@docjohnhinds is the man behind Cricolol
I recently brought him to our EM Critical Care Grand Rounds at @stonybrookem
He gave two fantastic lectures! I then brought him back to EMCrit Studios to record a few of the take-home lessons from his talks.
See Cases from the Races on the RagePodcast site to see the inspiration for this ‘cast.
Blunt Traumatic Arrest: a Road Racing Doc's Approach
If the patient is in blunt traumatic arrest, John and his team immediately perform the following before any further assessment:
- Intubation using a bougie and confirmed by waveform CO2
- Perform Bilateral Finger Thoracostomy
- Place Pelvic Compression Device
- Straighten Long Bone Fractures to Length
- Administer Fluid Bolus (Administer Blood if In-Hospital)
Only then reassess and decide what to do
Impact Apnea
Airway positioning and rescue ventilation can save a life
More on this soon when the Wilson, Hinds, Davies study is published. Until then, see the LiTFL CCC Entry
Central Line Placement
In John's unit, they use infraclavicular left subclavian for all ICU CVC placements
Additional New Information
More on EMCrit
EMCrit 153 – In Memory – John Hinds, On How He Ran His Unit(Opens in a new browser tab)
EMCrit Wee – Cricolol by Dr. John Hinds(Opens in a new browser tab)
Additional Resources
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit Wee (392.5) – Naughty or Nice? Bad Behavior in Healthcare with Liz Crowe, PhD - January 15, 2025
- EMCrit 392 – All Things Defibrillation with Sheldon Cheskes - January 10, 2025
- EMCrit 391 – Pericardiocentesis and Tamponade Temporization - December 27, 2024
Loved this cast and especially the wee. Can you post or describe his didactic approach for left subclavian lines? They have 5 lumen lines? Are they available in the states? How many French? Are our TPL lumen 20cm? What about femoral lines for trauma? Do they avoid upper lines if pt may need dialysis or is a renal pt?
Thanks for having me on, Scott! It was good fun visiting. For those of you our there who want to know what emcrit HQ looks like, it is indeed a hollowed out volcano with Scott’s head carved in the side of it, 200 feet high. Don, thanks for the kind words! We use an arrow 8.5fr 5 lumen line; 20cm for left side, 16cm for right. http://www.teleflex.com/emea/documentLibrary/documents/940483-000001-8-5-FR-5-LUMEN-0906.pdf Left side is the line of choice, leaving the right free for a CRRT line (to provide a straighter route to the svc, and hence more reliable flow) Femoral access is only allowed… Read more »
my video is linked in the shownotes. John, be happy to post and feature any videos you create on the EMCrit site.
yes i would love to see your variations. i have put in many maybe 25 but still find IJ way easier especially instead of left subclavian as i usually put in right subclavian and in fact never have done a left sided one
For trauma it may be ok to do right i would imagine.
i have done about 5 of the finger thoracostomy in arrests and nurses look at me like I’m nuts. but i get it and am grateful for the knowledge
I’d love to see that video, too. Especially the way you teach it, as you suggetsed that walking off the clavicle to be … not so smart. I found that trick to be handy for begginers when placing SC lines in the obese pts. Love to hear your view. We use BBraun Certofix, preferably SC, no preference in side. And US guided IJs in coagulopathic pts. Love the tip on suturing only the part on the catheter itself, not using the Lego thing.
Why not use US for subclavian access when the patient is stable in the ICU? Sound like you have done enough subclavians and know that you will occasionally hit the aa (of questionable significance), cause a PTX (same) and even cases of reported tamponade. The old NEJM paper was from 1994 that said there was no difference, and people are much more savvy with US today than at that time. The newer CCM paper says you can reduce complication rates. Also you can easily confirm the location of the catheter and guidewire using real time US, making dilating the subclavian… Read more »
Hey wonderful wonderful podcast… John you had mentioned that 50% of your blunt traumatic arrests have a dc from the hospital with neuro intact. I think…? Are you saying that 50% of your blunt CA pts gain ROSC and then 50% of them are DCed from the hospital with neuro intact? Would you mind clarifying? Thanks!!
