Coda Change

The Force is strong with this one… Despite years of research and new technology, the adjusted mortality rate for traumatic brain injury remains near 25%. Currently, primary injury occurs before we can intervene, and all our pre-hospital, ED and ICU care is directed towards preventing remarkably complicated and poorly understood secondary injuries.

TBI is a heterogenous group of diseases often treated homogenously. You too can master the ways of the Force, by reviewing the Top 10 items you need to know to care for your next patient with a severe traumatic brain injury. Topics covered will include the most up to date evidence, anticoagulation reversal, early aggressive care, and future directions. Become a master of this complicated disease process in your clinical practice.

Neurologically intact recovery after out-of-hospital cardiac arrest remains dismal. In the United States, an 8% meaningful recovery rate is hopeful at best. The introduction of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR) is not new but has been shown to provide upwards of 27-30% meaningful recovery, when applied to the appropriate patient population. In 2011 we began extracorporeal CPR (ECPR) in our emergency department - a suburban non-academic center in San Diego, California, USA; the results have been very promising. As a result, we also began refining all aspects of resuscitation. What specific things did we change about the way we do resuscitation?Proper preparation of the resuscitation suite: If we assume the patient will end up on ECMO, then early femoral vessel access is the priority. Traditional paramedic offloading was problematic for many reasons. To address that we:attempt transfer of the patient from medic gurney to hospital gurney in the ambulance bay, where there is more room.When ‘CPR ala fresca’ isn’t possible, we bring the patient into the resuscitation room on the right side of the room, which allows the doctor accessing femoral vessels to be sterile-prepped with ultrasound in-hand.Early femoral arterial transduction to guide the resuscitationHemodynamic-Directed Dosing of Epinephrine intra-arrestNurse Code-Team Leader: assign the rote elements of the code, the ACLS protocols, to a trained nurse code team leader. This provides physician cognitive offload.Use a mechanical chest compression deviceUse an Impedence Threshold Device:increases venous returndecreases intracranial pressure (ICP)increases coronary perfusion pressure (CPP)

Does any of this make a difference? Well, review of CARES data (U.S.-based cardiac arrest registry) shows that the 2014 arrest recovery rate, with meaningful neurologic outcome, at our hospital was almost double that of the nationwide data. And of the 50 patients included in the CARES database for our hospital, only 4 of those were resuscitated with ECPR. Perhaps we are just paying better attention and providing better overall care throughout the resuscitation. Perhaps we can all improve our resuscitation outcomes.

Reuben Strayer takes us through the myriad uses of Ketamine, and dispells some myths in the process. A Special K classic.

Is Suspended Animation only in the realms of science fiction, or is this a realsitic treatment option? Mervyn Singer questions if we can prevent secondary reperfusion injury following cerbral ischaemia.

In Coping with Isolation - All alone on Kangaroo Island, Tim talks with brutal honsety about the reality of being a rural doctor.

Oli Flower brings lessons from cage fighting that are relevant to all health care professionals. Be open minded about this one!

Christine Bowles takes on the big issue of Sex in critical care. In 2015, why is sexual equality in the workplace even an issue and how can we address it?

Roger Harris shows us just how complex decisions about resuscitation can be and when stopping can be the right thing to do.

Chris Nickson challenges us to examine lessons that are 150 years old

ENT surgeon Georgie Harris takes you through a logical approach to managing the horrific scenario of a transcected airway