Trauma Care Day 3

There were several streams running simultaneously today which were interesting for prehospitalists, not least the PHEM/HEMS Programme. We tried to get to as many as possible to share some of the key learning points and interesting messages, and again we have recorded some interviews which we will share in future podcasts.

‘One RTC – 3 perspectives’ – Darren North

The fire service have only had a statutory duty to attend RTCs since 2004. Their role is to protect people from harm – patients and practitioners.

Strategy of the Fire Service at RTCs “The Team Approach”:

  1. Safe approach and control of hazards (risk assessment starts in the fire station and planning en route – share message with the team, role allocation)
  1. Stabilisation (car needs to be solid so the patient and initial rescuers are safe) and initial access. When a car is on it’s side, if fire service not yet there, consider placing one individual at either end of the car to stabilise it.
  1. SRS/Glass management – cover glass, open windows/sunroof (but wary of environment), make safety systems safe eg airbags
  1. Space creation – remove shopping, luggage, parcel shelves etc
  1. Full access – depending on plan, following liaison with medical service
  1. Patient extrication & transport (in some regions fire service have role in taking patients to hospital)
  1. Evaluate and training (hot debrief – at the back of the fire engine on scene, but this is limited to fire service as health providers have usually taken the patient to hospital)

What can the fire service offer the medics:

  • A safe working environment
  • Rapid initial access
  • Free entrapment ASAP
  • Extra pairs of hands
  • Medical assistance/equipment
  • Debrief (hot and structured)

Key messages

  • Identify who is charge, generally officer in charge will have Incident Commander tabard, not necessarily the ‘white helmet’
  • Speak plain English
  • IMG_6616
  • Always try to be better
  • Be honest about time frames
  • Train together
  • Be careful what you say

And then I moved into the Trauma in Children Programme, to listen to:

The Highs & Lows of Pre Hospital Paediatric Trauma – Dr Kevin Enright

We have interviewed Kevin to share in a future podcast but hear is a summary of his talk.

Very serious injuries in children is rare – so exposure to severely injured children prehospital is infrequent and the evidence is sparse – highlights the importance of shared experience.

Children are brave, honest and constructive. This should be remembered when assessing and treating seriously injured children.

Recent report covering the last 2 years of TARN data:

https://www.tarn.ac.uk/Content/ChildrensReport2/index.html

When children are injured/ill and scared they regress. Remember this, especially when managing adolescents; children may not be as interactive or as co-operative as you would expect for their age.

Significant cervical spine injury in children is exceptionally rare. Three cases described: high speed RTC, traumatic cardiac arrest. Patients had high cord injuries.

What do an advanced prehospital team offer at scene to a seriously injured/ill child?

  • CRM (experience + discipline – there is one way to do this and we must do it fast and efficiently)
  • Leadership
  • Order & calm (slightly more exposure)

Policy that paediatric patients are not declared dead at scene. If the prehospital team consider the patient to be futile they will take them to the nearest local hospital. This has a huge impact on the local hospital – is that fair? It is hard enough for those who work in MTC paediatric centres. Should the prehospital team make the decision and not attempt resus in hospital at all?

Prehospital paediatric RSI

  • We do it less despite similar injury aetiology/patterns
  • Most children’s airways can be managed by basic manoeuvres
  • However, children with a significant head injury deserve best airway care – ventilation, metabolic, haemodynamics, positioning. Must have appropriate training & experience otherwise risk/benefit balance is skewed.
  • Children’s airways are different, be prepared for this (NB don’t even think about it though with children with craniofacial deformities)

Injured children are compensating to try and survive.

