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Wed Jul 16 18:12:51 BST 2003

Thanks for your comments Mark - specific comments below to the many points
you raise. Plenty to discuss!

John

-----Original Message-----
From: MARK FORREST [mailto:atacc.doc at virgin.net] 
Sent: 16 July 2003 00:50
To: Trauma & Critical Care mailing list
Subject: Re: Motor cyclist trauma scenario - outcome

Dear John,
A sad case but one that highlights many pre-hospital and in-hospital
problems, especially in the UK.

Air ambulances remain a very limited and expensive resource in the UK and as
such their value should be optimised:

- most valued transport resource should carry most valuable trauma
practitioner.
 This will obviously involve a degree of compromise as staffing the aircraft
with consultant thoracic surgeons is both unrealistic and probably far from
ideal. However, the medical crew should have all of the 'front-line' resus
room skills (ie those skills required within the first 10-20 minutes of
arrival in A&E). This obviously includes RSI, advanced airway skills,
advanced assessment skills and possibly thoracotomy and the ability to cross
clamp and aorta (wow, discuss!!!).

In addition 'finger thoracostomy' in positively ventilated patients should
be a mandatory core skill for flight crews - needle thoracocentesis is too
unreliable. 
-Aircraft must land 'on-site'.
 Unfortunately, many UK hospitals use the RAF designated landing sites which
are frequently simply local fields, requiring a further transfer and a road
journey before hospital. Use of such sites also potentially endangers both
the aircraft,  aircrew and the general public. I am aware of one UK site
where an aircraft was stoned by youths who objected to being moved on by the
police. Proper designated hospital sites can then avoid communication
failures by direct communication to the hospital.

Immediate access to land ambulance for secondary transfer cannot always be
relied upon because of demands/pressures on the ambulance services.....

There are significant hazards in loading and unloading patients from
aircraft and vehicles - this type of handling needs to be kept to a minimum.

Communication failure was compounded by the fact that 3 different ambulance
services were involved in responding to and coordinating this incident.

- Aircraft must be of a suitable size:
Whilst maintaining manoeuvrability in confined landing areas, the aircraft
should allow sufficient access to the patient to perform airway management,
thoracostomy, cannulation etc and also enough room for more than one trauma
carer. Many UK air ambulances do not meet this standard. I agree!

This patient was hypoxic, had signs of aspiration, life-threatening
abdominal bleeding, possible chest trauma and a catastrophic head injury.

He clearly needed the earliest possible definitive airway and control of his
ventilation (EtCO2).
Once intubated or during any air transfer close monitoring was essential for
signs of tension developing...how long had the tension been present?
Did he ever have a chest injury or was it produced by the thoracocentesis
and exacerbated by ventilation?

My personal view is that without access to resuscitation room interventional
skills at the scene that it would have been far safer to have transferred
this patient to the nearest emergency department by road - there would have
been a much higher chance of maintaining the patient's airway and
recognising and managing tension pneumothorax in the road ambulance. I do
not know how much on scene time was lost waiting for the air ambulance
........

Was time lost performing DPL rather than FAST? No

This patient arrived in the early evening and there was not immediate access
to FAST at time - no dedicated U/S stored in the ED (another systems
failure!). This was compounded by a junior surgeon only being immediately
available to attend this patient who was reluctant to operate.....

Fluids used for resuscitation? 

He received no fluid (no IV access established) until he received blood on
arriving at the helipad while waiting for a vehicle for secondary transfer.
Cardiac out quickly restored post intubation/thoracostomy etc

- did they pop the clot??
- in the exsanguinating patient which is more important  permissive
hypotension or CPP?
- if exsanguinating where you unable to keep up with blood loss?
- would hypertonics been more effective in maintaining any kind of blood
pressure until into theatre. They can be given through small lines and are
rapidly effective at restoring a pressure (and may also have helped head
injury if he survived)?
-Was x-clamping the aorta an option or was the lesion too high? 

This would have been undertaken if there had been a surgeon willing to
operate immediately........

Air ambulance transfer was taken to provide the best definitive care,
however the logistics of the transfer had not been planned out effectively
in the 'cold light of day' and the landing site issues seriously compromised
the patient. In addition, with the 'retrospectoscope' the general surgeon in
the DGH could have performed a DPL and the necessary laparotomy . At this
stage the head injury was a secondary issue.

As for acceptable time for road transfer without RSI/def airway; - well no
time is the answer as such an airway is clearly essential in this patient,
only option may have been LMA with IPPV, but the fact that aspiration
already appears to have occurred raises obvious concerns about this
approach. However, a contaminated airway with ventilation is better than no
airway! Bottom line is that he needed someone who could perform RSI and
intubation rapidly and effectively during transfer to definitive surgery.
(RSI should not take more than 2 or 3 minutes, including any attempt at
pre-oxygenation).

Again in the absence of RSI, I think the only correct option was to take him
unintubated to the nearest hospital and to accept the 2 hour turn around in
setting up secondary transfer to a tertiary centre if required....

