Got droperidol?

If you’ve been following blogs such as THE PHARM recently, you’ll probably have seen reference to a chap called Minh le Cong and a drug called ketamine.  Now it’s no secret that many in the prehospital and emergency fields are fond of ketamine – it’s a useful dissociative agent with analgesic properties and can be given IM, IV or IN and used for analgesia, sedation and induction.

Like any drug it requires familiarity with use and titration to effect (although I prefer pre-drawn drugs for RSI, with doses based on IBW and haemodynamics).  I reckon that if I polled a roomful of doctors and asked them to give a dose of ketamine, many would be hesitant having not used it before.  Safe practice mandates familiarity with the drug and appropriate training and monitoring…

Sedation of the Acutely Agitated Patient – a High Risk Procedure

But there is an area of practice that has bugged me for some time, namely the management of an acutely agitated patient. This is a difficult situation – the patient is agitated and may be a risk to self and others. The staffing in a rural hospital is minimal – there is no ‘Code Black’ with security officers –  the team may involve an RN and EN initially, with the on-call doctor off site and taking some time to arrive.

Whilst a calm environment and de-escalation is ideal, sometimes situational urgency mandates use of agents to calm the patient. It’s all well and good if the patient is cooperative and insightful enough to take a dose of oral medication (typically olanzapine antipsychotic +/- oral diazepam)…but if not, they may require a rapid ‘takedown’ with IM or IV medication.

And this is a problem, as the agents commonly recommended by many Health Department protocols STILL include short-acting agents associated with profound respiratory depression.  Alternating cycles of extreme agitation, and administration of short- and long-acting agents can lead to increasing amounts being used and a slide into respiratory collapse.

Looking few various protocols from various sources can be confusing; there’s a wide variety in suggested agents – a quick search in an (unnamed) rural ED showed a variety of available protocols. This is potentially dangerous – in a crisis, the ‘occasional sedatonist’ is likely to seek some form of protocol..and yet may lack familiarity with the agents in use.

The Occasional Sedationist may be reassured by a protocol and lulled into a false sense of confidence in administering drugs without adequate backup

Many protocols seem to encourage polypharmacy, including the use of IV midazolam. Other agents in some of these protocols include ;

ORAL – olanzapine, diazepam, lorazepam, risperidone

IM – olanzapine, haloperidol, clonazepam, midazolam, lorazepam zuclopenthixol

IV – midazolam, diazepam, lorazepam

Even though there have been recent Coroner’s reports on deaths of such patients, a recent report failed to address the issue of safe sedation and instead focus on the need for more rapid transfer. Whilst I am in favour of rapid transport of patients requiring retrieval (not least because of the demands on staff in a resource-limited environment), it’s not the lack of a helicopter that kills these patients – it’s the cycle of agitation-sedation and cardiorespiratory collapse, occasionally exacerbated by restraint that is dangerous. Couple this with a general failure to approach the clinical situation with the same diligence as we would for providing procedural sedation in ED or OT, with it not unheard of for these patients to be nursed in a dark room, supervised by a mental health worker outside the door, with occasional recording of routine obs – scant appreciation of the fact that we are giving administering anaesthetic agents!

Moreover, many of the protocols available in EDs make vague reference to ‘safe environment’ without specifying the need for airway equipment, the use of ETCO2 to monitor nor airway or anaesthetic risk assessment.

Pertinent Coroners reports are here :

David Lee Coroners report

Lyji Vaggs Coroners report

Adam Fernandez Coroners report

 

Droperidol & ketamine – safer than short-acting benzos!

So the Twittersphere was abuzz today with the announcement of the DORM-2 study from Melbourne – a prospective observational study looking at the safety of droperidol for management of these patients.  Older readers may remember concerns from 15 years or so ago regarding droperidol and prolongation of the QTc causing torsade de pointes. The study demonstrated no prolongation of the QTc in the cohort studied, nor any incidences of torsades de pointes (a criticism is that this is relatively rare and would require a larger study). More importantly, the study demonstrated the effectiveness of droperidol in achieving a state of rousable sedation – the goal in this situation.

I think this is important. I use droperidol occasionally in theatre for both sedative and anti-emetic properties; it’s available in most hospital or can be ordered in.  And I think it’s a useful addition to the armamentarium. So much so that I’ve dropped haloperidol from my approach and will run with initial olanzapine where possible; if this fails, IM droperidol titrated to target sedation score.

