March 25, 2014

Pericardiocentesis

March 25, 2014/ Jeffery Hill, MD M.Ed

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.

March 24, 2014

Look Before You Leap - Awake Fiberoptic Intubation

March 24, 2014/ Steven Carleton, MD PhD

Look Before You Leap, Drive Your Ferrari Like it is a Wheelchair, Harken Ye to the Wicked Witch of the West!

A 37 year-old woman presents with stridor, drooling, tachypnea and accessory respiratory muscle use. She has an adequate blood pressure, but is tachycardic to 120. Her oxygen saturation on room air is a reassuring 97%. She cannot answer questions, appears to have an altered mental status though she follows commands, and suddenly has a brief period of either myoclonus or seizure with unresponsiveness. No post-ictal period is noted after this episode.

March 21, 2014

Awake Fiberoptic Intubation

March 21, 2014/ Jeffery Hill, MD M.Ed

Like all procedures, success in the performance of an awake fiberoptic intubation comes from proper preparation. Preparation for this procedure means so much more than proper preparation of the patient (preoxygenation, positioning, local anesthesia, etc.). To be fully prepared is to have a well practiced, working knowledge of your equipment and the options you have in setting it up. To be fully prepared is to be practiced in the motor skills necessary to drive the scope, advance the tube and troubleshoot as you go.

March 19, 2014

Lessons in Transport - Plasma? We Got That...

March 19, 2014/ Ryan Gerecht, MD

Why is Air Care starting to transport and infuse plasma? Multiple studies, many from military combat zones, strongly suggest that clinical outcomes are improved by administration of plasma alongside RBCs in a 1:1 ratio. (1,2) Furthermore, the concept of damage control resuscitation advocates for minimizing crystalloid infusion and maximizing early aggressive resuscitation with blood products in patients with life threatening hemorrhage. Recent unpublished analysis suggests that expanding these resuscitation principles to the prehospital environment via helicopter EMS was associated with improved outcomes.

March 18, 2014

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

March 18, 2014/ Jeffery Hill, MD M.Ed

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.

March 14, 2014

Lessons in Transport - Cognitive Biases in Critical Care Transport

March 14, 2014/ Ryan Gerecht, MD

As critical care transport professionals we are often perceived as an action oriented specialty. We frequently pride ourselves on procedural excellence and efficiency. (a difficult intubation, or fast scene-time etc.) However, the reality is that we spend the vast majority of our patient care time engaged in cognitive behavior... in THINKING rather than acting!

Because of this, it is imperative that we make every possible effort to understand how we think while caring for others. In addition, we should be aware of some of the cognitive biases that threaten our thinking processes, decision making, and thus the patients who place their trust in us.

March 13, 2014

Drill, Baby, Drill

March 13, 2014/ Jeffery Hill, MD M.Ed

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.

March 10, 2014

Ultrasound in HEMS

March 10, 2014/ Jeffery Hill, MD M.Ed

Critics out there may slight the use of ultrasound in the prehospital environment, saying it is just going to delay patient transfer and won’t add much to your decision making. However, when used properly, the ultrasound should never delay patient care and, when used in the correct patient population, it could help greatly in both decision making and treatment. Let’s first talk about when to use it. The logistics of this may be a bit tricky.

March 01, 2014

Finger Thoracostomy

March 01, 2014/ Jeffery Hill, MD M.Ed

We talked about needle thoracostomy a while back and when we did, we talked about the propensity for the needle to fail. There are a lot of reasons why the needle could fail to relieve a tension pneumothorax (or to only temporarily relieve a tension pneumothorax). The needle may be too short to enter the thorax in the first place* or the catheter could kink, allowing reaccumulation of air in the thorax.

