PHEMCAST

From: https://www.bbc.co.uk/news/uk-wales-46441129

From: https://www.ultimatekilimanjaro.com/blog/should-i-use-supplemental-oxygen-on-kilimanjaro/

This is one of the organisations Lucy mentions: British Exploring

And this is the Global Health MSc

The Wilderness Society Guidelines are available here.

This is the link to the Wilderness Medical Society.

Consensus statement from the UIAA on People with Pre-Existing Conditions Going to the Mountains, and their website for more useful resources.

Li Y, Zhang Y, Zhang Y. Research advances in pathogenesis and prophylactic measures of acute high altitude illness. Respiratory Medicine. 2018; 145: 145-152. https://doi.org/10.1016/j.rmed.2018.11.004

The Faculty of Prehospital Care have also published guidance on the Medical Provision for Wilderness Medicine. Thanks to Dave Hillebrandt for sharing this with us.

Drowning is important: 1,000 people drown every day, 2 every 3 minutes, 41 per hour. It is the world’s 3rd leading cause of accidental death: 3.6 million people over 10 years.

Disease of youth

• 64% < 30 years old
• 43% < 15 years old
• 25% < 5 years old

Male: female ratio 2:1

In 40%, alcohol is on board

Initial Responses/Sudden Death (first 3-5 min)

• Skin cooling

Short-Term Responses (5-30 min)

• Superficial Nerve and Muscle Cooling

Long-Term Responses (30 min +)

• Cooling of deep tissues

Post-immersion (during rescue)

• Collapse of arterial pressure
• Continued cooling

Lethal aspiration of salt water 22ml/kg (approx 1.5 litre), fresh water 44ml/kg

Be aware that drowning can take up to 4 hours – observe and watch for 6!

Better outcomes:

• Rescued and BLS commenced < 5-10 min
• Children
• Those who have not aspirated
• Water temperature < 10 oC, core body temperature 33-35 oC
• Neurologically intact on arrival at hospital
• Minimum blood pH > 7.1, blood glucose < 11.2mmol/L
• ROSC on scene
• Spontaneous ventilation in ED

Worse prognosis

• Risk of death or severe neurological impairment after hospital discharge is reported to be nearly 100% when the duration of submersion exceeds 25 min
• Following 30 mins resuscitation, if no signs of life, resuscitation is futile -> stop

It is important to remember that casualties who have entered water sometimes have access to a “bubble” of air – particularly if they had entered the water following a boating incident or were in a car at the point they entered the water. In these circumstances it is impossible to judge the point at which submersion has occurred. 

This is a regular point of discussion and concern. Water temperature is a key determinant: icy versus not. In the UK sea water is very unlikely to be icy or cold enough – however, small areas of water may well be, particularly in the winter months. 

• Szpilman D, Bierens JJ, Handley AJ, Orlowski JP (2012) Drowning. New Engl J Med. 366: 2102–10. 
• Tipton & Golden (2011). Decision making guide for immersion incidents involving total (head under) submersion. Resuscitation. 82: 819-824.
• Golden & Hervey, 1981 
• Oakley & Pethybridge, 1997
• Tipton 2016
• Bierens 2014. Handbook of Drowning.

https://phemcast.co.uk/wp-content/uploads/2020/05/covid-02-05-2020-18.41.mp3

Current case definition for COVID-19 can be accessed here.

This is the Emergency Medicine Specialty guide we discussed in the podcast, which includes use of the NEWS and 40 step test (edit: since recording the podcast yesterday (!) we’ve been made aware of the Sit to Stand test). Here is a review of both if you’d like to read more.

As at May 1st, the advice from PHE is ‘There is currently sustained transmission of COVID-19 throughout the UK as defined by the four nations Public Health experts, therefore there is an increased likelihood of any patient having coronavirus infection. Therefore, whilst in this phase all patient contacts require level 2 PPE in accordance with Table 4‘: T4_poster_Recommended_PPE_additional_considerations_of_COVID-19

*Where an FFP3 mask with a non-shrouded valve is worn, it should be accompanied by a full-face visor. If a visor is not available, then a risk assessment should be carried out regarding the risk of splash to the valve. If a large splash (as opposed to droplets) does occur, then the FFP3 mask should be replaced immediately.

There are a number of PHE PPE videos available, this is the one describing donning and doffing Level 2.

From PHE Guidance for ambulance trusts: Where AGPs such as intubation are performed, PPE guidance set out for AGPs (section 8.1) should be followed (disposable fluid repellent coveralls may be used in place of long-sleeved disposable gowns). For any direct patient care of patient known to meet the case definition for a possible case, plastic apron, FRSMs, eye protection and gloves should be used. Where it is impractical to ascertain case status of individual patients prior to care, use of PPE including aprons, gloves, FRSM and eye protection should be subject to risk assessment according to local context. PPE is not required for ambulance drivers of a vehicle with a bulkhead and those otherwise able to maintain social distancing of 2 metres. If the vehicle does not have a bulkhead then use of a FRSM is indicated for the driver (additional PPE would be as for other staff if providing direct care).