Of course ketamine DOES also have a role; and I am a particular fan of it’s use for transport of such patients without the need for risking RSI in an unfasted patient with unproved airway (obesity, OSA and COPD are not uncommon in these patients, as are complications of intubation such as aspiration and the need for an ICU bed at the other end). There are protocols available for running ketamine infusions once initial sedation is achieved. I won’t reproduce them (for examples see here and here), but suggest that early consultation and advice from the retrieval service is mandatory…

Safe Sedation Guidelines 2015

Moreover, it helps bolster a rationale approach to sedation of the acutely agitated psychiatric patient – there’s been a bit written on this recently, with release of a Consensus Statement – The Acutely Agitated Patient in a Remote Location as well as a collaborative effort between some emergency and rural clinicians in Australia to guide practice in rural ED or on the wards.

We’ve termed it ‘Surviving Sedation Guidelines’ in recognition of the very real risks that use of these agents can pose.

Listen to a podcast here on the “aikido of emergency sedation” from Minh, Casey and myself

See also posts on Surviving Sedation Guidelines 2015 from the PHARM here, from BroomeDocs here and from KIDocs here

KEY PRINCIPLES OF SURVIVING SEDATION GUIDELINES

Early Goal Directed Sedation (EGDS) – titrated sedation to an objective level using a validated sedation scoring system

Consideration of emergency sedation as a form of procedural sedation/anaesthesia. 

 Minimum standards of patient assessment, resuscitation equipment and clinical monitoring 

De-emphasis on sedative drug choices with more emphasis on continuous clinical assessment and titration to effect

There is a lot more to psych sedation than just bunging in a dose of benzo and walking away…I’d encourage people to read the extensive notes on Minhs blog post regarding this, and consider the use of droperidol, as well as stalwarts olanzapine and diazepam in a stepwise approach titrated to a desired sedation level.

Other than oral diazepam, there is no mention of using short acting benzos such as midazolam…and I think this is a GOOD thing! See what you think….

An updated version of the guidelines is here: SSG2015 v6.0

 

Screen Shot 2015-04-18 at 5.39.00 pm

Screen Shot 2015-04-18 at 5.39.27 pm

Frozen Out

Disappointing news this week from CountryHealth SA – on April Fools Day they announced that an agreement has been reached with the AMA(SA) regarding rural doctor contracts

…but neglected to inform the Rural Doctors Association of SA, who not only represent rural doctors in this State but with whom CHSA were supposedly negotiating.

The current impasse remains – apparently around 50% of doctors have signed contracts with CHSA – which means 50% have not.  Whilst the AMA(SA) appear to endorse the contract, the RDASA do not.  Which makes one wonder with whom CHSA are negotiating….

You can read details from the RDASA webpage media release and letter to members.

Sticking points remain :

(i) a freeze on free-for-service payments for three years

Rural doctors work in private practice and provide oncall services to their local hospital. Freezing fee-for-service payments disadvantages the oncall doctor, who not only forgoes clinic income by attending the hospital, but also faces CPI increases in rent, utilities, staff costs etc.

(ii) EPAS system

The EPAS system has been trialled in some SA hospitals an universally condemned by frontline clinicians. It detracts from patients care and takes significantly longer to complete notes.  Whilst not adverse to using an electronic system of hospital notes, such a system needs to be fit for purpose. Rural doctors are hesitant to endorse this system until it is proven to work effectively.

(iii) Payment for ADMITTED non-Medicare patients

It has always struck me as perverse that the oncall doctor attends the hospital for emergency presentations…but in the case of patients involved in a car crash or seriously unwell from overseas, CHSA reneges on it’s obligations to pay the doctor and somehow insists that such patients are ‘private patients’ – which requires the oncall doctor to bill privately.

This is problematic. Critically ill patients are in no position to provide informed financial consent. Moreover, rural hospitals are public hospitals. The fact that the hospital has no resident doctor and requires an on call contractor to attend, should not negate the need to pay that doctor for attending.

Such work is stressful, involves medicolegal risk and a high degree of emergency medicine skill.  To spend several hours stabilising a sick patient who is then retrieved to the mainland and then not to be paid for it is a slap in the face for rural doctors – especially when everyone else involved in the patient care is paid (nurses, retrieval, tertiary centre doctors).

Of course, such presentations are not uncommon in places such as Kangaroo Island which have high tourist visitation (200,000 tourists to 4500 locals) and where unsealed roads and wildlife are not infrequent causes of car crashes.

Rather than practice “Airway-Breathing-Cash or Credit Card?”, would it be too much to ask CHSA to pay the doctor for attending – and let CHSA admin chase the insurer?

Hopefully CHSA will re-engage with RDASA in negotiation to achieve a workable contract.  Read more in media release and letter to members

Being Expert Enough….

I reckon that I am lucky to be a rural doctor.  It wasn’t an area of medicine to which I was exposed as a student or trainee, and it was only good fortune that lead to my career evolving the way it has. Rural medicine offers all of the “best bits” of medicine without the tedium of being confined to one area as a “partialist”. Whilst much of the work of a rural generalist involves office-based primary care, we also have responsibility for emergency medicine via the local hospital and some of us will participate in elective and emergency procedural skills, such as anaesthesia, obstetrics and surgery.

Swiss Amry Knife

It’s no secret that my interests revolve around trauma, prehospital care and anaesthesia, particularly in the rural context. But I am also interested in palliative care, paediatrics, chronic pain, depression, internal medicine and chronic disease management. As my colleague Casey Parker at BroomeDocs put it, the generalist rural doctor is the “swiss army knife” compared to the partialists “scalpel”. Each has their uses. In the bush, you need the multitool!

And therein is the dilemma for the generalist – how to maintain skills and clinical knowledge across such a  broad array of clinical arenas? Particularly in fast-moving areas such as emergency medicine and critical care, where evidence-base may be rapidly evolving?

The answer, of course, is to use FOAMed – Free Open Access Medical Education – the rapid dissemination of ideas and learning resources, via the tools of Web2.0, to allow distributed, non-hierarchical, asynchronous learning “anywhere – anytime – anyone”.  To my mind, FOAMed is particularly useful for those seeking to develop mastery, rather than teach the basics (for that, it remains textbooks and standard alphabet courses).  The use of Web2.0 (blogs, podcasts, social media such as twitter, Google+, even Facebook) affords rapid sharing of ideas amongst peers – and extends the reach from local colleagues to allow exchange with a global community of like-minded peers and experts….all of whom willing to share ideas and content for free.

This is not a new concept in medicine – as Joe Lex points out, it dates back to Hippocrates “and to teach them this art – if they desire to learn it – without fee and covenant” – this is from the Hippocratic Oath and sharing of knowledge is part of being a clinician.  But for some, the technology and terminology in social media and FOAMed can be a barrier.

This is a shame. FOAMed has been a revelation for my practice.  A few years ago I was “comportable” in my practice. I met the required needs of credentialling (attendance at an entry-level emergency course every triennium), easily accrued my CPD points with my College and felt pretty happy in my practice. But I was not challenged. My interest in trauma and airway management lead to some online resources, at about the same time that Chris Nickson and Mike Cadogan were launching the “lifeinthefastlane” website for emergency physicians and the concept of FOAMed.

Since then I’ve been swept up in a rich learning environment, that has forced me to be challenged, to engage in discussion of concepts in my areas of interest which I would never have been able to do before. It’s made me submit papers for publication, to abandon traditionally safe roles (such as directing on EMST) and join the faculty of more modern courses, to speak at conferences, lead simulation training with paramedic and nursing colleagues and to run airway workshops. I feel connected to a rich information flow, of which I was previously oblivious. And trather than drown in a sea of information overload, apropriate use of filters allows me to receive and engage only in content which interests me.

It’s well worth exploring.

And so leads to the topic of this post – “Being Expert Enough”. I am helping out at the inaugural “Critically Ill Airway” workshop at The Alfred in May – the brainchild of Chris Nickson and anaesthetic/intensive care/emergency medicine colleagues. It should be a good course – Scott Weingart is an external consultant, there will be the likes of Andy Buck from ETMcourse and many others as Faculty.

“This is the challenge and discipline of rural medicine – our specialty is providing care across a broad range without immediate backup”

I will be speaking to a topic dear to my heart – that of the “occasional intubator” – this is pretty much is the default setting for much of the work we do as rural doctors, and requires us to have sufficient expertise to be safe and competent without backup across a large range of competencies.

https://vimeo.com/122820309

To that end, Chris is ‘flipping the classroom’ and including some content prior to the airway course itself. Above is a “teaser” of my lecture and skills station for the CIA course. It should be fun…

Even if airway management in the critically unwell is not your “thing”, do consider exploring FOAMed – I reckon it’s the best paradigm for post-Fellowship learning.  I am glad that both RAGP and ACRRM are allowing such online learning to be counted for CPD, not so much for the need for points – but because with increasing interaction amongst clinicians comes acceleration in learning and knowledge translation…which flows to us being better clinicians and patient benefit.

