Clinical Governance was a day of two halves; a morning of hard hitting clinical governance in the form of the morbidity and mortality review, and the airway audit. The afternoon was a brief look at the management of head injuries followed by an entertaining simulation and skills station.

Morbidity & Mortality

Sarah C presented a packed morbidity and mortality session, full of useful nuggets of information:

• In trauma, take into account the patients entire clinical state, not just blood pressure when considering the need for blood products
• Consider medical causes of cardiac arrest following relatively innocuous trauma
• The most common ECG rhythms in traumatic cardiac arrest are PEA and bradyasystolic rhythms, however VF and VT can occasionally be seen, requiring defibrillation
• Patients with significant burns can rapidly become hypothermic – keep the patient warm with blankets and environmental heating when possible

• In full thickness burns limiting neck movement or mouth opening then a primary surgical airway may be considered as the primary means of securing the airway

Airway Audit

Since Anthony Lewis has moved on from Sydney HEMS, Clare H-B has taken on the considerable task of compiling the airway audit. Unfortunately Clare couldn’t attend to present the data so Karel went through data from two months (August and September).

Over 90% of intubations were achieved on first-look, with the remaining cases intubated on the second attempt.

• If the initial attempt at intubation is unsuccessful, change something prior to having another look (adjust patient/operator position, better suction etc.)
• Additional rocuronium is held in the interhospital (3x50mg) and primary (2x50mg) packs if the retrieval team are not carrying sufficient in their own drug pouch
• In cases with significant epistaxis/facial haemorrhage, consider keeping the patient in a lateral position until immediately before intubation, to aid airway drainage

Head Injury Management

Eoin talked us through a few controversies in head injury, as well as highlighting a potential new development in the diagnosis of minor head injury

• S100b is a protein found mainly in astroglial cells and schwann cells. Levels are elevated following head trauma
• Testing S100b is still at an early phase but with a reported sensitivity of 99%, it may be a useful rule-out test if applied to appropriate, low-risk patients.
• However a specificity of 12-28% may lead to increased investigation of false-positive results. With time it could become the D-Dimer of head injuries!

Eoin talked us through the practice in Bergen, Norway where the EMS personnel have markedly reduced their use of cervical collars, replacing them by either:

• Awake patient – stabilise their own neck
• Unconscious patient – lateral trauma position
• Intubated patient – a pillow to stabilise the cervical spine and manual stabilisation during movement/transfers

The Bergen EMS SOP recommends the use of a hard cervical collar in only two situations:

• Difficult extrication of the unconscious patients where manual inline stabilisation cannot be maintained
• Stabilisation of the cervical spine while carrying a patient over uneven terrain

An excellent article covering some of the (somewhat limited) evidence behind this move, along with a description of the lateral trauma position can be found on the Scancrit blog

 Neurosurgery for Dummies!

As our European HEMS registrars are discovering, Australia is a pretty big place and there can be lengthy transfer times to definitive care. It may be a rare occurrence but there have been occasions where it has been necessary for a non-specialist to decompress an extradural haematoma in a rural hospital.

The neuroprotection SOP recommends that for patients with an extradural or acute subdural haematoma where the transfer is likely to take more than two hours, the case should be discussed with the receiving neurosurgeon, with one of the options being on-site burr hole exploration.

• Aim to place the burr hole at the centre of the haematoma
• Use the CT to find the best site – count the number of slices of the CT from the vertex down to the centre of the haematoma and multiply this by the slice width
• Try to avoid ‘plunging’ into the brain as the burr hole is completed. This can be better avoided with the use of a modern perforator drill bit with clutch mechanism
• With a subdural haematoma, incise the dura in a cruciate manner – subdural blood is likely to be more clotted than extradural blood and gentle efforts to remove it (forceps or careful suction) may not be sufficient

There are several excellent articles describing simple burr hole placement for the non-neurosurgeon:

•  ‘The Occasional Burr Hole’ by Keith MacLellan – in a hurry, just read the  bold print
• ‘Emergency burr holes: how to do it’ – a great, up to date description by London neurosurgeon, HEMS physician and all-round nice guy, Mark Wilson

And remember, in the words of Mitchell & Webb, ‘brain surgery – it’s not exactly rocket science!’

Neuro Trauma Simulation

One of the new registrars coped admirably after being thrown in at the deep end with a tricky simulation, written by resident sim maestro Morgan

The team were tasked to a remote rural hospital,  to retrieve a patient who had sustained a skull fracture with underlying extradural haemorrhage following an assault. Unknown to the retrieval team, he had also been stabbed in the back with a developing pneumothorax and was becoming increasingly hypoxic as the scenario progressed.

The team successfully identified the pneumothorax as well as the patient’s deteriorating conscious level and instigated the necessary neuroprotective measures prior to transferring the patient to Sydney for neurosurgical intervention.

But despite their best efforts, a combination of bad weather and the helicopter breaking meant that there was no way they were leaving the hospital without decompressing that expanding extradural haemorrhage…

Temporal Burr Hole Placement

Learning points

• Don’t forget to look for injuries other than the ones stated in the initial handover – every patient has a front, two sides and a back
• Once you’ve found one stab wound, look elsewhere for another one
• A complete primary survey is essential
• Even after being highlighted earlier, our registrar demonstrated that it is surprisingly easy to ‘plunge’ into the brain when drilling a burr hole with a standard perforator and burr