The Resus Room

By Simon Laing, Rob Fenwick & James Yates

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Description

Podcasts from the website TheResusRoom.co.uk Promoting excellent care in and around the resus room, concentrating on critical appraisal, evidenced based medicine and international guidelines.

Episode Date
Heat Illness; Roadside to Resus
43:30

If you live in the UK you may be fooled in to thinking that Heat Illness isn't really something we need to worry about...but you'd be wrong! Each year there are 800 deaths due to Heat Illness and figures in more temperate climates are significantly more.

In this podcast we tackle the topic of Heat Illness, all the way through Heat Cramps, Heat Syncope, Heat Exhaustion and to Heat Stroke.

We'll cover the following;

  • Definition, clinical spectrum and categories
  • Scale of the problem
  • Thermoregulatory physiology
  • Impact of hyperthermia
  • Clinical findings
  • Those at greatest risk
  • Acclimatisation
  • Differentials
  • Management

As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you, and most importantly, we hope we haven't missed the summer heat wave...!

Enjoy

Simon, Rob & James 

Jun 17, 2019
June 2019; papers of the month
33:19

Status Epilepticus in children, lying and standing blood pressures in syncope or presyncope and decompressing paediatric tension pneumothoraces.

You'll no doubt have seen and heard about the two papers published this month in the Lancet, both Consept and Eclipse look at the use of keppra vs phenytoin as a second line anti convulsant therapy for children in status epilepticus. We take a look at both papers, and have a think about what this means for practice.

There has been a large amount of focus on the optimal position for needle decompression of tension pneumothoraces in adults, but an open access paper from SJTREM looks at the best position in children, take a look at the paper here.

Finally, should all patients with a presentation of syncope/presyncope be getting a lying and standing blood pressure, or is it an ineffective test?

Make sure you take a look at the papers yourself, remembering that the paper from SJTREM on paediatric pneumothoraces is totally open access.

We'd love to hear your thoughts and comments.

Enjoy!

Simon & Rob

 

Jun 01, 2019
Drowning; Roadside to Resus
50:34

Drowning is a huge worldwide problem, and here in the UK there are around 350 accidental deaths from drowning each year.

From the patient who is potentially well enough for discharge on scene, all the way through to the resuscitation and prognostication of a cardiac arrest due to drowning, the topic carries a number of unique questions and challenges.

In this podcast we run through;

  • The scale of the problem
  • Modes of drowning
  • Prognostic factors
  • Extrication
  • Advanced Life Support in Drowning
  • Termination of resuscitation
  • Medical management

As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you.

Enjoy!

Simon, Rob & James

 

May 15, 2019
May 2019; papers of the month
35:33

So first up a huge welcome to SJTREM, the free open access journal who we've teamed up with in the delivery of the podcast, every paper they publish is available online to read for free.

Each month we'll be covering one of their papers in our Papers of the Month episodes, giving you the opportunity to review the literature yourself, come to your own conclusions and join the conversation. SJTREM have made our podcast a sustainable venture and together we look forward to promoting review and discussion of the best evidence and education, to all, for free!

This month we'll be looking at an analysis of REBOA and having a think about whether it is benefiting those patients that are receiving it. We take a look at paper that reviews what we really know about the use of ETCO2 in cardiac arrest and have a think about how much importance we should put on it. Finally we take a look at the utility of prehospital blood gases; should this be the standard of care, or is it a step too far?Make sure you take a look at the papers yourself, remembering that the paper from SJTREM on prehospital blood gases is totally open access.

We'd love to hear your thoughts and comments.

Enjoy!

Simon & Rob

May 01, 2019
GCS 8, intubate?
18:38

'Patients with GCS scores of 8 or less require prompt intubation', that's what ATLS tells us.

The mantra of GCS 8, intubate has pervaded teaching for those involved in the management of patients with a reduced GCS (Glasgow Coma Scale). But on reflection it would seem slightly odd that the gain or loss of a single point on the Glasgow Coma Scale could simply account for a change in the decision as to whether a patient would benefit from intubation and ventilation. So should the patient with a GCS of 9 be best managed without a definitive airway, but when that slips to 8 we should reach for the portex®?

In this podcast we take a deeper look at the GCS, we have a think about the role that it was designed to perform and consider how it should best be applied to acutely ill patients when considering protecting their airway.

The podcast is based upon the blog from the TEAM Course blog(Training in Emergency Airway Management), make sure to go and have a look at the post and other resources available on that site.

Enjoy!

SimonRob & James

References

GCS 8 intubate; TEAMcourse

Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.2013;74(5):1363-6.Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4.

Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G.The Glasgow Coma Scale at 40 years: standing the test of time.Lancet Neurol. 2014;13(8):844-54.

Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-5.

Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale.Ann Emerg Med. 2011;58(5):427-30.

Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor.J Trauma. 2003;54(4):671-8.

Isbister GK, Downes F, Sibbritt D, Dawson AH, Whyte IM. Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes.Crit Care Med. 2004;32(1):88-93.

Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia.Lancet. 1996;348(9020):123-4.

Kulig K, Rumack BH, Rosen P. Gag reflex in assessing level of consciousness.Lancet. 1982;1(8271):565.

Rotheray KR, Cheung PS, Cheung CS, et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?.Resuscitation. 2012;83(1):86-9.

Moulton C, Pennycook A, Makower R. Relation between Glasgow coma scale and the gag reflex.BMJ. 1991;303(6812):1240-1.

Apr 15, 2019
April 2019; papers of the month
37:44

So we've got a massively important paper that we're going to kick off April's Papers of the Month podcast with, which is the RCT we've been waiting for; whether patients who have a ROSC should go to the cath lab, without a stemi, if the presumed cause is a coronary event? We've covered this topic in the past, for a background take a listen to PCI following ROSC and our December '17 papers of the month podcast.

Next up, on the topic of over-testing, we have a look if we should be sending troponins and BNP's on our patients attending with syncope.

Lastly, having spoken recently about the importance of ED airway registry's, we take a look at an open access paper from SJTREM that describes the practice, success and complication rates of ED advanced airway management.

As always make sure you take a look at the papers yourselves and draw you own conclusions, we'd love to hear your thoughts.

Enjoy!

Simon & Rob

References & Further Reading

Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. Lemkes JS. N Engl J Med.2019

Do High-sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope? Clark CL. Acad Emerg Med.2019

Airway Management in the Emergency Department(The OcEAN-Study) - a prospective single centre observational cohort study. Bernhard M. Scand J Trauma Resusc Emerg Med.2019

PCI following ROSC podcast

December 2017; Papers of the Month Podcast

Apr 01, 2019
Advanced Airway Management Updates
20:49

We were lucky enough to be back at the fantastic TraumaCare Conference last week.

There were a whole host of fantastic talks on offer and the Emergency Medicine stream, arranged by our very own Rob Fenwick, included a pro/con debate on whether Emergency Medicine should be managing the trauma airway. During that debate a number of important papers were raised on the evolution and improvement in advanced airway management. In this podcast we'll run through some of the most important points from that talk.

Make sure you take a look at the papers yourself and come to your own conclusions.

Enjoy!

Simon & Rob

 
 
Mar 18, 2019
March 2019; papers of the month
32:11

We've got a broad array of topics and papers for you this month!

First up we look at a paper from the NEJM assessing the potential benefits in providing ventilations to patients undergoing an RSI. Next we look at patients presenting with both syncope and pre-syncope to the emergency department, this paper quantifies the risk that we should be apportioning to these two different presentations. Finally, we look at a paper that suggests the manual pulse check in CPR is dead, and that the time has come for doppler and ultrasound to replace it!

As always make sure you take a look at the papers yourselves and draw you own conclusions, we'd love to hear your thoughts.

Enjoy!

Simon & Rob

References & Further Reading

Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. Casey JD. N Engl J Med.2019

 Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope. Bastani A. Ann Emerg Med.2019

Comparison of manual pulse palpation, cardiac ultrasonography and Doppler ultrasonography to check the pulse in cardiopulmonary arrest patients. Zengin S. Resuscitation.2018

 

Mar 01, 2019
Hypothermia; Roadside to Resus
59:40

Hypothermia is a common problem for both pre and in-hospital clinicians. Understanding the underpinning physiology helps us deliver first class care to our patients, decreasing associated morbidity and mortality.

There is some extremely difficult decision making to be done in severe cases of hypothermia and the podcast gives us an opportunity to explore them further.

We'll cover the subject in depth with particular reference to the following categories of hypothermia; treatment, modifications in cardiac arrest and prognostication.

Enjoy!

Simon, Rob & James

References

ERC 2015; Cariac arrest in specialist circumstances

LITFL; hypothermia

RCEMLearning; hypothermia

Up to Date; Hypothermia

At the bedside, out of the cold: management of hypothermia and frostbite.BiemJ.CMAJ. 2003

The prehospital management of hypothermia - An up-to-date overview. Haverkamp FJC. Injury. 2018 

Accidentalhypothermia-an update: The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Paal P. Scand J Trauma Resusc Emerg Med. 2016

Accidental hypothermia. Brown DJ. 2012 N Engl J Med.

Feb 14, 2019
February 2019; papers of the month
29:33

Ketamine and trauma are the topics for this months papers.

The three papers we cover are really important for all of us involved in the care of critically unwell patients. Hypotensive resuscitation in the context of trauma has been an evolving area of practice in the treatment of our acute trauma victims. A paper published in SJTREM this month meta-analyses the data that exists out there on the topic and looks to give us an idea of the benefits and potential risks associated with such an approach, the paper is available here and is well worth a full read.

Morphine has been a mainstay of the treatment of acute severe pain in the Emergency Department for decades, but as the popularity of ketamine grows we take a look at another meta-analysis, this time comparing the efficacy of ketamine versus morphine in this setting and group of patients.

And lastly, if you have ever had a patient become severely agitated with ketamine sedation, you'll be keen to avoid that happening again! The last paper we look at is a randomised control trial looking at the potential benefits of using either midazolam or haloperidol to achieve that.

We hope you find the podcast useful, as ever please go and take a look at the papers yourself and we'd love to hear any thought or comments you have either rat the bottom of the page, or via twitter @TheResusRoom.

Enjoy!

Simon & Rob

References

Risks and benefits of hypotensive resuscitation in patientswith traumatic hemorrhagic shock: a meta-analysis. Owattanapanich N. Scand J Trauma Resusc Emerg Med.2018 

A Systematic Review and Meta-analysisof Ketamine as an Alternativeto Opioids for Acute Pain in the Emergency DepartmentKarlow N. Acad Emerg Med.2018

Premedication With Midazolamor Haloperidolt o Prevent Recovery Agitation in Adults Undergoing Procedural Sedation With Ketamine: A Randomized Double Blind Clinical Trial. Akhlaghi N. Ann Emerg Med.2019 

St Emlyns; JC: Should we premedicate for ketamine sedation?

