Trauma: Lessons from the Military. Wing Commander Dr Paul Nealis


 

 

Key points

Stop bleeding!

Tourniquets are great.

Pack bleeding wounds firmly.  A roll of gauze works well. “Haemostatic dressings” eg quik clot, don’t seem to make much difference.  It appears the pack needs to be absorbent probably because they absorb water out of the blood in the wound thereby increasing the concentration of clotting factors.http://emtutorials.com/wp-admin/post-new.php

Don’t get hung up on big IV lines.  The difference in flow rate between a 18 and 16 gauge is not that great.  If the patient is bleeding out that fast they aint going to make it, and sometimes 18s are just easier to get in especially in a shocked patient.

Permissive hypotension: aim for a systolic of 80 (90 if head injury).  Don’t rely on mental status (BP 60 systolic but compensating and still conscious… 60 and compensating  still conscious …. 60 and still conscious … dead).

For massive haemorrhage transfuse and give tranexamic acid early.  For us this may mean sending an “unknown patient” label down to get some O-negative blood from the lab before the patient arrives.  Get FFP thawing ASAP. Get platelets ASAP.

Use ketamine rather than fentanyl in major trauma -> lives saved,  presumably by avoiding the sympatholytic effects of fentanyl

Ketamine appears to reduce the incidence of Post Traumatic Stress Disorder by 60%!  This may be by reducing the patients’ experience of pain and mutilation.

ED teams (in the military ED docs and nurses and military medics) resuscitate the patient, others behind the red line.  When the external bleeding has been stopped and the patient resuscitated, then the anaesthetist and surgeon are invited to take the patient to theatre/operating room

Some of the slides:

Audio only:

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Disaster Medicine. Wing Commander Dr Paul Nealis

Be prepared.

Be prepared for the unexpected, logistical challenges, politics and politicians, strange infections, psychological stress,  Aussie docs not recognising melioidosis and a mysterious man in a Hawaiian shirt … with a small fleet of Black Hawk helicopters.

You need to be flexible, creative and psychologically tough.

Military doctor Paul Nealis discusses disaster medicine in the context of the 2004 Boxing Day tsunami in Sumatra.

 

 

 

Slides

 

Audio only

 

To volunteer:

NZ Medical Assistance Team

Australian Medical Assistance Teams (AUSMAT)

This presentation may not reflect the views of the NZ Ministry of Defence

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Anaesthetising and shocking an 89-year-old

About once a year I get to cardiovert a nonagenarian.  There are a lot of good learning points from a case like this and I used a different anaesthetic from earlier posts (see Salvage Cardioversion of a Surgical Patient and Fast AF)

The case

This one was a sprightly 89-year-old (near enough to a nonagenraian) who had developed chest pain and a rapid palpitation after an afternoon at the beach with family.

She had had a few episodes of AF before, that last about 5 months ago, and she was conveniently on warfarin due to this.  She was very clear that her heart rhythm had been regular for the last several months.  She had a history of hypertension and congestive heart failure but was not on any diuretics.

Her pain had settled and her blood pressure was high normal in ED and she had no signs of failure.   No other precipitatant for her fast AF was found (eg fever, hypovolaemia).

We were debating the pros and cons of wait-and-see vs rate control vs chemical or electrical cardioversion.

Her rate was 160 so I keen to convert or slow.

As this patient was warfarinised the time of onset of AF was less important, for patient with normal coagulation we don’t want to cardiovert if the atrial fibrillation has been going for ore than 72 hours for fear of throwing off a thrombus from the quivering atria.  In these patients we want to rate control rather than chemically (eg procainamide or amiodarone) or electrically cardioverting.

While we debating the options between ourselves and with the patient she developed 9/10 chest pain again so the decision was made for us.

We gave her 50µg (~ 1µg/kg) of fentanyl with no effect on the pain.

It was time for electricity.