Ultrasound is fine; and I have no problems using it – it’s a great option and indeed a vital skill for everyone doing CVC’s. However, I do feel that if you are going to teach resuscitationists to do resuscitation lines; they should be learning – and regularly practicing – landmark subclavians. Otherwise, the first time they are faced with a hypotensive patient, in a hard collar, with a busted pelvis and surgical emphysema; they will fail. The CCM paper is one we reviewed. Their landmark complication rate for SC in stable patients is frankly terrifying. I would shut the doors… Read more »
Awesomeness, gentlemen. I have seen impact apnea up close and personal. A couple years ago at the grocery store I heard a terrible thump behind me, followed by a father’s panicked cry for help. His 4yo daughter had fallen out of the grocery cart and smacked her head on the tile floor. She had a strong pulse but was stone cold apneic for 60-90 seconds. I simply did simultaneous jaw thrust and C-spine immobilization and tried to wait patiently. Just as I was about to start giving rescue breaths, she started breathing on her own and very quickly thereafter woke… Read more »
Hi Bill, thanks for the comments! We carry Ez-IO’s and cordi. The IO is for tibial or humeral, whichever site suits injury pattern best Have used the IO twice; 1. BASICS prehospital job where a patient was trapped in a car with limited access, for ketamine to facilitate extrication. He had a CVC once extricated. 2. Patient with multiple amputations. 2x IO attempts failed by an experienced paramedic trainer, by which time a CVC was in IO’s are great; fast and with a fairly low learning curve and a good option for some patients and practitioners. I certainly wouldn’t want… Read more »
Great podcast Scott! I just started Karim’s the Masters of Trauma Science (Military and Austere Environments) thru Queen Mary University in London. We discussed the initial care of blunt traumatic arrest and the need to stabilize the pelvis on everyone. This podcast reinforces my decision to change the Clinical Practice Guidelines and require pelvic immobilization be applied to all cases of blunt traumatic arrest in all the EMS and SWAT agencies I serve as Medical Director for. I too like the SAM Pelvic Sling, but I like the SAM Junctional Tourniquet better. It is approved as a pelvic binder. It… Read more »
Jim–haven’t played with the junctional tourniquet yet, but from what you have stated seems to make a lot of sense
Hi Jim,
I lecture and teach on the Trauma Science MSc
Be sure to get to the summer school, it’s excellent!
-John
From a Paramedic in the field… tl:dr – do we do chest compressions while waiting for the fluid bolus to get in after everything else is done? After we intubate, do a bilateral needle decompression ( finger thoracosotmy isnt in our scope), put on the pelvic binder, straighten any long bone fx’s and start infusing a fluid bolus…….Is there any merit to doing chest compressions on the blunt trauma arrest patient? We do not transport blunt traumatic cardiac arrests in my service. Should we be doing compressions after the above interventions, (my other choice is just staring at the IV… Read more »
Follow up: Does initial ecg have any part in treatment? Not doing compressions on a Pulseless Electrical activity sinus tach makes sense…..does the same hold true for Asystolic blunt trauma arrests?
Hi Brian, thanks for the questions Initial rhythm has no bearing on management; and indeed we specifically don’t go looking for a rhythm if the patient is “clinically lifeless”. The management will be the same whatever it is. Certainly resuscitation should not be withheld regardless of what the presenting rhythm may be http://www.ncbi.nlm.nih.gov/pubmed/23354262 Chest compressions are optional. Some believe they cause harm, some are more equivocal. There is even a body of theory that if needle decompression is all you have, the intrathoracic pressure generated by CPR may help “force air out”; though that sounds like hokum to me. The… Read more »
Maybe I’m misunderstanding something but without a pulse ( or the chance of an undetectable palpable pulse in PEA) how does intubating and ventilating correct any hypoxia without perfusion/circulation?
Which to me makes sense to look at initial rhythm. If I saw a PEA I would be able to think maybe there is still some circulation and spending the time to intubate is worthwhile……but if I saw Asystole on the monitor I’m not sure I see the value in intubating and ventilating. I am most probably missing something here though.