 

Feb 01, 2019
Shock; Roadside to Resus
58:33

If you're involved in the care of critically unwell patients then you will frequently encounter patients who are shocked. The European Society of Intensive Care Medicine defines shock as;

'Life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen utilization by the cells. It is a state in which the circulation is unable to deliver sufficient oxygen to meet the demands of the tissues, resulting in cellular dysfunction.’

The assessment for shock needs to be part of the routine workup of every potentially unwell patient. Shock carries with it a high mortality rate, a range of meaningful interventions and the potential to make a real difference to our patients' outcomes. 

In this podcast we cover

  • Defining shock in adults
  • Significance of shock
  • What shock looks like
  • A recap of cardiac physiology
  • Causes of shock
  • Ultrasound evaluation
  • Fluid therapy
  • Inotropes and vasopressors

As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you.

Enjoy!

SimonRob & James

References

Consensuson circulatory shockand hemodynamic monitoring. Task forceof the EuropeanSociety of Intensive Care Medicine. Cecconi M. Intensive Care Med.2014

NICE Intravenous fluid therapy in adults in hospital. Clinical guideline. December 2013

ALIEM; Choosing the right vasopressor agent in hypotension

Resus; The Shock Index

ALIEM; Shock Index: A Predictor of Morbidity and Mortality?

A comparisonof the shockindexand conventionalvital signsto identifyacute, critical illnessin the emergency departmentRady MY. Ann Emerg Med.1994 

TheResusRoom; Sepsis

RCEM guidance; Noradrenaline Infusion

Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Puskarich MA. Crit Care Med. 2011

Early goal-directed therapy in the treatment of severe sepsis and septic shock.Rivers E. N Engl J Med. 2001

Early lactate clearance is associated with improved outcome in severe sepsis and septic shock.Nguyen HB. Crit Care Med. 2004 

Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.Jones AE. JAMA. 2010

A randomized trial of protocol-based care for early septic shock.ProCESS Investigators. N Engl J Med. 2014

Early goal-directed therapyin the treatmentof severe sepsisand septic shockRivers E. N Engl J Med.2001

The significance of non-sustained hypotension in emergency department patients with sepsis.Marchick MR. Intensive Care Med. 2009

Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis.Natthida Owattanapanich. Scand J Trauma Resusc Emerg Med. 2018.

TheResusRoom; The Crystalloid Debate

Jan 14, 2019
January 2019; papers of the month
29:29

Happy New Year!! Hopefully you got a bit of downtime over the festive period and are feeling suitably refreshed and ready to attack 2019!

We've got 3 great papers to kick off the year. First up we look at the recent PReVENT trial which looks at ventilator strategies in patients without ARDS with respect to tidal volumes. This paper continues the work from the much cited ARDSNet paper from 2000, and we'd highly recommend you go and have a look at that paper first.

Next we look at another paper from JAMA which compares Thrombolysis to Aspirin in minor non-disabling strokes. We say enough about this one in the podcast, but for a bit of background to our thoughts and the evidence surrounding stroke, check out our previous Stroke Thrombolysis podcast.

Lastly we have a look at a paper investigating their systems use of push-dose-pressors, which whilst not the most methodologically sound piece of research, certainly brings out some interesting thoughts and points.

As always make sure you take a look at the papers yourselves and we'd love to hear and comments or feedback you've got.

Enjoy!

Simon & Rob

References & Further Reading

Effectof a LowvsIntermediateTidalVolumeStrategyon Ventilator-FreeDaysin IntensiveCareUnitPatientsWithout ARDS: A Randomized Clinical Trial. JAMA.2018 Writing Group for the PReVENT Investigators

Ventilationwith lowertidal volumesas comparedwith traditionaltidal volumesfor acute lung injury and the acute respiratory distress syndrome. Acute Respiratory Distress SyndromeNetwork. N Engl J Med.2000

PReVENT; The Bottom Line

EMCrit; Vent and Prevent, an update

Effectof AlteplasevsAspirinon FunctionalOutcomefor PatientsWith AcuteIschemicStrokeand MinorNondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. Khatri P. JAMA.2018

TheResusRoom; Stroke Thrombolysis podcast

Push dose pressors: Experience in critically ill patients outside of the operating room. Rotando A. Am J Emerg Med.2018

Jan 01, 2019
Christmas Special '18
34:43

Festive greetings to all!

We hope you've had a fantastic 2018 and have some time off over Xmas and New Year to celebrate with friends and family. We thought we'd bring you some of the most influential papers that we've read over the last 12 months, that haven't necessarily fitted in that closely with some of the topics we've covered...we hope you enjoy!

Thanks for all of your support with the podcast throughout 2018 and we wish you a very happy 2019.

SimonRob & James

References

Pediatric golf cart trauma: Not par for the course. Tracy BM. J Pediatr Surg. 2018

What to eat and drink in the festive season: a pan-European, observational, cross-sectional study. Parker HL, et al. Eur J Gastroenterol Hepatol. 2017.

Work of Breathing into Snow in the Presence versus Absence of an Artificial Air Pocket Affects Hypoxia and Hypercapnia of a Victim Covered with Avalanche Snow: A Randomized Double Blind Crossover Study. Karel Roubík. PLoS One. 2015.

Dec 20, 2018
Cardiac Arrest Masterclass; London Trauma Conference 2018
23:45

Cardiac arrest management is core business of a resuscitationist and practice is constantly evolving in the pursuit of improving patient outcomes. 

We were lucky enough to be invited to the London Trauma Conference's Cardiac Arrest Masterclass stream, where Matt Thomas put on a superb array of talks around all things cardiac arrest. 

We managed to borrow a bit of time from some of the speakers and caught up with some of the topics covered including; airway management, ECGs pre/post arrest, POCUS, CRM and breaking bad news. We found the day hugely useful and we hope the podcast sums up some of the great points from the day.

Enjoy!

SimonRob & James

References

London Trauma Conference

AIRWAYS-2; podcast

SPIKES Protocol

LITFL; Killer ECG Patterns

Beyondprognostication: ambulancepersonnel's livedexperiencesof cardiacarrestdecision-makingAnderson NE. Emerg Med J.2018

Zero Talent Battle

Dec 17, 2018
December 2018; papers of the month
31:38

Well the year maybe coming to a close but the high quality papers keep on coming out!

We've got 3 great articles to cover in this episode which have some key points to reflect on in our practice. First up we take a look at the application of Canadian c-spine rules by ED triage nurses and the potential impact this approach could hold.

Next up we have a look at the addition of magnesium to current ED rate control of uncompromised patients presenting with rapid AF.

Lastly we look at a paper on the conservative management of traumatic pneumothoraces, including those undergoing positive pressure ventilation, which reviews the complication rate of this approach.

As always make sure you take a look at the papers yourselves and form your own opinions, we would love to hear you comments and feedback.

Enjoy!

Simon & Rob

References & Further Reading

Ian G. Stiell, Catherine M. Clement, Maureen Lowe, Connor Sheehan, Jacqueline Miller, Sherry Armstrong, Brenda Bailey, Kerry Posselwhite, Jannick Langlais, Karin Ruddy, Susan Thorne, Alison Armstrong, Catherine Dain, Jeffrey J. Perry, Christian Vaillancourt, 2018, 'A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses', Annals of Emergency Medicine, vol. 72, no. 4, pp. 333-341

Wahid Bouida, Kaouthar Beltaief, Mohamed Amine Msolli, Noussaiba Azaiez, Houda Ben Soltane, Adel Sekma, Imen Trabelsi, Hamdi Boubaker, Mohamed Habib Grissa, Mehdi Methemem, Riadh Boukef, Zohra Dridi, Asma Belguith, Semir Nouira, 2018, 'Low‐dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double‐blind Study (LOMAGHI Study)', Academic Emergency Medicine

Steven P. Walker, Shaney L. Barratt, Julian Thompson, Nick A. Maskell, 2018, 'Conservative Management in Traumatic Pneumothoraces', Chest, vol. 153, no. 4, pp. 946-953

SGEM#232: I Can See Clearly Now the Collar is Gone – Thanks to the Triage Nurse

London Trauma Conference; Cardiac Arrest Masterclass

Dec 01, 2018
Chemical Burns, Maternal arrest, Amputation and Mental Toughness; BASICSFPHC18 Day 2
29:57

We were delighted to be back to cover the joint Faculty of Prehospital Care and BASICS conference, day 2,  held at the Royal College of Surgeons of Edinburgh. Again we were absolutely spoilt for choice when it came to content for the podcasts but we managed to catch up with:

• Dr Anne Weaver – a consultant in Emergency Medicine and Prehospital Care working for the Royal London Hospital and London HEMS. She talked to us about chemical burns and a novel treatment for managing these injuries.
• Dr Virginia Beckett – an Obstetrics and Gynaecology consultant who is a member of the mMOET working group and has recently published on the topic of cardiac arrest in pregnancy. She was talking on the topic of resuscitative hysterotomy.
• Sam Cooper – a Critical Care Paramedic from Derbyshire, Leicestershire and Rutland Air Ambulance who discussed a case of prehospital amputation and the learning points that arose from it.
• Dr Rob Lloyd – an Emergency Medicine trainee, blogger and fellow podcaster who has an interest in performance psychology. He talked about Mental Toughness, framed by his experiences working in a hospital deep in a South African township.

Once again, our thanks to Caroline Leech for being instrumental in the organisation of today and inviting us up. We’re already looking forward to next year….

Enjoy!

SimonRob & James

References

PonderMed

Diphoterine

A video showing a similar demonstration to the one at the conference showing why Diphoterine works and the limitations of water

Pre-hospital Obstetric Emergency Training; POET

VA Beckett, M Knight, P Sharpe, 2017, 'The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study', BJOG: An International Journal of Obstetrics & Gynaecology, vol. 124, no. 9, pp. 1374-1381

Realtime simulation of peri-mortem c-section; Bradford Teaching Hospital

K. M. Porter, 2010, 'Prehospital amputation', Emergency Medicine Journal, vol. 27, no. 12, pp. 940-942

Caroline Leech, Keith Porter, 2016, 'Man or machine? An experimental study of prehospital emergency amputation', Emergency Medicine Journal, vol. 33, no. 9, pp. 641-644

 

Nov 23, 2018
Sick Paeds, Extrication and Drowning; BASICSFPHC18 Day 1
33:07

We were delighted to be invited to cover the joint Faculty of Prehospital Care and BASICS conference held at the Royal College of Surgeons of Edinburgh.

