Hi Guys,
Right in the link my recent lecture on Damage Control RESUS!!!!
Enjoy.......

Damage Control RESUS easy way

                                                               THE FXXXKIN VENOMOUS SNAKE

you are a doctor or medic going on expedition or remote site sooner or later you will have to cope with snake, venomous venomous, bites.

There are several species of snakes spread across the four continents

AFRICA AND MIDDLE EAST: Cobras, spitting cobras, vipers and asps

ASIA: Cobras, Russel s viper and Pit Viper

AUSTRALASIA: black snakes, tiger snakes

AMERICAS: coral snakes, rattlesnakes

PRESENTATION

• local pain, swelling, bruising, blistering on the site of bite
• regional linphnodes enlargement

Depending on snake:

• incoagulable blood and spontaneous systemic bleeding
• Hypotension to shock
• progressive generalized paralysis 
• acute renal failure from rabdomiolisis

TREATMENT

• Remove rings and bracelets from the site affected before swalling
• clean wound and apply pressure-immobilization: perform a bandage such as for ankle sprains with a 10 cm wide bandage as long as possible and include a splint to immobilize the limb affected
• supportive therapy: cristalloids and colloids in case of shock and acute renal insufficiency
• assist ventilation in case of respiratory distress by respiratory muscles paralysis 
• ANTIVENOM: SLOW IV INJECTION OF 4-5 VIALS DILUTED IN 500 ML OF NORMAL SALINE (usually antivenin is polyvalent for the most dangerous species of snake for a specific region.

Be prepared with Adrenaline 0,5 mg i.m. in case of anaphylactic shock.

Pressure bandage

I triede to do the stuff as simple as possible from yours docvpb that’s all 

HAVE A NICE DAY ON THE

EDGE!!!!!

Welcome to the Fabulous World of Thoracic Traumas (Part. 1)

Hi Guys!!!!

Recently I realized something very strange: after attending, over the years, courses such as ATLS, ETC, PHTLS, PTC etc ... my mind became in such a way compartmentalized, schematized, excuse the term: protocollized; and if, on one hand this thing has been of great help giving me the cold blood to perform lifesaving maneuvers even in moments of extreme excitement and agitation, on the other hand in part made me lose flexibility in my way of thinking clinically, which in some cases could get me out of situations with no apparent way out. 

Chest traumas for example: 

when I think of a chest trauma my mind immediately set up on ATLS scheme: life-threatening injuries that require immediate treatment: pneumothorax, hemothorax, flail chest, Cardiac tamponade etc ... but the problem is that my mind tends to consider these lesions as separate entities !!!! ....What happens when all come together in the same patient ?? !!

Clinical case: 

A military vehicle passes over a pressure plate and triggers an Improvised Explosive Device (IED); aftermath is a big explosion ... but well located: Endeed all the kinetic energy has been absorbed by anterior-left section of the vehicle ... .and then indirectly has invested in full the driver only.

When Medevac Helo arrives the patient's conditions are already extremely critical; 

At first glance: Subject is conscious in extreme respiratory distress; 

CatC.: no overt external bleedings;

A: airway patent;

B: the problem is purely in the chest (a very bad contusion)....In addition to a widespread bruising you notice multiple rib fractures on the right with feeble paradoxical movements of the chest cage: thoracic excursions are very limited ;
at palpation: widespread crackles with great pain evoked: in short words, you do not discern where there is subcutaneous emphysema or a broken rib!!!!
Auscultation: absolutely of no use (for background noise);
saturation nearly 76% in O2 mask;

C: FC. 120 bb / min. NBP: 80/50 mmHg, One 14 Gauge IV access.

