CGD 9th April 2014 – Neurosimulation

Harnessing the experience of colleagues in the morbidity & mortality meeting, the manual dexterity of Karel Habig, the technological spectacularness of Skype to deliver a world expert to our meeting, the enthusiasm of two of our registrars, and the dynamism of the Sim Teams, the flipped-classroom CGD was particularly neurostimulating today… Continue reading

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Simulation 31/03/2014 – Heloconstrictors and Helodilators

A high fidelity simulation in the AW 139 aircraft.

The lead -in

15-year-old male with a stab wound

Scene

The initial assessment was performed at a scene outside pub.

The patient

A – Patent

B – RR 32, sats 96% on high-flow O2, bilateral equal airway entry

Chest USS revealed a haemo-pneumothorax on the left side. There was evidence of a 2cm stab wound with a small amount of ooze

C – HR 120bpm sinus tachycardia, BP 112/56. IV access present with a palpabable radial pulse and no other stab wounds noted

D – E4 M6 V4, pupils equal and reactive, smells of alcohol. There were no external signs of head injury and the patient was co-operative

E – No extremity injuries noted

Initial plan: package the patient for a 30-minute air transfer to the children’s hospital (a major trauma centre).

 In flight the patient develops PEA cardiac arrest 15 minutes from hospital…

Questions to ask yourself at this point:

Do you land or continue to destination? What guides this decision?

How can space/access to the patient be improved in the AW 139?

Traumatic cardiac arrest and clamshell thoracotomy in flight: really?!

There are crucial CRM points to consider between the doctor/crewman/pilot/paramedic; how would you manage these?

Scenario Progress

Decision was made to land.

Traumatic cardiac arrest protocol was followed in-flight and on ground.

Cold intubation of the patient was difficult due to limited access. The patient was positioned north-south in the helicopter.

3 units of blood given, bilateral thoracostomies performed but patient remained in cardiac arrest.

Cardiac ultrasound revealed cardiac standstill and evidence of cardiac tamponade with clots.

Clamshell thoracotomy performed in the back of helicopter with relief of cardiac tamponade and ROSC.

Post-procedure sedation, paralysis and TXA was given.

Learning points

  1. Always strive to improve access around your patient. In the AW 139, you can achieve this by:
    1. Move paramedic’s and doctor’s seats as far back in the cabin as possible facing forward and fold rear seats up (see representation below).
    2. Move patient stretcher a further 6cm south, moving secured equipment if required.
    3. Come off seatbelt and on to wander lead early
    4. Anticipate clinical demise of patients! Get the surgical bag (red loaf) out of the primary pack (blue) and keep nearby
  1. If you want to free up your hands for clinical activity ‘hot mic’ between doctor and paramaedic
  2. CRM can help you make decisions. Discuss difficult problems with all your crew.
  3. Don’t forget eye protection for all surgical procedures
  4. To land or not to land: This is multifactorial depending on expected arrival to destination and aviation factors (weather, availability of landing sites).
  • PRO – Frees up crewman and pilot to aid with fast/efficient treatment of the patient.
  • CON – Time critical lesion requiring definitive surgery

Again: ANTICIPATE THE CLINICAL DEMISE OF YOUR PATIENTS!

Management of traumatic cardiac arrest can be found on the HOPs here, with an excellent review of management found here.

Thanks to Matt (Doctor), Phil (ICP), Pat (Crewman), Carla (STAR, Sim controller), Alex (Scenario orchestrator) Cliff (debriefer) and Bubba & Lucas (Experiential insight-providers).

Standard configuration (left) vs space-optimised configuration (right)

Standard configuration (left) vs space-optimised configuration (right)

AW 139 space difficulties

AW 139 space difficulties

 

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Clinical Governance Day 9th April 2014

Our next CGD will focus on neurotrauma. Facilitators Ed Burns and Phil Webster have flipped the classroom. See below for your pre-CGD preparation.

CGD Flyer (3)

Here are the FOAM reading references for everyone….

1. Read this overview of management of traumatic brain injury by Emergency Physician / Intensivist Chris Nickson from LITFL (10 mins)

2. Download this podcast on “Fine Tuning The Injured Brain” by Bart Besinger and listen to it in your car on the way to work (25 mins). Right click the link as ‘save link as’.