This two-day prehospital extravaganza covered a broad range of topics and the content was delivered by some excellent speakers. As such, we were absolutely spoilt for choice when it came to content for the podcasts but we managed to catch up with:

  • Dr Abi Hoyle – a paediatric emergency medicine consultant with a background in military and retrieval services. She gave us some key tips when dealing with paediatric patients.
  • Ian Dunbar – a technical and medical rescue consultant with years of experience in the UK Fire and Rescue Service and ongoing involvement with British Touring Car Championship and the FIA. He did some myth busting around extrication from vehicles.
  • Professor Mike Tipton – a leading figure in extreme physiology who is the Associate Head of Research at the Extreme Environments Laboratory in Portsmouth, is trustee/director of Surf Life Saving GB, sits on the medical committee for the RNLI and was awarded an MBE for services to physiological research in extreme environments. Mike spoke on the topic of drowning.

Massive thanks to Dr Caroline Leech who put together this brilliant programme and extended the invitation to us. We hope you enjoy the podcast and extract some learning to inform your practice.

Enjoy!

SimonRob & James

References

Resus Council UK; Prehospital Resuscitation

Michael J. Shattock, Michael J. Tipton, 2012, '‘Autonomic conflict’: a different way to die during cold water immersion?',The Journal of Physiology, vol. 590, no. 14, pp. 3219-3230 

Faculty of Pre-Hospital Care and Basics Conference

Nov 20, 2018
Cricoid Pressure; Roadside to Resus
32:04

We've heard a lot about advanced airway management recently, with some really significant publications over the last few months and in the last few weeks in JAMA we've had another!

Cricoid pressure during emergency anaesthesia and for those at high risk of aspiration has been common place for more than half a century. But it's a topic that has caused quite some debate. On one hand it has the potential to reduce aspiration, a very real and potentially very serious complication of RSI. But on the other it has the potential to hinder the view on laryngoscopy and decrease first pass success.

The founding evidence for cricoid pressure has always been a little soft. In this podcast we look at the background of cricoid pressure and then run through this key paper, discussing the implications it holds for both pre and in-hospital advanced airway management.

As always we'd love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you.

Enjoy!

Simon, Rob & James

References

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anaesthesia: The IRIS Randomized Clinical Trial. Birenbaum A. JAMA Surg 2018

Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Sellick BA Lancet.1961

Safer Prehospital Anaesthesia 2017;AAGBI

JC: Cricoid Pressure and RSI, do we still need it?St Emlyn’s

Cricoid: To press, or not to press?(Hinds and May)

 

Nov 08, 2018
November 2018; papers of the month
33:30

Welcome back to November's Papers Podcast! We've got 3 great papers for you again this month.

First up we take a look at a paper that looks to quantify the amount of experience needed to be a proficient intubator, in this case in arrest. Next we have a look at a paper which shows a significant difference in mortality in cardiac arrest dependant on the intravascular access route used. Finally we have a look a really interesting paper in the dispatch method of a HEMS service which we be of real interest to all those involved in paramedicine and prehospital critical care.

Make sure you take a look at the papers themselves and form your own opinions. We'd love to hear any thoughts and feedback you have.

Enjoy!

Simon & Rob

References & Further Reading

How much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation? Kim SY. Resuscitation.2018

A novel method of non-clinical dispatch is associated with a higher rate of criticalHelicopter Emergency Medical Service intervention. Munro S .Scand J Trauma Resusc Emerg Med.2018

Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Kawano T. Ann Emerg Med.2018

Nov 01, 2018
Burns; Roadside to Resus
01:05:11

With bonfire night approaching we thought it would be a good time to have a think about burns.

However burns are a significant issue at all times of year with around 130,000 presentations to UK EDs annually, 10,000 cases are admitted to hospital, 500 of these have severe burns and 200 of these will die. But most importantly intervention that we make can make a big difference to both morbidity and mortality, really affecting outcomes. 

Throughout this episode we'll be covering the essential first responder management, all the way through to the critical care that maybe required for the sickest of burns patients. 

In the podcast we cover

  • Burn type and burn severity

  • The importance of history

  • Assessing burn extent

  • Assessing burn depth

  • The A-E assessment and specifics regarding the burns patient

  • NAI, antibiotics, tetanus cover, analgesia, special circumstances eyes & chemicals

  • Conveyance and destination

As always we'd love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you.

Enjoy!

Simon, Rob & James 

 

References

British Burn Association First Aid Clinical Practice Guidelines

BBA Clinical Practice Guideline for Management of Burn Blisters

BBA Clinical Practice Guideline for Deroofing Burn Blisters

RCEMLearning; Major Trauma, Burns

National Burn Care Referral Guidance

WHO; fact sheet on burns

NHS Standard Contract for Specialised Burns Care (All Ages) Schedule 2- The Services A. Service Specification

LITFL; burns

Clinical review: The critical care management of the burn patient. Jane A Snell. Crit Care 2013

Fluid resuscitation in major burns. Mitra B ANZ J Surg. 2006

How well does the Parkland formula estimate actual fluid resuscitation volumes? Cartotto RC. J Burn Care Rehabil. 2002

Fluid resuscitation management in patients with burns: update. Guilabert P. Br J Anaesth. 2016

ISBI Practice Guidelines for Burn Care 2016

 

Oct 15, 2018
October 2018; papers of the month
24:10

Welcome back to October's Papers Podcast, this month we move airway from advanced airway management and bring you a broad array of papers.

First up we have a look at the relative success of a variety of pharmacological strategies for managing the acutely agitated patient in ED. Next up we have look at the well know CURB-65 score and it's ability to predict the need for critical care interventions. Lastly, we may all feel at times that performing a CT head on those well patients solely because they take anticoagulants may be a little on the excessive side, we review a paper that looks at the yield of positive scans in this cohort.

As ever don't just take our word for it, go and have a look at the papers yourself, we would love to hear any comments or feedback you have.

Enjoy!

Simon & Rob

References & Further Reading 

IntramuscularMidazolam, Olanzapine, Ziprasidone, or Haloperidolfor TreatingAcuteAgitationin the Emergency Department. Klein LR. Ann Emerg Med. 2018

Performanceof the CURB-65Scorein PredictingCritical CareInterventionsin PatientsAdmitted With Community-AcquiredPneumonia.Ilg A. Ann Emerg Med.2018

Incidenceof intracranial bleedingin anticoagulatedpatientswith minor head injury: a systematic review and meta-analysis of prospective studies. Minhas H. Br J Haematol.2018

Oct 01, 2018
September 2018; papers of the month
26:43

So we're back with September's papers of the month a little later than usual but we wanted to give you a little time to digest AIRWAYS-2... before we give you some more prehospital research on advanced airway management in cardiac arrest!

The American version of AIRWAYS-2, PART, has just been released in JAMA, looking at the laryngeal tube versus endotracheal intubation as a primary strategy for advanced airway management. The paper is fascinating accompaniment to AIRWAYS-2.

Next we have a look at a paper assessing Emergency Medicine clinicians' ability to predict hospital admission at the time of triage, should we be making early calls on the destination of our patients?

Finally we have a look at the potential role of esmolol in cases of refractory VF and a paper that reports twice the survival rates in those that receive it!

As always we strongly suggest you have a look at the papers yourself and come to your own conclusions. Make sure you check out the hyperlinked blogs below that we mention in the podcast that contain some fantastic critiques. We'd also love to hear any comments either at the foot of this page or on twitter to @TheResusRoom.

Enjoy!

Simon & Rob

References & Further Reading

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac ArrestA Randomized Clinical Trial. Henry E. Wang, MD. 2018

Emergency medicinephysicians' abilityto predicthospital admissionat the timeof triage. Vlodaver ZK. Am J Emerg Med.2018

Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patientswith refractory ventricular fibrillationDriver BE. Resuscitation.2014

King Laryngeal Tube

 

Sep 14, 2018
Intubation or supraglottic airway in cardiac arrest; AIRWAYS-2
55:43

So we're back from our summer hiatus with a real treat. The long awaited AIRWAYS-2 paper has just been released and we've been lucky enough to speak with the lead author, Professor Jonathan Benger, about the paper and discuss what the findings mean for cardiac arrest management.

AIRWAYS-2 looks at the initial advanced airway management strategy for paramedics attending out of hospital cardiac arrests, essentially whether or not the aim should be to place a supraglottic airway device or an endotracheal tube when advancing from simple airway techniques. The study was a huge undertaking with many speculating over how the results would change practice, including discussion of how it may affect paramedic's practice of intubation, all of which we cover in the podcast.

Before you listen to the podcast make sure you have a look at the paper yourself, have a listen to PHEMCAST's previous episode which covers the study design and have a look at the infographics on the website which summarise the primary outcome and secondary analysis and which we refer to in the interview with Professor Benger.

In the podcast we refer to Jabre's paper which can be found below and we also covered in May's papers podcast. Have a listen to the interview and let us know any thoughts or feedback you have, we're sure this one will create a lot of discussion!

Simon, Rob & James

References & Further Reading

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. The AIRWAYS-2 Randomized Clinical Trial. Benger J. JAMA. 2018

PHEMCAST; the LMA

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomised Clinical Trial. Jabre P. JAMA. 2018

TEAM Course

Aug 28, 2018
August 2018; papers of the month
27:47

Welcome to August's papers of the month.

So this is our last offering for the summer until whilst we take a short break until September, so we had to finish off we 3 great papers!

First up we look at the drug of the moment (or decade...) in tranexamic acid and the effect that it has on outcomes in primary intracerebral haemorrhage.

Next, what role does point of care ultrasound (POCUS) hold in the patient presenting with undifferentiated shock? We look at a randomised control trial of POCUS in this patient cohort that assesses the ability to translate POCUS into a mortality benefit.

Finally we look at a delphi study published in the EMJ which explores expert opinion upon multiple aspects of paediatric traumatic arrests. The results are fascinating and may inform some of the CRM used in the next case you see.

As always we strongly suggest you have a look at the papers yourself and come to your own conclusions. Make sure you check out the hyperlinked blogs below that we mention in the podcast that contain some fantastic critiques. We'd also love to hear any comments either at the foot of this page or on twitter to @TheResusRoom.

Enjoy!

 

Simon & Rob

References & Further Reading

Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Sprigg N. Lancet. 2018

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With UndifferentiatedHypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Atkinson PR. Ann Emerg Med. 2018

Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and managementRickard AC. Emerg Med J. 2018

St Emlyns JC; Tich Tich Boom?

