PreHospital Air Medical Plasma Trial (PAMPer)

Fresh frozen plasma (Wikimedia)

Fluid resuscitation, including type and amount, has been scrutinized for prehospital care of trauma patients. This recent multi-center study demonstrated remarkable results. The abstract is reproduced from the NEJM website:

The New England Journal of Medicine

Abstract

BACKGROUND

After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting.

METHODS

To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days.

RESULTS

A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, −9.8 percentage points; 95% confidence interval, −18.6 to −1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan–Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients’ arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury–acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions.

CONCLUSIONS

In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427.)

Who Knew?

Two vampires walked into a bar.

The bartender said, “what will it be?”

The first vampire said, “I’ll have a blood.”

The second vampire said, “I’ll have a plasma.”

“Right”, the bartender replied, “one blood and one blood lite.”

 

 

Meet Dr. Samrat in Nepal

Dr. Samrat graduated from the Peoples’ Friendship University of Russia in Moscow and earned his post-graduate degree in General Practice and Emergency Medicine from Tribhuvan University Teaching Hospital in Kathmandu, Nepal.
After working in Patan Academy of Health Science and Kathmandu Model Hospital, he joined CIWEC Clinic and Hospital in Kathmandu a few years ago. CIWEC is a travel medicine facility that cares for patients with a variety of travel-related and general health issues. Dr. Samrat describes his practice: “We deal with common issues like common respiratory illness, gastrointestinal illness and also rare and complicated issues requiring prolonged hospital care or care in the intensive care unit. We look after both outpatients and inpatients.  We help people with their travel needs including vaccinations and recommendations for their specific travel plans.”
Despite having access at CIWEC to UpToDate, a point of care medical information site provided by his employee, he uses the CMES thumb drive to access up-to-date cme at home. He likes having this option because “…the CMES thumb drive has helped me a lot while dealing with these issues. This has also given opportunities to interact with colleagues for the improvement in the overall care of our patients.”
Who Knew? The national flag of Nepal (Nepali: नेपालको झण्डा) is the world’s only non-quadrilateral national flag. The flag is a simplified combination of two single pennons, known as a double pennon. Its crimson red is the color of the rhododendron, Nepal’s national flower, while the blue border is the color of peace.

Guatemala Gets a Slice of CMES-Pi

Dr. Manoj Thomas visited Timmy Global Healths partner Asociacion Pop Wuj Clinic in Xela, Guatemala this past March. Asociacion Pop Wuj is a collectively owned, non-profit, Spanish language school that promotes community development through a variety of programs including a daycare center, construction of safe stoves, reforestation and ecological education, a student scholarship program, and a comprehensive health and nutrition program.

Working with Dr. Carmen and Dr. Herman he set up a CMES-Pi at the Xela clinic. The regular access to up-to-date continuing medical education content for the staff is welcomed as travel to conferences is difficult and costly for the organization.

We welcome Asociacion Pop Wuj and there impressive work in the community.

The Pop Wuj team with Dr. Manoj Thomas (on right).

The Pop Wuj team tries out the CMES-Pi connectivity.

Emergency Severity Index: The Ups and Downs of Triage

Who’s next? (Wikimedia Commons)

Jessica Mason MD and Wendy Chan MD discuss the history and present methods of triage in the May EM:RAP podcast of Annals of Emergency Medicine: Emergency Severity Index.

How do you risk stratify in your emergency department? Do you use a three-step system of emergent, urgent or non-urgent? Or the five-step triage protocol with ESI 1 indicating a critical patient to an ESI 5 indicating nothing serious? Neither provide an ideal system, but what about front-end physician triage, split flow and vertical flow? Update your triage knowledge by listening to the podcast…it might make your day flow smoother.

Larreys Flying Ambulance (National Library of Medicine)

Who Knew? Baron Dominique Jean Larrey is credited with inventing triage during the Napoleonic Wars but did you know he invented the first ambulance? The horse-drawn “flying ambulances” could maneuver quickly across a battlefield delivering injured men to field hospitals.

Thumbs Up Nigeria

Meet Dr. Dare Ogunlusi from Ekiti State University Teaching Hospital in Nigeria. He is an attending in the Department of Accident and Emergency.

He is the newest recipient and participant in CMES. Techies Without Borders (TWB) was referred to Dr. Dare by his friend and colleague Dr. Lisa Charles from Victoria Hospital in St. Lucia. TWB mailed a thumb drive to Dr. Dare after discussing the cme options that would best work for him. He will be testing the thumb drive and providing feedback on usability and content for his specific location.

