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

 

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