First10EM; TXA in ICH (TICH-2) 

Aug 01, 2018
Adrenaline in Cardiac Arrest; PARAMEDIC2
36:40

Drugs in cardiac arrest are controversial. Prehospital research is notoriously difficult to perform. PARAMEDIC2 has just published in the New England Journal of Medicine and is a multi centre randomised placebo controlled trial looking at adrenaline (or epinephrine depending on which side of the pond you reside) in out of hospital cardiac arrest, no mean undertaking and a landmark paper.

The paper has gained a huge amount of traction online with multiple blogs discussing the primary outcome which showed a higher survival rate in those receiving adrenaline when compared to placebo. This has been accompanied with a firm debate over the secondary outcomes, which include the rate of survival with a favourable neurological outcome (mRS 0-3), which showed no statistically significant difference between the two treatment arms, but in pure numbers gave a higher proportion of favourable outcomes in the adrenaline group.

The trade off for this increased survival is the significant number of survivors with a poor neurological outcome.

The question on everyone's lips then being; should we continue to administer adrenaline in cardiac arrest given the findings from this study?

In the podcast we run over the main findings of the paper and are lucky enough to speak to the lead author Professor Gavin Perkins about the paper and some of the questions we and you have had following publication of the paper. A huge thanks to Gavin for taking the time to do this.

Have a listen, enjoy, and let us know any thoughts or feedback you have

Simon, Rob & James

References & Further Reading

PARAMEDIC2; Warwick University Clinical Trials Unit

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. Perkins GD. N Engl J Med. 2018

PARAMEDIC2 Protocol

Testing Epinephrine for Out-of-Hospital Cardiac ArrestCallaway CW. N Engl J Med. 2018

First10EMParamedic 2: Epinephrine harms/helps in out of hospital cardiac arrest

REBEL Cast Ep56 PARAMEDIC-2: Time to Abandon Epinephrine in OHCA?

Jul 25, 2018
Head Injury; Roadside to Resus
47:50

Head injury worldwide is a significant cause of morbidity and mortality.

Besides prevention there isn't anything that can be done to improve the results from the primary brain injury, there is however a phenomenal amount that can be done to reduce the secondary brain injury that patients suffer, both from a prehospital and in hospital point of view.

In the podcast we run through head injuries, all the way from initial classification and investigation, to specifics of treatment including neuro protective anaesthesia and hyperosmolar therapy, to give a sound overview of the management of these patients.

As always we welcome feedback via the website or on Twitter and we look forward to hearing from you.

Enjoy!

Simon, Rob & James

References & Further Reading

Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016

Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned? Boone MD. Surg Neurol Int. 2015

Life in the fast lane; hypertonic saline

Life in the fast lane; Traumatic brain injury

Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality. T Lawrence. BMJ Open. 2016

Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. M.Majdan. The Lancet. 2016

The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. Gale SC. J Trauma. 2005

What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population? Rotheray KR. Resuscitation. 2012

NICE Head Injury Guidelines 2014

MDCALC Canadian Head Injury

TheResusRoom; The AHEAD Study

TheResusRoom; Anticoagulation, head injury & delayed bleeds

Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement 

A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuriesManara AR. J Intensive Care Soc. 2016

Jul 16, 2018
July 2018; papers of the month
26:11

Welcome to July's papers podcast. 

There has been a plethora of superb and thought provoking papers published this month and we've got the best 3 that caught our eye for you.

In this episode we look at the potential benefit of early vs late endoscopy in patients presenting with an acute upper GI bleed.  Next we look at both intra and post ROSC hyperoxia and the associated outcomes. Finally we have a look at the utility of straight leg raise as a test to rule out potential pelvicfractures in out trauma patients.

We strongly suggest you source the papers and come to your own conclusions and we'd love to hear any comments either at the foot of this page or on twitter to @TheResusRoom.

Enjoy!

Simon & Rob

References & Further Reading

Delayed endoscopy is associated with increased mortality in upper gastrointestinal hemorrhageJeong N. Am J Emerg Med. 2018 

Association between intra- and post-arrest hyperoxia on mortality in adults with cardiac arrest: A systematic review and meta-analysis. Patel JK. Resuscitation. 2018

Straight leg elevation to rule out pelvic injury. Bolt C. Injury. 2018

Jul 02, 2018
External Haemorrhage; Roadside to Resus
41:45

Managing external haemorrhage is easy right?! Then why does haemorrhage remain a major cause of death from trauma worldwide? Ok, some of that is from internal sources, but….

No one should die from compressible external haemorrhage

With the right treatment applied in a timely fashion, the vast majority of these bleeds can be stopped. But with new advances like haemostatic agents, changing advice surrounding tourniquet use and practice changing evidence coming out of conflict zones can mean it’s difficult to remain current with the latest best practice.

So what options are available to us, how do we use them and what’s the evidence. Here’s the line-up for this months’ podcast:

  • Haemorrhage control ladder
  • Evidence based guidelines on haemorrhage control
  • Direct pressure
  • Enhanced pressure dressings
  • Haemostatic agents and wound packing
  • Tourniquets
  • Case studies

As always we welcome feedback via the website or on Twitter and we look forward to your engagement.

Enjoy!

SimonRob & James

 

References & Further Reading

Bennett, B. L & Littlejohn, L. (2014) Review of new topical hemostatic dressings for combat casualty care. Military Medicine. Volume 179, number 5, pp497-514.

Lee, C., Porter, K. M & Hodgetts, T. J. (2007) Tourniquet use in the civilian prehospital setting. Emergency Medicine Journal. Volume 24, pp584-7. 

Nutbeam, T & Boylan, M. (2013) ABC of prehospital emergency medicine. Wiley Blackwell. London.

Shokrollahi, K., Sharma, H & Gakhar, H. (2008) A technique for temporary control of haemorrhage. The Journal of Emergency Medicine. Volume 34, number 3, pp319-20.

Trauma! Extremity Arterial Hemorrhage; LITFL 

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Rolf Rossaint. Critical Care 2016.

NICE 2016. Major Trauma; Assessment and Initial Management

FPHC 2017; Position statement on the application of Tourniquets

 

 

Jun 20, 2018
June 2018; papers of the month
30:12

Welcome back to our monthly round up of the best papers in the resuscitation world.

Again we've got 3 great papers covering some really important points of practice. First up we have a look at one of the most talked about diagnostic tests in Emergency Medicine, Troponin. We're are always looking to increase the sensitivity of the assay and test in order to ensure the patient hasn't got Acute Coronary Syndrome, but what are the implications of implementing a high sensitivity test? In our first paper we have a look at this exact scenario, the difference in patient outcomes and some of the resource implications to the service.

Next up we have a look at apnoeic oxygeationn. We've covered this a number of times before and most recently in our Roadside to Resus episode on RSI. This time we have a look at the most recent systematic review and meta-analysis on the topic to see if there is more definitive evidence of benefit with this technique.

Lastly we've found a paper that suggests a place for prognosticating off pH in cardiac arrest, is this something we should be adopting?

Have a listen but most importantly have a look at the papers yourself and let us know your thoughts.

Enjoy!

Simon & Rob

References & Further Reading

Low-level troponin elevations following a reduced troponin I cutoff: Increased resource utilization without improved outcomes. Becker BA. Am J Emerg Med. 2018 

Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-Analysis. Oliveira J E Silva L. Ann Emerg Med. 2017 

Association between acidosis and outcome in out-of-hospital cardiac arrest patients. Lin CC. Am J Emerg Med. 2018.

Jun 01, 2018
Paediatric Arrest; Roadside to Resus
01:13:58

The management of a cardiac arrest can be stressful at the best of times, but add into that the patient being a child and you have the potential for an overwhelmingly stressful situation.

Fortunately the major resuscitation bodies have some sound guidance on the management of paediatric arrests. In this episode we run through some of those guidelines and also the evidence base on the topic (scant at best!). We also touch on conveyance of the prehospital paediatric arrest, bringing familiy into the resuscitation area and knowing when to cease resuscitation.

We hope the podcast helps you prepare that little bit more for the next case you might see and that it may also ease the stress of such an emotive case.

Simon, Rob & James

May 21, 2018
Top 10 Trauma Papers 2018
28:40

Professor Simon Carley from St. Emlyns caught up with us at the superb Trauma Care Conference and talked through his top papers in trauma from the last 12 months.

There's something for everyone from diagnosing arterial injuries, blood pressure targets in the head injury patient, to i.v. contrast all the way through to imaging in kids.

If you haven't already, make sure you go and check out the St Emlyn's blog that underpins the talk that Simon gave. And if you're looking for a great value conference to suit all health care disciplines then make sure to keep an eye out for tickets when they go on sale for Trauma Care 2019.

A huge thanks to Simon C for his time recording the podcast and we'd love to hear any comments or feedback.

Enjoy!

Simon L & Simon C

References & Further Reading

For all the papers pop over to the St Emlyn's blog for the hyperlinks and abstracts

May 10, 2018
May 2018; papers of the month
26:04

Dare we say it, we think this month's papers podcast is the best yet, we've got 3 superb papers and topics to consider!

The literature has been pretty airway heavy this month so we've got 3 papers on and around the topic for you.

First up we have a look at a really interesting paper from London HEMS looking at the risks v benefit of prehospital rapid sequence intubation in patients who are awake but hypotensive, is RSI a much needed move or something we should be looking to avoid prehospitally.

Airways-2 will soon be published looking at supraglottic airway management compared to intubation as first line airway management in out of hospital cardiac arrest, but JAMA has just published a paper comparing bag-mask ventilation vs endotracheal intubation in the same situation. It'll be interesting to see if this papers results fall inline with Airways-2.

Finally we take a look at a systematic review trying to give us the answer to direct or video laryngoscopy in emergency endotracheal intubation outside the OR.

Have a listen but most importantly have a look at the papers yourself and let us know your thoughts.

Enjoy!

May 01, 2018
Statistics Demystified
22:28

Evidence based medicine (EBM) allows us to deliver the best care to our patients and understanding the concepts involved is crucial.

Over the last 18 month we've been building an online course to give people a sound understanding of EBM and we thought we'd give you a free taster of what it's all about.

Have a listen to one of our episodes here on statistics and if you want to find out more have a read below about the full course at www.CriticalAppraisalLowdown.co.uk

Enjoy!

SimonRob & James

 

Apr 23, 2018
Trauma Care 2018
30:39

For this episode we’ve been lucky enough to catch a number of the speakers from the traumacare conference.

First up, conference organiser Caroline Leech (EM + PHEM consultant) gave us a few minutes of her time to talk about the latest major trauma key performance indicators from NICE.

Nicola Curry (Consultant Haematologist) spoke about transfusion in trauma and the use of massive haemorrhage protocols. Importantly, she covers the evidence behind the current strategies and where future research opportunities exist.

