Clinical 2010

N

NeuralNet

Longterm Registered User
I attended a cardiac resuscitation conference in Edinburgh this week.

A few things of note:

1.The ONLY interventions in cardiac arrest proven to work.
CPR
​
Defibrillation
​
Cooling (going to big in the future)
​
2.High O2 after an arrest may be harmful
3.No evidence any of the cardiac drugs work and some could be even harmful to outcome


4. Ischaemic Pre-Conditioning.

 Professor Douglas Chamberlain came up with this, which I have to admit I have never heard of.

The Principle
It seems cardiac surgeons repeatedly occlude the coronary arteries for a short time, and this makes the myocardium more resistant to myocardial ischaemia.

Quote
Exposure of myocardial tissue to a brief, repeated period of vascular occlusion in order to render the myocardium resistant to the deleterious effects of ISCHEMIA or REPERFUSION. The period of pre-exposure and the number of times the tissue is exposed to ischemia and reperfusion vary, the average being 3 to 5 minutes.

THE MAGIC
If you blow up a BP cuff on an arm and repeatedly cut off the circulation then this has the same effect on the heart. Itseems to help in pre and post cardiac arrest, reducing damage and improving outcome.

Quote
Transient limb ischemia (three 5-minute blood pressure cuff inflations to 200 mm Hg around the upper arm followed by 5 minutes of reperfusion) before arrival in the catheterization laboratory for percutaneous coronary intervention (stenting). Remote ischemic preconditioning was associated with less chest pain and fewer ischemic ECG abnormalities during percutaneous coronary intervention. At 6 months, there were fewer major adverse cardiac events in the remote ischemic preconditioning group compared with control.


Google “pre-conditioning” as see

Remember, none of this is UKRC guidelines, but of interest only

PLEASE KEEP THIS THREAD CLEAR OF RUBBISH

Regards

NN
 
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I'd put a bet on that they'll lose the atropine from the non-shockable side of the algorithm, as you're hinting NeuralNet. That's the way Australia/NZ have gone and also the paeds side of things.

Interestingly, the ischaemic pre-conditioning seems to help other organs, particluarly the liver. I saw one guy recently who had serious cardiogenic shock and we reckoned that this was the only reason that he hadn't necrosed most of his liver.

There's a seminar being run in November in London on the new guidelines and the science around the changes (on of many, no doubt). I'll post the details when I get them.

Thanks for the update, NN
 
Heard that cooling line before but just how to carry that out on a casualty is the big catch. Although the current view is that compressions are enough may i request vents as well!! Great post Neuralnet!!
 
There's a forthcoming one day seminar on Trauma Critical Care in London, if any are interested. The hot topics are


• Trauma Systems
• Spinal cord injury
• Future technologies and developments in non invasive monitoring
• Management of traumatic brain injury
• Lessons from the military practice


ICS Seminar-Trauma Critical Care if anyone is interested.
 
Tracheal Intubation

Journal: Emergency Medical Journal

March 2010, Volume 27, Issue 3

A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008

The committee concluded that paramedic tracheal intubation can no longer be recommended as a mandatory component of paramedic practice, and should not be continued to be practised in its current format.

SAD are suitable alternatives to tracheal intubation.

SAD should be introduced into all ambulance services, and ambulance trusts should ensure that both paramedics and technicians receive adequate initial and ongoing training in the use of these devices.


NN
 
Get your Crichothyrotomy Ballpoint pen ready

EMJ April 2010


Airflow efficacy ballpoint pen tubes: a consideration of bystander Crichothyrotomy

Summary:

The belief that ballpoint pens can be used is partially founded.

Many pens have increase air resistance to produce adequate airflows.

Studies of other commonly found objects may be appropriate.



Just in-case you were thinking about it

NN
 
NN,
I attended a lecture by the Prof a few weeks back. The guy is a legend. I have been told about times he has ben Shoooed away by clinical staff during a resus, thinking he is just an old crackpot. I do hope you enjoyed yourself, the guy is Mr protocol C and i learned a lot from the 3hrs I was there. (Did you get to hear the only defib in the hospital story?).

3L
 
3leadecg said:
NN,
I attended a lecture by the Prof a few weeks back. The guy is a legend. I have been told about times he has ben Shoooed away by clinical staff during a resus, thinking he is just an old crackpot. I do hope you enjoyed yourself, the guy is Mr protocol C and i learned a lot from the 3hrs I was there. (Did you get to hear the only defib in the hospital story?).

3L
Click to expand...

Totally agree, a truely great man.

NN
 
Since introducing the new protocols in London, where a nonwitnessed arrest gets two minutes of CPR before defibrillation our number of out of hospital cardiac arrests that not only get ROSC, but actually survive to discharge has increased dramatically, HEMS are already using theraputic hypothermia on ROSCs that they attend on the car.
 
bigjl said:
Since introducing the new protocols in London, where a nonwitnessed arrest gets two minutes of CPR before defibrillation our number of out of hospital cardiac arrests that not only get ROSC, but actually survive to discharge has increased dramatically, HEMS are already using theraputic hypothermia on ROSCs that they attend on the car.
Click to expand...


Really interesting:

Could you give a summary of your new protocol?
How do you manage the airway?

NN
 
Book review "Tactical Emergency Medicine"

May be of interest

From EJM

By Professor Rob Russell

Tactical emergency medicine offers a wide range of fascinating insights into an area of medicine in America which, though possibly familiar from the film or television screen, has yet to be fully explored in the UK. While medical aspects of military operations are familiar to some, the tactical environment is also taken to include support to the police and other civilian agencies. Tactical Emergency Medical Support (TEMS) is offered as part of some emergency medicine residency programs, with graduates going on to act as the directors of tactical medical programmes. TEMS is a challenging task, and this book clearly brings out the level of organisation and preparation required to achieve a good standard.

The initial part of the book deals with tactical concepts. This includes interesting discussions on putting the TEMS team together, with the advantages and disadvantages of the different medical skill levels and law enforcement status available. Part of this includes the question of arming civilian TEMS providers. The possibility of armed civilian paramedics and prehospital care doctors is definitely alarming.

Medical concepts form the second and largest section of the book. Planning, especially for environmental aspects, is well covered with a single but notable exception. While there is a chapter on preparation for mass gatherings in a later section and triage is given a chapter of its own, there is no section or discussion of how to respond to a major medical incident. Indeed, there seems to be some confusion around the subject. The term ‘mass casualty incident’ is used but not clearly defined. The authors describe a mass casualty incident as being short of a disaster. This is in contrast to the NATO definition of a ‘MASCAL’ as an incident in which the casualties overwhelm the resources available to treat them.

The final four sections of the book are shorter and deal with administration, applied concepts, CBRNE (Chemical, Biological, Radiological, Nuclear, Environmental) and public health and training programmes and scenarios. The chapter on ‘Testifying in a legal proceeding’ is again interesting on two levels. There is a large amount of generic advice which would be useful for any care provider being called to court. However, a lot of the detail is specific to the US legal system. While interesting and explanatory of the plot line of many a TV drama, it does not carry over to the UK. The chapter ‘VIP protection and care’ is similarly fascinating reading but ultimately unlikely to be of practical application to most UK providers.
At times the authors slightly over reach themselves and skim the surface of subjects that, although relevant, would possibly be better left to a different book. The chapter entitled ‘Medical support of the tactical athlete’ is an example of this. Nutrition and sports injuries are both large subjects that can only be touched on in a single chapter. While a chapter on the use of canine support was interesting, another chapter on providing first aid for dogs was superfluous. In particular, at least in this reviewer's opinion, canine CPR and emergency thoracotomy take the concept of medical support too far!

In summary, Tactical emergency medicine is rarely less than an intriguing read, especially as a glimpse into a somewhat different philosophy of prehospital care. As a handbook and introduction, it covers all the bases apart from the on-the-ground response to a major incident. However, any carer planning to practise in this area will find it necessary to read further.



NN
 
The research behind resuscitation can be critiqued through the "Resuscitation" Journal published Monthly by Elsvere.

There is a lot of research going on all the time with regards to resuscitation. Unfortunately, the drug therapy issue has not been able to be effectively researched as ethics committies are reluctant to allow a Randomised Control Trial where one casualty may receive a drug another no drug and another a placaedbo.

The thing for everyone to remember and is stated by neuralnet is that there will be lots of conferences going on at present, but until the resuscitation council (UK), Resuscitation Council (EU) and the American Heart Association publish their new guidelines, then the current guidelines should be followed.

There is very good evidence to back up 2 minutes of CPR prior to Defibrillation as this helps with equilibrium of the ventricles reverting Right Ventricle Diostention and allowing a higher success rate of defibrillation.

having worked for almost 5 years in the Pre-Hospital Emerggency Research Unit (PERU) i have a very strong liking for research around resuscitation. And i must also thank Douglas Chamberlain (Prof) who was the boss and who stopped me taking sugger in my coffee. He is a very knowledgeable gentleman.
 
