Clinical Governance Day 18th November 2015

CGD 18 Nov

The next Sydney HEMS Clinical Governance Day is coming up next Wednesday, November 18th at Bankstown.

This CGD will include our September M&M as well as review some recent challenging winch missions. A subtle theme of bleeding filters through this session with a look at coagulopathy in trauma, bleeding in non-compressible sites and a review of the recent literature on Idarucizumab (a potential agent for the reversal of dabigatran).

NSW Health staff welcome, sign-in required. See here for directions.

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New Traumatic Cardiac Arrest Guideline

TCAsmOur Standard Operating Procedure for the management of traumatic cardiac arrest prioritises the rapid management of reversible causes (hypoxia, tension pneumothorax, hypovolaemia, and cardiac tamponade). Although it has been in operation for several years, it can still appear unfamiliar to ambulance crews and other rescuers as external chest compressions and intravenous adrenaline (epinephrine) are often omitted so that other proactive clinical interventions can be instituted.

ILCOR (the International Liaison Committee on Resuscitation) has now completed its five-yearly consensus review and the European Resuscitation Council (ERC) and American Heart Association (AHA) have published their updated 2015 guidelines on cardiac arrest management, including traumatic cardiac arrest. The Australian and New Zealand Resuscitation Councils usually publish their guidelines a bit later, which do not tend to differ significantly from the European & American versions.

The ERC guideline for traumatic cardiac arrest management1 is available for download here. It is reassuringly up-to-date and constitutes a bold step away from traditional approaches. For us, the heartening finding is that it is entirely consistent with our operating procedures on traumatic cardiac arrest and haemorrhage control. Here is the algorithm:


Examples from the accompanying text that support our existing operating procedures and approach include:

1. Absence of nihilism:
Traumatic cardiac arrest (TCA) carries a very high mortality, but in those where ROSC can be achieved, neurological outcome in survivors appears to be much better than in other causes of cardiac arrest. The response to TCA is time critical and success depends on a well-established chain of survival, including advanced prehospital and specialised trauma centre care.

2. Lack of priority given to chest compressions:
Immediate resuscitative efforts in TCA focus on simultaneous treatment of reversible causes, which takes priority over chest compressions.

3. Proactivity regarding commencing resuscitation, and discontinuing based on response and sonographic cardiac standstill:
The American College of Surgeons and the National Association of EMS physicians recommend withholding resuscitation in situations where death is inevitable or established and in trauma patients presenting with apnoea, pulselessness and without organised ECG activity. However, neurologically intact survivors initially presenting in this state have been reported. We therefore recommend the following approach: Consider withholding resuscitation in TCA in any of the following conditions:
• no signs of life within the preceeding 15 min;
• massive trauma incompatible with survival (e.g. decapitation, penetrating heart injury, loss of brain tissue).

We suggest termination of resuscitative efforts should be considered if there is:
• no ROSC after reversible causes have been addressed;
• no detectable ultrasonographic cardiac activity.

4. Application of aggressive interventions in the prehospital setting:
all interventions other than definitive (surgical/radiological) haemorrhage control appear prior to ‘transport to hospital’.

5. Haemorrhage control measures:
the use of tourniquets…, topical haemostatic agents.., splints…, blood products…, and tranexamic acid while moving the patient to surgical haemorrhage control
Give TXA in the prehospital setting when possible

6. Open thoracostomy in preference to needle methods or chest tube insertion:
Thirteen percent of all cases of TCA are caused by tension pneumothorax. To decompress the chest in TCA, perform bilateral thoracostomies in the 4th intercostal space, extending to a clamshell thoracotomy if required. In the presence of positive pressure ventilation, thoracostomies are likely to be more effective than needle thoracocentesis and quicker than inserting a chest tube.

7. Resuscitative thoracotomy in penetrating traumatic cardiac arrest:
Cardiac tamponade is the underlying cause of approximately 10% of cardiac arrest in trauma. Where there is TCA and penetrating trauma to the chest or epigastrium, immediate resuscitative thoracotomy (RT) via a clamshell incision can be life saving. The chance of survival is about 4 times higher in cardiac stab wounds than in gunshot wounds.

