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

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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Clinical Governance Day 8th October 2014

CGD served up a mixture of cases discussions, audit, hot off the press journal articles and finished the day with a cracking multiple-casualty scenario.  

Airway Audit

In his final appearance before sadly leaving Sydney HEMS, Anthony Lewis went through a number of interesting airway cases for the month of July. There were a number of learning points:

  • Although not used as often as the bougie in our service, the stylet is an invaluable aid in the management of a difficult intubation – in this case a grade 3 view, unable to pass the bougie through the cords. A stylet in a straight-to-cuff shape allowed for endotracheal intubation on second look, with no desaturation.
  • Penetrating trauma to the neck with suspected tracheal involvement can prove to be a particularly challenging airway. Unidentified transection or near-transection of the trachea can be made worse by injudicious or vigorous intubation
  • If time allows, share the decision making with a colleague, in our case the Senior Retrieval Consultant (SRC) – that’s what they’re there for!

The Day Terrorism Arrived in Norway

Christian Buskop, anaesthetist  and current Sydney HEMS registrar

Christian Buskop, anaesthetist and current Sydney HEMS registrar

Christian gave us a fascinating and thought-provoking insight into the terrorist incidents on 22 July 2011 in Oslo and Utøya Island, from his first hand experience working with the Norwegian Air Ambulance on that day.

In the deadliest attack in Norway since World War 2, a car bomb exploded in the government quarter of Oslo, killing eight and injuring 209 people. This was followed hours later by a gunman opening fire on a youth camp on Utøya Island, 40km from Osl0. 69 people were killed on the island, with a further 110 injured.

  • Lightweight emergency stretchers were one of the most useful pieces of equipment on the day, allowing rapid movement of patients from the casualty clearing station to the trauma centre
  • In keeping with some previous mass casualty incidents, there was a degree of communication breakdown, in this case leading to confusion about the location of the casualty clearing station
  • Co-ordination of helicopter activity was challenging in poor weather conditions with uncontrolled airspace and an unsettled security setting. At one point there were 30 helicopter movements in one hour.

An excellent summary of the EMS response was published the following year and is well worth a read for anyone involved in pre-hospital care or major incident planning

Winch Review

Cameron Edgar covered several complex pre-hospital cases where winching was required, highlighting some of the logistical challenges involved.

This included a complicated multi-agency mission in the Blue Mountains involving abseiling down to the patient who had fallen 10 metres into a canyon. Following stabilisation of the seriously injured walker, he was extricated in several stages – first by ropes to the top of the canyon and then carried to a safe area prior to an accompanied stretcher winch.

The Warriewood Blowhole close to the northern beaches of Sydney is a popular site for teenagers in the warmer months and has been the scene of several winching operations in recent years. For one of the new HEMS registrars, it proved to be a particularly eventful day when a teenager sustained multiple injuries after falling when climbing down to the blowhole.

ARISE trial

While the triage scenario was running, Cliff went through the findings of the recently published ARISE study, the second of three multi-centre studies looking at Early Goal-Directed Therapy (EGDT) in sepsis.

In keeping with the ProCESS trial, there was no difference in all-cause mortality at 90 days between usual care and EGDT. While awaiting PROMISe, the final study in the trio, it seems to be that the fundamental goals in the management of sepsis are early recognition, source control, early antimicrobial therapy, considered use of fluids and vasopressors and close observation.

Triage Scenarios

To end the day the doctors and paramedics were put through their paces in pairs, in a challenging scenario involving the initial assessment of multiple casualties following a minibus crash.

Brian checks his twitter feed, leaving the HEMS registrar to do all the work

Brian checks his twitter feed, leaving the HEMS registrar to do all the work

There were many learning points from the subsequent debrief:

  • Arriving by helicopter allows for an excellent opportunity to assess the entire scene
  • Try to make brief notes as you perform an initial triage sieve. This allows for a more accurate situation report and better allocation of available resources
  • Decide beforehand whether to perform a triage sieve in pairs or individually. Working separately is possible and may be faster but requires regular communication to ensure casualties are not missed or triaged twice
  • If triage tags are not available, improvise. Consider writing on the patient with a marker pen to assign a triage category
  • It is possible to get bogged down in the treatment of a patient prior to completing a triage sieve. Consider what life-saving procedures are possible and appropriate. The military talk about: tourniquet application, basic airway manoeuvres and decompression of tension pneumothoraces
  • Make sure that the entire scene has been assessed and all casualties are triaged. It’s easy to miss a quiet patient – they’re often the ones who need help the most!

