Thoracostomy

27 ago

medest118:

An other fundamental procedure for prehospital emergency care teached on animal model at Sidney HEMS.
Enjoy the video.

Originally posted on Greater Sydney Area HEMS:

Here is a recommended open ‘finger’ thoracostomy technique for ventilated patients as taught by Dr Geoff Healy at Sydney HEMS Team Induction training August 2015, using porcine tissue.

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Why would you clamp a tracheal tube?

24 ago IMG_1584

medest118:

Very imprtant tip to improve care during transfer of the ventilated patients. There’s also an explaination video of the technique based on animal model. Surprisingly efficient and comfortably simple for retrivialist professionals.

Originally posted on Greater Sydney Area HEMS:

This video explains the rationale for clamping the tracheal tube in PEEP-dependent patients prior to switching ventilator circuits, a manoeuvre that is included in our Difficult Oxygenation Operating Procedure

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Evolution of inexpensive videolaryngoscopy: from concept to practice

20 ago

medest118:

Low budget (but perfectly working) video laryngoscope make us re-thinking about the usefulness of allocating resources in medical equipment. Is there a reason for medical technology to be so expensive? Thanks to the authors every medical professional can understand what there’s behind big companies manufactured devices. It’s time to open our mind and realazing that economical interests (and relaite conflicts) are not limited to big pharma but spreaded in many fields of medical supplies.

Originally posted on Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds:

Evolution of inexpensive videolaryngoscopy: from concept to practice

Author:
Dr. John George Karippacheril,
Specialist Anaesthesiologist, Abu Dhabi,
Former Associate Professor of Anaesthesiology,
Manipal University, India.
Email: johngeorgedon@gmail.com
Twitter: @johngeorgedon

“Vision is the art of seeing what is invisible to others” — Jonathan Swift

Not many procedures in Medicine have received the attention and focus of medical practice, especially in critical care, as laryngoscopy. A secure airway serves as a lifeline to the critically ill, yet the process of securing it remains at times enigmatic, more of an art than a science. Inability to secure the airway or airway related critical incidents remains a cause of morbidity and mortality in hospitals globally. Not every physician or healthcare provider may have the training or the tools they need to achieve a high degree of competence.

But why is this procedure fraught with difficulties, with dangers lurking around the corner? Well, it depends…

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Resuscitative hysterotomy

18 ago

medest118:

Another educational workshop from Sidney HEMS.
Today’s topic is resuscitative hysterectomy.
Watch the video for more information about the technique.

Originally posted on Greater Sydney Area HEMS:

This practical workshop is part of the Sydney HEMS Team Induction Training, and is one component of a learning program that also includes online preparatory material, simulation, a multi-station formal team objective structured practical assessment (also called ‘the exam’), and human factors training.

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Clamshell Thoracotomy Training

15 ago cc12504-1

medest118:

Great educational video on a lifesaving procedure.

Originally posted on Greater Sydney Area HEMS:

Induction Training for new HEMS Team members includes a procedure lab for life, limb and sight saving procedures.

Here’s an excerpt from a session on clamshell thoracotomy by Dr Geoff Healy

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HEMS winch Training

14 ago

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NICE released Major Trauma Guidelines Draft.

8 ago Logo MEDEST2
NICE-1024x131
The National Institute for Health and Care Excellence (NICE) published a Guidelines Draft on Major Trauma. The great thing about is that everyone can consult the draft and send suggestion (but only if you work for a stackholder organization) about the recommendations and scientific evidences contained.
Consult the documents at the links below:

Here are some highlights with a particular regard to pre-hospital environment recommendations:

Airway management

RSI and orotracheal intubation is the preferred method to manage airways (when compromised) in a trauma patient.
In prehospital setting RSI and OTI has to be performed on scene in less than 30 min from the initial call. Backup plan is SGA (in patients with reduced level of consciousness and no glottic reflexes) or basic airways maneuver plus adjuncts (patients with GAG reflexes still present), and transfer to Trauma Center (within 60 min) to manage airways. If Trauma Center is more than 60 minutes away, reach local hospital to perform RSI and than transfer the patient.

“The GDG had a strong belief that RSI of anaesthesia and intubation delivered by a competent person is the gold standard of care when maintaining the airway of both adults and children and made a recommendation for RSI of anaesthesia and
intubation accordingly.”

