Episode 29: The Big Sick 2019

Author: Eoghan Colgan @eoghan_colgan
Special Guests: Soren Rudolph, Tim Harris, Philip Spinella, Caroline Leech, Niklas Nielson, Hermann Brugger & Matthieu Komorowski

27/02/19

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Guest Bios

Soren Rudolph

Senior Consultant Anesthesiologist, trauma manager and prehospital doctor. Works at the University Hospital of Copenhagen, Rigshospitalet level 1 trauma center, Emergency Medical Services Copenhagen and HEMS Denmark. 

Dedicated to trauma resuscitation, prehospital care and airway management.

Twitter: @sorenrudolph

Professor Tim Harris

Professor Tim Harris was born in the UK but has spent around half his life overseas. He trained in Emergency Medicine and Intensive care medicine in Australia, and in pre-hospital Medicine in Australia and the UK. He has worked in 43 hospitals in 11 countries and mixed training with travel with volunteer work in Africa, India and Samoa. He has worked at Barts Health for 10 years and was appointed Professor Emergency Medicine at QMUL and BH in 2012. He divides his academic time between teaching and research. His main interests are resuscitation, ultrasound, and point of care testing but most academic time is working to facilitate large multicentre studies at BH. BH research team have run 14 portfolio studies and published over 40 scientific papers in their four year existence. He is CLRN lead for North Thames and chairs the London Emergency Medicine Academic committee.

Phillip Spinella

Dr Philip C. Spinella is a pediatric intensivist and Director of the Critical Care Translational Research Program at Washington University in St Louis School of Medicine and the St Louis Children’s Hospital. He served as an active duty US Army physician for 12 years, which included a 1-year deployment to Iraq.  He continues to serve as a Consultant to the US Army Blood Research Program and is the Chair of the Steering Committee for the Norwegian Navy Blood Far Forward Research Program. His publications are in the area of blood component and whole blood resuscitation for traumatic hemorrhagic shock, clinical and translational research regarding the effects of RBC storage duration on outcomes, immunology and coagulation, and coagulation monitoring by thromboelastography. He is also an Affiliate Investigator at the Blood Systems Research Institute in San Francisco, CA.

Caroline Leech

Caroline Leech is a Consultant in Emergency Medicine at University Hospital Coventry (UK). She has 20 years experience of pre-hospital care primarily in London and the West Midlands. Caroline is an Associate Editor of the Emergency Medicine Journal, Executive of the Faculty of Pre-Hospital Care (RCSEd), Vice-Chair of the charity TraumaCare, Director of the West Midlands Emergency Surgical Skills Course, and Deputy Clinical Lead of The Air Ambulance Service. 

Niklas Nielsen

Niklas Nielsen is a staff specialist in Anaesthesia and Intensive Care at Helsingborg Hospital and associate professor at the Department of Clinical Sciences, Lund University, Sweden. His research interest is on various aspects of post-cardiac arrest care with focus on targeted temperature management, biomarkers for prediction, trial methodology, trial conduct and follow-up. He was PI for the recent TTM-trial 33°C versus 36°C and is currently leading the TTM2-trial www.ttm2trial.org.  He is involved in the Anaesthesia, Intensive Care and Emergency Medicine programs at Lund University.

Hermann Brugger

Dr Brugger is a general practitioner and emergency physician. He is the founder and head of the EURAC Institute of Mountain Emergency Medicine in Bolzano, Italy. He has published extensively on various topics in mountain emergency medicine including several landmark publications on avalanche rescue and accidental hypothermia. He has received numerous scientific awards. He is an associate Editor of High Altitude Medicine and Biology, a guest lecturer at the University of Padova, as well as an associate Professor and lecturer at the Innsbruck Medical University.Outside his research activities and hospital work He is a mountain rescue physician for the Mountain Rescue Organization of South Tyroland has performed more than 2000 mountain rescue operations. He is an enthusiastic mountaineer and ski-tourer with several ascents in Europe, the Americas and Asia.

Matthieu Komorowski

Matthieu holds full board certification in anesthesiology and critical care in both France and the UK. He was previously a research fellow at the European Space Agency and holds additional qualifications in mountain, diving and hyperbaric medicine. He worked with the NASA Human Research Program and developed simplified anesthesia protocols for future space exploration missions. He currently pursues a PhD in machine learning applied to intensive care at Imperial College London and the Massachusetts Institute of Technology. For his work, he received several awards including the first prize of Research and Innovation of the British Royal Society of Medicine. He is an affiliate of Harvard University where he teaches reinforcement learning in healthcare.

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Show Notes

'The Big Sick' is a conference about critical care and emergency medicine. The overall theme is the resuscitation of the sickest patients, specifically what to do during the first hours after the critically ill or injured patient is presented to us. The speakers are some of the biggest names in critical care providing the latest research and thinking in their fields.

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Take Home Points

Soren Rudolph

• Only a few select patients will need immediate intubation

• Most can take time and think carefully about how best to proceed

• Resuscitation before intubation

  • Optimise the conditions that can kill a patient during intubation

    • Hypovlaemia

    • Severe Acidaemia

    • Hypoxia

• Haemodynamic Compromise

  • Fluid resuscitation prior to intubation

  • Pressors prior to intubation (push-dose +/_ infusion)

  • Dose anaesthetics smart

    • Low on sedatives

    • High on paralytics

  • There is a role for awake intubation in this setting

• Hypoxia

  • Pre-oxygenation

  • Peri-intubation oxygenation (through all phases of the intubation) – including apneic oxygenation

  • Delayed Sequence Intubation

    • Ketamine sedate patient to aid oxygenation prior to intubation

Tim Harris

• In haemorraghic shock we tend to focus resuscitation on restoring coagulation first and then perfusion

  • Blood products – restore coagulation proteins a and haemoglobin

  • Tranexamic acid to reduce fibrinolysis

  • Lower volume than volume lost – permissive hypotension

    • Less pressure on clotting vessels

• We don’t how long we can leave patients ‘hypotensive’

  • The longer we leave them in this state:

    • Increased incidence of organ failure

    • Particularly kidneys

• We don’t know what the right BP to aim for is

  • One method is using brain perfusion as a guide – are they conscious and orientated?