For the coverall-type Level 3 PPE most commonly being used by ambulance clinicians, have a look at these two guidelines on donning and doffing.

Reference available here.

Aerosols are produced when an air current moves across the surface of a film of liquid; the greater the force of the air the smaller the particles that are produced. Aerosol generating procedures (AGPs) are defined as any medical and patient care procedure that results in the production of airborne particles (aerosols). AGPs can produce airborne particles <5 micrometres (μm) in size which can remain suspended in the air, travel over a distance and may cause infection if they are inhaled. Therefore AGPs create the potential for airborne transmission of infections that may otherwise only be transmissible by the droplet route.

The most recent assessment by WHO (2014) states that there is only consistent evidence that there is an increased risk of transmission for the following procedures: tracheal intubation, tracheotomy procedure, non-invasive ventilation, and manual ventilation before intubation as AGPs. This evaluation is based on a systematic review by Tran et al. whose review included 10 studies (5 case-control; 5 cohort), all of which investigated transmission of SARS from patients to healthcare workers in intensive care or other healthcare settings during the 2002-2003 SARS outbreaks.

First person attending scene

Subsequent attendance at scene of responder(s) trained and equipped to use level 3 PPE

Anyone who is not trained or does not have access to level 3 PPE must then withdraw from the scene.

Click here for more from the Resus Council on COVID-19.

Just before you go … something to make you smile! (thankfully the music department at Plymouth Uni have got the tech to make me sound like I can actually sing!!!)

For more on the growing evidence base around COVID-19, please have a read of this blog from our colleague, and Defence Professor of Emergency Medicine, Jason Smith.

World Health Organization. Infection prevention and control of epidemic and pandemic-prone acute respiratory infections in health care. WHO guidelines. https://www.who.int/csr/bioriskreduction/infection_control/publication/en/ (2014).

Tran K, Cimon K, Severn M, et al. Aerosol generating procedures (AGP) and risk of transmission of acute respiratory diseases (ARD): A systematic review. PloS One 2012; 7. Conference Abstract.

https://www.gov.uk/government/publications/covid-19-guidance-for-ambulance-trusts/covid-19-guidance-for-ambulance-trusts#patient-assessment

Tim Cook PPE review: https://onlinelibrary.wiley.com/doi/epdf/10.1111/anae.15071

Health Service Journal: Exclusive: deaths of NHS staff from covid-19 analysed

Infection Control and Hospital Epidemiology. Volume 31, Issue 5 May 2010 , pp. 560-561. Coronavirus Survival on Healthcare Personal Protective Equipment. Lisa Casanova (a1), William A. Rutala (a2), David J. Weber (a2) and Mark D. Sobsey (a1). DOI: https://doi.org/10.1086/652452

PLoS One. 2011; 6(11): e27932. Survival of Influenza A(H1N1) on Materials Found in Households: Implications for Infection Control. Jane S. Greatorex, 1  Paul Digard, 2  Martin D. Curran, 1  Robert Moynihan, 2  Harrison Wensley, 2  Tim Wreghitt, 1  Harsha Varsani, 1  Fayna Garcia, 1  Joanne Enstone, 3  and Jonathan S. Nguyen-Van-Tam 3 , 4 , * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222642/

https://www.nice.org.uk/guidance/ng171/resources/acute-myocardial-injury-algorithm-pdf-8717541373

https://www.nice.org.uk/guidance/ng171/chapter/3-Diagnosing-acute-myocardial-injury-in-patients-with-suspected-or-confirmed-COVID-19

See also: Clinical guide for the management of critical care for adults with COVID-19 during the coronavirus pandemic

https://phemcast.co.uk/wp-content/uploads/2019/09/infant-with-fluid-clarification.mp3

Note how a rolled towel is placed under the baby’s shoulders to allow space for the occiput and avoid flexion of the neck and airway.

From: https://www.jems.com/2017/02/28/an-overview-of-ems-pediatric-airway-management/

Video links to examples of children with signs of respiratory distress:

Example video showing a bulging fontanelle (excuse the slightly cheesy style!)

From: http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/Floppy%20Baby.htm

Sadly, NAI in under 2’s causes more than 10% of serious injuries to children.

Stigmata of possible NAI include:

Example of subconjunctival haemorrhage:

From: http://champprogram.com/question/3a.shtml

2017 NICE guidance: When to suspect maltreatment in under 18s. 

Click for UK Sepsis Trust guidance for different clinical settings. Scroll down for the Screening and Action tool for under 5s for prehospital care and ambulance services.

References regarding IM benzylpenicillin that Tim mentions:

Example of a paediatric drug calculator from WATCh.

https://phemcast.co.uk/wp-content/uploads/2019/07/back-pain_final-12072019-17.13.mp3

So, where is the Cauda Equina?

From Core EM

How does a herniated disc cause CES?

This fab infographic summarising the key points about the CES guidance was produced by @DrLindaDykes and @saspist.

Here is the full guideline from The Society of British Neurological Surgeons and The British Association of Spinal Surgeons.