Stuart Reid (EM + PHEM consultant) covered the ways of optimising timely transfer of major trauma patients. This had an inter-hospital focus, but there were certainly some elements which can be applied to a primary patient transfer.

David Raven (EM consultant) provided an update to the ongoing work with the HECTOR project. We’ve previously heard about their amazing course but this time he was able to let us know about the “silver trauma safety net” which is being used by the ambulance service in the West Midlands. This aims to provide appropriate recognition and triage of trauma in the elderly population.

Finally, Elspeth Hulse (anaesthetic SpR) gave us a timely reminder about the identification and management of organophosphate poisoning - really useful from both and EM and PHEM perspective.

Thanks again to Caroline for the invite to the conference and keep and eye out for a special podcast in the next few weeks where Simon Carley will be running through his top 10 trauma papers of 2017/18 (we were going to try and condense it, but there was way too much good stuff!)

Enjoy!

SimonRob & James

References & Further Reading

Trauma Care

St Emlyns

HECTOR

Apr 18, 2018
A case to make you think...
24:20

In this episode Rob takes us through a case he saw recently that brought about some invaluable learning.

We're not going to give you anymore clues than that!

Enjoy!

Simon & Rob

References & Further Reading

(anonymised to keep the anticipation!)

 
 
 
 
Apr 08, 2018
April 2018; papers of the month
31:41

 

Welcome back to April's papers of the month.

We've got 3 papers this month that look to challenge our work up strategies for the critically unwell. First up we look at a paper on the Ottawa subarachnoid haemorrhage rule, specifically considering if we can decrease scanning in patients with a suspected SAH and what application of the rule might mean for our practice.

Next up we look at a paper that might shine some real doubt on the use of IO access in our patients in cardiac arrest.

Lastly we look at a validation paper for the PERC rule for those patients with a suspected pulmonary embolus and this paper brings about some interesting points on external validity

Once again we'd really encourage you to have a look at the papers yourself and we've love to hear any thoughts or feedback you have.

Enjoy!

Simon & Rob

 References

Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. Perry JJ. CMAJ. 2017  

Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Kawano T. Ann Emerg Med. 2018 

Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. Freund Y. JAMA. 2018

 CORE EM; IO in Cardiac Arrest

 

 

Apr 01, 2018
RSI; Roadside to Resus
48:08

Gaining control of the airway in a critically unwell patient is a key skill of the critical care team and littered with potential for difficulty and complications.

NAP4 highlighted the real dangers faced with their review of complications of airway management in the UK, lessons have been learnt and practice has progressed. As always there is room to improve on current practice and a recent paper published in Anaesthesia describes a comprehensive strategy to optimise oxygenation, airway management, and tracheal intubation in critically ill patients in all hospital locations.

In this podcast we cover;

  • Why this matters to all involved in critically unwell patients, not just those delivering RSI
  • Recap of RSI, the procedure and its indictions
  • Headlines from NAP4
  • Strategies highlighted to optimise airway management and oxygenation
  • How this impacts our prehospital and inhospital practive

We'd love to hear your thoughts so please leave your comments below or contact us via twitter @TheResusRoom

Enjoy!

Mar 20, 2018
The Crystalloid Debate
22:15

How often do you prescribe or give i.v. fluids to your patients? How much thought goes into what's contained in that fluid? What effect will you fluid choice have on your patient?

Two trials on crystalloid administration in the acutely unwell patient have occupied a lot of conversation in the research world over the last few weeks, both published in the NEJM and in this podcast we take a look at them.

In the podcast we cover the following;

  • Whats the big deal with crystalloids
  • Previous trials on fluid administration
  • NEJM papers on crystalloids
  • Myburgh's editorial

Make sure you take a look at the papers yourself and come up with your own conclusions. There are a whole host of superb FOAM resources out there on the topic that are well worth a look and referenced below.

We'd love to hear any thoughts and comments below.

Enjoy!

Mar 12, 2018
March 2018; papers of the month
27:08

Welcome to March's papers of the month. We know we're biased but we've got 3 more superb papers for you this month!

First up we review a paper looking at oxygen levels in patient's with a return of spontaneous circulation following cardiac arrest, is hyperoxia bad news for this patient cohort as well as the other areas we've recently covered?

Secondly we have a look at a paper reviewing the association between time to i.v. furosemide and outcomes in patients presenting with acute heart failure, you may want to have a listen to our previous podcast on the topic first here.

Lastly, when you see a pregnant patient with a suspected thromboembolic event, can you use a negative d-dimer result to rule out the possibility? We review a recent paper looking at biomarker and specifically d-dimers ability to do this. 

We'd love to hear from you with any thoughts or feedback you have on the podcast. And we've now launched of Critical Appraisal Lowdown course, so if you want to gain some more skills in critical appraisal make sure you go and check out our online course here.

Enjoy!

Simon & Rob

References & Further Reading

Association Between Early Hyperoxia Exposure AfterResuscitation from Cardiac Arrest and Neurological Disability: A Prospective Multi-Center Protocol-Directed Cohort Study. Roberts BW. Circulation. 2018

The DiPEP (Diagnosis of PE in Pregnancy) biomarker study: An observational cohort study augmented with additional cases to determine the diagnostic utility of biomarkers for suspectedvenous thromboembolism during pregnancy and puerperium. Hunt BJ. Br J Haematol. 2018

Time to Furosemide Treatment and Mortality in PatientsHospitalized With Acute Heart Failure. Matsue Y . J Am Coll Cardiol. 2017

MDCALC; Framingham Heart Failure Diagnostic Criteria

REBEL.EM; Door to Furosemide in AHF

Modified Rankin Scale

Mar 01, 2018
Sepsis; Roadside to Resus
01:09:54

So the three of us are back together and going to take on Sepsis!

It's vital to have a sound understanding of sepsis. It has a huge morbidity and mortality but importantly there is so much that we can do both prehospital and in hospital to improve patient outcomes.

In the podcast we cover the following;

  • Definitions
  • Scale of problem
  • Different bodies; NICE/Sepsis Trust/3rd international consensus definition including qSOFA
  • Handover and pre alerts
  • Treatment; Sepsis 6
  • The evidence base behind treatment
  • Contentious areas
    •  Prehospital abx
    • Fever control
    • Steroids
    • ETCO2

We hope the podcast helps refresh your knowledge on the topic and brings about some clarity on some contentious points. As always don't just take our word for it, go and have a look at the primary literature referenced below.

Enjoy!

SimonRob & James

References & Further Reading

Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Kumar. Critical Care Medicine. 2006

Prognostic value of timing of antibiotic administration in patientswith septic shock treated with early quantitative resuscitation. Ryoo SM. Am J Med Sci. 2015 

The association between time to antibiotics and relevant clinicaloutcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. de Groot B. Crit Care. 2015

Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Puskarich MA. Crit Care Med. 2011

Early goal-directed therapy in the treatment of severe sepsis and septic shock. Rivers E. N Engl J Med. 2001

Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Nguyen HB. Crit Care Med. 2004 

The prognostic value of blood lactate levels relative to that of vitalsigns in the pre-hospital setting: a pilot study. Jansen TC Crit Care. 2008

Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Jones AE. JAMA. 2010

Lower versus higher hemoglobin threshold for transfusion in septic shock. Holst LB. N Engl J Med. 2014

A randomized trial of protocol-based care for early septic shock. ProCESS Investigators. N Engl J Med. 2014

Trial of early, goal-directed resuscitation for septic shock. Mouncey PR. N Engl J Med. 2015

Goal-directed resuscitation for patients with early septic shock. ARISE Investigators. N Engl J Med. 2014

Acetaminophen for Fever in Critically Ill Patients with SuspectedInfection. Young P. N Engl J Med. 2015

NICE; Sepsis: recognition, diagnosis and early management

The Sepsis Trust

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer M. JAMA. 2016

NHS E; Improving outcomes for patients with sepsis. A cross-system action plan

Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Alam N. Lancet Respir Med. 2018

Adjunctive Glucocorticoid Therapy in Patients with Septic ShockVenkatesh B. N Engl J Med. 2018

PHEMCAST; End Tidal Carbon Dioxide

Current clinical controversies in the management of sepsis. Cohen J. J R Coll Physicians Edinb. 2016

St Emlyns; qSOFA 

RCEM; Severe Sepsis and Septic Shock Clinical Audit 2016/2017 National report

RCEM & UK Sepsis Trust; Toolkit: Emergency Department management of Sepsis in adults and young people over 12 years- 2016

Feb 22, 2018
Devastating Brain Injuries
13:38

On a not infrequent basis we will come across patients in hospital who have a CT head scan that appears to show an unsurvivable event. Having sourced opinion from our neurosurgical and neurology colleagues we may well be given the advice to withdraw care for the patient.

It has become increasingly recognised that prognosticating in such patients at an early stage is extremely difficult with numerous cases surviving what was initially thought to be an unsurvivable event, with a good neurological outcome.

This joint document from the Intensive Care Society, Royal College of Emergency Medicine, Neuro Anaesthesia and Critical Care Society of Great Britain & Ireland and the Welsh Intensive Care Society gives new guidance for such perceived devastating brain injuries and will challenge many peoples thinking on the topic with additional questions being asked on resource utilisation.

In this podcast Caroline Leech, EM and PHEM Consultant in Coventry, discusses the guidelines and the implications they hold for our practice.

As always make sure you read the document yourself, we would love to hear your thoughts.

Enjoy!

Simon & Caroline

References

Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement 

A case for stopping the early withdrawal of life sustainingtherapies in patients with devastating brain injuriesManara AR. J Intensive Care Soc. 2016

Feb 12, 2018
February 2018; papers of the month
26:41

Welcome back, we've got 3 absolute beauties of papers for you this month!

You'll have struggled not to have heard about the ADRENAL trial, a trial of iv steroids in the sickest of patients with septic shock. We also have a look at a trial that many have been quoting as sound evidence for the utility of pH during the prognostication of patients in cardiac arrest. Finally we have a look at a paper that may shed some concern on the use of Double Sequential Defibrillation that we covered recently on the podcast...

We'd love to hear from you with any thoughts or feedback you have on the podcast. And we've now launched of Critical Appraisal Lowdown course, so if you want to gain some more skills in critical appraisal make sure you go and check out our online course here.

Enjoy!

Simon & Rob

References & Further Reading

TheBottomLine; ADRENAL

St Emlyns; ADRENAL

Adjunctive Glucocorticoid Therapy in Patients with Septic ShockVenkatesh B. N Engl J Med. 2018

External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose CardioversionGerstein NS. Ann Emerg Med. 2018

Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study. Shin J. Crit Care. 2017

 

Feb 01, 2018
Tranexamic Acid; time to treatment
12:14

In this episode we cover a paper that you have to know about!

