The final one is the most contentious: Pharmacologically assisted laryngeal mask insertion: a consensus statement(1). Here is the summary:
The PALM technique is an acceptable tool for managing the prehospital airway
The PALM technique is indicated in a rare set of circumstances
The PALM procedure is a rescue technique
The PALM procedure should be checklist driven
At least a second generation SAD should be used
End-tidal CO2 monitoring is mandatory
No preference is expressed for any particular drug
No preference is expressed for any particular dosing regime
Flumazenil is highly unlikely to have a role in managing the PALM patient
The PALM procedure should only be carried out by practitioners of level 7 or above competences
The availability of a trained assistant, familiar with the procedure would be advantageous
The training required to achieve competency in performing the PALM procedure must include in-hospital insertion of SADs, simulation training and training in the transfer of critically ill patients
Data should be collected and collated at a national level for all patients who receive the PALM procedure
They qualify the first point with the statement: The consensus group felt that, in the hands of a specific set of practitioners and in certain circumstances, patients would benefit from the technique. It was recognised that pre-hospital airway management can be very challenging, and deeming the technique unacceptable could deprive patients of a potentially life saving intervention. It was felt that having another tool available to clinicians which could potentially improve patient outcome was important. This was despite the lack of a robust evidence base. It was felt that the technique is indicated in, and should be limited to, a very specific set of circumstances as described below
The publication lists some ‘Organisations represented at the consensus meeting’, which include some commercial training and equipment companies.
It also states that ‘The Royal College of Anaesthetists, although represented at the initial meeting, was unable to support the outcomes agreed by the other represented organisations.‘
This is a very interesting development. I can see the pros and cons of this. Since practitioners are out there doing PALM anyway, it is in the interests of patients to produce a statement that encourages monitoring, checklists, training, and data collection. To meet all the requirements, one must undergo ‘training in the transfer of critically ill patients’, which would normally necessitate more advanced airway and anaesthesia skills anyway.
A tough one – what would you want if there was no RSI capability but you were hypoxic with trismus and basic airway maneouvres were failing? An all out ban on PALM, or PALM provided by someone trained in surgical airway if it fails (as per the consensus recommendations)?
This and some of the other statements can be downloaded in full at the Faculty of Pre-hospital Care site
1. Pharmacologically assisted laryngeal mask insertion: a consensus statement Emerg Med J. 2013 Dec;30(12):1073-5
Two popular pelvic compression devices are the SAM Pelvic Sling II and the T-POD®.
In a direct comparison 50 health care volunteers secured both devices correctly 100% of the time.
The SAM Pelvic Sling II was quicker to apply, but participants preferred the T-POD®.
The authors conclude that very little separates the devices. Pelvic circumferential compression devices (PCCDs): a best evidence equipment review Eur J Trauma Emerg Surg (2012) 38:439–442
[EXPAND Click for abstract]
Purpose Traumatic disruption of the pelvis can lead to significant morbidity and mortality. ATLS® guidance advocates temporary stabilisation or ‘closure’ of the disrupted pelvis with a compression device or sheet. We undertook a best evidence equipment review to assess the ease and efficacy of the application of two leading commercially available devices, the T-POD® and the SAM Pelvic Sling™ II.
Methods Fifty health care professionals and medical students participated in pelvic circumferential compression device (PCCD) education and assessment. Participants received a 10-min lecture on the epidemiology and aetiology of pelvic fractures and the principles of circumferential compression, followed by a practical demonstration. Three volunteers acted as trauma victims. Assessment included the time taken to secure the devices and whether this was achieved correctly. All participants completed a post-assessment survey.
Results Both devices were applied correctly 100% of the time. The average time taken to secure the SAM Pelvic Sling™ II was 18 s and for the T-POD®, it was 31 s (p ≤ 0.0001). Forty-four participants (88%) agreed or strongly agreed that the SAM Pelvic Sling™ II was easy to use compared to 84% (n = 42) for the T-POD®. Thirty-nine participants (78%) reported that they preferred and, given the choice in the future, would select the T-POD® over the SAM Pelvic Sling™ II (n = 11, 22%).
Conclusions The results of this study indicate that both PCCDs are easy and acceptable to use and, once learned, can be applied easily and rapidly. Participants applied both devices correctly 100% of the time, with successful application taking, on average, less than 60 s.
Notes from Days 2 & 3 of the London Trauma Conference
Day 2 of the LTC was really good. There were some cracking speakers who clearly had the ‘gift’ when it comes to entertaining the audience. No death by PowerPoint here (although it seems Keynote is now the presentation software of choice!). The theme of the day was prehospital care and major incidents.
The golden nuggets to take away include: (too many to list all of course)
‘Pull’ is the key to rapid extrication from cars if time critical from the Norweigan perspective. Dr Lars Wik of the Norweigen air ambulance presented their method of rapid extrication. Essentially they drag the car back on the road or away from what ever it has crashed into to control the environment and make space (360 style). They put a paramedic in the car whilst this is happening. They then make a cut in the A post near the roof, secure the rear of the car to a fire truck or fixed object with a chain and put another chain around the lower A post and steering wheel that is then winched tight. This has the effect of ‘reversing’ the crash and a few videos showed really fast access to the patient. The car seems to peel open. As they train specifically for it, there doesn’t seem to be any safety problems so far and its much quicker than their old method. I guess it doesnt matter really how you organise a rapid extrication method as long as it is trained for and everyone is on the same page.
Dr Bob Winter presented his thoughts on hangings – to date no survivor of a non-judicial hanging has had a C-spine injury, so why do we collar them? Also there seems no point in cooling them. All imaging and concern for these patients should be based on the significant soft tissue injury that can be caused around the neck.
Drownings – if the patient is totally submerged probably reasonable to search for 30mins in water that is >6 degrees or 90mins if <6 degrees. After that it becomes a body recovery (unless there is an air pocket or some exceptional circumstance). Patients that have drowned should have early ventilatory support if they show any signs of resp distress.
Drs Julian Thompson and Mark Byers reassured us on a variety of safety issues at major incidents. It seems the risk to rescuers from secondary bombs at scene is low. Very few terrorist attacks world wide, ever, have had secondary devices so rescuers should be reassured (a bit). Greatest risk to the rescuer, like always, are the silly simple things that are a risk every day, like tripping over your own feet! With reference to chemical incidents, simple PPE seems to be sufficient for the vast majority of incidents, even fairly significant chemical ones, all this mucking about in full air tight suits is probably pointless and means patients cant be treated (at all). This led to the debate of how much risk should we, as rescue staff, accept? Clearly there are no absolute answers but minimising all risk to the rescuer is often at conflict with your ability to rescue. Where the balance should lie is a matter for organisations and individuals I guess.
Sir Prof Keith Porter also gave us an update on the future of Prehospital emergency medicine as a recognised medical specialty. As those in the know, know, the specialty has been recognised by the GMC and the first draft of trainees are currently in post. More deaneries will be following suit soon to begin training but it is likely to take some time to build up large numbers of trained specialists. Importantly for those of us who already have completed our training there will be an option to sub specialise in PHEM but it will involve undertaking the FIMC exam. Great, more exams – see you there.
Day 3 – Major trauma
The focus of day 3 was that of damage control. Damage control surgery and damage control resucitation. We had indepth discussions about how to manage pelvic trauma and some of the finer points of trauma resuscitation.
Specific points raised were:
Pelvic binders are great and can replace an ex fix if the abdomen needs opening to fix a spleen for example.
You can catheterise patients with pelvic fractures (one gentle try).
Most pelvic bleeds are venous which is why surgeons who can pack a pelvis is better than a radiologist who can mainly only treat arterial bleeds.
Coagulopathy in trauma is not DIC and is probably caused by peripheral hypoperfusion.
All the standard clotting tests that we use (INR etc) are useless and take too long to do. ROTEM or TEG is much better but still not perfect.
