Spinal Immobilization free essay sample

These resources have been analysed and a conclusion drawn from them in regards to spinal immobilisation in the pre-hospital setting. Method: This assignment uses an evidence based approach; the author explores spinal injuries and the current management of them in the pre-hospital setting across a number of countries. The author relates current practice with recent literature and draws a final conclusion from the findings. Conclusion: Prehospital care for patients with acute traumatic spinal injuries requires great care to avoid secondary injury; recognition of otential injury is of great importance. Although injuries to the spinal cord occur in 2% of the patients that paramedics immobilize, pre-hospital management and treatment can play a significant role in the patient’s outcome. There is growing evidence that full body immobilization can be of more harm than good if not done correctly. Introduction Traumatic spinal cord injuries are severe, life threatening and life altering . Managing the risk of spinal cord injury in trauma patients is an understandable concern for medical professionals. We will write a custom essay sample on Spinal Immobilization or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Spinal immobilization is initiated on a regular basis in pre-hospital setting for patients at risk of a spinal cord injury. In the past immobilization has been thought to be a relatively harmless procedure. There is now, however, growing evidence that this approach can be harmful, pre-hospital spinal immobilization in trauma patients should be questioned and explored. There is a large amount of literature on pre-hospital immobilization; the purpose of this paper is to review the current literature and make a recommendation for New Zealand practice. This paper explores current pre-hospital management of spinal cord injuries, the literature around cervical spine immobilization and full body immobilization. Spinal cord injury Spinal cord injury is injury to the spine with any localised damage to the spinal cord or to the roots that lead to some functional loss, either loss of motor function (paralysis) or sensory loss (paresthesias). Spinal cord injuries are caused by the spine being forced beyond its normal range, injury can be caused by hyperflexion, hyperextension, rotation, compression, or penetrating injury of the spinal cord. The leading causes of injury to the spinal cord includes car accidents (40%), falls (21%), acts of violence (15%), sporting injury (13%) (Sanders, 2012) Spinal injuries may be classified into sprains, strains, fractures, dislocations and/or actual cord injuries. Spinal cord injuries are further classified as complete or incomplete and may be the result of pressure, contusion or laceration of the spinal cord (Marieb amp; Hoehn, 2010). It is very important for paramedics and emergency personal to know that pain from a spinal cord injury is not necessarily localized to the area of the injury. In 18% of cervical, 63% of thoracic and 9% of lumbar injuries, the pain is located elsewhere (Bernhard, Gries, Kremer, amp; Bottiger, 2005). Current Management Pre-hospital management of acute spinal cord injury is of critical importance, it has been estimated that 25% of spinal cord damage may occur or be aggravated after the initial event (Bernhard, Gries, Kremer, amp; Bottiger, 2005). Pre-hospital treatment of patients with a spinal cord injury involves recognition of patients at risk and appropriate immobilisation (Tintinalli, 2011). Spinal immobilization and spinal precautions are common practices in the pre-hospital setting of patients with trauma. Despite this practice, spinal cord injuries are rare, approximately 2%, and are often obvious at the scene. Several rules exist that are designed to help pre-hospital providers clinically clear the cervical spine this helps reduce the need for radiography and reduce adverse effects from spinal immobilization (Alejandro amp; Schiebel, 2006). The goal of pre-hospital management of spinal cord injuries is to reduce neurological deficit and to prevent any additional loss of neurological function. Therefore, prehospital management at the scene should include a rapid primary evaluation of the patient, resuscitation of vital functions (airway, breathing, and circulation), a more detailed secondary assessment, and finally transportation to definitive care. In addition, after arriving at the scene, it is important to evaluate the scene and to understand the mechanism of injury in order to identify the potential for spinal cord injuries (Bernhard, Gries, Kremer, amp; Bottiger, 2005). Currently in New Zealand according to St John (2011) clinical guidelines and Wellington free Ambulance (2011). If the patient has any of the following signs or symptoms they should have their cervical spine immobilised: 1. Tenderness at the posterior midline of the cervical spine or 