Lessons in Transport - Plasma? We Got That...

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Lessons in Transport - Plasma? We Got That...

Why 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 Recent unpublished analysis suggests that expanding these resuscitation principles to the prehospital environment via helicopter EMS was associated with improved outcomes.

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Lessons in Transport - Cognitive Biases in Critical Care Transport

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Lessons in Transport - Cognitive Biases in Critical Care Transport

As 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.

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Lessons in Transport - Upper GI Bleeding

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Lessons in Transport - Upper GI Bleeding

It 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...

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Lessons in Transport - Surviving Sepsis Part 2

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Lessons in Transport - Surviving Sepsis Part 2

"Around every 3rd heartbeat someone dies of sepsis"

Blood Product Administration:

  • Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration has decreased to < 7.0 g/dL to target a hemoglobin concentration of 7.0-9.0 g/dL in adults (grade 1B).
  • FFP NOT be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).
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Lessons in Transport - Surviving Sepsis

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Lessons in Transport - Surviving Sepsis

We routinely transport patients with severe sepsis and septic shock by both air and ground. Take a few moments to review these high yield management pearls from the 3rd edition of the Surviving Sepsis Campaign Guidelines.

Initial Resuscitation:

  • Goals during the first 6 hours of resuscitation:
  • CVP 8-12 mmHg (a debate on the utility of CVP or lack their of is beyond the scope of this LIT)
  • MAP >  65 mmHg
  • Urine output >  0.5ml/kg/hr
  • Central venous or mixed venous oxygen saturation 70% or 65% respectively (grade 1c)
  • In patients with elevated lacate levels we should target resuscitation to normalize lactate (grade 2c)
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Lessons in Transport - Avoiding Medication Errors

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Lessons in Transport - Avoiding Medication Errors

It 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...

  • Dynamic and potentially dangerous
  • Fast paced... where speed is perceived as excellence
  • Limited in space, resources, and personnel
  • Built on inferred indications with little access to confirmatory tests
  • Frequent patient care hand offs of high acuity patients
  • Defined by actions and inaction that have immediate consequences with little recovery time to stop sequential errors
  • Not reproducible... No mission is ever the same
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Lessons in Transport - Hypotensive Resuscitation

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Lessons in Transport - Hypotensive Resuscitation

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. 

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Lessons in Transport - The Lethal Triad

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Lessons in Transport - The Lethal Triad

To 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

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Lessons in Transport - TXA has Arrived!!

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Lessons in Transport - TXA has Arrived!!

To 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

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Lessons in Transport - Therapeutic Hypothermia Part 3

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Lessons in Transport - Therapeutic Hypothermia Part 3

Common 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.

  • If bradycardia is severe, associated with persistent hypotension, and is not responsive to fluid and vasopressor therapy, a decision in conjunction with medical control to discontinue hypothermia may be made.

2) Dysrhythmias: generally does not occur unless temperatures fall < 30*C and hypothermia related ventricular fibrillation is rare unless temperature is < 28*C.

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Lessons in Transport - To Cool or Not to Cool?

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Lessons in Transport - To Cool or Not to Cool?

To 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)

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Lessons in Transport - Post-Intubation Checklists

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Lessons in Transport - Post-Intubation Checklists

Post-Intubation Checklists

Making 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?

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