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Posts from the ‘Uncategorized’ Category

The Bind About Pelvic Binders – Part 4

Originally posted on The Collective:

Is this the last bit for now? Dr Alan Garner following up on pelvic binders after all the stimulating comments. If you haven’t already, check out part 1, part 2 and part 3.

During the writing of part three of this series on pelvic fractures and particularly after reading Julian Cooper’s comments (thank you Julian) I realised that the observational data around pelvic binders does not entirely fit with the theories. Let’s start with the theory and I might directly borrow Julian’s comments from Part 2 as he says it better than I could:

“In any type of pelvic injury. the bleeding will be either:

  1. Venous or bone ends: in which case keeping things still with a binder is likely to allow clot formation (low pressure bleeding, low or high flow).
  2. “Slow” arterial (the sort of thing seen as a blush on contrast CT) which will probably trickle on…

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Episode 24 – Mild Traumatic Brain Injury/Concussion

Originally posted on FOAMcast:

(ITUNES OR LISTEN HERE)

The Free Open Access Medical Education (FOAM)

We cover the Taming the SRU podcast, “Ketamine Cagematch” (iTunes), a debate between Dr. Minh Le Cong and Dr. Chris Zammit.

Dogma persists that ketamine may increase intracranial pressure, which would be bad in traumatic brain injury (TBI) given the fixed space in the cranial vault.  These are largely from Yet, these patients often need sedation, for agitation or intubation, and drops in blood pressure are also deleterious (see EMCrit on neuroprotective intubation).

PRO (Le Cong): The literature doesn’t show clinically significant deleterious outcomes from ketamine use in the head injured patient.  Review in Annals on ketamine and ICP.  Deleterious effects of apnea may result from other sedative agents.

CON (Zammit): Studies showing that ketamine does not increase ICP confounded by the presence of other sedatives on board.  As…

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Revisiting Old Stories About Little Airways

Originally posted on The Collective:

Dr Andrew Weatherall returns to stuff about paediatric airways, a bit of a companion to an earlier post with some practical tips. 

There are some things you’re taught from a very young age to believe in. Then it turns out it’s just plain wrong. Santa Claus. The Tooth Fairy. The Public Holiday Numbat. (Well, the last one might be specific to my upbringing.)

And in medicine there are plenty of examples those too. Oxygen is always good. You can’t manage trauma without a cervical collar. Then of course there’s pretty much everything about the paediatric airway. As if managing kids didn’t come with challenges anyway, we all get to work with information that is just plain wrong.

And there’s no mistaking that clinicians find paediatric airways difficult. The staff from Royal Children’s Hospital Melbourne have recently published a sizeable prospective study of emergency department intubations. This is from a big, clinically…

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Auckland HEMS Air Ambulance Fellows wanted!

Originally posted on Auckland HEMS:

Fellow – Adult Emergency Department-076540

Helicopter Emergency Medicine Service (HEMS)

Fellow position – 6 month fixed term (ACEM accredited special skill term in Air Ambulance)

June 2015 – December 2015

Auckland City Hospital is the largest public Hospital in New Zealand and one of the best trauma centres in the country .The Emergency department is a modern purpose built, world class facility that opened in 2003. We have an enthusiastic team of clinicians who have expertise in resuscitation, ultrasound, simulation, toxicology and retrieval medicine. The closely knit team consists of  FACEM’s, Medical officers and Resident Medical Officers. The department sees about 60,000 adult patients annually with a high patient acuity.

The department in conjunction with the Auckland Rescue Helicopter trust run the Helicopter Emergency Medical service (HEMS) which has been successful in providing fully integrated care for trauma patients. The department is also active in research and is currently involved…

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My favourite VL view to increase first pass intubation

Originally posted on MEDEST:

A debate is ongoing among #FOAMED social media about increasing first passage rate in tracheal intubation and some difficulties when using VL.

At the beginning of my experience with VL I experienced some difficulties, but with a radical change in technical approach I reached a good security on first pass success.

Here are my consideration and I hope will be useful for anyone is starting using VL

 

There are some fundamental differences in VL technique respect to DL, that makes the DL more easy and intuitive to pass the tube trough the cords.

3axysThe 3 axys theory for airway management

“Sniffing position” align the pharyngeal axis with the laryngeal one

Sniffing positionSniffing position

Perfoming Direct Laryngoscopy with the laryngoscope we align the mouth axis to have a direct view of the cords.

DL viewDL VIEW

 

 

 

 

 

 

 

 

 

 

This view coincide with the route…

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Why? How? What? Big Questions for Prehospital Simulation

Originally posted on The Collective:

At CareFlight another round of training many people is about to come up so it seemed like a good chance to ask Dr Sam Bendall for her first contribution. 

Sam is an Emergency Physician who is passionate about education, particularly all things simulation. She works half-time at Royal Prince Alfred Hospital in Sydney in the Emergency Department where she helped develop and teaches the RPA Trauma Team Training program, teaches on the CIN nurses programs and helped develop the ED Essentials program. 

At CareFlight she is a retrieval doc (the other half-time) and the Deputy Director of Education. The CareFlight Education Team are always up to interesting things – from training the Australian Defence Force medical on how to look after all things ballistic, medical, surgical and paediatric, to running the Pre-Hospital Trauma Course both in Sydney and other locations (Malaysia, anyone?), to running Trauma Care Workshops all over the country. Oh…

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A Short Video About Bleeding Airways

Originally posted on The Collective:

Managing the airway in prehospital and retrieval medicine is a challenge and has inspired many a discussion in many a setting. And anyone working in the area would appreciate the additional challenge when there’s lots of blood getting in the way.  As a result everyone has tips and and tricks to try and manage things.

This is by no means the first time people have come up with an approach (or shared an approach) but in the spirit of wide-ranging discussion, here’s a suggestion from Dr Alan Garner recorded for posterity in video.

It runs for about 10 minutes and you’ll note that at the end there’s an update as the approach evolved.

All thoughts, feedback and experience very welcome.

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Keeping Things Calm: Remote Retrieval of the Psychiatric Patient

Originally posted on The Collective:

Jodie Mills, RN works with CareFlight’s Top End Medical Retrieval Service, flying out of Darwin across vast stretches of the Northern Territory. She grew up in the Royal Melbourne Hospital ICU before moving to Darwin 8 years ago where she completed midwifery studies.  She joined CareFlight 4 years ago and slightly pities all those who don’t get to fly in the top end. 

When asked to contribute to a blog and write about psychiatric aeromedical retrieval all I heard was my colleagues’ collective signs of “not another psych job!!”

The thing is, I’ve developed a bit of an interest in these patients after closely looking at the psychiatric retrievals in NT for the last 3 years. This specialised patient group presents a huge challenge to both the flight crew and our remote colleagues when presenting acutely unwell in our communities.

By the Numbers

I recently presented at the ASA/FNA/ASAM Aeromedical Retrieval Conference…

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Prehospital anaesthesia

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MEDEST Review 30. One year in Review.

Originally posted on MEDEST:

MEDEST-review

 

 

 

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.

The latest Review of the year is dedicated to a collection of the most important (for us) articles of this 2014.

This is MEDEST way to wish you all Merry Xmas.

Logo MEDEST xmas

Enjoy the reading:

Cardiac Arrest

Chest compression

Mechanical Devices

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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…

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