2. Focal neurological deficit or 3. Decreased level of alertness or 4. Evidence of intoxication or 5. Clinically noticeable pain that may distract the patient from pain of a cervical spine injury. Australia’s Queensland Ambulance service has similar cervical immobilisation criteria to New Zealand, they use a clear flow chart to that is similar to the Canadian C-spine Rule but includes distracting injury and intoxication. Their other treatments focus on limiting neurological deficit and prevent secondary injury. This is achieved through appropriate spinal immobilisation, maintaining a high index of suspicion of spinal cord injury (Clinical pratice guidelines Trauma, 2011). Saskatchewan, Canada also use the Canadian C-Spine rule, this rule is only used if the patient is co-oprative and has a Glasco comoa scale (GCS) of 15. If the patient meets ther criteria for cervical spine immobilization they are also fully immobilised on a long spine board or scoop stretcher. Full immobilization includes the head, neck and spine; this is done to prevent any further injuries during transport. Canada also administers an anti-emetic (anti-nausea medication) to prevent any unwanted and preventable movement (Saskatchewan Emergency Treatment Protocol Manual, 2012). In the United States of America to determine whether it is appropriate to apply full spinal immobilization which can include rigid collar, backboard, three point restraining device and head immobilization device, in the prehospital setting the following is assesses. If any of the below findings are positive, full spinal immobilization is to be implemented (Emergency medical services pre-hospital treatment protocols, 2012). 1. Midline bony spinal tenderness to palpation 2. Physical findings with a neurologic deficit 3. Altered mental status to including substance abuse and loss of consciousness 4. The presence of additional painful or distracting injuries 5. The complaint of numbness 6. Language barrier i. e. patient not understanding the questions asked, dementia, speaks a different language, or mentally delayed 7. Pain in cervical region on movement 8. Children under the age of 12 9. Significant mechanism of injury or care provider judgment It appears that the United States of America fully immobilize the majority of suspected/ potential spinal cord injuries. Litigation associated with error in spinal management can be very costly, with the average payouts being $3 million per incident in the United States (Abram amp; Bulstrode, 2010). The Literature Cervical spine immobilization It is believed that movement of the non-immobilised patient with an unstable vertebral column injury places the spinal cord at risk of primary or worsening damage. There is a lot of evidence that cervical immobilisation can restrict movement, but evidence proving that cervical collard protect against secondary injury is lacking (Ramasamy, Midwinter, Mahoney, amp; Clasper, 2009). In prehospital care, paramedics are trained to immobilize all patients with possible spinal cord injury; in order to prevent additional neurologic injury. Many patients will be found to have no injury to the spine at all. Some will have an unstable fracture with an intact spinal cord; the goal is to prevent movement of the spine therefore preventing damage to the spinal cord. Others will unfortunately already have neurological disability on initial examination. In these patients, the goal is to prevent further cord injury (Peery, Bruice, amp; White, 2007). A number of risks may be associated with application of the cervical collar. If the jaw support of the collar clamps the teeth together, the airway may be compromised if the patient vomits. Cervical collars have also been found to place pressure on the neck this can cause an increase in intracranial pressure. Acute respiratory failure, hypoxia and hypoventilation have also been reporter (Bernhard, Gries, Kremer, amp; Bottiger, 2005; Hann, 2004; Abram amp; Bulstrode, 2010; Engsberg, et al. , 2013). A rise in intracrainal pressure (ICP) has been associated with a worse neurological outcome in patients suffering from a head injury. Cervical spine immobilisation has been foud to increase the ICP by approximatly 4. 5 mmHg. This is relevent because head injuries occur in an average of 34% of trauma patients (Abram amp; Bulstrode, 2010). Galim, et al. 2012) applied cervical spine imobilisation to nine fresh cadervers in order to assitaine weather or not collars exacerbate cervical spine injuries. X-ray’s were taken befor and after application of the collar. Galim found after the application of the collar there was a grossly abnormal seperation of the verterbra in all nine cadervers. The average seperation mesurement was 7. 