Grand Rounds Recap 5.22.24

Air care grand rounds - top 10 air care cases of the year - r3 small groups - r4 capstone

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air care grand rounds: too sick to transport? with Dr. Susan Wilcox

Increasing regionalization due to:

• Growth of specialty centers

• Increasing development of healthcare systems

• Hub-and-spoke models

• Development of ECMO, trauma, transplant, and stroke centers

The higher the acuity of the centers, the higher the acuity of the patient that needs to get there.

 Myth: Some patients are “too sick to transport”

 Myth Part B: The receiving hospital gets to decide if a patient is too sick to transport.

 What drives the concern?

• Relative to inactions, actions receive more attention, elicit stronger emotional reactions, trigger higher regret, and are often perceived as more consequential.

 Parachute Study

• Systematic analysis of parachute use that found no benefit.

•  The authors concluded “We think that everyone might benefit if the most radical protagonists of evidence-based medicine organized and participated in a double blind, randomized placebo-controlled crossover trial of the parachute.”

 This shows that we are sometimes limited by the data that we have.

 Benefits of transport are evidenced based.

CESAR Trial

• Published in 2009

• Found that even those who didn’t get ECMO, but were transported to a tertiary care center had better outcomes

No matter where you go, critical care transport will be part of your life as a sending physician, receiving physician, or both.

Knowing the capabilities of your system BEFORE disaster strikes is crucial

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top 10 air care cases of 2023-2024 with drs. tillotson and hinckley

Difficulty Breathing

• Tracheal Lacerations

  • Rare Complication of endotracheal intubation

  • Most commonly secondary to overinflation of the cuff or sudden movement of the ETT opposed to injury from the tube itself

  • Presentation:

    • Pneumomediastinum

    • Subcutaneous emphysema

    • Inability to ventilate

  • ETT Cuff Pressures

    • Pressure between 20-30 mmHg

    • Manometer = gold standard

    • Allows seal but also capillary refill

    • OR study (Peds) elevated 60-80% of the time

  • Time vs. Temp relationship for ETT

    • It takes approximately 4 minutes to get below freezing and roughly 8 minutes to get to 10 degrees.

    • At this temperature, the tube is essentially ridged and unable to be manipulated.

  • In-flight trouble shooting

    • Consider mainstem intubation

    • Check cuff pressures

    • Confirm with ETC02

    • Check PEEP

    • Run portable labs

Binding the Pelvis

• Some studies suggest sensitivity of physical exam for identifying pelvic instability may be <25% if GCS <13

• Belongs in the C of MARCHHHH primary survey

• Level B evidence for pelvic binding improving hemodynamic stability and decreasing transfusion requirements

• Level C evidence for improved survival for binding

• No harm when applied correctly

• Almost impossible to apply in flight

• Who gets bound?

  • Palpable Instability present

  • Mechanism + GCS 15 + pain on compression + shock

  • Mechanism + GCS <15 + shock

Aortic Dissection

• Tearing of the layers of the aorta

• Risk factors: HTN, genetic (Marfan’s), substance use

• Management:

  • Goal: prevent propagation

  • Symptom control: pain and nausea

  • Decrease shearing force on the aorta (goal HR <60, SBP <110)

    • Beta blocker 1st line; prevents reflexive tachycardia

    • Hypotension

Tension Pneumothorax

• The R in MARCHHH - the question you are asking is “do I have to be concerned about tension pneumothorax?”

• Non-ventilated patients can often arrest from tension PTX from respiratory failure without ever becoming hypotensive

  • If you are waiting on hypotension, JVD, and/or tracheal deviation you are waiting too long

• Non-ventilated patients - you’re looking for severe progressive respiratory distress with hypoxia

• Needle thoracotomy - 4th ICS anterior axillary line (mid clavicular line last resort)

• Finger thoracotomy - arrest or peri-arrest

Ruptured AAA

• Localized dilation of all 3 layers of the aorta wall

• Most common site is infrarenal

• Size matters

  • >5 cm —> increased rupture risk

  • Growth rate

• Rupture is retroperitoneum in 20-70% of cases

• Evaluation:

  • Palpable mass

  • Audible burit

  • Pulses intact

  • No risk of rupture by palpation

• Rupture Triad: Pain + Hypotension + Mass

  • Hypotension is least common finding; and is often a late finding

• Diagnosis:

  • Imaging (CT>POCUS)

  • POCUS is faster, better for unstable patients

• Management:

  • Blood pressure goals unclear

  • Blood products; activate MTP

  • Get to OR ASAP 

ETCO2

• ETCO2 is always lower than pCO2, but you don’t know how much lower until you get a blood gas.

