Coda Change

TBI Management: Beyond the Resus Room by Andrew Chow

In this podcast, Andrew Chow highlights the latest evidence for TBI. Andrew shares some clinical pearls for TBI management & highlights a future direction for the management of patients with a traumatic brain injury.

Studies have shown that the demographic of TBI patients has shifted. We are now seeing an increase in the number of elderly patients with a TBI injury that need intensive care admission.

Andrew suggests that with this change in demographic, we need to consider different injury patterns and treatment protocols.

Andrew provides a summary of the latest evidence impacting intensive care management of patients with TBI.

He shares some clinical pearls and provides a brief run through of multi-modal advanced neuro monitoring.

One thing is for sure and that is that our knowledge of TBI is still growing.

The future of TBI management is evolving and Andrew predicts that it will be individualised, patient centric and involve multi-modal monitoring.

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From #CodaZero Live, Behny explains the importance of Echo and lists some of the ways in which Echo can help us during a cardiac arrest. It is more than we think!

Echo is a quick, easy and simple tool, making it invaluable in many situations including cardiac arrests. It is a bedside test that is non invasive and painless for the patient. It is easily taught to any doctor or nurse and is performed in real time at the bedside. It can be used to guide and inform management and treatment, so why isn't everyone embracing Echo? Behny challenges us to consider another bedside tool which compares to the effectiveness and usefulness of Echo. Moreover, in the chaos of cardiac arrests, Echo can help to exclude some of the 4Hs & 4Ts. It can help to check the rhythm, check the quality of compressions and assess for post-resuscitation care. It is an invaluable tool in managing a patient suffering cardiac arrest. Behny suggests that the focused 2D echo is our generations stethoscope. We need to open our minds and embrace the capabilities of Echo and challenge each other to learn how to effectively utilise this tool in times that matter.

Tune in to a fascinating podcast by Behny Samadi on the value of Echo in Cardiac Arrest.

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Updates in pain management by Gavin Pattullo

Opioids are often a mainstay of therapy in trauma pain, though they are in turn the cause of much trauma. For every 4000 Australians prescribed an opioid there will be one death in the community as a result. In-patients similarly have greater risk of harm when their analgesia is opioid based.

This presentation will focus on some of the valuable lessons learnt in pain management resulting from the opioid crisis. These include:

1. Our need to differentiate clinically between pain and nociception. Pain - the affective unpleasant experience - is assessed by clinicians enquiring with the use of the words: coping, bothersomeness and troubling. While nociception is focussed on asking about physical feelings and sensations.

Profound levels of nociception and the potential to lead to reports of significant pain, a major feature of trauma patients, requires firstly a focus on the two most effective anti-nociceptive strategies of neural blockade and NSAIDs/COX-2 inhibitors before introducing less effective strategies.

1. Pain, the affective distressing unpleasant experience, when present with or without the use of anti-nociceptive strategies has historically been managed solely with biological strategies of opioids and adjuvant agents. An increasing focus in clinical practice on non-pharmacological strategies to manage pain, including placebo enhancing communication strategies and message framing.
2. Avoidance of over-reliance on pain scores. Clinicians are too often misled and poor decisions are made when the robustness of pain scores is over-relied upon. Pain scores can be useful provided there is clear understanding in both the enquirer and the patient of whether the question is relating to the level of nociception or pain being experienced.
3. Ensuring optimal effectiveness of the opioid avoiding strategy of neural blockade. Four clinical assessment endpoints indicate effectiveness of neural blockade: presence of Dynamic pain relief, Analgesia, Sensory anaesthesia and Opioid sparing/elimination (DASO).

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In this podcast, Ken Sakurai provides an update on the recent RCTs for Vitamin C in Sepsis.

The battle against sepsis continues, with Vitamin C the most recent weapon in our arsenal. Since Prof. Marik's 2017 trial on metabolic resuscitation, there has been renewed interest in the use of vitamin C.

Ken reviews the rationale and pre-clinical evidence for Vitamin C use in treatments, as well as the most recent RCTs for Vitamin C in Sepsis.

For more head to: codachange.org/podcasts

Oli covers the initial management of patients with traumatic cervical spinal cord injury. He covers the neurological assessment – how and why we do the ASIA or ISNCSCI Exam and why it matters. It's not always straight forward, but getting a motor and sensory level and determining if a patient has perianal sensation and voluntary anal contraction can be really helpful prognostically.

The importance of avoiding hypoxia, including ways to manage an airway in this context are then discussed.

Oli then talks blood pressure targets – still a controversial area, but aiming for a MAP > 85 mmHg may really help. Hypotension definitely doesn't help.

Timing of surgery is another hot topic in acute SCI. Low quality evidence suggests surgery in

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The importance of sex and gender in medical research.