February 24, 2014

The Decision to Intubate

February 24, 2014/ Steven Carleton, MD PhD

The I.C. Cordes College of Airway Knowledge, written by Dr. Steven Carleton, is known to many who have passed through our doors. Today, however, we begin to set them free to the #FOAMed world starting off with I.C. Cordes #1 - The Decision to Intubate. I felt like I had found a mint copy of the Amazing Fantasy Introducing Spiderman comic book or a Honus Wagner baseball card receiving these collected cases by email from Dr. Carleton earlier today. - Jeffery Hill, MD

February 23, 2014

Transporting Intra-Aortic Balloon Pump Patients by Air Care

February 23, 2014/ Bill Hinckley, MD

Many historians argue that the first use of aeromedical evacuation was during the Siege of Paris in 1870, using hot air balloons (though there seems to be some question regarding the truth of this claim). We're still using balloons during air medical missions in 2014, albeit in a much different way.

The efficacy of IABPs has recently been called into question; see Cliff Reid's recent blog post at http://resus.me/double-balloon-pump-fail/ . Regardless, the decision to initiate IABP therapy isn't going to be ours. But the challenge of moving an extraordinarily sick patient receiving this therapy WILL be ours. We must be ready. How?

February 18, 2014

Lessons in Transport - Upper GI Bleeding

February 18, 2014/ Ryan Gerecht, MD

It is 2am on a cold, dark, winter night and you are dispatched to a small rural hospital to transport a patient by ground with a GI bleed back to UCMC medical ICU. Enroute dispatch notifies you that your patient has deteriorated and is profoundly hypotensive. The ED physician at the outside hospital is attempting intubation for airway control. On arrival you find a middle-aged male with all the classic stigmata of end-stage liver disease. More importantly he has a systolic blood pressure of 60 and a HR of 130. A literal fountain of blood spews from the patients mouth, around a successfully placed endotracheal tube, and is now beginning to pool on the floor. You know this patient needs massive resuscitation from his likely bleeding esophageal varices... but you are 55 minutes by ground to UCMC and know that your patient will not survive the transport unless something is done to control the bleeding...

February 17, 2014

Resuscitation of Penetrating Trauma Patients

February 17, 2014/ Jeffery Hill, MD M.Ed

In our last podcast we covered the basics of the evaluation of the patient with blunt trauma. We switch gears a little bit this week and focus a little more on penetrating trauma. In this podcast, Dr. Hinckley and Dr. Chris Miller discuss several facets of the care of penetrating trauma patients including the initial approach and evaluation, detection of subtle presentations of shock, and triggers to initiate transfusion of blood products. In this accompanying blog post, I’d like to focus primarily on why we might want to withhold fluids on penetrating trauma patients.

February 14, 2014

Traction Splints - Applying the KTD Traction Splint

February 14, 2014/ Jeffery Hill, MD M.Ed

Immobilization of midshaft or distal femur fractures is thought to decrease pain for the patient during transport and to decrease the amount of bleeding and hemorrhage. Application of a traction splint, however, is a somewhat uncommon, and therefore potentially unfamiliar, procedure. A look at the literature on the use of traction splints in the prehospital environment shows that they are used uncommonly. And, when they are used, they are frequently placed incorrectly.

February 11, 2014

Needle Thoracostomy

February 11, 2014/ Jeffery Hill, MD M.Ed

There has been much digital ink spilled over the topic of needle thoracostomy (check below for some additional reading) with most of the hub bub surrounding the proper location to place the needle. We’re not going to completely rehash that which has already been said, but instead focus on distilling the highlights and turning our attention to a video showing how to perform what is ultimately a potentially life saving procedure. We won’t go much into finger thoracostomy as we will cover that procedure in a future blog post. So I heard that you’re setting yourself up for failure if you choose the 2nd ICS MCL to decompress the chest?

Blog

Look Before You Leap, Drive Your Ferrari Like it is a Wheelchair, Harken Ye to the Wicked Witch of the West!

Taming the SRU

SRU (pronounced "shrew") = Shock Resuscitation Unit

Categories

Links

Some Helpful Foam

Tags