For us rural generalists, separated by distance and needing to maintain knowledge across a broad array of domains, FOAMed means that deficits in knowledge are no longer an excuse as the weak link in patient care.

LINK – REGISTER HERE for CRITICALLY ILL AIRWAY COURSE, May 7-8 The Alfred, Melbourne

 

 

 

 

 

 

Lessons for management of acute agitation in rural EDs

The South Australian Coroner has just released a report into the sad death of Mr Simos, who died whilst awaiting transfer from a rural ED back to a tertiary centre where he was under a current detention order.

The Coroners report can be accessed here. As with all Coroner’s reports, it makes for salutary reading and in due course I shall add it to the other list of Coroners cases of relevance for rural doctors, over at ruraldoctors.net.

Case summary

The full report can be read online. In essence though, this as a patient whose medical history involved :

  • florid psychosis, being treated as a “detained” patient (level 3 treatment order)
  • obesity
  • COPD
  • obstructive sleep apnoea
  • poorly controlled diabetes
  • hypercholesterolaemia

The patient absconded from an open ward, where he was under psychiatric care in the city. He was subsequently apprehended by police and taken to a rural hospital under existing treatment orders, with a view to being returned to the city psychiatric unit. During the course of this admission he required sedation with olanzapine and lorazepam, and an RFDS transfer was requested. Further episodes of agitation resulted in the administration of midazolam, then respiratory depression requiring assisted ventilation and reversal with flumazenil. Anaesthetic consultation was sought in regard to the pros and cons of intubation; this was deferred as patient was maintaining own airway.  Some 12 hours after admission, transfer had still not eventuated. On advice of liaison psychiatrist, haloperidol and promethazine were administered for further agitation.  A short while afterwards the patient suffered a cardiorespiratory arrest.  The cause of death was undetermined – respiratory depression, agitated delerium and QTc abnormalities were considered and dismissed in Coroners report.

Expert analysis and Coroner’s recommendations

The Coroner made comment of the need for timely transfer of such detained patients from rural facilities to tertiary centres, mindful of the limitations of managing such patients in rural SA.  Existing guidelines were acknowledged.

Expert opinion from the CountryHealthSA lead for emergency medicine was not critical of any particular management decisions. There was opinion given that management of such cases should involve

  • a structured response (rural doctors, hospital, retrieval service, psychiatric expertise
  • a “team leader” responsible for management decisions
  • a “flow chart” to guide delivery of care, including assessment, drug use, physical restraint, transport type and final destination

No criticism was made regarding decision to intubate/not intubate, nor use of medications. No comment was made on use of RASS, ETCO2, staffing, availability of airway expertise nor use of alternatives such as ketamine infusion.

Why does this matter?

Such cases are not uncommon in rural Australia. This sad case highlights several teaching points that I would encourage ALL rural doctors to consider, namely :

  • familiarity with initial “go to” drugs for managing acute agitation
  • assessment of risk of sedation vs exacerbating medical issues (this patient was obese, with OSA and COPD, probable underlying IHD)
  • appropriate monitoring
  • options for transfer or retrieval
  • demands of such acutely unwell patients on clinical staff in rural hospitals and ability to deliver care over a potentially prolonged period of time

The Coroner’s report doesn’t really cover these in much detail – of course in this case appropriate decisions were made and cause of death remains unclear. However I believe that the Coroner’s report could have done more to illustrate appropriate standards of care and to inform other rural clinicians. That it has not done so has prompted this post.

In short, whilst the Coroner has recommended more rapid transfer of such patients to the receiving institution, the Coroner & advising experts have not taken the opportunity to educate rural clinicians on the pertinent issues of safe sedation for this cohort.  This man died because of the medical interventions, not because of a lack of transfer.

Typically such patients are unfasted. They may require large doses of drugs for initial control of agitation and all require meticulous monitoring. My approach to these patients has been guided by knowledge gleaned from the FOAMed world, in particular an excellent discussion from the BroomeDocs blog a few years ago, as well as the ongoing work from Dr Minh le Cong and others on psych sedation in rural Australia.

