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

Posted in General PH&RM | Tagged , | Leave a comment

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.

Australian-UVR-Levels-In-Summer

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.

Posted in General PH&RM, Tips | Tagged | Leave a comment

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.

Posted in training | Tagged , , , , , | Leave a comment

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).
Posted in Cases, simulation, training | Tagged , , | Leave a comment

Clinical Governance Day 7th October 2015

CGD 07 Oct

The next Sydney HEMS Clinical Governance Day is coming up next Wednesday, October 7th at Bankstown with a full day devoted to overdose, envenomation & all things TOXICOLOGY !! 

We are fortunate enough to have Dr Kate Sellors return to Bankstown. Kate is a former Sydney HEMS colleague and an Emergency Physician from Prince of Wales Hospital with a special interest in Clinical Toxicologist. 

Throughout the day we will be looking at a general approach to a poisoned patient, learning the ins and outs of the major toxicologic killers (including beta-blockers, calcium-channel blockers & TCAs) as well as being schooled in the killer creepy-crawlies that inhabit Australia !! This day should not be missed….

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

Big Tox Killers in Overdose (CCBs, TCAs, BBs).

Helpful Tox-Treatments.

Envenomation.

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

Posted in training | Tagged , | Leave a comment

Clinical Governance Day 23rd September 2015

CGD 23-09-15

This weeks Clinical Governance Day sees the team from Bankstown trekking south to Killalea State Park to rendezvous with the Wollongong team for a joint-CDG focussing on seaside scene safety and the challenges of coastal rescue and resuscitation.

Special thanks goes out to Wayne Cannon, Kent Robinson and the team at the Wollongong Base who have organised what promises to be a fantastic day of outdoor simulation.

Details for the day can be found here…

As you can appreciate – staff safety on the day is of upmost importance and as a result numbers have been limited to staff from both bases. Rest assured, our regular CDG program will be back up and running on October 7th.

We look forward to seeing you there.

Posted in training | Tagged | Leave a comment

Clinical Governance Day 9th September 2015

CGD 09-09-15

For this weeks CGD we have some fascinating updates & clinical discussions lined up for you including;

  • Haemodynamic responses to prehospital intubation with ketamine
  • A US perspective to urban search & rescue following a massive landslide
  • Oxygen therapy in STEMI
  • A recent case of a nasty complex burn

Here are some helpful links to browse in preparation for the burns discussion; [Releasing the Roman Breastplate] & [Trauma! Major Burns], both courtesy of Life In the Fast Lane. 

It would also be helpful to review the AVOID trial ahead of Journal Club.

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

Posted in training | Tagged | Leave a comment