MEDEST

47 ysr old male collapsed on the field. First ALS unit found him arrested in VF.
Shocked 3 times he regained a palpable central pulse.
When we arrived the patient arrested again. VF on the monitor. Shocked 4 times. Mechanical chest compression and tracheal intubation on board. He received Epi, Amio (300+150), Calcium Gluconate and Bicarb (suspected iper K in kidney insufficiency) before the ROSC.
15 minutes passed from the collapse to ROSC,  7 of wich were of “no flow” (no chest compressions, no AED from bystanders).
PMH: Hypertension, kidney insufficiency, heavy smokers. Medication history unknown.
He had chest pain before collapsing, as referred from bystanders.

Vitals at ROSC: GCS 3 T, RR 10 MV, SaO2 100%, EtCO2 35,  HR 70 bpm. NIBP 100/70 12 lead EKG at ROSC is shown below

An echo of the heart performed on the field (in the ambulance running to the ED, so I apologize for the low quality of the images) confirmed the lateral wall MI and shown distended IVC, B lines in both lungs and no sign of aortic dissection. No free fluid was present in the abdomen.

After administration of Heparin and Aspirin the patient arrived in ED and taken straight to cat-lab where a PTCA was performed 50 min after the collapse.

I think that increasing the use of ultrasonography on the field, and using it when really makes the difference, with a Point Of Care approach, is a big step for the care of critical patients out of the hospital.

Every prehospital emergency system have to instruct their professionals on how to use POC Ultra Sonography on the field and need specific “problem solving” protocols to help it’s diffusion.

22 years old male hit from a car on the roadside of an urban area.
The ground EMS ambulance (physician, nurse staffed), dispatched on scene, find the patient alert, oriented and spontaneously breathing. His vitals are:
GCS 15 , RR 20, SaO2 95, HR 85, SBP 110
No mention of head trauma.
Chest no sign of trauma, bilateral and equal expansion and air entry.
Pulse is strong.
He has a profound laceration with loss of substance but not evisceration on left flank and no external bleeding from the wound.
The abdomen is painful and resistant to palpation in left flank.
There is an open fracture to left tibia (VNS 9).
The ground team, after the primary survey, activates the local medical helicopter.
The place is 10 k from a level 1 Trauma Center on a local road in an urban area and the helicopter is at 10 minutes flight distance. There is a safe landing space at 500 mt from the point of the accident.
A Level 2 hospital (general surgery, orthopedics, anesthesiologist, radiology and laboratory 24/7) is at 2 km distance from the scene.
Is this a proper activation for HEMS?
What international litterature says about advantages of air medical service vs ground medical service?

So what about the case?

Severity: The patient is slightly tachycardic, and the mechanism of trauma give us some clue on possible abdominal injuries, so he need a quick transport to an hospital with a general surgery (and orthopedics naturally for the tibial fracture)

Speed: non simultaneous activation. This kind of missions become competitive on long distances (45 miles) from Level 1 Trauma center (or the appropriate hospital). So GEMS is faster anyway.

Trauma center access: no difference between HEMS and GEMS and even there is doubt on the fact that this patient really need a Level 1 Trauma Center

Crew: this patient does not need an over skilled staff for some particular procedure.

We can conclude that for the standard HEMS activation criteria, this is not an appropriate activation and the best way to reach the hospital for this patient is a ground ambulance.
Any suggestion on the theme treated is, as usual, very welcome

Below you can read the answer to my question (Cricoid pressure in new DAS (Difficult Airway Society) Guidelines: still on?) from Chris Frerk, Chair of DAS guidelines group:

“Mario

Thanks for your thoughtful comments

The website posting is necessarily brief and there will be more detail in the developing paper.

Your point is well made re cricoid pressure vs BURP and external laryngeal manipulation.

The paper is predominantly aimed at anaesthesia for surgery in the UK though we recognise that the existing 2004 guidelines are referred to in ED and ITU settings. Current UK practice does endorse cricoid pressure for RSI (which includes most ED intubations) though we are aware this is not the case in other countries – we’ve taken the stance so far that this paper isn’t the place to debate RSI techniques but we do have a developing section on RSI.

 I think we do need to be more explicit about when cricoid pressure would be expected to be applied – we are already clear in the paper  that if it is applied and laryngoscopy is difficult the pressure should be removed (with suction at hand). In the elective scenario (with no cricoid pressure) then we say BURP / external laryngeal pressure (different from cricoid pressure) should be tried to see if view improves.

The group meet again soon and we’ll be discussing your thoughts in more detail then.

Thanks for taking the time to contribute”

Chris Frerk

Chair of DAS guidelines group

Now is only a matter of time.
We wait for the release of the new DAS Guidelines on intubation and, as Chris anticipated, on RSI.

Stay tuned on MEDEST and all the FOAMED community to be up to date on this and all the news from the Emergency Medicine World

Background story:

This is the post I wrote about the DAS April 2015 draft on intubation Guidelines:

DAS (Difficult Airway Society) released a draft of its intubating Guidelines for evaluation and comment before definitive update.

Previuos 2007 Guidelines are available here DAS Intubation Guidelines

This is the link to download the Update (April 2015) on DAS intubation guidelines 2015

What’s new on this draft:

Plan A (face mask ventilation and intubation)

• Preoxygeneation is now included (to mantain even during the intubation, O2 nasal cannula).
• VL is considered as standard approach (same leve than DL).
• Cricoid pressure is no longer mentioned and replaced with BURP.
• BURP has to be released if difficult intubation(laryngoscopy is predicted.

The authors invite all to send suggestions and comments to intubation@das.uk.com.

Last night (Italy time at least) on Twitter a debate about the presence on less of cricoid pressure aroused:

23:06 @MyEmergencyMed: Difficult Airway Society 2015
 intubating Guidelines http://t.co/3I82OaQEhV vía
 @MEDEST118
 23:12 @MDaware: cc @ketaminh MT @MyEmergencyMed: DAS
 2015 intubating Guidelines http://t.co/qmIQLonSTQ vía
 @MEDEST118

https://twitter.com/MDaware/status/585897954936025089

23:13 @ketaminh: @MDaware @MyEmergencyMed
 @MEDEST118 have u checked original source
 material…editor?
 23:13 @MDaware: @ketaminh @MyEmergencyMed
 @MEDEST118 nope in a meeting

23:18 @ketaminh: @MDaware @MyEmergencyMed
 @MEDEST118 ok let me help you then
 http://t.co/T2MiXq28dA
 23:22 @MDaware: @ketaminh @myemergencymed @medest118
 interestingly the guidelines say "Remove cricoid
 pressure" — not use it! http://t.co/3mAGwKRKoj
 23:23 @ketaminh: @MDaware @MyEmergencyMed
 @MEDEST118 stick to social media, editor! cricoid
 pressure still advocated by DAS as far as I can tell .
 remove prn
 23:29 @ketaminh: @MDaware @MyEmergencyMed
 @MEDEST118 well…you have to use it if you are to
 remove it

So let’s see what the released material from DAS says about cricoid pressure?

On the algorithm:

And then on the Highlights:

Pretty controversial.

So let’s ask directly to DAS wich is their position on cricoid pressure.

And let’s wait for their answer.

Stay in touch!

62 yrs old male found unconscious GCS 6 (E1,V1, P4). Sign of vomiting and inhalation. Profoundly hypoxic, hypertensive (BP 200 over 110). Pupils were miotic with anisocoria dx>sx.

The team, after aspiration of gastric material from the airway, decided for airway control, before transport. The patient is overweight with a “taurine” neck so VL was chosen as first choice for airway management.

RSI (Fentanyl. Midazolam, Sux) performed. In the video you can see a detailed explanation of the VL technique that is slightly different from DL technique.

 Post-intubation management included ventilation optimization (EtCO2 35-38 mmHg in suspected intracranial hypertension) oxygenation and haemodynamic management.

Spinal immobilization is performed in all trauma patients from the rescuers in EMS systems all over the world, regardless the mechanism of injury and the clinical signs.
This kind of approach is nowadays been rebutted from the recents evidences and the actual guidelines.
ACEP, in Jan 2015, released a policy statement entitled :”EMS Management of Patients with Potential Spinal Injury” clarifying the right indications, and contraindications, for spinal immobilization in prehospital setting.
The lack of evidence of beneficial use of devices such as spinal backboards, cervical collars etc… is in contrast with the demonstrated detrimental effects of such instruments: airway compromise, respiratory impairment, aspiration, tissue ischemia,increased intracranial pressure, and pain, consequent to spinal immobilization tools, can result in increased use of diagnostic imaging and mortality.

Already in 2009 a Cochrane review demonstrated the lack of evidences on use of spinal restriction strategies in trauma.

Recently the out of hospital validation of Nexus criteria and Canadian C-spine rules, strongly driven to a revisited approach to spinal immobilization.

So in 2013 American Association of Neurological Surgeons and the Congress of Neurological Surgeons “Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injurie”  and Faculty of Pre-Hospital Care “Pre-hospital Spinal Immobilisation: An Initial Consensus Statement” stated those changes.

Based on this statements:

1. Spinal immobilization should not be used for patients with penetrating trauma without evidence of spinal injury.
2. Spinal immobilization should be considered in all trauma patients with a cervical spine or spinal cord injury or with a mechanism of injury having the potential to cause cervical spinal injury.
3. Spinal motion restriction should not be considered for patients with plausible blunt mechanism of injury and any of the following:
   • The patient is GCS 15 (normal lev el of alertness)
   • There is no posterior mid-line tenderness
   • There is no distracting injury (other painful injury)
   • There is no focal neurological signs and /or symptoms (e.g., numbness and/or motor weakness)
   • There is no anatomic deformity of the spine
   • There is no intoxication (alcohol or drugs, including iatrogenic)
4. The long spinal board is an extrication device solely.
5. Backboards should not be used as a therapeutic intervention or as a precautionary measure either inside or outside the hospital or for inter-facility transfers. For this purpose, a scoop stretch or vacuum mattress should be used.
6. EMS providers ahs to be properly educated on assessing risk for spinal injury and neurologic assessment, as well as on performing patient movement in a manner that limits additional spinal movement in patients with potential spinal injury.

References

1. 2015 ACEP Policy statements: EMS Management of Patients with Potential Spinal Injury
2. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. Oct-Dec 1999;3(4):347-352.
3. Cochrane Rewiev Spinal immobilisation for trauma patients
4. Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury.
5. The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
6. Evaluation of the Safety of C-Spine Clearance by Paramedics
7. 2013 American Association of Neurological Surgeons and the Congress of Neurological Surgeons Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injurie
8. Faculty of Pre-Hospital Care “Pre-hospital Spinal Immobilisation: An Initial Consensus Statement”