Lessons in Transport - Surviving Sepsis Part 2

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Lessons in Transport - Surviving Sepsis Part 2

"Around every 3rd heartbeat someone dies of sepsis"

Blood Product Administration:

  • Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration has decreased to < 7.0 g/dL to target a hemoglobin concentration of 7.0-9.0 g/dL in adults (grade 1B).
  • FFP NOT be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).
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Lessons in Transport - Surviving Sepsis

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Lessons in Transport - Surviving Sepsis

We routinely transport patients with severe sepsis and septic shock by both air and ground. Take a few moments to review these high yield management pearls from the 3rd edition of the Surviving Sepsis Campaign Guidelines.

Initial Resuscitation:

  • Goals during the first 6 hours of resuscitation:
  • CVP 8-12 mmHg (a debate on the utility of CVP or lack their of is beyond the scope of this LIT)
  • MAP >  65 mmHg
  • Urine output >  0.5ml/kg/hr
  • Central venous or mixed venous oxygen saturation 70% or 65% respectively (grade 1c)
  • In patients with elevated lacate levels we should target resuscitation to normalize lactate (grade 2c)
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Multiple Helicopter Scenes

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Multiple Helicopter Scenes

It is not uncommon for multiple helicopters to land on the scene of a multi-car accident or a single vehicle accident with multiple seriously injured victims.  Assessing, caring for, and transporting multiple victims adds a significant amount of complexity to these scene flights.  With multiple helicopters flying in, it is especially crucial that we heed all the lessons of crew resource management.  Situational awareness both in the air and on the ground is key.  But the challenges of multiple helicopter scenes are not limited only to safety considerations.

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Lessons in Transport - Avoiding Medication Errors

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Lessons in Transport - Avoiding Medication Errors

It takes an estimated 80-200 correctly executed tasks to successfully administer a single dose of a medication to a critically ill patient...

Our reality in transport medicine...  We routinely work in an environment that is prone to medical error. An environment that is...

  • Dynamic and potentially dangerous
  • Fast paced... where speed is perceived as excellence
  • Limited in space, resources, and personnel
  • Built on inferred indications with little access to confirmatory tests
  • Frequent patient care hand offs of high acuity patients
  • Defined by actions and inaction that have immediate consequences with little recovery time to stop sequential errors
  • Not reproducible... No mission is ever the same
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Survival and the Rule of 3's

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Survival and the Rule of 3's

Thankfully survival situations are uncommon.  Because these situations are so uncommon, however, when confronted with a survival situation, we often find ourselves woefully unprepared.  Some of us have had formal survival training through Boy Scouts/Girl Scouts/military/Wilderness Medicine courses.  Many of us, however, have had to rely on the Air Care & Mobile Care training sessions or maybe even what we see on Survivorman or other such TV shows.  Some of us may hope just being near Dr. Mel Otten has allowed us to glean the crucial bits of knowledge we may need.

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Keep Calm and Don't Walk into the Tail Rotor

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Keep Calm and Don't Walk into the Tail Rotor

Funny things happen when you start work in new environments.  Surely most clinicians have experienced this first hand.  Think back to that first time you scrubbed in and walked into an operating room, the first time you set foot in an ICU, the first time you worked in an ED different than the one you trained in.  What was that like? overwhelming? empowering? disorientating?  Did you ever get caught up in just trying to figure out where the heck the 25 gauge needles and 10 ml syringes were in the supply closet?

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Crew Resource Management: Lessons from the World of #FOAMed

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Crew Resource Management: Lessons from the World of #FOAMed

On Monday we published our first post in the Air Care and Mobile Care Online Flight Physician Orientation on Crew Resource Management.  Also on Monday afternoon we were able to tweet with some of the leaders in Prehospital Medicine and Helicopter EMS from around the globe.  We'll try to do this throughout the course so we can leverage the full power of free online access to medical education.  If you follow on twitter you may have caught the conversation, but in case you missed it, I've storify'd the tweets (embedded below) for you.