The use of tranexamic acid(or TXA) has become widespread in the case of major trauma and post partum haemorrhage. This time we discuss a recent paper that asks us if giving it within 3 hours is enough, or whether we need to be even more specific regarding its urgency of administration in order to save lives from bleeding.

There is a superb podcast over at our buddies site PHEMCAST which covers an interview with one of the authors and we'd highly recommend listening to that!

Enjoy!

Simon & Rob

References

Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Gayet-Ageron A. Lancet. 2017

Jan 22, 2018
Prehospital Care; FPHC conference
29:12

Prehospital Care is evolving rapidly and is one of the most exciting and dynamic specialties to be involved with at the moment.

As a reflection of it's progress the Faculty of Pre Hospital Care held  its first scientific conference this week. We were lucky enough to be invited by Caroline Leech, EM & PHEM Consultant and the person responsible for organising this superb event, to interview some of the superb speakers at the event.

Here are the speakers we were lucky enough to catch up with and the topics they discuss

Matt Thomas – Hyperoxia: when oxygen is harmful

Jo Manson – The hyperacute inflammatory response to trauma

Rob Moss – FPHC Consensus Statement - Spinal

Malcolm Russell – FPHC Consensus Statemnent – External Haemorrhage

Tim Nutbeam – Pre-hospital research: what do we not know? 

David Menzies – Impact brain apnoea & motorsport

Stacey Webster – Calcium in pre-hospital blood transfusion: the missing link

Rod Mackenzie Injury prevention, control & recovery

A huge thanks to all involved in the conference for having us at the conference and we hope to see you all next year!

SimonRob & James

 
References and links
 
 
 

Ionised calcium levels in major trauma patients who received blood in the Emergency DepartmentWebster S. Emerg Med J. 2016

TOP-ART

Jan 12, 2018
January 2018; papers of the month
26:23

Happy New Year!!

Welcome back to the podcast and what we hope will be a superb year. We've got three excellent papers that are extremely relevant to our practice and will have an impact on practice.

First up it's a paper looking at the benefit of iv versus oral paracetamol in the Emergency Department, something we do really frequently but what does the evidence say? Next we have a look at the difference that topical TXA could make to epistaxis in terms of bleeding cessation. Lastly we look at a systematic review looking at adenosine versus calcium channel blockers for SVT.

Very soon we'll be releasing our Critical Appraisal Lowdown course, so keep an eye out for that.

And finally a huge thanks to our sponsors ADPRAC for all of the support with TheResusRoom.

Enjoy!

Simon & Rob

 

 

 

Jan 01, 2018
Handover; Roadside to Resus
39:39

Handover matters.

Handover of patient care occurs at multiple points in the patient's journey and is a crucial point for transference of information and inter professional working.

Whether it's the big trauma in Resus with the prehospital services presenting to the big crowd, right the way through to the patient coming to minors who looks like they will be going home shorty, each of these transactions of information needs to be done correctly.

Handover can be stressful though and different parties will have different priorities that they are trying to juggle. In this podcast we explore handover, some of the barriers and issues that exist. We have a look at the evidence that exists on it's importance, impact and associated techniques. We also look at tools that exist that can be used to facilitate effective handover.

As ever make sure you look at the articles mentioned in the podcast yourself and we would love to hear your thoughts.

Enjoy!

SimonRob & James

References & Further Reading

Information loss in emergency medical services handover of trauma patients. Carter AJ. Prehosp Emerg Care. 2009

Maintaining eye contact: how to communicate at handover. Dean E. Emerg Nurse. 2012

The handover process and triage of ambulance-borne patients: the experiences of emergency nursesBruce K. Nurs Crit Care. 2005

Handover from paramedics: observations and emergency department clinician perceptions. Yong G. Emerg Med Australas. 2008 

Review article: Improving the hospital clinical handover between paramedics and emergencydepartment staff in the deteriorating patient. Dawson S. Emerg Med Australas. 2013

Dec 11, 2017
December 2017; papers of the month
27:55

You've got a critically unwell patient who needs an RSI. You've got lots of things to think about but specifically do you ramp them up or keep them supine, additionally do you use a checklist or are those things a complete waste of time? This month we have a look at 2 papers which should shed some light on the subject.

We also look at a systematic review and meta-analysis which hopefully helps us answer a question we've been looking at on the podcast for quite some time: in the the context of a cardiac arrest that has gained a ROSC, if the ECG is not diagnostic of a STEMI but the history is suggestive of a cardiac event, should the patient go straight to the cathlab for PCI?

As always don't just take our word for it but go and have a look at the papers yourself and we would love to hear your thoughts.

A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults. Janz DR. Chest. 2017

Early coronary angiography in patients resuscitated from out of hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis. Khan MS. Resuscitation. 2017

JC: Should non ST elevation ROSC patients go to cath lab? St.Emlyn’s

CHECK-UP Checklist; The Bottom Line 

Dec 01, 2017
Traumatic Arrest; Roadside to Resus
44:30

Traumatic Cardiac Arrest; for many of us an infrequent presentation and it that lies the problem.

In our previous cardiac arrest podcast we talked about the approach to the arresting patient, however in trauma the approach change significantly.

We require a different set of skills and priorities and having the whole team on board whilst sharing the same mental model is key.

Have a listen to the podcast and let us know your thoughts. The references are below but if you only read one thing take a look at the ERC Guidelines on traumatic cardiac arrest which we refer to.

Enjoy!

SimonRob & James

References & Further Reading

Resuscitation to Recovery Document

Roadside to Resus; Cardiac Arrest

ERC Guidelines; Traumatic Arrest

Traumatic cardiac arrest: who are the survivors? Lockey D. Ann Emerg Med. 2006

Conversion to shockable rhythms during resuscitation and survival for out-of hospital cardiac arrest. Wah W. Am J Emerg Med. 2017 

Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Beck B. Resuscitation 2017.

An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. Seamon MJ. J Trauma Acute Care Surg. 2015

EAST guidelines 2015; ED Thoracotomy

Nov 20, 2017
Massive PE Thrombolysis
26:28

If you talk to people about the topic of thrombolysis in PE they'll tell you about the controversy of the submassive category, but there's a universal acceptance that thrombolysing massive PE's is well evidenced and straight forward.

In this episode we delve back into the literature and not only explore massive PE thrombolysis, but also the gold standard to which it is judged upon, heparin.

Have a listen to the podcast and as always we would love to hear your thoughts.

Enjoy!

Simon & Rob

References & Further Reading

Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. A Scientific Statement From the American Heart Association. 2011

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1438862/pdf/jrsocmed00257-0051.pdfValue of anticoagulants in the treatment of pulmonary embolism: a discussion paper. Paul Egermayer. Journal of the Royal Society of Medicine 1981.

Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. BARRITT DW. Lancet. 1960

Treatment of pulmonary embolism in total hip replacement. Johnson R. Clin Orthop Relat Res. 1977

PAIMS 2: alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen activator Italian multicenter study 2. Dalla-Volta S. J Am Coll Cardiol. 1992 

Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Goldhaber SZ. Lancet. 1993

Nov 10, 2017
November 2017; papers of the month
24:43

Welcome back to November's papers podcast!

This month we've got some great topics to discuss.

We look at another paper on the topic of oxygen therapy, this time a hug article from JAMA on oxygen therapy in the context of acute stroke and the impact on disability.

Next up we look at a fascinating case report of a extradural haematoma that was drained via an I.O. needle prior to surgical evacuation.

Lastly we follow up on our previous podcast on PE; the controversy, which looked at the prevalence of PE in those patients presenting with undifferentiated syncope. This paper puts a great counter to the conclusions arrived at in that Prandoni paper.

Enjoy!

Simon & Rob

References & Further Reading

Temporising extradural haematoma by craniostomy using an intraosseous needle. Bulstrode H. Injury. 2017 

Prevalence of pulmonary embolism in patients presenting with syncope. A systematic review and meta-analysis. Oqab Z. Am J Emerg Med. 2017 

Nov 01, 2017
Return in spontaneous circulation; Roadside to Resus
54:10

Last time in Roadside to Resus we discussed cardiac arrest with a view to obtaining a return in spontaneous circulation, ROSC.

However gaining a ROSC is just one step along the long road to discharging a patient with a good neurological function back into the community. In fact ROSC is really where all of the hard work really starts!

In this podcast we talk more about the evidence base and algorithms that exist to guide and support practice once a ROSC is achieved. We'd strongly encourage you to go and have a look at the references and resources yourself listed below and would love to hear your feedback in the comments section or via twitter.

Enjoy!

SimonRob & James

References & Further Reading

Resuscitation to Recovery Document

Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. Niklas Nielsen. N Engl J Med 2013

Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Dumas F. Circ Cardiovasc Interv. 2010

Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia. Sandroni C. Resuscitation. 2013

Roadside to Resus; Cardiac Arrest

PCI following ROSC; TRR

Oct 16, 2017
Pre-Hospital Care; BASICS & FPHC Conference '17
34:38

This podcast covers some highlights from the talks at the BASICS and The Faculty of Pre-Hospital Care 2017 Conference.

We were lucky enough to be invited by Caroline Leech to cover the day and managed to grab a couple of minutes with a handful of the superb speakers;

Dr. Tom Evens; Elite sports for high performance clinicians

Dr. Les Gordon; Pre-hospital management of hypothermia

Dr. Helen Milne; Retrieval and transfer medicine

Surgeon Commander Kate Prior; The battlefield

Dr Chris Press; Prehospital management of diving emergencies

Miss Aimee Yarrington; Obstetric Emergencies

Professor Mark Wilson; Pre-hospital Care, where are we going?

 

Thanks to all involved for making the podcast and for a great day at the conference, and to PHEMCAST for the collaboration!

Simon, Rob & Clare

 

Oct 06, 2017
October 2017; papers of the month
31:27

Welcome back to October's papers podcast!

This month we have a look at a paper that shines further light on the use of ultrasound in predicting fluid responsiveness in the spontaneously ventilating patient. We look at a paper that sets to challenge the concerns over hyperoxia in presumed myocardial infarction. And lastly we look at how stress impacts in a cardiac arrest situation on the team leader's performance.

Make sure you have a look at the papers yourself and we would love to hear any feedback and alternative thoughts on the ones we cover! Lastly thanks for your support with the podcast

Enjoy!

Oct 01, 2017
Cardiac Arrest; Roadside to Resus
01:13:44

We have a significant way to go with respect to our cardiac arrest management.