Also, as I am sure will please many – pressure isn’t flow so dont use pressors in trauma!
Chris Hill is an emergency and prehospital care physician based in the United Kingdom
For me, this is one of those ‘why didn’t I think of that?!’ studies… extending the FAST scan to measure pubic symphyseal widening to detect open-book pelvic fractures. A pubic symphysis width of 25 mm was considered positive; the authors state that this width is considered diagnostic for anterior-posterior compression fracture of the pelvis in the non-pregnant patient.
Since only four of the 23 patients studied had radiological widening, the authors’ conclusions make sense: Further study with a larger cohort is needed to confirm this technique’s validity for diagnosing PS widening in APC pelvic fractures.
A reasonable question might be: ‘so what?’, especially if pelvic binders are routinely applied to polytrauma patients and radiographs are rapidly obtained. However as a retrieval medicine doctor working in remote and austere environments I wonder whether this could be useful to us. Perhaps if combined with this intervention?
BACKGROUND: The focused abdominal sonography in trauma (FAST) examination is a routine component of the initial work-up of trauma patients. However, it does not identify patients with retroperitoneal hemorrhage associated with significant pelvic trauma. A wide pubic symphysis (PS) is indicative of an open book pelvic fracture and a high risk of retroperitoneal bleeding.
STUDY OBJECTIVES: We hypothesized that an ultrasound image of the PS as part of the FAST examination (FAST-PS) would be an accurate method to determine if pubic symphysis diastasis was present.
METHODS: This is a comparative study of a diagnostic test on a convenience sample of 23 trauma patients at a Level 1 Trauma Center. The PS was measured sonographically in the Emergency Department (ED) and post-mortem (PM) at the State Medical Examiner. The ultrasound (US) measurements were then compared with PS width on anterior-posterior pelvis radiograph.
RESULTS: Twenty-three trauma patients were evaluated with both plain radiographs and US (11 PM, 12 ED). Four patients had radiographic PS widening (3 PM, 1 ED) and 19 patients had radiographically normal PS width; all were correctly identified with US. US measurements were compared with plain X-ray study by Bland-Altman plot. With one exception, US measurements were within 2 standard deviations of the radiographic measurements and, therefore, have excellent agreement. The only exception was a patient with pubic symphysis wider than the US probe.
CONCLUSION: Bedside ultrasound examination may be able to identify pubic symphysis widening in trauma patients. This potentially could lead to faster application of a pelvic binder and tamponade of bleeding.
Splinted any pelvises lately? Karim Brohi’s excellent trauma.org article outlines the strengths and weaknesses of the different devices on the market. One such is the T-POD, which has now been described in a small series in which its application to patients with unstable pelvic injury was associated with improved haemodynamics and decreased symphyseal diastasis.
Here’s a video demonstrating application of the device.
Some patients with life-threatening arterial haemorrhage from a pelvic fracture may be peri-arrest prior to transfer to the angiography suite. French authors describe their use of a balloon catheter to occlude the infrarenal aorta to allow resuscitation to achieve sufficient stability for the transfer. As well as exsanguinating pelvic haemorrhage, intra-aortic balloon occlusion has already been described for the treatment of hemorrhagic shock in the case of ruptured abdominal aortic aneurysm, in abdominal trauma, in gastrointestinal bleeding, and in postpartum hemorrhage.
Features of note regarding the technique include:
it can be done blind (without radiological guidance)
it can be done prior to transfer to a centre with interventional radiology
it can be done in cardiac arrest (and has resulted in ROSC and subsequent survival)
The authors are at pains to point out that the intra-aortic balloon occlusion method described in the study ‘should be reserved to patients in critically uncontrollable hemorrhagic shock (CUHS) and is not a first-line treatment of pelvic fractures in hemorrhagic shock.’ Intra-Aortic Balloon Occlusion to Salvage Patients With Life-Threatening Hemorrhagic Shocks From Pelvic Fractures J Trauma. 2010 Apr;68(4):942-8.