A safe and structured approach to such patients might involve :

  • early telepsych consultation and teleconference with retrieval service re: transport urgency and available options
  • an agreed plan for both immediate and ongoing restraint
  • if using chemical restraint, to carefully consider risks of these agents in regard to unfasted airway, body habitus, cardiorespiratory effects and underlying concomitant medical conditions (anaesthetic risk)
  • weigh risks of harm to self/others if agitation not adequately controlled

I like to think of such patients as medical emergencies (akin to a combative or resp depressed head injured patient), requiring full monitoring, including

  • 1:1 nursing by an acute care nurse
  • pulse, BP, ECG, RR, SpO2
  • waveform capnography
  • use of the Richmond-Agitation Sedation Score (RASS)
  • immediate access to O2, suction, airway equipment and difficult airway trolley
  • immediate access to skilled anaesthetic assistance
  • at least two IVs
  • consideration of safety for transport including maintenance of own airway vs ETT, and use of safety harness if not intubated

In particular, I would encourage rural doctors to be aware of the PSYCH RISK ASSESSMENT MATRIX (Casey Parker) and the use of KETAMINE for SEDATION and TRANSFER (Minh le Cong et al)

The Consensus Statement can be downloaded from the RFDS website here and I believe should be mandatory across rural SA hospitals.

If you are a rural doctor or nurse or paramedic with responsibility for these patients, please read the Consensus Statement and ensure follow the bulletpoints above.

Not all rural doctors use RASS or ETCO2 monitoring, and often such patients are nursed in a dark environment without immediate access to airway kit, O2, suction.

THINK OF MANAGEMENT OF SUCH PATIENTS AS SIMILAR TO THE MANAGEMENT OF PROCEDURAL SEDATION AS A MINIMUM

That it was not explicity referenced in the Coroner’s report is a missed opportunity – hence this post.

ADDENDUM

Thanks to Minh le Cong who indicates a similar case from Western Australia. There are many valuable lessons from this case, including :

  • the value of regular audit of cases in rural hospitals (something I have never seen seen in CountryHealthSA),
  • the need for good-quality case notes,
  • problems of using Glasgow Coma Score rather than Richmond Agitation Sedation Score
  • early and structured use of titrated aliquots of agents to achieve controlled sedation, rather than repeated cycles of agitation requiring sedation in a small unit with limited staffing,
  • ownership of the management of such cases, in consultation with local and receiving facilities,
  • parallels with the need for expeditious transfer of such patients.

I’ve been pushing for local review of all retrieval cases. Such audit can help drive quality improvement in individual hospitals (not just clinical skills/knowledge, but also equipment needs and of course teamwork/human factors).

Similar audit of anaesthetic ‘near misses’ is practiced in some States (eg: Queensland rural GP-anaesthetists conduct quarterly teleconference audit facilitated by a FANZCA).

Quite why such processes do not exist in South Australia concerns me – indeed, the local lead for rural anaesthesia told me that “there’s no need for audit – we already do this in response to coroner’s cases“.

That’s a classic “wait until the horse has bolted before closing stable door” in my opinion!

Screen Shot 2015-03-18 at 8.17.59 am

 

Both the SAFE PSYCH SEDATION MATRIX and RASS can be downloaded as PDFs

from the RURAL HOSPITAL CHECKLISTS or RERN ACTION CARDS links.

 

Screen Shot 2015-03-18 at 8.18.10 am

 

Consensus Statement – The Acutely Agitated Patient in a remote location can be found at http://healthprofessionals.flyingdoctor.org.au/clinical-resources/?q=cat103%7Cref%7Cformat

smaccUS

A reminder that smaccUS is rapidly approaching – from the orginal smacc2013 held in Sydney, then smaccGOLD on the Gold Coast, in 2015 the world’s most exciting and innocative critical care conference will be held in Chicago.

Screen Shot 2015-03-11 at 6.37.11 pm

Wondering what all the fuss is about?  Have a read of the reviews from previous smacc conferences here

I am putting the final touches to my talk “All alone on Kangaroo Island” – the program looks fantastic….so hurry up and get your registration in, places are limited!

smacc.net.au

Critically Ill Airway

I am just putting final touches to the “Being Expert Enough” session for the forthcoming Critical Ill Airway Course to be held at The Alfred Hospital in Melbourne, May 7-8th 2015.

The course is being convened by that powerhouse of energy, Dr Chris Nickson of LITFLsmacc & RAGE podcast fame. Co-conspirators include external collaborators like Scott Weingart of EMCrit.org, Rick Levitan of airwaycam.com as well as local talent such as Andy Buck of ETMcourse, trauma and prehospital anaesthetist Dr Brent May and the combined brilliance of The Alfred ICU and Anaesthetic faculty.

This promises to be a well-run and fun course, with small group instruction and heaps of scenario-based training and hands on workshops. There are still some places left, so have a look over at the CIA website for more details.