At this point mind of Medevac doctor is fully in ATLS mode: the B is critical and requires action; Overt lesions are bilateral PNX and Flail chest and he focuses on those; Thus Bilateral chest tube and RSI, followed by endotracheal intubation and IPPV... 

but the clinical situation seems to improve only slightly: the SatO2 goes up from 67% to 82%; the heart rate remains at 110 bb / min; NBP settles on 85 mmHg sys... Even if not copletely satisfied the doctor takes on board the patient for transport but still feels that something is missing ... the mind at this point goes for the tangent ... Head become a caldron of questions:

 "the B is complete; I treated all that was to be treated !!!",

" maybe I missed internal bleedings?! but there are no signs of intraabdominal haemorragies !! ",

" No fractures evident ",

" but why heart rate doesn’t go down? "

... and so on ...Patient arrives at Role 2 hospital alive....
.... but what wasn’t  right ?? !!:

A rib fragment had damaged the pericardium and was about to give cardiac tamponade... if transport had lasted more than 10 min. perhaps the wounded would die... 

At this point a big question arises: "Why doctor had not thought of that?"... 

very easy: his mind was so schematically focused on more obvious lesions to not be able to move with flexibility on the occult....

Bottom line: In certain situations such as those of extreme urgency, although the schematic way of thinking, given to us by courses such as ATLS, is often a necessary factor and essential to avoid falling into panic, however is always better to keep mind trained to a minimum of flexibility just in attempt to save the day even in these rare and complex clinical cases. 

Just talking about thoracic traumas give a glimpse on how many underlying lesions a blunt thoracic trauma can hide: 

not one, not two, not three but we could say an entire Fabulous world of chest injuries!!!!!

We start from the aforementioned life-threatening injuries:

1) Tension pneumothorax:

Most often a result of  blunt thoracic trauma, the Tension PNX is consequence of a progressive accumulation of pressurized air in the pleural cavity with valve mechanism; air enters in the pleural space at each inspiratory phase but cannot get out, is trapped during the expiratory phase; The consequence of this mechanism is not only the complete collapse of the affected lung but also the compression, by air accumulated, on mediastinum and its shifting and compression on controlatheral Emithorax (thus on controlatheral lung and also vascular structures).

Clinical features:

the patient will show respiratory distress but also hypotension and tachycardia, due to the pressure exerted on great vessels and then due to all the pathophysiological consequences resulting from a reduced venous return to the heart.... could be also detected a reduced expansion of  involved Hemithorax and absent breath sounds on auscultation (Mmmmhhh….try a little to auscultate a patient in an outdoor setting or in a crowded ED... .Mmmmmmmhhh….);
to all this stuff add open or closed hemorrhagic lesions almost constantly present in this type of trauma and...... going back to my opening speech ....What a mess !!!!!

Instrumental diagnosys:

Just two words: as soon as possible FAST US, FAST US, FAST US and again FAST US ...

Treatment:

In prehospital setting the classic needle decompression can really save the day;

There are specially crafted needles for this purpose ... ... fast, easy and comfortable to use .... (Thanks to my friends US Army paramedics to let me try those needles)....

.... unfortunately in Italy they are not available... .to us Italians if it's too easy we don’t like it right ???! So usually 14G needle in 2nd intercostal space on the midclavicular or better in 4th or 5th intercostal space lateral approach (I tried them both and I guarantee that the lateral positioning was successful in 98% of cases ... but it’s up to you!!!!).

More recently in the prehospital setting was introduced the so-called "Finger Thoracostomy" but I cannot express myself on this field not having tried it yet.

Clearly the needle is only a bridge leading to the insertion of the chest tube ... .a technique usually reserved for the ED ... .insertion in 4th or 5th intercostal space midaxillary .... recommend use in adults at least a 36F.

2) Open Pneumothorax:

A consequence of penetrating injuries of the chest and more in particular a result in the vast majority of cases of gunshot wounds.

The primary cause is the establishment of a pathophysiological link between the pleural space and outdoor environment with loss of pressure balance in thoracic cavity.

In practice, the lung will tend to collapse during inspiration and to expand slightly during expiration.

Clinical feature:

In severe cases, the wounded will be in respiratory distress and you will see clearly the picture of “sucking chest wound”: very noisy airflow mixed with blood (foam and bubbles ) going out from the lesion.

Treatment:

In prehospital setting an Ashermann’s dressing (fairly widespread also in our country)

or the classic bandage closed on three sides can save the day.

Obviously everything on hold for chest tube in ED.