“The GDG suggested that the second best device for airway management was the supraglottic device. This device provides less protection than RSI of anaesthesia and intubation against aspiration; however this device provides greater protection than
basic airway adjuncts, and can be administered safely by in the pre-hospital environment by paramedics or physicians staff.”

“Supraglottic devices can only be used in patients without airway reflexes to avoid stimulating vomiting or laryngospasm,, and
are therefore only appropriate for use in patients with a reduced level of consciousness.”

“For patients with airway reflexes, where a supraglottic device cannot be used, the GDG recommended the use of basic airway manoeuvres and adjuncts until such time as RSI of anaesthesia and intubation is available.”

“The GDG therefore concluded that where possible, RSI should be delivered at scene and within a timeframe than minimised
pre-hospital time. Pre-hospitals systems should develop to make this widely available. Where pre-hospital RSI is not possible within a 30-minute window, the GDG recommended transporting the patient with supraglottic or basic airway adjuncts to a MTC within 60 minutes, otherwise to a TU”

Pre-hospital Tension Pneumothorax

  • Closed pneumo
Perform chest decompression of a suspected tension pneumothorax only in haemodynamically unstable patients or in pts who have respiratory compromise.
Perform open thorachostomy to drain tension pneumothorax in haemodynamically unstable patients (preferred on simple needle decompression).
Simple open thorachostomy can be performed only in intubated (and positive pressure ventilated) patients. In all other cases insert a chest drain to prevent a sucking chest open wounds
  • Open pneumo
No more vented or 3-sided occlusive dressing in open (sucking) pneumothorax: use a simple occlusive dressing to treat an open pneumothorax in the pre-hospital setting

“The GDG limited the recommendation to intervene to people who are haemodynamically unstable or have severe respiratory compromise. The GDG agreed that people who have signs of a tension pneumothorax but are haemodynamically normal can wait until hospital for a more definitive diagnosis and possible decompression.”

“Needle decompression is a simpler technique to perform than insertion of a chest drain but is associated with a number of complications. These include the cannula blocking, the catheter not being long enough and therefore, not penetrating the
thoracic parietal pleura, or incorrect placement of the needle, all of which result in the decompression not being successful. The GDG agreed by consensus that open thoracostomy is more effective and stable than needle decompression.”

“An open thoracostomy can only be used on intubated patients. A surgical incision is made, blunt dissection is performed, and the pleura penetrated. The wound is then left open. This is a rapid way of decompressing a tension pneumothorax in a critically injured trauma patient who is intubated. The positive pressure ventilation prevents the thoracostomy wound from acting as an open, ‘sucking’, chest wound”

“The GDG agreed that given the lack of evidence, no recommendation could be made around whether an occlusive dressing for an open pneumothorax should be vented or three-sided. Additionally, the GDG accepted there was no evidence to make a
recommendation around supplementing the dressing with a chest drain in the prehospital setting.The GDG decided through expert consensus to recommend using a simple occlusive dressing to treat an open pneumothorax in the pre-hospital setting. The GDG emphasised the importance of a ‘simple’ dressing that provides an airtight seal that is fast and straightforward to apply. The priority should be transporting the patient to a hospital where a chest drain can be inserted.”

Haemorrhage control

First line intervention is direct pressure with simple dressing.
If direct pressure failed use tourniquets (no difference between mechanical or penumatic ones) as backup method. Is controversial when tourniquets has to be used (as first line) over direct pressure
Use Tranexamic acid in suspected haemorrahagic patients as soon as possible but never beyond 3 hrs from trauma

“In the absence of any evidence in favour of haemostatic dressings, the GDG did not believe that they offered any improvement over and above standard dressings with direct pressure.”

“Whereas, immediate haemorrhage control can be achieved by direct pressure, the decision of when direct pressure should be
used over tourniquets was considered controversial as the GDG tried to weigh up the risk and cost of placing a tourniquet on a person who did not require it compared with those that do.”

Vascular access

In adults use IV access as first line and IO as rescue technique if IV failed
In children, when difficult vascular access is suspected, use IO access as first line technique

Fluid resuscitation

In pre-hospital environment the target for volume titration has to be maintaining a palpable central pulse (femoral or carotid)
In pre-hospital, if blood products are not available, small boluses of crystalloids are the preferred fluid volume replacement.