CIA

Importantly this course is open to ANYONE who manages the airway of critically ill patients (doctors and paramedics). Of course I am interested – as a rural clinician I am no stranger to the concept that “critical illness doesn’t respect geography” and want to make sure we are all on the path to expertise, regardless of location. So expect a distillation of FOAMed goodness for occasional intubators whether in ED, ICU, rural or prehospital locations.

Register at the CIA website – first in, best dressed!

CIA Course will Grill Your Corn
Critically Ill Airway Course will Grill Your Corn

See you there!

 

Updated RERN Action Cards

I’ve been playing around with cognitive aids such as checklists and action cards for a couple of years (some are available via the RESOURCES section of this site or RURALDOCTORS.NET. Most of these were designed for handing off to nursing staff in the rural ED, partly to mitigate against the phenomenon of people disappearing off to the ‘big book of infusions’ to look up compatibilities during infrequent care of critical patients. I certainly have no problem with cognitive offloading and use of such aids in a crisis – pilots do it, and I think use of action cards is an under-utilised phenomenon in the emergency medicine.

These checklists and action cards were designed to be used both in printed format or electronically as PDFs (ipads are great for this). However working in the prehospital environment soon teaches that reliance on technology (particularly iPad or iPhone) is not without problems – mobile coverage is dismal in country (and can be at altitude)…and power failures, inadvertent water splashes or hard knocks can trash iShiny devices too easily. Recognising this, MedSTAR issue their staff with a “Vuey Tuey” – basically a 20 page clear pocket folder that fits easily in a flight suit pocket. It contains useful phone numbers, flight times to rural hospitals and other useful information.

OLYMPUS DIGITAL CAMERA
This is the Vuey Tuey issued to MedSTAR doctors to carry in flight suit – it contains useful information for “on the job” and doesnt require batteries
OLYMPUS DIGITAL CAMERA
Extra pages can be added and content modified to preference. So good, I decided to make my own for RERN…

I’ve snaffled a few of these “Vuey Tueys” from eBay (they’re also available from Army Surplus stores online). The 40 page one is not overly thick (about 1cm) and accommodates 80 sheets of paper. The aim was to create a series of action cards useful for rural doctors, particularly members of the South Australian Rural Emergency Responder Network (doctors who respond to prehospital incidents to back up local volunteer crews where no ICP available).

So here’s a series of RERN ACTION CARDS – designed with members of the South Australian rural doctor RERN team in mind  – but the content may be useful for any rural doctor who is looking for a quick pocket reference that can be easily adapted to local use.

The original was created in Pages on OSX, then converted to indivdiual PDFs and merged into one document. I am more than happy to share original files if anyone wants them to modify, or can download the entire PDF here.

One quirk of the “Vuey Tuey” is the page size – 95 x 135mm! So I generally print out two sheets onto A4 and trim up with a paper cutter.

Contents include:

  • principles of prehospital care
  • airway
  • breathing
  • circulation
  • crisis algorithms
  • drug doses

I am a big fan of making content available for all to share – and am happy to add extra sections or modify content if needed.

I should also emphasise that this content is NOT from MedSTAR, but a collation of various tips and FOAMed that I’ve found useful. Interestingly some retrieval services make their content available to share – I remain impressed with the efforts of SydneyHEMS, AucklandHEMS and UK-HEMS in this regard. Indeed, Karel Habig and colleagues gave some useful lectures at the 2014 Rural Medicine Australia conference – it’s refreshing to see such content from prehospital care creeping into rural arenas – and the PROTECTAustralia paradigm is very worthwhile.

Certainly with approx 2/3rds of trauma coming from rural areas, it makes sense to engage with rural clinicians and strive to drive “quality care, out there”

I am no expert, but seems to me that much of critical care is about doing the basics, well – and that whilst some rural doctors embrace the challenge of managing these patients, others are understandably nervous or feel under-prepared. I think this is where FOAMed, delivering asynchronous content, robust clinical governance and standardisation of protocols such as infusions etc can make a difference.

Anyhow, here are the cards. It’s a work in progress. Enjoy!

RERN ACTION CARDS – click to download (NB RERN = Rural Emergency Responder Network)

Feedback and suggestions for additions/alterations welcomed.

They’re not accidents, are they?

It was back in 2001 that I read a piece in the British Medical Journal entitled “BMJ bans accidents” – hardly a new idea (it dates back to at least 1993) – yet we still hear reference to “road traffic accidents” (RTAs) or “motor vehicle accidents” (MVAs).