IMG_6618

Top tips

  • Analgesia, warmth & splintage
  • Confidence & rapport (the healthcare professional is the right person to do this, not the parent – how can they be constructive?)
  • Mechanism of injury
  • Clinical assessment
  • Compensatory mechanisms (but they will be getting acidotic, coagulopathic)
  • Fluids? (2-5ml/kg, ideally blood products but crystalloid ok)
  • Scoop & run

The Evidence for Night HEMS – Leigh Curtis

This was a review of the 2 year trial KSS air ambulance conducted into night HEMS. If, like me, you thought that night HEMS is “Expensive … dangerous … pointless”, the data that Leigh presented was interesting. For their geography and population it turned out that they flew 1373 missions, and contacted 942 patients (1.9 missions on average per night), who had an average ISS of 23.5. Offline 15% of time due to weather minima.

Immersive Simulation in PHEM – Mark Forrest

We have interviewed Mark to share in a future podcast, but he had lots of great ideas, and recommended that we build SIM into everyday, using an example from Sydney HEMS; small and often.

Thinking about Pre-Hospital Death – Gareth Grier

This was an excellent talk which I recommend you watch when the video is available as it is difficult to reproduce the content here. One important point was:

We take a burden home with us when we have attended an incident when a patient has died. It can be a lonely place.

This is a topic we will revisit in future podcasts.

Pre Hospital Thoracotomy for Blunt Trauma – Tom Konig

We are going to catch Tom for a podcast tomorrow, but for now here is a taster:

 

Developing high performance through marginal gains – Adam Nash

Adam introduced the concept used by Team SKY and GP Olympic Cycling team: Focus on doing a few small things really well, once you do this aggregating these gains will become part of a bigger impact on performance.

To read/here more about it, try these St Emlyns resources:

http://stemlynsblog.org/ed-need-matt-parker-st-emlyns/http://www.stemlynspodcast.org/e/marginal-gains-in-the-ed/

IMG_6625

Adam used the concept in a project to examine patient packaging. By working with some student paramedics to adjust techniques they were able to reduce packaging of a simulated time critical patient from nearly 13 minutes to just over 5.

Paediatric trauma patients: do they get a worse deal? – Phil Hyde

We were hoping to record a podcast on this for you – but Phil had to shoot off. We will catch up with him at a later date – but in the interim, here are the learning points.

In one word – yes: children get a raw deal.

Epidemiology:

  • Trauma is the biggest killer of children, with two peaks of death – the under 1s (injuries inflicted by other humans) and 6 +.
  • The mechanisms of trauma death in children are: RTCs, falls and other humans hurting them
  • The main cause of death is due to severe head injury.

Providing PH care to little humans:

Data from the Confidential enquires into head injuries in children 2010

In patients with a GCS of 8 or less transported by ambulance:

  • Oxygen not provided in 30%
  • Saturations not measured in 70%
  • BP not measured in 55%

This seems unbelievable – and definitely unacceptable.

Lots of ambulance services (in 2010) did not have appropriate kit to deal with small humans– including 92% not having appropriate sized supraglottic devices.

Phil raised his concerns around safe transport to the correct destination: very short drive times for low GCS patients – getting the balance right between this, and getting patients to the right centre first time is difficult – and we probably haven’t got the balance right yet.

In the UK our child mortality from trauma is high. We are performing very poorly compared to comparators, the mortality is 8.6% of children majorly injured, increasing to 18% when GCS<15. This is the same as Sweden in the early 1980’s the Swedish trauma systems have decreased mortality 3 fold during this time…

PH care is made more difficult as there is a fear of criticism from the paediatric fraternity. Children are considered very special / difficult and different – they require special training and equipment… This attitude is not helpful in the delivery of high quality Prehospital care. PH care delivery is generic in terms of training and experience of personnel – it is impractical to provide a ‘special’ service for children.

In PH care children require the same as adults – physiological support of their (injured) organs. Post PH care they can enter a paediatric specific system.

How we improve the care we offer to little humans:

  • We become experts in supporting HUMAN physiology, HUMAN trauma care, HUMAN medical logistics.. (no matter how big the humans are).

