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