Next Clinical Governance Day is on Wednesday 22 October

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CGD summary 24/09/14

A very useful CGD with a focus on obstetric emergencies and neonatal resuscitation.

Started off with a comprehensive (and brave) talk by our medical student, Amy, on the physiological changes of pregnancy. A good run through of this can be found here.

We then had a talk from our resident NICU expert Rachel on neonatal resus – the Australian Resucitation Council flowchart can be found here.

Neil Greensmith then took us through some real life Sydney HEMS obstetric cases followed by Rachel (again!) taking us through trauma in the pregnant woman. Here’s a summary from trauma.org.

Finally, after lunch we had a couple of fun obs themed simulations, the first on neonatal resus with a PPH in a remote setting, dealt with superbly by Jamie & Cameron. The video shows how they reprioritised from neonatal resuscitation when they realised how sick the mother was..


This was followed by Mike Culshaw dealing with consummate calm with an eclamptic fit. Our sim expert Morgan has kindly written some valuable learning points on these two scenarios, which can be found here.

Thanks to everyone involved in a successful day.

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Clinical Governance Day 8th October 2014

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Clinical Governance Day 24th September 2014

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Clinical Governance Day 10 September 2014

We started off the new term with a series of interesting presentations based around the theme of drowning and water rescue.

Inland Water Rescue in the UK

Thanks to the wonders of the internet, Matt Ward, Head of Clinical Practice at the West Midlands Ambulance Service presented a very informative talk on inland water rescue in the UK, in particular, the work of the Severn Area Rescue Association and its involvement in the rescue operation following the severe floods affecting Tewkesbury, Gloucester in 2007.

Drowning: pathophysiology and management

Tom talked us through the physiology of drowning and its management

An excellent summary from Life in the Fast Lane can be found here

Role of HEMS physician in water rescue

  • This is one of the few situations where the physician needs to act independently without paramedic support as the paramedic is outside the helicopter on the end of a winch cable!
  • Make sure everything is secured in the aircraft – kit can easily be blown around when the doors are open
  • Physician moves to rear left seat but remains on wander lead in preparation for receiving the patient
  • Connect BVM to oxygen supply but keep it secured within the dropdown emergency airway bag
  • Suction underneath head of the bed
  • Supraglottic airway to hand
  • Patients are usually fine (but cold) or in full cardiac arrest so prepare for both
  • Further resuscitation can be performed once landed on a nearby helipad or oval

Simulation scenarios

It seemed fitting that a day focused on water rescue should have a number of water-based simulation scenarios to put the new registrars through their paces.

The standard of practice was excellent with some great examples of teamwork and the sharing of a mental model.

Dr Rachel managing a paediatric drowning

Dr Rachel managing a paediatric drowning

Case Discussions

The day was brought to a close with a discussion of a number of interesting cases attended by the new registrars since joining Sydney HEMS. There were many learning points from each case including:

  • Regional Trauma Centres provide excellent care to a number of major trauma patients however there are times when a regional trauma centre should be bypassed in order for the patient to receive specialist care only available in a major trauma centre.
  • The Senior Retrieval Consultant (SRC) is always available to provide advice and to share in this decision making process.
  • Although the days are getting warmer, it can still get cold in the bush overnight. It is possible that you may be winched in to a patient but unable to be winched out due to poor weather or darkness. Make sure you’re prepared for the possibility of remaining with a patient overnight and consider taking thermals, a beanie, food and drink.
  • There is an excellent operating procedure for managing raised intracranial pressure. Have a low threshold for paralysing patients for the duration of transfer following adequate sedation and analgesia. Paralysis may mask seizure activity but it is effective in preventing coughing or gagging which can aggravate raised ICP.
  • Prophylactic phenytoin in intracerebral haemorrhage is controversial. Following intracerebral haemorrhage it may reduce the chance of early seizures but does not alter long-term outcome.
  • IV nimodipine is often started at the referring hospital on the advice of the receiving neurosurgeon. Consider stopping IV nimodipine during transport of the patient, particularly if there is a need to rationalise the number of IV infusions.

The next Clinical Governance Day is on 24 September 2014, when we hope to be back in the refurbished training building. More details to follow

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