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Monthly Pre-hospital Care Meeting

NHS. Monthly Pre-hospital Care Meeting. Welcome. 25 th January 2008. NHS. Hosted by Pre-Hospital Care ( www.pre-hospitalcare.co.uk ) and Essex Police Sponsored…… Multi-disciplinary Open forum Sharing, developing and learning CPD Range of activities – open to suggestions

Jeffrey
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Monthly Pre-hospital Care Meeting

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  1. NHS Monthly Pre-hospital Care Meeting Welcome 25th January 2008

  2. NHS • Hosted by Pre-Hospital Care (www.pre-hospitalcare.co.uk) and Essex Police • Sponsored…… • Multi-disciplinary • Open forum • Sharing, developing and learning • CPD • Range of activities – open to suggestions • Linked to international PHC projects • Networking

  3. NHS • Themed evenings • Keynote lecture (30 – 40 minutes) • Short lecture (10-15 minutes) • Case Review with discussion • Literature / Journal Review • Guidelines / practice update • Practical demonstration / sessions

  4. So you’re not an anaesthetist….. How do you manage head injuries at scene? Dr Aaron Pennell MBBS MSc Medical Advisor to Tactical Firearms Group Essex Police

  5. Objectives • Review the aetiology and pathology of brain injury • Understand the basis for current treatments • To review the current situation and recommendations • To discuss other options of managing brain injuries • To discuss how this may change in the future

  6. Aetiology and Pathology • Around a million brain injuries a year in the UK • 150 000 minor, unconscious for < 15 mins, recovery in 3-6 months • 10 000 moderate, unconscious for up to 6 hours, some long term sequlae • 11 000 severe, unconscious for > 6 hours, 4500 will need long term care • and only around 15% will return to work within 5 years • More than 120 000 people in the UK are currently suffering from the long term • effects of a brain injury • Around 2500 brain injuries a day in the UK Source: http://www.headwayessex.org.uk/facts/statistics.html

  7. Function and Anatomy

  8. Function and Anatomy

  9. Function and Anatomy

  10. Function and Anatomy

  11. Function and Anatomy

  12. Aetiology and Pathology Causes of Brain Damage Contusion Haematoma Hypoxia Diffuse Axonal Injury

  13. Aetiology and Pathology D.A.I

  14. Aetiology and Pathology D.A.I

  15. Aetiology and Pathology D.A.I

  16. Aetiology and Pathology D.A.I

  17. Aetiology and Pathology Haematoma

  18. Aetiology and Pathology Haematoma

  19. Aetiology and Pathology Haematoma

  20. Aetiology and Pathology Hypoxia and ischemia • Permanent damage to neurones occur after a few minutes if perfusion • falls below a critical threshold • Brain looses its capability to autoregulate in head injury and is particularly • vulnerable to hypoxia and ischemia • Reduction in MAP (<60mmHg) especially with > ICP causes acute damage • Brain injury causing unconsciousness causes early respiratory deterioration • and bradycardia and is a sinister cause of ischemic damage

  21. Management MAP CPP HYPOXIA

  22. Management • Early airway maintenance • Early stabilisation of gas exchange • Restoring and maintaining a functional perfusion pressure • Minimising raising intracranial pressure • RSI and Controlled ventilation • Volume & perfusion management • Pharmacological manipulation

  23. Management • Rapid Sequence Induction (of anaesthesia) • Facilitates endotracheal Intubation in those with a GCS > 3 • Permits controlled ventilation • Maximising oxygenation • Minimising increased ETC02 • Currently a ‘doctor only’ skill in the UK • Also • Seizure control • Agitation control • Makes management more controlled

  24. Management • Alternatives to RSI: • Effective airway control • LMA, OPA, NPA X2 • High flow (15lpm) 02 +/- ventilatory support • Use of benzodiazepines / opiates …….(Diazepam, Midazolam, Morphine etc) • May be beneficial for the severely agitated patient • Can have undesired haemodynamic effects if used in sufficient doses to • try and create a ‘psuedo – RSI’ • Respiratory depression – not a problem – allows for better ventilation – IF • YOU CAN MANAGE THE AIRWAY • Hypotension – will be detrimental if already a > ICP – but can use fluids to • maintain SBP ~ 80-90mmHg • This is probably a useful alternative for the non RSI trained practitioner IF • THEY HAVE THE AIRWAY AND VENTILATION SKILLS

  25. Management • Establishing and maintaining a functional perfusion pressure: • IV access • Current (sensible) debates on what type of fluid is best • Hypertonic saline • Normal Saline • Aim to maintain SBP of 90-100mmHg • Hypotension is bad ! • Cooper DJet al (2004)Prehospital hypertonic saline resuscitation of patients with hypotension • and severe traumatic brain injury: a randomized controlled trial. JAMA. 2004 Mar 17;291(11):1350-7. • Lenartova L et al (2007) Severe traumatic brain injury in Austria III: prehospital status and treatment • Wien Klin Wochenschr. Feb;119(1-2):35-45. Links • Myburgh J et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury (2007) • N Engl J Med. Aug 30;357(9):874-84

  26. Management • Pharmacological Adjuncts • Mannitol – NO • Frusemide - Maybe • Steriods – NO • Antibiotics – Maybe (meningococcal disease) • Vasoactive agents – Maybe in ICU • Seizures • Treat with benzodiazepine • Do not get fraught over resp depression – ventilate !!!

  27. Summary • Major head injuries are a challenge pre-hospital • While anaesthetic skills are perhaps ‘gold standard’ this DOES NOT • preclude the delivery of other quality interventions • Airway management and maximising oxygenation/ventilation • Use of opiates and benzodiazepines for the difficult to manage agitated • head injury (rememeer the caveats for this) • Maintaining a functional perfusion pressure • Treatment of seizures • Triage to an appropriate centre

  28. Any Questions / Discussion ?

  29. Open Discussion “Should ambulance paramedics be taught RSI”

  30. Journal Review: Strote J, Range Huston H (2006) Taser use in restraint related deaths Pre Hospital Emergency Care. 10:4 447-450

  31. Case series of TASER related deaths – convenience sample • 2001 – 2005 • Identified through internet search – PM reports requested • Analysed for • Demographics • Pre-existing cardiac disease • Toxicology • Evidence of excitable delirium • Restraint techniques used • Listed cause of delirium

  32. 75 cases identified • 37 PM reports available • All male 18 – 50 years • CV disease found in 54.1% • Toxicology for illicit drugs found in 75.7% • TASER considered a contributory case of death in 27% • Cause of death: • Intoxication/stimulant 18 (48.6%) • Cardiac Arrest/arrhythmia 12 (32.4%) • Excitable delirium 3 (11.1%) • Positional Asphyxia 2 (5.4%) • CCF 1 (2.7%) • Undtermined 1 (2.7%)

  33. Discussion • Used standard search engines to seek data! • Role of: • a) Restraint techniques • b) Toxicology • c) Pre-existing disease

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