Further readingMatt 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 editionVasopressors in Trauma: A Never Event? : Anesthesia &amp; AnalgesiaBlood pressure in trauma resuscitation: ‘pop the clot’ vs. ‘drain the brain’? – Wiles – 2017 – AnaesthesiaBlood pressure management in trauma: from feast to famine? – Wiles – 2013 – AnaesthesiaPermissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trialsRisks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis | Scandinavian Journal of Trauma, Resuscitation and Emergency MedicineEarly vasopressor use following traumatic injury: a systematic reviewVasopressors in traumatic brain injury: Quantifying their effect on mortalityEffect of early use of noradrenaline on in-hospital mortality in haemorrhagic shock after major trauma: a propensity-score analysis

<h2>Further reading</h2>Matt has kindly provided a list of references from his Trauma Care talk which this podcast is based on:<a href="https://associationofanaesthetists-publications.onlinelibrary.wiley.com/toc/13652044/2022/77/S1" rel="nofollow" target="_blank">Peri-operative and critical care management of the brain – current evidence. Anaesthesia: Vol 77, No S1.</a><a href="https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1265-x" rel="nofollow" target="_blank">The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition</a><a href="https://journals.lww.com/anesthesia-analgesia/fulltext/2021/07000/vasopressors_in_trauma__a_never_event_.13.aspx" rel="nofollow" target="_blank">Vasopressors in Trauma: A Never Event? : Anesthesia &amp; Analgesia</a><a href="https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14042" rel="nofollow" target="_blank">Blood pressure in trauma resuscitation: ‘pop the clot’ vs. ‘drain the brain’? – Wiles – 2017 – Anaesthesia</a><a href="https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.12249" rel="nofollow" target="_blank">Blood pressure management in trauma: from feast to famine? – Wiles – 2013 – Anaesthesia</a><a href="https://journals.lww.com/jtrauma/Abstract/2018/05000/Permissive_hypotension_versus_conventional.16.aspx" rel="nofollow" target="_blank">Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials</a><a href="https://sjtrem.biomedcentral.com/articles/10.1186/s13049-018-0572-4" rel="nofollow" target="_blank">Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine</a><a href="https://bmjopen.bmj.com/content/7/11/e017559" rel="nofollow" target="_blank">Early vasopressor use following traumatic injury: a systematic review</a><a href="https://www.sciencedirect.com/science/article/abs/pii/S0002961020305857" rel="nofollow" target="_blank">Vasopressors in traumatic brain injury: Quantifying their effect on mortality</a><a href="https://www.sciencedirect.com/science/article/pii/S0007091218301740" rel="nofollow" target="_blank">Effect of early use of noradrenaline on in-hospital mortality in haemorrhagic shock after major trauma: a propensity-score analysis</a>

Vasopressors in Trauma

Read more about the Cochrane injuries group: https://injuries.cochrane.org/about-us-0Have 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.htmlhttps://partone.litfl.com/unclotting.htmlAcute Coagulopathy of TraumaTranexamic AcidThe 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.ukReferencesCrash 2: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60835-5/fulltextCrash 3: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltextWOMAN: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltextUse 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. 2022OKAMOTO, 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/S0007091220306826Henry 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/fullAgeron, 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: 33016996Marcucci 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.

Read more about the Cochrane injuries group: <a href="https://injuries.cochrane.org/about-us-0" rel="nofollow" target="_blank">https://injuries.cochrane.org/about-us-0</a>Have a listen to the earlier TXA podcast here: <a href="https://phemcast.co.uk/2018/01/18/episode-26-tranexamic-acid/" rel="nofollow" target="_blank">https://phemcast.co.uk/2018/01/18/episode-26-tranexamic-acid/</a>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:<a href="https://partone.litfl.com/clotting.html" rel="nofollow" target="_blank">https://partone.litfl.com/clotting.html</a><a href="https://partone.litfl.com/unclotting.html" rel="nofollow" target="_blank">https://partone.litfl.com/unclotting.html</a><blockquote><a href="https://litfl.com/acute-coagulopathy-of-trauma/" rel="nofollow" target="_blank">Acute Coagulopathy of Trauma</a></blockquote><blockquote><a href="https://litfl.com/tranexamic-acid/" rel="nofollow" target="_blank">Tranexamic Acid</a></blockquote>The Resus Room podcast which discusses Tim and colleagues paper on gender differences in TXA administration is available here: <a href="https://www.theresusroom.co.uk/courses/papers-of-june-2022/" rel="nofollow" target="_blank">https://www.theresusroom.co.uk/courses/papers-of-june-2022/</a>Want to read more about Crash 4? <a href="https://crash4.lshtm.ac.uk" rel="nofollow" target="_blank">https://crash4.lshtm.ac.uk</a>ReferencesCrash 2: <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60835-5/fulltext" rel="nofollow" target="_blank">https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60835-5/fulltext</a>Crash 3: <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext" rel="nofollow" target="_blank">https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext</a>WOMAN: <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext" rel="nofollow" target="_blank">https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext</a>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. 2022OKAMOTO, 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. <a href="https://www.jstage.jst.go.jp/article/kjm1952/11/3/11_3_105/_article/-char/ja/" rel="nofollow" target="_blank">https://www.jstage.jst.go.jp/article/kjm1952/11/3/11_3_105/_article/-char/ja/</a>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 <a href="https://www.sciencedirect.com/science/article/pii/S0007091220306826" rel="nofollow" target="_blank">https://www.sciencedirect.com/science/article/pii/S0007091220306826</a>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. <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001886.pub4/full" rel="nofollow" target="_blank">https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001886.pub4/full</a>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: 33016996Marcucci 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.

TXA – an update

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 timeIndependent of actual or suspected injuries patients should be handled gently. A focus on absolute movement minimisation is not justifiedWhen clinicians are not available, FRSs should where necessary assess patients, deliver clinical care and make and enact extrication plans (including self-extrication)1Self-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 minimisedIncidents 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 instances2Clinical care during entrapment:-Can be delivered by FRS or clinical services1-Should be limited to necessary critical interventions to expedite safe extrication3-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 clinicianImmobilisation:-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 extricationPatient 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 effectOn initial call to Emergency Services-Attempt to clarify entrapment status-Attempt to identify patients who require disentanglement (and dispatch an appropriate priority senior2 response)-A standard multi-agency MVC trauma message should be developed to ensure the correct resources are deployedMulti-professional datasets should be developed with patient and public engagement and should include entrapment status, entrapment time, injuries, extrication approach, clinical careAgreed nomenclature for categories of patientNot 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 

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 timeIndependent of actual or suspected injuries patients should be handled gently. A focus on absolute movement minimisation is not justifiedWhen clinicians are not available, FRSs should where necessary assess patients, deliver clinical care and make and enact extrication plans (including self-extrication)1Self-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 minimisedIncidents 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 instances2Clinical care during entrapment: -Can be delivered by FRS or clinical services1 -Should be limited to necessary critical interventions to expedite safe extrication3 -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 clinicianImmobilisation: -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 extricationPatient 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 effectOn initial call to Emergency Services -Attempt to clarify entrapment status -Attempt to identify patients who require disentanglement (and dispatch an appropriate priority senior2 response) -A standard multi-agency MVC trauma message should be developed to ensure the correct resources are deployedMulti-professional datasets should be developed with patient and public engagement and should include entrapment status, entrapment time, injuries, extrication approach, clinical careAgreed 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: <ol> <li><a href="https://sjtrem.biomedcentral.com/articles/10.1186/s13049-020-00818-6" rel="nofollow" target="_blank">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).</a></li> </ol> <ul> <li><a href="https://sjtrem.biomedcentral.com/articles/10.1186/s13049-021-00989-w" rel="nofollow" target="_blank">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).</a></li> </ul> <ul> <li><a href="https://bmjopen.bmj.com/content/12/5/e061076" rel="nofollow" target="_blank">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</a></li> </ul> <ul> <li><a href="https://sjtrem.biomedcentral.com/articles/10.1186/s13049-021-00919-w" rel="nofollow" target="_blank">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 </a>29, 108 (2021).</li> </ul> <ul> <li><a href="https://sjtrem.biomedcentral.com/articles/10.1186/s13049-022-00992-9" rel="nofollow" target="_blank">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)</a>.</li> </ul> <ul> <li><a href="https://sjtrem.biomedcentral.com/articles/10.1186/s13049-022-00996-5" rel="nofollow" target="_blank">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).</a></li> </ul> <ul> <li>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</li> </ul> <ul> <li>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</li> </ul> <ul> <li><a href="https://sjtrem.biomedcentral.com/articles/10.1186/s13049-022-01029-x" rel="nofollow" target="_blank">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</a></li> </ul>

Extrication

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!

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 <a href="https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/" rel="nofollow" target="_blank">here</a>. If you’d like to read more about ‘nocebo’ i.e. the non-pharmacological adverse effects of an intervention, have a look at <a href="https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15601" rel="nofollow" target="_blank">this article</a>. <h3>Penthrox</h3> For more information on Penthrox, you can read about it in the <a href="https://bnf.nice.org.uk/drug/methoxyflurane.html" rel="nofollow" target="_blank">BNF</a>, <a href="https://www.medicines.org.uk/emc/medicine/31391#gref" rel="nofollow" target="_blank">The Emergency Medicines Compendium</a> and on the <a href="https://penthrox.co.uk/healthcare/simple-to-use/" rel="nofollow" target="_blank">manufacturers own website.</a> Jon is the author of the Pain and analgesia chapter in the 2nd edition of the ABC of Prehospital Medicine, to be published soon!

Pain (& analgesia)

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.

Before you listen to this new podcast, we encourage you to go back and have a listen to <a href="https://phemcast.co.uk/2017/02/23/episode-16-blood/" rel="nofollow" target="_blank">Episode 16: Blood</a> 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 <a href="https://www.thelancet.com/journals/lanhae/article/PIIS2352-3026(22)00040-0/fulltext" rel="nofollow" target="_blank">here</a>, and you can read more about the trial at the <a href="https://www.birmingham.ac.uk/research/bctu/trials/portfolio-v/rephill/index.aspx" rel="nofollow" target="_blank">University Of Birmingham Clinical Trials site</a>.On the day of publication, Critical Care Reviews hosted a Livestream which is <a href="https://criticalcarereviews.com/livestreams/rephill" rel="nofollow" target="_blank">available to watch</a> 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.

RePHILL

This podcast is dedicated to the memory of Emmanuel Cauchy. George’s adventures! Grading frostbiteStages of frostbite. From Cauchy et al, 2016.Grade 1Grade 2Grade 3Grade 4Stages of frostbite. From Cauchy et al. 2001The 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 &amp; 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 &amp; 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 &amp; 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.

This podcast is dedicated to the memory of Emmanuel Cauchy. <h3>George’s adventures!</h3> <h3>Grading frostbite</h3>Stages of frostbite. From <a href="https://www.wemjournal.org/article/S1080-6032(15)00460-3/fulltext" rel="nofollow" target="_blank">Cauchy et al, 2016.</a> Grade 1 Grade 2 Grade 3 Grade 4 Stages of frostbite. From<a href="https://doi.org/10.1580/1080-6032(2001)012[0248:RSOCOS]2.0.CO;2" rel="noreferrer noopener nofollow" target="_blank"> Cauchy et al. </a>2001 <h3>The GELOX study</h3> The Hyperbaric oxygen study described by Carron is now in print and available<a href="https://www.mdpi.com/1648-9144/57/11/1284" rel="nofollow" target="_blank"> here</a>. <h3>Guidelines</h3> The guidelines mentioned by Chris can be found on the <a href="https://wms.org/magazine/1250/frostbite_cgp" rel="nofollow" target="_blank">Wilderness Medical Society website</a>. <h3>References</h3> 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 &amp; 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 &amp; 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 &amp; 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.

Cold Injury

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’.AirwayIntubationMore detail on intubation from 5 minute sonoFront of neck accessBreathingPneumothoraxLung pathologies including PE and pulmonary contusionPulmonary oedemaPleural effusionCirculationFAST scan in traumaFree fluid/haemoperitoneum in the RUQPericardial effusion with engorged IVCDisabilityOcular ultrasoundEMCRIT post on use of ultrasound to diagnose raised ICP with ocular sonographyExtremityRib &amp; sternal fracturesUltrasound guided hip nerve blocks (including femoral and FIB)Cardiac arrestUse of ultrasound in cardiac arrest (US)POCUS in cardiac arrest (UK)Further ResourcesFAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Kenji Inaba. Ann Surg. 2015Marik 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 papers2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism

<h2>Some useful videos:</h2>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:<a href="https://www.youtube.com/watch?v=I1Bdp2tMFsY" rel="noreferrer noopener nofollow" target="_blank">How does ultrasound work?</a>Want to know how to use ultrasound? <a href="https://www.youtube.com/watch?v=531t0deTQwg" rel="noreferrer noopener nofollow" target="_blank">This is a whole 45 minute introductory lecture.</a> 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 <a href="https://radiopaedia.org/articles/point-of-care-ultrasound-curriculum" rel="noreferrer noopener nofollow" target="_blank">here</a>.The <a href="https://www.sonosite.com/clinical-media" rel="noreferrer noopener nofollow" target="_blank">Sonosite website</a> has some excellent resources, which you can filter according to specialty, including prehospital using ‘EMS/Air Med/Ambulance’.Airway<a href="https://youtu.be/NvTan3189P4" rel="noreferrer noopener nofollow" target="_blank">Intubation</a><a href="https://www.coreultrasound.com/endotracheal-tube-confirmation/" rel="noreferrer noopener nofollow" target="_blank">More detail on intubation</a><a href="https://www.coreultrasound.com/endotracheal-tube-confirmation/" rel="noreferrer noopener nofollow" target="_blank"> </a><a href="https://www.coreultrasound.com/endotracheal-tube-confirmation/" rel="noreferrer noopener nofollow" target="_blank">from 5 minute sono</a><a href="https://youtu.be/xGa8m65SoA8" rel="noreferrer noopener nofollow" target="_blank">Front of neck access</a>Breathing<a href="https://www.youtube.com/watch?v=2EYc8UO4crY" rel="noreferrer noopener nofollow" target="_blank">Pneumothorax</a><a href="https://www.youtube.com/watch?v=AqzamVrIqXI" rel="noreferrer noopener nofollow" target="_blank">Lung pathologies including PE an</a><a href="https://www.youtube.com/watch?v=AqzamVrIqXI" rel="noreferrer noopener nofollow" target="_blank">d</a><a href="https://www.youtube.com/watch?v=AqzamVrIqXI" rel="noreferrer noopener nofollow" target="_blank"> pulmonary contusion</a><a href="https://www.youtube.com/watch?v=VzgX9ihnmec" rel="noreferrer noopener nofollow" target="_blank">Pulmonary oedema</a><a href="https://www.youtube.com/watch?v=X1E7OgOLzw0" rel="noreferrer noopener nofollow" target="_blank">Pleural effusion</a>Circulation<a href="https://www.youtube.com/watch?v=l3Xmp4Xq4SQ" rel="noreferrer noopener nofollow" target="_blank">FAST scan in trauma</a><a href="https://www.youtube.com/watch?v=ooLzAUVbhZ8" rel="nofollow" target="_blank">Free fluid/haemoperitoneum in the RUQ</a><a href="https://youtu.be/501Jo_3FKSM" rel="noreferrer noopener nofollow" target="_blank">Pericardial effusion with engorged IVC</a>Disability<a href="https://www.youtube.com/watch?v=A0gQmqWcIn8" rel="noreferrer noopener nofollow" target="_blank">Ocular ultrasound</a><a href="https://emcrit.org/pulmcrit/pulmcrit-algorithm-diagnosing-icp-elevation-ocular-sonography/" rel="noreferrer noopener nofollow" target="_blank">EMCRIT post</a> on use of ultrasound to diagnose raised ICP with ocular sonographyExtremity<a href="https://www.coreultrasound.com/rib-and-sternal-fractures/" rel="noreferrer noopener nofollow" target="_blank">Rib &amp; sternal fractures</a><a href="https://canadiem.org/hip-nerve-block-toolkit/" rel="noreferrer noopener nofollow" target="_blank">Ultrasound guided hip nerve blocks</a> (including femoral and FIB)Cardiac arrest<a href="https://www.youtube.com/watch?v=USjx9gvtUGw" rel="noreferrer noopener nofollow" target="_blank">Use of ultrasound in cardiac arrest</a> (US)<a href="https://www.youtube.com/watch?v=lCHLJ3yZ0mU" rel="noreferrer noopener nofollow" target="_blank">POCUS in cardiac arrest</a> (UK)<h2>Further Resources</h2>FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Kenji Inaba. Ann Surg. 2015Marik 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.<a href="https://theresusroom.co.uk/ultrasound-in-cardiac-arrest/" rel="noreferrer noopener nofollow" target="_blank">https://theresusroom.co.uk/ultrasound-in-cardiac-arrest/</a><a href="https://resus.me/prehospital-ultrasound/" rel="noreferrer noopener nofollow" target="_blank">ResusMe bibliography of PH ultrasound papers</a><a href="https://academic.oup.com/eurheartj/article/41/4/543/5556136" rel="noreferrer noopener nofollow" target="_blank">2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism</a>

Ultrasound

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 &amp; 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

<h2>Definitions</h2> 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. <h2>Toxidromes</h2> There are some <a href="https://litfl.com/tox-library/flashcards/" rel="noreferrer noopener nofollow" target="_blank">superb resources</a> on the Life in the Fast Lane site on this topic. Really recommend having a look! <h2>De-escalation</h2> There is a useful summary on some de-escalation strategies &amp; techniques, from HSI <a href="https://hsi.com/resources/conflict-de-escalation-techniques" rel="noreferrer noopener nofollow" target="_blank">here</a>. <a href="https://www.bfwh.nhs.uk/onehr/wp-content/uploads/2016/02/Conflict-Resolution-workbook-2.pdf" rel="noreferrer noopener nofollow" target="_blank">This handbook</a> from a UK NHS Trust outlines some key principles from their conflict resolution training. <h2>Further reading</h2> JRCALC Clinical Guideline: Acute Behavioural Disturbance.  <a href="https://www.nice.org.uk/guidance/ng10" rel="noreferrer noopener nofollow" target="_blank">NICE. NG10. 2015. Violence and aggression: short term management in mental health, health and community settings.</a> <a href="https://www.rcem.ac.uk/docs/College%20Guidelines/5p.%20RCEM%20guidelines%20for%20management%20of%20Acute%20Behavioural%20Disturbance%20(May%202016).pdf" rel="noreferrer noopener nofollow" target="_blank">RCEM. Best Practice Guideline. 2016. Guidelines for the Management of Excited Delirium/Acute Behavioural Disturbance.</a> <a href="https://fflm.ac.uk/wp-content/uploads/2019/05/AcuteBehaveDisturbance_Apr19-FFLM-RCEM.pdf" rel="noreferrer noopener nofollow" target="_blank">Faculty of Forensic and Legal Medicine. 2019. Acute behavioural disturbance (ABD): guidelines on management in police custody.</a> <a href="https://collegeofparamedics.co.uk/COP/News/Statements%20and%20Consultations/COP/News/Statements_and_consultations.aspx?hkey=58e66fcf-4996-4b0a-b599-b3d52fc19348" rel="nofollow" target="_blank">College of Paramedics. Acute Behavioural Disturbance Position Statement</a> <a href="https://www.cqc.org.uk/sites/default/files/20160422_briefguide-Restraint_physical_mechanical.pdf.pdf" rel="noreferrer noopener nofollow" target="_blank">The CQC brief guide to restraint</a>

Acute behavioural disturbance

This was a joint podcast with our friends &amp; 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 CAMERAOLYMPUS DIGITAL CAMERAOLYMPUS DIGITAL CAMERAOLYMPUS 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 &amp; 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 illnessFrom 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 &amp; 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

This was a joint podcast with our friends &amp; colleagues at WEMCast – to hear more from them, have a look at their <a href="https://wemcast.podbean.com" rel="nofollow" target="_blank">podcast back catalogue</a>, and there’s more information on the World Extreme Medicine <a href="https://worldextrememedicine.com" rel="nofollow" target="_blank">website</a>. <ul><li></li><li></li><li></li><li>OLYMPUS DIGITAL CAMERA</li><li></li><li>OLYMPUS DIGITAL CAMERA</li><li>OLYMPUS DIGITAL CAMERA</li><li>OLYMPUS DIGITAL CAMERA</li><li></li><li></li><li></li><li></li></ul> <h2>Mosquito born disease</h2> Malaria risk areas. From: <a href="https://www.iamat.org/risks/malaria" rel="nofollow" target="_blank">https://www.iamat.org/risks/malaria</a> 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 &amp; symptoms, variants, at-risk countries and treatment, have a look at the <a href="https://travelhealthpro.org.uk/factsheet/52/malaria" rel="nofollow" target="_blank">Travel Health Pro website</a>. Dengue risk areas. From <a href="https://travelhealthpro.org.uk/factsheet/13/dengue" rel="nofollow" target="_blank">https://travelhealthpro.org.uk/factsheet/13/dengue</a> 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 <a href="https://travelhealthpro.org.uk/factsheet/13/dengue" rel="nofollow" target="_blank">Travel Health pro website</a> 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 <a href="https://travelhealthpro.org.uk/disease/196/zika-virus" rel="nofollow" target="_blank">here</a>. <h2>Exertional heat illness</h2>From <a href="https://moveitnq.com.au/exercising-in-the-heat/" rel="nofollow" target="_blank">https://moveitnq.com.au/exercising-in-the-heat/</a> The UK Faculty of Sport and Exercise Medicine has produced a position statement on exertional heat illness, available <a href="https://www.fsem.ac.uk/position_statement/exertional-heat-stroke/" rel="nofollow" target="_blank">here</a>, and the Royal College of Emergency Medicine’s elearning platform also has a <a href="https://www.rcemlearning.co.uk/reference/heat-related-illness/" rel="nofollow" target="_blank">module on the spectrum of heat related illness</a>. From <a href="https://tactical-medicine.com/products/caervest-core-body-cooling" rel="nofollow" target="_blank">https://tactical-medicine.com/products/caervest-core-body-cooling</a> To find out more about the CAER vest mentioned in the podcast, have a look at <a href="https://www.youtube.com/watch?v=fGGRh5pEULY&amp;t=2s" rel="nofollow" target="_blank">this YouTube</a> video. Or read <a href="https://www.mdpi.com/1648-9144/56/10/539" rel="nofollow" target="_blank">this article</a>. <h2>Pitted keratolitis</h2> <h2>Further reading</h2> Smith M, Withnall R &amp; Boulter MK. An exertional heat illness triage tool for a jungle training environment. J Royal Army Medical Corps, 2018. 164, 287-289. DOI: <a href="https://doi.org/10.1136/jramc-2017-000801" rel="noreferrer noopener nofollow" target="_blank">10.1136/jramc-2017-000801</a> 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. <a href="https://doi.org/10.3390/ijerph17197037" rel="noreferrer noopener nofollow" target="_blank">https://doi.org/10.3390/ijerph17197037</a>

The Jungle

Guidance documentsCollege of Paramedics Statement on Intubation, available here.AAGBI Safer Prehospital Anaesthesia 2017, available here.PositioningFrom: http://anaesthesiatoday.blogspot.com/2013/03/10-common-procedural-basics_29.html Recommended Rich Levitan resources Podcast 70 – Airway Management with Rich Levitan Airway axesFrom: McGuire B, Hodge K. Tracheal intubation. Anaesthesia &amp; 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 https://www.resus.com.au/apnoeic-oxygenation-resuscitation-time/ https://anaesthetists.org/Home/Resources-publications/Guidelines/Safer-pre-hospital-anaesthesiaArticle 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 &amp; 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 &amp; 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. &amp; 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

<h2>Guidance documents</h2>College of Paramedics Statement on Intubation, available <a href="https://www.collegeofparamedics.co.uk/COP/Professional_development/Intubation_Consensus_Statement_/COP/ProfessionalDevelopment/Intubation_Consensus_Statement_.aspx?hkey=5c999b6b-274b-42d3-8dbc-651c367c0493" rel="nofollow" target="_blank">here</a>.AAGBI Safer Prehospital Anaesthesia 2017, available <a href="https://anaesthetists.org/Home/Resources-publications/Guidelines/Safer-pre-hospital-anaesthesia" rel="nofollow" target="_blank">here</a>.<h2>Positioning</h2>From: <a href="http://anaesthesiatoday.blogspot.com/2013/03/10-common-procedural-basics_29.html" rel="nofollow" target="_blank">http://anaesthesiatoday.blogspot.com/2013/03/10-common-procedural-basics_29.html</a> <h2>Recommended Rich Levitan resources</h2> <blockquote><a href="https://emcrit.org/emcrit/rich-levitan-airway-lecture/" rel="nofollow" target="_blank">Podcast 70 – Airway Management with Rich Levitan</a></blockquote> <h2>Airway axes</h2>From: McGuire B, Hodge K. Tracheal intubation. Anaesthesia &amp; Intensive Care Medicine. 2019. 20(12);681-686. From: <a href="https://veteriankey.com/tracheal-intubation/" rel="nofollow" target="_blank">https://veteriankey.com/tracheal-intubation/</a> <h2>Epiglottoscopy</h2> <h2>Bimanual Laryngoscopy</h2> 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 <h2>Further resources</h2> <blockquote><a href="https://litfl.com/direct-laryngoscopy/" rel="nofollow" target="_blank">Direct Laryngoscopy</a></blockquote> <blockquote><a href="https://litfl.com/bimanual-laryngoscopy/" rel="nofollow" target="_blank">Bimanual laryngoscopy</a></blockquote> <a href="https://www.resus.com.au/apnoeic-oxygenation-resuscitation-time/" rel="nofollow" target="_blank">https://www.resus.com.au/apnoeic-oxygenation-resuscitation-time/</a> <a href="https://anaesthetists.org/Home/Resources-publications/Guidelines/Safer-pre-hospital-anaesthesia" rel="nofollow" target="_blank">https://anaesthetists.org/Home/Resources-publications/Guidelines/Safer-pre-hospital-anaesthesia</a>Article available <a href="//jamanetwork.com/journals/jama/fullarticle/2698493" rel="nofollow" target="_blank">here</a>. Click <a href="https://www.theresusroom.co.uk/airways-2/" rel="nofollow" target="_blank">here</a> to hear what our friends over at the Resus Room think about Airways 2 <h2>References (kindly shared by Rich)</h2> 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). <a href="https://doi.org/10.1186/s13049-015-0136-9" rel="nofollow" target="_blank">https://doi.org/10.1186/s13049-015-0136-9</a> 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). <a href="https://doi.org/10.1186/s13054-017-1603-7" rel="nofollow" target="_blank">https://doi.org/10.1186/s13054-017-1603-7</a> 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 &amp; 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 &amp; 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. &amp; Arakawa, J. Learning curve for paramedic endotracheal intubation and complications. Int J Emerg Med 6, 38 (2013). <a href="https://doi.org/10.1186/1865-1380-6-38" rel="nofollow" target="_blank">https://doi.org/10.1186/1865-1380-6-38</a> 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

Intubation

A UK Prehospital Emergency Medicine Podcast. This podcast and associated website aims to:- Share knowledge and expertise in the field of prehospital medicine with specific reference to the UK working environment- Make this content relevant to all professional prehospital practitioners

A UK Prehospital Emergency Medicine Podcast. This podcast and associated website aims to: - Share knowledge and expertise in the field of prehospital medicine with specific reference to the UK working environment - Make this content relevant to all professional prehospital practitioners

PHEMCAST

https://phemcast.files.wordpress.com/2016/12/vent-final.mp3 Ventilation – a dark art. Difficult to be a master, easy to be average (or terrible)! This is “part 1”, which includes some of the basic (and not very basic) concepts behind ventilation. We recorded over 60 minutes of excellent content with George – we will post more below as soon as it is edited. . Check out Georges powerpoint – its excellent! introduction-to-mechanical-ventilation-11nov2016-podcast

<a href="https://phemcast.files.wordpress.com/2016/12/vent-final.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2016/12/vent-final.mp3</a> Ventilation – a dark art. Difficult to be a master, easy to be average (or terrible)! This is “part 1”, which includes some of the basic (and not very basic) concepts behind ventilation. We recorded over 60 minutes of excellent content with George – we will post more below as soon as it is edited. . Check out Georges powerpoint – its excellent! <a href="https://phemcast.files.wordpress.com/2016/12/introduction-to-mechanical-ventilation-11nov2016-podcast.pptx" rel="nofollow" target="_blank">introduction-to-mechanical-ventilation-11nov2016-podcast</a>

Episode 13: The Ventilator

Guest contributor: Lauren Weekes  https://phemcast.files.wordpress.com/2017/09/et-06092017-16-24.mp3 What is ETCO2?   % or partial pressure of carbon dioxide measured somewhere near the mouth at the end of a normal exhalation (hence end tidal, end of tidal volume breath) To get a measurement the following systems need to be functioning: Metabolically active tissue to produce CO2 Circulation &amp; cardiac output to carry that CO2 to the lungs in blood Transfer of CO2 between the blood and the air in the lung Gas in and out of the lung to excrete the CO2   Brilliant monitor in anaesthesia in that in elective cases, we start off with healthy patients are looking for deviations from the norm- and a normal ETCO2 trace tells you that all those components are functioning. It is still extremely useful in prehospital care, but we just have to remember that an abnormal trace or value may be caused by problems with one or more of those systems i.e circulation, gas exchange, ventilation (rarely tissue metabolism) Much better than pulse oximetry, because of the difference in lag time between clinical change occurring and being able to see it on the monitor- less than 3 seconds for sidestream capnography, compared to up to 90s for pulse oximetry    How does ETCO2 relate to arterial CO2?  What we’re REALLY interested in is arterial CO2 as this is the clinically significant value in a number of clinical scenarios; for example in the brain-injured patient, we want to keep arterial CO2 values normal as we know that this determines the state of cerebral vasoconstriction or dilation, and thus affects ICP. In non-brain injured patients, high arterial CO2 can lead to a respiratory acidosis, and low pH values are harmful to most body tissues, in particular the clotting cascade (because of its reliance on enzymes, which function best in a narrow range of pH), and cardiac contractility. In healthy people, ETCO2 is usually 0.5-1kPA LOWER than the arterial value. Why is this? CO2 is only found in parts of the lung which participate in gas exchange, i.e are perfused with blood. So the trachea and first few generations of bronchi do not participate in gas exchange and are known as the dead space. They ARE however filling with gas during breaths, and as such gas from this dead space DILUTES the gas containing CO2 that has come predominantly from the alveoli. What we are assuming when we ask ETCO2 to substitute for arterial CO2 is that there is normal matching of ventilation to perfusion occurring in the lungs, so that all the mixed venous CO2 returning to the lungs from respiring tissue can equilibrate with alveolar gas and be eliminated via ventilation    What causes a discrepancy between arterial and ETCO2?  Artefact  Loose connections, not having nasal prongs up nose, dilution with high oxygen flows (partic when using nasal prongs)  Failure of venous CO2 to cross to ventilated alveoli  Alveolar dead space- alveoli are ventilated but not perfused Classically low cardiac output states, PE, etc  Failure of alveolar gas to be transported out of the lungs because alveoli are perfused but not ventilated (shunt):   pneumonia and pulmonary edema, pulm haemorrhage (alveoli filled with fluid) tissue trauma: alveolar wall swelling atelectasis: collapse of alveoli from failure to expand, or absorption of the air out of the alveoli without replacing it mucous/vomit plugging Global ventilation failure e.g airway obstruction, hypoventilation esp where tidal volume is very low- dead space is fixed, so as a proportion of each breath it gets higher as tidal volume reduces until there is minimal ALVEOLAR ventilation      How do we measure it?   Usually by infra-red absorption- CO2 absorbs infra-red light in a manner proportional to its concentration in the sampled gas. Can be measured from a breathing circuit attached to an invasive airway device e.g supraglottic airway or endotracheal tube, or from a number of methods in the spontaneously breathing patient, such as a specific nasal cannula, or a sampling tube attached to an oxygen mask. Important to note that the waveform, and values for ETCO2 are very different in the spontaneously breathing patient, and we’ll come back to that later. Might be measured directly from the breathing circuit (mainstream) or sucked out of the circuit in a sampling tube (sidestream). Might display results as a waveform with a value given for ETCO2, or simply a number (capnometry) although the latter much less useful. Colorimetric devices are available which change colour, based loosely on percentage of gas present. pH related. Occasionally used as an adjunct to waveform    What does the waveform mean?  The classic waveform that you will see in textbooks come from CO2 measured in the ventilated patient. The graph has time in seconds along the x axis and partial pressure in kPa along the y axis Phase I (inspiratory baseline) reflects inspired gas, which is normally devoid of carbon dioxide. Phase II (expiratory upstroke) is the transition between dead space and alveolar gas from the respiratory bronchioles and alveoli. Phase III is the alveolar plateau, when largely homogenous gas from the alveoli empties. This is the most accurate reflection of arterial co2 Phase 0  is the inspiratory downstroke, the beginning of the next inspiration In the spontaneously breathing patient, there is not usually a plateau phase, which makes interpretation of ETCO2 values more difficult    EVIDENCE ETT placement  All major anaesthetic organisations mandate the use of ETCO2 to confirm ETT placement Good evidence that the trace is not completely flat even in cardiac arrest- Silvestri Ann Emerg Med 2005 Should seen &gt;7 waveforms to exclude oesophageal (Orinato 1993)    Cardiac arrest- general   2010 &amp; 2015 ERC guidelines recommend use of waveform capnography Not new- 1978 paper Kalenda in Resuscitation described the use of capnogram as a guide to CPR efficacy    Predicting ROSC  Grmec 2003 &amp; 2011 in Critical Care ETCO2 of &gt;2.4kpa after 20min predictive of rosc , &lt;1.3 = no ROSC Alwens 2001 used cut off 10mmHg Systematic review in 2013 Resuscitation used cut off of 1.3kPa but this wasn’t 100% sensitive across all studies Concerns also raised by Norwegian paper in Resuscitation again 2011 showing a number of confounding factors made interpretation of etco2 problematic inc rhythm, bystander CPR, cause of arrest    CPR quality  As noted in 1978, ETCO2 drops off when chest compressions become ineffective. Qvigstad et al showed in again in Resuscitation in 2013, confirming inter-individual variation in effectiveness of CPR using ETCO2 as a surrogate for CO    Trauma  Deakin et al. (J. trauma 2004) showed that end-tidal CO2 may be of value in predicting outcome from major trauma (19). In a study of 191 blunt trauma patients, only 5% of patients with an end-tidal CO2 determination of 3.25 kPa survived to discharge      PRACTICAL USE When should we use ETCO2 monitoring in the prehospital setting?  Mandatory if intubating (RSI, cardiac arrest) Mandatory if performing procedural sedation where consciousness impaired Highly recommended in cardiac arrest Highly recommended in all critically ill patients    In cardiac arrest: Attach to circuit/ BVM at soonest available opportunity Use it to confirm intubation (if using) Use it as a guide:  If ETCO2 has been steady during CPR but then begins to fall, consider changing rescuer As corroborating evidence around decision making- if there has been no ROSC after 20min of full ALS protocol and ETCO2 remains below 1.3kPA, you are highly unlikely to resuscitate that patient If there is a sudden increase in ETCO2- well done, you’ve achieved ROSC (even if you can’t yet feel a pulse- in fact, maybe you needn’t do a pulse check if you’ve got ETCO2) Optimise ventilation post ROSC as you are now dealing with a head-injured patient.    In the critically ill patient:  If I can only have one monitor on an entrapped patient, I’d pick capnography You will learn more quickly than any other method when your patient is deteriorating- e.g in blood loss, ETC02 will gradually fall. In the head injured patient who’s coning, you’ll see apnoeas and gradually rising ETCO2. In the heart failure patient who’s about to arrest, you’ll see their ETCO2 fall precipitously almost before anything else. In the comatose patient, you’ll be able to see that their airway is obstructed on the capnography a full 30 to 60s before their sats drop (by which point you’re already a long way down the oxygen dissociation curve). You can also see when your treatment is working- if you give a patient in septic shock some fluid and improve their CO, you’ll see a rise in ETC02 You can confirm adequacy of respiratory function in the fitting or post-ictal patient when all other methods fail    PITFALLS Device failure- lines blocking, batteries running out, pump failure.  Test by blowing Over-interpreting the accuracy of non-invasive capnography  Those lovely graphs showing curare clefts, rebreathing, bronchospasm etc you see on lots of different websites and in textbooks? They are almost all referring to capnography in the intubated and ventilated patient, who has a constant tidal volume. Numbers are often wildly inaccurate in the critically unwell population, and there may be an ET-arterial gradient of 10kPA. What CAN you tell from it? 1. Ventilation is occurring (accurate RR) 2. There is a cardiac output 3. You can interpret trends ie a gradual rise or fall in CO2, in the given clinical context 4. Very low is bad whichever way you look at it    Sometimes a low ETCO2 value is due to hyperventilation (because as we all remember, arterial CO2 concentration is almost linearly related to alveolar minute ventilation) BUT it may be hypoventilation with increased proportion of dead space ventilation compared to alveolar ventilation    Not using capnography  The more you use it, the more familiar with various patterns you will become Stick it on everyone –it causes no harm. See what happens when you give a decent dose of morphine: slows respiratory rate but breaths are normal volume You get reduced alveolar MINUTE ventilation but normal alveolar TIDAL ventilation Therefore what you see at ETCO2 is reasonably representative of arterial concentration because the same number of alveoli are ventilated and have opportunity to equilibrate with the blood CO2 This is unlike when a patient is making low tidal volume breaths, because then you’re largely ventilating dead space, and a much smaller number of alveoli are ventilated and thus equilibrium cannot occur between blood and gas    Demonstration traces:   From: Capnography Outside the Operating Rooms, Anesthes. 2013;118(1):192-201. doi:10.1097/ALN.0b013e318278c8b6 A Prolonged phase II, increased α angle, and steeper phase III suggest bronchospasm or airway obstruction. B Expiratory valve malfunction resulting in elevation of the baseline, and the angle between the alveolar plateau and the downstroke of inspiration is increased from 90°. This is due to rebreathing of expiratory gases from the expiratory limb during inspiration. C Inspiratory valve malfunction resulting in rebreathing of expired gases from inspiratory limb during inspiration (reference 5 for details). D Capnogram with normal phase II but with increased slope of phase III. This capnogram is observed in pregnant subjects under general anesthesia (normal physiologic variant and details in reference 9). E Curare cleft: Patient is attempting to breathe during partial muscle paralysis. Surgical movements on the chest and abdomen can also result in the curare cleft. F Baseline is elevated as a result of carbon dioxide rebreathing. G Esophageal intubation resulting in the gastric washout of residual carbon dioxide and subsequent carbon dioxide will be zero. H  Spontaneously breathing carbon dioxide waveforms where phase III is not well delineated. I  Dual capnogram in one lung transplantation patient. The first peak in phase III is from the transplanted normal lung, whereas the second peak is from the native disease lung. A variation of dual capnogram (steeple sign capnogram – dotted line) is seen if there is a leak around the sidestream sensor port at the monitor. This is because of the dilution of expired PCO2with atmospheric air. J Malignant hyperpyrexia where carbon dioxide is raising gradually with zero baseline suggesting increased carbon dioxide production with carbon dioxide absorption by the soda lime. K Classic ripple effect during the expiratory pause showing cardiogenic oscillations. These occur as a result of to-and-for movement of expired gases at the sensor due to motion of the heartbeat during expiratory pause when respiratory frequency of mechanical ventilation is low. Ripple effect like wave forms also occur when forward flow of fresh gases from a source during expiratory pause intermingles with expiratory gases at the sensor. L  Sudden raise of baseline and the end-tidal PCO2(PETCO2) due to contamination of the sensor with secretions or water vapor. Gradual rise of baseline and PETCO2occurs when soda lime is exhausted. M Intermittent mechanical ventilation (IMV) breaths in the midst of spontaneously breathing patient. A comparison of the height of spontaneous breaths compared to the mechanical breaths is useful to assess spontaneous ventilation during weaning process. N  Cardiopulmonary resuscitation: capnogram showing positive waveforms during each compression suggesting effective cardiac compression generating pulmonary blood. O  Capnogram showing rebreathing during inspiration. This is normal in rebreathing circuits such as Mapleson D or Bain circuit. Useful links:  https://lifeinthefastlane.com/ccc/capnography-waveform-interpretation/ http://www.capnography.com/new/index.php?option=com_content&amp;view=article&amp;id=131&amp;Itemid=993

Guest contributor: Lauren Weekes <a href="https://phemcast.files.wordpress.com/2017/09/et-06092017-16-24.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2017/09/et-06092017-16-24.mp3</a> What is ETCO2? <ul> <li>% or partial pressure of carbon dioxide measured somewhere near the mouth at the end of a normal exhalation (hence end tidal, end of tidal volume breath)</li> <li>To get a measurement the following systems need to be functioning: <ul> <li>Metabolically active tissue to produce CO2</li> <li>Circulation &amp; cardiac output to carry that CO2 to the lungs in blood</li> <li>Transfer of CO2 between the blood and the air in the lung</li> <li>Gas in and out of the lung to excrete the CO2</li> </ul> </li> <li>Brilliant monitor in anaesthesia in that in elective cases, we start off with healthy patients are looking for deviations from the norm- and a normal ETCO2 trace tells you that all those components are functioning.</li> <li>It is still extremely useful in prehospital care, but we just have to remember that an abnormal trace or value may be caused by problems with one or more of those systems i.e circulation, gas exchange, ventilation (rarely tissue metabolism)</li> <li>Much better than pulse oximetry, because of the difference in lag time between clinical change occurring and being able to see it on the monitor- less than 3 seconds for sidestream capnography, compared to up to 90s for pulse oximetry</li> </ul> How does ETCO2 relate to arterial CO2? <ul> <li>What we’re REALLY interested in is arterial CO2 as this is the clinically significant value in a number of clinical scenarios; for example in the brain-injured patient, we want to keep arterial CO2 values normal as we know that this determines the state of cerebral vasoconstriction or dilation, and thus affects ICP. In non-brain injured patients, high arterial CO2 can lead to a respiratory acidosis, and low pH values are harmful to most body tissues, in particular the clotting cascade (because of its reliance on enzymes, which function best in a narrow range of pH), and cardiac contractility.</li> <li>In healthy people, ETCO2 is usually 0.5-1kPA LOWER than the arterial value. Why is this? CO2 is only found in parts of the lung which participate in gas exchange, i.e are perfused with blood. So the trachea and first few generations of bronchi do not participate in gas exchange and are known as the dead space. They ARE however filling with gas during breaths, and as such gas from this dead space DILUTES the gas containing CO2 that has come predominantly from the alveoli.</li> <li>What we are assuming when we ask ETCO2 to substitute for arterial CO2 is that there is normal matching of ventilation to perfusion occurring in the lungs, so that all the mixed venous CO2 returning to the lungs from respiring tissue can equilibrate with alveolar gas and be eliminated via ventilation</li> </ul> What causes a discrepancy between arterial and ETCO2? <ol> <li>Artefact</li> </ol> Loose connections, not having nasal prongs up nose, dilution with high oxygen flows (partic when using nasal prongs) <ol> <li>Failure of venous CO2 to cross to ventilated alveoli</li> </ol> Alveolar dead space- alveoli are ventilated but not perfused Classically low cardiac output states, PE, etc <ol> <li>Failure of alveolar gas to be transported out of the lungs because alveoli are perfused but not ventilated (shunt):</li> </ol> <ul> <li>pneumonia and pulmonary edema, pulm haemorrhage (alveoli filled with fluid)</li> <li>tissue trauma: alveolar wall swelling</li> <li>atelectasis: collapse of alveoli from failure to expand, or absorption of the air out of the alveoli without replacing it</li> <li>mucous/vomit plugging</li> <li>Global ventilation failure e.g airway obstruction, hypoventilation esp where tidal volume is very low- dead space is fixed, so as a proportion of each breath it gets higher as tidal volume reduces until there is minimal ALVEOLAR ventilation</li> </ul> How do we measure it? <ul> <li>Usually by infra-red absorption- CO2 absorbs infra-red light in a manner proportional to its concentration in the sampled gas.</li> <li>Can be measured from a breathing circuit attached to an invasive airway device e.g supraglottic airway or endotracheal tube, or from a number of methods in the spontaneously breathing patient, such as a specific nasal cannula, or a sampling tube attached to an oxygen mask. Important to note that the waveform, and values for ETCO2 are very different in the spontaneously breathing patient, and we’ll come back to that later.</li> <li>Might be measured directly from the breathing circuit (mainstream) or sucked out of the circuit in a sampling tube (sidestream).</li> <li>Might display results as a waveform with a value given for ETCO2, or simply a number (capnometry) although the latter much less useful.</li> <li>Colorimetric devices are available which change colour, based loosely on percentage of gas present. pH related. Occasionally used as an adjunct to waveform</li> </ul> What does the waveform mean? <ul> <li>The classic waveform that you will see in textbooks come from CO2 measured in the ventilated patient.</li> <li>The graph has time in seconds along the x axis and partial pressure in kPa along the y axis</li> <li>Phase I (inspiratory baseline) reflects inspired gas, which is normally devoid of carbon dioxide.</li> <li>Phase II (expiratory upstroke) is the transition between dead space and alveolar gas from the respiratory bronchioles and alveoli.</li> <li>Phase III is the alveolar plateau, when largely homogenous gas from the alveoli empties. This is the most accurate reflection of arterial co2</li> <li>Phase 0  is the inspiratory downstroke, the beginning of the next inspiration</li> <li>In the spontaneously breathing patient, there is not usually a plateau phase, which makes interpretation of ETCO2 values more difficult</li> </ul> EVIDENCE ETT placement <ul> <li>All major anaesthetic organisations mandate the use of ETCO2 to confirm ETT placement</li> <li>Good evidence that the trace is not completely flat even in cardiac arrest- Silvestri Ann Emerg Med 2005</li> <li>Should seen &gt;7 waveforms to exclude oesophageal (Orinato 1993)</li> </ul> Cardiac arrest- general <ul> <li>2010 &amp; 2015 ERC guidelines recommend use of waveform capnography</li> <li>Not new- 1978 paper Kalenda in Resuscitation described the use of capnogram as a guide to CPR efficacy</li> </ul> Predicting ROSC <ul> <li>Grmec 2003 &amp; 2011 in Critical Care</li> <li>ETCO2 of &gt;2.4kpa after 20min predictive of rosc , &lt;1.3 = no ROSC</li> <li>Alwens 2001 used cut off 10mmHg</li> <li>Systematic review in 2013 Resuscitation used cut off of 1.3kPa but this wasn’t 100% sensitive across all studies</li> <li>Concerns also raised by Norwegian paper in Resuscitation again 2011 showing a number of confounding factors made interpretation of etco2 problematic inc rhythm, bystander CPR, cause of arrest</li> </ul> CPR quality <ul> <li>As noted in 1978, ETCO2 drops off when chest compressions become ineffective.</li> <li>Qvigstad et al showed in again in Resuscitation in 2013, confirming inter-individual variation in effectiveness of CPR using ETCO2 as a surrogate for CO</li> </ul> Trauma <ul> <li>Deakin et al. (J. trauma 2004) showed that end-tidal CO2 may be of value in predicting outcome from major trauma (19). In a study of 191 blunt trauma patients, only 5% of patients with an end-tidal CO2 determination of 3.25 kPa survived to discharge</li> </ul> PRACTICAL USE When should we use ETCO2 monitoring in the prehospital setting? <ul> <li>Mandatory if intubating (RSI, cardiac arrest)</li> <li>Mandatory if performing procedural sedation where consciousness impaired</li> <li>Highly recommended in cardiac arrest</li> <li>Highly recommended in all critically ill patients</li> </ul> In cardiac arrest: Attach to circuit/ BVM at soonest available opportunity Use it to confirm intubation (if using) Use it as a guide: <ul> <li>If ETCO2 has been steady during CPR but then begins to fall, consider changing rescuer</li> <li>As corroborating evidence around decision making- if there has been no ROSC after 20min of full ALS protocol and ETCO2 remains below 1.3kPA, you are highly unlikely to resuscitate that patient</li> <li>If there is a sudden increase in ETCO2- well done, you’ve achieved ROSC (even if you can’t yet feel a pulse- in fact, maybe you needn’t do a pulse check if you’ve got ETCO2)</li> <li>Optimise ventilation post ROSC as you are now dealing with a head-injured patient.</li> </ul> In the critically ill patient: <ul> <li>If I can only have one monitor on an entrapped patient, I’d pick capnography</li> <li>You will learn more quickly than any other method when your patient is deteriorating- e.g in blood loss, ETC02 will gradually fall. In the head injured patient who’s coning, you’ll see apnoeas and gradually rising ETCO2. In the heart failure patient who’s about to arrest, you’ll see their ETCO2 fall precipitously almost before anything else. In the comatose patient, you’ll be able to see that their airway is obstructed on the capnography a full 30 to 60s before their sats drop (by which point you’re already a long way down the oxygen dissociation curve).</li> <li>You can also see when your treatment is working- if you give a patient in septic shock some fluid and improve their CO, you’ll see a rise in ETC02</li> <li>You can confirm adequacy of respiratory function in the fitting or post-ictal patient when all other methods fail</li> </ul> PITFALLS Device failure- lines blocking, batteries running out, pump failure. Test by blowing Over-interpreting the accuracy of non-invasive capnography <ul> <li>Those lovely graphs showing curare clefts, rebreathing, bronchospasm etc you see on lots of different websites and in textbooks? They are almost all referring to capnography in the intubated and ventilated patient, who has a constant tidal volume.</li> <li>Numbers are often wildly inaccurate in the critically unwell population, and there may be an ET-arterial gradient of 10kPA.</li> <li>What CAN you tell from it? 1. Ventilation is occurring (accurate RR) 2. There is a cardiac output 3. You can interpret trends ie a gradual rise or fall in CO2, in the given clinical context 4. Very low is bad whichever way you look at it</li> </ul> Sometimes a low ETCO2 value is due to hyperventilation (because as we all remember, arterial CO2 concentration is almost linearly related to alveolar minute ventilation) BUT it may be hypoventilation with increased proportion of dead space ventilation compared to alveolar ventilation Not using capnography <ul> <li>The more you use it, the more familiar with various patterns you will become</li> <li>Stick it on everyone –it causes no harm. See what happens when you give a decent dose of morphine: <ul> <li>slows respiratory rate but breaths are normal volume</li> <li>You get reduced alveolar MINUTE ventilation but normal alveolar TIDAL ventilation</li> <li>Therefore what you see at ETCO2 is reasonably representative of arterial concentration because the same number of alveoli are ventilated and have opportunity to equilibrate with the blood CO2</li> <li>This is unlike when a patient is making low tidal volume breaths, because then you’re largely ventilating dead space, and a much smaller number of alveoli are ventilated and thus equilibrium cannot occur between blood and gas</li> </ul> </li> </ul> Demonstration traces:  From: Capnography Outside the Operating Rooms, Anesthes. 2013;118(1):192-201. doi:10.1097/ALN.0b013e318278c8b6 A Prolonged phase II, increased α angle, and steeper phase III suggest bronchospasm or airway obstruction. B Expiratory valve malfunction resulting in elevation of the baseline, and the angle between the alveolar plateau and the downstroke of inspiration is increased from 90°. This is due to rebreathing of expiratory gases from the expiratory limb during inspiration. C Inspiratory valve malfunction resulting in rebreathing of expired gases from inspiratory limb during inspiration (reference 5 for details). D Capnogram with normal phase II but with increased slope of phase III. This capnogram is observed in pregnant subjects under general anesthesia (normal physiologic variant and details in reference 9). E Curare cleft: Patient is attempting to breathe during partial muscle paralysis. Surgical movements on the chest and abdomen can also result in the curare cleft. F Baseline is elevated as a result of carbon dioxide rebreathing. G Esophageal intubation resulting in the gastric washout of residual carbon dioxide and subsequent carbon dioxide will be zero. H  Spontaneously breathing carbon dioxide waveforms where phase III is not well delineated. I  Dual capnogram in one lung transplantation patient. The first peak in phase III is from the transplanted normal lung, whereas the second peak is from the native disease lung. A variation of dual capnogram (steeple sign capnogram – dotted line) is seen if there is a leak around the sidestream sensor port at the monitor. This is because of the dilution of expired PCO2with atmospheric air. J Malignant hyperpyrexia where carbon dioxide is raising gradually with zero baseline suggesting increased carbon dioxide production with carbon dioxide absorption by the soda lime. K Classic ripple effect during the expiratory pause showing cardiogenic oscillations. These occur as a result of to-and-for movement of expired gases at the sensor due to motion of the heartbeat during expiratory pause when respiratory frequency of mechanical ventilation is low. Ripple effect like wave forms also occur when forward flow of fresh gases from a source during expiratory pause intermingles with expiratory gases at the sensor. L  Sudden raise of baseline and the end-tidal PCO2(PETCO2) due to contamination of the sensor with secretions or water vapor. Gradual rise of baseline and PETCO2occurs when soda lime is exhausted. M Intermittent mechanical ventilation (IMV) breaths in the midst of spontaneously breathing patient. A comparison of the height of spontaneous breaths compared to the mechanical breaths is useful to assess spontaneous ventilation during weaning process. N  Cardiopulmonary resuscitation: capnogram showing positive waveforms during each compression suggesting effective cardiac compression generating pulmonary blood. O  Capnogram showing rebreathing during inspiration. This is normal in rebreathing circuits such as Mapleson D or Bain circuit. Useful links:  <a href="https://lifeinthefastlane.com/ccc/capnography-waveform-interpretation/" rel="nofollow" target="_blank">https://lifeinthefastlane.com/ccc/capnography-waveform-interpretation/</a> <a href="http://www.capnography.com/new/index.php?option=com_content&amp;view=article&amp;id=131&amp;Itemid=993" rel="nofollow" target="_blank">http://www.capnography.com/new/index.php?option=com_content&amp;view=article&amp;id=131&amp;Itemid=993</a>

Episode 20: End Tidal Carbon Dioxide

https://phemcast.files.wordpress.com/2019/03/ketfinal.mp3      Huge thanks to the team at World Extreme Medicine and WEM Cast for sharing the interview with Richard Harris.       Dosing These are a guide only, each patient will need a bespoke approach depending on their pre-existing condition, degree of cardiovascular compromise, conscious level and drugs already administered. Clearly you also need to remain within your scope of practice and the guidelines for your organisation.  For analgesia (IV/IO): 0.1 – 0.5mg/kg For analgesia (IN): 3mg/kg For sedation (IV/IO): 1mg/kg For sedation (IM): 4-5mg/kg For anaesthesia (IV): 1-2mg/kg  Click here for an example of how ketamine can affect patients. Know the concentration you carry!      Click here for an example of what can occur if the incorrect concentration of ketamine is administered. References  The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for the Relief of Moderate to Severe Pain in Children With Limb Injuries. YMEM. American College of Emergency Physicians; 2015 Mar 1;65(3):248–254.e1. McQueen C, Crombie N, Cormack S, Wheaton S. Prehospital use of ketamine for analgesia and procedural sedation by critical care paramedics in the UK: a note of caution? Emergency Medicine Journal. 2014 Dec;31(12):1029. Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, et al. Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomised controlled trial. Emergency Medicine Journal. 2014 Oct;31(10):840–3. Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012 Jun 1;59(6):504–12.e1–2. Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, et al. Morphine and Ketamine Is Superior to Morphine Alone for Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial. Ann Emerg Med. 2012 Jan 11. Bredmose PP, Lockey DJ, Grier G, Watts B, Davies G. Pre-hospital use of ketamine for analgesia and procedural sedation. Emerg Med J. 2009;26(1):62–4. Howes MC. Ketamine for paediatric sedation/analgesia in the emergency department. Emerg Med J. 2004 May 1;21(3):275–80. Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351–4. Gunning M, Perkins Z, Quinn T. Trench entrapment: is ketamine safe to use for sedation in head injury? Emerg Med J. 2007 Nov 1;24(11):794–5. McGlone RG, Howes MC, Joshi M. The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emerg Med J. 2004 May 1;21(3):290–5. Roback MG, Wathen JE, MacKenzie T, Bajaj L. A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med. 2006 Nov 1;48(5):605–12. Newton A, Fitton L. Intravenous ketamine for adult procedural sedation in the emergency department: a prospective cohort study. Emerg Med J. 2008 Aug 1;25(8):498–501. Chang LC. Raty SR. Ortiz J. Bailard NS. Mathew SJ. The Emerging Use of Ketamine for Anesthesia and Sedation in Traumatic Brain Injuries. CNS Neuroscience &amp; Therapeutics. 2013; 19: 390–395 Morris C. Perris A. Klein J. Mahoney P. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia. 2009; 64(5): 532-539. 

<a href="https://phemcast.files.wordpress.com/2019/03/ketfinal.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2019/03/ketfinal.mp3</a> Huge thanks to the team at <a href="https://worldextrememedicine.com" rel="nofollow" target="_blank">World Extreme Medicine</a> and <a href="https://wemcast.podbean.com" rel="nofollow" target="_blank">WEM Cast</a> for sharing the interview with Richard Harris. <h4>Dosing</h4> These are a guide only, each patient will need a bespoke approach depending on their pre-existing condition, degree of cardiovascular compromise, conscious level and drugs already administered. Clearly you also need to remain within your scope of practice and the guidelines for your organisation. <ul> <li>For analgesia (IV/IO): 0.1 – 0.5mg/kg</li> <li>For analgesia (IN): 3mg/kg</li> <li>For sedation (IV/IO): 1mg/kg</li> <li>For sedation (IM): 4-5mg/kg</li> <li>For anaesthesia (IV): 1-2mg/kg</li> </ul> Click <a href="https://www.youtube.com/watch?v=htApRMWDueg" rel="nofollow" target="_blank">here</a> for an example of how ketamine can affect patients. Know the concentration you carry! <a href="https://phemcast.co.uk/2019/03/03/episode-32-ketamine/ketamine-10mg-per-ml-v2/" rel="nofollow" target="_blank"></a> <a href="https://phemcast.co.uk/2019/03/03/episode-32-ketamine/ketamine-50mg-per-ml/" rel="nofollow" target="_blank"></a> <a href="https://phemcast.co.uk/2019/03/03/episode-32-ketamine/ketamine-100mg-per-ml/" rel="nofollow" target="_blank"></a> Click <a href="https://www.youtube.com/watch?v=IEIaegVWnmA" rel="nofollow" target="_blank">here</a> for an example of what can occur if the incorrect concentration of ketamine is administered. <h4>References</h4> <ol> <li>The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for the Relief of Moderate to Severe Pain in Children With Limb Injuries. YMEM. American College of Emergency Physicians; 2015 Mar 1;65(3):248–254.e1.</li> <li>McQueen C, Crombie N, Cormack S, Wheaton S. Prehospital use of ketamine for analgesia and procedural sedation by critical care paramedics in the UK: a note of caution? Emergency Medicine Journal. 2014 Dec;31(12):1029.</li> <li>Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, et al. Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomised controlled trial. Emergency Medicine Journal. 2014 Oct;31(10):840–3.</li> <li>Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012 Jun 1;59(6):504–12.e1–2.</li> <li>Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, et al. Morphine and Ketamine Is Superior to Morphine Alone for Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial. Ann Emerg Med. 2012 Jan 11.</li> <li>Bredmose PP, Lockey DJ, Grier G, Watts B, Davies G. Pre-hospital use of ketamine for analgesia and procedural sedation. Emerg Med J. 2009;26(1):62–4.</li> <li>Howes MC. Ketamine for paediatric sedation/analgesia in the emergency department. Emerg Med J. 2004 May 1;21(3):275–80.</li> <li>Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351–4.</li> <li>Gunning M, Perkins Z, Quinn T. Trench entrapment: is ketamine safe to use for sedation in head injury? Emerg Med J. 2007 Nov 1;24(11):794–5.</li> <li>McGlone RG, Howes MC, Joshi M. The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emerg Med J. 2004 May 1;21(3):290–5.</li> <li>Roback MG, Wathen JE, MacKenzie T, Bajaj L. A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med. 2006 Nov 1;48(5):605–12.</li> <li>Newton A, Fitton L. Intravenous ketamine for adult procedural sedation in the emergency department: a prospective cohort study. Emerg Med J. 2008 Aug 1;25(8):498–501.</li> <li><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/cns.12077" rel="nofollow" target="_blank">Chang LC. Raty SR. Ortiz J. Bailard NS. Mathew SJ. The Emerging Use of Ketamine for Anesthesia and Sedation in Traumatic Brain Injuries. CNS Neuroscience &amp; Therapeutics. 2013; 19: 390–395</a></li> <li><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2044.2008.05835.x" rel="nofollow" target="_blank">Morris C. Perris A. Klein J. Mahoney P. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia. 2009; 64(5): 532-539.</a> </li></ol>

Episode 32: Ketamine

To provide a bit of balance following our earlier hyperoxia podcast, this episode we are discussing circumstances when we want to deliver extra oxygen to patients and ways to do this effectively, including an interview with Sydney HEMS Consultant Yash Wilmalasena on apnoeic oxygenation. Hope you find it useful! https://phemcast.files.wordpress.com/2016/03/oxygenation-16032016-15-25.mp3   Some of the stuff we talked about: Optimal patient positioning when managing the airway and assisting ventilation has traditionally been taught as ‘sniffing the morning air’, shown here. But now, learning from bariatric practice we are realising that ramping is better for airway optimisation. In this position the patient’s tragus is lined up with their sternal notch to make the airway as straight as possible. Taken from: http://www.emsworld.com/article/11264318/airway-management-and-ventilation-best-practices A water’s circuit looks like this:  This is an image of the oxygenation dissociation curve mentioned in the podcast. Taken from Weingart &amp; Levitan 2012. Here are some other great resources which demonstrate some of the principles we have discussed: Our Birmingham Emergency Medicine colleagues review the evidence so far for apnoeic oxygenation: http://www.heftemcast.co.uk/apnoeic-oxygenation/ There are some short videos from Scott Weingart demonstrating some of the techniques discussed available here: http://emcrit.org/preoxygenation A well written blog post summarising the key features of a BVM from the Life in the Fast Lane team: http://lifeinthefastlane.com/ccc/bag-mask/ This is a great (and entertaining!) video cast from Emergency Medicine colleagues in the States discussing and demonstrating techniques for optimal bag-valve-mask ventilation. References Wilmalasena Y, Burns B, Reid C, Ware S., Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Annals of Emergency Medicine. 2015; 65(4): 371-376. Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. 2012; 59(3): 165-175. Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Annals of Emergency Medicine. 2014; 65(4): 349-355. Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the Emergency Department. The Journal of Emergency Medicine. 2010; Grant S, Khan F, Keijzers G, Shirran M, Marneros L. Ventilator-assisted preoxygenation: protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator. Emergency Medicine Australasia. 2016: 28(1); 67-72. Von Goedecke A, Wenzel V, Hormann C, Voelckel WG, Wagner-Berger HG, Zecha-Stallinger A, Luger TJ, Keller C. Effects of face mask ventilation in apneic patients with a resuscitation ventilator in comparision with a bag-valve-mask. Journal of Emergency Medicine. 2006: 30(1); 63-67. Semier MW, Janz DR, Lentz RJ, Matthews DT, Norman BC, Assad TR, Keriwala RD, Ferrell BA, Noto MJ, McKown AC, Kocurek EG, Warren MA, Huerta LE, Rice TW. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. American Journal of Respiratory Critical Care Medicine. 2016; 193(3): 273-280. (FELLOW Trial) How to cite this podcast: Nutbeam T, Bosanko C. Oxygenation. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

To provide a bit of balance following our earlier hyperoxia podcast, this episode we are discussing circumstances when we want to deliver extra oxygen to patients and ways to do this effectively, including an interview with Sydney HEMS Consultant Yash Wilmalasena on apnoeic oxygenation. Hope you find it useful! <a href="https://phemcast.files.wordpress.com/2016/03/oxygenation-16032016-15-25.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2016/03/oxygenation-16032016-15-25.mp3</a> Some of the stuff we talked about: Optimal patient positioning when managing the airway and assisting ventilation has traditionally been taught as ‘sniffing the morning air’, shown here. But now, learning from bariatric practice we are realising that ramping is better for airway optimisation. In this position the patient’s tragus is lined up with their sternal notch to make the airway as straight as possible. Taken from: <a href="http://www.emsworld.com/article/11264318/airway-management-and-ventilation-best-practices" rel="nofollow" target="_blank">http://www.emsworld.com/article/11264318/airway-management-and-ventilation-best-practices</a> A water’s circuit looks like this: This is an image of the oxygenation dissociation curve mentioned in the podcast. Taken from Weingart &amp; Levitan 2012. Here are some other great resources which demonstrate some of the principles we have discussed: Our Birmingham Emergency Medicine colleagues review the evidence so far for apnoeic oxygenation: <a href="http://www.heftemcast.co.uk/apnoeic-oxygenation/" rel="nofollow" target="_blank">http://www.heftemcast.co.uk/apnoeic-oxygenation/</a> There are some short videos from Scott Weingart demonstrating some of the techniques discussed available here: <a href="http://emcrit.org/preoxygenation" rel="nofollow" target="_blank">http://emcrit.org/preoxygenation</a> A well written blog post summarising the key features of a BVM from the Life in the Fast Lane team: <a href="http://lifeinthefastlane.com/ccc/bag-mask/" rel="nofollow" target="_blank">http://lifeinthefastlane.com/ccc/bag-mask/</a> This is a great (and entertaining!) video cast from Emergency Medicine colleagues in the States discussing and demonstrating techniques for optimal bag-valve-mask ventilation. References Wilmalasena Y, Burns B, Reid C, Ware S., Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Annals of Emergency Medicine. 2015; 65(4): 371-376. Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. 2012; 59(3): 165-175. Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Annals of Emergency Medicine. 2014; 65(4): 349-355. Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the Emergency Department. The Journal of Emergency Medicine. 2010; Grant S, Khan F, Keijzers G, Shirran M, Marneros L. Ventilator-assisted preoxygenation: protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator. Emergency Medicine Australasia. 2016: 28(1); 67-72. Von Goedecke A, Wenzel V, Hormann C, Voelckel WG, Wagner-Berger HG, Zecha-Stallinger A, Luger TJ, Keller C. Effects of face mask ventilation in apneic patients with a resuscitation ventilator in comparision with a bag-valve-mask. Journal of Emergency Medicine. 2006: 30(1); 63-67. Semier MW, Janz DR, Lentz RJ, Matthews DT, Norman BC, Assad TR, Keriwala RD, Ferrell BA, Noto MJ, McKown AC, Kocurek EG, Warren MA, Huerta LE, Rice TW. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. American Journal of Respiratory Critical Care Medicine. 2016; 193(3): 273-280. (FELLOW Trial) How to cite this podcast: Nutbeam T, Bosanko C. Oxygenation. PHEMCAST. 2016 [cite Date Accessed]. Available from: <a href="http://www.phemcast.co.uk/" rel="nofollow" target="_blank">http://www.phemcast.co.uk</a>

Episode 6: Oxygenation

https://phemcast.files.wordpress.com/2016/04/ph-sepsis-10042016-08-56.mp3 We hope you enjoyed our sepsis podcast. It is obviously a huge topic and there is lots of information to cover; a couple of other recently released podcasts are available which are produced with the Emergency Medicine community in mind, but will no doubt expand your knowledge.   St Emlyns Induction podcast on Sepsis. March 2016. A great summary of what to do when a patient with suspected sepsis first arrives in the ED. And from our buddies at HEFT EM CAST: http://www.heftemcast.co.uk/sepsis-in-the-ed/ A bit more detail covering some of the research in an easy to understand way. It particularly discussed the original Rivers trial which we mention in the podcast. It’s worth remembering that sepsis is a spectrum of disease when assessing patients.  It is worth noting, that with “Sepsis 3” many of these terms will become out-of-date – but validation work is required… The Rivers’ paper can be accessed here: http://www.nejm.org/doi/full/10.1056/nejmoa010307 It was a single centre study which compared standard care with protocolised resuscitation packaged together as early goal-directed therapy (EGDT). This is what the study did:  As you will see the trial was relatively small – with only 263 patients being recruited into the trial. What was impressive, and changed practice, forming the basis of the Surviving Sepsis Campaign, was the significant reduction in mortality. Patients in the standard care group had a mortality of 46% compared with the treatment group 30%, which was statistically significant (p=0.009). Further large randomized controlled studies to try and demonstrate the same mortality benefit from Rivers-style EGDT have not shown the same results (Process, Arise, PROMISe). Patients in these trials were randomly assigned to one of two groups. The ‘intervention’ group received the new treatment, in this case EGDT, which was being tested. The ‘standard care’ group were looked after according to how the clinician would usually treat a patient with severe sepsis. This was the same principle as in the Rivers trial: the standard care group is the ‘control’ group against which changes in outcome for the ‘intervention’ group are compared. The mortality in both groups in all 3 trials was similar, there was not the significant reduction in mortality seen in the Rivers study. This was probably because, as we say in the podcast, ‘standard’ care for sepsis has improved considerably in the intervening years. The control group received many similar treatments as the ‘intervention’ group (just not full protocolised EGDT) highlighting that with good sepsis care (fluid resuscitation, close monitoring, early appropriate antibiotic administration), mortality can be reduced. Red flag sepsis is a way of identifying those patients with sepsis who are high risk  and who warrant immediate treatment:  Have a look at the UK Sepsis Trust website: http://sepsistrust.org. There are toolkits available to download, including one specifically written for the prehospital environment with the College of Paramedics, which summarises the recognition and management of sepsis.  Link to the Sepsis-3 guideline.  Reviewed (again for the Emergency Medicine community) here. When Tim talks about test characteristics he is referring to the ability of a test to correctly identify the presence or absence of an illness. Some may think that if a test is positive it always means the patient has the illness, or indeed if it is negative it rules out the possibility of that illness but this is not the case with many of the tests we use. Think about ECG as an example, So, where the box is green, the test has given us the correct result for the patient. But, where the box is red the test has given us the incorrect result: you will all be able to think about patients in whom the ECG was normal, but the patient turned out to have had an MI, or when the ECG showed an MI but the patient turned out not to have had one. These tables are used when assessing the usefulness of a test (or it’s sensitivity and specificity), and, when researching how useful tests are we need the majority of patients to fall into the green boxes. We will put together a podcast on test characteristics over the next couple of months, which will explain this in more detail. An amazing podcast on the subject can be found at SMART EM: SMART Testing: Back to Basics As always, any feedback, comments etc. – please let us know on the blog below!  Herlitz J, ng AB, m BW-S, Axelsson C, Bremer A, Hagiwara M, et al. Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care. Scand J Trauma Resusc Emerg Med. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine; 2012 Jun 27;20(1):1–1. Studnek JR, Artho MR, Garner CL, Jones AE. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med. 2012 Jan;30(1):51–6. Puskarich MA, Marchick MR, Kline JA, Steuerwald MT, Jones AE. One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. Crit Care. 2009;13(5):R167. Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe Sepsis in Pre-Hospital Emergency Care. Am J Respir Crit Care Med. 2012 Dec 15;186(12):1264–71. Band RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF. Arriving by Emergency Medical Services Improves Time to Treatment Endpoints for Patients With Severe Sepsis or Septic Shock. Academic Emergency Medicine. 2011 Aug 30;18(9):934–40. Seymour CW, Cooke CR, Heckbert SR, Spertus JA, Callaway CW, Martin-Gill C, et al. Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study. 2014 Oct 28;:1–9. Trust US. You Gov Poll – Public Awareness of Sepsis. UK Sepsis Trust; 2014 Nov pp. 1–1. MD GEH, MD RET, MD RS, MD JDL, BS AMB, BS AJS, et al. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Aug 26;:1–31. Amado Alejandro Baez MD MSc MFFF, MD LC. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Oct 17;:1–16. Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med. 2013 Jun;44(6):1116–25. Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department*. Crit Care Med. 2010 Apr;38(4):1045–53. Yealy DM, Huang DT, Delaney A, Knight M, Randolph AG, Daniels R, et al. Recognizing and managing sepsis: what needs to be done? ??? ??? 2015 Apr 24;:1–10. Báez AA, Hanudel P, Perez MT, Giráldez EM, Wilcox SR. Prehospital Sepsis Project (PSP): knowledge and attitudes of United States advanced out-of-hospital care providers. Prehosp Disaster Med. 2013 Apr;28(2):104–6. Harnden A. Parenteral penicillin for children with meningococcal disease before hospital admission: case-control study. BMJ. 2006 Jun 3;332(7553):1295–8. Femling J, Weiss S, Hauswald E. EMS Patients and Walk-In Patients Presenting With Severe Sepsis: Differences in Management and Outcome. South Med J. 2014. Gray A, Ward K, Lees F, Dewar C, Dickie S, McGuffie C, et al. The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments. Emergency Medicine Journal. 2013 Apr 12;30(5):397–401. Seymour CW, Cooke CR, Mikkelsen ME, Hylton J, Rea TD, Goss CH, et al. Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care. 2010 Apr;14(2):145–52. 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. Wang HE, Weaver MD, Shapiro NI, Yealy DM. Opportunities for Emergency Medical Services care of sepsis. Resuscitation. 2010 Feb;81(2):193–7    How to cite this podcast: Nutbeam T, Bosanko C. Sepsis. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

<a href="https://phemcast.files.wordpress.com/2016/04/ph-sepsis-10042016-08-56.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2016/04/ph-sepsis-10042016-08-56.mp3</a> We hope you enjoyed our sepsis podcast. It is obviously a huge topic and there is lots of information to cover; a couple of other recently released podcasts are available which are produced with the Emergency Medicine community in mind, but will no doubt expand your knowledge. <a href="http://ebem.podbean.com/e/induction-podcast-on-sepsis/?token=459a610f7e5d542b87760678682f6143" rel="nofollow" target="_blank">St Emlyns Induction podcast on Sepsis</a>. March 2016. A great summary of what to do when a patient with suspected sepsis first arrives in the ED. And from our buddies at HEFT EM CAST: <a href="http://www.heftemcast.co.uk/sepsis-in-the-ed/" rel="nofollow" target="_blank">http://www.heftemcast.co.uk/sepsis-in-the-ed/</a> A bit more detail covering some of the research in an easy to understand way. It particularly discussed the original Rivers trial which we mention in the podcast. It’s worth remembering that sepsis is a spectrum of disease when assessing patients. It is worth noting, that with “Sepsis 3” many of these terms will become out-of-date – but validation work is required… The Rivers’ paper can be accessed here: <a href="http://www.nejm.org/doi/full/10.1056/nejmoa010307" rel="nofollow" target="_blank">http://www.nejm.org/doi/full/10.1056/nejmoa010307</a> It was a single centre study which compared standard care with protocolised resuscitation packaged together as early goal-directed therapy (EGDT). This is what the study did: As you will see the trial was relatively small – with only 263 patients being recruited into the trial. What was impressive, and changed practice, forming the basis of the Surviving Sepsis Campaign, was the significant reduction in mortality. Patients in the standard care group had a mortality of 46% compared with the treatment group 30%, which was statistically significant (p=0.009). Further large randomized controlled studies to try and demonstrate the same mortality benefit from Rivers-style EGDT have not shown the same results (Process, Arise, PROMISe). Patients in these trials were randomly assigned to one of two groups. The ‘intervention’ group received the new treatment, in this case EGDT, which was being tested. The ‘standard care’ group were looked after according to how the clinician would usually treat a patient with severe sepsis. This was the same principle as in the Rivers trial: the standard care group is the ‘control’ group against which changes in outcome for the ‘intervention’ group are compared. The mortality in both groups in all 3 trials was similar, there was not the significant reduction in mortality seen in the Rivers study. This was probably because, as we say in the podcast, ‘standard’ care for sepsis has improved considerably in the intervening years. The control group received many similar treatments as the ‘intervention’ group (just not full protocolised EGDT) highlighting that with good sepsis care (fluid resuscitation, close monitoring, early appropriate antibiotic administration), mortality can be reduced. Red flag sepsis is a way of identifying those patients with sepsis who are high risk  and who warrant immediate treatment: Have a look at the UK Sepsis Trust website: <a href="http://sepsistrust.org" rel="nofollow" target="_blank">http://sepsistrust.org</a>. There are toolkits available to download, including one specifically written for the prehospital environment with the College of Paramedics, which summarises the recognition and management of sepsis. <a href="http://jama.jamanetwork.com/article.aspx?articleid=2492881" rel="nofollow" target="_blank"> Link to the Sepsis-3 guideline. </a> Reviewed (again for the Emergency Medicine community) <a href="http://stemlynsblog.org/sepsis-16/" rel="nofollow" target="_blank">here</a>. When Tim talks about test characteristics he is referring to the ability of a test to correctly identify the presence or absence of an illness. Some may think that if a test is positive it always means the patient has the illness, or indeed if it is negative it rules out the possibility of that illness but this is not the case with many of the tests we use. Think about ECG as an example, So, where the box is green, the test has given us the correct result for the patient. But, where the box is red the test has given us the incorrect result: you will all be able to think about patients in whom the ECG was normal, but the patient turned out to have had an MI, or when the ECG showed an MI but the patient turned out not to have had one. These tables are used when assessing the usefulness of a test (or it’s sensitivity and specificity), and, when researching how useful tests are we need the majority of patients to fall into the green boxes. We will put together a podcast on test characteristics over the next couple of months, which will explain this in more detail. An amazing podcast on the subject can be found at SMART EM: <a href="https://itunes.apple.com/gb/podcast/smart-em/id512413488?mt=2" rel="nofollow" target="_blank">SMART Testing: Back to Basics</a> As always, any feedback, comments etc. – please let us know on the blog below! <ol> <li>Herlitz J, ng AB, m BW-S, Axelsson C, Bremer A, Hagiwara M, et al. Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care. Scand J Trauma Resusc Emerg Med. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine; 2012 Jun 27;20(1):1–1.</li> <li>Studnek JR, Artho MR, Garner CL, Jones AE. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med. 2012 Jan;30(1):51–6.</li> <li>Puskarich MA, Marchick MR, Kline JA, Steuerwald MT, Jones AE. One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. Crit Care. 2009;13(5):R167.</li> <li>Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe Sepsis in Pre-Hospital Emergency Care. Am J Respir Crit Care Med. 2012 Dec 15;186(12):1264–71.</li> <li>Band RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF. Arriving by Emergency Medical Services Improves Time to Treatment Endpoints for Patients With Severe Sepsis or Septic Shock. Academic Emergency Medicine. 2011 Aug 30;18(9):934–40.</li> <li>Seymour CW, Cooke CR, Heckbert SR, Spertus JA, Callaway CW, Martin-Gill C, et al. Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study. 2014 Oct 28;:1–9.</li> <li>Trust US. You Gov Poll – Public Awareness of Sepsis. UK Sepsis Trust; 2014 Nov pp. 1–1.</li> <li>MD GEH, MD RET, MD RS, MD JDL, BS AMB, BS AJS, et al. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Aug 26;:1–31.</li> <li>Amado Alejandro Baez MD MSc MFFF, MD LC. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Oct 17;:1–16.</li> <li>Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med. 2013 Jun;44(6):1116–25.</li> <li>Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department*. Crit Care Med. 2010 Apr;38(4):1045–53.</li> <li>Yealy DM, Huang DT, Delaney A, Knight M, Randolph AG, Daniels R, et al. Recognizing and managing sepsis: what needs to be done? ??? ??? 2015 Apr 24;:1–10.</li> <li>Báez AA, Hanudel P, Perez MT, Giráldez EM, Wilcox SR. Prehospital Sepsis Project (PSP): knowledge and attitudes of United States advanced out-of-hospital care providers. Prehosp Disaster Med. 2013 Apr;28(2):104–6.</li> <li>Harnden A. Parenteral penicillin for children with meningococcal disease before hospital admission: case-control study. BMJ. 2006 Jun 3;332(7553):1295–8.</li> <li>Femling J, Weiss S, Hauswald E. EMS Patients and Walk-In Patients Presenting With Severe Sepsis: Differences in Management and Outcome. South Med J. 2014.</li> <li>Gray A, Ward K, Lees F, Dewar C, Dickie S, McGuffie C, et al. The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments. Emergency Medicine Journal. 2013 Apr 12;30(5):397–401.</li> <li>Seymour CW, Cooke CR, Mikkelsen ME, Hylton J, Rea TD, Goss CH, et al. Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care. 2010 Apr;14(2):145–52.</li> <li>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.</li> <li>Wang HE, Weaver MD, Shapiro NI, Yealy DM. Opportunities for Emergency Medical Services care of sepsis. Resuscitation. 2010 Feb;81(2):193–7</li> </ol> How to cite this podcast: Nutbeam T, Bosanko C. Sepsis. PHEMCAST. 2016 [cite Date Accessed]. Available from: <a href="http://www.phemcast.co.uk/" rel="nofollow" target="_blank">http://www.phemcast.co.uk</a>

Episode 7: Sepsis

https://phemcast.files.wordpress.com/2017/12/tp-1-fin-11_11_2017-00-08.mp3 Firstly, go and read Simon and Tim Harris’ great 2005 paper on the subject which we reference repeatedly in the podcast. It is available free open access here. A pneumothorax exists when air accumulates in the potential space between the visceral and parietal pleura: From: www.wisdomjobs.com A tension pneumothorax exists when the air in the pleural cavity is under high pressure resulting in compression of the surrounding structures. Simon mentions Rutherford’s diagram in the podcast. This is taken from a 1968 paper examining the progressive pathophysiology of a tension pneumothorax. The graph shows the changes in intrapleural pressure (on the ipsilateral and contralateral sides) in spontaneously breathing goats who had air injected into one side of their chest. We can’t find the full article free/open access anywhere I’m afraid. But this is the reference: THE PATHOPHYSIOLOGY OF PROGRESSIVE, TENSION PNEUMOTHORAX. Rutherford RB, Hurt HH, Brickman RD, Tubb JM. Journal of Trauma and Acute Care Surgery, March 1968,8(2):212-227  The imaging findings of tension pneumothorax might look like this: From: http://www.unboundedmedicine.com  More plain film images are available in this article on the Radiopaedia website. And you can see what a CT scan of a patient with tension pneumothorax looks like in this vimeo shared on the Life in the Fast Lane website. If you want to know about ultrasound findings of pneumothorax, check out this great R.E.B.E.L.EM post. References: Leigh-Smith S, Harris T. Tension pneumothorax—time for a re-think? EMJ. 2005; 22:8-16.  doi.org/10.1136/emj.2003.010421 Roberts DJ, Leigh-Smith S et al. Clinical Presentation of patients with a Tension Pneumothorax – a systematic review. Annals of Surgery. 2015; 261: 1068-78. doi: 10.1097/SLA.0000000000001073

<a href="https://phemcast.files.wordpress.com/2017/12/tp-1-fin-11_11_2017-00-08.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2017/12/tp-1-fin-11_11_2017-00-08.mp3</a> Firstly, go and read Simon and Tim Harris’ great 2005 paper on the subject which we reference repeatedly in the podcast. It is available free open access <a href="http://emj.bmj.com/content/22/1/8" rel="nofollow" target="_blank">here</a>. A pneumothorax exists when air accumulates in the potential space between the visceral and parietal pleura: From: <a href="http://www.wisdomjobs.com" rel="nofollow" target="_blank">www.wisdomjobs.com</a> A tension pneumothorax exists when the air in the pleural cavity is under high pressure resulting in compression of the surrounding structures. Simon mentions Rutherford’s diagram in the podcast. This is taken from a 1968 paper examining the progressive pathophysiology of a tension pneumothorax. The graph shows the changes in intrapleural pressure (on the ipsilateral and contralateral sides) in spontaneously breathing goats who had air injected into one side of their chest. We can’t find the full article free/open access anywhere I’m afraid. But this is the reference: <a href="http://journals.lww.com/jtrauma/Fulltext/1968/03000/THE_PATHOPHYSIOLOGY_OF_PROGRESSIVE,_TENSION.9.aspx?WT.mc_id=EMxALLx20100222xxFRIEND" rel="noreferrer noopener nofollow" target="_blank">THE PATHOPHYSIOLOGY OF PROGRESSIVE, TENSION PNEUMOTHORAX. </a>Rutherford RB, Hurt HH, Brickman RD, Tubb JM. Journal of Trauma and Acute Care Surgery, March 1968,8(2):212-227 The imaging findings of tension pneumothorax might look like this: From: <a href="http://www.unboundedmedicine.com" rel="nofollow" target="_blank">http://www.unboundedmedicine.com</a> More plain film images are available in this article on the <a href="https://radiopaedia.org/articles/tension-pneumothorax" rel="nofollow" target="_blank">Radiopaedia</a> website. And you can see what a CT scan of a patient with tension pneumothorax looks like in this <a href="https://vimeo.com/103700899" rel="nofollow" target="_blank">vimeo</a> shared on the <a href="https://lifeinthefastlane.com/tension-pneumothorax-an-alternative-view/" rel="nofollow" target="_blank">Life in the Fast Lane website</a>. If you want to know about ultrasound findings of pneumothorax, check out this great <a href="http://rebelem.com/ultrasound-detection-pneumothorax/" rel="nofollow" target="_blank">R.E.B.E.L.EM post</a>. References: Leigh-Smith S, Harris T. Tension pneumothorax—time for a re-think? EMJ. 2005; 22:8-16.  <a href="http://doi.org/10.1136/emj.2003.010421" rel="nofollow" target="_blank">doi.org/10.1136/emj.2003.010421</a> Roberts DJ, Leigh-Smith S et al. Clinical Presentation of patients with a Tension Pneumothorax – a systematic review. Annals of Surgery. 2015; 261: 1068-78. doi: 10.1097/SLA.0000000000001073

Episode 24: Tension pneumothorax 1

https://phemcast.files.wordpress.com/2017/01/blood-final-27012017-11-55.mp3   There is the potential for significant controversy in this month’s episode – and we would really appreciate the feedback of the prehospital community on this one. We have held the ‘no clear fluids’ mantra close to our hearts for most of our prehospital careers. We ‘know’ that giving sea water to our patients, and diluting all of blood’s ‘good bits’ can’t be healthy. We believed in permissive hypotension – we were probably wrong. Priorities for the bleeding trauma patient must include:  Minimum time to control of bleeding (tourniquets / haemostatics / knife / interventional radiology) Normothermia Appropriate choice of destination (knife / IR) ? Early correction of hypotension (especially if blunt trauma / associated head injury)  The balances of harms in the context of blunt trauma between the negative effects of infusing saline versus the negative effects of hypotension are unknown and prehospital actions need to be customised to an individual patient and situation. In systems in which a potentially less harmful resuscitation strategy can be delivered sooner – PH systems with packed red cells / fresh frozen plasma / whole blood or freeze dried plasma, then it seems pragmatic to aim for normotension (predicted normal blood pressure) sooner in the patient’s care timeline than we have been e.g. at one hour. In patients with penetrating trauma permissive hypotension may remain useful for longer or at least until a patient can be differentiated and the bleeding controlled. Lots to think about!   References: RePhill Trial Homepage: http://www.birmingham.ac.uk/research/activity/mds/trials/bctu/trials/portfolio-v/Rephill/index.aspx  Smith IM, James RH, Dretzke J, Midwinter MJ. Prehospital Blood Product Resuscitation for Trauma. Shock. 2016 Jul;46(1):3–16. Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients. Powell EK, Hinckley WR, Gottula A, Hart KW, Lindsell CJ, McMullan JT. J Trauma Acute Care Surg. 2016 Sep;81(3):458-62. Penn-Barwell JG, Roberts SA, Midwinter MJ, Bishop JR: Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012. J Trauma Acute Care Surg 78(5):1014–1020, 2015. Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, et al.: Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care 19(1):1–9, 2015. Weaver AE, Eshelby S, Norton J, Lockey DJ: The introduction of on-scene blood transfusion in a civilian physician-led pre-hospital trauma service. Scand J Trauma Resusc Emerg Med 21(Suppl1):S27, 2013. Bodnar D, Rashford S, Williams S, Enraght-Moony E, Parker L, Clarke B: The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells. Emerg Med J 31(2):93–95, 2014.

<a href="https://phemcast.files.wordpress.com/2017/01/blood-final-27012017-11-55.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2017/01/blood-final-27012017-11-55.mp3</a> There is the potential for significant controversy in this month’s episode – and we would really appreciate the feedback of the prehospital community on this one. We have held the ‘no clear fluids’ mantra close to our hearts for most of our prehospital careers. We ‘know’ that giving sea water to our patients, and diluting all of blood’s ‘good bits’ can’t be healthy. We believed in permissive hypotension – we were probably wrong. Priorities for the bleeding trauma patient must include: <ul> <li>Minimum time to control of bleeding (tourniquets / haemostatics / knife / interventional radiology)</li> <li>Normothermia</li> <li>Appropriate choice of destination (knife / IR)</li> <li>? Early correction of hypotension (especially if blunt trauma / associated head injury)</li> </ul> The balances of harms in the context of blunt trauma between the negative effects of infusing saline versus the negative effects of hypotension are unknown and prehospital actions need to be customised to an individual patient and situation. In systems in which a potentially less harmful resuscitation strategy can be delivered sooner – PH systems with packed red cells / fresh frozen plasma / whole blood or freeze dried plasma, then it seems pragmatic to aim for normotension (predicted normal blood pressure) sooner in the patient’s care timeline than we have been e.g. at one hour. In patients with penetrating trauma permissive hypotension may remain useful for longer or at least until a patient can be differentiated and the bleeding controlled. Lots to think about! References: RePhill Trial Homepage: <a href="http://www.birmingham.ac.uk/research/activity/mds/trials/bctu/trials/portfolio-v/Rephill/index.aspx" rel="nofollow" target="_blank">http://www.birmingham.ac.uk/research/activity/mds/trials/bctu/trials/portfolio-v/Rephill/index.aspx</a> <ol> <li>Smith IM, James RH, Dretzke J, Midwinter MJ. Prehospital Blood Product Resuscitation for Trauma. Shock. 2016 Jul;46(1):3–16.</li> <li><a href="https://www.ncbi.nlm.nih.gov/pubmed/27050884" rel="nofollow" target="_blank">Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients.</a> Powell EK, Hinckley WR, Gottula A, Hart KW, Lindsell CJ, McMullan JT. J Trauma Acute Care Surg. 2016 Sep;81(3):458-62.</li> <li>Penn-Barwell JG, Roberts SA, Midwinter MJ, Bishop JR: Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012. J Trauma Acute Care Surg 78(5):1014–1020, 2015.</li> <li>Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, et al.: Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care 19(1):1–9, 2015.</li> <li>Weaver AE, Eshelby S, Norton J, Lockey DJ: The introduction of on-scene blood transfusion in a civilian physician-led pre-hospital trauma service. Scand J Trauma Resusc Emerg Med 21(Suppl1):S27, 2013.</li> <li>Bodnar D, Rashford S, Williams S, Enraght-Moony E, Parker L, Clarke B: The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells. Emerg Med J 31(2):93–95, 2014.</li></ol>

Episode 16: “Blood”

https://phemcast.files.wordpress.com/2016/02/amputation.mp3   Welcome to PHEMCAST episode 5: Amputation One of the things we never want to have to do, but need to be prepared for. Have a listen, consider your kit, your top-cover arrangements, and when and how you may need to get this done. This podcast covers, which patients to consider, how to do it and discussion around consent, capacity and top-cover arrangements. This podcast features interviews with Professor Sir Keith Porter and Caroline Leech, which we hope you will enjoy.   Which patients / scenarios:  An immediate and real risk to the patient’s life due to a scene safety emergency. A deteriorating patient physically trapped by a limb when they will almost certainly die during the time taken to secure extrication A completely mutilated non-survivable limb retaining minimal attachment, which is delaying extrication and evacuation from the scene in a non-immediate life-threatening situation. The patient is dead and their limbs are blocking access to potentially live casualties.    Which kit:  CAT x 2 Scalpel Gigli saw (and spare) Arterial forceps x 4 Tuff Cut scissors Appropriate dressing (e.g. Israeli combat bandage)    Preparation:  Sedation or anaesthesia Brief team Plan next phase    Stages of amputation process:  Apply an effective proximal tourniquet. Amputate as distally as possible. Perform a guillotine amputation. Apply haemostats to large blood vessels. Leave the tourniquet in situ.  (consider IV antibiotics if can be delivered as concurrent activity)   Please contribute to the blog below – specifically around top cover arrangements, decision making and individual competency around this procedure.   References: Porter KM. Prehospital amputation. Emerg Med J. 2010 Dec 1;27(12):940–2. Reid C, Clancy M. Life, limb and sight-saving procedures–the challenge of competence in the face of rarity. Emerg Med J. 2013 Feb 1;30(2):89–90. . Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351– Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. Tourniquet use in combat trauma: UK military experience. J R Army Med Corps. 2007 Dec 1;153(4):310–3. Akporehwe NA, Wilkinson PR, Quibell R, Akporehwe KA. Ketamine: a misunderstood analgesic? BMJ. 2006 Jun 24;332(7556):1466. McNicholas MJ, Robinson SJ, Polyzois I, Dunbar I, Payne AP, Forrest M. ‘Time critical’ rapid amputation using fire service hydraulic cutting equipment. Injury. 2011; 42: 1333-1335.

<a href="https://phemcast.files.wordpress.com/2016/02/amputation.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2016/02/amputation.mp3</a> Welcome to PHEMCAST episode 5: Amputation One of the things we never want to have to do, but need to be prepared for. Have a listen, consider your kit, your top-cover arrangements, and when and how you may need to get this done. This podcast covers, which patients to consider, how to do it and discussion around consent, capacity and top-cover arrangements. This podcast features interviews with Professor Sir Keith Porter and Caroline Leech, which we hope you will enjoy. Which patients / scenarios: <ol> <li>An immediate and real risk to the patient’s life due to a scene safety emergency.</li> <li>A deteriorating patient physically trapped by a limb when they will almost certainly die during the time taken to secure extrication</li> <li>A completely mutilated non-survivable limb retaining minimal attachment, which is delaying extrication and evacuation from the scene in a non-immediate life-threatening situation.</li> <li>The patient is dead and their limbs are blocking access to potentially live casualties.</li> </ol> Which kit: <ul> <li>CAT x 2</li> <li>Scalpel</li> <li>Gigli saw (and spare)</li> <li>Arterial forceps x 4</li> <li>Tuff Cut scissors</li> <li>Appropriate dressing (e.g. Israeli combat bandage)</li> </ul> Preparation: <ul> <li>Sedation or anaesthesia</li> <li>Brief team</li> <li>Plan next phase</li> </ul> Stages of amputation process: <ul> <li>Apply an effective proximal tourniquet.</li> <li>Amputate as distally as possible.</li> <li>Perform a guillotine amputation.</li> <li>Apply haemostats to large blood vessels.</li> <li>Leave the tourniquet in situ.</li> </ul> (consider IV antibiotics if can be delivered as concurrent activity) Please contribute to the blog below – specifically around top cover arrangements, decision making and individual competency around this procedure. References: Porter KM. Prehospital amputation. Emerg Med J. 2010 Dec 1;27(12):940–2. Reid C, Clancy M. Life, limb and sight-saving procedures–the challenge of competence in the face of rarity. Emerg Med J. 2013 Feb 1;30(2):89–90. . Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351– Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. Tourniquet use in combat trauma: UK military experience. J R Army Med Corps. 2007 Dec 1;153(4):310–3. Akporehwe NA, Wilkinson PR, Quibell R, Akporehwe KA. Ketamine: a misunderstood analgesic? BMJ. 2006 Jun 24;332(7556):1466. McNicholas MJ, Robinson SJ, Polyzois I, Dunbar I, Payne AP, Forrest M. ‘Time critical’ rapid amputation using fire service hydraulic cutting equipment. Injury. 2011; 42: 1333-1335.

Episode 5: Amputation

https://phemcast.files.wordpress.com/2015/12/episode-3-hyperoxia.mp3 Hello and welcome to our next episode – we hope you enjoy it. This episode concentrates on hyperoxia – the delivery of lots (often too much) oxygen and the harms it may cause our patients. We both had colds – many apologies for the blocked noses and many sniffs! We hope you find it useful. To follow: Dr Matt Thomas from the Great Western Air Ambulance discussing his groups work around reducing hyperoxia post-rosc. Further reading:   https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/ Cornet AD, Kooter AJ, Peters MJL, Smulders YM. The potential harm of oxygen therapy in medical emergencies. Crit Care. 2013 Apr 11;17(2):313. Rincon F, Kang J, Maltenfort M, Vibbert M, Urtecho J, Athar MK, et al. Association Between Hyperoxia and Mortality After Stroke. Crit Care Med. 2014 Feb;42(2):387–96. Stub D, Smith K, Bernard S, Bray J, Stephenson M, Cameron P, et al. A randomized controlled trial of oxygen therapy inacute myocardial infarction Air Verses Oxygen InmyocarDial infarction study (AVOID Study). American Heart Journal. Mosby, Inc; 2012 Mar 1;163(3):339–345.e1. 3.    Asfar P, Singer M, Radermacher P. Understanding the benefits and harms of oxygen therapy. Intensive Care Med. 2015 Jan 30. Calzia E, Asfar P, Hauser B, Matejovic M, Ballestra C, Radermacher P, et al. Hyperoxia may be beneficial. Crit Care Med. 2010 Oct;38:S559–68. Asfar P, Calzia E, Huber-Lang M, Ignatius A, Radermacher P. Hyperoxia during septic shock–Dr. Jekyll or Mr. Hyde? Shock. 2011 Nov 21;37(1):122–3. Cornet AD, Kooter AJ, Peters MJL, Smulders YM. The potential harm of oxygen therapy in medical emergencies. Crit Care. 2013 Apr 11;17(2):313. Ligtenberg JJM, Stolmeijer R, Broekema JJ, Maaten ter JC, Zijlstra JG. A little less saturation? Crit Care. 2013 Jun 12;17(3):439.    How to cite this podcast: Nutbeam T, Bosanko C. Hyperoxia. PHEMCAST. 2015 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

<a href="https://phemcast.files.wordpress.com/2015/12/episode-3-hyperoxia.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2015/12/episode-3-hyperoxia.mp3</a> Hello and welcome to our next episode – we hope you enjoy it. This episode concentrates on hyperoxia – the delivery of lots (often too much) oxygen and the harms it may cause our patients. We both had colds – many apologies for the blocked noses and many sniffs! We hope you find it useful. To follow: Dr Matt Thomas from the Great Western Air Ambulance discussing his groups work around reducing hyperoxia post-rosc. Further reading: <ol> <li> <a href="https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/" rel="nofollow" target="_blank">https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/</a></li> <li>Cornet AD, Kooter AJ, Peters MJL, Smulders YM. The potential harm of oxygen therapy in medical emergencies. Crit Care. 2013 Apr 11;17(2):313.</li> <li>Rincon F, Kang J, Maltenfort M, Vibbert M, Urtecho J, Athar MK, et al. Association Between Hyperoxia and Mortality After Stroke. Crit Care Med. 2014 Feb;42(2):387–96.</li> <li>Stub D, Smith K, Bernard S, Bray J, Stephenson M, Cameron P, et al. A randomized controlled trial of oxygen therapy inacute myocardial infarction Air Verses Oxygen InmyocarDial infarction study (AVOID Study). American Heart Journal. Mosby, Inc; 2012 Mar 1;163(3):339–345.e1. 3.    Asfar P, Singer M, Radermacher P. Understanding the benefits and harms of oxygen therapy. Intensive Care Med. 2015 Jan 30.</li> <li>Calzia E, Asfar P, Hauser B, Matejovic M, Ballestra C, Radermacher P, et al. Hyperoxia may be beneficial. Crit Care Med. 2010 Oct;38:S559–68.</li> <li>Asfar P, Calzia E, Huber-Lang M, Ignatius A, Radermacher P. Hyperoxia during septic shock–Dr. Jekyll or Mr. Hyde? Shock. 2011 Nov 21;37(1):122–3.</li> <li>Cornet AD, Kooter AJ, Peters MJL, Smulders YM. The potential harm of oxygen therapy in medical emergencies. Crit Care. 2013 Apr 11;17(2):313.</li> <li>Ligtenberg JJM, Stolmeijer R, Broekema JJ, Maaten ter JC, Zijlstra JG. A little less saturation? Crit Care. 2013 Jun 12;17(3):439.</li> </ol> How to cite this podcast: Nutbeam T, Bosanko C. Hyperoxia. PHEMCAST. 2015 [cite Date Accessed]. Available from: <a href="http://www.phemcast.co.uk/" rel="nofollow" target="_blank">http://www.phemcast.co.uk</a>

Episode 3: Hyperoxia

https://phemcast.files.wordpress.com/2016/12/final-thora.mp3   Details of the surgical skills course mentioned in the podcast can be found here: https://wmstc.co.uk/portfolio/phem-ess/ The Sydney HEMS Traumatic Cardiac arrest operating procedure can be viewed on their website, and there are a number of useful references within the document: Policies and Procedures An excellent ‘how to do it’ paper, published in 2005, by the London HEMS team, can be accessed via the link below:  Click to access v022p00022.pdf    Equipment required for resuscitative thoracotomy: Surface anatomy:  Appearance of pericardial clot  A foley catheter being used to fill a cardiac wound – note how easily this could be pulled out.  An open chest with aortic compression  Simulation of resuscitative thoracotomy by London HEMS team. For an entertaining and insightful discussion about the impact of undertaking thoracotomy, listen to Dr John Hinds talk from SMACC 2015. Highly recommended. http://intensivecarenetwork.com/hinds-crack-the-chest-get-crucified/ And for a summary of the evidence and recommendations, have a look at the St Emlyns blog: http://stemlynsblog.org/jc-east-lets-be-blunt-about-ed-thoracotomy/ References  Smith JE, Rikard A, Wise D. Traumatic Cardiac Arrest. Journal of the Royal Society of Medicine 2015. 108(1): 11-16. Wise et al. Emergency thoracotomy: “how to do it”. EMJ; 2005: 22-24. Hunt et al. Emergency thoracotomy in thoracic trauma: a review. Injury; 2006 (37): 1-19. Clay et al. Emergency Department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World Journal of Emergency Surgery; 2006: 1:4. Rhee et al. Survival after Emergency Department thoracotomy: review of published data for last 25 years. J Am Coll Surg; 2000. 190(3): 288-298 ACS Committee on Trauma Working Group. Practice Management guidelines for ED Thoracotomy. J Am Coll Surg. 2001, 193 (3): 303-309. Editorial. When should we stop resuscitative efforts after blunt traumatic arrest. Injury; 2008 (39): 967-969. Joint Position Statement of Nat Assoc EMS Physicians and ACS Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital cardiopulmonary arrest. J Am Coll Surg; 2003 (1): 106-111. Tarney et al.Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study. Resuscitation; 2011: 1194-1197

<a href="https://phemcast.files.wordpress.com/2016/12/final-thora.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2016/12/final-thora.mp3</a> Details of the surgical skills course mentioned in the podcast can be found here: <a href="https://wmstc.co.uk/portfolio/phem-ess/" rel="nofollow" target="_blank">https://wmstc.co.uk/portfolio/phem-ess/</a> The Sydney HEMS Traumatic Cardiac arrest operating procedure can be viewed on their website, and there are a number of useful references within the document: <a href="https://sydneyhems.com/resources/policies-and-procedures/" rel="nofollow" target="_blank">Policies and Procedures</a> An excellent ‘how to do it’ paper, published in 2005, by the London HEMS team, can be accessed via the link below: <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726527/pdf/v022p00022.pdf" rel="noopener noreferrer nofollow" target="_blank">Click to access v022p00022.pdf</a> Equipment required for resuscitative thoracotomy: Surface anatomy: Appearance of pericardial clot A foley catheter being used to fill a cardiac wound – note how easily this could be pulled out. An open chest with aortic compression Simulation of resuscitative thoracotomy by London HEMS team. For an entertaining and insightful discussion about the impact of undertaking thoracotomy, listen to Dr John Hinds talk from SMACC 2015. Highly recommended. <a href="http://intensivecarenetwork.com/hinds-crack-the-chest-get-crucified/" rel="nofollow" target="_blank">http://intensivecarenetwork.com/hinds-crack-the-chest-get-crucified/</a> And for a summary of the evidence and recommendations, have a look at the St Emlyns blog: <a href="http://stemlynsblog.org/jc-east-lets-be-blunt-about-ed-thoracotomy/" rel="nofollow" target="_blank">http://stemlynsblog.org/jc-east-lets-be-blunt-about-ed-thoracotomy/</a> References <ul> <li>Smith JE, Rikard A, Wise D. Traumatic Cardiac Arrest. Journal of the Royal Society of Medicine 2015. 108(1): 11-16.</li> <li>Wise et al. Emergency thoracotomy: “how to do it”. EMJ; 2005: 22-24.</li> <li>Hunt et al. Emergency thoracotomy in thoracic trauma: a review. Injury; 2006 (37): 1-19.</li> <li>Clay et al. Emergency Department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World Journal of Emergency Surgery; 2006: 1:4.</li> <li>Rhee et al. Survival after Emergency Department thoracotomy: review of published data for last 25 years. J Am Coll Surg; 2000. 190(3): 288-298</li> <li>ACS Committee on Trauma Working Group. Practice Management guidelines for ED Thoracotomy. J Am Coll Surg. 2001, 193 (3): 303-309.</li> <li>Editorial. When should we stop resuscitative efforts after blunt traumatic arrest. Injury; 2008 (39): 967-969.</li> <li>Joint Position Statement of Nat Assoc EMS Physicians and ACS Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital cardiopulmonary arrest. J Am Coll Surg; 2003 (1): 106-111.</li> <li>Tarney et al.Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study. Resuscitation; 2011: 1194-1197</li></ul>

Episode 14: Thoracotomy

https://phemcast.files.wordpress.com/2018/01/txa-final.mp3   The paper which we discuss in the interview is available open access here How does tranexamic acid work? Taken from: https://pbrainmd.wordpress.com/2015/10/15/1335/ Critical appraisal aids To understand more about hierachy of evidence and how a systematic review fits into this please have a look at these resources available from the Cochrane group.  http://consumers.cochrane.org/levels-evidence  http://training.cochrane.org/path/grade-approach-evaluating-quality-evidence-pathway The CASP checklist can be used for assessing the quality of a meta-analysis. More TXA research trials Want to know more about the ongoing Crash 3 trial?  Want to know more about the Halt it trial?    References  CRASH-2 (available open access here) The WOMAN Trial (available Open access here) The meta-analysis of topical tranexamic acid which Ian mentions is a Cochrane review, available here.

<a href="https://phemcast.files.wordpress.com/2018/01/txa-final.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2018/01/txa-final.mp3</a> The paper which we discuss in the interview is available open access <a href="https://www.sciencedirect.com/science/article/pii/S0140673617324558" rel="nofollow" target="_blank">here</a> <h4>How does tranexamic acid work?</h4> Taken from: <a href="https://pbrainmd.wordpress.com/2015/10/15/1335/" rel="nofollow" target="_blank">https://pbrainmd.wordpress.com/2015/10/15/1335/</a> <h4>Critical appraisal aids</h4> To understand more about hierachy of evidence and how a systematic review fits into this please have a look at these resources available from the Cochrane group. <a href="http://consumers.cochrane.org/levels-evidence" rel="nofollow" target="_blank">http://consumers.cochrane.org/levels-evidence</a> <a href="http://training.cochrane.org/path/grade-approach-evaluating-quality-evidence-pathway" rel="nofollow" target="_blank">http://training.cochrane.org/path/grade-approach-evaluating-quality-evidence-pathway</a> The <a href="http://www.cebma.org/wp-content/uploads/Critical-Appraisal-Questions-for-a-SR-or-MA.pdf" rel="nofollow" target="_blank">CASP</a> checklist can be used for assessing the quality of a meta-analysis. <h4>More TXA research trials</h4> Want to know more about the ongoing <a href="http://crash3.lshtm.ac.uk/" rel="nofollow" target="_blank">Crash 3 trial</a>? Want to know more about the <a href="http://haltit.lshtm.ac.uk/" rel="nofollow" target="_blank">Halt it trial?</a> <h4>References</h4> <ul> <li>CRASH-2 (available open access <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60835-5/fulltext" rel="nofollow" target="_blank">here</a>)</li> <li>The WOMAN Trial (available Open access <a href="https://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-11-40" rel="nofollow" target="_blank">here</a>)</li> <li>The meta-analysis of topical tranexamic acid which Ian mentions is a Cochrane review, available <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010562/full" rel="nofollow" target="_blank">here</a>.</li></ul>

Episode 26: Tranexamic Acid

https://phemcast.files.wordpress.com/2017/11/io-fin-10-11-2017-22-41.mp3 The various devices which Tony discusses are:       This video shows the rapidity of infusion entering the circulation from a humeral IO. This is the paper mentioned by Tony, which shows the stepwise improvement in mortality amongst combat casualties from military conflict 2003-2012, including the ‘unicorn’ graph:  Anatomy of bones and the humerus related to intraosseus access Long bone anatomy     Humeral anatomy       The surface anatomy of the shoulder  The bony anatomy of the shoulder  Muscular attachments of the shoulder  Blood vessels and nerves around the proximal humerus     A demonstration of the landmarking process for humeral intraosseus insertion is available here. Want to know more about EZ-IO access? The education resources which Tom mentions are available here.

<a href="https://phemcast.files.wordpress.com/2017/11/io-fin-10-11-2017-22-41.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2017/11/io-fin-10-11-2017-22-41.mp3</a> The various devices which Tony discusses are: <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/bone-injection-gun/" rel="nofollow" target="_blank"></a> <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/fast1/" rel="nofollow" target="_blank"></a> <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/ez-io-with-blue-needle/" rel="nofollow" target="_blank"></a> <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/cook-needle/" rel="nofollow" target="_blank"></a> This <a href="https://www.youtube.com/watch?v=oLl4jTON7xU" rel="nofollow" target="_blank">video</a> shows the rapidity of infusion entering the circulation from a humeral IO. This is the <a href="https://www.ncbi.nlm.nih.gov/pubmed/25909424" rel="nofollow" target="_blank">paper</a> mentioned by Tony, which shows the stepwise improvement in mortality amongst combat casualties from military conflict 2003-2012, including the ‘unicorn’ graph: <h4>Anatomy of bones and the humerus related to intraosseus access</h4> Long bone anatomy <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/long-bone-diagram-long-bone/" rel="nofollow" target="_blank"></a> <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/anatomy-of-the-humerus/" rel="nofollow" target="_blank"></a> Humeral anatomy <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/anatomy-of-prox-humerus/" rel="nofollow" target="_blank"></a> <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/anatomy-of-humerus/" rel="nofollow" target="_blank"></a> The surface anatomy of the shoulder The bony anatomy of the shoulder Muscular attachments of the shoulder Blood vessels and nerves around the proximal humerus <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/nerve-and-arterial-anatomy-at-prox-humerus/" rel="nofollow" target="_blank"></a> <a href="https://phemcast.co.uk/2017/11/14/episode-23-intraosseus-access/axillary-nerve-anatomy/" rel="nofollow" target="_blank"></a> A demonstration of the landmarking process for humeral intraosseus insertion is available <a href="https://www.youtube.com/watch?v=-d7DpV7Jx2k&amp;t=19s" rel="nofollow" target="_blank">here</a>. <h4>Want to know more about EZ-IO access?</h4> The education resources which Tom mentions are available <a href="https://www.teleflex.com/en/usa/ezioeducation/index.html" rel="nofollow" target="_blank">here</a>.

Episode 23: Intraosseus access

https://phemcast.files.wordpress.com/2017/06/vent-final.mp3 Many apologies for the delay in the release of this podcast! A second apology is due for the sound quality – it was recorded at a ‘live’ HEMS base – this has led to lots of background noise I am afraid. We have done our best to edit this out / reduce its effect but I’m afraid we are not experts in this area! This podcast is part 2 of this series on the ventilator – and you should be familiar with the first in this series before progressing further! Others have written excellent summaries of the themes of this podcast – please follow the links below:  These from Life in the Fast Lane (LITFL), PEEP and the Open Lung Approach to Ventilation And these from derangedphysiology.com  In summary:  PEEP is important – you need to understand its benefits and potential harms. If the patient is requiring more oxygen than you would expect try increasing the PEEP. You really, really need to know your kit. Know what your ventilator can and can’t do –  know how it works and how its alarms work.

<a href="https://phemcast.files.wordpress.com/2017/06/vent-final.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2017/06/vent-final.mp3</a> Many apologies for the delay in the release of this podcast! A second apology is due for the sound quality – it was recorded at a ‘live’ HEMS base – this has led to lots of background noise I am afraid. We have done our best to edit this out / reduce its effect but I’m afraid we are not experts in this area! This podcast is part 2 of this series on the ventilator – and you should be familiar with the <a href="https://phemcast.co.uk/2016/12/02/episode-13-the-ventilator/" rel="nofollow" target="_blank">first in this series</a> before progressing further! Others have written excellent summaries of the themes of this podcast – please follow the links below: <ul> <li>These from Life in the Fast Lane (LITFL), <a href="https://lifeinthefastlane.com/ccc/positive-end-expiratory-pressure-peep/" rel="nofollow" target="_blank">PEEP</a> and the <a href="https://lifeinthefastlane.com/ccc/open-lung-approach-to-ventilation/" rel="nofollow" target="_blank">Open Lung Approach to Ventilation</a></li> <li>And these from <a href="http://www.derangedphysiology.com/main/core-topics-intensive-care/mechanical-ventilation-0/Chapter%202.1.1/positive-pressure-and-positive-end-expiratory-pressure-peep" rel="nofollow" target="_blank">derangedphysiology.com</a></li> </ul> In summary: <ul> <li>PEEP is important – you need to understand its benefits and potential harms.</li> <li>If the patient is requiring more oxygen than you would expect try increasing the PEEP.</li> <li>You really, really need to know your kit. Know what your ventilator can and can’t do –  know how it works and how its alarms work.</li></ul>

Episode 18: The Ventilator Part 2

https://phemcast.files.wordpress.com/2019/01/stroke_final.mp3   The Danish mnemonic to help remember the elements of a cerebellar neurological examination:  There are lots of Youtube videos to demonstrate these signs, here are a few which I thought were particularly helpful: Disdiadochokinesis Ataxia Nystagmus Intention tremor If you would like to read more, there is a blog post Martin and I wrote here on the subject of dizziness, including some videos demonstrating elements of the HINTS exam, and another one from the St Emlyns team. This is the paper Martin mentions. Want to know more about stroke thrombolysis? Have a listen to this episode from our friends over at The Resus Room.

<a href="https://phemcast.files.wordpress.com/2019/01/stroke_final.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2019/01/stroke_final.mp3</a> The Danish mnemonic to help remember the elements of a cerebellar neurological examination: There are lots of Youtube videos to demonstrate these signs, here are a few which I thought were particularly helpful: <a href="https://www.youtube.com/watch?v=2EZqnmxWyAY" rel="nofollow" target="_blank">Disdiadochokinesis</a> <a href="https://www.youtube.com/watch?v=yhgUOY2ohUE" rel="nofollow" target="_blank">Ataxia</a> <a href="https://www.youtube.com/watch?v=YntJiBCz3pA" rel="nofollow" target="_blank">Nystagmus</a> <a href="https://www.youtube.com/watch?v=mBr1ZZ1dr3E" rel="nofollow" target="_blank">Intention tremor</a> If you would like to read more, there is a blog post Martin and I wrote <a href="https://derriforded.weebly.com/derrifoam-blog/dizziness-vertigo" rel="nofollow" target="_blank">here</a> on the subject of dizziness, including some videos demonstrating elements of the HINTS exam, and <a href="http://www.stemlynsblog.org/dizziness/" rel="nofollow" target="_blank">another one</a> from the St Emlyns team. <a href="https://www.annemergmed.com/article/S0196-0644(17)31795-X/fulltext" rel="nofollow" target="_blank">This</a> is the paper Martin mentions. Want to know more about stroke thrombolysis? Have a listen to <a href="https://theresusroom.co.uk/stroke-thrombolysis/" rel="nofollow" target="_blank">this episode</a> from our friends over at The Resus Room.

Episode 31: Stroke & Dizziness

https://phemcast.files.wordpress.com/2018/04/lost-final.mp3   Cardiac arrest is the end point, it is the symptom, not the diagnosis. The pathophysiological process varies, and this is particularly relevant in trauma vs medical. In medical cardiac arrest, the pathological processes tend to affect the heart’s ability to pump: eg primary cardiac event, chemical/electrolyte abnormality, but full circulation. In trauma the process is generally not primarily due to pump failure, but due to hypovolaemia or obstruction. It might be better to consider traumatic cardiac arrest as a completely different disease eg LOST: Low Output State due to Trauma The 2015 European Resuscitation Council and UK Resuscitation Council Algorithms for Traumatic Cardiac Arrest:       To read the whole ERC guideline on special circumstances cardiac arrest including trauma, click here. Ultrasound during TCA: Cureton et al. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma. 2012; 73: 102-10. The outcomes from different resuscitative interventions in a haemorrhagic shock model in porcine model:  From: Watts et al. Closed chest compressions reduce survival in a model of haemorrhagic-induced traumatic cardiac arrest . EMJ 2017; 34: 860-900. (A866) Impact brain apnoea: Wilson et al. Impact brain apnoea – A forgotten cause of cardiovascular collapse in trauma. Resuscitation. 2016; 105: 52-58. References  Barnard et al. Epidemiology and aetiology of TCA in England… Resuscitation; 110 (2017): 90-94. Russell RJ et al. The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services. Phil Trans R Soc. 2011; 366. Doi: 1098/rstb.2010.0232 Wise et al. Emergency thoracotomy ‘how to do it’. EMJ; 2005: 22-24. Morrison et al. Resuscitative thoracotomy following wartime injury. Jeffcoach DR et al. Use of CPR in hemorrhagic shock, a dog model. Lockey et al. Traumatic cardiac arrest: who are the survivors? Annals of Emergency Medicine; 2006. Grasner et al. Cardiopulmonary resuscitation in traumatic cardiac arrest – there are survivors. Critical Care; 2011. Zwingmann et al. Survival and neurological outcome after OOH TCA in pediatric &amp; adult populations: a systematic review. Critical Care; 2012. Slessor et al. To Be Blunt: are we wasting our time? Emergency Deaprtment Thoracotomy following blunt trauma: a systematic review &amp; meta-analysis. Anneals of EM; 2015: 297-307. Leis CC et sl. TCA: should advanced life support be initiated? J Trauma. 2013; 74: 634-8. Jacobs et al. Effect of adrenaline on survival in out of hospital cardiac arrest: randomised double-blind placebo controlled trial. Resuscitation. 2011; 82: 1138-43. Smith et al. Traumatic Cardiac Arrest. Journal of Royal Society of Medicine. 2015; 108: 11-16. Sperry et al. Early use of vasopressors after injury: caution before constriction. J Trauma. 2008; 64: 9-14/

<a href="https://phemcast.files.wordpress.com/2018/04/lost-final.mp3" rel="nofollow" target="_blank">https://phemcast.files.wordpress.com/2018/04/lost-final.mp3</a> Cardiac arrest is the end point, it is the symptom, not the diagnosis. The pathophysiological process varies, and this is particularly relevant in trauma vs medical. In medical cardiac arrest, the pathological processes tend to affect the heart’s ability to pump: eg primary cardiac event, chemical/electrolyte abnormality, but full circulation. In trauma the process is generally not primarily due to pump failure, but due to hypovolaemia or obstruction. It might be better to consider traumatic cardiac arrest as a completely different disease eg LOST: Low Output State due to Trauma The 2015 European Resuscitation Council and UK Resuscitation Council Algorithms for Traumatic Cardiac Arrest: <a href="https://phemcast.co.uk/2018/04/16/episode-28-lost/2015-erc-tca-algorithm/" rel="nofollow" target="_blank"></a> <a href="https://phemcast.co.uk/2018/04/16/episode-28-lost/resus-uk-tca-algorithm/" rel="nofollow" target="_blank"></a> To read the whole ERC guideline on special circumstances cardiac arrest including trauma, click <a href="https://ercguidelines.elsevierresource.com/european-resuscitation-council-guidelines-resuscitation-2015-section-4-cardiac-arrest-special/fulltext" rel="nofollow" target="_blank">here</a>. Ultrasound during TCA: Cureton et al. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma. 2012; 73: 102-10. The outcomes from different resuscitative interventions in a haemorrhagic shock model in porcine model: From: Watts et al. Closed chest compressions reduce survival in a model of haemorrhagic-induced traumatic cardiac arrest . EMJ 2017; 34: 860-900. (A866) Impact brain apnoea: Wilson et al. Impact brain apnoea – A forgotten cause of cardiovascular collapse in trauma. Resuscitation. 2016; 105: 52-58. <h3>References</h3> <ol> <li>Barnard et al. Epidemiology and aetiology of TCA in England… Resuscitation; 110 (2017): 90-94.</li> <li>Russell RJ et al. The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services. Phil Trans R Soc. 2011; 366. Doi: 1098/rstb.2010.0232</li> <li>Wise et al. Emergency thoracotomy ‘how to do it’. EMJ; 2005: 22-24.</li> <li>Morrison et al. Resuscitative thoracotomy following wartime injury.</li> <li>Jeffcoach DR et al. Use of CPR in hemorrhagic shock, a dog model.</li> <li>Lockey et al. Traumatic cardiac arrest: who are the survivors? Annals of Emergency Medicine; 2006.</li> <li>Grasner et al. Cardiopulmonary resuscitation in traumatic cardiac arrest – there are survivors. Critical Care; 2011.</li> <li>Zwingmann et al. Survival and neurological outcome after OOH TCA in pediatric &amp; adult populations: a systematic review. Critical Care; 2012.</li> <li>Slessor et al. To Be Blunt: are we wasting our time? Emergency Deaprtment Thoracotomy following blunt trauma: a systematic review &amp; meta-analysis. Anneals of EM; 2015: 297-307.</li> <li>Leis CC et sl. TCA: should advanced life support be initiated? J Trauma. 2013; 74: 634-8.</li> <li>Jacobs et al. Effect of adrenaline on survival in out of hospital cardiac arrest: randomised double-blind placebo controlled trial. Resuscitation. 2011; 82: 1138-43.</li> <li>Smith et al. Traumatic Cardiac Arrest. Journal of Royal Society of Medicine. 2015; 108: 11-16.</li> <li>Sperry et al. Early use of vasopressors after injury: caution before constriction. J Trauma. 2008; 64: 9-14/</li></ol>

Episode 28: LOST

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