually....Many factors contribute to the development of pressure sores, but pressure leading to ischemia is the final pathway. Tissues are capable of withstanding enormous pressures when brief in duration, but prolonged exposure to pressures slightly above capillary filling pressure initiates a downward spiral towards ulceration...Irreversible changes may occur after as little as 2 hours of uninterrupted pressure."  (Decubitus Ulcers by Don R. Revis,Jr. May 15, 2008   www.emedicine.com/med/topic2709.htm)

"Factors known to be associated with the risk of bedsore development include: advanced age, immobility, poor nutrition and incontinence.  Such risk factors have been quantified in the Norton Scale and the Braden Scale. 13 Allman 14, using related but different criteria, found that 17% (14%-20% with 95% confidence) of hospitalized patients are at risk.  Certainly all paralyzed and otherwise immobile patients are included in that group."   (Cost Saving Through Bedsore Avoidance - National Decubitus Foundation: http://leedergroup.com/bullitins/bed-sores)

This and previous studies suggest that immobilization on rigid spine boards is painful and may produce tissue-interface pressure high enough to result in the development of pressure necrosis. Ann Emerg Med 1995 Jul;26(1):31-6


Hypothermia
"Passive re-warming methods, to be used in mildly hypothermic victims and as an adjunct in moderate-severe hypothermia, include heat packs to arms and groin areas, heating lamps, warmed blankets and warm-air-heated "sleeping bag" devices.”  (Hypothermia Prevention, Recognition and Treatment. Weinberg AD: Hypothermia. Annals of Emergency Medicine Feb.1993;22 (Pt. 2):370-377  www.hypothermia.org/weinberg.htm)

Hypothermia in Trauma
"Hypothermia is a serious problem in the management of a trauma patient."   (PHTLS 6th edition Pg. 99.)
"Over 4% of the patients arriving by air at the Trauma Center in Las Vegas, Nevada are hypothermic.  This is greater than 10 times the rate of hypothermia in patients arriving by ground.  Hypothermia is a major cause of death in trauma victims."   (Navy STTR FY2004 Topic # NO4-T021:  www.rockyresearch.com)

"Although hypothermia was more common in more seriously injured patients, stratified analysis revealed that hypothermic patients have a significantly higher mortality than patients with the same severity of injury who remain normothermic."    (Journal of Trauma-Injury, Infection and Critical Care  59(5):1081:1085, Nov. 2005  www.jtrauma.com/pt/re/jtrauma/abstract00005373-200511000-00010.htm)

"Hypothermia in trauma patients is generally considered an ominous sign"  (www.jtrauma.com/pt/re/jtrauma/abstract00005373-198709000-00011.htm)

Trauma Triad of Death
The Trauma triad of death is a medical term describing the combination of hypothermia, acidosis and coagulopathy. This combination is commonly seen in patients that have sustained severe traumatic injuries and results in a significant rise in the mortality rate

Significance of Hypothermia

  • Hypothermia present in 21% to 66% of trauma patients upon ED admission
  • 100% mortality <32 degrees Celcius
  • Increases cost, morbidity, mortality and length of stay

Hyperthermia
"Pre hospital Care:  Immediate cooling and support of organ-system dysfunction is essential.

  • Remove the patient from the hot environment, remove excess clothing, and transfer to a shady place, a cool vehicle, or a cool building.

  • Support airway, breathing, and circulation with intravenous fluids, supplemental oxygen and assist ventilation as indicated.

  • Initiate cooling measures with any resources available, but to not impede transfer to hospital if heatstroke is suspected.

  • Apply tepid water to the patient and fan the patient to increase water vapor pressure gradient and promote evaporative cooling.

  • Apply ice packs to the patient's neck, axillae, and groin.  Alternatively, cover, do not tightly wrap, the patient with a wet sheet. 

  • Transport the patient with air conditioning turned on and windows down."
    (Heat exhaustion and Heat Stroke   March 16, 2006   www.emedicine.com/emerg/topic236.htm)
  • "Heat Injuries:  A. Move to a cool environment, remove clothing.  B. Attempt to reduce temperature (fan, mist with water, ice packs) while rapidly transporting.”    (Patient Care Protocols-Pierce County, Washington  and the Emergency Medical Program Director Jan. 2008)

    Therapeutic Induced Hypothermia:
    "During the last 5 years there has been considerable research on the use of therapeutic mild or moderate hypothermia for the treatment of cerebral ischemia and traumatic brain injury to preserve central nervous system tissue and improve functional outcome."   (Critical Care Nursing-A Holistic Approach  Seventh Edition)

