TTHM a2.2 Grand Rounds (7/29)
10a ~ Approach to Clinical Questions & Critical Review of Therapy Articles (Wojcik)
*BMA TXA article http://www.bmj.com/content/345/bmj.e5839 (from CRASH2 data)
Randomized studies: “intention to treat” versus “per protocol” ~ switching groups?
Odds Ratios show bigger effects in more common phenomena, more comparable to Relative Risk in rarer phenomena such as deaths in trauma.
*Odds Ratio https://en.m.wikipedia.org/wiki/Odds_ratio
*Relative Risk https://en.m.wikipedia.org/wiki/Risk_ratio
*Absolute Risk Reduction https://en.m.wikipedia.org/wiki/Absolute_risk_reduction
*Number Needed to Treat https://en.m.wikipedia.org/wiki/Number_needed_to_treat
Later will evaluate Diagnosis Articles…
11a ~ Airway Emergencies (Johnson)
Have your team with at least 4 roles (intubator, Resp Ther/bag, Cspine, cric&meds…)
Choice of Meds for:
*Blunt Trauma VSS
*Blunt Trauma Shock
*% that Fail?! 3-3-2 neck eval & Mallampati 1-4… OPAs & NPAs?
Try to get the view right away & don’t lose it!
Cric if needed! Atropine to prevent vagal response if 1:1:1 > 1:1 > PRBC… Colloids & Crystalloids… (frozen, fridge, & freeze dried products ~ FDP)… LR less acidosis so Military gives LR > NS (even with PRBCs).
How much blood before you give some Calcium? (every 4th unit in military)…
US in helicopter can look at RV & optic nerve… Special Operations Ultrasound Training
Portable ETcapno & O2 Sats, with pulse checks…
*Things for next shift… or not…
Safety Pins for the tongue to clear airway… “100 uses for a safety pin”… makes great suture replacement! Ketamine finally coming back. In Africa, they have antimalarials & ketamine. Raising ICP? …or might improve CPP? Ketamine can be USED to TREAT Ketamine or other emergence phenomena…
No ketamine to kids under 3? or known schizophrenia? military burn pts? Does not cause PTSD… “Retrieval medicine pts” get ketamine in Australia… don’t always get intubation!
*Pts on ketamine with trauma can still be hemodynamically unstable, hypotense…
*Great for opiate induced hyperalgesia/dependence. Can use IV, IM, or IN… Neb?
1200mcg Fentanyl lollipops… minimal PCA risk…
Special Ops use IOs… Tibia in hospitals… but field ops use “FAST1″ (green needle) at sternum.
Yellow (long) needle humerus vs Blue (medium) needle tibia. Only special smaller needle for sternum. Pink (short) needles for Peds & puppies.
Which tourniquet is the best tourniquet? ~ The one you have.
+”Plus One” loose proximal extra tourniquet. Venous Tourniquets dangerous too.
+ Pain Control & hemostatic agents
+ Time Mark: 6hrs ~ irreversible damage. Don’t remove from pt in shock!
230p ~ Emergency Ethics (Brenner)
ELSIM, Clinical BioEthics, Center for BioEthics & Humanities, Ethics Consult Service, ACEP Ethics Committee
Rapid Decision Making Model:
*Already a rule that applies?
*Is there an option to buy time?
*Impartiality test ~ what would you want? (Golden Rule)
*Universality test ~ would everyone approve?
*Interpersonal Justifiability test ~ could you justify actions to peers c good reason?
EMTALA: #1 Law governing the U.S. practice of EM.
Zink, “Anyone, Anything, Anytime”…
1968 ~ ACEP (vs AMA)
1989 ~ ABEM recognized by ABMS.
Good Samaritan Laws do afford some protections but vary across jurisdictions.
NY Safe Act 9.46 Mental Hygeine Law
Impaired Drivers ~ No law NYS; Mandatory: CA, DE, NV, NJ, OR, PA…
ID Reporting ~ NYS DOH requirements…
NYS Surrogate Decision Makers, differs by Jurisdiction: https://www.health.ny.gov/publications/1503.pdf