ETM Podcast Episode 1 – Minh Le Cong – Trauma Airway (part 1)

Head over to the excellent ResusRoom.mx blog, where Andy B has put up an incredibly insightful post based on the BBC's "How to Avoid Mistakes in Surgery" production, with Dr Kevin Fong who was the presenter from another production named Extreme A&E. 

BBC iPlayer link for UK viewers

It was my pleasure recently to be involved in a podcast over at Minh's PHARM  alongside Dr Nicholas Chrimes (consultant anaesthetist at Monash Hospital), and Dr Peter Fritz (emergency physician & retrieval specialist) on the topic of difficult airways. Traditionally, difficult airway algorithms are linear, and quite complex - something that may have limited utility in a high stress difficult airway situation. 

Well the cat is pretty much out of the bag, (thanks to Minh over at the PHARM Podcast) the reason my posts on EDExam have slowed down a bit is because I've been spending nearly all of my spare time in the last 9 months working on a new project. Utilising the results from our Trauma Education Needs Survey, (thanks to all who participated), Amit Maini (from www.edtcc.com) and I have created a new Emergency focused trauma course, called the Emergency Trauma Management Course (ETM Course). 

I love direct laryngoscopy (DL); it’s such a satisfying technique and one that you usually only get to perform when it'll really make a difference to the patient (in ED). So when I first heard about videolaryngoscopes (VL) I was a little sad. I felt that all those years learning how to do DL, often with heart racing, would now be wasted.

I know I know, it's been like, forever since the last post. No we did not disappear over the Bermuda Triangle. No we didn't retire to our private island in the Caribbean (although we wish we had). So, just letting you know, we are still here - thanks for sticking with us.

It's been a fantastic (and busy) day at the EDTCC headquarters.  A mammoth whiteboard session with EDExam's very own Andy Buck, on a collaborative upcoming project (more to follow), followed by a podcast on Minh Le Cong's (@rfdsdoc) PHARM blog with some of Oz ED's greats - Casey Parker (@broomedocs) of Broomedocs blog, and the vivacious Michelle Johnston (@Eleytherius) from LITFL blog.

Listen to the podcast here.

This podcast was stimulated by a great review article in the BMJ by Tim Harris and Karim Brohi (@karimbrohi) at the Royal London Hospital.

In this article, the key concepts of damage control resuscitation, and fluid resucitation in different settings are explored and outlined. I highly recommend that you get access to the full article. 

"Summary points

• Critically injured trauma patients may have normal cardiovascular and respiratory parameters (pulse, blood pressure, respiratory rate), and no single physiological or metabolic factor accurately identifies all patients in this group

• Initial resuscitation for severely injured patients is based on a strategy of permissive hypovolaemia (hypotension) (that is, fluid resuscitation delivered to increase blood pressure without reaching normotension, aiming for cerebration in the awake patient, or 70-80 mm Hg in penetrating trauma and 90 mm Hg in blunt trauma) and blood product based resuscitation

• This period of hypovolaemia (hypotension) should be kept to a minimum, with rapid transfer to the operating theatre for definitive care

• Crystalloid or colloid based resuscitation in severely injured patients is associated with worse outcome

• Once haemostasis has been achieved, resuscitation targeted to measures of cardiac output or oxygen delivery or use improves outcome

• Tranexamic acid administered intravenously within 3 h of injury improves mortality in patients who are thought to be bleeding"

BMJ 2012; 345 doi: 10.1136/bmj.e5752 (Published 11 September 2012)

Resources

Karim Brohi's (@karimbrohi) lecture on Permissive Hypotension

Broome Docs Massive Transfusion Protocol 

PHARM Podcast 39 - Haemorrhagic shock in remote settings with the Three Resusciteers

EMCrit Blog - Tranexamic Acid (TXA), Crash 2 with Tim Coats.

EMCrit Blog - Podcast 30 - Haemorrhagic Shock Resuscitation with Richard Dutton MD

Physiotherapy? That's not one of the makor risk factors for PE I hear you cry...

But that's how this scenario played out on a recent shift on the floor...

Scenario

30 something previously well female presents acutely to the ED via ambulance, after a syncopal episode in the street whilst walking home after an appointment with her physiotherapist. She had been receiving treatment for a "calf sprain" that she had complained of, with ongoing pain in her right calf for the preceding 2 weeks. Bystanders called for an ambulance, and on arrival to the ED, she was found to have a systolic BP of around 70mmHg, hypoxic with saturation of 80% on air, and tachycardic with a rate of 150 bpm. She denied having any chest pain. She was immediately transferred to a resuscitation bay, and rapidly assessed.

Following the publication of the International Stroke Trial (IST-3) in May 2012 in the Lancet, I have had various discussions with my colleagues regarding the utility of thrombolysis for acute stroke. When presented with the unfortunate hypothetical scenario where they have been afflicted with the neurological insult in question, it surprised me somewhat that the general consensus was that they would choose to be thrombolysed (colleagues from radiology, medicine, emergency medicine as well as neurologists). Looking at the abstract of the IST-3 study, it's not hard to see why...

Andy Buck and I in a resus bay at the Royal Darwin Hospital

What a way to cap an amazing week, working in the Northern Territory of Australia! I met up with Andy Buck from EDExam, and we recorded a podcast with none other than the king of pre-hospital critical care - Minh Le Cong over at the PHARM blog. The main discussion focussed around crash airways, as well as chest pain pathways.

Check out the podcast HERE.

Minh Le Cong PHARM Blog with Andy Buck and Amit Maini