What do we need:

  • Generic, human SOPs
  • To spend time around sick small humans – best place is PICU, many will offer observational placements on request.
  • https://www.spottingthesickchild.com
  • Airway / Breathing / Circulation Kit for humans
  • Monitoring for humans
  • Transport for humans

We are empowered to:

  • Become expert in human trauma care
  • Make our system fit for humans
  • Make emotion positive
  • Embrace injury prevention

 

 

Episode 8: Chemical Suicide

Chemical Suicide

The recent resurgence in this method of suicide has put emergency responders at a significant increase of serious injury and death.

This podcast discussed the current most frequent methods of attempted and successful inhalational suicide  – keep safe.

 

 

There are a multitude of professional and advisory websites out there.

We are keen not to raise awareness of specific combinations of chemicals / products.

Trauma Care Day 2

Today has been a really good day at Trauma Care – there were several lecture streams running and I also gave a presentation on Pelvic Binders so I didn’t get to hear as many as I would like to have done, but here are a couple of summaries which I hope you will find interesting. We have also recorded a three interviews already which will feature in future podcasts. Many of the lectures were recorded today and will be available to view soon on the Trauma Care website.

All things Pre Hospital Ketamine – Minh Le Cong

Key point: patients remember if you manage their pain well.

Ketamine covers the full range of PH analgesia and anaesthesia, and can be administered IN, IV, IM, sublingual. It is highly lipophilic, rapidly absorbed, therefore particularly suitable for IN and SL admininstration.

Ketamine can be particularly useful in bariatric patients, where large doses of opiates in addition to past medical history of respiratory problems or chest injuries may not be ideal. Also good for patients on chronic pain long term opiate therapy with acute injury

Minh told a story about a patient who had undergone a prehospital amputation following the Christchurch earthquake – the full account can be heard here:

https://prehospitalmed.com/2014/06/23/urologist-anaesthetist-ketamine-prehospital-amputation-lifesaving-story/

He also talked about the outcomes of the SKEPTIC trial which was a retrospective review of patients who’d received ketamine vs those who had not, comparing shock index. The periscope video of the SKEPTIC trial presentation is accessible here:

https://prehospitalmed.com/2016/04/12/ketamine-for-prehospital-rsi-the-skeptic-trial-by-dr-faizan-arshad/

The Royal Flying Doctors Service (RFDS) use infusion of ketamine to manage agitated mental health patient without need for intubation. The paper published describing this and the protocol they use are linked below:

https://www.flyingdoctor.org.au/assets/files/Ketamine_Sedation_Acute_Agitation_Aeromedical_Retrieval.pdf

https://www.flyingdoctor.org.au/assets/files/Consensus_Statement_-_The_Acutely_Agitated_Patient_in_a_remote_location.pdf

Emergence phenomena – Minh reports 12 cases during his career. This possibility should be respected but not feared. Key is to consider environment, perhaps it is unsurprising that patient’s get agitated when the aircraft starts up!

Following the lecture I found this on Minh’s PHARM website: a review of prehospital ketamine administrations.

https://prehospitalmed.com/2016/01/16/adverse-event-profile-of-2008-prehospital-ketamine-administrations/

 

Extrication & Immobilisation continued…. – Rob Fenwick

Extrication – a patient centred approach

Why does extrication matter?

  • Trauma is a killer, road trauma is a killer (leading cause of death of people aged <40 yrs), 4-5 deaths per day in the UK, 20-30% have a significant entrapment
  • For each patient that dies, 10x more a significantly injured
  • 50% die in first hour, 18% die between 1-6 hours, 15% preventable

Brown et al – patients requiring prolonged extrication increases mortality

Life saving interventions cannot be delivered while the patient is in the car.

The longer the time a patient is in the car in cold weather, the colder they will get, and mortality increases for every degree reduction in temperature.

Physical vs medical entrapment: Only 11% of patients ‘requiring extrication’ were actually physically trapped

Why do we extricate the way we do?

  • fear of exacerbating spinal injury
  • fear of being sacked when we ‘cause’ a spinal injury
  • fear of being sued when we ‘cause’ a spinal injury
  • that is how we have been taught
  • based on expert opinion + isolated case reports

What are we trying to do?