33 mm (see figure 1). The collars did not cause the injury, but th is appears to promote seperation between vertebrea. This seperation sugests collars push the head away from the body, this causes stretching of the soft tissue including the spinal cord. Galin, et al recognises that the use of cadervers could repersent worst case scernario because of the difference in muscle tone in compard to an unconscious patine. The result of a randomized controlled trial on healthy volunteers has provided some useful insight into cervical spine immobilization and its effectiveness in trauma patients (Alejandro amp; Schiebel, 2006). Figure 1 Hann (2004) found that in general only 55% of patients will fit perfectly into cervical immobilization collars. The majority of patients will have an ill-fitting Collar. True cervical immobilization is likely to be unobtainable. Even a halo frame (which has mental pins that are screwed into the skull), allows a small amount of motion. However, the rigid cervical immobilization collar remains the best and most effective for the needs of the prehospital setting (Hostler, Colburn, amp; Seitz, 2009). Ideally, only patients with unstable spines would have a cervical collar applied. But these patients cannot be identified in the pre-hospital setting; determining spinal injury out of hospital is not easy nor is it accurate (Horodyski, DiPaola, Conrad, amp; Rechtine, 2011). In both Canada and Australia the Canadian C-Spine Rule is used to determine which patients could benefit from immobilisation (see figure 2). In one study on 8,283 patients who were assessed by emergency services and the Canadian C-Spine rule was applied. The paramedic’s received a short online tutorial on how the C-Spine rule worked. This study found that paramedics were able to apply this rule reliably, and did not miss any cervical spine injuries. The rule was found to be accurate; only 12 patients had clinically significant spinal cord injuries (Vaillancourt, et al. 2009). Figure 2 Full spinal immobilization There is growing questioning of the need to fully immobilise a patient, with many suggestions that immobilisation does not prevent additional spinal cord injuries, however it may in fact cause such injuries (Krell, et al. ,2006; Alejandro amp; Schiebel, 2006; Bernhard, Gries, Kremer, amp; Bottiger, 2005; Peery, Bruice, amp; White, 2007). The use of a spinal board is com mon in attempt to provide rigid spinal immobilization in the pre-hospital setting for trauma patients with potential spinal injuries. Nevertheless, the benefit of long backboards is largely unproven (Alejandro amp; Schiebel, 2006). A number of studies in the literature do present complications when poor standards of immobilisation are performed. Issues include occipital, lumbar and sacral pain development when padding is inadequate or absent, increased respiratory compromise with incorrect chest strapping, pressure sore development due to inadequate padding and spinal miss-alignment again are as a result of inappropriate/ inadequate padding. Perry, Brice amp; White (2007) found that if a patient is lying on a spinal board which is poorly trapped, it is likely the patient would move more during transport than if they were places on the stretcher. Inadequate pre-hospital spinal immobilization was found to occur on a regular basis; the main problem being straps had greater than four centimetres slack. Straps that have a four centimetres or greater slack cannot sufficiently immobilise a patient with a potential spinal injury. Abram amp; Bulstrode (2010) has noted that correct immobilisation of the cervical spine, with placing a patient on a backboard with the straps tightened correctly, that the patients respiratory function can be restricted by up to 15%. If the patients head is strapped in place but the body is poorly immobilized, this creates a situation where the body can pendulum at the neck. This situation is potentially more dangerous than not immobilising at all because it allows transport forces to move the weight of the body against an unstable spine (Peery, Bruice, amp; White, 2007). The general theory of spinal immobilisation is that movements would be reduced if neck protection is used along with a backboard to aid smooth extrication form a motor vehicle. Engsberg, et al (2013) found a significant decrease in movement (as opposed to full assistance i. e. spine board) when the patient exited the vehicle unassisted with a cervical collar in place to protect the neck. The results indicated that an unassisted cervical protected technique had significantly less range of motion than the unassisted unprotected and the fully assisted technique. In fact, with the addition of the cervical spine collar the level of protection was increased and range of motion was decreased in many instances (Engsberg, et al. , 2013). The use of backboards have been found to induce three to five as much movement than a scoop stretcher if the patient is on the ground (Krell, et al. , 2006). Abram amp; Bulstrode (2010) sugests that the risk of futher neurological injury due to inadiquate immobilisation may be