Harnessing the experience of colleagues in the morbidity & mortality meeting, the manual dexterity of Karel Habig, the technological spectacularness of Skype to deliver a world expert to our meeting, the enthusiasm of two of our registrars, and the dynamism of the Sim Teams, the flipped-classroom CGD was particularly neurostimulating today…

Morbidity & Mortality – Sarah Coombes

Some valuable learning points from the February review of our cases, including:

• Remember bilateral thoracostomies for traumatic cardiac arrest
• Clinical examination of pelvis is unreliable, always place a pelvic splint
• CPR in traumatic cardiac arrest is of questionable benefit
• When pronouncing life extinct on scene, keep a copy of Form A’s!
• One can estimate mortality with a modified Baux score:

Baux score = Age + % BSA burn +[17 × (Inhalation Injury, 1= yes, = no)]

→ Baux score of 160 is the point of futility with 100% mortality

The relationship between head injury severity and hemodynamic response to tracheal intubation – Matt Miller

Matt produced an excellent review of this Zane Perkins paper published last year. This paper looked at 97 UK HEMS trauma patients with clinical signs of head injury who underwent pre-hospital RSI with standard drugs (etomidate + suxamethonium).

Outcomes assessed:

• Changes in BP (+20%) or HR (+20% or drop to below 50bpm)

Key Results:

• 1 in 10 patients had >100% increase in SBP, unrelated to the severity of head injury

What we thought:

• Head injury severity does not reduce the risk of a hypertensive response to intubation
• Is this something that we all should be considering in our prehospital head injury RSIs?

ABC of EVD’s – Charlie von Heldreich

Fantastic summary of extra-ventricular drains for interhospital transfers:

• There are 2 main types of ICP monitor

1. Ventriculostomy/EVD on un-injured side – it goes directly in to the ventricle
2. Bolt – intraparenchymal on injured side

• EVD is the gold standard – accurate, therapeutic & diagnostic but high risk of infection, are invasive, difficult insertion and irritating to manage
• Troubleshooting an EVD:

1. If dislodged – sit patient up, contact receiving hospital
2. Sudden drainage e.g. falls on floor – clamp, and readjust height
3. Loss of waveform – find a cause and check equipment
4. Unsecured aneurysms and bright red blood in drain – raise burette level, treat hypertension, deepen sedation, inform receiving centre to prepare theatres, will likely need blood products ready

Lots of excellent management tips can be found on our neuroprotection HOP

Skype Neuro Q&A – Mark Wilson

In a first of hopefully many such sessions, we were blessed to have a Skype Q&A session with the brilliant St Mary’s Hospital Neurosurgeon and pre-hospitalist  Mark Wilson from the AANS Annual Scientific Meeting in San Fransisco. Some of the questions he answered for us and educated us on included:

• There was a debate at AANS about the value of ICP monitoring. Summary: DO IT
• Key learning point about EVDs: if the filter paper on top of the EVD system gets wet then the whole system will fail. BE CAREFUL.

Specific audience questions:

1. Rural setting Burr hole decision-making key factors:

• If you can CT, CT. If not, a reduced LOC, blown pupil or a palpable depressed skull # with prolonged transfer, then there is an indication for a temporal diagnostic Burr hole

2. Is there a right ICP with patient with head injury?

• Before aiming, assess why the ICP might be up and lower it, sort out venous drainage, free neck, sort ventilator settings, avoid high intraabdominal pressures
• Targets he recommends: aim for normal, but he doesn’t feel that permissive hypotension has produced adverse effects on outcomes, but hypoxia DOES increase mortality. AVOID HYPOXIA

3. Is there a role for prophylactic anticonvulsants e.g. levetiracetam (Keppra)?

• If there is a dural breach or significant haematoma, then there is value in prophylactic anticonvulsants.
• Phenytoin should be used, no evidence that levetiracetam is better
• Give a loading dose in the field if your patient is seizing

4. Ketamine vs Etomidate?

• Mark likes ketamine, theoretical benefits

5. Fentanyl?

• Recommends gentle titration of fentanyl, not the often used 3mcg/kg as this can sometimes be too high
• But notes that London population is very different to the Australian population!

6. C-spine collars?

• Mark says he never ever ever keeps blocks and tape on (unless needed for packaging)
• Dogmatic use of collars is not critical

7. Impact brain apnoea?

• Documented in animals that if you hit animal over head it stops breathing for a bit, but when they do post-mortems their brain looks completely normal
• Often patients exhibit similar phenomenon, and apnoea and hypoxia can cause deterioration rather than TBI
• If have a sats trace and normal ICP you are probably perfusing brain fine

Burr Holes – Karel/Yash

Karel reminded us that extradurals are the ‘tension pneumothorax of the skull’ and should be operated on within 2 hours! We were given coconuts, some workmans equipment and some guidance:

Sims!

Our excellent neurosimulations reminded us that:

• A negative FAST does not exclude haemorrhage.
• If someone has attempted intubation but failed before you get there, find out exactly why they failed
• You can always intubate with an Ambu ® aScope through an iGel:

iGel size + 3 = Size of ETT you can pass