“The GDG discussed the situation when a pre-hospital practitioner is treating a patient in profound haemorrhagic shock but does not have access to blood products. In this case small boluses of crystalloids would be appropriate.”

Pain control

IV Morphine is the first line recommended agent. Ketamine (at pain relief doses) the second option.
Caution is recommended when Morphine is administered in a haemodinamically unstable patient.
Intranasal administration is the recommended route of administration when IV is not available.

“Two studies compared IV morphine with IV fentanyl and found no difference between the interventions for pain relief and adverse side effects.”

(Many) Things that I Like about these guidelines

  1. The airway management approach! Totally agree on RSI and OTI as gold standard in trauma, and if performed, better be fast. The 30 min target is a quite fair indication but, as any other straight timing, depends on  the circumstances. The thing I appreciate is the idea of DO IT IN THE SHORTEST TIME POSSIBLE. Great. And if plan A (Ventilation+Oxygenation) fails? Plan B (Oxygenate) SGA and rush to TC, if close, or to any other trauma unit. And if for any reason placing a SGA is not possible? Use BVM and adjuncts and rush again. Love it!
  2. Thoracostomy better than needle decompression, both in prehospital and in hospital, for tension pneumothorax drainage. We are all aware of the bunch of studies indicating as needle decompression is inadequate in most cases, and all the FOAMED drums are rumbling on these frequencies. But till now none (first of all the Archaic Trauma Life Support)  officially stated this in a guideline (that I’m aware to, at least). So WELCOME expert consensus of NICE GDG!
  3. Simple occlusive dressing in open pneumo. Straight and simple.
  4. The choice for prehospital fluid replacement goes on crystalloids only cause blood products are not available, but in the text is highlighted as both crystalloids and colloids are detrimental on coagulation process (so they are banned in hospital setting). The future is blood products even in prehospital environment!

(Few) Things that I don’t like about these guidelines

  1. The choice of open simple thoracostomy just in intubated pts has to be more clearly highlighted. I suggest as an adjunct to main (yellow background) recommendation. And so as to be for thoracostomy plus chest drainage in non intubated pts.
  2. Why they just mention Morphine (as opioid) for pain control and don’t include fentanyl in the main recommendation, if in the text is clearly indicated as all the available evidences show no differences between the two drugs in terms of clinical effects and adverse events? I think Fentanyl due to its wide diffusion (with great satisfaction) worths a mention!

Draft closes for comments on 21 of September.

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Load-Play-Go and “6 minutes approach” in Out of Hospital Cardiac Arrest . Is this just fool?

3 ago PROTOCOLLO ELS da plastificare_eng

PROTOCOLLO ELS da plastificare_engI’m really surprised of the great debate that the previous post (Load-Play-Go in Out of Hospital Cardiac Arrest. The “6 minutes approach”) arouse around the “6 minutes approach”, and all the comments on the “load-play and go” way to manage the OHCA patients potentially candidate to Externa Life Support.

Most of the comments affirmed that 6 minutes to run a code is an utopia, and that stay and play is the right and only way to manage out of hospital cardiac arrest (OHCA).

“This is silly. 6 minutes to work a code into the back of your ambulance?….”, “I just wish I could convince more people that out-of-hospital cardiac arrest is a “stay and play” and not a “half ass cpr that provides nothing to the patient and rush to the hospital” kind of call……”, “There’s next to nothing that will be done in the hospital that you can’t do in the field (in most cases at least)…….” and many more….

So I want to add some considerations on this topic to clarify more on my thoughts about this argument.

The “6 minutes approach” is intended in patients who suffer a Cardiac Arrest from medical conditions (and in general the traumatic patient is not the right candidate for ECMO).

Traumatic cardiac arrest is another story (Mind of Resuscitation in Traumatic Cardiac Arrest).

The “6 minutes approach” is a way of thinking more than a realistic scenario (at least in the majority of the situations). It means that when you decided that the patient you are resuscitating on the field is the right candidate to External Life Support (and this depends on criteria that the institution where anyone works estabilsh), you don’t have to esitate and go straight to the ECMO center (even after more than 6 minutes!). It doesn’t mean you don’t have to perform all the meaningful (?) interventions that current guidelines indicates, but it means only that these interventions  (mechanical chest compression, ventilation, defibrillation, medications) can be performed on the way to ED, in the back of your ambulance, to allow the patient to arrive fast at his destination.

