Transcript SPRINT`s - CCT CORE

STABILIZING PATIENTS RAPIDLY FOR INTERFACILITY TRANSPORT:
THE SPRINT COURSE
Assistance
Advisors
Burns
Jim Johnson MD
Christopher Lentz MD
Cardiac
Charles Bethea MD
Raj Chandwaney MD
Neurology
David L. Gordon MD
Anna Wanahita MD
Obstetrics
Michael Gardner MD
Pediatrics
Amanda L. Bogie MD
Michael Gomez MD
Cecilia C. Guthrie MD
Surgery & Trauma
John Blebea MD
Jason Lees MD
Michael Charles MD
Referring
Facility
Course overview & “5 W’s”
General principles/steps for all patients
Principles related to specific diagnoses
Recommendations summary
Post-course follow-up & plans
Discussion outline
Receiving
Hospital
SPRINT overview: 5 W’s
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What is SPRINT?
Why a new program?
Who are audience targets?
Where and when are courses?
SPRINT general
principles
Core message: “Fast, Safe, and Sound”
– Strive for quickness (while avoiding haste)
– Keep patient safety as top priority
– Practice sound, evidence-based medicine
Goal: Minimize HEMS time at referring hospital
– Time HEMS crew spends at patient’s bedside
– SPRINT’s focus: “Patient stabilization time” (PST)
SPRINT goal:
Streamline PST
• Efficiency is desirable in any acute patient
• Incremental benefit with time savings
– Trauma
– Vascular emergencies
• Categorical endpoint: meeting time window
– Percutaneous coronary intervention for STEMI
– Lysis therapy for ischemic stroke (iCVA)
SPRINT and patient care timeline
• SPRINT time frame
after transport decision
• SPRINT is not intended to address:
– Making decision to transport
– Determining transport mode/service
– Designating receiving facility
SPRINT is not meant to dictate transport
decisions, modalities, or receiving centers
SPRINT steps: Initial information
Referring & receiving hospital data
• Unit, physician, contact info
• Bed status: Ready, not ready, etc.
Patient parameters
• Name and birthdate
• Complaint/transport reason
• Height, weight & widest girth
SPRINT steps:
Initial info
Additional clinical parameters
• Medications
• Equipment (eg. pumps, vent)
• Safety (eg. patient agitation)
Other issues
• Will family be at referring hospital with patient?
• Weather questions on referring hospital end
SPRINT steps:
Logistics & paperwork
Prepare the LZ and personnel
• Refer to LZ training courses
• Prepare to assist crew as needed
SPRINT steps:
Airway
• #1 issue (for flight crews & receiving doctors)
• Endotracheal intubation (ETI) problems:
– HEMS ETI is widely perceived as too frequent
– Flight crew ETI is associated with prolonged PST
• Flight crew can offer significant ETI expertise
• Decision on ETI pre-transport vs. in-flight:
– Estimation of ETI difficulty isn’t always precise
– Patient and logistics factors contribute to decision
– Bottom line: Situational judgment is best
• Guides to assist referring providers:
– If airway needs management, manage it
– When in doubt, secure airway
• Discuss prn with en route crews
• When airway is managed
– Describe difficulties to crew
– Note airway, size, and depth
SPRINT steps:
Airway
SPRINT steps:
Breathing
• Breathing problem: manage airway
• Mechanical ventilation preferred
• Optimize/report vent settings
• Vascular access
– 2 functioning and secured lines usually required
– If IV access is problematic, alert en route HEMS crew
• Fluids: Discuss with receiving; prepare infusates
SPRINT steps:
Circulation
SPRINT steps: Medications
• Drug Rx often causes preventable delays
• Execute/consider following time savers:
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Administer all ordered medications
Clarify allergies
Anticipate medications that may be needed
Alert transport crews to drugs/times given:
Antibiotics
Analgesics
Sedatives
Paralytics
Cardiovascular support (cardio-/vaso-active agents)
Disease-specific therapy
SPRINT steps:
Other procedures
• Gastric tube
• Foley catheter
• Pneumothorax tx
SPRINT steps:
Flight crew arrival
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Crew to pt for pass-off
Assure 2 IVs
Transfer infusions to HEMS pumps
Assure ordered meds given
Discuss situation with family
Situationally consider:
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“ABCs” management
Spinal immobilization
Analgesia, sedation, antiemetics, other prn meds
Foley, gastric tube, Dx-specific therapy
SPRINT steps:
Patient hand-off
1) Patient demographics
2) Chief complaint & HPI
3) Dx and basic therapies
– Labs, radiography, meds
– Identify treatment as:
• Fully completed
• Partly complete
• Planned/ordered
– Admin times for key meds
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Analgesia
Antiepileptics
Sedation
Paralytics
4) Ventilator patients
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Airway/lung assessment
ETI medications/problems
ETT size, depth
ETT confirmation method
Vent changes/responses
5) Summarize working dx
6) Ask if report complete
7) Receiving crew review
– Presentation key points
– Interventions/meds
– Points to consider
Diagnosis-specific principles
Burns
Cardiac
Neurology
Obstetrics
Pediatrics
Trauma
Vascular
Streamlining PST: Burns
1) Airway: “Aggressive can be conservative”
– Inhalational/airway, facial burns: ETI likely
– Save PST on by managing airway early
2) Fluids (warm if possible)
– Use formula (BRI, Parkland) to calculate fluids
– Monitor and report urine output
3) Dressings: Use minimalist approach
4) Thermoregulation: Keep patients warm
Streamlining PST:
STEMI for PCI
1) Administer meds
– ASA almost always
– No clopidogrel
– Heparin bolus 50-70 u/kg
2) No IV infusions
– No heparin drip
– No nitroglycerin drip
3) Consider R-sided EKG
4) Gown patient
Streamlining PST:
Seizures
1) Stop seizures
2) Report what worked (and when)
3) Avoid paralytics
Streamlining PST:
Stroke
1) Avoid paralytics
2) Generate BP plan
– Hemorrhage mgmt?
– Lysis-eligible: 185/110
– Post-lysis: 180/105
Streamlining PST: Obstetrics
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Transport by air?: Contractions and cervix
Perfusion: left lateral decubitus position
Analgesics and antiemetics (both are fine)
BP control: Formulate plan and start treating
Streamlining PST: Pediatrics
Airway:
Intubate if needed
Watch tube size/depth
Streamlining PST:
Pediatrics
• VS: Pay attention to BP cuff, SpO2 site, temp
• Fluids: Make plan for fluids and have them ready
Streamlining PST: Trauma
Airway, breathing, and circulation
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Consider managing airway
Assure IV access in place
Foley catheters
Assure infusates (e.g. blood) are ready
Spinal immobilization
• In unclear cases: fully immobilize
• Discuss with receiving surgeon
• Clarify why spine (or parts) cleared
Streamlining PST: Trauma
1) Fractures: Splint, treat pain
2) Guard against hypothermia
3) Pneumothorax/chest tubes
– Thoracostomy: Heimlich valve
– Pneumothorax: Decompress?
Streamlining PST: Vascular
1) Cold extremities: Time is key
– Clarify time of sx onset
– Heparin bolus/infusion: almost always
2) Aortic disease (non-trauma)
– Large-bore access; judicious analgesia
– Permissive hypotension (AAA)
– Anti-impulse Rx (dissection)
• Decision to transfer → T0
• Execute logistics/admin jobs
Summary
• Develop a concrete clinical plan
• Provide ordered and/or needed Tx
• Expedite the report to transport crew
• Facilitate movement to transport vehicle
SPRINT: Post-course
[email protected]
Thanks for your time –
and for your time savings