  • Reduce secondary injury – by restricting movement
  • Limited case reports suggesting that patient’s injuries had got worse between their initial assessment in at scene and in hospital – BUT were these really just natural progression of disease with spinal oedema increasing signs/symptoms?

Spinal fractures occur in 2% of all major trauma. Unstable spinal fractures occur in all major trauma 0.7%. Remember this when you get on scene – 98% of patients will not have a spinal injury.

The awake patient will develop a position of comfort with muscle spasm protecting the injured spine. Hauwald, 2002

A co-operative patient does not require immobilization unless their conscious level deteriorates. Muscle spasm is superior to any artificial method. Blackham & Benger, 2009.

 

Immobilisation with cervical collar is not harmless

  • Uncomfortable
  • Causes delays
  • Increased ICP
  • Increased risk of aspiration
  • Pressure sores
  • Reduced airway opening
  • Reduced respiratory efficiency

Forget immobilisation, deliver spinal care

  • Stop hypoxia
  • Stop the bleeding
  • Minimize force
  • Minimse movement

 

Episode 7: Sepsis

We hope you enjoyed our sepsis podcast. It is obviously a huge topic and there is lots of information to cover; a couple of other recently released podcasts are available which are produced with the Emergency Medicine community in mind, but will no doubt expand your knowledge.

 

St Emlyns Induction podcast on Sepsis. March 2016. A great summary of what to do when a patient with suspected sepsis first arrives in the ED.

And from our buddies at HEFT EM CAST:

http://www.heftemcast.co.uk/sepsis-in-the-ed/

A bit more detail covering some of the research in an easy to understand way. It particularly discussed the original Rivers trial which we mention in the podcast.

It’s worth remembering that sepsis is a spectrum of disease when assessing patients.

Slide1

It is worth noting, that with “Sepsis 3” many of these terms will become out-of-date – but validation work is required…

The Rivers’ paper can be accessed here: http://www.nejm.org/doi/full/10.1056/nejmoa010307

It was a single centre study which compared standard care with protocolised resuscitation packaged together as early goal-directed therapy (EGDT). This is what the study did:

rivers jpg

As you will see the trial was relatively small – with only 263 patients being recruited into the trial. What was impressive, and changed practice, forming the basis of the Surviving Sepsis Campaign, was the significant reduction in mortality. Patients in the standard care group had a mortality of 46% compared with the treatment group 30%, which was statistically significant (p=0.009).

Further large randomized controlled studies to try and demonstrate the same mortality benefit from Rivers-style EGDT have not shown the same results (Process, Arise, PROMISe). Patients in these trials were randomly assigned to one of two groups. The ‘intervention’ group received the new treatment, in this case EGDT, which was being tested. The ‘standard care’ group were looked after according to how the clinician would usually treat a patient with severe sepsis. This was the same principle as in the Rivers trial: the standard care group is the ‘control’ group against which changes in outcome for the ‘intervention’ group are compared. The mortality in both groups in all 3 trials was similar, there was not the significant reduction in mortality seen in the Rivers study. This was probably because, as we say in the podcast, ‘standard’ care for sepsis has improved considerably in the intervening years. The control group received many similar treatments as the ‘intervention’ group (just not full protocolised EGDT) highlighting that with good sepsis care (fluid resuscitation, close monitoring, early appropriate antibiotic administration), mortality can be reduced.

Red flag sepsis is a way of identifying those patients with sepsis who are high risk  and who warrant immediate treatment:

red flag

Have a look at the UK Sepsis Trust website: http://sepsistrust.org. There are toolkits available to download, including one specifically written for the prehospital environment with the College of Paramedics, which summarises the recognition and management of sepsis.

 Link to the Sepsis-3 guideline. 

Reviewed (again for the Emergency Medicine community) here.

When Tim talks about test characteristics he is referring to the ability of a test to correctly identify the presence or absence of an illness. Some may think that if a test is positive it always means the patient has the illness, or indeed if it is negative it rules out the possibility of that illness but this is not the case with many of the tests we use.

