Coda Change

Gareth Grier discusses who should be intubated following severe trauma pre-hospital.

This talk will look at current and previous pre oxygenation practices and some of the current research. It will also discuss the notion of commitment to evolution of practice, the breakdown of cognitive biases and how to move forward with adequate self reflected practice.

Peter Brindley explains why teamwork is the strongest drug in the hospital. Modern acute care medicine is eye-wateringly complex and potentially dangerous. It really can’t be delivered safely without deliberately addressing our teamwork (in both acute and chronic situations). Unfortunately, historically, human factors were commonly left to chance, and recently have been threatened by decerebrate checklists and meaningless ‘psychobabble’. Peter describes communication and its critical role in the effectiveness of any team. He compares the voice of a team leader to a drug. Like a drug, it can be a placebo or a nocebo, depending on its use. As such you must use the right drug at the right dose for the right patient and the right time! Moreover, other forms of communication play an integral part of any team environment. Peter discusses verbal, paraverbal, non-verbal and other forms of communication which all need attention. Rudeness, and its damaging potential is highlighted. Peter contends that rudeness alone will decrease both team and individual performance, impair diagnosis and impede procedures. Peter puts his message in to real world examples. Specifically, Peter discusses the management of airways – especially difficult airways whether that be anatomical, physiological or situation difficulties. In cases such as these, it is the clinician’s job to be understood when they communicate. Practical strategies to improve communication and teamwork exist and Peter highlights these in this talk. We have much to learn but must also avoid overly simple answers to exceedingly complex problems. It’s time to get back to basics. Come be part of a practical revolution and resuscitate by voice. For more like this, head to our podcast page. #CodaPodcast

Richard will cover the rationale and evidence for prehospital blood product transfusion in trauma, look at the available current and future options, suggest best clinical practice and highlight areas of future research.

William Knight presents the considerations in the management of extra-cranial injuries in patients with traumatic brain injuries (TBI). Patients with TBI often have concomitant systemic injuries that complicate the management of the TBI. In this talk William presents his five top areas to think about – prognostication, suitability for the operating room, use of ventilators, pressure considerations and monitoring. Prognostication becomes difficult when a brain injury is added to other injuries due to the long-term nature of neurological damage. This means that other clinicians can be unsure when managing extra-cranial injuries in such patients. Adding a brain injury on top of other injuries tends to make people unsure, and enhances nihilism. Intensivists in the neurological ICU tend to be very protective of their TBI patients. However, some simple measures and tests can go a long way to reassuring the treating team of a patient’s suitability for the operating room. William describes the ‘lay flat test’, which is as simple as it sounds – laying a patient flat and observing the ICP. If it rises, then they are likely not appropriate. One must also consider the urgency of the proposed procedures. William describes the ventilator as the single most lethal piece of equipment for a patient with a brain injury. The use of ventilators needs to be done appropriately and William describes the parameters to consider. Pressure is a broad category. There are more acronyms than you can poke a stick at. William tries to make sense of them for you as he describes how he manages pressures in the TBI patient complicated by systemic injuries. He makes the point that you need to remember other places of elevated pressure in the multi-trauma patients outside of the lungs and the brain. Consider your compartments including in the legs, arms, and abdomen. Evidently, monitors do not save people; the use of monitors do. What does all the data mean, how do you monitor in the neuro ICU and how do you deal with contradicting data points. Using the data and taking in the whole picture in the TBI patient with extra-cranial injuries is complex. Join William Knight as he attempts to make sense of this complex area of medicine! Finally, for more like this, head to our podcast page. #CodaPodcast

Jo Anna Leuck discusses how to learn from error in paediatric sepsis. Rory was a healthy 12-year-old boy, known for his smile and for standing up for others. A simple fall during basketball practice caused an abrasion on his arm. This is the suspected beginning of a cascade of events that led to his death from sepsis. Rory was seen by both his paediatrician and a local Emergency Department and was sent home with a diagnosis of a viral illness. He returned the next day in septic shock and died shortly thereafter. A review of the medical records revealed that there were errors that occurred during his emergency department visit. This talk will attempt to move away from the controversy of the actual article and instead focus on how these common errors could have occurred during any busy shift and what we can do to prevent them in the future. Jo Anna’s intention in giving this talk is to continue to use this case to raise awareness of both paediatric sepsis and common medical error. When considering paediatric sepsis Jo Anna asks - Was this preventable? Were there clues? Why was this missed? Jo Anna discusses what we can we do better. Recognition is the first step. Often procedures are used in this case. The Paediatric Sepsis Score is one such example. Jo Anna talks about vital signs and how they are tricky in kids due to the changing reference ranges depending on age. Jo Anna recommends having easily accessed charts and stresses thinking twice about the size and age of the child in front of you. The physical exam is as important as always. In kids, there are certain signs that should raise suspicion such as skin mottling. And in terms of treatment Jo Anna stresses rapid access, rapid fluid boluses and thorough re-evaluation alongside age-appropriate empirical antibiotics. Lastly, Jo Anne touches on the errors that this case highlights. She provides some strategies to improve your practice. Before discharge consider three main components. Vital signs, diagnostic studies, and communication! Simple, but careful attention to these components of care will lead to the medical profession learning from errors and preventing them in the future. For more like this, head to our podcast page. #CodaPodcast  