Words are important; I have been convinced of the BMJ argument for the past decade. I am not alone – others say “if you care, use the term crash“. The premise is simple – use of the term “accident” implies a sense that bad outcomes are due to fate or luck, rather than factors within our control. Indeed use of the term “accident” almost absolves anyone of culpability.

I am currently working in the prehospital environment. Like colleagues, I do not judge my patients – they are invariably critically unwell and my job is simple – to ensure they receive the best possible care with the minimum of delay, working within a well-governed organisation of trained clinical professionals.

However Christmas and New Year are fast approaching, and there is a sense of inevitability; namely that this holiday season will again be marred by tragedy on our roads, often due to drink- or drug-driving.

What would be the best Christmas gift for colleagues and myself this year?

That we did not have to respond to roadside primaries, nor for community members to experience personal tragedy.

With this in mind, I’d recommend the following video – a montage of road safety videos from the TAC in Victoria, Australia (ironically, this stands for Transport Accident Commission)

It is sobering stuff. I remember hearing trauma surgeon Karim Brohi talk at the Australian Trauma Society conference in Melbourne, 2006 – he commented that “it’s better to be the fence at the top of the cliff, rather than the ambulance at the bottom“.

In trauma medicine we tend to get very excited about the sexy things – prehospital REBOA, clamshell thoracotomy, helicopters etc and debate is always heated on chestnuts such as subclavian vs IO access, fluid resuscitation, skill mix of retrieval teams etc.

There is no doubt that the downstream consequences of trauma are horrific.

Instead I wonder if the greatest gains in trauma medicine are actually to be found with the unsexy – with primary prevention (um, that’s the GPs) and with rehabilitation (thats rehab physicians, physiotherapists and other allied health).

We don’t often consider the contributions from primary care and rehabilitation in trauma care – perhaps we should.

Prevention is indeed better than cure. Please, this Christmas – don’t drink or drug-drive.

 

Airway Classics – A Love Supreme?

Many people are eagerly awaiting the release of the new Difficult Airway Society UK (DAS UK) guidelines, in the wake of their recent Annual Scientific Meeting.

Some recommendations are available HERE and include :

  • acceptance of gentle mask ventilation during RSI
  • use of videolaryngoscopy as an option in initial intubation plan
  • apnoeic diffusion oxygenation
  • didactic technique and training for emergency surgical airway

One other recommendation caught my eye – namely to use second generation LMAs

Now the Classic LMA (cLMA) was the brainchild of Archie Brain; it is a wonderful device and has been in commercial use since 1987. It is easy to use and affords the ability to ventilate – although does not protect the airway. Some critics would argue that the LMA has deskilled a generation of anaesthetists, who may use the cLMA for routine cases rather than bag-mask or intubate. I disagree – it is just another tool in the armamentarium.

 

LMA Classic - cLMA
LMA Classic – cLMA

 

However I made a decision a few years ago to switch to the Supreme LMA – a lovely second generation LMA that is a step up form the ‘initial’ second generation LMA (the ProSeal). The Supreme combines an integral bite block with a gastric drainage channel in the tip, unlike the ProSeal.

Supreme LMA - sLMA Note gastric drainage channel at tip of cuff
Supreme LMA – sLMA
Note gastric drainage channel at tip of the LMA bowl (R)

But there is a problem – once in place, it is almost impossible to pass an ETT tube through the Supreme.

Many people will be familiar with the Intubating LMA (iLMA) – the brand most use ins the FastTrach. It’s not a bad device – it allows blind intubation rates of up to 90%, using the LMA as a rescue ventilation device and then as conduit for an ETT.

FastTrach Intubating LMA - iLMA
FastTrach Intubating LMA – iLMA

The large handle on the device is designed to facilitate manoevuring of the iLMA in the oropharynx, ideally allowing the bowl of the LMA to align with the glottic opening and hence allow blind passage of an ETT. There is a great paper from the originator of these maneouvres, Chandy Verghese. A description is available HERE – anyone using the FastTrach should be able to perform the “Chandy Manouevre(s)

I like the FastTrach – it is a good ‘go to’ device for rural and remote doctors as allows both rescue ventilation and possible intubation – no pissing around with fancy fibreoptics or calling for help – none is available in the bush! However there are some problems – it’s expensive and it doesn’t have a gastric drainage channel. Furthermore, one can get into a world of hurt if attempting to remove the iLMA over the ETT per instructions. This might include stripping off the pilot cuff of the ETT or ‘losing the airway’…one should read the infamous ‘exploding scrotum‘ case for a masterclass in airway catastrophe.

