Neurologic Emergencies in the Air

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Neurologic Emergencies in the Air

Several months ago, I sat down and talked about the management of neurologic emergencies in the prehospital environment with Dr. Erin McDonough, an Emergency Physician and Neurointensivist who attends both in the ED and the Neurosciences ICU, and is a member of the Cincinnati Stroke Team.  In the brief podcast found below and on iTunes, we covered a wide range of topics including blood pressure management in spontaneous ICH, aneurysmal SAH, and ischemic stroke and some of the more rare complications associated with tPA administration.

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The Glories of End Tidal CO2

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The Glories of End Tidal CO2

If you were to choose one vital sign for your critically ill patient, what would you choose?  Blood pressure?  Pulse?  Respiratory rate?  O2 sat? Temperature? Certainly it’s nice to know if a patient’s BP is super low or sky high, but if you are evaluating someone for the presence of shock, and you are waiting on the BP cuff to cycle one more time, you are already behind in recognizing and correcting the patient’s physiologic derangements.

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PEEP PEEP PEEP

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PEEP PEEP PEEP

Ventilator management can be one of the more intimidating aspects of caring for critically ill patients both in the ED and in the prehospital setting.   There are several great #FOAMed resources out there on varying aspects of ventilator management including the well-known series by Dr. Weingart of emcrit.org (here and here).  Ventilator management can be an absolutely massive topic but for this post, and specifically for the embedded video below, I wanted to do a little deeper dive on only one of the components of ventilatory management: PEEP.

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Sepsis in the Air

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Sepsis in the Air

Next to STEMI and neurologic emergencies such as spontaneous ICH, SAH, and ischemic stroke, one of the most common pathologies we transfer from one facility to another on Air Care is sepsis.  However, unlike many of the other patients we transfer, these patient’s are usually being transferred from the ICU of an outlying facility to the ICU of a tertiary referral center that can deliver a higher intensity of care.  I sat down and discussed with Dr. Bill Knight, a former flight MD and now Emergency Medicine and Neurocritical care physician, about some of the complexities of caring for these patients.

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The Myth of the Stable STEMI Transfer

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The Myth of the Stable STEMI Transfer

We fly/transfer many patients with STEMI on Air Care and Mobile Care.  And, fortunately, a majority of these patients end up doing very well.  You accept them at the referring facility, load them in the helicopter, and transfer them to the cath lab at the receiving facility without incident.  You certainly may make some adjustments in nitro drips, maybe give some metoprolol, certainly review their outside hospital records, but usually the biggest benefit you are offering them is rapidity of transport.  Transport 20 or 30 of these patients without incident and you might get lulled into thinking that these patients are so incredibly stable that nothing bad will happen during the course of the transport.  To do so would be folly.

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Running a Code (in Tight Quarters)

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Running a Code (in Tight Quarters)

How many hands does it take to run a code?   Think about that for a bit...

In the SRU, the available hands seem essentially limitless.  There's a train of PCAs and medical students lined up to perform CPR, a nurse to run the monitor and defib, a nurse and/or pharmacist pulling up meds and mixing drips, a nurse charting, a MD dedicated to the airway, a RT to help with bagging, not to mention the MD running the whole show.  At a minimum you probably have 10 hands ready to ensure compressions are as uninterrupted as possible, to keep a check on the respiratory rate, to hook up monitors, push meds, defib, and all the other tasks that are necessary to code a patient.

Now what do you do in the back of the helicopter when a patient loses a pulse?

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Prehospital TBI - Beyond the "Code"

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Prehospital TBI - Beyond the "Code"

Of the injuries that one will care for in the pre-hospital setting, traumatic brain injury is one of the most challenging.  Quite often, more than one organ system has been injured and they require rapid, thoughtful, and precise management of their airway and hemodynamics.  In addition, TBI patients require frequent reassessment to detect progression of the primary neurologic injury.  This is easier said than done in the dynamic, unpredictable, and resource-limited prehospital environment.

