Grand Rounds Recap - 8/6/2104

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Air Care Grand Rounds

Procedure kits that we carry in the black bag:

Some of the challenges to think about when performing these procedures in the aircraft include:

  • Positioning: you are stuck at the head of the bed, the patient is packaged, their arms are down to their side, and space is limited.
  • Sharps: high risk of accidental injury when in the back of a squad or in the helicopter. Be careful!

Helicopter equipment: as flight team members we need to be able to perform tasks that are usually not done by physicians: spiking fluids, hanging blood, drawing up meds, assembling bristo-jets, etc. The more of this you can do during a stable patient interaction the smoother things will go when you encounter the super sick patient requiring lots of intervention.

Balloon pump: [http://tamingthesru.com/transporting-intraaortic-balloon-pump-patients-by-air-care/] Take your time loading the device and recognize that due to the very short cables it is best to keep the device in the aircraft. Utilize extra help from the transferring and receiving facilities to ensure the loading and unloading of these patients is smooth. Review the physiology and function of the IABP here: [http://ca.maquet.com/clinician-information/e-learning-programs/accredited/theory-program/]

Traumatic arrest: manage the airway, get access (go for the IO), double needle decompression [http://tamingthesru.com/needle-thoracostomy/]  followed by double finger thoracostomy, and pericardiocentesis. No role for ACLS drugs in these patients. Work these patients on scene and terminate the resuscitation if unsuccessful. [http://tamingthesru.com/resuscitation-of-penetrating-trauma-patients/]

I.C. Cordes Airway of Horrors with Dr. Carleton

  • The failed airway
    • Can't intubate, but can oxygenate - you have time
    • Cant intubate, can't oxygenate (CICO) - you have no time
  • The surgical airway: takes time and practitioners are reluctant to do it (8-10 attempts made prior to cric)
    • SMART pneumonic to evaluate for difficult cricothyrotomy
    •  Surgically altered airway
    •  Mass inside or outside the airway
    •  Access (can you actually get to the membrane?)
    •  Radiation therapy
    •  Trauma
  • Indications for cricothyrotomy
    • Massive tracheobronchial bleeding
    • Severe mid-facial trauma
    • Oropharyngeal edema
    • Foreign body obstruction of the upper airway
    • Anatomic variants
    • Masseter spasm/clenched teeth
    • Failed airway without other rescue options
  • - Tip: Preferable to use an ETT for cricothyrotomy over a trach tube as the trach tube is rigid and designed to go through a tracheostomy.

Open technique (no drop)

  1. Find cartilage
  2. Vertical skin incision
  3. Find cartilage again- tactile
  4. Horizontal incision through CTM (inferior CTM and blade facing caudally) 
  5. Insert trach hook along the blade to grab superiorly (inferior margin of thyroid cartilage)
  6. Dilate
  7. Intubate

Rapid Four Step Technique

  1. Find cartilage
  2. Stab straight down horizontal through the skin and membrane
  3. Slide trach hook down the blade and hook the inferior cartilage (cricoid cartilage)
  4. Intubate through non-dilated hole

Bougie technique

  1. Slide trach hook down blade
  2. Hook the superior margin of the cricoid cartilage
  3. Remove blade, insert bougie
  4. Slide ETT over bougie

CPC with Dr. Grosso and Dr. Powell

  • 21yo Spanish speaking M with chief complaint of 2 weeks of abdominal pain, some vomiting, mild headache. Noted on exam to have normal vitals, mild jaundice, photophobia, and diffuse abdominal tenderness. Labs remarkable for eosinophilia with normal WBC, direct hyperbilirubinemia, and mild hyonatremia at 134 with mild thrombocytopenia at 140k. CT abdomen completely normal.
  • Test of choice: CT head showed obstructive hydrocephalus. Followup MRI showed cystic structure in the 3rd ventricle which was shown on pathology to beextraparenchymal neurocysticercosis.
  • Neurocysticercosis: 92% of cases are seen in Latino patients. The 3 most common presenting symptoms are: seizure (66%), hydrocephalus (16%), headache (15%). It is the most common cause of seizure worldwide.

EBM Quick Hit: Subgroup Analysis with Dr. Lafollette

  • Goal: identify a specific useful patient population so you can anwer the question: "does this study fit the patient in front of me?"
  • It is by definition a secondary analysis. They can be designed a priori or post-hoc. If post-hoc, ask yourself "is the intervention making an artificial subgroup?" (eg: a study of tight glycemic control shows shorter ICU stay in the control group. But, did the intervention group have longer ICU stays because of the tight glycemic control?)
  • The more subgroup analyses that are performed increases the likelihood of false positive results. Consider the test of interaction which increases the p-value stringency. The initial study p-value is divided by the number of subgroup analyses. Use this new lower p-value to judge the subgroup results.
  • Remember that the initial study design matters. If the initial study design was poor, the subgroups are still based on a poor study.

International Medicine with Dr. Winston

  • International medicine refers to health work abroad with a focus on infectious diseases, prevention, maternal and infant health, water, and sanitation.
  • Global health is the overlap between public health and international medicine. It is more inclusive of research, knowledge sharing, prevention, sustainability, overall health improvement and health equity.

Quick Hit on Ebola with Dr. Widners

  • Transmitted via bodily fluids, but current recommendations include airborne precautions (N95) to protect yourself.
  • If you suspect Ebola call the CDC at 1-770-488-7100
  • More info available at: http://www.cdc.gov/ebola