Drowning

phemcast

Player FM - Internet Radio Done Right

11 subscribers

Vor acht Jahren hinzugefügt

Inhalt bereitgestellt von phemcast. Alle Podcast-Inhalte, einschließlich Episoden, Grafiken und Podcast-Beschreibungen, werden direkt von phemcast oder seinem Podcast-Plattformpartner hochgeladen und bereitgestellt. Wenn Sie glauben, dass jemand Ihr urheberrechtlich geschütztes Werk ohne Ihre Erlaubnis nutzt, können Sie dem hier beschriebenen Verfahren folgen https://de.player.fm/legal.

<div class="span index">1</div> <span><a class="" data-remote="true" data-type="html" href="/series/the-agile-brand-with-greg-kihlstromr">The Agile Brand with Greg Kihlström®</a></span>

1
The Agile Brand with Greg Kihlström®

Abbestellen

vor 22 hoursvor 22h ago

Abbestellen

Wöchentlich+

Expert mode marketing technology, AI, and CX insights from top brands and Martech platforms fill every episode, focusing on what leaders need to know to build customer lifetime value and long-term business value. The Agile Brand with Greg Kihlström® features executives and thought leaders from top brands and platforms discussing the industry's trends, like first-party data strategies, artificial intelligence, consumer data privacy, omnichannel customer experience, and more. The Agile Brand is hosted by Greg Kihlström, advisor and consultant to leading brands, speaker, entrepreneur, and best-selling author. It provides a fresh perspective on the continually evolving dynamic between brands and the audiences they serve.

vor 4 Jahren

MP3•Episode-Home

Some facts

Drowning is important: 1,000 people drown every day, 2 every 3 minutes, 41 per hour. It is the world’s 3rd leading cause of accidental death: 3.6 million people over 10 years.

Disease of youth

64% < 30 years old
43% < 15 years old
25% < 5 years old

Male: female ratio 2:1

In 40%, alcohol is on board

4 stages of Immersion associated with particular risk in drowning

Initial Responses/Sudden Death (first 3-5 min)

Skin cooling

Short-Term Responses (5-30 min)

Superficial Nerve and Muscle Cooling

Long-Term Responses (30 min +)

Cooling of deep tissues

Post-immersion (during rescue)

Collapse of arterial pressure
Continued cooling

Fresh versus salt water drowning

Lethal aspiration of salt water 22ml/kg (approx 1.5 litre), fresh water 44ml/kg

Be aware that drowning can take up to 4 hours – observe and watch for 6!

Prognostication

Better outcomes:

Rescued and BLS commenced < 5-10 min
Children
Those who have not aspirated
Water temperature < 10 ^oC, core body temperature 33-35 ^oC
Neurologically intact on arrival at hospital
Minimum blood pH > 7.1, blood glucose < 11.2mmol/L
ROSC on scene
Spontaneous ventilation in ED

Worse prognosis

Risk of death or severe neurological impairment after hospital discharge is reported to be nearly 100% when the duration of submersion exceeds 25 min
Following 30 mins resuscitation, if no signs of life, resuscitation is futile -> stop

It is important to remember that casualties who have entered water sometimes have access to a “bubble” of air – particularly if they had entered the water following a boating incident or were in a car at the point they entered the water. In these circumstances it is impossible to judge the point at which submersion has occurred.

What about cold water???

This is a regular point of discussion and concern. Water temperature is a key determinant: icy versus not. In the UK sea water is very unlikely to be icy or cold enough – however, small areas of water may well be, particularly in the winter months.

References

Szpilman D, Bierens JJ, Handley AJ, Orlowski JP (2012) Drowning. New Engl J Med. 366: 2102–10.
Tipton & Golden (2011). Decision making guide for immersion incidents involving total (head under) submersion. Resuscitation. 82: 819-824.
Golden & Hervey, 1981
Oakley & Pethybridge, 1997
Tipton 2016
Bierens 2014. Handbook of Drowning.

45 Episoden

phemcast

Drowning

phemcast

11 subscribers

published vor 4 Jahren

MP3•Episode-Home

Some facts

Drowning is important: 1,000 people drown every day, 2 every 3 minutes, 41 per hour. It is the world’s 3rd leading cause of accidental death: 3.6 million people over 10 years.

Disease of youth

64% < 30 years old
43% < 15 years old
25% < 5 years old

Male: female ratio 2:1

In 40%, alcohol is on board

4 stages of Immersion associated with particular risk in drowning

Initial Responses/Sudden Death (first 3-5 min)

Skin cooling

Short-Term Responses (5-30 min)

Superficial Nerve and Muscle Cooling

Long-Term Responses (30 min +)

Cooling of deep tissues

Post-immersion (during rescue)

Collapse of arterial pressure
Continued cooling

Fresh versus salt water drowning

Lethal aspiration of salt water 22ml/kg (approx 1.5 litre), fresh water 44ml/kg

Be aware that drowning can take up to 4 hours – observe and watch for 6!