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Crew Resource Management

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Crew Resource Management

We kick off the Air Care & Mobile Care Online Orientation with posts on some of the most important aspects of helicopter EMS - safety, survival and the basics of operating around the helicopter as a crew member.  We’ll start off by talking about Crew Resource Management (CRM).  In this first podcast, chief pilot Bob Francis, flight nurse Dennis Schmidt, and Dr. Ryan Gerecht sit down and talk about the basics of CRM and what it means to pilots and flight crew.

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Trouble with Trachs - Recannulating the Stenosed Trach Site

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Trouble with Trachs - Recannulating the Stenosed Trach Site

TracheOTOMY sites can close up rapidly (within hours).  Why is this?  Essentially, there is (usually) no missing tissue with this procedure.  Occasionally the procedure does involve cutting a small section of the tracheal ring out but this is much less common now that percutaneous techniques are more in vogue  The percutaneous technique involves, essentially, dilation of the skin, soft tissue, and trachea and, as such, these sites can close up very rapidly.

TracheOSTOMYsites are less of of problem as they do involve the removal of tissue.  If they are fresh, however, these sites can also close relatively quickly.

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A Crack in the Ice? An In-Depth Breakdown of the TTM Trial

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A Crack in the Ice? An In-Depth Breakdown of the TTM Trial

   Like many other Emergency Medicine residencies, we took the time in our last Journal Club to break down the Targeted Temperature Management Article.  There is tons out there in the #FOAMed space about this trial.  And, one of our 4th year residents, Dr. Trent Wray, took some extra time to break down the article in gory detail and put it into the context of the previously published literature.

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Lessons in Transport - Hypotensive Resuscitation

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Lessons in Transport - Hypotensive Resuscitation

Permissive Hypotensionis also known as hypotensive resuscitation or low volume resuscitation

What is it?

A resuscitation strategy in the critically ill trauma patient (primarily applicable to penetrating trauma but also adapted to blunt trauma) where we allow the systolic BP to remain as low as necessary to avoid exsanguination while still maintaining critical end organ perfusion. (typically defined as appropriate mental status & or the presence of a radial pulse)

The Thought Process:"Don't pop the clot"...

By allowing lower blood pressures we avoid the potential disruption of an unstable fresh clot and thus worsening bleeding caused by higher BP's. 

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Lessons in Transport - The Lethal Triad

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Lessons in Transport - The Lethal Triad

To successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the LETHAL TRIAD of TRAUMA...

Bleeding causes acidosis, coagulopathy, and hypothermia... 

Acidosis and hypothermia causes more coagulopathy which causes more bleeding... and so begins a deadly cycle

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Lessons in Transport - TXA has Arrived!!

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Lessons in Transport - TXA has Arrived!!

To successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the LETHAL TRIAD of TRAUMA...

Bleeding causes acidosis, coagulopathy, and hypothermia... 

Acidosis and hypothermia causes more coagulopathy which causes more bleeding... and so begins a deadly cycle

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Lessons in Transport - Therapeutic Hypothermia Part 3

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Lessons in Transport - Therapeutic Hypothermia Part 3

Common Issues in Therapeutic Hypothermia

1) Bradycardia: may occur during induced hypothermia (even to as low as 35 bpm) and except in rare cases, is NOT a reason to discontinue hypothermia.

  • If bradycardia is severe, associated with persistent hypotension, and is not responsive to fluid and vasopressor therapy, a decision in conjunction with medical control to discontinue hypothermia may be made.

2) Dysrhythmias: generally does not occur unless temperatures fall < 30*C and hypothermia related ventricular fibrillation is rare unless temperature is < 28*C.

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Transvenous Pacemaker Insertion - Part 3

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Transvenous Pacemaker Insertion - Part 3

We used Part 1 and Part 2 in this series to give you an in depth understanding of all the critical steps of the procedure.  After reading those posts you should have a good grasp of the indications for the procedure, the complications you may encounter, and you will have read, seen, and heard step by step instructions for placing a transvenous pacemaker in the ED. This final installment in the series should bring it all together for you.  Here you will see the placement of the transvenous pacemaker from start to finish from the point of view of the operator (Dr. J'Mir Cousar) all filmed in glorious HD.

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