8. Prehospital ultrasound in the shocked patient:
Ultrasonography should be used in the evaluation of the compromised trauma patient to target life-saving interventions if the cause of shock cannot be established clinically. Haemoperitoneum, haemo- or pneumothorax and cardiac tamponade can be diagnosed reliably in minutes, even in the prehospital phase.

Our Traumatic Cardiac Arrest Operating Procedure was first approved in 2009, and was based on the best available evidence and experience of our HEMS clinicians who have trained in many services within Australia and overseas. The apparent deviation from ‘standard ACLS’ practiced on trauma patients did require some discussion and defence. Our literature review and recommendations published in 20132 remain pertinent and our operating procedure is now consistent with international guidelines, thanks to the evolution of evidence and the consensus process of ILCOR. Of course, it is still an evidence-light zone and some measure of the effectiveness of this approach is much needed. Survival is still very poor from traumatic cardiac arrest and we all need to collaborate on improving practice in a clinical sphere where small gains can mean massive differences to patients and their families.

1. Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, et al. European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation. 2015 Oct;95:148–201. (Full text)
2. Sherren PB, Reid C, Habig K, Burns BJ. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Crit Care. 2013;17(2):308. (Full text)

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Clinical Governance Day 4th November 2015

CGD 04 Nov

The next Sydney HEMS Clinical Governance Day is coming up next Wednesday, November 4th at Bankstown.

We will have our usual features of Airway Audit plus Morbidity and Mortality which always makes for brilliant discussion.  One of our paramedic/physician teams will dissect a challenging prehospital case involving an injured jet-skier and we will discuss the recently published FELLOW trial which lit up social media after challenging the usefulness of apnoeic oxygenation  !!

Here are some interesting takes on the FELLOW trial from around the #FOAM world for your pre-reading;

NSW Health staff welcome, sign-in required. See here for directions.

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Ventricular Assist Devices

We may come across patients with Ventricular Assist Devices (VADs), either in the prehospital or interhospital setting. Prehospital & retrieval medicine practitioners should have a basic understanding of how they function,  what can go wrong, and how to troubleshoot in emergencies.

These two talks by HEMS Physician Chris Partyka will take you through the essentials:



Further Reading:

Chris’ blog post at The Blunt Dissection

Case report from the ED ECMO guys on use of CPR in VAD patients.

LifeInTheFastLane on VADs with multiple other links.

EMCrit on VADs

EMS Field Guide to VADs

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Lessons from our HEMS Airway Registry

Our monthly audit of airway cases held at our Clinical Governance Days seeks to improve identifies learning points at Clinical Governance days. Here are some key points from a recent Clinical Governance Day.


Slip, slop, slap, slide and SEEK SHADE!

The Australian sun can be brutal. Bright ambient light reduces the relative illumination of the larynx during prehospital laryngoscopy. Sun protection, in the form of shielding the airway & intubator from direct sunlight is essential to first look intubation success. Assistants can be utilised to hold sheets or blankets above our heads – but a single layer may not be sufficient, and adding a space blanket may help. Problems will be compounded if laryngoscope brightness is not optimal. It is best practice to check batteries and laryngoscope brightness in kit checks & before RSI.

How big is that kid?

We all know from hospital practice that children come in all shapes and sizes – ages and weights are not always predictable. In the prehospital & retrieval setting we have the added challenge of errors in the initial scene information conveyed to us. The child will often turn out to be a different age than the initial scene call information suggests. We can help to protect ourselves against ‘size’ errors by discussing the size of the child & equipment/drug dose choices with the team. Those team members with kids admit they frequently compare the patient’s size to their own children – or you could use a Broselow tape…..

HOP HOP HOP….. to our Helicopter Operating Procedure – Prehospital RSI

“If there are no features (apart from C-Spine immobilization) to predict a difficult airway the first attempt at laryngoscopy may be taken by the retrieval paramedic”

Or to put it another way ….

“If a difficult airway is anticipated or adequate pre-oxygenation is difficult then the physician should perform the laryngoscopy. “

It is always important to discuss who is to undertake laryngoscopy with your other team member to ensure you are both on the same page with respect to potentially difficult airway or anatomy before you pick up the laryngoscope.

