Escharotomy Man 2.0

By Sydney HEMS registrar Jamie Andrews

For Clinical Governance Day on 5th of November 2014, (Burns theme for Guy Fawkes Night care of the UK contingent!) I was tasked with re-producing Dr Ed Burns’ escharotomy model. Ed had previously hoped that the model could be made to bleed when cut to the appropriate depth to more accurately simulate the procedure itself.

Using the instructions on the Sydney HEMS website  I obtained the necessary equipment from K-mart and Bunnings (No financial incentives provided).

Keen to rise to the bleeding challenge, I used fake-blood purchased from a costume shop (in plentiful supply post-halloween) to fashion blood packets using sandwich bags.

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The blood packets were then strapped to the red (deep-tissue) layer that had been attached to the resus mannequin.

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I taped the bags over the anticipated incision areas on the model and then completed the model again as per Ed’s instructions.

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The final finish was applied with spray paint and charcoal.

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The finished Escharotomy Man 2.0

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During our first Burns simulation scenario (brilliantly authored and run by Dr Morgan Sherwood) the model was put through its paces. The bleeding was quite variable depending upon where the cuts were made, but quite successful in the end.

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After completion of the scenario other staff had the opportunity to participate and perform their own escharotomies on unused parts of the mannequin.

I aim to refine the bleeding packets for the next time we run a burns scenario by using a larger number of smaller bags, and placing them widely in areas that may be incised.

 

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Education Inservice Tuesday 18 November 2014

A session with consultants from Sydney HEMS will be held on Tuesday 18 November as part of the Education Inservice week in Rozelle, NSW. This will be an opportunity to discuss current approaches to trauma and critical care.

Please bring details of any cases you would like to discuss that involve:

  • Resuscitation
  • Major adult or paediatric illness
  • Trauma
  • Interaction with medical teams / retrieval services

Timetable:

1300 Introduction – Dr Cliff Reid

1310 Prehospital & retrieval medicine & the role of HEMS – Dr Karel Habig

1340 Trauma update: the bleeding patient – Dr Geoff Healy

1410 Break

1430 Rural trauma case discussions – Dr Brian Burns

1530 Education & clinical Q&A – Dr Cliff Reid

1600 Finish

Dr Cliff Reid is an emergency physician and the Supervisor of Training for Greater Sydney Area HEMS, and a Clinical Associate Professor with the University of Sydney

Dr Karel Habig is an emergency physician and the Medical Manager for Greater Sydney Area HEMS

Dr Brian Burns is an emergency physician and the Head of Research for Greater Sydney Area HEMS, and a Clinical Associate Professor with the University of Sydney

Dr Geoff Healy is a consultant anaesthetist and the Medical Equipment Lead for Greater Sydney Area HEMS

All consultants are employed by NSW Ambulance as staff specialists in prehospital & retrieval medicine

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Introduction to Retrieval Medicine

Several of the Sydney HEMS retrieval physicians describe some of the challenges of prehospital & retrieval medicine

 

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Clinical Governance Day 19th November 2014

 

mattWe are pleased to welcome our guest speaker from the UK, Matt Ward.

Matt is lead paramedic for emergency care for West Midlands Ambulance Service, and one of the directors of the West Midlands CARE team.
He’ll be sharing clinical and research experience in the management of stroke and cardiac arrest.

 

  • Pastries will be available from 0740hrs for those who arrive early, although we can’t guarantee how long they will last :-) 
  • For lunch we will be joining the crews down in the hangar for a hamburger BBQ in aid of Movember; please bring $6 if you wish to join in with this.
  • Please note the usual free sandwiches will not be provided on this occasion.

See here for directions

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Clinical Governance Day 5th November 2014

 

CGDFlyerBURNS

See here for directions

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Clinical Governance Day Summary 22nd October 2014

With a theme of haemorrhage and trauma, it was always going to be a fun-filled day and it certainly didn’t disappoint. Arranged by Laura and Hannah, an excellent turnout of consultants, registrars, paramedics and medical students filled the room and were presented with a series of relevant and interesting teaching sessions.

Damage Control Resuscitation

Trauma Team Personnel

War, huh! what is it good for?

Some might say ‘absolutely nothing’ but others might argue that it has at least led to an advancement in the management of major trauma.

Through the wonders of Skype, we were able to listen to the excellent Damian Keene, anaesthetic registrar, major in the British army and PHEM trainee, talking about his extensive experience working in Camp Bastion, Afghanistan.

Damian took us through a typical case involving a severely injured soldier requiring resuscitation and damage control surgery. Through detailed documentation, it was possible to see the rapid and life-saving treatment that the patient received.