Prognostication

Better outcomes:

Rescued and BLS commenced < 5-10 min
Children
Those who have not aspirated
Water temperature < 10 ^oC, core body temperature 33-35 ^oC
Neurologically intact on arrival at hospital
Minimum blood pH > 7.1, blood glucose < 11.2mmol/L
ROSC on scene
Spontaneous ventilation in ED

Worse prognosis

Risk of death or severe neurological impairment after hospital discharge is reported to be nearly 100% when the duration of submersion exceeds 25 min
Following 30 mins resuscitation, if no signs of life, resuscitation is futile -> stop

What about cold water???

References

Szpilman D, Bierens JJ, Handley AJ, Orlowski JP (2012) Drowning. New Engl J Med. 366: 2102–10.
Tipton & Golden (2011). Decision making guide for immersion incidents involving total (head under) submersion. Resuscitation. 82: 819-824.
Golden & Hervey, 1981
Oakley & Pethybridge, 1997
Tipton 2016
Bierens 2014. Handbook of Drowning.

45 Episoden

Alle Folgen

phemcast

1
Vasopressors in Trauma

vor 2 years

—

Further reading Matt has kindly provided a list of references from his Trauma Care talk which this podcast is based on: Peri-operative and critical care management of the brain – current evidence. Anaesthesia: Vol 77, No S1. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition Vasopressors in Trauma: A Never Event? : Anesthesia & Analgesia Blood pressure in trauma resuscitation: ‘pop the clot’ vs. ‘drain the brain’? – Wiles – 2017 – Anaesthesia Blood pressure management in trauma: from feast to famine? – Wiles – 2013 – Anaesthesia Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine Early vasopressor use following traumatic injury: a systematic review Vasopressors in traumatic brain injury: Quantifying their effect on mortality Effect of early use of noradrenaline on in-hospital mortality in haemorrhagic shock after major trauma: a propensity-score analysis…

phemcast

1
TXA – an update

vor 2 years

—

Read more about the Cochrane injuries group: https://injuries.cochrane.org/about-us-0 Have a listen to the earlier TXA podcast here: https://phemcast.co.uk/2018/01/18/episode-26-tranexamic-acid/ Do you want to revise your clotting pathways and the mechanism of action of TXA?! Here are some links to the excellent Life in the Fast Lane: https://partone.litfl.com/clotting.html https://partone.litfl.com/unclotting.html Acute Coagulopathy of Trauma Tranexamic Acid The Resus Room podcast which discusses Tim and colleagues paper on gender differences in TXA administration is available here: https://www.theresusroom.co.uk/courses/papers-of-june-2022/ Want to read more about Crash 4? https://crash4.lshtm.ac.uk References Crash 2: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60835-5/fulltext Crash 3: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext WOMAN: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext Use of tranexamic acid in major trauma: a sex-disaggragated analysis of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2 and CRASH-3) trials and UK trauma registry (Trauma and Audit Research Network) data. Tim Nutbeam. Br J Anaesth. 2022 OKAMOTO, SHOSUKE, and UTAKO OKAMOTO. “Amino-methyl-cyclohexane-carboxylic acid: AMCHA a new potent inhibitor of the fibrinolysis.” The Keio Journal of Medicine 11.3 (1962): 105-115. https://www.jstage.jst.go.jp/article/kjm1952/11/3/11_3_105/_article/-char/ja/ Grassin-Delyle S et al. Pharmacokinetics of intramuscular tranexamic acid in bleeding trauma patients: a clinical trial. British Journal of Anaesthesia, Volume 126, Issue 1,2021 https://www.sciencedirect.com/science/article/pii/S0007091220306826 Henry DA, Carless PA, Moxey AJ, O’Connell D, Stokes BJ, Fergusson DA, Ker K. Anti‐fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD001886. DOI: 10.1002/14651858.CD001886.pub4. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001886.pub4/full Ageron, FX., Coats, T.J., Darioli, V. et al. Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: usefulness for tranexamic acid treatment criteria. Scand J Trauma Resusc Emerg Med 29, 6 (2021). Guyette FX et al. Tranexamic acid during prehospital transport in patients at risk for hemorrhage after injury: A double-blind, placebo-controlled, randomized clinical trial. JAMA Surg 2020. PMID: 33016996 Marcucci M et al. Rationale and design of the PeriOperative ISchemic Evaluation-3 (POISE-3): a randomized controlled trial evaluating tranexamic acid and a strategy to minimize hypotension in noncardiac surgery. Trials. 2022 Jan 31;23(1):101. doi: 10.1186/s13063-021-05992-1. PMID: 35101083; PMCID: PMC8805242.…