So problems with the FastTrach are not uncommon in inexperienced hands – precisely the time when you least want to have an additional problem after failed intubation. My advice? Once in, leave both iLMA and ETT in situ until the patient is either awake or you are somewhere with backup!

Furthermore, the FastTrach has a somewhat hyperacute angle, meaning that even if you have a basic fibreoptic device (such as a malleable FO stylet), this cannot be used to turn blind intubation into fibreoptic intubation via the iLMA conduit.

What we need is a device combining the benefits of a second generation LMA (eg Supreme) with an intubating LMA. Enter the second generation iLMA, the AirQ-II

I first heard of these in 2011 from James duCanto in the States. They’ve also had some coverage from Scott Weingart over at EM-Crit in the past. It’s basically a second generation iLMA which is :

  • cheap
  • useful as a rescue ventilation device ie 2nd generation LMA
  • able to be used as an intubating LMA for blind intubation
  • less acute curvature of the tube will allow passage of both flexible and malleable stylet fibreoptics, for visual intubation
  • integral bite block and gastric drainage channel
The AirQ-II iLMA with separate orogastric tube
The AirQ-II iLMA with separate orogastric tube

 

An elevation bar helps direct ETT tip from bowl of LMA into trachea. The orgastric tube is passed down separate channel adjacent and under the bowl of LMA, into the oesophagus
An elevation bar directs ETT tip from bowl of LMA into trachea. The orogastric tube (left) is passed down separate channel adjacent and behind the bowl of LMA, into the oesophagus

I’ve replaced the FastTrachs with Air-Q IIs in both my RERN prehospital pack and also on our hospital difficult airway trolley. Indeed, for the finance-limited environment of a small rural hospital, the combination of the AIrQ-II along with a fibreoptic device such as a Levitan FPS scope offers a fairly robust option for difficult intubation – drop in an AirQ-II, then wither blindly intubate or use the malleable fibreoptic stylet to pass the tube under direct vision. Then leave the ETT-LMA in site and pop down an orogastric (difficult to do with the FastTrach). James DuCanto writes well on this with a simple guide and Weingart explains how to mould a malleable stylet to conform to the AirQ anatomy.

If you don’t need an intubating LMA, then follow the guidance of DAS2015 and go with a second generation supraglottic device – like the Supreme.

But if you want to allow maximum flexibility including integral intubating-LMA capability, it’s hard to beat the Cook Gas AirQ-II – especially of trying to put together an affordable yet robust difficult airway kit for rural/remote.

DISCLAIMER – I HAVE NO FINANCIAL TIES OR INTERESTS TO THE DEVICES DISCUSSED

RAGE podcast – great FOAMed

I just have to give a shout out to the RAGE PODCAST this week. If you have been living under a rock, the RAGE podcast is a semi-regular “resuscitationists awesome guide to everything” featuring top quality FOAMed contributers who are credible in their field.

“Do not go gentle into that good night

Rage, rage against the dying of the light

Dylan Thomas

This months session is entitle neuroRAGE and deals with all things to do with neurosurgical emergencies. It features Mark Wilson who speaks authentically on experiences as a HEMS physician, neurosurgeon and with some significant anaesthetic experience. I managed to talk with Mark on “Burr holes in the bush” a couple of years ago and since then the idea of prehospital Burr holes has been enthusiastically mooted elsewhere. Is this something that a prehospital service clinician needs to be able to do? Is an extradural the ‘tension pneumothorax of the skull?

Mark gives good talks (if you saw him at smaccGOLD and were impressed, the good news is that he’s back at smaccUS). He’s also prepared to share – he gave a great talk at medSTAR clinical governance day earlier this month and was a major contributor to Sydney HEMS themed neurotrauma session earlier this year – content from the latter is available online. He also runs the AcuteBrain website and is a coninventor of the GoodSAMApp

B1F9Bn4CQAEWB0W

Also on RAGE, Cliff Reid also gives a lovely description of being on the end of both an LP and in the K-hole, reinforcing the need for concomitant benzos and (where possible) a calm, low stimulus environment to avoid emergence phenomena.

I’ve certainly noticed similar tales of spiral ‘helter skelter’ sensations amongst my dissociated patients…to me this emphasises the need to be familiar with ketamine for both induction, dissociation and analgesia – something all trainees should endeavour to gain experience with in their anaesthetic placements or in ED.

Here’s a video of the potential nasty dissociative effects of ketamine – I love the drug, but consider adding some benzo if appropriate

Anyhow – trust me on this – LISTEN TO THE neuroRAGE podcast. It’s a good one!