I learnt how to do my subclavians in your place John! Did about 10 there, and 80 or so in New Zealand (and not a PTX so far despite some walking off the clavicle ;-)). Since I’ve got back to Ireland I’ve done about 5… As you mention US guided IJs seem to have taken over.
I always remember in CAH the lines were all shoved into the hilt – i’ve not seen anywhere else do that (about 6 different places now) – i have no objections but just wondering if there was any data behind that?
Hi Andy, No good data, but then it’s hard to get a meaningful comparison with other units. The thinking is that it’s better to put in an appropriate sized line to the hilt than have an incorrectly sized one hanging out. A 20cm left sided line and 15/16cm right sided line lie acceptably in almost all adult patients (we audit this regularly, along with other CVC data – complications, resites, sequale, infections etc.) Having the line to the hilt means it is secured only by the hub; not the stupid clip-on thingy that inevitably falls off. This reduces the number… Read more »
Interesting thoughts from John Hinds – you can tell the voice of experince! I have been interested in the head impact apnoea since a case I saw in the early 1990s when flying with the London HEMS service. The patient was “dead on scene” without much of a mark on them – but in a position where their airway was obstructed. I worried about this a lot as the head injury seemed clinically and on PM to be very minor – and then found some of the animal work on post head injury apnoea from the 1940s and 1950s while… Read more »
Absolutely! And can’t wait for Mark Wilson’s SMACC talk on the topic.
Thanks Tim, great to have feedback from such an esteemed chap as yourself! There are certainly individual – and indeed male/female – variations on post concussion severity and presentation. It’s entirely likely that IBA has similar individual variability. It’s such a tough “disease” to study, due to its hyper acuity and the fact that – as you know – often one which is only diagnosed by best-guess after death. Gareth Davies and Mark Wilson are the real leaders on this. They’ve kindly allowed Brian Burns and myself to join in as there had been a lot of independent work going… Read more »
Does the concept of impact apnea change your recommendations for management of blunt trauma arrest?
I have been preaching the dogma of NO ACLS meds or closed chest compressions in the setting of trauma arrest.
Do yo believe that closed chest compressions +/- ACLS medications might be reasonable in a blunt trauma patient who has suffered a hypoxic event from impact apnea?
Follow-up question: wondering how dogmatic to be about admonishing use of ACLS meds/chest compressions in traumatic arrest for our EMS services? Are there some circumstances in apparent blunt trauma arrest that closed chest compressions +/- ACLS medications might be reasonable, such as high spinal injury, impact apnea, commotio cordis? Unfortunately, many articles and guidelines are still fuzzy on this topic, with some recommending optional chest compressions and others still recommending full ALS: Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the joint NAEMSP-ACSCOT position statements. Millin MG1, Galvagno SM, Khandker SR, Malki A,… Read more »
tell the ems services to do compressions b/c that is the best they can do without docs in the bus. bilateral finger thoracostomy or large needle decompression and pelvic binder makes a lot of sense as well. see no role for acls meds; most of us don’t see much role in medical ACLS for that matter.
they need an airway
not sure where either compressions or acls meds would play a role in impact apnea
Scott, If one considers cardiac arrest following impact apnea a primary respiratory arrest, then might an ACLS approach (good quality, uninterrupted compressions, defibrillation, +/- meds) be reasonable for for treatment of the ensuing arrthymias? A similar argument might be made for other traumatic primary respiratory arrests, such as high cervical injuries, isolated head injury, airway obstruction, impact apnea. This is the way we approach all primary respiratory arrests (traumatic or medical). This is in direct contradistinction to the approach to trauma arrests from hypovolemia where chest compressions, defibrillation and meds are likely just a distraction from those procedures that need… Read more »
Hello, I have a quick question. Do you guys intubate maintaining spinal precautions? What do you carry with you aside the bougie/LMA? direct or portable video laryngoscopy?
Resident from Montreal, Canada