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Posts from the ‘Uncategorized’ Category

DIY to Stop the Blood

Originally posted on The Collective:

This thing comes from Dr Andrew Weatherall, paediatric anaesthetist and prehospital doc. He also blogs over at www.theflyingphd.wordpress.com

I don’t do DIY. This is partly because in the same way I wouldn’t expect a carpenter to have a crack at fixing their kids’ bones in preference to seeing an orthopod, I think it makes sense to use professionals.

It’s also because I’m just not that great at it. Anything I did make would end up looking like something trying to squeeze itself into the shape of the thing it is sort of supposed to be. And I’m fond enough of my family to want to protect them from the risks of my own handiwork.

Here's one I prepared earlier (via CC and flickr user mhlradio)

Here’s one I prepared earlier (via CC and flickr user mhlradio)

Anyway, I do paediatric anaesthesia. I get to spend more than enough time trying to make things that aren’t quite right for the situation fit…

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The “3 SIMPLE Rules”: an easy and accurate tool for recognizing VT

Originally posted on MEDEST:

Following the discussion on ectopy and aberrancy (view Ectopy or aberrancy? Google Ecg+ community comments on a clinical case.)  Ken Grauer, EKG master and author of many EKG books, gave us the permission to share his “3 SIMPLE Rules” to recognize VT in a simple ad accurate way.
 
  • Rule #1 Is there extreme axis deviation during WCT

Extreme axis deviation is easy to recognize. The QRS complex will be entirely negative in either lead I or lead aVF. The presence of extreme axis deviation during a WCT rhythm is virtually diagnostic of VT.
  • Rule #2 Is lead V6 all (or almost all) negative?

IF ever the QRS in lead V6 is either all negative (or almost all negative)  then VT is highly likely.
  • Rule #3 Is the QRS during WCT “ugly”?

The “uglier” the QRS the more likely the rhythm is. VT originates from a ventricular…

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The Bind When It Comes to a Binder (Part 3)

Originally posted on The Collective:

There’s been a lot of stimulating discussion after parts 1 and 2 of this series from Dr Alan Garner (you can check those here and here). Here’s part 3. 

Thanks for sticking with the discussion so far. In part 2 we had a look at AP compression injuries and lateral compression injuries. Short summary is binders make sense and there is some observational evidence of benefit in AP compression injuries. However in lateral compression, binders make no biomechanical sense and there is definite evidence they increase fracture displacement both in cadavers and real live trauma patients.

The final group that we have not yet considered in the Young and Burgess classification is the vertical shear group. These patients are complex because the injuries are both horizontally and vertically unstable. You will see what I mean if you have a look at this Xray:

Pelvic Xray copy

Is putting a binder around the…

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Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?

Originally posted on MEDEST:

DCR copy

The fluids of choice in prehospital field are, in most cases, cristalloids (Norma Saline or Lactate Ringer).

But what is the physiological impact of saline solutions when administered in large amounts (as the latest ATLS guidelines indicates) to hypotensive trauma patients?

Is aggressive Fluid resuscitation the right strategy to be pursued?

The triad of post-trauma lethal evolution is:

  • Hypotermia
  • Acidosis
  • Coagulopathy

Aggressive fluid resuscitation with cristalloids, and saline solutions in particular, can be detrimental in many ways:

  1. Cristalloids tend to displace the already formed clots and improves bleeding
  2. Normal Saline produce hypercloremic acidosis worsening coagulation and precipitating renal and immune dysfunction
  3. Cristalloids diluts the coagulation factors and precipitate the coagulation system (dilution coagulopathy)
  4. Cristalloids rapidilly shift in intercellular space worsening SIRS process and interstitial edema (brain edema, bowel wall edema) with consequent compartment hypertension

So wich is the perfect fluid to infuse in trauma?

The perfect fluid doesn’t exists.

