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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…

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A ballad for Minh

rfdsdoc:

My mate Rob can carry a tune !

Originally posted on AmboFOAM:

My friend Minh from the PHARM blog has been hit hard by the news of a ketamine shortage.  I haven’t the wherewithal to set up a benefit concert for Minh, but the least I could do was record this number to help ease his pain (although in a way that ketamine never could)

Hang in there brother!

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The Death of the Cervical Collar?

rfdsdoc:

let the debate begin!

Originally posted on AmboFOAM:

Those fantastic Vikings over at one of my favourite FOAMed sites, ScanCrit have been rampaging through the dogma of cervical collars for some time, and now it seems the campaign is coming to a head:

Bergen EMS will no longer apply c-collars to patients

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Winch bag. Can it be a FOAMED experience?

Originally posted on MEDEST:

We are tryng to assemble a special bag dedicated to winch operations.

This need came from many of us who found very difficult to be winched on the scene with the actual rescue bag, cause of his weight and size.

So we decided to assemble a smaller bag, less heavy with just the essentials to supply the team for a short period of time  in order to stabilize the patients before winching him on board.

We have to choose what is important and what is not in the actual bag.

Analyzing the majority of our missions, found that mostly of the procedures we perform where linked to some specific situations:

  • Traumatic cardiac arrest
  • Advanced airway management/RSI
  • Traumatic Emo/pneumo
  • Brain trauma
  • Traumatic shock (hemorragic, obstructive, spinal)
  • Anaphylaxis
  • Non traumatic shock

On this basis we decided to allocate a limited amount of drugs and equipment specifically targeted for this emergency situations.

The…

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EMERGENCY TRAUMA MANAGEMENT COURSE MANUAL – FREE SAMPLE CHAPTERS FOR DOWNLOAD!

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Trauma Junkie? Have I got the course for you!

Originally posted on AmboFOAM:

For all you trauma junkies out there (and let’s face it, that’s most of us at some stage) there is a new way to get your fix of top-notch, innovative, interactive and exciting education….

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Auckland HEMS – the first two years

Originally posted on Auckland HEMS:

This slideshow, assembled by Dr Chris Denny, shows the ARHT & Auckland HEMS team during the first two years of the HEMS initiative. It was presented at a recent strategic planning meeting to plot the future course of the service. The gentleman whose photo is shown at the start is the late Dr Robin Mitchell, a UK-trained emergency physician who was instrumental in laying the groundwork for Auckland HEMS.

Enjoy!

(and rest assured no mannequins were harmed in the making of this slideshow… sort of…)

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tPA for Stroke. Again. Sorry about that.

Originally posted on AmboFOAM:

Sorry to carry on about this, but I can’t help myself…

The other night SBS television in Australia aired a special on stroke (found online here)  It brought together some stroke survivors, neurologists, emergency doctors and so on to discuss stroke and stroke treatment.  Of course the issue of tPA for stroke reared it’s ugly head again and it is clear that the debate over this has not been settled. 

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To thump or not thump?

Originally posted on rain0021:

I wonder if the authors of the October 4th’s NEJM Journal Watch Alert saw the irony?

Firstly a review of a paper which examined the utility of the precordial thump for out of hospital cardiac events.

Nehme Z, Andrew E, Bernard SA, Smith K.  Treatment of monitored out-of-hospital ventricular fibrillation and pulseless ventricular tachycardia utilising the precordial thump. Resuscitation 2013 Aug 29

The author’s abstract (I’m too stingy to buy the complete paper) suggests that few studies have described the value of the precordial thump as first-line treatment of monitored out-of-hospital cardiac arrest from ventricular fibrillation and pulseless ventricular tachycardia.

Using data from the Victorian Ambulance Cardiac Arrest Registry  out-of-hospital cardiac arres witnessed by paramedics between 2003 and 2011. The study outcomes were: impact of first shock/thump on return of spontaneous circulation and more importantly, survival to hospital discharge.  434 cases met the eligibility criteria. Seventeen patients (16.5%) observed a precordial thump induced rhythm…

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Nepean Difficult Airway Course

Infectious diseases physician owns the airway with a steak knife and pen

Karel Habig: To air is human

Originally posted on Auckland HEMS:

From The Intensive Care Network – another podcast from the SMACC 2013 conference. This is Dr Karel Habig, Medical Director of the Greater Sydney Area HEMS, discussing how experience from aeromedical retrieval can improve medical practice.

Click HERE for the audio (right click to open it in a new tab), accompanying slides are below:

 

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Prehospital tranexamic acid use in primary and secondary air medical evacuation

Originally posted on Auckland HEMS:

BC_AmbulanceIn the latest edition of Air Medical Journal the British Columbia Ambulance Service’s AirEvac And Critical Care Operations has published a case series detailing the use of tranexamic aid by flight paramedics.

The abstract for the paper can be found HERE. The paper details 13 patients who recieved TXA over a 4 month period, with 9 patients from MVAs, 3 patients who had fallen, and one industrial accident. The average time to administration of TXA from first patient contact was 32 minutes. No complications were reported.

The authors make the point that while tranexamic acid in theory has more benefit in major trauma the earlier it is administered, the importance of it should not be overplayed. Its use occurs in their protocol after a primary survey has occurred, critical interventions have been done, and transport has been initiated. They also mention several cases where the patient met the criteria…

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ALF

Originally posted on expensivecare:

Here are the slides and references for the talk I’m giving on Acute Liver Failure (ALF) at the Bedside Critical Care meeting in Cairns, QLD on Thursday 26th September 2013.

Lee WM, Stravitz RT, Larson AM. Introduction to the revised American Association for the Study of Liver Diseases position paper on acute liver failure 2011. Hepatology. 2012 Feb. 23;55(3):965–967.
The most up-to-date guidelines from the American Association for the Study of Liver Disease. Freely available here.

Patton H, Misel M, Gish RG. Acute liver failure in adults: an evidence-based management protocol for clinicians. Gastroenterol Hepatol (N Y). 2012 Mar.;8(3):161–212.
Another recent and easy to read review of ICU management of ALF. Also freely available here.

Bernal W, Auzinger G, Dhawan A, Wendon J. Acute liver failure. The Lancet. 2010 Jul. 17;376(9736):190–201.
Slightly older but still pretty good review from the Lancet.

Drolz…

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