Best wishes
Mark F

----- Original Message -----
From: "Black, John" <John.Black at orh.nhs.uk>
To: "'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>
Sent: Tuesday, July 15, 2003 5:30 PM
Subject: Motor cyclist trauma scenario - outcome

The patient was rapidly packaged and hot loaded (rotors running) on to an
air ambulance without the resources for RSI. The patient was flown to the
nearest multidisciplinary hospital (12 minutes). Because of a predictable
communication failure, and the fact that the helipad is several hundred
yards away from the ED, there was no land ambulance available for immediate
secondary transfer.

The patient was obtunded and was intubated by the flight paramedics shortly
after landing (without drugs). Part of the trauma team was despatched on
foot to the helipad with mobile medical team trauma packs; bilateral
thoracostomies performed, right chest under tension (post intubation).
Patient was transfused and central pulse restored whilst waiting for
secondary land ambulance transfer. Patient remained very unstable
haemodynamically on arrival in the ED and had a positive DPL but died prior
to transfer to the operating theatre.

PM principle findings: Base of skull/vault fracture, tight swollen brain
with bilateral temporal lobe contusions, there was a large small bowel
mesentery laceration with free intra-peritoneal bleeding. No major
intra-thoracic injury identified.

Such critically injured patients are frequently transported regularly in the
UK by aircraft without access to definitive airways etc, because there are
not always the resources at the scene required for drug assisted
intubation/finger thoracostomy etc, and because of a logical desire to get
patients to hospital as quickly as possible ('the Golden Hour' principle).

The hazards of rapid air ambulance transfer frequently out weigh the
benefits in terms of rapid transport to hospital as I believe this case
illustrates - although this is not currently widely accepted on the basis of
existing practice.

If you accept that patients with airway obstruction (requiring an airway
adjunct for airway maintenance) and hypoxia despite high flow oxygen are
relative contraindications to air transport, unless there are the resources
for resuscitation room interventions at the scene (RSI etc), up to what
transport time would you accept by road as an alternative in the multiply
injured patient?

What strategies could you recommend for persuading a cash strapped NHS
Hospital Trust that having a helipad within close proximity to the Emergency
Department is absolutely essential for any hospital offering definitive
multidisciplinary trauma (and regional ITU) care?

In terms of what to do in the field following emergency thoracocentesis, I
personally would advocate that it is always removed as it is likely to
enlarge any underlying pneumothorax if it is indeed still patent and in the
pleura in the spontaneously ventilated patient, and if not is likely to
create a false sense of security in the attendants. In patients who are
subsequently ventilated, the threshold for thoracostomy should be very low.
On arrival in hospital the CXR (or CT!) will guide the need for further
intervention.

John Black

-----Original Message-----
From: Walter.Mauritz at auva.sozvers.at [mailto:Walter.Mauritz at auva.sozvers.at]

Sent: 15 July 2003 06:31
To: trauma-list at trauma.org
Subject: AW: Anesthesia and Hypotension

Stephen,

The patient (as John decribed him) was unconscious, but had vomited. This
implies that he still had some reflexes, and intubation without relaxants
would be difficult. To intubate brain trauma patients  with the use
relaxants but without anesthesia is an excellent model for increasing
intracranial pressure - something we would like to avoid.
I agree as far as the possible pneumothorax is concerned - I would leave the
neede in place, too, and wait for a chest Xray.

best regards

Walter Mauritz

-----Ursprüngliche Nachricht-----
Von: Stephen R. [mailto:usafmedic45 at hotmail.com]
Gesendet am: Montag, 14. Juli 2003 17:32
An: trauma-list at trauma.org
Betreff: Re: Anesthesia and Hypotension

My thought process here is that this patient is unconscious and has unknown
intraabdominal or intrathoracic pathology going on.   Why would there be a
need for anesthesia?  This patient is unconscious....even the need for a
paralytic is uncertain (unless I missed somewhere that this patients jaws
are clenched or he has a gag reflex).  At most this patient needs a dose of
succinylcholine (or, as I prefer, vecuronium).

As for everyone assuming that this patient has a pneumo.....this patients
breath sounds are crackles with good air entry bilaterally.   There is no
evidence of the existence of the pneumo  which everyone (especially my
prehospital colleagues) seem hell bent on finding.  Just as "not all that
wheezes is asthma" in a medical patient, "not all that is diminished,
decreased, crackly, coarse or otherwise messed up in the breath sounds is a
pneumo" in a trauma patient.  I am not advocating! pulling out the already
placed thoracostomy. Leave it in until hospital and a chest film that
diagnoses definitely yea or nay on the issue of a pneumothorax.  But then
again this is just my two cents, and I am just a respiratory therapist, what
do I know about lungs?  *Laughs*

Stephen L. Richey, CRT, EMT-I/D, ERT, FF

  _____

Help STOP SPAM with the new MSN  <http://g.msn.com/8HMUENUS/2731??PS=> 8 and
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