  • Junctional wounds (e.g. axilla or groin) which are too proximal for tourniquet application are challenging to manage – Damian reported excellent results with topical haemostatic agents – in their case Celox gauze
  • Intraosseous access would generally be gained prior to arrival in hospital. For rapid transfusion and resuscitation, large bore subclavian access was the route of choice in hospital with a second anaesthetist dedicated to the procedure
  • Initial transfusion was in a 1:1 ratio, Packed Red cells:Plasma
  • Once bleeding was controlled they immediately switched to individually tailored transfusion – based on clinical and laboratory assessment, including point of care thromboelastometry

What really came across was how refined and streamlined the entire process was – from time of injury to definitive surgery – with every facet of care optimised to ensure the patient received the best care possible – something which many civilian trauma centres could only aspire to.

A comprehensive review article detailing the defence forces approach to trauma was published in Anaesthesia in 2013 and is recommended reading

Acute Coagulopathy of Trauma

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Coagulopathy of Trauma

Jamie channeled his inner Karim Brohi and talked us through the complicated and evolving subject of acute traumatic coagulopathy.

  • Coagulopathy is present in up to 25% of major trauma patients on arrival in the Emergency Department and is associated with a significant increase in mortality.
  • Conventional teaching has previously been that coagulopathy was a result of dysfunction (through acidosis and hypothermia), depletion and dilution of clotting factors.
  • pH>7.1 is unlikely to adversely affect coagulation
  • Minimising patient heat loss is important but temperature needs to be below 33°C to affect coagulation
  • Inappropriate IV fluids can affect coagulation through dilution of clotting factors

Acute traumatic coagulopathy is currently thought to be far more complex than originally taught, with a dynamic imbalance of procoagulant and anticoagulant factors as well as impaired platelet function and hyperfibrinolysis

‘The Lethal Triad’ – it’s not just a Chinese organised crime syndicate

 

Europe’s Stance on Management of Bleeding and Coagulopathy

 The Advanced Bleeding Care Group have recently published an updated consensus guideline on the management of bleeding and coagulopathy following major trauma. In a similar approach to the Surviving Sepsis Campaign, the group hope that the launch of the STOP the Bleeding Campaign will reduce the number of preventable deaths from haemorrhage following trauma

  • S – Search for patients at risk of coagulopathic bleeding
  • T – Treat bleeding and coagulopathy as they develop
  • O – Observe response to interventions
  • P – Prevent secondary bleeding and coagulopathy

, by standardising and improving the level of care that these patients receive.

While the group attending the CGD did not agree with all the recommendations (vasopressors in trauma), it was felt that this was a useful project, with the potential to standardise and improve the level of care that these patients receive.

An app is free to download and contains a useful summary of the recommendations. The full recommendations are also available.

Practical Haemorrhage Control

Maxillofacial haemorrhage control with Karel Habig

In a practical session looking at haemorrhage control, Karel walked us through the initial management of massive traumatic maxillo-facial haemorrhage.

There is a stepwise process to achieving haemostasis:

  • Intubate
  • Manually reduce and align mid-face fractures – this is crucial as without this subsequent steps can further distract a displaced facial fracture and worsen bleeding
  • Insert bilateral nasal epistats (posteriorly, not superiorly) but do not inflate
  • Cervical collar to splint the mandible
  • Dental props – inserted bilaterally, the largest size which will comfortably fit
  • Inflate epistats – firstly posterior balloons with water, followed by incremental filling of the anterior balloons until haemostasis achieved

Literature Review

Following lunch, Jamie and Laura facilitated a lively group discussion on two papers relevant to critical care and retrieval medicine.

In the first, a review article looking at delirium and sedation in ICU it was apparent that delirium is a significant problem in ICU which often goes unrecognised.

Evidence suggests that management of sedation and delirium can have an important effect on patients treated in ICU. While it did not appear that any sedative performed significantly better than another the take-home message appeared to be that good care required regular assessment of sedation in ICU while keeping it to the minimum necessary for patient comfort and safety, along with using a protocol to routinely monitor and treat pain and delirium.

 

The second paper which was reviewed was from the TRISS Trial Group, recently published in the NEJM. It was a multi-centre RCT investigating whether a higher (9g/dL) or lower (7g/dL) transfusion threshold had any effect on mortality in septic shock.

There was no significant difference in the primary outcome, which was mortality at 90 days. Not surprisingly, secondary outcomes showed that patients in the higher threshold group received significantly more blood transfusions.

It was felt to be a well designed study which although only partially blinded (full blinding would have been very difficult) had few flaws and good internal and external validity.

Amongst the group discussing the paper, it was felt that this generally supported their current practice rather than changing it. A review of this article, along with many others can be found on the excellent Wessex Intensive Care Society website

 

Next Clinical Governance Day is on 5th November

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Clinical Governance Day 22nd October 2014

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