NICE guidance on Low back pain and sciatica in over 16s: assessment and management

NICE clinical knowledge summary on Cauda Equina Syndrome red flags.

Thinking about posture:

https://phemcast.co.uk/wp-content/uploads/2019/03/f-psychosomatic-final-31032019-08.27.mp3

Many thanks to Suzanne O’Sullivan for her time in putting this podcast together. Her excellent books “It’s all in your head” and “Brainstorm” are well worth a read.

It is certainly one of the PHEMcast recordings which is going to change my own practice the most.

We can all find these patient’s challenging to look after – we often fail to communicate effectively and meaningfully. This is understandable as so much of our training and experience is based around the treatment of the physical condition.

The key things I took away from this interview were:

There are a huge number of terms to describe psychosomatic illness – some of which are not useful. A common nomenclature here will help communication between both health care professionals and our patients.

Psychosomatic: a physical illness or other condition) caused or aggravated by a mental factor such as internal conflict or stress.

Non-epileptic seizures  = dissociative seizures.

The terms ‘functional’ and ‘supratentorial’ are best avoided!

As always please let us know your thoughts!

https://phemcast.co.uk/wp-content/uploads/2019/03/ketfinal.mp3

Huge thanks to the team at World Extreme Medicine and WEM Cast for sharing the interview with Richard Harris.

These are a guide only, each patient will need a bespoke approach depending on their pre-existing condition, degree of cardiovascular compromise, conscious level and drugs already administered. Clearly you also need to remain within your scope of practice and the guidelines for your organisation.

Click here for an example of how ketamine can affect patients.

Know the concentration you carry!

Click here for an example of what can occur if the incorrect concentration of ketamine is administered.

https://phemcast.co.uk/wp-content/uploads/2019/01/stroke_final.mp3

The Danish mnemonic to help remember the elements of a cerebellar neurological examination:

There are lots of Youtube videos to demonstrate these signs, here are a few which I thought were particularly helpful:

Disdiadochokinesis

Ataxia

Nystagmus

Intention tremor

If you would like to read more, there is a blog post Martin and I wrote here on the subject of dizziness, including some videos demonstrating elements of the HINTS exam, and another one from the St Emlyns team.

This is the paper Martin mentions.

Want to know more about stroke thrombolysis? Have a listen to this episode from our friends over at The Resus Room.

https://phemcast.co.uk/wp-content/uploads/2018/10/head-injury_final.mp3

Quite a few of our previous podcasts include content which is relevant to this Head Injury one. Why not go back and have a listen to:

Episode 3: Hyperoxia

Episode 20: End Tidal Carbon Dioxide

Episode 28: LOST (Low Output State in Trauma)

The Munroe-Kellie Doctrine is illustrated by the following pictures:

Or, alternatively, by Elfyn’s pint of Guinness analogy!

Allows giraffes to drink from pools without a rush of blood to the head and eat leaves from trees without fainting.

This graph shows what happens to cerebral arterioles in uninjured brains, taken from Researchgate.net (Pires et al., 2013.)

Without autoregulation, in an injured brain, the arterioles will not change diameter in response to variations in blood pressure, and cerebral blood flow will have a linear relationship with blood pressure.

Cerebral perfusion pressure = Mean arterial pressure – intracerebral pressure

The diameter of the arterioles, and therefore Cerebral perfusion pressure, is also affected by extremes of oxygen and carbon dioxide. If you would like to read more about this, have a look at this Life in The Fast Lane post.

The Brain Injury Foundation guidelines which Fliss mentions can be accessed here.

Doubts over head injury studies. Roberts I, Smith R, Evans S. BMJ. 2007 Feb 24; 334(7590): 392–394. (This is the paper Elfyn mentions regarding the now redacted original publications on the use of mannitol)

Wakai A, McCabe A, Roberts I, Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD001049. DOI: 10.1002/14651858.CD001049.pub5

The HIRT trial: https://emj.bmj.com/content/32/11/869

The HITS-NS trial: The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study.

Wilson et al. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. 

Impact Brain Apnoea. https://www.ncbi.nlm.nih.gov/pubmed/27211834

…. if you would like to hear more on the subject of Head Injury – have a listen to what the Resus Room team have to say about it:

https://phemcast.co.uk/wp-content/uploads/2018/07/mi.mp3

Another invitation to the Trauma Care Conference this year inspired us to combine two of the excellent speakers into this podcast considering major incidents. Thanks to both our speakers for sharing their talks from the conference.

Trauma Care offer more than the annual conference; there are monthly webinars and regional meetings too, click here for more information.

The Joint Emergency Services Interoperability Programme (JESIP) website and National Ambulance Resilience Unit (NARU) website have lots of resources to support your response to a major incident.

The papers which Chris mentions regarding IED injury patterns and management in children are both from the Journal of the Royal Army Medical Corps:

Thompson, Crooks, Clasper, Lupu, Stapely, Cloke. The pattern of paediatric blast injury in Afghanistan.

Ramasamy, Hill, Clasper. Improvised Explosive Devices: Pathophysiology, Injury Profiles and Current Medical Management