Balanced saline…

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Scary Little Creatures

Originally posted on The Collective:

Dr Andrew Weatherall does prehospital doctor stuff but spends lots of time serving the somnolent god of anaesthesia  in a tertiary paediatric hospital. He has particular interests in cardiac, thoracic, trauma and liver transplant anaesthesia and is trying to be a PhD student in his spare time.  You can also find him as @doc_andy_w 

Little creatures have the potential to cause significant stress. It’s true of spiders. It’s true of parasites. And for many medicos, it’s true of paediatric patients. All too often, the experienced clinician confronted with the alien life-form of a kid goes through a rapid medical devolution, retreating to the almost foetal uselessness of a medical student confronted for the first time by having to do a procedure they’ve only read about.

Dance all you like tiny peacock spider, still wary. [via Jurgen Otto on Flickr under "Some Rights Reserved CC licence 2.0]

Dance all you like tiny peacock spider, still wary. [via Jurgen Otto on Flickr under “Some Rights Reserved CC licence 2.0]

It’s entirely reasonable to feel less…

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Bougie aided video assisted intubation through King Laryngeal Tube

Originally posted on MEDEST:

If you have a patient with a King LT in place and want to intubate him use the Bougie and the videolaryngoscope. It works perfectly.

Here is the video tutorial.

Logo MEDEST2

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The Bind About Pelvic Binders (Part 2)

Originally posted on The Collective:

This is part 2 in Dr Alan Garner’s series on pelvic fractures and the approach to binders. You can find part 1 here

In part one we had a look at the evidence for benefit from pelvic binders. In short there is no study yet published showing a significant improvement in mortality. Not even a cohort study.

Of course, it still might be OK to use them if they possibly help as long as there is no evidence of harm either (and they don’t cost too much). The probability of good has to outweigh the probability of evil. It is the potential for evil that I want to examine now so we can see where the balance lies.

Before we can do that though we need to have a quick look at the types of pelvic ring fractures (no one is suggesting that non-pelvic ring fractures of the pelvis…

View original 1,253 more words

The Bind When it Comes to Using a Binder

Originally posted on The Collective:

This post by Dr Alan Garner is the first of a trio on the topic of pelvic fractures and the evidence for what to do. Alan is an emergency physician at Nepean Hospital in Sydney and the Medical Director of CareFlight, having started in prehospital medicine in 1996. He has a bunch of other interests but there’s not enough space for that here.

Unfortunately I am old enough to remember when MAST suits were considered standard of care. In many states of the US it was law that ambulances had to carry them – that is how convinced everyone was that the things were doing good, not evil. We were all misled by measuring surrogates of outcome such as blood pressure rather than the outcomes that really matter, morbidity and mortality. Of course when good studies evaluating mortality were eventually done we discovered the evil side of the device and…

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Mechanical CPR: Three CHEERS or a big thumbs down?

Originally posted on AmboFOAM:

There has been a fair bit about mechanical CPR devices floating around the FOAMasphere lately, so I thought I should probably do a post.

These devices are not exactly new (check out the Thumper, in use in Victoria in the 70s) However, there seems to be a surge in interest in these devices, and I must say there seems to me to have been a largely positive buzz about them in spite of the evidence for their effectiveness being somewhat lacking to say the least.

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Auckland HEMS Checklist Reference Manual

Originally posted on Auckland HEMS:

Dear colleagues,

In June of this year our Canadian HEMS Fellow Dr. Robert Gooch shared one of our emergency checklists with the Prehospital and Retrieval Medicine (PHARM) community. Thank you to those of you who provided feedback on this initiative. We continue to draw inspiration from the work of Dr. Atul Gawande. http://atulgawande.com/

Now, in the spirit of Free Open Access Medicine, we are keen to share our complete Auckland HEMS Checklist Reference Manual with the PHARM community. At the start of September we made this manual operational within our service.

Innovation is one element of success; implementation is another core element.  http://www.sjtrem.com/content/19/1/53/abstract This article emphasizes the importance of end-users ‘the sharp end’ being involved throughout the checklist development process. We are fortunate to have input into this checklist from our pilots, crewmen, paramedics and doctors. Even our CEO (who is also a pilot) has shared his experience.

We see…

View original 350 more words

Why the VideoLarygoscopy don’t gonna kill the DirectLaryngoscopy (at least in the near future)

Originally posted on MEDEST:

A novel publication goes to enrich the long-living debate on direct laryngoscopy (DL) vs video laryngoscopy (VL) efficacy in emergency intubation.

The recent article, pubblished on JEMS and titled  “Deploying the Video Laryngoscope into a Ground EMS System” ,compares the success rate beetwen DL vs VL in a ground EMS Service. The device used was the King Vision with channeled blade. The partecipants had a prior training on the divide, consisting in didactic orientation and practical skills on manikins.

The result of the study shown that “Within the first 100 days of the study, the video laryngoscope utilizing the channeled blade has shown to be at least as effective as DL in relation to first-attempt success” and considering that “the mean experience in our group with DL is nine years, yet the success rate remains unacceptable” “It’s time to consider transition from a skill that’s difficult to obtain and maintain…

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GSA HEMS Airway training – a recipe for success

SCAT Paramedic Martin Pearce tubing like a boss!

SCAT Paramedic Martin Pearce tubing like a boss!

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Hymn to Simulation Team Training/ Inno alla Simulazione

Originally posted on MEDEST:

Blessed the emergency systems who train their professionals with simulation

Blessed the emergency professionals who challenge themselfs day by day in simulation

Facing their fears to win their weakness

Improving the quality of their work for the good of all patients

They are the future of emergency medicine

Shame on emergency systems who don’t train with simulation

Shame on emergency professionals who don’t have the umility to challenge themselfs

Running from their fears and weakness

Compromising the quality of their work and the health of the patients

They will disappear from emergency medicine panorama

Beati i sistemi d’emergenza che allenano i loro professionisiti con la simulazione.
Beati i professionisti che giorno per giorno si mettono in gioco allenandosi con la simulazione,
Affrontando le loro paure per vincere le proprie debolezze
Migliorando la qualità del proprio lavoro per il bene dei pazienti
Di loro sarà il futuro dell’emergenza sanitaria
Poveri i…

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PEEP zero. Is this the answer?

Originally posted on MEDEST:

Inspiring discussion on Twitter (Minh Le Cong@rfdsdoc, Karim Brohi @karimbrohi and Peter Sherren@PBSherren)
The topic:
Your hypotensive blunt/penetrating trauma patient with associated severe TBI needs a vent. How do you set it and how you achive your physiological goals?
Is it possible to mantain eucapnia, avoiding hypercapnic insult to the brain, using low minute ventilation strategy and not depressing stroke volume with high intrathoracic pressure?
“Permissive hypoventilation” in a swine model of hemorrhagic shock.

Conclusions: Although permissive hypoventilation leads to respiratory acidosis, it results in less hemodynamic suppression and better perfusion of vital organs. In severely injured penetrating trauma patients, consideration should be given to immediate transportation without PPV.

But what if we have concomitant severe TBI? How can we avoid respiratory acidosis and hypercapnia (due to hypoventilation) and conseguent insult to the brain?
Is PEEP…

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The occasional intubator needs a plan. I got one! Do You?

Originally posted on MEDEST:

want you

Following some discussion on who owns the airway (see the comments at the post Paralytic is the answer on EMPills Blog)

Have to admit: I’m an occasional intubator.

I manage something like 10 airways per month, all of them are “non conventional”, (no operating room, no chance to wake the patient, no chance to call an expert), and usually I have no time to evalute any of common indicators to predict difficult airway (time is often a rare issue in ground or air prehospital scenarios).

Half of the airway I manage are CRASH, half needs an RSI, so, shame on me, I’m also an occasional “paralytic agents user”.

So I desperatley need a plan

But lissen, I got one!

Dear collegue, wathever intubator you are, occasional or regular,  feel free to submit any comment on the plan and also fell free, if you think it’s useful, to use and…

View original 34 more words

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