For many years it was widely assumed that the occurrence and outcome of disease was the same for women and men.

Our understanding was that studies involving only men would be equally relevant for women. In the last two decades however, it has been shown that this assumption is highly prejudice and can have a detrimental impact on the health of women.

It is, therefore, really important to incorporate a sex and gender research lens in medical research.

First, Kelly makes the important distinction between sex and gender and how this can impact medical diagnosis, treatment and outcomes.

Then, she identifies how the incorporation of sex and gender into research has allowed for advancements across healthcare: Improved accuracy, avoiding misinterpretation, reduced unintentional bias and greater social equity to name a few.

In this presentation, Kelly Thompson refers to case studies to examine the differences in the interpretation of health data when examining through a sex and gender research lens.

The severity of disease, risk factors and treatment effectiveness are just a few of the reasons why this is so important.

Kelly encourages researchers to ensure gender diversity in the research team and to explain how sex and gender are accounted for in research applications moving forward.

For more head to: codachange.org/podcasts/

Vascular Access Part 1: Reducing risk and increasing catheter longevity The aim of having a structured decision matrix in the approach to vascular access is to reduce catheter-associated complications and to increase device longevity. There are over 15,000 central venous catheters placed in Australia annually. The actual insertion process for placing a central line only accounts for a small part of the 'life span' of that line (approximately 1%), but the choices made at the time of insertion have a huge impact on the longevity of the device and the associated complications. In this introductory talk Evan Alexandrou outlines the top ten tips for reducing complications associated with vascular access devices:

1. Always use ultrasound: Never do a blind puncture
2. Ensure with the site chosen for the catheter that it exits the skin on a flat surface.
3. Consider the Axillary vein in preference for the subclavian vein
4. Use micro-puncture techniques
5. Avoid using a scalpel if possible
6. Avoid catheters being inserted all the way to the hub
7. Use impregnated dressings when possible
8. Use sutureless securing techniques
9. Secure the dressing on a flat surface (refer rule 2)
10. Ensure optimal positioning of the catheter tip by utilising ultrasound or intracavitary ECG

We hope you enjoy part 1 of the Vascular Access series: Reducing risk and increasing catheter longevity by Evan Alexandrou. For more head to: codachange.org/podcasts

From #CodaZero Live, Varun Harish provides an overview of the surgical management of burn injuries.

He talks us through how surgeons make decisions regarding burn management, including the importance of early assessment and intervention.

Burns evolve, what you see at the beginning is going to be very different in 24 hours and different again in three days.

Importantly, the management and principles of intervention differ for minor burns compared to severe burns.

For smaller burns, the golden rule is two weeks. If there is a good chance that the burn will heal in two weeks, intervention is avoided. If this is not the case, intervention in the way of a skin graft or other surgical procedure is usually the best option.

Varun details how the management priorities shift for larger burns. Larger burns significantly increase the chances of infection, making it important to intervene earlier rather than later.

Tune in to an interesting talk on the Surgical management of burn injuries by Varun Harish.

For more head to: codachange.org/podcasts

Global warming and the Jellyfish toxidrome.

From #CodaZero Live, Alice Young provides a brief update on the presentation, complications and management of Irukandji syndrome; and why we all need to know about it.

With ocean temperatures rising we are seeing an increasing number of Irukandji jellyfish and subsequent stings in waters further and further south.

On average there are approximately 50-100 people stung every year in Australia.

Reports show that people typically experience symptoms between five minutes and two hours post sting. Symptoms include systemic symptoms, severe pain, headaches, shortness of breath and often what is described as an impending sense of doom.

Irukandji jellyfish have the potential to cause Irukandji syndrome - a life threatening envenomation syndrome that causes severe pain, heart failure and intracranial haemorrhage.

As these jellyfish stings are becoming more and more common in southern regions of Australia, it is important that healthcare workers understand the characteristics of the sting and how to respond with treatment.

Listen to the full episode "Global warming and the Jellyfish toxidrome" wherever you get your podcasts.

For more head to: codachange.org/podcasts

Did you know that around a third of patients that present with a severe burn, also have a pre-existing mental health condition? Furthermore, around 80% of patients report having had a major life event or severe stress prior to the burn. Psychological management of patients with burns is complex and so important. This talk will help you discover if all burns are traumatic, how and why a trauma-related disorder may evolve and increase your understanding of how trauma responses can interfere with many aspects of physical and psychological recovery. How do we give our patients some control back in situations where they have no control over what is happening to them? How do we help our patients manage the rehabilitation process? Crucially, how do we support our patients through their journey of acceptance and loss? Tune in to a discussion by A/Prof Caryl Barnes on the Psychological Management of Burns. For more head to: codachange.org/podcasts/