The Procedure

We obtained a written request for treatment and anaesthesia (AKA consent) from the patient.  (By the way we were not going to “sedate” this patient.  “Procedural Sedation” is an old lie from when we were trying to pretend we weren’t doing anaesthetics in ED.  We are anaesthetising people – call it anaesthesia)

The patient was given oxygen by nasal prongs and “non-rebreather” mask.  All airway equipment was prepared including having all RSI drugs at the bedside, including a pressor (eg adrenaline and/or phenylephrine), the right size intubating LMA, OPAs, NPAs and a ETT out on the airway trolley (have it there and you won’t need it, and it’s good practice for the team).

Monitoring was prepared including oximetry, BP set to go every 2.5 minutes and ECG.  Unfortunately we don’t use capnography due to cost for short procedural anaesthesia.

The patient was given 20mg of propofol and 20mg of ketamine IV. Also known as ketafol.

 

Ketafol

I had been wary of giving ketamine to a patient with tachycardia but Cliff Reid and others on Twitter have convinced me it won’t make the patient more tachycardic.  The ketamine is a great analgesic, maintains BP and airway reflexes but tends to make people puke and have bad trips.  The propofol is a great anaesthetic, tends to prevent nausea and bad trips but tends to drop BP.

We cranked the nasal prongs up to 10L a minute once she was dozing off.

The defib was set to 150J, maybe could have used less on a skinny old lady, and synchronised.  With one shock (remember to hold the shock button down for a while, it doesn’t fire straight away in synch mode) she was back to sinus rhythm.

The patient breathed spontaneously through out.  Her BP dipped to 88 systolic.  Her saturations stayed at 100%.  She did not remember being shocked.  She did have some vivid but not unpleasant dreams.

It was early evening.  We possibly could have got her home that night but her ECG was a little abnormal when she reverted (ST elevation in V1 and V2, probably just due to incomplete LBBB, but we had no old ECGs to compare with) and her family were understandably a little nervous about taking her home.  She was discharge from ED without incident the next morning.

So we can get away with tiny doses of anaesthetics, especially a combination of propofol and ketamine in the elderly with good results.

Remember the arm brain time is slower in the elderly.  Give it at least a minute before you start thinking about giving another bolus of anaesthetic.

Cautionary tale

Some colleagues of mine in a hospital far, far away, somewhere near the centre of Australia, had an elderly person with conscious VT and they rightly wanted to cardiovert her.  Unfortunately her veins were crap and they could only get a line in her foot.  They gave propofol, then more propofol, then a little bit more propofol and finally she went to sleep.  Then all the propofol finally made it to her heart and brain -> PEA.

They had the good sense to cardiovert her to sinus rhythm and do CPR until the propofol was metabolised and the patient woke up with no adverse effect.

Just remember that it can take a long time for drugs to get from a foot to the target organs, especially in a compromised elderly person.

Alternative anaesthetics

Mean while back in 2014 most junior doctors or paramedics are not allowed to give propofol unsupervised.  I’m sure this will change in time. In the mean time I would give one mg of midazolam, wait a few minutes and see if you needed another milligram.  When the patient is midly sedated give 20mg of ketamine as analgesia.  The combination should give excellent anaesthesia for a cardioversion, the patient will just take a bit longer to wake up from the midazolam than from propofol.

Another anaesthetic option is to use etomidate alone or etomidate and ketamine, though again etomidate usually requires supervision by a senior doctor.  Make sure you give an antiemetic as etomidate makes people puke too.

 

Ketafol image from: http://www.wellsphere.com/healthcare-industry-policy-article/ketofol-is-this-the-8220-game-changer-8221-of-procedural-sedation-analgesia/1917360

 

 

 

 

 

 

 

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Oxy morons. Avoid prescribing oxycodone

It has been interesting moon-lighting at another hospital to see how much oxycodone (common brands names: oxynorm and oxycontin) was being used professionally and recreationally.

I was out with a friend who told me he had been given 1 1/2 oxycontin tabs by an acquaintance a while ago and had been high as a kite for a couple of days.  Interestingly he said there was no “come down”.  Sounds like a very desirable drug of abuse.

In the ED everyone was prescribing oxycodone to everybody, from the ED reg to the ENT reg to the ortho house officer.

“… we are looking at a disaster in the making. We have been complacent about the warnings from the rest of the western world, with harms arising from pharmaceutical opioids overtaking those from heroin. This has reached epic proportions in the United States, with oxycodone particularly over-represented. Pharmaceutical opioids in the United States now kill more people than firearms or road traffic accidents, and more than the combined death rates from heroin and cocaine overdoses. This is shocking and shameful …” Dr Jeremy McMinn* 

Oxycodone is more addictive and more expensive than morphine.

Oxycodone is no safer in renal failure than morphine.

Most people with morphine “allergy” were just given too much  and developed nausea, vomiting, dysphoria or an itchy rash from the histamine release caused by morphine.  It may be worth try a test dose of IV morphine to see if they can tolerate it, check with a senior first.

Generally in ED for analgesia we use paracetamol/acetaminophen and a NSAID such as ibuprofen.  For severe pain we will use a fast acting IV or IN opioid such as fentanyl to control the pain.  Once the pain is controlled if ongoing strong pain relief is required we will move to oral morphine (or IV if unable to take oral).  Oral morphine is available in fast acting and slow release forms.

In our hospital we have made oxycodone only able to be prescribed by order of a consultant, and I’m trying to have oxcodone removed from our ED.

As an aside, at the other hospital, as always, there was a granny who had bounced back into hospital because she had been discharged from the ortho ward on oxycodone, prescribed a bulk forming laxative but no stimulant laxative, and hadn’t crapped for a week and felt rotten.

It’s a shame that the resident who discharged her wasn’t working that weekend.  It would have been a good educational experience for him/her to come down, give the enema and readmit the patient.

This is a problem with all opioids, not just oxycodone.  Always prescribe a stimulant laxative when prescribing more than a few doses of opioids eg something with sennosides in it.  By the way sennosides are Category A (considered safe) in pregnancy.  Shame the resident wasn’t on that weekend.

 

*Dr Jeremy McMinn is a consultant psychiatrist and addiction specialist at Capital & Coast DHB. He is also the Co-Chair of the National Association of Opioid Treatment Providers and the New Zealand Branch Chair of the Australasian Chapter of Addiction Medicine

References:

http://www.bpac.org.nz/BPJ/2014/June/upfront.aspx

http://nzf.org.nz/nzf_882.html?searchterm=sennoside

 

 

 

 

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Pull my finger. Dorsal dislocation of PIP

A young adult male sustained an open dislocation of the PIP for his middle finger while playing rugby.

Pull my finger

Hopefully he wasn’t doing a Hopoate.

195810-john-hopoate

The finger was neurovascularly intact.  The wound was not obviously contaminated.

The finger was anaesthetised using a ring block at the level of the web space and the wound was cleaned.

The clinician puts on gloves to give a better grip.  The proximal phalynx was held in the clinicians non-dominant hand with the clinician’s thumb on the palmer aspect where it can be used to stabilise the distal end of the proximal phalynx.

The clinician then grabs the rest of the finger in her/his dominant hand and pulls and hyperextends the middle phalynx.  The middle phalynx is then flexed reducing the dislocation.

The PIP joint was grossly unstable indicating disruption of the volar plate – the ligament joining the palmar aspect of the proximal phalynx to the palmar aspect of the middle phalynx.  The volar plate prevents hyperextension and dorsal dislocation of the joint.

Volar plate

Where there is a large avulsion fracture, say > 30% of the joint surface talk to hands/ortho about potential fixation of the fragment.

Generally the PIP is splinted with 30˚ of angulation with a zimmer splint (1cm wide malleable aluminium strip with foam on one side).  The middle phalynx does not need to be taped to the splint – so it can flex but not extend past 30˚ of flexion.  This is called a dorsal blocking splint.

dorsal blocking splint

If the joint is not unstable when relocated some advocate simply buddy strapping the finger to one of its neighbour.

The laceration was cleaned and sutured (being careful to avoid the flexor tendons).

Any finger dislocation should be reviewed by a hand therapist at about a week.

Open dislocations should be discussed with hands or ortho who may want to wash the joint.

Audio:

 

Diagrams from: http://www.aafp.org/afp/2006/0301/p810.html

Music: Flume remix of Tennis Court by Lorde

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