CME development and utilization face challenges worldwide because resources are limited and infrastructure for the delivery of healthcare and information is fragile. Feedback from locations around the globe helps us improve our services and products. If you have colleagues who would be interested in either CMES or CMES-Pi, please contact Dr. Debra Stoner at: deb.twb@gmail.com

Gastric Lavage: Yes or No?

Antique gastric pump.
(Wikimedia Commons photo)

According to an EMRAP article, orogastric lavage was considered a standard procedure. It has never been proven to be of benefit. There are no recent studies. Although it was thought that removing the gastric contents might decrease the severity of the overdose, this is probably not the case. Why? Listen to the podcast or read the bullet points of the May 2018 article called “Pumping the Stomach” No More, by Anand Swaminathan MD and Sean Nordt MD, PharmD.

Do you still lavage for poison overdose? What substances? Leave a comment and share your knowledge.

Who Knew? Unlike many of our simpler medical and surgical instruments, mention of the stomach and duodenal tubes is not to be found in the classical writings of the ancient Greek and Arabian physicians…the somewhat uncertain origin of the stomach tube may be placed at about 144 years ago. Precursors of the stomach tube, however, were in common usage as early as the days of Imperial Rome. (Annals of Internal Medicine; The History of the Invention and Development of the Stomach and Duodenal Tubes by John R. Paine, MD)

 

 

 

Leeches: Friend or Foe

Leech
(WikiMedia Commons photos)

My experience with leeches is limited to a profound fear while hiking during the Nepal monsoon season where the rainforest leeches drop from the vegetation and make you their personal smorgasbord.

Have you ever used a leech medically to reduce swelling and vascular congestion? How do you remove leeches? How do you treat the wounds? Leave a comment and share your skills with us leech-less colleagues.

Who Knew? Leeches have 32 Brains. Their internal structure is divided into 32 segments. Each of these 32 segments has its own segment of the brain. Every leech also has two reproductive organs and 9 pairs of testes.

The Long & Short of Neck Injuries

Giraffe (WikiCommons photo)

Blunt neck trauma can be an airway nightmare. Listen to the podcast or catch the bullet points about workup and treatment from the May 2018 EMRAP article by Mel Herbert MD and Billy Mallon MD called Blunt Neck Trauma.

Who Knew? A giraffe’s neck is too short to reach the ground. It spreads its front legs or kneels to reach the ground for a drink of water.

 

Dr. Lisa Floats on a Wave of CME in St. Lucia

Dr. Lisa Charles, ED Director at Victoria Hospital, St. Lucia.

St. Lucia Pitons, World Heritage site. (Wikimedia)

Dr. Lisa Charles at Victoria Hospital in St. Lucia runs a tight ship on this Caribbean island. Emergency Medicine trained, she embraces continuing medical education (cme) as a means to keep her staff up-to-date. The staff at Victoria Hospital received thumb drives this past February and are putting them to good use. Several years ago she wrote a procedures manual for her ED staff at Victoria Hospital and is using the CMES articles to update her information.

Living on a small Caribbean island poses challenges for travel and access to cme credits which are mandatory for physicians in St. Lucia. She is permitted by the St. Lucian Medical Council to authorize articles as cme credits for her staff. She is also using CMES to provide some of the mandatory cme credit for her staff.

Who Knew? Together with Caribbean music genres such as Calypso, Soca, Dancehall, Reggae, Compas, Zouk, and Salsa, Saint Lucia has a strong country music tradition. In the 1950s the only radio stations heard in St. Lucia was from Texas, USA, where country music was popular. Even today you can hear George Jones, Patsy Cline and Johnny Cash’s voices drifting out of neighborhood bars.

 

Don’t Let Pediatric Tachycardia Get Your Heart Racing

Early ECG machine. Photo from Wikipedia.

According to Medscape, an online medical information site: “a heart rate of more than 160 beats per minute in infants and a respiratory rate of more than 60 per minute are associated with an increased mortality risk and often signal the development of septic shock.”

The May EM:RAP Pediatric Pearls podcast by Dr. Ilene Claudius, Dr. Sol Behar, Dr. James Salway and Dr. Liza Kearl offers prudent advice on differentiating respiratory from cardiac sources of pediatric tachycardia. Or pull up the PDF and have a fast read of the bullet points to keep your rate in check and your knowledge bounding.

Who Knew? Willem Einthoven, working in Leiden, the Netherlands, used the string galvanometer (the first practical electrocardiograph) he invented in 1901 which was more sensitive than previous 1870s inventions. He assigned the letters P, Q, R, S, and T to the waveform deflections. (Wikipedia)

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