KETAMINE: the background

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Dr M Bloch Consultant Anaesthetist RACH
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Plan

• Why
• How

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Persons Injured orKilled as a Result
Date Fatal Serious Slight Total
2001 50 270 1277 1597
2002 49 274 1211 1534
2003 50 278 1149 1477
2004 44 275 1107 1426
2005 53 243 1261 1557
2006 62 214 1167 1443
Total 308 1554 7172 9034
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• Different equipment.
• Different education and training.
• Different perspective, pressures and pitfalls.

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• 10 of 999 calls are for children, 5 of these
  require resuscitation (1997).
• Commonest cause of death gt1 yr TRAUMA.
• When required, response needs to prompt and
  effective. Prevent 20 injury and gather
  appropriate information (MOI / NAI). (Fiona
  Jewkes)
• Risk Benefit Cost Effective ? emotions

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Early recognition and initial management

• BIG SICK little sick

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How?Systematic approach attention to detail!
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PHPLS / APLS / PHECC / PEPP / PHTLS

• Immediate / Primary survey / Resuscitation phase
• Simultaneous assessment, identification and
  management of any immediate life-threatening
  problems, with ongoing assessment of the
  potential for developing other life-threatening
  complications.

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Secondary survey / Focussed review / Emergency
treatment
Continuing assessment, care and stabilisation.
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D DANGER (scene, self, patient) DANGER (scene, self, patient) DANGER (scene, self, patient) 4 DIMENSIONS up / down, front / back, left / right time
R RESPONSE (Patient, Help) RELATION (MOI, SAMPLE) Reassure Reassess ??
Ac AIRWAY with C-SPINE AIRWAY with C-SPINE AIRWAY with C-SPINE do airway think spine Safe ??O2?, maintainable / at risk (position / manoeuvres / adjuncts), unmaintainable (secure / definitive) Effort (signs of ? WOB esp. RR with ?TV, recession), Efficacy (depth / AE / O2 / CO2), Effect. (HR / LOC / colour / hyponia / ? FiO2), Exhaustion twelve FLAPS open / expanding PTx, flail, HTx. NGT AB on scene good 1st principles
B BREATHING BREATHING BREATHING do airway think spine Safe ??O2?, maintainable / at risk (position / manoeuvres / adjuncts), unmaintainable (secure / definitive) Effort (signs of ? WOB esp. RR with ?TV, recession), Efficacy (depth / AE / O2 / CO2), Effect. (HR / LOC / colour / hyponia / ? FiO2), Exhaustion twelve FLAPS open / expanding PTx, flail, HTx. NGT AB on scene good 1st principles
C CIRCULATION CIRCULATION CIRCULATION Assess clinical vs. measured (cough, movement, LOC, pulse, CFT, RR, temp. difference creeping proximally, colour pink, pale, mottled, urine vs. SaO2, BP, ETCO2, BD, lactate) On the floor and four more. Manage Controllable vs. uncontrollable haemorrhage arrest fluids. C en-route
D DISABILITY DRUGS ? analgesia, sedation ? appropriate antibiotics DONT EVER FORGET GLUCOSE AVPU (GCS modifications), PEARL, focal, recurrent seizures, protecting airway (prevent 20 injury)
E EMOBILISE EVACUATE EVALUATE EXPOSURE DRUGS ? analgesia, sedation ? appropriate antibiotics DONT EVER FORGET GLUCOSE 10 ? 20 survey vs. time-critical Hypothermia
F FEELING DRUGS ? analgesia, sedation ? appropriate antibiotics DONT EVER FORGET GLUCOSE Pain, anxiety and fear
G GUIDANCE DRUGS ? analgesia, sedation ? appropriate antibiotics DONT EVER FORGET GLUCOSE ask for help
H HARM DRUGS ? analgesia, sedation ? appropriate antibiotics DONT EVER FORGET GLUCOSE e.g. NAI
I IMMUNE / INFECTION DRUGS ? analgesia, sedation ? appropriate antibiotics DONT EVER FORGET GLUCOSE (mbloch_at_nhs.net)
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C-Spine

• Risks and benefits.
• Equipment and skills.
• Canadian and Nexus.

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Conclusion Systematic approach

• A combination of knowledge, skill and
  understanding is required to make the appropriate
  clinical judgement decisions.
• However non-technical skills are also required to
  optimise patient outcome including
• Anticipating and planning.
• Appropriate team leadership.
• Effective communication sharing mental models.
• Maintaining situation awareness and utilising
  appropriate personnel and resources.
• Calling for help early enough.