‘Cardiopulmoary Resuscitation is attempted in nearly 30,000 people who suffered OHCA in England each year, but survival rates are low and compare unfavourably to a number of other countries’

-  Resuscitation to Recovery 2017

25% of patients get a ROSC with 7-8% of patients surviving to hospital discharge, which as mentioned is hugely below some countries.

In this podcast we run through cardiac arrest management and the associated evidence base, right from chest compressions, through to drugs, prognostication and ceasing resuscitation attempts.

Make sure you take a look at the papers and references yourself and we would love to hear you feedback!

Enjoy!

SimonRob & James

References & Further Reading

Resuscitation to Recovery Document

"Kids Save Lives": Educating Schoolchildren in Cardiopulmonary Resuscitation Is a Civic DutyThat Needs Support for Implementation. Böttiger BW. J Am Heart Assoc. 2017

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival.Andersen LW. JAMA. 2017

Double sequential Defibrillation therapy for out-of-hospital cardiac arrests: the London experience. Emmerson AC, et al. Resuscitation. 2017

Dual sequential defibrillation: Does one plus one equal two? Deakin CD. Resuscitation. 2016

Thrombolysis during resuscitation for out-of-hospital cardiac arrest. Böttiger BW. N Engl J Med. 2008

Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Perkins GD. Lancet. 2015

Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Rubertsson S. JAMA. 2014

Effect of epinephrine on survival after cardiac arrest: a systematic review and meta analysis. Patanwala AE. Minerva Anestesiol. 2014

Impact of cardiopulmonary resuscitation duration on survival from paramedic witnessed out-of-hospital cardiac arrests: An observational study. Nehme Z. 2016 Mar;100:25-31. doi: 10.1016/j.resuscitation.2015.12.011. Epub 2016 Jan 13.

Predicting in-hospital mortality during cardiopulmonary resuscitationSchultz SC. Resuscitation. 1996

Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017

End-tidal CO2 as a predictor of survival in out-of-hospital cardiac arrest. Eckstein M. Prehosp Disaster Med. 2011

LITFL; cessation of CPR

Sep 21, 2017
Bicarbonate in arrest
17:13

Bicarbonate use in cardiac arrest.

The topic still provokes debate and multiple publications on the topic still hit the press reels. People talk of the increased rate of ROSC and the improvement in metabolic state, whilst others talk of the increase in mortality and worsening of intracellular acidosis.

A recent paper in Resuscitation looked at a huge cohort of patients receiving bicarbonate in arrest prehospitally. In this episode we take a look at the paper, review the guidelines and give our take on the current situation with regards bicarb in arrest

We hope you enjoy it and would love to hear your feedback!

Simon &  Rob

References & Further Reading

Prehospital Sodium Bicarbonate Use Could Worsen Long Term Survival with Favorable Neurological Recovery among Patients with Out-of-Hospital Cardiac Arrest. Kawano T, et al. Resuscitation. 2017

Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature. Velissaris D, et al. J Clin Med Res. 2016

Sep 11, 2017
September 2017; papers of the month
26:17

So we're back with some superb topics this month;

  • Early or late intubation in ICU patients, which is associated with worse outcomes?
  • What are the predictors of a poor outcome in patients presenting with syncope?
  • Does a cervical collar result in a demonstrable raise in ICP viewed by ultrasound?

Make sure you take a look at the papers yourself, they certainly provide food for thought and raise important questions in our practice

Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast

Enjoy!

 
Sep 01, 2017
Asthma; Roadside to Resus Part 2
23:44
Aug 21, 2017
Asthma; Roadside to Resus Part 1
30:10

Asthma is a common disease and presents to acute healthcare services extremely frequently.

The majority of presentations are mild exacerbations of a known diagnosis and are relatively simple to assess and treat, many being completely appropriate for out patient treatment.

On the other hand around 200 deaths per year are attributable in the UK to asthma, and therefore in the relatively young group of patients there is a real potential for critical illness with catastrophic consequence if not treated effectively. The majority of these deaths occur prior to the patient making it to hospital making the prehospital phase extremely important and hugely stressful in these cases.

It is also worth noting that of the deaths reported that many were associated with inadequate inhaled corticosteroids or steroid tablets and inadequate follow up, meaning that our encounter with these patients at all stages of their care even if not that severe at the point of assessment is a key opportunity to discuss and educate about treatment plans and reasons to return.

In part 1 of this podcast we will run through

  • Pathophysiology
  • How patients present
  • Guidelines
  • Treatment
    • Salbutamol
    • Ipratropium
    • Steroids
    • Magnesium

Part 2 will be out shortly, we hope you enjoy the episode and would love to hear your feedback!

SimonRob & James

References & Further Reading

BTS Asthma Guidelines 2016

Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Goodacre S. Lancet Respir Med. 2013 

Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017

Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV. Injury. 2016

TheResusRoom; Needle Thoracostomy podcast

TheResusRoom; BTS Asthma Guidelines 2016 podcast

LITFL; Non-invasive ventilation (NIV) and asthma

Intensiveblog; Asthma mechanical Ventilation Pitfalls

BestBets; In a severe Exacerbation of asthma can Ketamine be used to avoid the need for mechanical ventilation in adults?

Aug 14, 2017
August '17; papers of the month
29:13

We're back with more great papers for you this month, hot off the press!

There's been a lot of talk over the last few years about apnoeic oxygenation and whether it really holds any benefit to patients undergoing RSI, we have a look at a systematic review that may help answer that question.

Next up we have a look at the choice of sedation agent used in the Emergency Department and how this correlates with patient satisfaction.

Finally, following on from our recent podcast on Double Sequential Defibrillation, we have a look at a paper published looking at the results of DSD from the London prehospital service. Will this reveal a patient benefit?

Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast.

Enjoy!

Aug 01, 2017
Acute Heart Failure; Roadside to Resus
39:36

This is the first of a new series of Roadside to Resus podcasts. We've been joined by James Yates, a Critical Care Paramedic with the Great Western Air Ambulance to make it a truly multidisciplinary team.

Each monthly episode we'll be discussing acute presentations, including the latest and most influential evidence base surrounding them. We really want  to break down some barriers between pre-hospital and in hospital teams and it soon becomes evident in this first podcast that many of the problems we face are shared throughout the patient journey and across disciplines!

We're starting off with Acute Heart Failure and in the podcast we run through;

  • The underlying physiology and help explain the different problems we may find in each subset
  • The keys to diagnosis, including the most predictive parts of history and examination
  • We discuss the evidence base for treatment and the trends of use both pre and in-hospital
  • We talk about CPAP and whether the evidence supports it's use
  • Finally, the direction that further treatment in the UK may move

 

 

Once again we hope you find the podcast useful. Get in touch with any comments, questions or suggestions for further topics. Most of all don't take our word for it, but make sure you delve into the references yourself and make up your own mind.

Enjoy!

Jul 20, 2017
Cervical Spine Immobilisation
32:50

C-spine immobilisation is a controversial topic because of a lack of high quality evidence from clinical trials. Historical approaches have been challenged, however NICE guidance continues to recommend 3-point immobilisation for all patients with suspected spinal injury despite considerable clinical equipoise.

In this episode we discuss the complexities of balancing the risks and harms when trying to provide a patient centred approach, rather than a “one-size fits all” model.
 
As always, there are a number of papers, guidelines and resources that you should have a look at (it’s not exhaustive, but a good place to start!)
 
Enjoy!
 

Rob

References & Further Reading
 
 
NICE Guidance
 
 
 
Faculty of prehospital care consensus statements
 
 
 
Cochrane reviews
 
 
Papers of interest
 
 
 
 
 
 
 
Podcasts
 
 
Jul 10, 2017
July 2017; papers of the month
24:01

We're back with 3 superb topics this month!

First off we have a look at the utility of ultrasound for the detection of pneumothoraces in the context of blunt trauma.

Next we look at the need to scan facial bones when scanning a patient's head following trauma.

Last of all we look at a paper reviewing the association between the use of a bougie and the first pass success when performing ED RSI.

Have a listen to the podcast and most importantly make sure you have a look at the references and critically appraise the papers yourself. We'd love to hear your thoughts and comments at the bottom of the page.

Enjoy!

Jul 01, 2017
Double Sequential Defibrillation
27:03

Guidelines. Algorithms. Evidence based medicine. These all play a significant part in the safe and effective management of the majority of our patients. As a result there is a danger that treatment pathways are followed blindly without critiquing their use and there is real risk we can loose sight of what’s best for the patient in front of us. Guidelines encourage inflexible decision making, which creates further challenge when we are met by patients who do not fit standard treatment pathways.

If this is the case then the management of cardiac arrest, which is taught and delivered in a didactic and protocol driven fashion, is surely the pinnacle of the problem. Standard Advanced Life Support (ALS) is totally appropriate for the majority of cardiac arrests, but what happens when it fails our patients? Refractory ventricular fibrillation (rVF) is, by its very nature, defined by the failure of ALS, but frustratingly there is very little evidence, or guidance, surrounding how to manage this patient group.

I was faced with this situation when called to support an ambulance crew who were resuscitating an out-of-hospital VF arrest. When benchmarked against the ALS guidelines their management had been exemplary, but the patient remained in VF after eight shocks. So what now? The UK Resuscitation Council doesn’t specifically discuss rVF, but offers the advice that it is “usually worthwhile continuing” if the patient remains in VF. Not a particularly controversial statement, but not much help either. They do discuss the potential for ECMO use, but this is currently a very rare option in UK practice, or thrombolysis for known or suspected pulmonary embolism.

Other potential interventions not in the guidelines include IV magnesium and placing defibrillator pads in the anterior-posterior orientation. PCI can also be considered if there is a suitable receiving centre available and the patient can be delivered in a safe and timely fashion.

A final option is the use of double sequential defibrillation (DSD), using two defibrillators, charged to their maximum energy setting, to deliver two shocks in an almost simultaneous fashion.DSD was first described in human subjects in 1994 when it was used to successfully defibrillate five patients who entered rVF during routine electrophysiologic testing. These patients were otherwise refractory to between seven and twenty single shocks. Looking at the available literature there has been little interest in DSD since then, until the last two to three years when it appears to have undergone a small revival. Sadly, there is no evidence for its use beyond case reports and small case series. The case reports appear to show good results with four in the last two years reporting survival to discharge with good neurological outcome. There are also a handful of other cases discussed in online blogs and articles with good outcomes. But these case reports and articles almost certainly represent an excellent example of publication bias. The most recent case series reviewed the use of DSD by an American ambulance service over a period of four years. During this time DSD was written into their refractory VF protocol, with rVF defined as failure of five single shocks. The study included twelve patients, three of whom survived to discharge with two of these demonstrating a cerebral performance score of 1. Despite appearing to demonstrate reasonable outcomes for DSD, sadly this study has a number of significant limitations. One important point the authors fail to discuss is that the two neurologically intact survivors received their DSD shocks after two and three single shocks respectively, not after five shocks which would have been per-protocol and consistent with the authors definition of refractory VF.

