Activity on the blog is a bit slow at the moment as we are both transitioning into new jobs. For now, have a look at this video. It´s footage from the 2012 boxing day stabbing in London. 18 year old Seydou Diarrassouba bled to death in front of hundreds of onlookers after being stabbed in a nearby Foot Locker store.
If you look carefully, you will see how Seydou goes into cardiac arrest. The police start CPR before the EMTs arrive and take over. Eventually the doctor-paramedic team from London HEMS arrives. I have no direct info about exactly what went down, but apparently they performed an emergency thoracotomy on the street in front of this massive crowd with some very aggressive elements. At least one person gets tasered by the police.
There is the learning point. I think this video illustrates the conditions big-city police and medical professionals sometimes have to deal with. It illustrates important points about scene-safety in prehospital care.
The medical emergency in itself is challenging, but the psychological pressure from the presence of the aggressive crowd must have been immense. How do you prepare for this?
For many years, ATLS has dictated cervical collar as part of the A in ABC, and any patient that enters a trauma bay gets a cervical collar slapped on before anyone cares about airways, breathing and circulation. The last couple of years, some rougue docs have tried opposing the validity of the extreme focus on cervical collars, and it is finally starting to trickle into the system. Here’s the case against cervical collars – and for bringing the focus back on the important parts of the ABC to save your patient. More>>
We often talk about ECMO in terms of circulatory or respiratory support. A more obscure field is ECMO supporting airway management. ECMO could provide respiratory support in a patient with a failed emergency airway or during entire airway surgeries. Here are two papers worth reading. Hong et al, from a recent issue of Journal of Critical Care describes using ECMO for ventilatory support in airway surgery where conventional mangement was impossible. The other, by Willms et al in Respiratory Care 2012, is a review of reported cases where patients were put on ECMO for emergent airway obstructions. More>>
Cardiac anaesthesia can be boring as hell. On the upside, there is no better way to get a true understanding of cardiac physiology than directly observing, actually seeing, what the heart does.
This is what VF, cardioversion and sinus rythm really look like.
This patient had hypothermic cardioplegia for cardiac surgery. Surgery was performed at a core temperature around 27°C with a heart in ventricular fibrillation. Then we started rewarming. At 30°C the heart was still fibrillating but was still too cold to be shocked into a sinus rhythm. The video below is shot at about 32°C. After the second shock the heart cardioverts from hopeless non-perfusing VF into glorious SR.
Tension pneumothorax is a killer. It needs immediate intervention. Unless we do a thoracotomy we are to perform a needle decompression. Classically this is done in the 2nd intercostal space in the midclavicular line. Some clinicians opt to use the 5th intercostal in the anterior axillary line. Two similar studies in the recent issue of Injury aim to measure the thickness of the chest wall at these two sites. More>>
Heart rate monitor watches are becoming increasingly popular in outdoor sports. That has resulted in some interesting case reports where heart rate recordings have been downloaded and analysed from victims´watches. The most recent one was published in Resuscitation. It details the heart rate variations of a person buried in an avalanche. It is an absolutely chilling demonstration of death from asphyxia. More>>
Vasopressin has been advocated in and out of the CPR algorithm. Adrenaline is still hanging in there. And now the Greeks want to add steroids?! In this pretty solid multi center trial, they randomised cardiac arrest patients to standard adrenaline or to adrenaline + vasopressin + the corticosteroid Solu-Medrol. They more than doubled the survival with good neurological outcome! More>>
A study in SJTREM compares CPR hands-off times with various airway devices. It reinforces what we already know. In order to maintain hands-off times within CPR guideline recommendations the endotracheal tube is not a realistic option for inexperienced EMTs. More>>
Monitoring of a patient in severe septic shock and with high dose pressor infusions. We happened to have two intra-arterial blood pressures, shown as the red tracings and numbers on the monitor. A central pressure from a PiCCO line in the femoral artery (top tracing), and a peripheral pressure from an arterial cannula in the arm (bottom tracing). You’ll also see atrial fibrillation and a no-good pulse-ox trace. The interesting part is the difference between the central and peripheral art line readings. More>>
ECMO or Impella, or ECMO and Impella? With increased focus on mechanical support for acute severe heart failure and cardiac arrest, there’s more research looking into which type of mechanical assistance that’s most appropriate. Each type of assist device has it’s own pros and cons. More>>