• Get a blood gas when possible to help guide your ventilation.

• In shock, the “fix” is fixing the shock

Status Epilepticus

• Prolonged seizures and/or recurrent seizures without return to baseline

• Management:

  • 1st line: benzodiazepines

  • 2nd line: Keppra, fosphenytoin, valproate

  • 3rd line + airway: propofol or versed drip

  • 4th line: ketamine or phenobarbital drip

• Specific causes not reversed by the above management options:

  • Hypoglycemia

  • Hyponatremia

  • Isoniazid toxicity

  • Drugs (illicit, serotonergic, etc)

Active Labor

• Tocolysis: Mag 4-6g IV over 20-30 minutes (watch for respiratory depression, hyporeflexia)

  • Document reflexes q30 minutes

• Can also borrow terbutaline 0.25 mg subcutaneous q 20-60 minutes

• Transport likely safe if:

  • Multiparous mother dilated <5 cm + contractions not <5 minutes apart

  • Primiparous mother dilated <6 cm + contractions not <5 minutes apart + transport time <1 hour

Motorcycle Collision

• LVAD Basics

  • Mechanical pump, driveline, power source/controller

  • Patients should know their parameters

  • “Hum” on epicardium

  • Variables: Speed, Flow, Power

• Exam

  • Assessing perfusion: mental status, capillary refill, skin turgor, UOP

  • MAP (goal = no pulse pressure)

  • Rhythm: native function needed

• LVAD Complications

  • Bleeding

  • Infection

  • Pump thrombus

  • Arrhythmia

  • Suction event

DASH-1A

Performance Bundle to Achieve DASHH-1A Success

• Implementation of a DASHH-1A bundle of care had a high degree of compliance and was shown to improve our program’s overall adult DASHH-1A success rates

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r3 small groups WITH Drs. glenn, haffner, and jackson

In Flight Emergencies:

• As a responding physician to an in-flight emergency, you may recommend diverting the plane, however, the captain (lead pilot) will make the final decision. 

• Some newer AED's have the capability of providing you with a rhythm strip. If you or your patient do not have a watch capable of providing you with an ECG, consider asking those on board to allow you to borrow theirs. 

• The medications and supplies available to you on most flights are scarce, ask the flight crew if they have an expanded supply or medication kit. Be resourceful and have flight attendants ask passengers if they have supplies you may need such as glucometers, inhalers, epi-pens, etc. 

• If you choose to respond to an in-flight medical emergency, you are protected by Good Samaritan Laws - but probably not if you'd be considered clinically intoxicated. Accepting monetary rewards may also waive your legal protection. 

Common venomous snakes in the United States include:

• Coral Snakes (Elapidae family) which produces a neurotoxin

• Rattlesnake, Cottonmouth, Copperhead (Viperidae family) which produces a hematologic toxin resulting in significant local tissue damage and coagulopathy

• Field treatment involves splinting the extremity, immobilizing the patient as possible, and moving the patient quickly to definitive care

• Hospital management involves local wound care, supportive care, and administration of antivenom (Antivenin or Crofab respectively)

• Pericardiocentesis can be performed with ultrasound or using a subxiphoid approach

• Indications for ED pericardiocentesis include cardiac tamponade resulting in significant hemodynamic compromise

• Aspirate when advancing the need to prevent inserting into the myocardium

• Remove pericardial fluid until you achieve clinical improvement

• Obtain a post-procedure chest X-ray to evaluate for iatrogenic pneumothorax

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r4 capstone WITH Dr. kletsel

• Stick to an intentional routine.

• Use checklists for complex procedures, such as airway management.

• Maintain a routine during shift work, especially when it comes to obtaining adequate sleep during a string of night shifts. 

• Routines are also helpful when applied to intentional, on-shift teaching. 

• Don’t be afraid to show your emotions.

• Especially when faced with patients in a bad situation.

• This is what makes us human and helps us connect to our patients.

• It is the suppression of emotions, rather than the display of them, that is associated with higher rates of physician burnout. 

• Always try to make time for a debrief.

• This will help team dynamics, individual performance, and hopefully bring about meaningful changes.

• Ideally, this is a "hot" debrief occurring shortly after a difficult clinical case. 

• STOP5 is an established model for a "hot" debrief in the ED that can be completed in a few minutes and can be led by anyone involved in the case.

• When needed, don’t be afraid to ask for help.

• We all have different levels of training, experience, and expertise.

• Reach out to those with more clinical experience than you.

• Recognize when there is room for improvement in terms of efficiency, volume, task priority.