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NeuralNet

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Emergency Medicine Journal, October 2009; 26:738-740
Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest

Methods: Patients in prehospital traumatic cardiac arrest were identified over a 39-month period from an air ambulance database. The use of thoracostomy or needle decompression was identified together with indications, findings and outcome. Primary outcome was return of cardiac output by arrival at hospital.

Results: 18 of 37 cases underwent chest decompression (17 thoracostomy, 1 needle decompression). Four patients had a return of cardiac output (3 tension pneumothorax, 1 bilateral pneumothorax). Six further cases were positive for intrathoracic injury. In 2 cases the injuries identified were incompatible with life and resuscitation efforts were consequently ceased.

Conclusions: Chest decompression in traumatic cardiac arrest identifies and treats a high proportion of potentially life-ending injuries and should be considered as part of the resuscitation effort of patients in traumatic cardiac arrest. In a proportion of patients, non-survivable injuries are identified which guide resuscitation efforts.

Extracts taken from Discussion:
Given the observed incidence of tension pneumothorax in our cohort of patients, we support the routine practice of bilateral chest decompression by suitably trained paramedic crews as part of the resuscitation attempts of these patients.

We have identified a high proportion of patients in prehospital traumatic cardiac arrest with potentially life-ending injuries who can be treated and diagnosed by chest decompression. In all patients undergoing resuscitation attempts, the practice of routine chest decompression must therefore be considered and, we suggest, is mandatory if external or clinical signs of injury are present.


NeuralNet Comment:
I think this just supports 4Hs 4Ts, and reminds us to treat reversible causes of cardiac arrest.

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NN
 
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Capillary Refill Time (CRT)

Capillary Refill Time (CRT)

Remember this?

Well a study in EMJ October 2007 stated:

“This leaves CRT in adults as an invalidated and unhelpful test, especially if its results are acted upon in isolation. In view of the wide range of simple bedside tests that a hospital physician has available, the usefulness of CRT must be questioned in clinical practice.”

It was used in Trauma Score for years but Champion who developed Trauma Score arbitrarily used a normal value of less than 2 seconds, although this was not based on experimental evidence.

There you go now

NN

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Emergency Medical Journal 11th November 2009

This month’s journal I found the review of three papers of interest.


1. Prehospital advanced airway management by ambulance technicians and paramedics: is clinical practice sufficient to maintain skills.

Yet another review of paramedic intubation skills coming in against intubation by paramedics


2. Respiratory Rate a neglected sign

States respiratory rate > 27bpm requires immediate medical review



3. The effect of paramedic experience on survival from cardiac arrest.

Inconclusive, although preliminary finding may show the more experienced the paramedic the better chance of survival.


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NeuralNet said:
2. Respiratory Rate a neglected sign

States respiratory rate > 27bpm requires immediate medical review



3. The effect of paramedic experience on survival from cardiac arrest.

Inconclusive, although preliminary finding may show the more experienced the paramedic the better chance of survival.


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Click to expand...

2. Err.. Didn't we already know this? If it is a panic attack, asthma, or other respiratory disorder, even if correct by Paramedic treatment, most systems and protocols call for transport to medical care.

3. This is pretty much common sense, more experienced medics are going to read the scene and recognise signs and symptoms on a subconscious level rather than pedantically following mnemonics and will there start the most appropriate treatment sooner. Earlier BLS, AED, ALS, and thrombolysis is going to have a significant effect on survival probability.

For example, if an experienced medic watches the oral exam videos below they will pick up on the chief complaints within a few minutes, where as a less experienced medic or lay person will take as long as the student in the videos to grasp what is going on:

YouTube - Nancy Caroline's Oral Exam 15 (1/3)

YouTube - Nancy Caroline's Oral Exam 15 (2/3)

YouTube - Nancy Caroline's Oral Exam 15 (3/3)
 
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NeuralNet said:
NeuralNet Comment:
I think this just supports 4Hs 4Ts, and reminds us to treat reversible causes of cardiac arrest.
Click to expand...

While it is good to see use of evidence based clinical thinking in this case I think that the outcome of the research may have been a foregone conclusion.

As NN wrote, if you treat reversible causes the patient is going to get better..

Just watch out for gung-ho aeromedics, especially the doctors, as some have the need to do the most that they can. I witnessed one do a roadside thoracostomy to insert a drain into a biker involved in an MVC. The biker was conscious, boarded, and presented with two broken bones and a pneumothorax (not tension)...
 
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NeuralNet said:
Capillary Refill Time (CRT)

Remember this?

Well a study in EMJ October 2007 stated:

“This leaves CRT in adults as an invalidated and unhelpful test, especially if its results are acted upon in isolation. In view of the wide range of simple bedside tests that a hospital physician has available, the usefulness of CRT must be questioned in clinical practice.”