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Seminar in London on 22nd November 2010 - "What is new in resuscitation"

Blurb:
"The 2010 International Consensus on Cardiopulmonary Resuscitation (CPR) Science and new CPR guidelines will be published in October. This one day seminar will cover all the guideline changes and new CPR science of relevance to healthcare professionals working in critical care medicine. Specific topics will include updates in basic and advanced life support, advances in defibrillation, in-hospital CPR, post cardiac arrest treatment, and outcome after cardiac arrest."

ICS Seminar-What Is New In Resuscitation?

So, more geared towards critical care medicine, but some good speakers

Dr Stephen Brett, London
Dr Charles Deakin, Southampton
Dr Jerry Nolan, Bath
Dr Gavin Perkins, Warwick
Dr Jas Soar, Bristol

and you can get 4 CPD points
 
NeuralNet said:
Journal: Emergency Medical Journal

March 2010, Volume 27, Issue 3

A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008

The committee concluded that paramedic tracheal intubation can no longer be recommended as a mandatory component of paramedic practice, and should not be continued to be practised in its current format.

SAD are suitable alternatives to tracheal intubation.

SAD should be introduced into all ambulance services, and ambulance trusts should ensure that both paramedics and technicians receive adequate initial and ongoing training in the use of these devices.


NN
Click to expand...

Is this affecting current UK paramedic training or practice (local protocols?) LMAs are virtually unknown in many US States, with the National Standard (aside from ET intubation) being the dual lumen combi tube or King LT.
The LMA and its effectiveness is a balance between speed of insertion and the fact it doesn't protect the airway 100% from regurgitation. Although the regurgitation can be reduced by inserting the airway prior to BVM ventilations, thus preventing gastric inflation. [URL="http://emj.bmj.com/content/early/2010/05/31/emj.2009.084343.full.pdf"][url]http://emj.bmj.com/content/early/2010/05/31/emj.2009.084343.full.pdf[/URL][/URL]
 
M4MED....The direct answer to your question is No! As far as im aware UK Ambulance Services still have non-drug assisted intubation as a skill for paramedics.
I put together an entire presentation on this subject for a critical care course. The essential facts are:

The HPC competency framework for UK paramedics states

A working knowledge of the techniques by which the individuals' airways may be secured including endotracheal intubation, insertion of a laryngeal mask airway, and use of a Combitube.’​

　​
1. Yes, their are issues around initial and ongoing training regarding paramedic intubation. Namely, give or take you only need to do 25 tubes in theatres to be signed off as competent. Your intuabting in a well lit controlled environment, Is this realistic? and of course skill fade is also a problem.

However- The College of Paramedics (BPA) in response to the Airway working groups recommendations concluded that there were several flaws relating to the data that supported their recommendations. In addition there is insufficient data to support the introduction of SAD and removal of intubation as a skill for UK paramedics.

I can upload the powerpoint doc if folk think this would be useful, it includes benefit/risk of both Intubation + SAD and a few devices that are currently on the market.

As a footnote, the Airway working group consisted of a whole lot of anaesthetists and other 'experts'....say no more!
 
Sparkymedic, great post and thanks for taking the time to reply, that is exactly what I was looking for. I'd really appreciate it if you could put up the powerpoint please.
Many thanks
M4MED
 
good to see people sharing their knowledge,still think they should be teaching kids about resus in school instead of useless subjects like religious studies,bless you my children :(
 
Dear All,

As from the 1st June 2010, London Ambulance Service have decided that the Supraglottic Airway Device will be the frontline device for airway management for all staff including Paramedics.
Student Paramedics will be taught Intubation but will be expected to gain experience in the use of SAD's whilst on there clinical attachments.
Practicing qualified paramedics may still carry on to intubate but MUST use a Bougie and CO2 monitoring on all cases, which is now available thoughout the service.

The memo also mentions that on average a London Paramedic will only intubate once a year !.

Russ
 
Does that mean SAD are now the new 'Gold Standard' for airway management?.
I guess as LAS are keeping intubation as a skill for both new and existing paramedics their autonomy as clinicians is intact, which is good:)
 
The BPA position paper on this topic is the download section.

M4MED - You'll have to PM me mate if you would like a copy of the presentation i mentioned as i cant seem to upload a powerpoint file!
 
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