Kieran Henry gives his insights into hospital handovers of major trauma. He makes the comparison between prehospital care and the life lived in a Western movie. Kieran stresses that he does not want you to behave like a cowboy, jumping off your horse (ambulance) as it is still moving into town, without much dialogue and with no one really knowing what is happening. Instead, be the preacher man! Be cool, concise, and clear in your messaging. Prepare, practice and be professional. Much like the preacher man, you will be listened to if this is how you carry yourself. You will then be able to convert the non-believers. Delivering the handover message effectively and efficiently is crucial. Tune in to Kieran to learn how to convert the non-believers into believers and do good patient handovers. Hospital Handover of Major Trauma: Kieran Henry For more like this, head to our podcast page. #CodaPodcast

Simon Finfer explains the future of sepsis treatment focusing on life after surviving sepsis. Sepsis is the life-threatening condition that arises when the body’s response to an infection damages its own tissues and organs. It can lead to shock, failure of multiple organs, and death. Organ failure and death are more likely if sepsis is not recognised early and not treated promptly. Sepsis is the leading cause of death from infection around the world and contributes to or causes half of all deaths occurring in hospitals in the USA. Many people who survive severe sepsis recover completely and their lives return to normal. But some people, especially those who had pre-existing chronic diseases, may experience permanent organ damage, the common problems that afflict those who have recovered from sepsis have been termed the post-sepsis syndrome. Longer term effects of sepsis are extensive. They include sleep disturbance including insomnia and nightmares. People experiences hallucinations, flashbacks and panic attacks. Muscle and joint pain occur, which can be severe and disabling. Similarly, functional impairments such as extreme tiredness and fatigue, inability to concentrate and impaired cognition occur. These effects even extend to a loss of confidence and self-belief. The global medical community has improved sepsis survival. Because of that, Simon contends that all these long-term effects of sepsis must be paid attention. The current trials overwhelmingly look at survival. The future of research therefore should include post-sepsis outcomes. For instance, Simon asks the question – are these long-term effects due to sepsis, or rather, are they due to being in the ICU. Simon discusses the future of sepsis care. Specifically, he discusses the idea of post-sepsis care and follow up. Much like there is respiratory follow up following an acute episode of respiratory disease, Simon believes there needs to be dedicated care for sepsis survivors. As he explains, the acute treatment of sepsis is the beginning of the road. For more like this, head to our podcast page. #CodaPodcast

Alistair Nichol explains the use of hypothermia in the treatment of traumatic brain injury (TBI). TBI is a major cause of mortality and long-term morbidity. It leads to terrible outcomes and is a major cause of health burden across the globe. Prophylactic hypothermia presents a promising treatment to address this hidden epidemic. The pathophysiology of TBI is exceedingly complex. Evidently, one drug will likely not be the answer. This leads Alistair to discuss hypothermia as a treatment for TBI, which has huge potential benefit. As Alistair explains, it acts in many different places, in many ways, across many time periods. Could this be the ‘drug’ to give? The questions then become, when should you give it, how should you give it and how low should you aim? Alistair recommends inducing hypothermia as early as humanly possible. In the case of TBI, this means at the roadside if practical. How low should you go? Given the effect of hypothermia on coagulation, and the propensity for trauma patients to bleed, this is a tricky question. Alistair states that 32 degrees is ideal however this leads to further haematological complications. To that end, 35 degrees is a sensible aim, to then go lower once bleeding has been excluded in the Emergency Department. How do you do it? Ice is unfavourable, given the difficulty of controlling the temperature and the adverse effects including ice burns. Alistair also warns against the use of ice cold saline due to the effects of positive fluid balances in TBI patients. Alistair explains the current methods, such as surface cooling pads and intravascular cooling catheters. It is not a risk-free treatment. Risk of infection rises due to effects on cellular processes. Propofol-related Infusion Syndrome (PRIS) is also being increasingly recognised as an adverse outcome. Finally, the re-warming following hypothermia is risky. Alistair explains the complex process of re-warming. Alistair concludes by explaining the current trials underway and the potential future for this treatment. For more like this, head to our podcast page. #CodaPodcast

Ryan Radecki urges you to rethink the acute management of stroke. The current way of thinking about stroke and the acute treatment has been around for decades. In this time, a lot has changed, new technologies have been developed and we have learnt a lot about the underlying physiology of stroke. Endovascular therapy, CT perfusion, and patient-level predictive modelling are now all at the disposal of clinicians. Moreover, Ryan wonders if we are using the current treatments – namely tPA – more safely or effectively. In acute stroke management there are two key factors to consider. Successful reperfusion and salvageable tissue. To restore and save brain tissue one must successfully re-perfuse the tissue. The classic method for achieving this is by using tPA. However, Ryan contends that this is akin to using a sledgehammer to fix a teacup. It is a dangerous drug, with many risks, and it is not appropriate for all patients. Salvageable tissue is the second key factor. If brain tissue is dead, it stays dead. It does not matter what drug you give. Evaluating this tissue makes sense. To this end, Ryan believes that new technologies can be better utilised. As he sees it, some of the new advances in stroke care do not recognise the underlying pathophysiology of the problem. They just deliver pre-historic care, faster. Further, he argues that the new advances do not individualise care. So, what should be done? Ryan explains that perfusion imaging makes sense, as every patient has unique cerebrovascular anatomy. The goal should not be to give more patients tPA but to give it to patients who have the best risk-benefit ratio. He argues against expanding the treatment population for tPA against rational judgement. Moreover, the goal should be to tailor evaluation to identify the patients that will benefit from this intervention and to identify patients who should be put onto a different pathway. Aim to individualise care with the available technology and investigations. Finally, Ryan discusses the clinical trials underway, which may produce zero, subtle, or huge changes in practice. For more like this, head to our podcast page. #CodaPodcast