overestermated. They back this statement up with a 5 year retrospective study. The neurological outcomes for patients where no routine pre-hospital immobilization was used were compared to trauma patients who received spinal immobilization. Two physicians acted independently, the patients were categorised into disabling r non-disabling. The trial found deterioration occurred less frequently and there was less over all neurological disability in the patients with no routine immobilization. It was suggested that, a large amount of force is required to damage the spine and injure the spinal cord; Abram amp; Bulstrode concluded that movement created during transport was unlikely to generate sufficient energy to res ult in additional injury. There were however weaknesses in this study. Patients who died at the scene or during transport were excluded. It was concluded that neurological deterioration in patients with spinal cord injury occurs in around 5% of patients even with good immobilization of the spine. Conclusion Immense care needs to be taken when providing medical care to an acutely injured patient with suspected spinal injury in the pre-hospital setting. Approximately 2% of all trauma patients will have sustained a spinal injury. Patients with acute traumatic spinal injury are at risk of neurologic deterioration which is thought to be due to secondary injury to the spinal cord. A potential cause of secondary injury is through unintentional manipulation of the spinal cord predominately in the setting of an unstable injury. Minimizing the chances of secondary injury can be challenging in the pre-hospital setting due to the location and accessibility of the patient, transport. Treatment that is initiated in the pre-hospital setting can lead to significant morbidity in other body areas, such as pressure areas, decreased respiratory effort. There is large variation in how care is administered in the pre-hospital setting from one country to another. There is a possibility that fill body immobilization may be contributing to mortality and morbidity in some patients, this warrants further investigation. The Canadian C-spine study showed that only 0. 14% of patients immobilized had clinically significant spinal cord injuries. New Zealand could improve their current practice by improving pre-hospital criteria to establish which patients really are at significant risk for needing spinal immobilization, this could reduce the number of patients exposed to the unnecessarily risks of spinal immobilization. Bibliography Abram, S. amp; Bulstrode, C. (2010). Routine spinal immobilization in trauma patients: What are the advantages and disadvantages. The Surgeon, 218-222. Ahn, H. , Singh, J. , Nathens, A. , MacDonald, R. D. , Travers, A. , Tallon, J. , . . . Yee, A. (2011, August). Pre-Hospital Care Management of a Potential Spinal Cord Injured Patient: A Systematic Review of the Literature and Evidence-Based Guidelines. Journal of Neurotrau ma, 8(28), 1341–1361. doi:10. 1089/neu. 2009. 1168 Ahn, H. , Singh, J. , Nathens, A. , MacDonald, R. D. , Travers, A. , Tallon, J. , . . . Yee, A. (2011, August). Pre-Hospital care management of a potential spinal cord injured patient: A systemic review of the literature and evidance-based guidelines. Journal of Neurolotrauma, 28, 1341-1361. doi:10. 1089/neu. 2009. 1168 Alejandro, A. , amp; Schiebel, N. (2006). Is routine spinal immobiilization an effective intervention for trauma patients? Emergency Medicine, 110-112. Bernhard, M. , Gries, A. , Kremer, P. , amp; Bottiger, B. (2005). Spinal cord injury Prehospital management. Resuscitation, 127-139. Clinical pratice guidelines Trauma. (2011, September). Retrieved from Queensland Ambulance Service: http://www. mbulance. qld. gov. au/medical/pdf/09_cpg_trauma. pdf Dunn, T. M. , Dalton, A. , Dorfman, T. , amp; Dunn, W. W. (2004). Are emergency medical technition-basics able to use a selective immobilization of the cervical spine protocol? Prehospital emergency care, 207-211. Emergency medical services pre-hospital treatment protocols. (2012, January 3). Retrieved from Commonwealth of Massachuse tts : http://www. mass. gov/eohhs/docs/dph/emergency-services/treatment-protocols-1001. pdf Engsberg, J. R. , Standeven, J. W. , Shurtleff, T. L. , Eggars, J. L. , Shafer, J. S. , amp; Naunheim, R. S. (2013). Cervical spine motion during extraction. The Journal of Emergency Medicine, Vol 44, 122-127. Galim, P. B. , Dreiangel, N. , Mattox, K. L. , Reitman, C. A. , Kalantar, S. B. , amp; Hipp, J. A. (2012). Extrication collars can result in abnormal seperation between vetebrae in the presence of a dissociative injury. The Journal of Trauma, 12-16. doi:10. 1097/TA. ob013e3181be785a Hann, A. (2004, August 20). A photographic guide to prehospital spinal care: Edition 5. Retrieved April 2, 2013, from Emergency technologies: http://www. neann. com/pdf/psc. pdf Horodyski, M. , DiPaola, C. P. , Conrad, B.