I know (from 20 years of out of hospital working experience) that real life is different from planning a situation on the paper. But the right mentality of professionals in these cases has to be determinated to a fast transport toward the closest ECMO capable center. 

To all the fans of “stay and play” in medical cardiac arrest (I myself am a fan of stay and play, but in traumatic cardiac arrest where manouvers performed on the field can be determinant if performed fast) just want to remember that the only “advanced” interventions that have probated evidences to improve mortality are chest compressions and defibrillation. The rest is usual and traditional but not evident. So I don’t ask to go against the (old) guidelines, but at least do it on the way, don’t loose time.

In cases when there is chance of good recovery (short no flow time, good pre-arrest conditions, young age) is right to give a real chance to the patient with a second level diagnosys, not available on the field, and in the meantime, with extracorporeal circulation now we can, mantaining the brain alive.

ECMO doesn’t cure anything, just give us time. Time to perform a clinical oriented diagnostic process and, when it’s possible, to find the cause of cardiac arrest, to treat it (PTCA for AMI, thrombectomy for pulmonary embolism, electrolyte EGA oriented replacement for electrolyte imbalance), and hopefully recovery the patient to a good quality of life.

I thought stay and play was the best option for patients in the past when ELS and mechanical chest compression devices where not available and the excellent experience of prehospital professionals made the difference in term of quality of interventions and resuscitation. Today, not for all patients, not for all conditions, the field is not the right place to run a code anymore. We have to abdicate a piece of our self-consideration to admit that ECMO opened new chance for OHCA patients, inside the hospital and this can make the difference for a selected group of patients.

Our mission is to find which is this group. Our mission is to train our system to take those patients to the right place in the shortest possible time.

Until that time many “wrong” patients will be taken to the hospital, and also many “right” patients will be left on the field, wasting money and allowing futility.

But when that time will come, cardiac arrest treatment will have a new prospective to really improve the quality of life.

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Managing airways in TBI

1 ago amleto_laringo

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Load-Play-Go in Out of Hospital Cardiac Arrest. The “6 minutes approach”.

29 lug

In the Prehospital Emergency System where I work (from late 1996) we are historically used to manage cardiac arrest events with a deep “Stay and Play”, except for some sporadic cases (mostly pediatric patients) . The rising of A-V ECMO era (and in Florence there is a major ECMO center) and lastly of mechanical chest compression devices, took us to rethink the whole approach to the management of cardiac arrest.

Is there now a role for a “Load-Play and Go” approach in some selected patients.

Let’s try to figure out some of the major challenges that this new approach can pose to emergency physician working in a prehospital environment.

  • Which are the inclusion criteria to choose, in a so urgent and confusing situation (as OHCA is), the right patient with a reasonable hope of good functional recovery.
  • Do we have to change our ALS schedule and management in those selected cases?

Wich is the right patient

The all V-A ECMO process is a really expensive stuff in term of both, human and financial resources. So the development of criteria to predict wich patient is potentially a candidate to good neurological outcome is oriented to spare money (for the collectivity) and to avoid futility (for the patients).

For sure a relatively young age, and the absence of invalidant comorbidities can play a role in these decision. But also the no flow” time, intended as the time from when the CA happened to the start of chest compressions in the witnessed CA and a shockable rythm finding or a potential reversible cause in non witnessed CA are sign of predictable good outcome.

The V-A ECMO, last but not least, needs a strict time schedule from the CA to the cannulation process to be effective and so the transport time to ECMO Center plays also a fundamental role in the decision making.

Putting all together these specification we can, with a good approximation, describe the right candidate for External Cardiac Life Support (ECLS).

But what about the pratical approach to those patients. Is still the classical ALS protocol the way to follow?

The six minutes approach to Load-Play and Go in OHCA

The basic skills are not different, but the real difference is the mind of the resuscitationist (S. Weingarth dixit) in these cases.

If you already decided this is the right patient the right time, we propose a six minute approach to manage all the features you need to perform in the first phase of a OHCA before “loading” the patients, “playing” during the “going” phase toward ECMO Center.

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