Cardiogenic Shock can humble the finest of critical care crew. Knowing the physiology and new adjuncts that can be a critical part of resuscitation can salvage the sickest LVs out there. Take a deep dive into cardiogenic shock and Impella support with Dr. Adam Gottula
Read MoreWhy is Air Care starting to transport and infuse plasma? Multiple studies, many from military combat zones, strongly suggest that clinical outcomes are improved by administration of plasma alongside RBCs in a 1:1 ratio. (1,2) Furthermore, the concept of damage control resuscitation advocates for minimizing crystalloid infusion and maximizing early aggressive resuscitation with blood products in patients with life threatening hemorrhage. Recent unpublished analysis suggests that expanding these resuscitation principles to the prehospital environment via helicopter EMS was associated with improved outcomes.
Read MoreTXA… What can be said about TXA that hasn’t already been said. TXA is good for what ails you.
Nosebleed? No problem.
Menorrhagia? TXA can fix that.
Involved in a motor vehicle crash with multiple pelvic fractures, a busted up spleen, hemorrhaging internally? TXA has your back.
In this podcast, Dr. Hill, Dr. Steuerwald, and Dr. Gerecht sit down and talk through the indications for using TXA in the prehospital environment and briefly discuss some of the evidence for its use.
Read MoreAs critical care transport professionals we are often perceived as an action oriented specialty. We frequently pride ourselves on procedural excellence and efficiency. (a difficult intubation, or fast scene-time etc.) However, the reality is that we spend the vast majority of our patient care time engaged in cognitive behavior... in THINKING rather than acting!
Because of this, it is imperative that we make every possible effort to understand how we think while caring for others. In addition, we should be aware of some of the cognitive biases that threaten our thinking processes, decision making, and thus the patients who place their trust in us.
Read MoreIt is 2am on a cold, dark, winter night and you are dispatched to a small rural hospital to transport a patient by ground with a GI bleed back to UCMC medical ICU. Enroute dispatch notifies you that your patient has deteriorated and is profoundly hypotensive. The ED physician at the outside hospital is attempting intubation for airway control. On arrival you find a middle-aged male with all the classic stigmata of end-stage liver disease. More importantly he has a systolic blood pressure of 60 and a HR of 130. A literal fountain of blood spews from the patients mouth, around a successfully placed endotracheal tube, and is now beginning to pool on the floor. You know this patient needs massive resuscitation from his likely bleeding esophageal varices... but you are 55 minutes by ground to UCMC and know that your patient will not survive the transport unless something is done to control the bleeding...
Read MoreIt takes an estimated 80-200 correctly executed tasks to successfully administer a single dose of a medication to a critically ill patient...
Our reality in transport medicine... We routinely work in an environment that is prone to medical error. An environment that is...
Permissive Hypotensionis also known as hypotensive resuscitation or low volume resuscitation
What is it?
A resuscitation strategy in the critically ill trauma patient (primarily applicable to penetrating trauma but also adapted to blunt trauma) where we allow the systolic BP to remain as low as necessary to avoid exsanguination while still maintaining critical end organ perfusion. (typically defined as appropriate mental status & or the presence of a radial pulse)
The Thought Process:"Don't pop the clot"...
By allowing lower blood pressures we avoid the potential disruption of an unstable fresh clot and thus worsening bleeding caused by higher BP's.
Read MoreTo successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the LETHAL TRIAD of TRAUMA...
Bleeding causes acidosis, coagulopathy, and hypothermia...
Acidosis and hypothermia causes more coagulopathy which causes more bleeding... and so begins a deadly cycle
Read MoreTo successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the LETHAL TRIAD of TRAUMA...
Bleeding causes acidosis, coagulopathy, and hypothermia...
Acidosis and hypothermia causes more coagulopathy which causes more bleeding... and so begins a deadly cycle
Read MoreCommon Issues in Therapeutic Hypothermia
1) Bradycardia: may occur during induced hypothermia (even to as low as 35 bpm) and except in rare cases, is NOT a reason to discontinue hypothermia.
2) Dysrhythmias: generally does not occur unless temperatures fall < 30*C and hypothermia related ventricular fibrillation is rare unless temperature is < 28*C.
Read MoreIn last weeks Lessons in Transport we reviewed who should & should not receive therapeutic hypothermia post return of spontaneous circulation from cardiac arrest...
Here are the answers to the scenarios...
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Read MoreTo COOL or NOT To COOL that is the question...
(Read each of the following scenarios & honestly ask yourself if this is a patient suitable for therapeutic hypothermia)
Scenario 1: 67 yo male scene STEMI, witnessed Vfib arrest with ROSC, GCS 3T, stable vitals
Scenario 2: 24 yo female MVC, ejected, hypotensive for EMS, 10 minute cardiac arrest with ROSC, GCS 3T
Scenario 3: 2 yo female cardiac arrest suspected choking, ROSC after removing food from her airway. GCS 4T (1T2)
Read MoreMaking a checklist can help cognitively unload you in high stakes and high pressure situations. Post-intubation consider the following important points:
Protecting the Tube
Continuous wave form ETCO2... each and every time
Secure Endotracheal Tube at the appropriate depth (See LIT week 6)
Analgesia and Sedation
Restraints... Do you know where the soft restraints are stored?
SRU (pronounced "shrew") = Shock Resuscitation Unit
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