Bloody airways – dental blocks before epistat inflation

In patients with life-threatening maxillo-facial haemorrhage the procedure for splinting the facial bones and tamponading epistaxis following control of the airway can be life-saving. The epistat balloons placed in the nasal cavity  splint the facial bones against the dental blocks and then the mandible. The mandible is splinted by the C-Collar to the clavicle.  We reminded staff of the correct procedure outlined in the Major Haemorrhage Control Operating Procedure.  You should insert the epistats prior to dental blocks (McKesson Props) but only inflate them once the C-Collar is on and dental blocks in place. Each posterior balloon is full inflated with saline and then anterior balloon gently inflated a little at a time alternating sides. This reduces the chance of misaligning fractures further – see reference below.

  1. Harris et al. 2010 The emergency control of traumatic maxillofacial haemorrhage. European Journal of Emergency Medicine 17:230–233

Hold your breath I’m giving Ketamine

Intravenous Ketamine is extremely effective for the prehospital management of agitated or combative head injured patients as it retains airway reflexes and spontaneous respirations better than other agents as well as having a superior haemodynamic profile. However on occasion a brief period of apnoea may be experienced immediately following administration.  Provided the patient is adequately monitored and the team are prepared this is rarely of clinical consequence but it can be avoided by slowing rate of administration. Speed of administration is the main factor correlated with occurrences of apnoea following ketamine injection particularly in sedation doses.

Slow down the “bolus” to avoid unwanted apnoea.

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Clinical Governance Day 21st October 2015

CGD 21 Oct

The next Sydney HEMS Clinical Governance Day is coming up next Wednesday, October 21st at Bankstown base. This weeks theme is MAN vs MACHINE, specifically a look at the challenges of failing cardiac-support devices. 

Our speakers will cover pacemaker failure & transvenous pacing, ventricular assist devices and extra-corporeal cardiac support.

Prior to the CGD, it would be worth reading over a few of the attached papers/blogs to enhance our learning on the day!

All NSW Health staff welcome, sign-in required. See here for directions.

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The Toxicology Sessions: Simulation Summary

Our CGD on Wednesday culminated in a toxicological based simulation – with 3 year old Vera having consumed her grandfather’s medications. Why do pills look like lollies?

Tox Sim 02 Tox Sim 01Tox Sim 03

The take home debrief points were:

  1. How do we best use available resources like the on call toxicologist?Like all clinicians in Australia we have access to the Poisons line, with their on call toxicologist available 24 hours a day. We advocate involving them in the decision making process for management of the critically ill toxicology patient.For CGD we had the lovely Dr Kate Sellors as our knowledgable toxicologist (who’s previously worked with the service).We discussed the pros and cons of delegating that important phone call. The consensus was that the safest and most efficient way might be to ask someone to initiate the call and commence the conversation, but to make it clear that once the toxicologist was on the phone that you would like to speak with them in person to clarify certain aspects. One useful consideration is the use of a portable phone, so you can hear the conversation taking place and also when you are on the phone can stay near to the patient to continue with management and provide up to date information to the toxicology service.
  2. Methods of eliminating error when calculating multiple drug doses and infusions for children. Use available reputable drug dosing calculators (on the net or your smart phone).Paramedic + Dr both calculating them separately and then comparing. Double checking your final dose with a rough estimate compared to a known adult dose to see if it passes the whiff test. Using a whiteboard to write out important numbers/doses & keep track of what was given.There was a difference in opinion between emergency medicine background vs anaesthesia background regarding the practice of drawing up individual doses into labelled, small syringes. In the heat of the moment it is probably best to practice what you are most comfortable and familiar with.
  3. Optimise your risk assessment by obtaining accurate history (drugs, doses), timing and clinical features. Formulate the assessment with the aid of the toxicologist on call. Know your toxidromes and clinical manifestations for ingestions, including the time of the expected clinical course – when transferring these patients you need to know what might go wrong and when to guide you in your management – expect the worst.
  4. In Ca channel blocker OD – High dose Insulin Euglycaemic Therapy will take ~30mins to take effect, so it’s important to consider and commence it early in the resuscitation. Again, this is probably best done in consultation with the toxicologist (especially in the paediatric population).
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