phemcast

1
Extrication

vor 3 years

—

Road traffic collisions are a leading cause of death and injury. Following a road traffic collision many patients will remain trapped in their vehicle. Extrication is the process by which injured or potentially injured people are removed from their vehicle by the rescue services. Rescue service training focuses on the absolute movement minimisation of potentially injured patients’ spine and has developed extrication techniques with the focus of movement minimisation. Unfortunately these techniques take significant amounts of time (30 minutes plus); this delays access to potentially lifesaving treatments for injuries. In this Road Safety Trust funded project, the EXIT team across nine published academic studies reconsider extrication, provide evidence of harm, demonstrate that current techniques do not minimise movement as intended and provide a framework of principles for evidence-based extrication: Operational and clinical team members should work together to develop a bespoke patient centred extrication plan with the primary focus of minimising entrapment time Independent of actual or suspected injuries patients should be handled gently. A focus on absolute movement minimisation is not justified When clinicians are not available, FRSs should where necessary assess patients, deliver clinical care and make and enact extrication plans (including self-extrication) 1 Self-extrication or minimally assisted extrication should be the standard ‘first line’ extrication for all patients who do not have contraindications, which are: -An inability to understand or follow instructions, -Injuries or baseline function that prevents standing on at least one leg, (specific injuries include: unstable pelvic fracture, impalement, bilateral leg fracture) All patients with evidence of injury should be considered time-dependent and their entrapment time should be minimised Incidents where a patient may require disentanglement are complex and associated with a high morbidity and mortality. A senior FRS and clinical response should attend such instances 2 Clinical care during entrapment: -Can be delivered by FRS or clinical services 1 -Should be limited to necessary critical interventions to expedite safe extrication 3 -Rescuers should be aware that clinical observations may prolong entrapment time and as such should be kept to the minimum -FRS and clinical personnel should be aware of the physical and observable signs of patient deterioration and if identified should make this known to the responsible clinician Immobilisation: -Longboards are an extrication device and should not be used beyond the extrication phase -Kedrick Extrication Devices prolong extrication time and their use should be minimised -Pelvic slings should not be applied to patients until they have been extricated -Cervical collars should only be used following assessment and should be loosened or removed following extrication Patient focused extrication: -Build a connection with patients, explain actions, and use their name -Where appropriate, reassure patients as to the safety of their co-occupants and others involved in the incident (including animals) -Provide an ‘extrication buddy’ -Allow communication with family members or other close contacts -Rescue teams should not publish extrication related imagery to social media or other outlets -Minimise the ability of the public to view the accident, take photographs or record videos. Provide education to this effect On initial call to Emergency Services -Attempt to clarify entrapment status -Attempt to identify patients who require disentanglement (and dispatch an appropriate priority senior 2 response) -A standard multi-agency MVC trauma message should be developed to ensure the correct resources are deployed Multi-professional datasets should be developed with patient and public engagement and should include entrapment status, entrapment time, injuries, extrication approach, clinical care Agreed nomenclature for categories of patient Not injured, Minor injuries (evidence of energy transfer but no evidence of time-dependent injury), Major injury (currently stable but should be assumed to be time-dependent), Time critical injured (Time critical due to injury; use fastest route of extrication) m Time critical hazard (e.g. secondary to fire or other hazard) These principles have been adopted by national level stakeholders in the UK are being incorporated into national clinical and operational guidance which will reduce entrapment time and may demonstrate morbidity and mortality reductions. Links to papers: Nutbeam T, Fenwick R, Smith JE, Bouamra O, Wallis L, Stassen W. A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped. Scand J Trauma Resusc Emerg Medicine 29 , 17 (2021). Nutbeam T, Kehoe A, Fenwick R, Smith JE, Bouamra O, Wallis L, Stassen W . Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN). Scand J Trauma Resusc Emerg Medicine 30 , 14 (2022). Nutbeam T, Weekes L, Heidari S, Fenwick R, Bouamra O, Smith JE, Stassen W et al. Sex-disaggregated analysis of the injury patterns, outcome data and trapped status of major trauma patients injured in motor vehicle collisions: a prespecified analysis of the UK trauma registry (TARN). BMJ Open 2022;0:e061076. doi:10.1136/ bmjopen-2022-061076 Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Wallis L, Dayson M, Shippen J . The role of cervical collars and verbal instructions in minimising spinal movement during self-extrication following a motor vehicle collision – a biomechanical study using healthy volunteers. Scand J Trauma Resusc Emerg Medicine 29 , 108 (2021). Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Shippen J . Maximum movement and cumulative movement (travel) to inform our understanding of secondary spinal cord injury and its application to collar use in self-extrication. Scand J Trauma Resusc Emerg Medicine 30 , 4 (2022) . Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Bowdler J, Wallis L, Shippen J . Assessing spinal movement during four extrication methods: a biomechanical study using healthy volunteers. Scand J Trauma Resusc Emerg Medicine 30 , 7 (2022). Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Bowdler J, Wallis L, Shippen J . Comparison of ‘chain cabling’ and ‘roof off’ extrication types, a biomechanical study in healthy volunteers. In press; Injury Nutbeam T, Brandling J, Wallis L, Stassen W. Understanding people’s experiences of extrication whilst being trapped in motor vehicles: a qualitative interview study. In press; BMJ Open Nutbeam T, Fenwick R, Smith JE, Dayson M, Carlin B, Wilson M, Wallis L, Stassen W. A Delphi Study of Rescue and Clinical Subject Matter Experts on the Extrication of Patients Following a Motor Vehicle Collision Scand J Trauma Resusc Emerg Med 30, 41 (2022). https://doi.org/10.1186/s13049-022-01029-x…

phemcast

1
Pain (& analgesia)

vor 3 years

—

This is the book Jon quotes, “Pain is a symphony…” The International Association for the Study of Pain’s revised definition of pain is available here . If you’d like to read more about ‘nocebo’ i.e. the non-pharmacological adverse effects of an intervention, have a look at this article . Penthrox For more information on Penthrox, you can read about it in the BNF , The Emergency Medicines Compendium and on the manufacturers own website. Jon is the author of the Pain and analgesia chapter in the 2nd edition of the ABC of Prehospital Medicine, to be published soon!…

phemcast

1
RePHILL

vor 3 years

—

Before you listen to this new podcast, we encourage you to go back and have a listen to Episode 16: Blood which we released in 2017 outlining the available evidence about prehospital blood, and the background to the RePHILL trial. The RePHILL (Resuscitation with Pre-Hospital Blood Products) original paper is available here , and you can read more about the trial at the University Of Birmingham Clinical Trials site . On the day of publication, Critical Care Reviews hosted a Livestream which is available to watch back including the investigators, an editorial by Simon Carley (of St Emlyns fame) and discussion panel. This is a really detailed and informative presentation which includes a summary of the results from the statistician.…

phemcast

1
Cold Injury

vor 3 years

—

This podcast is dedicated to the memory of Emmanuel Cauchy. George’s adventures! Grading frostbite Stages of frostbite. From Cauchy et al, 2016. Grade 1 Grade 2 Grade 3 Grade 4 Stages of frostbite. From Cauchy et al. 2001 The GELOX study The Hyperbaric oxygen study described by Carron is now in print and available here . Guidelines The guidelines mentioned by Chris can be found on the Wilderness Medical Society website . References Cauchy et al. The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries. The Journal of Hand Surgery. 2000; 25(5): 969-978. Cauchy et al. A Controlled Trial of a Prostacyclin and rt-PA in the Treatment of Severe Frostbite. NEJM. 2011; 364: 189-190. Cauchy et al. A New Proposal for Management of Severe Frostbite in the Austere Environment. Wilderness & Environmental Medicine. 2016; 27(1): 92-99. Cauchy et al. Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme. Wilderness & Environmental Medicine. 2001; 12(4): 248-255. Handford C, Buxton P, Russell K, Imray CEA, McIntosh SE, Freer L, Cochran A, Imray CHE. Frostbite: a practical approach to hospital management. Extreme Physiology & Medicine. 2014; 3, 7. Magnan et al. Hyperbaric Oxygen Therapy with Iloprost Improves Digit Salvage in Severe Frostbite Compared to Iloprost Alone. Medicina. 2021; 57(11): 1284.…

phemcast

1
Ultrasound

vor 4 years

—

Some useful videos: Hopefully you found the podcast interesting, but since this is quite a visual topic we have put together some videos to demonstrate some of the pathologies discussed and what they look like on ultrasound: How does ultrasound work? Want to know how to use ultrasound? This is a whole 45 minute introductory lecture. Although a face-to-face course is really required before you start on patients! The radiopaedia website is an amazing resource for all things imaging. Their section on POCUS is here . The Sonosite website has some excellent resources, which you can filter according to specialty, including prehospital using ‘EMS/Air Med/Ambulance’. Airway Intubation More detail on intubation from 5 minute sono Front of neck access Breathing Pneumothorax Lung pathologies including PE an d pulmonary contusion Pulmonary oedema Pleural effusion Circulation FAST scan in trauma Free fluid/haemoperitoneum in the RUQ Pericardial effusion with engorged IVC Disability Ocular ultrasound EMCRIT post on use of ultrasound to diagnose raised ICP with ocular sonography Extremity Rib & sternal fractures Ultrasound guided hip nerve blocks (including femoral and FIB) Cardiac arrest Use of ultrasound in cardiac arrest (US) POCUS in cardiac arrest (UK) Further Resources FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Kenji Inaba. Ann Surg. 2015 Marik PE, Cavallazzi R. Does central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41: 1774-81. Cavallaro F, Sandroni C, Marano C, et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. Intensive Care Med 2010; 36: 1475-83. https://theresusroom.co.uk/ultrasound-in-cardiac-arrest/ ResusMe bibliography of PH ultrasound papers 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism…

phemcast

1
Acute behavioural disturbance

vor 4 years

—

Definitions UK definition (RCEM): It describes the sudden onset of aggressive and violent behaviour and autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness. Australian definition (NSW Health): Behaviour that puts the patient or others at immediate risk of serious harm and may include threatening or aggressive behaviour, extreme distress, and serious self-harm which could cause major injury or death. Toxidromes There are some superb resources on the Life in the Fast Lane site on this topic. Really recommend having a look! De-escalation There is a useful summary on some de-escalation strategies & techniques, from HSI here . This handbook from a UK NHS Trust outlines some key principles from their conflict resolution training. Further reading JRCALC Clinical Guideline: Acute Behavioural Disturbance. NICE. NG10. 2015. Violence and aggression: short term management in mental health, health and community settings. RCEM. Best Practice Guideline. 2016. Guidelines for the Management of Excited Delirium/Acute Behavioural Disturbance. Faculty of Forensic and Legal Medicine. 2019. Acute behavioural disturbance (ABD): guidelines on management in police custody. College of Paramedics. Acute Behavioural Disturbance Position Statement The CQC brief guide to restraint…

phemcast

1
The Jungle

vor 4 years

—

This was a joint podcast with our friends & colleagues at WEMCast – to hear more from them, have a look at their podcast back catalogue , and there’s more information on the World Extreme Medicine website . OLYMPUS DIGITAL CAMERA OLYMPUS DIGITAL CAMERA OLYMPUS DIGITAL CAMERA OLYMPUS DIGITAL CAMERA Mosquito born disease Malaria risk areas. From: https://www.iamat.org/risks/malaria Malaria is transmitted through the bite of an infected female Anopheles mosquito. It is widely distributed throughout tropical regions of the world, within the majority of cases reported in Africa. If you would like to read more about malaria; its signs & symptoms, variants, at-risk countries and treatment, have a look at the Travel Health Pro website . Dengue risk areas . From https://travelhealthpro.org.uk/factsheet/13/dengue Dengue is a viral disease transmitted by mosquitos. Symptoms include high fever, muscle and joint pains, headache, nausea, vomiting and rash. It is generally a self limiting illness with improvement in symptoms and recovery occurring three to four days after the onset of the rash, although rarely can lead to dengue haemorrhagic fever. Again, the Travel Health pro website has some excellent information on this. Zica virus is spread by day-biting mosquitos. In addition a few cases of transmission by sexual contact have been reported. It is found in parts of Africa, Asia, the Pacific Islands, Central and South America and the Caribbean. The majority of people infected with Zika virus have no symptoms. For those with symptoms, it is usually a mild and short-lived viral type illness, with conjunctivitis and muscle/join pains. However, Zika virus is a cause of Congenital Zika Syndrome (microcephaly and other congenital anomalies) and neurological complications such as Guillain-Barré syndrome. Read more here . Exertional heat illness From https://moveitnq.com.au/exercising-in-the-heat/ The UK Faculty of Sport and Exercise Medicine has produced a position statement on exertional heat illness, available here , and the Royal College of Emergency Medicine’s elearning platform also has a module on the spectrum of heat related illness . From https://tactical-medicine.com/products/caervest-core-body-cooling To find out more about the CAER vest mentioned in the podcast, have a look at this YouTube video. Or read this article . Pitted keratolitis Further reading Smith M, Withnall R & Boulter MK. An exertional heat illness triage tool for a jungle training environment. J Royal Army Medical Corps, 2018. 164, 287-289. DOI: 10.1136/jramc-2017-000801 Alele FO, Malau-Aduil BS, Malau-Aduli AEO, Crowe MJ. Epidemiology of exertional heat illness in the military: A systematic review of observational studies. Int. J. Environ. Res. Public Health 2020, 17(19), 7037. https://doi.org/10.3390/ijerph17197037…

phemcast

1
Intubation

vor 4 years

—

Guidance documents College of Paramedics Statement on Intubation, available here . AAGBI Safer Prehospital Anaesthesia 2017, available here . Positioning From: http://anaesthesiatoday.blogspot.com/2013/03/10-common-procedural-basics_29.html Recommended Rich Levitan resources EMCrit 70 – Airway Management with Rich Levitan Airway axes From: McGuire B, Hodge K. Tracheal intubation. Anaesthesia & Intensive Care Medicine. 2019. 20(12);681-686. From: https://veteriankey.com/tracheal-intubation/ Epiglottoscopy Bimanual Laryngoscopy It should be noted that this is not entirely consistent with current standard UK practice, as it discusses cricoid pressure and a stylet being used in the ETT, rather than a bougie Further resources Direct Laryngoscopy Bimanual laryngoscopy Apnoeic Oxygenation in Resuscitation: Is it time? https://anaesthetists.org/Home/Resources-publications/Guidelines/Safer-pre-hospital-anaesthesia Article available here . Click here to hear what our friends over at the Resus Room think about Airways 2 References (kindly shared by Rich) Davis DP et al. The Effect of Paramedic Rapid Sequence Intubation on Outcome in Patients with Severe Traumatic Brain Injury. J Trauma 2003; 54:444-453 Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscope attempts. Anesth Analg. 2004 Aug;99(2):607-13, Hasegawa K et al. Association Between Repeated Intubation Attempts and Adverse Events in Emergency Departments: An Analysis of a Multicenter Prospective Observational Study. Annals of Emergency Medicine 2012; Volume 60, Issue 6, Pages 749–754.e2 Delson NJ et. al., Anesthesia and Analgesia, 2002; 94; S-123. Levitan RM et al. Laryngeal View During Laryngoscopy: A Randomized Trial Comparing Cricoid Pressure, Backward-Upward-Rightward Pressure, and Bimanual Laryngoscopy. Annals of Emergency Medicine 2006; 47(6):548-555 Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD011136. DOI:10.1002/14651858.CD011136.pub2. Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Mochmann HC, Arntz HR. Difficult prehospital endotracheal intubation – predisposing factors in a physician based EMS. Resuscitation. 2011 Dec;82(12):1519-24. doi: 10.1016/j.resuscitation.2011.06.028. Epub 2011 Jul 2. PMID: 21749908. Bossers SM, Schwarte LA, Loer SA, Twisk JW, Boer C, Schober P. Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. PLoS One. 2015 Oct 23;10(10):e0141034. doi: 10.1371/journal.pone.0141034. PMID: 26496440; PMCID: PMC4619807. Sunde, G.A., Heltne, J., Lockey, D. et al. Airway management by physician-staffed Helicopter Emergency Medical Services – a prospective, multicentre, observational study of 2,327 patients. Scand J Trauma Resusc Emerg Med 23, 57 (2015). https://doi.org/10.1186/s13049-015-0136-9 Crewdson, K., Lockey, D.J., Røislien, J. et al. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care 21, 31 (2017). https://doi.org/10.1186/s13054-017-1603-7 Gellefors M et al. Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations. British Journal of Anaesthesia, 120 (5): 1103e1109 (2018) Konrad, Christoph MD; Schupfer, Guido MD, MBA HSG; Wietlisbach, Markus MD; Gerber, Helmut MD, PhD Learning Manual Skills in Anesthesiology: Is There a Recommended Number of Cases for Anesthetic Procedures?, Anesthesia & Analgesia: March 1998 – Volume 86 – Issue 3 – p 635-639. doi: 10.1213/00000539-199803000-00037 de Oliveira Filho, Getúlio Rodrigues, MD The Construction of Learning Curves for Basic Skills in Anesthetic Procedures: An Application for the Cumulative Sum Method, Anesthesia & Analgesia: August 2002 – Volume 95 – Issue 2 – p 411-416 doi: 10.1213/00000539-200208000-00033 Je S, Cho Y, Choi HJ, et al An application of the learning curve–cumulative summation test to evaluate training for endotracheal intubation in emergency medicine Emergency Medicine Journal 2015;32:291-294. Toda, J., Toda, A.A. & Arakawa, J. Learning curve for paramedic endotracheal intubation and complications. Int J Emerg Med 6, 38 (2013). https://doi.org/10.1186/1865-1380-6-38 Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Mochmann H-C, Arntz H-R. Difficult prehospital endotracheal intubation – predisposing factors in a physician based EMS. Resuscitation. 2011;82:1519–24…

phemcast

1
Altitude

vor 4 years

—

From: https://www.bbc.co.uk/news/uk-wales-46441129 From: https://www.ultimatekilimanjaro.com/blog/should-i-use-supplemental-oxygen-on-kilimanjaro/ A portable hyperbaric chamber (Gamow bag) From: https://litfl.com/hypothermia/ Classic stretcher technique Improvised rucksack stretcher technique Want to know more? This is one of the organisations Lucy mentions: British Exploring And this is the Global Health MSc The Wilderness Society Guidelines are available here . This is the link to the Wilderness Medical Society . Consensus statement from the UIAA on People with Pre-Existing Conditions Going to the Mountains, and their website for more useful resources. Li Y, Zhang Y, Zhang Y. Research advances in pathogenesis and prophylactic measures of acute high altitude illness. Respiratory Medicine. 2018; 145: 145-152. https://doi.org/10.1016/j.rmed.2018.11.004 The Faculty of Prehospital Care have also published guidance on the Medical Provision for Wilderness Medicine. Thanks to Dave Hillebrandt for sharing this with us.…

phemcast

1
Drowning

vor 4 years

—

Some facts Drowning is important: 1,000 people drown every day, 2 every 3 minutes, 41 per hour. It is the world’s 3rd leading cause of accidental death: 3.6 million people over 10 years. Disease of youth 64% < 30 years old 43% < 15 years old 25% < 5 years old Male: female ratio 2:1 In 40%, alcohol is on board 4 stages of Immersion associated with particular risk in drowning Initial Responses/Sudden Death (first 3-5 min) Skin cooling Short-Term Responses (5-30 min) Superficial Nerve and Muscle Cooling Long-Term Responses (30 min +) Cooling of deep tissues Post-immersion (during rescue) Collapse of arterial pressure Continued cooling Fresh versus salt water drowning Lethal aspiration of salt water 22ml/kg (approx 1.5 litre), fresh water 44ml/kg Be aware that drowning can take up to 4 hours – observe and watch for 6! Prognostication Better outcomes: Rescued and BLS commenced < 5-10 min Children Those who have not aspirated Water temperature < 10 o C, core body temperature 33-35 o C Neurologically intact on arrival at hospital Minimum blood pH > 7.1, blood glucose < 11.2mmol/L ROSC on scene Spontaneous ventilation in ED Worse prognosis Risk of death or severe neurological impairment after hospital discharge is reported to be nearly 100% when the duration of submersion exceeds 25 min Following 30 mins resuscitation, if no signs of life, resuscitation is futile -> stop It is important to remember that casualties who have entered water sometimes have access to a “bubble” of air – particularly if they had entered the water following a boating incident or were in a car at the point they entered the water. In these circumstances it is impossible to judge the point at which submersion has occurred. What about cold water??? This is a regular point of discussion and concern. Water temperature is a key determinant: icy versus not. In the UK sea water is very unlikely to be icy or cold enough – however, small areas of water may well be, particularly in the winter months. References Szpilman D, Bierens JJ, Handley AJ, Orlowski JP (2012) Drowning. New Engl J Med. 366: 2102–10. Tipton & Golden (2011). Decision making guide for immersion incidents involving total (head under) submersion. Resuscitation. 82: 819-824. Golden & Hervey, 1981 Oakley & Pethybridge, 1997 Tipton 2016 Bierens 2014. Handbook of Drowning.…

phemcast

1
Episode 36: COVID-19

vor 5 years

—

https://phemcast.co.uk/wp-content/uploads/2020/05/covid-02-05-2020-18.41.mp3 Case definition Current case definition for COVID-19 can be accessed here . Risk stratification This is the Emergency Medicine Specialty guide we discussed in the podcast, which includes use of the NEWS and 40 step test (edit: since recording the podcast yesterday (!) we’ve been made aware of the Sit to Stand test ). Here is a review of both if you’d like to read more. PPE As at May 1st, the advice from PHE is ‘ There is currently sustained transmission of COVID-19 throughout the UK as defined by the four nations Public Health experts, therefore there is an increased likelihood of any patient having coronavirus infection. Therefore, whilst in this phase all patient contacts require level 2 PPE in accordance with Table 4 ‘: T4_poster_Recommended_PPE_additional_considerations_of_COVID-19 Level 2: disposable gloves disposable apron fluid repellent surgical mask eye protection (if risk of splashing) Level 3: disposable gloves fluid repellent coveralls/long sleeved apron/gown FFP3* or powered respirator hood eye protection *Where an FFP3 mask with a non-shrouded valve is worn, it should be accompanied by a full-face visor. If a visor is not available, then a risk assessment should be carried out regarding the risk of splash to the valve. If a large splash (as opposed to droplets) does occur, then the FFP3 mask should be replaced immediately. There are a number of PHE PPE videos available, this is the one describing donning and doffing Level 2. From PHE Guidance for ambulance trusts: Where AGPs such as intubation are performed, PPE guidance set out for AGPs (section 8.1) should be followed (disposable fluid repellent coveralls may be used in place of long-sleeved disposable gowns). For any direct patient care of patient known to meet the case definition for a possible case, plastic apron, FRSMs, eye protection and gloves should be used. Where it is impractical to ascertain case status of individual patients prior to care, use of PPE including aprons, gloves, FRSM and eye protection should be subject to risk assessment according to local context. PPE is not required for ambulance drivers of a vehicle with a bulkhead and those otherwise able to maintain social distancing of 2 metres. If the vehicle does not have a bulkhead then use of a FRSM is indicated for the driver (additional PPE would be as for other staff if providing direct care). For the coverall-type Level 3 PPE most commonly being used by ambulance clinicians, have a look at these two guidelines on donning and doffing . Aerosol generating procedures Reference available here . Aerosols are produced when an air current moves across the surface of a film of liquid; the greater the force of the air the smaller the particles that are produced. Aerosol generating procedures (AGPs) are defined as any medical and patient care procedure that results in the production of airborne particles (aerosols). AGPs can produce airborne particles <5 micrometres (μm) in size which can remain suspended in the air, travel over a distance and may cause infection if they are inhaled. Therefore AGPs create the potential for airborne transmission of infections that may otherwise only be transmissible by the droplet route. The most recent assessment by WHO (2014) states that there is only consistent evidence that there is an increased risk of transmission for the following procedures: tracheal intubation, tracheotomy procedure, non-invasive ventilation, and manual ventilation before intubation as AGPs. This evaluation is based on a systematic review by Tran et al. whose review included 10 studies (5 case-control; 5 cohort), all of which investigated transmission of SARS from patients to healthcare workers in intensive care or other healthcare settings during the 2002-2003 SARS outbreaks. Cardiac arrest From PHE: First person attending scene In order to minimise any delay attending a time critical cardiac arrest, it is acceptable for the first person to enter the scene wearing level 2 PPE (fluid repellent surgical mask, apron, gloves and eye protection). Where trained and equipped to use level 3 PPE, this may be used where it will not cause a delay commence resuscitation where this is indicated by local clinical guidance. If resuscitation is not commenced, or is terminated before the arrival of other resources, provide an early sitrep to reduce the number of responders who need to enter the scene do not place your face near the patient to assess breathing where available, place a surgical mask or oxygen mask on the patients face commence chest compressions, attach the defibrillator and defibrillate if indicated. None of these tasks are considered aerosol generating procedures (AGPs) do not progress to airway management or ventilation if not already available on-scene, request back up from a level 3 PPE trained response Subsequent attendance at scene of responder(s) trained and equipped to use level 3 PPE don level 3 PPE enter scene and determine whether the resuscitation should be continued according to local clinical guidance. if resuscitation is to be continued, take over patient management from any responder wearing level 2 PPE all responders wearing level 2 PPE are to leave the scene (more than 2m away from the patient) prior to the commencement of any airway management, ventilation or other AGPs. Responders may later re-enter if trained and equipped to wear level 3 PPE level 3 PPE responders to continue the resuscitation, including airway management and ventilation Anyone who is not trained or does not have access to level 3 PPE must then withdraw from the scene. From the Resuscitation Council: Click here for more from the Resus Council on COVID-19. Just before you go … something to make you smile! (thankfully the music department at Plymouth Uni have got the tech to make me sound like I can actually sing!!!) References For more on the growing evidence base around COVID-19, please have a read of this blog from our colleague, and Defence Professor of Emergency Medicine, Jason Smith. World Health Organization. Infection prevention and control of epidemic and pandemic-prone acute respiratory infections in health care. WHO guidelines. https://www.who.int/csr/bioriskreduction/infection_control/publication/en/ (2014). Tran K, Cimon K, Severn M, et al. Aerosol generating procedures (AGP) and risk of transmission of acute respiratory diseases (ARD): A systematic review. PloS One 2012; 7. Conference Abstract. https://www.gov.uk/government/publications/covid-19-guidance-for-ambulance-trusts/covid-19-guidance-for-ambulance-trusts#patient-assessment Tim Cook PPE review: https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.15071 Health Service Journal: Exclusive: deaths of NHS staff from covid-19 analysed Considering transmission from staff uniforms: Infection Control and Hospital Epidemiology. Volume 31, Issue 5 May 2010 , pp. 560-561. Coronavirus Survival on Healthcare Personal Protective Equipment. Lisa Casanova (a1), William A. Rutala (a2), David J. Weber (a2) and Mark D. Sobsey (a1). DOI: https://doi.org/10.1086/652452 PLoS One. 2011; 6(11): e27932. Survival of Influenza A(H1N1) on Materials Found in Households: Implications for Infection Control. Jane S. Greatorex, 1 Paul Digard, 2 Martin D. Curran, 1 Robert Moynihan, 2 Harrison Wensley, 2 Tim Wreghitt, 1 Harsha Varsani, 1 Fayna Garcia, 1 Joanne Enstone, 3 and Jonathan S. Nguyen-Van-Tam 3 , 4 , * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222642/ Acute myocardial injury in COVID https://www.nice.org.uk/guidance/ng171/resources/acute-myocardial-injury-algorithm-pdf-8717541373 https://www.nice.org.uk/guidance/ng171/chapter/3-Diagnosing-acute-myocardial-injury-in-patients-with-suspected-or-confirmed-COVID-19 See also: Clinical guide for the management of critical care for adults with COVID-19 during the coronavirus pandemic…

phemcast

1
Episode 35: The collapsed infant

vor 6 years

—

https://phemcast.co.uk/wp-content/uploads/2019/09/infant-with-fluid-clarification.mp3 A: Optimal airway position for infants Note how a rolled towel is placed under the baby’s shoulders to allow space for the occiput and avoid flexion of the neck and airway. From: https://www.jems.com/2017/02/28/an-overview-of-ems-pediatric-airway-management/ ‘B’ assessment Video links to examples of children with signs of respiratory distress: Stridor Grunting Increased work of breathing ‘D’ assessment Example video showing a bulging fontanelle (excuse the slightly cheesy style!) From: http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/Floppy%20Baby.htm Non accidental injury Sadly, NAI in under 2’s causes more than 10% of serious injuries to children. Stigmata of possible NAI include: Bruising on the cheeks, neck, genitals, buttocks and back Pattern bruising from an implement including fingertip bruising Burns to hands, legs, feet and buttocks Subconjunctival haemorrhage Epistaxis in infants Example of subconjunctival haemorrhage: From: http://champprogram.com/question/3a.shtml 2017 NICE guidance: When to suspect maltreatment in under 18s. Sepsis Click for UK Sepsis Trust guidance for different clinical settings. Scroll down for the Screening and Action tool for under 5s for prehospital care and ambulance services. References regarding IM benzylpenicillin that Tim mentions: Harnden A. Parenteral penicillin for children with meningococcal disease before hospital admission: case-control study. BMJ. 2006 Jun 3;332(7553):1295–8. Hahné SJM, Charlett A, Purcell B, Samuelsson S, Camaroni I, Ehrhard I, et al. Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: systematic review. BMJ. 2006 Jun 3;332(7553):1299–303. Sörensen HT, Nielsen GL, Schönheyder HC, Steffensen FH, Hansen I, Sabroe S, Dahlerup JF, Hamburger H, Olsen J: Outcome of pre-hospital antibiotic treatment of meningococcal disease. J Clin Epidemiol 1998, 51:717–721. Drug calculator Example of a paediatric drug calculator from WATCh.…

phemcast

1
Episode 34: Back pain

vor 6 years

—

https://phemcast.co.uk/wp-content/uploads/2019/07/back-pain_final-12072019-17.13.mp3 So, where is the Cauda Equina? From Core EM How does a herniated disc cause CES? This fab infographic summarising the key points about the CES guidance was produced by @DrLindaDykes and @saspist. Here is the full guideline from The Society of British Neurological Surgeons and The British Association of Spinal Surgeons. NICE guidance on Low back pain and sciatica in over 16s: assessment and management NICE clinical knowledge summary on Cauda Equina Syndrome red flags. Thinking about posture:…

Willkommen auf Player FM!

Player FM scannt gerade das Web nach Podcasts mit hoher Qualität, die du genießen kannst. Es ist die beste Podcast-App und funktioniert auf Android, iPhone und im Web. Melde dich an, um Abos geräteübergreifend zu synchronisieren.