EMNerd-The Case of the Anatomic Injury Part II

The total-body CT (typically referred to as the pan-scan) has quickly become a key component in the initial evaluation of trauma patients presenting to the Emergency Department. Despite this, the evidence supporting the benefits of the trauma pan-scan is lacking. Its rise to prominence due more so to riotous indignation than true evidentiary support. This […]

EMCrit by Rory Spiegel.

Non-Invasive Ventilation in the interhospital setting

NIV

The use of interhospital Non-invasive Ventilation (NIV) is controversial

Successful use of NIV requires the clinician to make a careful balance of the benefits of the therapy versus the risk of deterioration and need for intubation.

This is especially important when undertaking interhospital retrieval as a clinical deterioration during transport in a confined space is less than ideal.

NIV

With thanks to Dr Brian Burns (@hawkmoonHEMS) we have just published a study in the Emergency Medicine Journal:

The Open Access Link:

Click Here

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Study Background

  • Non-invasive ventilation (NIV) is an established evidence-based therapy in the management of acute respiratory failure in the ‘hospital’ setting.
  • There is an emerging evidence base for the use of NIV in the urban prehospital setting.
  • There is minimal reporting of the use of NIV in critically unwell patients requiring interhospital transfer.

Oxylog3000small

Study Overview

“An observational study of patients receiving NIV during interhospital retrieval at an Australian Helicopter Emergency Medical Service (GSA-HEMS) over a 14-month period.”

Results Summary

  • 106 cases (3.51% of reported retrieval missions) involved the use of NIV therapy
  • The most common indication for NIV was pneumonia (34.0%)
  • 86/106 patients received a successful trial of NIV therapy prior to transfer
  • 20/106 patients required intubation prior to the transport after they failed a trial of NIV therapy
  • 58/106 patients were transferred sucessfully on NIV
  • 28/106 patients had their NIV removed for transport
    • None of these 86 patients required intubation or died
  • 17/86 patient required intubation within 24 hours at the receiving centre.
  • NIV was successfully used in all available transport platforms including rotary wing
  • Patients receiving NIV were found to have prolonged mission durations

Clinical Pearls

From the study and wider anecdotal experience there appears to be four major factors to consider when using interhospital NIV:

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  • Patient factors

Patient factors such as co-morbidities, mask fit, air travel anxiety and motion sickness should all be considered. 

Successful NIV use is dependent on a trial of tolerability and patient cooperation. Careful patient selection is essential in order to avoid adverse outcomes. 

Selection for NIV use should be based on local protocols and senior advice.

  • Equipment factors

Not all transport ventilators provide adequate and effective NIV.

The patient may have to work harder to trigger an assisted breath than with devices designed to provide NIV as their primary function.

The oxylog 3000+ appears to provide reasonably effective NIV

  • Oxygen consumption

Oxygen flow can be in the range of 9–35 L/min with the Oxylog 3000+. Operation time can be estimated using a calculation:

Operation Time = Medical gas supply (L) / MV+0.5 (L/min)

Mask air leak can cause increased flow and therefore decreased operation time.

A recent small case series of NIV transport showed a mean oxygen consumption of 232.2 L.

  • Aviation considerations

Aviation factors such as transport distance, vehicle space, weight restrictions and patient access should always be considered.

In this study, six patients were transported by rotary wing with ongoing NIV without complication.

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Conclusions

  • NIV appears to be a safe management option in a select number of patients requiring interhospital transfer.
  • None of the patients transported using NIV required intubation during transport or died during the retrieval.
  • This was a “sick” cohort of patients with seventeen patients requiring intubation and mechanical ventilation at the receiving hospital within 24 hours.
  • Judicious patient selection and senior physician supervision are important contributors to patient safety when using NIV for interhospital transfer.

The Sweet Spot – Damian Roland

The Paediatric Emergency Department is a relatively unique area in medicine as the registrar workforce usually comes from one of two backgrounds: Emergency or Paediatrics. Consequently, we strive to have the optimal combination of both specialties – The Sweet Spot.

The two groups come with a very different skillset and approach to medical care. In some cases, the Emergency trainee may not have cared for children previously, or the Paediatric trainee not have worked in the ED since their intern year.

In this edition of the Sweet Spot, we welcome Dr Damian Rolandwhose weekly insights of  “What I Learned This Week” offer some wonderful and profound reflections on aspects of clinical and academic emergency medicine.

Damian Roland

Dr. Roland is also a Consultant and Senior Honorary Lecturer in Paediatric Emergency Medicine at Leicester Hospitals and University. He has an academic interest in Educational evaluation and Scoring Systems for children in urgent and emergency care. He developed the Paediatric Observation Priority Score , an award winning system that assists in illness recognition and safe discharge. He is active on social media and enjoys the debate and networking that it provides.

For Paediatric doctors new to the ED setting:

What are some common stumbling blocks & how can these be avoided/fixed? How does your mindset need to change?

The pace of the Emergency Department can be quite overwhelming to begin with. In my experience the biggest issue for the paediatric registrar who is new to this setting is understanding their responsibility to ALL patients in the department, not just those who appear to be the sickest. Essentially you can’t focus your attention on just one child at the expense of others.

This is a challenging balancing act and often goes against the grain for paediatricians. Once the ABCs are sorted though, if the department is chaotic with high inflow, there are some things that might need to be left for the in-patient team (however frustrating they may find this and you may feel by doing it!)

What are some knowledge deficits that can be ameliorated…

– quickly and easily?

Learn really basic first aid injury treatments (Can you put on a sling? Do you know basic wound dressings? What are the right dressings for different burns etc)

– with concerted study and experience? 

Fracture management can seen confusing at first but is fairly logical. Pattern recognition helps with X-ray diagnosis (i.e need experience) and management will come from a good textbook (or minor injuries DVD by Dr. Ffion Davies) 

The skill/attribute that differentiates an average registrar from an exceptional one is…?

Honesty; I have lost control of the department and this is what I am doing to re-gain it” as opposed to trying to make up something about each patient but not knowing key detail

Reliability; Not just turning up on time but completing tasks set and feeding back when they are done.

Pro-active; Those who start to predict what needs to be done before being asked to do it. A good theatre nurse will have the tool the surgeon needs before she asks for it. A good register will have started morning handover/reviewing patients and not just wait for the consultant to arrive.

Approachability; Juniors trust you for advice. You are good fun to work with but generate an ethos where people will work hard and not get distracted from urgent tasks in hand.

What is the most under-used feature in the history/examination/investigation?

History

  • “You have told me about the fever, cough etc. But what is it that the parents are MOST concerned about?”

Examination

  • Tibial torsion (flex the knee and hold here while holding the foot with your other hand – twist gently at the foot so slightly twisting the tibia) and axial load (flex the knee and apply pressure from the foot while pushing down gently on the knee – therefore putting pressure through the tibia) for tibial fractures.
  • A proper abdominal examination which involves distraction.

Investigation

  • Observation

Observation is an investigation

What is the most over-used feature in the history/examination/investigation?

  • FBC
  • Respiratory Rate (this is counter to popular teaching but often find the RR alone in asthmatics is used as an indicator for readiness for transfer/discharge Children with moderate/severe asthma will have a raised RR by definition. It is the trajectory of work of breathing that is important not isolated clinical features)

How is the communication different…

… with parents?

Clearly you can not be rude, abrupt or dismissive with parents. However you do need to find ways of maxising information transfer (both ways i.e parent to you and you to parent) in short time periods. You can’t spend 30 mins on an individual consultation as you will lose departmental oversight. If you are pulled into a long discussion you must let someone else know.

… with nursing colleagues?

ED nurses are brilliant but can be abrupt. Paediatricians can find being told what to do a little unsettling. Gain trust by being humble and don’t lose it by being arrogant. 

A strength that this group might be surprised they have is…?

Leadership skills in an emergency. A good resuscitation is not the sole preserve of ED and ICU staff. My experience is that paediatric registrars can really find and hone their skills when placed in (safe) learning environments. 

My three top tips for this group:

I think I have covered most things above but if there is one thing to take away from an ED attachment it is to understand why ED do what they do. As a paediatrician I understand why there can be frustation about referrals or decisions made about patients in the ED. I do my best to mitigate these and teach others about them as well. My ask would be to do the same in reverse. You will receive what you believe to be poor quality referrals in the future – use your ED attachment to understand why this may be and help ED staff improve them and your local staff to be less disparaging. This can only be for the benefit of patients. 

The most important piece of advice for Paeds Reg new to ED is:

You are the eyes and ears of the ED. You need constant surveillance of all patients not just the next patient in the queue.