3. “Burr Holes in the Bush” — another great podcast/ videocast. Tim Leeuwenburg (Kangaroo Island doctor) interviews Mark Wilson (Neurosurgeon + London HEMS doctor) about performing burr holes in the rural and remote setting (15 mins)

4. A short (3 min) video demonstrating an OT Burr hole x 2 for SDH.

5. Two short papers on how to perform a burr hole: The Occasional Burr Hole by Keith MacLellan and Emergency burr holes: “How to do it” by Mark Wilson

6. Some light relief – check out this highly educational video by UK comedians Mitchell and Webb

7. Our Neuroprotection Operating Procedure

Anyone who is still hungry for more knowledge may want to read the Neurosurgical Society Guidelines on Management of Acute Neurotrauma in Rural and Remote locations.

The paper presented by Matt Miller is ‘The relationship between head injury severity and hemodynamic response to tracheal intubation‘ by Zane Perkins et al, J Trauma Acute Care Surg. 2013 Apr;74(4):1074-80

All NSW Health staff welcome. Sign in required. See here for directions.

 

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Clinical Governance Day 26/3: The Morning After The Week Before

All of the attendees at this CGD were treated to a brilliant post-smaccGOLD desert, with an incredible guest speaker, a statistical review of one of the most important publications of the year, a fierce SIMWARS battle, and answers to the age old question: “what the smacc is FOAM?!?!”

 

Motorcycles: Cases from the Races – John Hinds

John Hinds is not only a fantastic speaker, but also an extremely experienced motorcycle racing doctor. He provided a fantastic insight in to the instantaneous care of trauma at high-speed motorcycle races.

“With average speeds of 135mph* and maximum speeds beyond 200mph*, when they crash, they crash big”

*That’s 217 and 321 km/h in new money

The key crash mechanisms and injuries to really be concerned about include:

  1. “Hitting the kerb” – they’ve either come to a dead stop or have been launched
  2. “Broken feet and a low GCS” – think neck and base of skull
  3. “Head-on collision with an apparently isolated femoral fracture” – The pelvis is probably being held together by the leathers
  4. “Beware the boot lying in the road” – riders are likely to have realised they are about to crash and put their foot down, leading to lower limb spiraling. Gruesome photos.

Interesting point for all to bear in mind: helmet removal is quite safe. In thousands of cases of helmet removal, John stated they have never had any deterioration due to the removal. Note that there might be significant CO2 buildup within the helmet thus high-flow O2 should be delivered if there is any delay in helmet removal.

 

The Death of EGDT – Sandra Ware

We were walked through a critical appraisal of what may be one of the biggest studies published this year so far by the hugely experienced Sandra Ware. The American ProCESS study is the first of three publications expected to answer the 13-year-old question: Is early goal-directed therapy (EGDT) superior to protocolised standard care (PSC) or unstandardised ‘usual care’ (UC).

The study was a multicentre, open label (i.e. both the researchers and participants know which treatment is being administered), randomised controlled trial in 31 EDs in the USA of 1,351 patients admitted between March 2008 and May 2013. The primary end-point was hospital mortality prior to discharge or 60 days, whichever came first. Secondary mortality outcomes included the rate of death from any cause at 90 days and cumulative mortality at 90 days and 1 year, while a range of morbidity outcomes were also assessed.

There were no significant differences between any of the primary or secondary outcome measures, although IV fluid administration was higher in the first six hours in the PSC group and vasopressor use in the same time period was higher in the EGDT and PSC group.

What are we to think? Perhaps the simple measures are the most important in the initial phases of sepsis management. This may be the start of a shift away from EGDT and early vasopressor with invasive monitoring to a more clinically directed, pragmatic approach to management of septic patients.

Excellent podcast by Scott Weingart interviewing ProCESS study author Derek Angus can be found here.

 

Social Media – Ed Burns

For all of us social media numpties, Ed gave a great talk introducing all things we need to know about how to maximise our knowledge, learning and development online:

 

What The SMACC is FOAM by Ed Burns on Prezi

 

SIMWARS

There was a highly dynamic and exciting SIMWARS battle held where the key learning points related to resuscitation of traumatic cardiac arrest (TCA) patients include:

  • Resuscitation of these patients is not always futile with up to a 7.5% survival to hospital discharge
  • Once successfully intubated, achieve adequate ventilation while minimising minute ventilation and high intrathoracic pressures
  • All TCA patients should have bilateral open thoracostomies
  • Early haemorrhage control with early blood transfusion through large-bore vascular access in sites above the diaphragm
  • Consider clamshell thoracotomy in penetrating TCA within 10 minutes of arrest
  • Consider perimortem caesarean delivery in gravid patients of greater than 20 weeks gestation in TCA within 4 minutes of arrest
  • Chest compressions may be omitted until pre-load and obstructive causes of TCA

Great article with rationale for management decisions by Peter Sherren & the team can be found here.SIMWARS 26th March 2014

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Clinical Governance Day 26th March 2014

CGD Flyer (1)

For directions click the ‘Contact’ tab above

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Simulation 18/3/14: The Paediatric Bee-Sting

The lead -in

3-year-old child collapsed in respiratory distress following bee-sting.

