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Blood Substitutes, "All Things Considered" - posted May 2nd, 2008
A report appearing the Journal of the American Medical Association says federal health officials permitted studies of blood substitutes to continue for years after learning that the substitutes posed health risks.
[NPR Article]
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RSI & Airway Management - posted May 2nd, 2008
This link points to a newspaper story about airway management gone bad. This unfortunate incident allows us an opportunity to review some of the issues related to airway management and PHTLS. It has long been the philosophy of PHTLS to discuss “principles versus preferences” when it comes to trauma care.
When it comes to the airway, the principle is clear, the airway must be open and patent. The preference relates to which of the many techniques is used to assure that this is accomplished. The selection of a procedure to use depends on many factors including the specific situation at hand, the training and expertise of the healthcare provider, the tools available, and alternatives should the initial selection prove unsuccessful.
Rapid Sequence Intubation (RSI), perhaps better referred to as Pharmacologically Assisted Intubation as there is nothing rapid about rapid sequence intubation, has had increasing utilization in the prehospital setting, particularly in the air-medical arena. Numerous studies have been published in the medical literature about this procedure. Most of the initial studies focused on the ability of prehospital care providers, usually air-medical staff, to successfully perform the RSI. Based upon the early studies, the application of RSI in the field expanded to many ground EMS agencies.
Recently, additional published studies have focused on the crucial question related to this (and, for that matter, any other) intervention – Does it make a difference in patient outcome after trauma? Surprisingly, the majority of these studies have shown a worse outcome in those patients treated with RSI compared to patients who did not undergo RSI. Subsequent analysis reveals that a number of issues likely contribute to this increase in morbidity and mortality:
- unrecognized and uncorrected hypoxemia as a direct result of the trauma sustained
- multiple and prolonged intubation attempts
- the development of hypoxemia during the intubation attempt
- inadvertent hyper- or hypoventilation after intubation resulting in hypocarbia or hypercarbia
- the development of hypotension during or immediately after drug administration
- failure to utilize available tools to confirm endotracheal tube placement.
These concerns are discussed in more detail with the specific references provided in the 6th Edition of PreHospital Trauma Life Support.
All of these effects point to the need for extreme attention to detail when providing care for victims of trauma and, in particular, when intervening actively to manage the airway. Whenever a trauma patient is encountered and the airway must be addressed, it is imperative that each of the following be part of the routine of providing care:
- initial assessment of the degree of oxygenation
- correction of hypoxemia
- assuring maintenance of oxygenation during airway control interventions
- assuring proper placement of invasive airway devices using multiple techniques and tools for confirmation
- monitoring of the oxygen saturation and end-tidal carbon dioxide to identify problems as rapidly as possible
- immediate consideration for alternative techniques if the initial chosen is unsuccessful after several attempts.
Finally, all interventions provided in the prehospital and out-of-hospital setting should be continuously and critically evaluated to assure that benefit is resulting from what we do for the injured trauma patient. Quality review and improvement programs must be in place to assess success and complications of the interventions we provide as well as to determine the improvement, or lack thereof, in patient outcome. This can only be accomplished by collecting data, analyzing the results, and questioning what we do. Active involvement by knowledgeable physician program directors as well as dedicated providers is an integral component of these efforts.
It is the principle that must always be kept in mind. While there will be a preference that will be applied as the initial intervention, alternatives must be considered and used early in the course if the initial preference does not work in the current situation.
by Dr. Peter Pons, PHTLS Associate Medical Director
*[Corresponding Podcast by Dr. Jeffrey Guy, PHTLS Associate Medical Director]
*[Star-Telegram article] (posted April 20th 2008)
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PHTLS Combined Instructor and Transition Course (PHTLS)*
Wednesday, July 23, 8 am to 5 pm
Session P5
Faculty: PHTLS National and State Faculty / Fee: $135 (includes textbook)
This unique PHTLS Instructor and Transition course is designed to orient PHTLS instructor candidates and ITLS instructors to PHTLS philosophy, administration and course content. After completion of the course, candidates will need to be monitored by PHTLS Affiliate Faculty to finalize their instructor training. PHTLS providers and/or ITLS instructors are eligible for participation. Proof of current PHTLS provider or ITLS Instructor status required.
*Enrollment is limited and preregistration is required for all NAEMT preconference courses. Courses are recognized for CECBEMS accreditation. NAEMT reserves the right to cancel if minimum registration is not met.
Preregistration for these courses closes on June 20. Visit www.emsexpoevents.com to register.
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Newsletter Spring, 2008
Work has begun on the 7th edition process. Watch for more information as the process progresses.
US and Dutch Faculty taught the inaugural course in the Philippines in January. Costa Rica hosted its inaugural course in February. Discussions continue with Austria, Slovakia and Oman for courses later this year. Other plans include European, Latin American and Australasian PHTLS courses.
The PHTLS Committee is planning a symposia within the next two years. The Committee has completed the strategic planning consultation process and is implementing its strategic plan. –Will Chapleau, PHTLS chair
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