  • If so then they likely have enough perfusion for that first 30-60mins of resuscitation

  • Not always easy in intubated/distracted patient

• His current practice:

  • Awake Patients:

    • Give blood products until they respond

  • Intubated/Ventilated depends on age:

    • Elderly: 100-110 SBP

    • Middle-aged: 90 - 100

    • Young: 80 - 90 

  • Will probably accept lower if awake

• Most evidence on permissive hypotension is old – there is need for a major trial to define ‘how low to go and how long for’

Philip Spinella

• Whole blood is the optimal blood product for traumatic shock

• Comparing whole blood to 1:1:1 blood products, whole blood is:

  • More efficacious as blood components are diluted by citrate and added solutions

  • safer (Group O) as there is no risk of fatal haemolytic reaction

  • logistically easier to provide (if withdrawn fresh)

  • storable for 14 days (cold-stored whole blood) compared to 5 days for platelets

• The future might be dried whole blood

  • Currently there is dried plasma

  • There will soon to be a dried platelet product

  • There is a synthetic red cell product in development

CAROLINE LEECH

• Three indications to perform pre-hospital amputation:

  • Patient is trapped and periarrest – amputation will allow extraction and resuscitation

  • Scene safety emergency – e.g. rising floow-water, chemical incident and it is essential; to extract quickly to avoid death

  • In a multi-trauma situation where you need to amputate the limb of a deceased person to access the living

• Procedure:

  • Traditional guillotine procedure – not aiming for flap, rather a straight cut through

    • Aim for fracture sites in a limb (reduces the time on cutting bone)

  • Sedate with Ketamine

  • Use a commercial tourniquet, can guide sedation on how much discomfort the tourniquet causes

  • Scalpel for skin – typically more then one as they can blunt easily

  • Trauma shears to cut muscle and sot tissue

  • Gigli saw with wire to cut bone

  • After patient out – ensure rapid haemorrhage control

    • Make sure tourniquet tight

    • Artery forceps for large vessels

    • Haemostatic gauze on stump with emergency bandage

  • Carry on patient resuscitation (RSI, fluid resus etc) 

Justin Brede

• Inflate a balloon in the aorta in medical cardiac arrest = down prioritize the lower body and centralize blood flow to heart and brainb

• A lot of animal studies and growing human studies

• Current pilot prehospital study happening in Norway

• Logistics:

  • Arrive on scene

  • First responders – establish Advanced Life Support

  • Then proceed to REBOA

    • Takes about 10-12 minutes from decision to occlusion

    • ALS continues

• Benefits: they are seeing a dramatic increase in ROSC with extraordinary cases of survival

• The full data on long-term benefits yet to be established

Niklas Nielson

• What the TTM trial showed:

  • No demonstrable difference in survival or quality of life between patients cooled to 33 degrees and those cooled to 36 degrees post-cardiac arrest

• Cooling has been downgraded in priority but there is still debate on how best to manage these cases

• Practice varies widely

• Now performing a phase 3 trial comparing rapid cooling to 33 degrees to normothermia (temp management if starts to have a fever)

• Uncertainly still exists around whether cooling helps at all:

  • Hawthorne Effect – a general increase in attention from the doctors may be having an impact rather than the treatment itself?

Hermann Brugger

• Most important predictor of survival is grade of burial:

  • Not fully buried – survival rate >90%

  • Fully buried (head under snow) – survival rate ~50%

• If fully buried then duration become very important

  • <18mins then chance of survival is >90%

  • After this survival drops precipitously

• Most die from asphyxia (around 75% of all victims) 

• If they can breathe under snow they could survive for a few hours

• If there is a connection to outside world then they can survive much longer (record is 48 hours)

• The density of the snow can impact survival (which varies between nations)

• Hypoxia can be affected by quality of snow

  • Higher the density the greater the lack of oxygen

  • Low density: there is an increase in CO2 (unsure why)

    • This may help as it hastens drop in temperature which is protective

• Prognostication Factors for survival:

  • Duration of burial

  • Patency of airway

    • an airpocket in front of mouth and nose of victim is a positive sign (rewarm these patients)

    • This indicates they were able to breathe after burial

  • Serum potassium (<8mmol) and core temperature (30 degrees) are now the cutoff’s for extracorporeal rewarming

• Overall survival has improved

  • The number of total deaths has stayed the same but the number of people exposed has greatly increased

Matthieu Komorowski

• Some of the considerations for medical support for a manned mission:

  • 900 day mission (500 on surface of mars)

  • Remote from help and crew autonomy

  • Exposed to extreme environments may precipitate illness unique to space on top of all the usual ones (IHD, cancer etc)

  • Space-specific conditions:

    • Cardiovascular system becomes deconditioned 

    • Bone loss in weightlessness (may not be able to stand on mars when arrive)

    • Radiation exposure (not protected by earth atmosphere)

  • Increased risk of infection in space:

    • Immune system is depressed in space (chronic stress)

    • New germs can appear

      • New strains are discovered on the filters of international space station

      • How will our immune system and antibitics reacte top them

    • Everything recirculates in the space station (difficult to clean)

• Ethical Consideration: at what point is it futile to continue treatment and better to palliate

  • There is a limit to what can be brought with them

    • Do they bring dialysis machines or ventilators?

  • Need to consider the impact on resources and risk to other crew members when treating certain conditions

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