However, keep in mind that when a bullet enter the chest will demage all organs that meets on his way and then comes out ... if goes well!!!! And again we go back to the initial speech ... .The open PNX will always be in good company !!!!

... And for this post is all about ... to continue your journey into the terrifying world of thoracic traumas you will have to wait few days ... ..

from your docvpb

have a nice day on the Edge…..

References:

1. Rosen's Emergency Medicine

2. Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6e (Roberts, Clinical Procedures in Emergency Medicine)

3. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, Seventh Edition

4. Emergency War Surgery: The Survivalist's Medical Desk Reference

5. Trauma, Seventh Edition

6. Wilderness Medicine: Expert Consult Premium Edition - Enhanced Online Features and Print, 6e  (Auerbach, Wilderness Medicine)

7. Special Operations Forces Medical Handbook

Forward Surgical Team (FST); What means to be a War Doc....

Hi Guys!!!!
Have you ever wondered what would it means to work in a Battlefield Operating Room??!!
Check out this Awesome video....

Battlefield OR

MEDEVAC during Vietnam war....when everything began....

Vietnam war MEDEVAC

Capnografia e Asma: accoppiata vincente?!

Hi Guys!!!!
My new post on EMpills....follow the link below!!!!....

Capnografia e Asma: accoppiata vincente?!

Massive Transfusion Protocol: Updates

Hi Guys!!!!
My new post on EMpills in the link below....

Massive Transfusion Protocol: Updates

Mechanical Ventilation: A guide for Dummies....Oxylog What?!

Hi Guys!!!!.....

My new post on EMpills:

Mechanical Ventilation: A guide for Dummies....Oxylog What?!

Follow the link below:

Mechanical Ventilation: A guide for Dummies....Oxylog What?!

DSI (Delayed Sequence Intubation): My Experience......

Hi Guys!!!!.....

My new post on EMpills:

DSI (Delayed Sequence Intubation): My personal Experience....

Follow the link below:

DSI (Delayed Sequence Intubation): Una tecnica utile...

Ketamine in Traumatic Brain Injury: Just a DOGMA?!

Contraindications to use of Ketamine in TBI: Pure DOGMA?!

Check it out on EMpills!!...Just follow the link below.....

http://empills.com/2014/08/ketamina-nel-trauma-cranico-puro-dogma/

COMBAT EMERGENCY MEDICAL SERVICES…ARE YOU CURIOUS…???!!!

Hi Guys…...............................!!!!!!!!!!!!!!!!!!!

Just in case you are wondering how Emergency Medical Service works in the war zones, here is my personal review…..so enjoy it.

War emergency medicine means just a simple foundation concept:

10-1-2;

10: Immediate life saving procedures must be applied within 10 minutes of wounding.

1: advanced stabilization manouvres must commenced within 1 hour of wounding (Enhanced field care).

2: if necessary Emergency war surgery must be performed within 1 hour but not later 2 hours of wounding.

How these numbers are fulfilled??!!

As in every military sector even war medicine requires a meticulous tactical planning, defining means and professional figures to be employed in specific theatres of operation.

This is how it works in Afghanistan:

Everything starts in the HOT ZONE (zone of fightings) where usually the wounding happens;

What can be done?!

Very few things!!! 

This is what we call “Care under fire”:

1) Respond to fire and search for fire cover; reach for the wounded only when possible… Heroism could be  rewarded just with two wounded instead of one!!!!  

2)Stop bleedings with combat tourniquet or compressive dressings, mantained by self aid if able.

3)Airway management is generally best deferred until Enhanced field care (EFC) phase.

4)Bring the wounded ASAP in the WARM ZONE for Enhanced field care(EFC).

Who perform these manouvres??!!

Bleeding control can be performed by the wounded himself; if uncounscious could be performed by a buddy ("Buddy to Buddy Aid") or the combat medic (a soldier trained in Immediate life support techniques, if present); usually there is one in every company.

