Clinical Governance Day – 29th November

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ECMO Education Day – Wed 15th November 2017

Not long to go until our ECMO Education Day this week…

If you intend to attend, you must REGISTER HERE

ECMO Flyer

 

We appreciate the kind sponsorship of this event from the following companies:

  • Stryker Medical ; Supply of the demonstration LUCAS 3 mechanical CPR equipment and kind provision of catering for the event.
  • Getinge Australia ; Supply of the demonstration Cardiohelp ECMO Machine.
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Clinical Governance Day – 1st November

Graphs and Gaffs

Matt Miller continued his ambitious mission to teach us all research methods in manageable 20 minute blocks. This month focussed on the use of graphs, using some amusing, published, graphs to illustrate how data can be misinterpreted if graphs are not presented correctly.

Key learnings were:

  • Take care with your Y axis.  It should include zero and the axis units need to be appropriate for the data being presented
  • If using two graphs for comparison, the scale should be the same
  • Make sure your graphs are not so busy that the message gets lost
  • When reading a paper, make sure you understand how the data has been presented before drawing any conclusions
  • Ensure you actually need a graph to illustrate a result. Sometimes text will do.

pie chart

Give PEEP a chance (or not)

Das Ragavan presented an update on the use of PEEP in patients with ARDS by reviewing the recently published randomised clinical trial from the ART group. In summary, in patients with moderate-severe ARDS, a ventilation strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28 day all-cause mortality. Routine use of lung recruitment and PEEP titration in this patient group was not recommended.

A link to the paper can be found here:

https://jamanetwork.com/journals/jama/article-abstract/2654894

Blood Audit

A reminder from Karel Habig that the state wide “Code Crimson” pathway is now live.

Cover-image-Trauma-Code-Crimson-Pathway

This pathway aims to standardise the:

  • pre-hospital identification of a trauma ‘Code Crimson’
  • activation of a trauma ‘Code Crimson’ pathway by pre-hospital medical retrieval teams and the subsequent notification to a receiving trauma centre
  • procedures instituted by trauma centres following activation of a trauma ‘Code Crimson’ pathway.

The most relevant sections for our service list the criteria for activation and outline the activation procedure.

Cirtieria for code crimson

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The entire pathway document can be found here.

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/382917/Trauma-Code-Crimson-Pathway-Final-20170919.pdf

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ECMO Education Day – Wed 15th November 2017

The ECMO Education Day on the 15th Nov will be a great opportunity to further your knowledge and skills of all things ECMO…. Understand the current evidence and applications,  know what goes on in that black box, and feel more prepared for your next ECMO transfer…
See attached poster, and look out for the finalised timetable.
If you intend to attend, you must REGISTER HERE
Hope to see you there

ECMO Poster

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Clinical Governance Day – 1st November

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REALITi User Manual

In 2017 we upgraded our iSimulate system to the new REALITi system. This allows improved fidelity in simulation by accurately replicating our Zoll monitors. This is just the tip of the iceberg when it comes to new and improved features, including remote audio and video display for observers, an electronic patient record with a huge database of ECGs and imaging, and many others. We used it successfully in the August 2017 HEMS Team Induction course and several software updates have been provided since.

The set up involving multiple iPads is more complex than that of its predecessor, so helpfully there is a YouTube Channel devoted to using the system.

 

 

 

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Clinical Governance Day – Wednesday 4th October

REBOA – The What, Why, How and When – Dr Jamie Moran, Retrieval Registrar, Sydney HEMS

This week Jamie Moran presented a summary of Resuscitative Endovascular Balloon Occlusion of the Aorta, or REBOA, based on his expereince with London HEMS.

The talk focused on zone III REBOA in the pre-hospital setting; the equipment needed to perform it, insertion technique and the ongoing care in the Emergency Department once the patient reaches hospital. Clinical examples were given to highlight some of the issues relating to patient selection and challenges of the technique in the field.

What

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an interventional technique, which may save lives in patients dying from catastrophic, non-compressible haemorrhage from severe pelvic trauma or junctional vascular injury. It involves placement of an endovascular balloon in the aorta to control haemorrhage and to augment afterload in traumatic arrest and haemorrhagic shock states

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London’s Air Ambulance has used it in the pre-hospital setting since 2014 and within the Emergency Department at The Royal London Hospital. The numbers of cases so far are small.

Why

Experience from the Royal London Hospital and London’s Air Ambulance shows that non-compressible torso haemorrhage is the leading cause of preventable trauma deaths. Severe pelvic fractures and torso vascular injuries are two important sources of this bleeding and contribute up to one third of all trauma deaths seen by the service. Trauma systems have optimized access to definitive haemorrhage control but many patients die from blood loss before this can be achieved.

REBOA may save lives in this patient group by reducing blood loss in the prehospital and resuscitation room phase, which buys time to get the patient to either the operating room or interventional radiology suite. Experimental evidence, mainly from large animal models, suggests that REBOA may increase myocardial and cerebral perfusion in the shocked state, reduce distal blood loss and promote clot formation. REBOA is likely to cause less physiological stress as a means of haemorrhage control than thoracotomy and aortic cross clamping.

How

Via a simple Seldinger technique – that is; needle puncture, guide wire insertion, over-the-wire balloon catheter. It is inserted under ultrasound guidance via the common femoral artery.

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The REBOA catheter is inserted into zone three (based on proven measurements in adults) of the aorta – a region between the most caudal renal artery and the aortic bifurcation.

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When

In any adult patient believed to be bleeding to death from a severe pelvic injury or junctional injury, after/during a simultaneous treatment bundle to stabilize the patient and promote blood clot formation. This includes blood transfusion, pelvic splintage, tranexamic acid, intubation and IPPV and addressing of other concurrent life threatening injuries.

By definition, these patients are bleeding to death and the massive transfusion pathway is activated in the receiving trauma unit in a timely manner so that blood products are available as soon as the patient arrives in the hospital or on the helipad. In addition, a specific REBOA activation call is made. This brings the additional expertise of a specifically trained REBOA operator, interventional radiologist and orthopaedic surgeon (in the case of pelvic injury) to the usual trauma response for these patients.

The Future

The UK REBOA trial is a Bayesian group sequential Randomised Controlled Trial (RCT) which will evaluate the use of REBOA in addition to standard treatment alone across the UK. The primary outcome measure is 90-day mortality in each group.

The study will also look into Zone 1 REBOA (insertion of REBOA balloon into the region of the aorta from the left subclavian artery to the coeliac trunk) as a means of controlling more proximal blood loss from, for example, blunt liver and splenic injuries.

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