Think about ECG as an example,test So, where the box is green, the test has given us the correct result for the patient. But, where the box is red the test has given us the incorrect result: you will all be able to think about patients in whom the ECG was normal, but the patient turned out to have had an MI, or when the ECG showed an MI but the patient turned out not to have had one. These tables are used when assessing the usefulness of a test (or it’s sensitivity and specificity), and, when researching how useful tests are we need the majority of patients to fall into the green boxes.

We will put together a podcast on test characteristics over the next couple of months, which will explain this in more detail. An amazing podcast on the subject can be found at SMART EM: SMART Testing: Back to Basics

As always, any feedback, comments etc. – please let us know on the blog below!

  1. Herlitz J, ng AB, m BW-S, Axelsson C, Bremer A, Hagiwara M, et al. Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care. Scand J Trauma Resusc Emerg Med. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine; 2012 Jun 27;20(1):1–1.
  2. Studnek JR, Artho MR, Garner CL, Jones AE. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med. 2012 Jan;30(1):51–6.
  3. Puskarich MA, Marchick MR, Kline JA, Steuerwald MT, Jones AE. One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. Crit Care. 2009;13(5):R167.
  4. Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe Sepsis in Pre-Hospital Emergency Care. Am J Respir Crit Care Med. 2012 Dec 15;186(12):1264–71.
  5. Band RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF. Arriving by Emergency Medical Services Improves Time to Treatment Endpoints for Patients With Severe Sepsis or Septic Shock. Academic Emergency Medicine. 2011 Aug 30;18(9):934–40.
  6. Seymour CW, Cooke CR, Heckbert SR, Spertus JA, Callaway CW, Martin-Gill C, et al. Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study. 2014 Oct 28;:1–9.
  7. Trust US. You Gov Poll – Public Awareness of Sepsis. UK Sepsis Trust; 2014 Nov pp. 1–1.
  8. MD GEH, MD RET, MD RS, MD JDL, BS AMB, BS AJS, et al. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Aug 26;:1–31.
  9. Amado Alejandro Baez MD MSc MFFF, MD LC. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Oct 17;:1–16.
  10. Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med. 2013 Jun;44(6):1116–25.
  11. Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department*. Crit Care Med. 2010 Apr;38(4):1045–53.
  12. Yealy DM, Huang DT, Delaney A, Knight M, Randolph AG, Daniels R, et al. Recognizing and managing sepsis: what needs to be done? ??? ??? 2015 Apr 24;:1–10.
  13. Báez AA, Hanudel P, Perez MT, Giráldez EM, Wilcox SR. Prehospital Sepsis Project (PSP): knowledge and attitudes of United States advanced out-of-hospital care providers. Prehosp Disaster Med. 2013 Apr;28(2):104–6.
  14. Harnden A. Parenteral penicillin for children with meningococcal disease before hospital admission: case-control study. BMJ. 2006 Jun 3;332(7553):1295–8.
  15. Femling J, Weiss S, Hauswald E. EMS Patients and Walk-In Patients Presenting With Severe Sepsis: Differences in Management and Outcome. South Med J. 2014.
  16. Gray A, Ward K, Lees F, Dewar C, Dickie S, McGuffie C, et al. The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments. Emergency Medicine Journal. 2013 Apr 12;30(5):397–401.
  17. Seymour CW, Cooke CR, Mikkelsen ME, Hylton J, Rea TD, Goss CH, et al. Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care. 2010 Apr;14(2):145–52.
  18. Hahné SJM, Charlett A, Purcell B, Samuelsson S, Camaroni I, Ehrhard I, et al. Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: systematic review. BMJ. 2006 Jun 3;332(7553):1299–303.
  19. Wang HE, Weaver MD, Shapiro NI, Yealy DM. Opportunities for Emergency Medical Services care of sepsis. Resuscitation. 2010 Feb;81(2):193–7

 

How to cite this podcast:

Nutbeam T, Bosanko C. Sepsis. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk