A session blog from Day 1 of State of the Art, London December 2015. See the full list.
Blogger Jack Wong
Learning from pre-hospital care
Back to the past
- Contrast to 25 years ago from personal experience – Limited understanding and guidance at the scene of RTA
- Development of pre-hospital care overtime with sub-specialty training in emergency medicine
Clinical Issue – Same principles – different methods
- Safety first
- Situational awareness
- Haemorrhage control: simple things first in trauma – direct pressure / tourniquet / haemostatic agents
- Coagulopathy related to hypothermia and shock
- Keep it simple!!
- Optimise O2 – Agree bail out / Safe Apneoa time during airway management
- Shared mental model / Combat breathing / Team work
- Challenge response check list – DAS 2015 vs Pre-hospital 2015
Ideas / Practice
- Ketamine + Rocuronium + Fentanyl (oral transmucosal) for intubation
- iGel for airway management
- Methonyflurane – The Green Whistle for analgesic
- ICU monitoring, telemedicine, rugged, ultrasound scanner, video-laryngoscope
- Local anaesthetic blocks
- Kit dump
- Ultrasound chest assessment
- Thoracotomy with simple toolkit
- Coordination by team leader
- Stay focus by team member
- Be nice!
- Life isn’t about waiting for the storm to pass. It’s about learning to dance in the rain.
Critical care in the field
- Critical Care starts in the ED
- Whole hospital high fidelity simulation training
- Front loaded expertise – Consultant Crit Care at front line
- Balistic injury in the young
- Blast Injury – Butterfly lungs (haemorrhage in parenchymal) – High risk of bleeding day 1-3
- IED patient
- Limited supplies
- Need for repatriation
It’s not just what you do, but when: Tempo, pace and sepsis
- Case studies – Sepsis gone wrong – Have we done enough?
- 37000 per year mortality in the UK – ICNARC
- Some sepsis survival get on with their daily life with normal function eg. Lily Allen
- Cognitive impairment – 17% of moderate to severe impairment post sepsis
- Blanket approach therapy is needed before we fully understand sepsis and host response.
- Challenge: Grey area patient – Patient who seem well but not get picked up as having sepsis
- Concept Red Flag Sepsis for grey area patient rather than using trial definition
- Reason for delayed presentation = patient not seeking help early hence needing better public awareness and patient education
Fixing the system
- Sepsis Six Bundle
- Checklist helps but it is not everything
- Using F1 pit stop as example of systematic improvement akin to sepsis managemenet bundle: Year 1950 1 minute vs Year 2013 3 seconds
Are you sepsis Savvy?
- Value of POC lactate, CRP, PCT especially for primary care.
- Future aim to reduce mortality.