    "Conclusion:  Our preliminary observations suggest that treatment with moderate hypothermia appears to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest."  (The New England Journal of Medicine, Treatment of comatose survivors of Out-of-Hospital Cardiac Arrest with induced Hypothermia.  Volume 346:557-563  February 21, 2002
    Number 8;   http://content.nejm.org/cgi/content/full/346/8/557)

    "The incidence of cardiomegaly as seen on chest X-ray was actually less in patients randomized to field cooling, suggesting that field cooling did not worsen cardiac function.”  (Hypothermia induced pre hospital shown feasible, safe in resuscitated cardiac arrest.) (June 4, 2007 by Steve Stiles, Seattle, WA   http://www.theheart.org/article/794537.do)

    "Our study results indicate that therapeutic hypothermia represents a major step in cardiopulmonary resuscitation, allowing cardiac arrest patients to survive with better neurological function," says lead author Mauro Oddo, M.D. from the department of critical care medicine at Lausanne University Hospital in Switzerland.  "We now have the ability to better restore brain function and improve quality of life."    Mild hypothermia to 33 degrees C(91.4 F) was induced with external cooling using ice bags and a cooling mattress....Based on our data, therapeutic hypothermia should become the standard of care for the treatment of comatose patients after cardiac arrest...."This treatment is easy to implement, has a low cost, and has no significant side effects"....."Therapeutic hypothermia is one of the most exciting new therapies for cardiac arrest patients in the last decade,"Dr. Merchant comments, "It has already begun to have a major impact on outcomes from cardiac arrest.  It is only a matter of time before we see patients not only survive cardiac arrest, but survive it well."    (Cooling Body Temperature in Cardiac Patients:  Society of Critical Care Medicine  http://www.csrt.com/e_news.php?display&419&item)

    "Animal studies suggest that the induction of therapeutic hypothermia in patients after cardiac arrest should be initiated as soon as possible after ROSC  to achieve optimal neuro-protective benefit."  (Pre hospital cooling; May 28, 2008:  http://lib.bioinfo.pl/auth:Kerner,T)

    "Cooling was initiated on-site with application of ice packs at the groin and neck and was continued in the ICU....Conclusion:  This small study suggests that a simple therapeutic hypothermia protocol is easy to implement and may increase the likelihood of survival to discharge after pre hospital cardiac arrest.  (Rapid implementation of therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors) (Emergency Medicine Spring Conference  April 24-26, 2007 San Diego, CA)

    "Davis, 50, thinks he owes his recovery to therapeutic hypothermia- an intervention Wake County paramedics began pioneering last year.  Last October, Wake County EMS became on of the first in the nation to use hypothermia in the field for cardiac arrest patients...The fire department was the first to arrive at their North Raleigh home, followed a moment later by Wake EMS.  An EMS supervisor brought in ice-cold saline solution and medicines to keep Mr. Davis from shivering during the hypothermia treatment.  After jump-starting him heart, paramedics placed ice packs around his head, armpits and groin and started him on the cold saline, then took him directly to WakeMed on New Bern Avenue.....Thirty nine days after his heart stopped, Mr. Davis left the hospital Aug. 31.  He made it to the car on his own steam, using a walker.”  (When the Heart Stops, Hypothermia Helps; N.C. EMS pioneers cooling patients to save lives, protect brains  "Perfect Health" by Jean Fisher  JEMS Magazine  http://www.jems.com/news)

    "Cooling the patient reduces the brain's need for oxygen, helping to minimize the damage that typically occurs after the heart stops and blood flow to the brain is interrupted...Surprisingly, most the damage to the brain actually occurs after the heart is restarted," said Dr. Laurence Katz, an emergency physician at UNC Hospitals who has been researching the use of hypothermia therapy for 17 years.  “During cardiac arrest, the brain is like a smoldering fire," Katz explains. "The blood returning to the brain carries toxins that act like gasoline being poured on a smoldering fire, igniting a pathway of devastation that causes irreversible brain damage over a 24 hour period.  Hypothermia helps put out that fire so the brain has a chance to recover function."  (UNC Hospitals using hypothermia therapy to prevent brain damage after cardiac arrest;  Oct. 2, 2007    http://www.unchealthcare.org/site/newsroom/news/2007/Oct/hypothermia/ )

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    * P.O. Box 65396 * University Place, WA. 98464
    877 - 460-3326 * 253 460-3326 * amy@turleybackboardpad.com

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