Daved van Stralen

Retrograde intubation training using a mannequin

The purpose of this study was to determine the efficacy of a mannequin for training emergency caregivers in the technique of retrograde intubation. This was a descriptive study using duration of time needed for completion of intubation as a measure of success. A cohort of 88 Emergency Medical Service (EMS) personnel included prehospital caregivers, registered nurses, and respiratory care practitioners. Participants were trained in retrograde intubation by modeling. Students practiced before they were tested. Every subject successfully completed intubation on the first timed effort. Subjects performed retrograde intubation in a mean time of 71 seconds (95% confidence interval +/- 4 seconds), with a range of 42 to 129 seconds. It was concluded that retrograde intubation can be taught easily with a mannequin and that this skill can be learned by emergency caregivers by modeling. Bag-valve-mask ventilation can be performed at any time without the need to restart or interrupt the procedure. Retrograde intubation can be introduced as an intubation technique for the difficult airway encountered by EMS personnel.

CBF and CBF/Pco2 reactivity in childhood strangulation

Four children with self-inflicted strangulation injuries had cerebral blood flow determined by stable xenon computed tomography (XeCTCBF) within 24 hours of admission. All had suffered a severe hypoxic-ischemic cerebral injury; 3 initially had fixed pupils, all were apneic with varying bradyarrhythmias, and the initial mean arterial pH was 7.26 (+/- 0.18). The initial blood glucose values were greater than 300 mg/dl (334 and 351 mg/dl) in the 2 patients who died compared to the 2 who survived (104 and 295 mg/dl). The cardiac index was depressed during the first several days of hospitalization in the 2 patients who died (less than 2.0 L/min/m2) compared to the 2 who survived. Total CBF was normal (63 +/- 8 ml/min/100 gm) and local variations in CBF were present. PCO2 reactivity was determined by hyperventilating the 4 patients for 20 min from an end tidal PCO2 of 39 +/- 3 torr to 29 +/- 1 torr and then repeating the XeCTCBF study. Marked regional variability in the CBF/PCO2 response was observed, ranging from 0.5-5.5 ml/min/100 gm/torr PCO2. In the 2 patients who died, the CBF/PCO2 was decreased (1.2 ml/min/100 gm/torr PCO2) compared to the 2 patients who survived (2.1 ml/min/100 gm/torr PCO2). Although CBF was normal in these 4 children, the hyperventilation response was depressed, variable, and even paradoxical which may be important in the evolution of further brain injury and is a critical factor in deciding whether hyperventilation may be of clinical benefit.(ABSTRACT TRUNCATED AT 250 WORDS)

Changing a pediatric sub-acute facility to increase safety and reliability

This chapter describes the efforts of a team of health care workers to make a sub-acute health care facility (SCF) serving profoundly damaged children into a high reliability organization (HRO). To obtain this goal, the health care team implemented change in four behavioral areas: (1) risk awareness and acknowledgment; (2) defining care; (3) how to think and make decisions; and (4) information flow. The team focused on five reliability enhancement issues that emerged from previous research on banking institutions: (1) process auditing; (2) the reward system; (3) quality degradation; (4) risk awareness and acknowledgment; and (5) command and control. These HRO processes emerged from the change effort. Three additional HRO processes also emerged: high trust, and building a high reliability culture based on values and on beliefs. This case demonstrates that HRO processes can reduce costs, improve safety, and aid in developing new markets. Other experiences in implementing high reliability processes show that each organization must tailor make processes to its own situation (e.g. BP, U.S. Chemical Safety and Hazards Board, Federal Aviation Administration, U.S. Navy Aviation Program, and Kaiser Permanente Health Care System). Just as in the flexibility called for in organizing for high reliability operations, flexibility is called for in deciding which HRO processes work in specific situations.

Mild head injury in children: Identification, clinical evaluation, neuroimaging, and disposition

Pediatric head injury presents in various degrees of severity. Early intervention in the patient with a severe head injury is the key to preventing secondary central nervous system damage. Patients with a head injury are easily identified, often by clinical examination alone. However, patients with a mild head injury present a challenge to practitioners, particularly in identification, knowing what is important in the clinical evaluation, deciding whether to use neuroimaging, and knowing where to send the child for observation. Use of the Glasgow Coma Score, primary survey, and identification of historic and clinical features that are suggestive of severe head injury may guide pediatric nurse practitioners in providing appropriate medical care and disposition.

Efficacy and Safety of Tranexamic Acid in Prehospital Traumatic Hemorrhagic Shock: Outcomes of the Cal-PAT Study

Introduction The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess the safety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-induced hemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administration by paramedics within the framework of North American emergency medicine standards and protocols. Methods This is an ongoing multi-centered, prospective, observational cohort study with a retrospective chart-review comparison. Trauma patients identified in the prehospital setting with signs of hemorrhagic shock by first responders were administered one gram of TXA followed by an optional second one-gram dose upon arrival to the hospital, if the patient still met inclusion criteria. Patients administered TXA make up the prehospital intervention group. Control group patients met the same inclusion criteria as TXA candidates and were matched with the prehospital intervention patients based on mechanism of injury, injury severity score, and age. The primary outcomes were mortality, measured at 24 hours, 48 hours, and 28 days. Secondary outcomes measured included the total blood products transfused and any known adverse events associated with TXA administration. Results We included 128 patients in the prehospital intervention group and 125 in the control group. Although not statistically significant, the prehospital intervention group trended toward a lower 24-hour mortality rate (3.9% vs 7.2% for intervention and control, respectively, p=0.25), 48-hour mortality rate (6.3% vs 7.2% for intervention and control, respectively, p=0.76), and 28-day mortality rate (6.3% vs 10.4% for intervention and control, respectively, p=0.23). There was no significant difference observed in known adverse events associated with TXA administration in the prehospital intervention group and control group. A reduction in total blood product usage was observed following the administration of TXA (control: 6.95 units; intervention: 4.09 units; p=0.01). Conclusion Preliminary evidence from the Cal-PAT study suggests that TXA administration may be safe in the prehospital setting with no significant change in adverse events observed and an associated decreased use of blood products in cases of trauma-induced hemorrhagic shock. Given the current sample size, a statistically significant decrease in mortality was not observed. Additionally, this study demonstrates that it may be feasible for paramedics to identify and safely administer TXA in the prehospital setting.

Ambiguity in the Operator's Sense

Ambiguity is a central problem for operators working in dynamic, high‐risk environments. Operators must decide on a course of action before knowing with certainty how the system will respond. Though ambiguity is expected, how it presents is unexpected. We reduce ambiguity when we can give meaning to information and events through use of context, responsiveness of the system, and when we can view events from a higher level. Preparation and training for routine operations helps identify potential ambiguities before events begin. The experienced operator engages the situation relying on real‐time experience to learn what works through action, thus further reducing ambiguity.

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Author(s): van Stralen, Daved; McKay, Sean D.; Inaba, Kenji; Hartwig, Mark; Mercer, Thomas A.