Scene

000 call by father who is the sole individual with the patient in a park. Easy access to the patient who is on the ground with father anxiously trying to rouse the patient. Upon initial assessment, another paramedic has responded and presents himself.

The patient

Initial assessment performed by the doctor while paramedic attached monitoring and unsuccessfully attempted IV access. ICP (intensive care paramedic) was preparing equipment for kit dump.

A – Tongue swelling, wheeze and stridor

B – Spontaneously ventilating, poor gas-flow, SpO2 89% on high-flow oxygen, improved with insertion of an oropharyngeal airway, equal chest rise

C – BP 65/42 mmHg, HR 150-165 bpm sinus tachycardic, no bleeding seen

D – GCS 5/15, pupils equal

E – Diffuse urticarial rash throughout

Questions to ask yourself at this point:

What are the immediate priorities in paediatric anaphylaxis?

What are the complications of our potential interventions?

Where is the most appropriate location to manage this patient?

Scenario Progress

IV line tissued, IO inserted, difficulty locating 1mL syringe, adrenaline 0.1mL 1 in 1,000 (100 micrograms) IM given, IV fluids bolus of 20ml/kg given and patient transferred on to stretcher.

Patient deterioration with bradycardia and reduced ETCO2, thus further dose of adrenaline given of 0.1mL of 1 in 1,000 (100 micrograms).

RSI performed, intubation by doctor as risk of difficult intubation. Initial attempt to use a bougie but size 4.0 mm endotracheal tube wouldn’t fit over the bougie, thus direct intubation without bougie.

Post-intubation, patient developed tachycardia, high airway pressures and reduced right-sided chest movement. Suspected right pneumothorax, therefore needle decompression performed followed by right thoracostomy – immediately improved the clinical picture.

Uneventful onward transfer.

Learning points

  1. Bougies are too big for size 4.0 ETT
  2. The location of 1 mL syringes: in the interhospital pack with the mucosal atomizing device
  3. Hydrocortisone is not kept in our primary packs, but in the interhospital pack medication pouch – the paediatric dose is 4 mg/kg IV
  4. IN ANAPHYLAXIS GIVE IM ADRENALINE ASAP:
    1. IM adrenaline 1:1000 (1 mg/mL) 0.01 mg/kg to a maximum of 0.3-0.5 mg IM [i.e. 0.01 mL/kg of 1:1000 adrenaline]
    2. IV adrenaline if no response to repeated IM adrenaline: 0.1-5.0 micrograms/kg/min

An excellent summary on the management of paediatric anaphylaxis can be found on the highly recommended Life in the Fast Lane blog here.

The kit dump and the drug perusal.

The kit dump and the drug perusal.

Thanks to Kariem (Doctor), Libby (ICP), Ben (Paramedic), Sanj (SRC, Patients father), Marty (Drip stand, Sim Controller) and Carla (STAR).

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CGD 12th March 2014 – A day to remember, and what we all should remember…

The lucky Sydney HEMS attendees to this Clinical Governance Day got a taster of some brilliant lectures to be delivered at smaccGOLD on the 19th-21st of March 2014. Not wanting to give the game away, here are the key learning points from the ever-essential Morbidity & Mortality review and Airway Audit:

Airway Audit – Anthony Lewis

Great cases to learn from this month, things to remember:

  • Always have a Plan A, B, C and D. Verbalise them to your team.
  • Senior clinicians at referring hospitals can be invaluable
  • Think about your doses of induction drugs: not too high, nor too low, aim for the Goldilocks dose.

 

Morbidity & Mortality – Karel Habig

Reviewed some difficult cases that people had in January, and the key learning points for the month include:

  • Never forget your Lifepak. Anywhere.
  • Cardiac arrest in trauma may be medical in nature: never assume it is purely traumatic
  • In septic interhospital transfers, consider USS to guide fluid therapy before transporting patients
  • If you’ve made a conscious decision to do or not to do something, document why! It may make your life much easier in the future.
  • In patients with ventilation difficulties, it is probable a good idea to document the ventilator settings, this may impact the patients clinical course and your legal course!
  • In alcoholics with a high lactacte, give thiamine – it will assist metabolism of lactate
  • Finally, remember: if you will use advanced airway then talk to SRC. There is a reason you are using it, so there is another person to talk to if you need to use it!

Look out for our review of smaccGOLD soon!

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