PHEMCAST

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YouTube videos:

From the police officer’s perspective: https://www.youtube.com/watch?v=toaA_TNwcxg

From the mother’s perspective: https://www.youtube.com/watch?v=0KJZXOKStao

The paper about watching resuscitation is this one:

http://www.nejm.org/doi/full/10.1056/NEJMoa1203366#t=article

This is a section taken from the London Ambulance Service clinical bulletin, from 2011, which includes the SPIKES mnemonic:

The alternative mnemonic mentioned in the podcast is GRIEV_ING, which has been developed for use in the ED.

References

Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. Spikes – a six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist. 2000; 5: 302-311.

Hobgood C, Harward D, Newton K, Davis W. The educational intervention “GRIEV_ING” improves the death notification skills of residents. Journal of Academic Emergency Medicine. 2005; 12: 296-301.

Jabre P, Belpomme V, Azoulay E et al. Fanily presence during cardiopulmonary resuscitation. The New England Journal of Medicine. 2013: 368 (11): 1008-1018.

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Case definition

Current case definition for COVID-19 can be accessed here.

Risk stratification

This is the Emergency Medicine Specialty guide we discussed in the podcast, which includes use of the NEWS and 40 step test (edit: since recording the podcast yesterday (!) we’ve been made aware of the Sit to Stand test). Here is a review of both if you’d like to read more.

PPE

As at May 1st, the advice from PHE is ‘There is currently sustained transmission of COVID-19 throughout the UK as defined by the four nations Public Health experts, therefore there is an increased likelihood of any patient having coronavirus infection. Therefore, whilst in this phase all patient contacts require level 2 PPE in accordance with Table 4‘: T4_poster_Recommended_PPE_additional_considerations_of_COVID-19

• disposable gloves
• disposable apron
• fluid repellent surgical mask
• eye protection (if risk of splashing)

• disposable gloves
• fluid repellent coveralls/long sleeved apron/gown
• FFP3* or powered respirator hood
• eye protection

*Where an FFP3 mask with a non-shrouded valve is worn, it should be accompanied by a full-face visor. If a visor is not available, then a risk assessment should be carried out regarding the risk of splash to the valve. If a large splash (as opposed to droplets) does occur, then the FFP3 mask should be replaced immediately.

There are a number of PHE PPE videos available, this is the one describing donning and doffing Level 2.

From PHE Guidance for ambulance trusts: Where AGPs such as intubation are performed, PPE guidance set out for AGPs (section 8.1) should be followed (disposable fluid repellent coveralls may be used in place of long-sleeved disposable gowns). For any direct patient care of patient known to meet the case definition for a possible case, plastic apron, FRSMs, eye protection and gloves should be used. Where it is impractical to ascertain case status of individual patients prior to care, use of PPE including aprons, gloves, FRSM and eye protection should be subject to risk assessment according to local context. PPE is not required for ambulance drivers of a vehicle with a bulkhead and those otherwise able to maintain social distancing of 2 metres. If the vehicle does not have a bulkhead then use of a FRSM is indicated for the driver (additional PPE would be as for other staff if providing direct care).

For the coverall-type Level 3 PPE most commonly being used by ambulance clinicians, have a look at these two guidelines on donning and doffing.

Aerosol generating procedures

Reference available here.

Aerosols are produced when an air current moves across the surface of a film of liquid; the greater the force of the air the smaller the particles that are produced. Aerosol generating procedures (AGPs) are defined as any medical and patient care procedure that results in the production of airborne particles (aerosols). AGPs can produce airborne particles <5 micrometres (μm) in size which can remain suspended in the air, travel over a distance and may cause infection if they are inhaled. Therefore AGPs create the potential for airborne transmission of infections that may otherwise only be transmissible by the droplet route.

The most recent assessment by WHO (2014) states that there is only consistent evidence that there is an increased risk of transmission for the f...

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Note how a rolled towel is placed under the baby’s shoulders to allow space for the occiput and avoid flexion of the neck and airway.