In the WARM ZONE or semipermissive zone:

Personnel could be still threatened by indirect fire but Enhanced field care (EFC) manouvres can be put in place under cover;

What I mean for under cover:

The ideal would be  a true Company Aid Post, in reality  EFC is performed on the back of a tank or everything can provide protection from fire.

Who perform EFC:

It depends on the Nation: US army has specifically trained Medics and Paramedics, EUropean forces often have a nurse or a doctor on the field; 

Italian Army itself is implementing a new strategy: A rescue helicopter with a critical care Physician and nurse on board, already on area of operations; the aim of this strategy is to save the time between the call for a MEDEVAC and  the MEDEVAC itself, that,I guarantee,in Afghanistan could be very long; furthermore it allow advanced stabilization manouvres right on the field or straight during flight.

What does it mean Enanched field care (EFC)??!! 

In small words what we call Damage control resuscitation in the civilian setting; 

anyway battlefield is very different from an Highway or every other possible civilian scenario so also life support techniques allowed are different;

On the field (Tactical Field Care):

<C> catastrophic haemorragy control: If not yet performed bleeding control is essential: Combat  Tourniquet and compressive dressings.

A: open airways ; If the wounded is unconscious: naso-orofaringeal cannula or recovery position or SGA (Supraglottic airways - Usually the iGel) if airway obstruction. 

What about the Neck Collar??

In military setting Neck collar is kept just for victims of  Blasts and vehicles accidents.

B: Breathing problems and torso trauma??... we go straight to needle decompression and occlusive medication in case of of open or sucking chest wounds; SGA if necessary.

C: IV (Intravenous infusion line) or IO (Intraosseous infusione line), (In the last times we tend to go straight by IO); Thus TXA (Tranexamic Acid) and start Normal Saline infusion,following damage control resuscitation guidelines.

Every nurse or physiscan present on the field are trained to perform those manouvres; 

Anyway More advanced techniques could be performed whereas  critical care trained personnel is available and this usually happens just before or during trasport on MEDEVAC helicopters.

These advanced techniques usually are Emergency CRIC to control airways, finger thoracostomy for PNX; Italian MEDEVAC is implementing PENTAX VL intubation instead of CRIC, but evidences are still very few…

Some MEDEVAC service such the US one have 0-neg on board and can even start blood transfusions…..this is great stuff!!!!!

Surgical treatment:

Definitive surgical treatment not always can be performed between 2 hours of wounding in  an advanced medical facility (a role 3 Field Hospital)…To obviate this problem NATO forces invented FST (Forward surgical teams): Highly versatile operating rooms deployed in advanced military outpost, able to perform just damage control surgery; this strategy permits to gain time and transport patient to an  AMF (Advanced Medical Facility) for definitive treatment in a following time.

Usually an FST is manned by 20 - person team: 1 Orthopedic surgeon, 3 General surgeons,2 Anaesthetists or certified registered nurse anesthetists (CRNAs) 3 Registered Nurses, 1 administrative officer, 1 detachment sergeant, 3 licensed practical nurses (LPN)'s, 3 surgical techs and 3 medics. 

To sum up current War EMS organization is the result of experiences gained during the most recent  conflicts: IRAQ and Afghanistan and is constantly  evolving; 

endeed in next combat operations could become obsolete……Just Think to a war in a place where the enemy has air supremacy……Helicopter MEDEVAC that now is so important, in a moment could become useless…………..

…..Have a good day on the Edge and Bye Bye……..

References:

1, For debate: the Operational Patient Care Pathway

2, TCCC: Tactical Combat Casualty Care Guidelines

3, Emergency War Surgery: The Survivalist's Medical Desk Reference 
4, 21st Century Emergency War Surgery Textbook by the U.S. Army - Weapons Injuries, Triage, Shock, Anesthesia, Infections, Critical Care, Amputations, Burns, Specific Injury Treatment
5, First to Cut: Trauma Lessons Learned in the Combat Zone, Real-World Scenarios of Patient Care and Surgery, Valuable Advice for Surgeons (Emergency War Surgery Series)
6, Wilderness Medicine: Expert Consult Premium Edition - Enhanced Online Features and Print, 6e (Auerbach, Wilderness Medicine)