Recommended Research?
What research would help Medics on the ground provide better care to sick patients in an austere, environment today? Has anyone ever told you any dogma that you hear but question and can’t find studies for such as; less than 8 intubate, trendelenberg position for hypovolemic patients, etc.? We have the opportunity to make some of this research happen and use real science to find the best practice for our patients. We simply need ideas and suggestions for research to be conducted.
In every basic medic course, the recommanded position of an unconsious casualty with a dressed open chest wound, is the recovery position with the injured side down. The reason for that are :
Pressure from contact with the ground acts somewhat like a splint to the injured side and helps to reduce pain. (If you position the casualty with his uninjured side toward the ground, the weight on the uninjured side might makebreathing difficult for the casualty.)
Now I followed a course a few months ago, and a doctor told me that a unconcious casualty with a dressed open chest wound should have a better oxygenation if placed with the injured side up. One of the reasons should be a better irrigation of the alveoli due to gravity (?!) Recent studies should tell that. Does anyone has a proof for this statement?
I have heard that as well and have been training like this for some time. It would be good to see the actual studies. It is this type of thinking that is taking our profession to the next level, questioning dogma and requiring proof. This may not be PFC exactly but it is a perfect example of how we can question recommendations. In the short term, I would be focussed on protecting the casualty’s airway and providing adequate ventilation while performing serial needle Ds with the largest needle I had with the injured side in the best position for me to visualize and treat. As soon as possible, but espesially once I have identified that this is going to be a prolonged situation, I would get to the cleanest environment possible and go for the chest tube then try and position the patient in a more natural, anatomical position such as having the head of the bed raised 30 – 45 degrees. This is what would be done in the ICU, as I understand it, and would support ventilatory efforts while reducing the possibility of aspiration and incidence of VAP. Anyone feel free to correct me or point anything out I may have overlooked. These discussions are a great way to improve and reinforce our knowledge.
Saw a recent case report of tongue edema secondary to prolonged use of the King LT (PMID 19695741) and I think this could have big implications in the PFC world.I. ‘d like to see a study with the King LT being used in more prolonged situations for airway control. Maybe get an Ambulatory Surgical Center for several months? Not really sure how
It was my understanding that the King LT was chosen to be part of the TC3 recommendations for the degree of first chance success rate in the field when compared to an ET tube. It should then be kept in mind that the King LT is not technically a definitive airway since it is supraglotic, and will not protect against aspiration. There are studies out there that show you can run mechanical ventilation through the King LT, which is good, but IMO it should not be used for prolong airway access. in the prolong field care environment, I would personally transition to an ET tube at the most available time.
On that note, has anyone discussed the use of GI prophylaxis and DVT prophylaxis in the prolonged field care setting. Lovenox is probably a touchy subject considering the lethal triad, however IV pepcid may be in order, however not part of my MES sets.
The King LT, like other supraglottic airways such as LMAs, have similar if not worse constraints for medics in a prolonged field care scenario. The first is that of security. Patients will be constantly moved over hundreds if not thousands of miles increasing the chance of dislodging. The other more pressing problem shared by the Endotracheal Tube is that of the Pharyngeal or Gag Reflex Arc. In order to prevent CN IX from triggering and allowing CN X to cause the gag it requires a large amount of drugs in a constant drip for suppression not to mention comfort of the patient. This is not the case in a cricothyroidotomy as it sits lower than the reach of CN IX. This is probably the biggest reason, besides inadequate intubation training for medics that we advocate for the continued training and use of the cricothyroidotomy by medics. There is definitely a time and place for all of these other airways, PFC just may not be one of them. I definitely welcome other points of view and discussion on this.
We have talked about DVT prophylaxis as far as nursing care goes, especially with the use of TXA. We advocate for manually “massaging” the lower extremities similar to the pneumatics used in ICUs. I don’t think that we have broadly discussed pharm, such as Lovenox, as an adjunct yet. That may be worth a look but If I give TXA it’s for uncontrolled and uncompressible bleeding in “the box,” either the chest or abdomen. I would like to hear more about this.
I believe Dr. Burns mentioned giving a PPI after suctioning the stomach contents. I only carry PO meds for this however which would probably not be indicated. I’d like to hear more about this as well.
Prolonged field care and the Golden Hour.
In the places where PFC is occurring, it is usually because time and distance separate the patient and medics from the Surgeon. Has there been any research/studies/reviews on PFC possibly extending the Golden Hour? If PFC has been shown to extend the Golden hour, how long does the effect last? Are the patients receiving PFC showing morbidity/mortality rates similar to those who have access to a surgeon? What should be our realistic goal in getting the patient to a damage control surgeon? I say realistic because arrival at a surgeon for damage control surgery in some places can take as long as 17-20 hours.
A little late to the party here…
I’d like to see more studies about TXA administration; specifically TXA being administered in Hextend, and TXA causing hypovolemia if administered too fast.