From: https://www.jems.com/2017/02/28/an-overview-of-ems-pediatric-airway-management/

Video links to examples of children with signs of respiratory distress:

• Stridor
• Grunting
• Increased work of breathing

Example video showing a bulging fontanelle (excuse the slightly cheesy style!)

From: http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/Floppy%20Baby.htm

Sadly, NAI in under 2’s causes more than 10% of serious injuries to children.

Stigmata of possible NAI include:

• Bruising on the cheeks, neck, genitals, buttocks and back
• Pattern bruising from an implement including fingertip bruising
• Burns to hands, legs, feet and buttocks
• Subconjunctival haemorrhage
• Epistaxis in infants

Example of subconjunctival haemorrhage:

From: http://champprogram.com/question/3a.shtml

2017 NICE guidance: When to suspect maltreatment in under 18s.

Click for UK Sepsis Trust guidance for different clinical settings. Scroll down for the Screening and Action tool for under 5s for prehospital care and ambulance services.

References regarding IM benzylpenicillin that Tim mentions:

• Harnden A. Parenteral penicillin for children with meningococcal disease before hospital admission: case-control study. BMJ. 2006 Jun 3;332(7553):1295–8.
• Hahné SJM, Charlett A, Purcell B, Samuelsson S, Camaroni I, Ehrhard I, et al. Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: systematic review. BMJ. 2006 Jun 3;332(7553):1299–303.
• Sörensen HT, Nielsen GL, Schönheyder HC, Steffensen FH, Hansen I, Sabroe S, Dahlerup JF, Hamburger H, Olsen J: Outcome of pre-hospital antibiotic treatment of meningococcal disease. J Clin Epidemiol 1998, 51:717–721.

Example of a paediatric drug calculator from WATCh.

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So, where is the Cauda Equina?

From Core EM

How does a herniated disc cause CES?

This fab infographic summarising the key points about the CES guidance was produced by @DrLindaDykes and @saspist.

Here is the full guideline from The Society of British Neurological Surgeons and The British Association of Spinal Surgeons.

NICE guidance on Low back pain and sciatica in over 16s: assessment and management

NICE clinical knowledge summary on Cauda Equina Syndrome red flags.

Thinking about posture:

https://phemcast.co.uk/wp-content/uploads/2018/10/head-injury_final.mp3

Quite a few of our previous podcasts include content which is relevant to this Head Injury one. Why not go back and have a listen to:

Episode 3: Hyperoxia

Episode 20: End Tidal Carbon Dioxide

Episode 28: LOST (Low Output State in Trauma)

Munroe-Kellie Doctrine

The Munroe-Kellie Doctrine is illustrated by the following pictures:

Or, alternatively, by Elfyn’s pint of Guinness analogy!

Autoregulation

Allows giraffes to drink from pools without a rush of blood to the head and eat leaves from trees without fainting.

This graph shows what happens to cerebral arterioles in uninjured brains, taken from Researchgate.net (Pires et al., 2013.)

Without autoregulation, in an injured brain, the arterioles will not change diameter in response to variations in blood pressure, and cerebral blood flow will have a linear relationship with blood pressure.

Cerebral perfusion pressure

Cerebral perfusion pressure = Mean arterial pressure – intracerebral pressure

The diameter of the arterioles, and therefore Cerebral perfusion pressure, is also affected by extremes of oxygen and carbon dioxide. If you would like to read more about this, have a look at this Life in The Fast Lane post.

References

The Brain Injury Foundation guidelines which Fliss mentions can be accessed here.

Doubts over head injury studies. Roberts I, Smith R, Evans S. BMJ. 2007 Feb 24; 334(7590): 392–394. (This is the paper Elfyn mentions regarding the now redacted original publications on the use of mannitol)

Wakai A, McCabe A, Roberts I, Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD001049. DOI: 10.1002/14651858.CD001049.pub5

The HIRT trial: https://emj.bmj.com/content/32/11/869

The HITS-NS trial: The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study.

Wilson et al. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis.

Impact Brain Apnoea. https://www.ncbi.nlm.nih.gov/pubmed/27211834

And finally...

.... if you would like to hear more on the subject of Head Injury – have a listen to what the Resus Room team have to say about it: