Lives On The Edge: Retrieval Services - Video n°3

Hi Guys!!!!


....3rd Episode... BEST Retrieval Services in the World.....

When you are working as Emergency physician or Paramedic In the most dangerous place in the world

you have Just Two Tasks:

N°1 - Take care of the Patient

N°2 - Take care to not "Become" the Patient!!!!


.....This time....The US Army PEDROS in Afghanistan!!!!

Look at the YouTube video in the link: US Army Medevac On The Frontlines (by Abc news)

Skin Wounds: Quick Guide to Management and Suturing

Hi Guys!!!!

Which is the most common Traumatic Injury that you usually encounter in the ED??....TBI??.... Chest concussion with Hypertensive Pneumothorax ??!Cardiac Tamponade??...Limbs Amputation??....No it’s the usual, simple, boring…superficial cutaneous wound….

Every ED resident or Registrar across the world sooner or later had to handle this kind of wound and suture it….

For this reason I decided to post a Quick extremely simple guide on superficial wound management and sutures…

First and most important rule: never close gun-shot wounds and extremely dirty wounds because they are at high risk of infection and Abscess; so let them to heal by second intention!!!

What you need:

-       Normal Saline (NaCl 0,9%) or Tap Water (YES tap Water - look at this study:Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial.) and a BIG Siringe

-       At least 3 sterile drapes

-       Surgical sterile gloves

-       Disinfectant (Betadine)

-       10 cc Siringe

-       22G or 24G needle

-       Kidney shaped basin

-       Cup to put in the disinfectant

-       Local Anaestetic (Lidocaine 2%)

-       Needle holder

-       Clamp

-       Scissors

-       Haemostatic Clamp

-       Grasping forceps

-       Sutures

How to do It:

STEP 1: STOP BLEEDING

press on the wound for at least 2-3 minutes.

STEP 2: CLEANING

 Irrigate the wound with copious Normal Saline or Tap Water in order to:

 Clean the wound,

 Remove clots,

 Move small foreign objects to the edges of the wound, so will be easier to remove them,

 Explore the wound to establish the deepness

And finally to identify bigger foreign objects and remove them quickly.

STEP 3: TRICHOTOMY of the zone surrounding the wound.

STEP 4: DISINFECTION

 Disinfect the wound and sorrounding tissues with abundant Betadine.

STEP 5: BE STERILE

if you are in the ED is MANDATORY;

of course if you are in a tent in the mid of the desert do the best as you can;

Wash your hands accurately and wear sterile gloves;

Border the sterile zone with sterile drapes….from now everything from suture instruments to gauzes 

must be passed to you in a sterile way.

Look at the you tube links below:

STEP 6: LOCAL ANAESTHESIA

The best option is Lidocaine 2% (is cheap and available everywhere):

Feautures:

Onset time 2 min.

It lasts for 1.5-2 hours

Do not use more than 280 mg; maximum dose in 70 Kg man: 14 ml.

Sistemic Adverse effects come from OVERDOSAGE and INTRAVASCULAR INJECTION:

-CNS: tongue numbness, eyebrows shivering, seizures.

-Cardiovascular App: Arhytmias.

Local Adverse effects are allergic reactions: Urticaria, Hives, rush, Oedema, Anafilactic shock.

THE TECHNIQUE:

aspire 10 cc of Lidocaine 2%;

Change the needle provided with the 10 cc siringe with a 22G or 24G needle;

Irrigate the wound with the local Anaesthetic.

REMEMBER: ALWAYS ASPIRE BEFORE INJECTING THE ANAESTHETIC SO YOU ARE SURE THAT YOU AREN’T PERFORMING AN INTRAVASCULAR INJECTION.

Look at the you tube link below:

STEP 7: SUTURE

Which needle and thread:

Thread: For superficial cutaneous wound always use non absorbable sutures; 

usually the most common available are:

-NYLON

-PROLENE

-NOVAFIL

Needle: For superficial cutaneous wound:  cutting curved needle.

Which size:

-Scalp: 3/0

-Face: 5-6/0

-Other body parts: 4/0

Which Technique:

Single interrupted suture is the best choice;

Look at the you tube link below:

Just for face wounds aiming to minimize the residual scar Intradermic continuous suture is better.

FINALLY YOU DID IT:

Just dress the sutured wound and remove stitches approximately after 7 days…

NOW you are ready for the next patient:

the shift especially at night is still very far from the end!!!!!!!!!!!!!!!

…AND…as alway have a good day or “NIGHT” on the EDGE……

Lives On The Edge: Retrieval Services - Videos n°2

Hi Guys!!!!

It's time...2nd Episode... BEST Retrieval Services in the World.....

When I think... Extreme Medicine, Harsh Environments, Very long evacuation distances and
 Mac Gyver Style Doctors....

Obviously I think to ROYAL FLYNG DOCTORS OF AUSTRALIA!!!!

...More on Intranasal Ketamine....

Hi Guys!!!

As you know I'm a great Fan of Ketamine and currently I'm trying to overcome the big diffidence that surrounds this great medication in Italy!!!!

Just because I spoke a few time ago about Intranasal Medications I decided to search and go deeply inside the Intranasal use of Ketamine.....

Ketamine Intranasal has been studied in the civilian setting as a sedative agent for procedural sedation in childrens and in the military setting by the US Army as an analgesic for battlefield casualties.

1) Procedural  sedation in childrens:

Several studies compared Intranasal Ketamine alone or in combination versus other sedatives for procedural sedation with the aim to perform dental procedures, CT scans etc.  in childrens:

Summary (Source: look at References):

-Dosage: Ketamine IN 3-9 mg/Kg

-Fast onset time and fast recovery (7+7 min.)

-Good level of sedation (mean sedation score of 4 where 5 is ideal sedation)

-Very safe: Desaturation and respiratory depression occurred in very few cases

-Spray (Atomizer) better than drops: better patient compliance, faster onset of action and faster
 recovery from sedation.


2)Analgesia for battlefield injured:

Use of Ketamine IN has been recently implemented by US Army as an alternative to IM Morphine or oral transmucosal fentanyl citrate (OTFC) for Analgesia in Battlefield casualties unable to continue to fight.

Summary ( source: PMI 100 Study):

-Dosage: Ketamine 50 mg intranasal (using nasal atomizer device) - 0,10 ml metered nasal spray     
               (10 mg/spray)
               Titration up to 5 sprays - interval of 90 seconds between sprays ; 
               Mean titrated Effective dose 43,5 - 46 mg
               Dosing every 3 hours as required
               50 mg IN Ketamine are approximately equivalent to 7,5 mg Morphine IV

-Onset time: 4 min. post dose

-Duration of action: 2,0 - 2,5 hours

-Avverse effects: Few events reported;for the most modest in severity such as Dizziness, fatigue, nausea
                           changes in vision, feeling of unreality.

  No allucinations were reported.

- Use of Ketamine not allowed in TBI (Traumatic Brain Injuries) and Ocular Traumas.

To summarize:

-Use of Ketamine Intranasal for procedural sedation and Analgesia is very promising.

-Unfortunately there are still very few studies on this topic and populations took onto consideration are very small.

-Use of Ketamine Intranasal for analgesia in adults has been studied just in the military setting (PMI 100 study); I couldn't find anything about the civilian setting.

-I couldn't find any study showing statistical frequency of the main two adverse effects of Ketamine ( Laringospasm; Emergence reaction) after its Intranasal use for procedural sedation and Analgesia;

In any case these are rare complications even after IV administration of Ketamine with Anaesthetic doses (1 - In two large trials conducted in emergency departments, the risk of laryngospasm in childrens, who are recognized to have a higher incidence of laryngospasm than adults, was 0.4 percent and 0.07 percent. 2- Emergence reaction has been showed to be uncommon and generally associated with higher (anesthetic) doses of Ketamine).

Conclusion:

For now Intranasal use of Ketamine for procedural sedation and Analgesia is still OFF-LABEL therefore BE CAREFUL when you opt for this technique;

More studies are needed in future;

However all the studies available at present showed that Ketamine by Intranasal route of administration is an easy, fast and effective way to perform short sedations and to relieve pain.

The future is very promising!!!

....As always have a good day on the edge....

References:
US Army slide show on IN Ketamine
US Army Intranasal Ketamine protocol
Safety and effectiveness of intranasal administration of sedative medications (ketamine, midazolam, or sufentanil) for urgent brief pediatric dental procedures.
Case report: prehospital use of intranasal ketamine for paediatric burn injury.
Ketamine as an analgesic: parenteral, oral, rectal, subcutaneous, transdermal and intranasal administration.
intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report.
A comparative evaluation of drops versus atomized administration of intranasal ketamine for the procedural sedation of young uncooperative pediatric dental patients: a prospective crossover trial.
Nasal midazolam and ketamine for paediatric sedation during computerised tomography.

             

Hi Guys!!!
Finally I MADE IT!!!!!!!!
I registered for SMACC 2013 in Sydney (Australia).....The best and most Innovative EM and Critical care Conference in the world.........
I'm going to post updates and pearls from the Conference via Twitter and on this Blog so from MARCH 11 to MARCH 13 stay tuned on this site or follow me on Twitter (@docvpb) and don't miss.... because the Revolution is just Began!!!!!!!!

Hi Guys,

I have just posted my PK talk on SMACC 2013 website!!!!!!!!!

It's about the Outstanding Intranasal way of Administration!!!!

Below the Video of the talk.....Enjoy and sorry in advance for my Italianish English Accent.....

Have a good Day on the Edge....

Lives On The Edge: Retrieval Services - Video n°1 -

Hi Guys,

Here a Video series about Retrieval Services across the world: very Tough STUFF!!!
Relax and Enjoy.......

N°1 is about MERT: British Medical Emergency Response Team