It was used in Trauma Score for years but Champion who developed Trauma Score arbitrarily used a normal value of less than 2 seconds, although this was not based on experimental evidence.

There you go now

NN
Click to expand...

I use CRT in course assessments (if it is in the protocols) and to test distal blood flow in complex limb injuries, that's about it.

It is more use in nursing and medical conditions than pre-hospital trauma.
 
NeuralNet said:
2. Respiratory Rate a neglected sign

States respiratory rate > 27bpm requires immediate medical review
Click to expand...

I think of respiratory rate like a heavy pendulum; it takes an awful lot to move it from its normal limits, and when it does it shows the patient is big sick

Remember this coarse respiratory assessment is also very useful in major incident “Triage Sieve”

triage_card.gif


Interestingly I looked for a card to copy for the site, and this was the only one I could find. The lower pulse rate on the card is wrong, it should be < 40bpm.

Also the use of capillary refill is now questionable (See above post)



Respiratory rate does tells you who's big sick very quickly!

Ref: Emergency Care: A Textbook for Paramedics

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NN
 
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Hypothermia

Hypothermia

The 1-10-1 rule (new to me)

On Immersion into cold water

1 - Cold Shock. An initial deep and sudden Gasp followed by hyperventilation that can be as much as 600-1000% greater than normal breathing. You must keep your airway clear or run the risk of drowning. Cold Shock will pass in about 1 minute. During that time concentrate on avoiding panic and getting control of your breathing. Wearing a lifejacket during this phase is critically important to keep you afloat and breathing.

10 - Cold Incapacitation. Over approximately the next 10 minutes you will lose the effective use of your fingers, arms and legs for any meaningful movement. Concentrate on self rescue initially, and if that isn’t possible, prepare to have a way to keep your airway clear to wait for self rescue. Swim failure will occur within these critical minutes and if you are in the water without a lifejacket, drowning will likely occur.

1 - HYPOTHERMIA. Even in ice water it could take approximately 1 hour before becoming unconscious due to Hypothermia. If you understand the aspects of hypothermia, techniques of how to delay it, self rescue and calling for help, your chances of survival and rescue will be dramatically increased.


Walk them off?
I was always taught never to walk a hypothermic off the hill. It seems things have changed.

The criterion for walking a hypothermic off the hill is:

1. Can they eat and drink

If so, get some carbohydrates and hot drink into them and then wherever possible walk them off.

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neuralnet
 
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RED FLAGS warn you something may be worse than first thought.
Here are some FYI.

Fall from Heights > 2 meters:
Indicates high energy with a high probability of serious injury


Calcaneum #s
Fall from height onto heels, there is a danger of a transmitted force through the body injuring the spine and neck


History of unconsciousness:
There is no physiological indication here just a probability of injury.
History of unconsciousness indicates high probability of serious injury and conversely, no unconsciousness, low probability of serious injury
REMEMBER IT’S ONLY A PROBABILITY


RTAs
They are lots, but ones I tend to remember and use:
RTAs > 30 mph
Ejection from vehicle
Entrapment > 15 mins
Rollover
Head on collisions
Un-restrained occupants


High pressure hose injuries:
At high force crap is blown into the tissues, looks nothing at first until the skin starts to de-slough and tissues necrose.


Falling onto glass:
The glass continues to cut through the skin, tendons, blood vessels, nerves, muscles until it stopped at the bone.


Red eye, history hammering:
Possible metal in eye with a danger of loss of sight


CHEST PAIN always to be taken seriously


Asthmatics
Respiratory rate > 25
Heart rate > 110
Unable to complete a full sentence
Asthmatic going quite indicates exhaustion and potential respiratory failure.
Bradycardia / Hypotensive


Shot, knifed & blast injuries:
It’s not good for the body to get shot, knifed or blown up.


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neuralnet
 
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Emergency Medicine Journal
January 2010 Vol 27 Issue Page 59.

CHEST COMPRESSION FIRST AID FOR RESPIRATORY ARREST DUE TO ACUTE ASPHYXIC ASTHMA

An import paper that will save many lives.

First, this is NOT CPR chest compressions.

In this paper three anecdotal cases were reviewed, where this technique was used and saved lives

Pathophysiology
In asthma extreme bronchial spasm causes expiratory difficulty and latterly hyper-expansion and over inflation of the lungs and chest wall.

Treatment
In this extreme state of respiratory failure the recommended action is mouth to mouth.

The problem is “that you cannot pump air into an already expanded bellowsâ€, airway pressures get higher and ventilation decreases, the patient dies.

Anecdotal Evidence
The paper reports 3 cases were in this over-inflated state the chest wall is compressed (squeezed) reducing the hyper-expansion. It is reported that surprisingly little effort is required and response is almost immediate.

As the title states the paper recommends this technique is not used as an advanced technique but as a first aid action.

It finally states that it is such a simple and safe action it's worth a try

Remember this is not a UK Resuscitation Recommendation.

There is lot more in the paper and I recommend you to read it.
I am unable to give the full document due to copyright

PLEASE KEEP THE CLINICAL THREAD CLEAR OF RUBBISH
REPLIES AND QUESTIONS WELCOME

NN
 
NeuralNet said:
Emergency Medicine Journal
January 2010 Vol 27 Issue Page 59.

CHEST COMPRESSION FIRST AID FOR RESPIRATORY ARREST DUE TO ACUTE ASPHYXIC ASTHMA

An import paper that will save many lives.

First, this is NOT CPR chest compressions.

In this paper three anecdotal cases were reviewed, where this technique was used and saved lives

Pathophysiology
In asthma extreme bronchial spasm causes expiratory difficulty and latterly hyper-expansion and over inflation of the lungs and chest wall.

Treatment
In this extreme state of respiratory failure the recommended action is mouth to mouth.

The problem is “that you cannot pump air into an already expanded bellowsâ€, airway pressures get higher and ventilation decreases, the patient dies.

Anecdotal Evidence
The paper reports 3 cases were in this over-inflated state the chest wall is compressed (squeezed) reducing the hyper-expansion. It is reported that surprisingly little effort is required and response is almost immediate.

As the title states the paper recommends this technique is not used as an advanced technique but as a first aid action.

It finally states that it is such a simple and safe action it's worth a try

Remember this is not a UK Resuscitation Recommendation.

There is lot more in the paper and I recommend you to read it.
I am unable to give the full document due to copyright

PLEASE KEEP THE CLINICAL THREAD CLEAR OF RUBBISH
REPLIES AND QUESTIONS WELCOME

NN
Click to expand...

Good paper to publicise.

It's not just these anecdotal reports, it's a recognised technique more usually used in critical care units as "manual chest decompression". I remmeber once having to explain to one woman what the reason why she had a residual problem of a bruised chest after her arrest with anaphylaxis was due to me physically squashing the air out of it on the previous day. She was too glad to be alive to be worried.

The high interthoracic pressures not only make ventilation more difficult but impede venous return to the heart, causing major circulatory problems. I tend to only ventilate an intubated asthmatic arrest at about 4 breaths per minute - it's not getting the oxygen in, it's getting the CO2 out that's the problem.
 
Thanks Seadog

It's an anecdotal report meaning not part of a full research study, and it's interesting that its being recommended as a first aid measure and not part of an advanced technique.


NN
 
Completely agree, NeuralNet, it is a simple technique and it will be interesting to hear reports coming in from the road if people start using it more early on. Thanks for putting the word out about the paper.
 
I will stick to a BVM and a T piece to be honest, unless it is a young well built male patient then I would be on the lookout for a pneumothorax.
 
bigjl said:
I will stick to a BVM and a T piece to be honest, unless it is a young well built male patient then I would be on the lookout for a pneumothorax.
Click to expand...

Not sure what your saying here.

If the patient needs ventilating, yes, BVM is fine
A common complication of asthma is a pneumothorax, and if it's a tension it needs to be treated, male, female, young or old.

The article is saying as a first aid measure you could try to decompress the chest and improve ventilation, thats all.

It's not instead of, it's in addition to the normal interventions.

NN
 
One thing Seadog, what do you mean by squeezing the air out ot your patient in arrest with anaphalaxis? Surely in a respiratory arrest due to anaphalaxis you would treating for an occluded airway, rather than treating for a hyperinflated chest?
 
My point behind a BVM and T piece was to make sure some Salbutamol and possibly some Atrovent got in there, as well as I'm Adrenaline, rather than experimenting with some new technique, as the primary treatment for Asthma that I am trained in is to treat the cause of the respiratory problem, Bronchospasm. What is interesting about the paper is that it recognises the aid to ventilation caused by chest compressions, but it is hardly a breakthrough though, it is the same thing as compression only CPR.
 
One other point NN, you are more likely to have a pneumothorax in young muscular males, hence why I was referring to males, mainly due to the extra effort being put in when breathing, or at least that is what I was told in training, I have only seen one patient to be afflicted in that way, not my patient, but I saw them being treated as they arrived at A/E, sadly the Para involved was highly educated with short road time, as is the future, and he didn't think to decompress the chest. Yet another example of new ways of training staff not working, you need a few years of patient time to fully understand when you should use the extended skills. Anyway, that's enough of the soapbox.
 
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