To help simplify their care, the following “Code of Care” forms the core principles that characterize optimal TBI care:

  1. NO Hypoxia (SpO2 < 90%) – therefore, apneic oxygenation for all TBI patients
  2. NO Hypotension (sBP < 90 mmHg) – greatest iatrogenic risk is with induction and provision of positive pressure ventilation
  3. Blown pupil -> Hyperosmotic therapy + Hyperventilate
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Video Laryngoscopy in the Field? Absolutely

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Video Laryngoscopy in the Field? Absolutely

Close your eyes... actually open them up, you won't be able to read the description if you close your eyes... Imagine you are on flying on the helicopter for a scene flight.  You land and are brought to the patient, a victim of a motorcycle accident who is clearly in need of an airway.  He is obtunded with sonorous respirations, a GCS of 6, O2 sats in the low 90's.  You start to look and assess the patient's airway and you are decidedly less than pleased.

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Rescue Me

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Rescue Me

Extraglottic devices are often term "rescue devices."  And I can't decide whether this is a term that glorifies or degrades.  While yes they can often save your tail after a failed attempt at direct or video laryngoscopy, they can do so much more. Running a code in a resource limited setting with 2 providers? The gold standard of 2 person bag valve mask technique ain't going to be an option for you.  And you think you can hold C-E mask seal while bagging for 20 min?  If you can, you must have hands that rival the late great Andre Rene Roussimoff...

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Decision is a Sharp Knife

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Decision is a Sharp Knife

In emergency medicine, EMS, and critical care transport medicine, I think we’d all (at least secretly) agree that there’s absolutely no greater joy than being able to say to ourselves, “That guy (or lady) is still walking the earth because of the care my team and I were able to give him (or her).”  I’m talking about the sort of patient that you bring back from the very brink of death with knowledge and skill borne of hard work and practice.

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Needle Cricothyrotomy

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Needle Cricothyrotomy

Circumstances rarely are such where we must perform a surgical airway emergently. When we do, it is always for the same indication: you have a patient that you can’t intubate AND can’t oxygenate. In most cases where a surgical airway is required, a traditional open or Seldinger technique is preferred.

In children, however, these approaches are contraindicated (most authors describe age less than 10 or so as the cut-off). Thus, the needle cricothyrotomy is a procedure that we must be prepared to perform as emergency providers as this can be done in pediatric patients.

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Intubating (not in the SRU)

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Intubating (not in the SRU)

Logistics are pretty much everything.  A focus on logistics is what helps UPS deliver 500,000,000 during the holiday season.  A focus on logistics is what helped the Allies win World War II.  But logistics doesn’t just happen on the global, macroscopic scale.  Logistics plays a role in every procedure we do in the ED and in the prehospital environment.  If you only focus on learning the mechanics of physically performing a procedure, you are neglecting crucial steps that will help ensure your success.  In this our latest podcast in the Air Care and Mobile Care Online Flight MD Orientation, Dr. Steuerwald and Dr Hill discuss some of the complicating factors for prehospital airways, focusing on both some of the logistical issues that come into play and some of the mechanical/physical considerations.

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Pericardiocentesis

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Pericardiocentesis

First, pericardiocentesis should be considered a temporizing procedure.  In the setting of trauma, you are hoping that the pericardiocentesis will clear a small amount of blood from the pericardial space and remove any tamponade the might be present.  It is likely, however, because of the mechanism of injury, that blood will again rapidly accumulate leading to recurrent tamponade physiology.  Ultimately (but not on Air Care — DON’T do a clamshell), these patients will need a pericardial window, exploration, and repair of whatever injury is causing the accumulation of blood. 

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Lessons in Transport - Your Friend and the Bleeding Patient's Friend: TXA in trauma

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Lessons in Transport - Your Friend and the Bleeding Patient's Friend: TXA in trauma

TXA… What can be said about TXA that hasn’t already been said.  TXA is good for what ails you.

Nosebleed? No problem.

Menorrhagia? TXA can fix that.

Involved in a motor vehicle crash with multiple pelvic fractures, a busted up spleen, hemorrhaging internally? TXA has your back.

In this podcast, Dr. Hill, Dr. Steuerwald, and Dr. Gerecht sit down and talk through the indications for using TXA in the prehospital environment and briefly discuss some of the evidence for its use.

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Drill, Baby, Drill

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Drill, Baby, Drill

You need access?  You need access right now?  Drill, baby drill.

The EZ-IO is pretty ridiculously easy to use.  The only real decision points in its use are what site to choose (humeral vs tibial) and what needle to use (pink, blue, or yellow).  There are a couple of other nuances which we will cover below and in the embedded video.

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