Book Title Ideas 6 Actionable Steps to Choose a Book Title That SELLS

Book Title Ideas 6 Actionable Steps to Choose a Book Title That SELLS Book Title Ideas: How to Choose the Perfect Title for Your Book I get how frustrating it can be.Writing the book might seem like the most difficult partand then you have to actuallytitle the darn thing!When it comes to writing a book,coming up with reasonable book title ideas is surprisingly one of the hardest parts to complete. It’s difficult because titles are essentially short hooks that advertise your book using the fewest words possible.It’s also what readers look for first whenthey discover new books, and can take less than 5 seconds to make a decision.This is why it’s so crucial to craft a perfect name. Heres how to come up with book title ideas:Write down the problem youre solvingCreate a subtitle to clarifyMake it memorableMake sure its genre-appropriateCreate it to stir intrigueInclude your character in the titleTo help spur your creative process, we’ve created a few essential guidelines for you to follow as you craft the perfect book title ideas for your masterpiece.Since there are different title considerat ions for fiction and non-fiction, we broke these two topics down separately into:How to Choose a Book Title for Non-FictionHow to Choose a Book Title for FictionLet’s create your selling title!NOTE: We cover everything in this blog post and much more about the writing, marketing, and publishing process in our VIP Self-Publishing Program. Learn more about it hereHow to Choose a Book Title for Non-FictionAs you begin crafting your book title ideas for your non-fiction book,the key is knowing that non-fiction readers are looking for solutions.Whether it’s losing weight, becoming a master in sales, or becoming better at fostering relationships, they’re simply looking for a book that will solve their problem. To leverage this idea, here are a set of rules to consider:#1 Your Title Must Include a Solution to a ProblemYour title should be crystal clear on what your readers will achieve by reading your book. Experts say that a title with a clear promise or a guarantee of results will further intrigue your readers.Here are some questions to consider when creating your title:Are you teaching a desirable skill?Can your personal discoveries impact someone’s life?Can your book solve a very difficult problem?Here are our favorite book titles that offer a clear solution to a problem with promising results:Asperger’s Rules!How to Make Sense of School and Friendshipby Blythe GrossmanHow Not to Die: Discover the Foods Scientifically Proven to Prevent and Reverse Diseaseby Michael GregerThe 4-Hour Workweek: Escape 9-5, Live Anywhere, and Join the New Richby Tim FerrissBook Title Ideas Action Plan:Write down the best solutions or teachings your book offers and form these into potential book title ideas.#2 Use a Subtitle for ClarityA great non-fiction title employs a subtitle to clarify what the desired outcome will be from reading yourbook.In this video clip, Chandler explainsin 5 simple steps how to create a compelling subtitle:Here are some questions to consider when creating your subtitle:How can your subtitle further expand on achieving a desirable outcome?What are the biggest pain points that yoursubtitle can provide a solution for?How can you further address your innovative solution in the subtitle?Here are our favorite book subtitles that spell out what their readers can expect from reading their books:The Crossroads of Should and Must:Find and Follow Your Passionby Elle LunaBetter Than Before: Mastering the Habits of Our Everyday Livesby Gretchen RubinWork Rules! Insights from Inside Google That Will Transform How You Live and Leadby Laszlo BockBook Title Ideas Action Plan:Make a list of 10 attention-grabbing subtitles that promise big outcomes and other positive benefits.#3 Make Your Title UnforgettableCatchy titles are memorable, boring titles are not. So make an effort to be more creative and fun with your book title! Use alliterationsto make your title easier to read and remember. A memorable and light-heart ed title adds additional character to your book and is also a great way to attract readers.Here are some questions to consider when creating your memorabletitle:Will a fun title turn a normally boring subject into something more interesting?Will adding humor to your title further entice readers?Will a cleverly written title stand out from other books in this genre?Here are our favorite books that engaged us with clever titlesand subtitles:Me Talk Pretty One Dayand Let’s Explore Diabetes With Owlsby David SedarisTrust me, I’m Lying: Confessions of a Media Manipulatorby Ryan HolidayFreakonomics: A Rogue Economist Explores the Hidden Side of Everythingby Steven D. LevittBook Title Ideas Action Plan:Experiment with different types of styles and poll your audience to determine whether a comedic, shocking, or even bizarre title will be the most appealing to your target audience.No matter which method works best on creating a compelling title for nonfiction books, a good thin g to remember is to always test multiple titles with different audiences to determine which book title generates the biggest response.Getting good feedback is the only way to know for certain which title is perfect for your book.How to Generate Book Title Ideas for FictionGenerally, fiction titles are allowed more creative wiggle room than their non-fiction counterparts. That being said, an effective fiction title must still pique your readers’ attention. And while it’s true that you can title your fictional book with random names, it still mustcatch the reader’s attention.Here are some key guidelines to keep in mind:#1 Your Title Should be Appropriate to Your GenreYour novel title should use language that resonates with both your genre and target audience. For example, a romantic book can call for dreamy language whereas an action book can warrant strong and powerful words.This means that you mustknow your books genre and words that best fit the style of title .Here are some questions to consider for appropriate genre titles:What genre best fits this story?Which are the perfect choice words for your genre?Here are our favorite fictional titles based on genre:Ready Player Oneby Ernest ClineThe Great Gatsbyby F. Scott FitzgeraldThe Godfatherby Mario PuzoBook Title Ideas Action Plan:Based on the genre of your book, pick out a few keywords that best suit its category and evoke strong emotions in your readers.#2 Your Book Title Should Pique YourReader’s InterestA great fiction title teases and leaves your audience wanting more. You want your audience to read your title and think, â€Å"I must read what’s behind that great book cover!†Create fictional titles intriguing enough tocapturethe imaginations of your readers, and get to them to read your story.Here are some questions to consider on how to pique interest with your title:Which key components of your story best captivatesyour readers?What emotions do you want your re aders to have once they read your title?Here are our favorite fictional titles that drew our attention:Fahrenheit 451by Ray BradburyThe Da Vinci Codeby Dan BrownFear and Loathing in Las Vegasby Hunter S. ThompsonBook Title Ideas Action Plan:Choose a theme that will best draw your reader’s attention. Come up with 5 titles that will catch your reader’s attention and pique their curiosity.#3 Look to Your Characters for Book Title InspirationA great book title captures the spirit of the protagonist. Some authors simply use the hero’s name for their  title.Others have combined the names of their hero along with their special qualities to inform the audience about their protagonist’s accomplishments like Charlotte’s Web by E.B. White.On the flip-side, a formidable antagonist can also be an amazing book title.Asinister name can convey a sense of dread and expectation for what’s to come like Doctor Sleep by Stephen King. Both choices are great ti tle ideas and should be seriously considered for your fictional book.Here are some questions to consider when including a character as a title:Between the hero and villain, who impacts the story more?Are there any stunning qualities from your characters that will draw a reader’s emotion?Can the plot of the story be summed up as a title?Here are our favorite fictional books that use characters for its title:Harry Potter(Literary Series) by J. K. RowlingBridget Jones’ Diaryby Helen FieldingEnder’s Gameby Orson Scott CardBook Title Ideas Action Plan:Determine which character best conveys what the story will tell in your title. You may also include creative words or themes to further showcase the character’s unique qualities or the journey itself.Your Next StepsUltimately, the title of your book depends on you, the author. By following these constructive guidelines, you will be able togenerate a number of book title ideas you can use to find the perfect one t hat grasps the attention of readers and soon become an Amazon bestseller in no time!#1 Join your FREE training!This training was created just for you. Make sure to save your spot and sign up right now so you can learn exactly what it takes to write and publishyour book within 90 daysor even less!You wont find this guide anywhere else. Take advantage of this offer so you can spark multiple book title ideas in as little as an hour!