This highlights a further problem with analysing the use of DSD. Not only is there a dearth of high-level evidence, but the literature that is available is highly inconsistent. There are a range of definitions for refractory VF, different orientations for the second set of pads, variable interventions prior to using DSD, a variety of timings between the shocks and so on. This means that comparison between studies and drawing meaningful conclusions is nearly impossible. Given these challenges, what are the explanations for why DSD might work?

The first theory is that by using DSD the myocardium is defibrillated with a broader energy vector compared to a single set of pads resulting in a more complete depolarisation of the myocardium. A second theory is that the first shock reduces the ventricular defibrillation threshold meaning that the second shock is more effective. A third explanation may simply be the large amount of energy delivered to the myocardium. These theories should be tempered by the fact that studies have demonstrated increasing defibrillation energy to result in increased defibrillation success, but only up to a plateau. After this the success of defibrillation drops sharply. Increased energy use has also been demonstrated to cause an increase in A-V block but without an associated increase in shock success or patient outcome.

The use of double sequential defibrillation is clearly an area that would benefit from further research, but despite this it is interesting to note that London Ambulance Service have enabled their Advanced Paramedic Practitioners to use DSD and some American EMS systems have written DSD into their protocols.

So returning to the case in point what did I choose to do with my patient?

After changing the pad position, administering magnesium and continuing defibrillation they remained in VF.  I considered transport to a hospital with interventional cardiology but the patient was several stories up in a property with an inherently complex extrication. So I chose to use DSD because I felt that all other avenues had been explored. The patient had suffered a witnessed arrest, received bystander CPR immediately and throughout the resuscitation they had maintained a high end tidal CO2 and a coarse VF. I felt that this was a patient who could still respond to non-standard cardiac arrest management in the absence of a response to guideline directed treatment. After two DSD shocks a return of spontaneous circulation was achieved and the patient survived to hospital admission, but sadly didn’t survive to hospital discharge.

We’re left with a even bigger question: if we accept that DSD is a potentially useful intervention in rVF, when should we consider using it? Would the outcome for this patient have been different if DSD had been used earlier?

The European Resuscitation Council states that the use of double sequential defibrillation cannot be recommended for routine use. But treating rVF is not routine and the guidelines have otherwise failed our patient. It is said that insanity is defined as doing the same thing over and over again, without changing anything, and expecting a different result. Is this not what the guidelines preach in rVF? It is up to you, the clinician, to determine whether DSD is appropriate for each rVF case you encounter. But I urge you to consider the patient in front of you and tailor your resuscitation to their needs, whether that includes DSD or an alternative option. Personally, I believe DSD does have a place in the management of rVF patients, after considering the other interventions previously discussed. Given that shock success declines over time, DSD could be used as early as the sixth shock, because at this point the guidelines have nothing further to add. Or maybe it’s me who’s insane…

James Yates (Critical Care Paramedic GWAAC)

References

Double sequential Defibrillation therapy for out-of-hospital cardiac arrests: the London experience. Emmerson AC, et al. Resuscitation. 2017 

A Case Series of Double Sequence Defibrillation. Merlin MA. Prehosp Emerg Care. 2016

Double sequential external shocks for refractory ventricular fibrillation. Hoch DH. J Am Coll Cardiol. 1994

Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Reportof Ten Cases. Cabañas JG. Prehosp Emerg Care. 2015

Double Sequential Defibrillation for Refractory Ventricular Fibrillation: A Case Report. Lybeck AM. Prehosp Emerg Care. 2015

Double simultaneous defibrillators for refractory ventricular fibrillation. Leacock BW. J Emerg Med. 2014

Simultaneous use of two defibrillators for the conversion of refractory ventricular fibrillation. Gerstein NS. J Cardiothorac Vasc Anesth. 2015

Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Cortez E. Resuscitation. 2016 

Double Sequential External Defibrillation and Survival from Out-of-Hospital Cardiac Arrest: A CaseReport. Johnston M. Prehosp Emerg Care. 2016

Dual defibrillation in out-of-hospital cardiac arrest: A retrospectivecohort analysis. Ross EM. Resuscitation. 2016

Refractory Ventricular Fibrillation Successfully Cardioverted With Dual Sequential Defibrillation. Sena RC. J Emerg Med. 2016

Dual sequential defibrillation: Does one plus one equal two? Deakin CD. Resuscitation. 2016

Magnesium therapy for refractory ventricular fibrillation. Baraka A. J Cardiothorac Vasc Anesth. 2000 

Jun 21, 2017
Mechanical CPR
21:19

High quality manual cardiopulmonary resuscitation (CPR) with minimal delays has been shown to improve outcomes following out-of-hospital cardiac arrest (OHCA). There are concerns that the quality of CPR can diminish over time and as little as 1 minute of CPR can lead to fatigue and deviation from the current recommended rate and depth of compressions.

With this in mind, a mechanical device to provide chest compressions at a constant rate, depth and without tiring has considerable theoretical benefits to patients, yet clinical equipoise remains about the role for this treatment modality.

In this podcast, we discuss and critically appraise 2 randomised controlled trials (RCTs) set out to answer exactly that question and give our take on the role for mechanical CPR devices in the future

Hope you enjoy and feel free to leave any feedback below!

Rob

References 

Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Perkins GD. Lancet. 2015

Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Rubertsson S. JAMA. 2014

Jun 15, 2017
June 2017; papers of the month
28:09

We're back with another look at the papers most relevant to our practice in and around The Resus Room.

The WOMAN trial was a huge trial that looked at tranexamic acid in post partum haemorrhage, it's gained a lot of attention online and we kick things off having a look at the paper ourselves.

Next up, and following on nicely from our previous Cardiac Arrest Centres podcast, we have a look at a systematic review and meta-analysis on whether prolonged transfer times in patients following cardiac arrest affects outcomes.

Finally we have a look at a paper on management of PEs in cardiac arrest which draws some very interesting conclusions on the management of such cases and the associated outcomes!

Please make sure you go and have a look at the papers yourself and as ever huge thanks to our sponsors ADPRAC for making this all possible.

Enjoy!

Jun 01, 2017
BTS 2017 Oxygen Guideline; pre and in-hospital
22:00

Oxygen is probably the drug that we give the most but possibly has the least governance over.  More has got to be good except in those at high risk of type II respiratory failure right?? Well as we know the evidence base has swung to challenge that idea in recent years and the new BTS guidelines for Oxygen use in Healthcare and Emergency Settings has just been published with a few things that are worth reviewing since the original publication in 2008. No apologies that this may be predominantly old ground here, this is an area we're all involved with day in and day out that is simple to correct and affects mortality

Historically oxygen has been given without prescription;

  • 42% of patients in the 2015 BTS audit had no accompanying prescription
  • When it is prescribed this doesn't always correlate with delivery
  • 1/3 of patients were outside of target SpO2 range (10% below & 22% above)

If nothing else is taken from this document then reinforcement of the fact that we need to keep oxygen saturations normal/near normal for all patients, except groups at risk of type II respiratory failure

Prescribe and delivery oxygen by target oxygen saturations

What is normal?

  • Normal Oxygen saturations for healthy young adults is approximately 96-98%, there is minor decrease with increasing age.
  • Healthy subjects desaturate to 90% SpO2 during night time; be cautious interpreting a single oximetry reading from a sleeping patient, short duration overnight dips are normal

 

Will mental status give me an early indication of hypoxaemia?

  • No, impaired mental function at a mean value of SaO2 64%, no evidence above SaO2 84%
  • Loss of consciousness at a mean SaO2 56%

 

Aims of oxygen therapy

  • Correct potentially harmful hypoxia
  • Alleviate breathlessness only in those hypoxic

 

Why the fuss about hyperoxia?

Hyperoxia has been shown to be associated with

  • Risk to COPD patients and those at risk of type II respiratory failure
  • Increased CK level in STEMI and increased infarct size on MR scan at 3 months
  • Association of hyperoxaemia with increased mortality in several ITU studies
  • Worsens systolic myocardial performance
  • Absorption Atelectasis even at FIO2 30-50%
  • Intrapulmonary shunting
  • Post-operative hypoxaemia
  • Coronary vasoconstriction
  • Increased Systemic Vascular Resistance
  • Reduced Cardiac Index
  • Possible reperfusion injury post MI

In patients with COPD studies have showed most hypercapnia patients arriving at hospital with the equivalent of SpO2 > 92% were acidotic, high concentration O2has been associated with more than double the mortality rate in those with acute exacerbations of COPD. Titrate O2 delivery down smoothly

 

Which patients are at risk of CO2 retention and acidosis if given high dose oxygen?

  • Chronic hypoxic lung disease
    • COPD/CF/Bronchiectasis
  • Chest wall disease
    • Kyphoscoliosis
    • Thoracoplasty
  • Neuromuscular disease
  • Morbid obesity with hypo ventilatory syndrome

 

What is the oxygen target?

Oxygen titrated to an SpO2 of 94-98%

Except in those at risk of hypercapnia respiratory failure, then 88-92%(or specific SpO2 on patient's alert card)

 

What about in Palliative Care?

Most breathlessness in cancer patients is caused by airflow obstruction, infections or pleural effusions and in these cases the issues need to be addressed. Oxygen does relieve breathlessness in hyperaemic cancer patients but not if SpO2 >90%. Midazolam and morphine also relieve breathlessness and are more likely to be effective.

 

Delivery Devices

  • Reservior masks can deliver O2 concentrations between 60-80%
  • Nasal cannualae at 1-6L/min can deliver 24-50%
  • Venturi masks allow accurate delivery of O2
  • If tachypnoeic over 30 breaths per minute an increase over the marked flow rate should be delivered, note this won't increase the FiO2!

Equivalent doses of O2

24% venturi = 1L O2

28 % venturi = 2L O2

35% venturi = 4L O2

40% venturi = nasal/facemask 5-6LO2

60% venturi = 7-10L simple face mask

 

Approach to oxygen delivery

Firstly determine if at risk of type II respiratory failure

If not;

  • SpO2 < 94%, deliver oxygen
  • Perform an ABG
    • If high PCO2 consider invasive ventilation, in the interim aim SpO2 94-98%
    • If PCO2 normal or low aim SpO2 94-98% and repeat ABG in 30-60 minutes

If at risk of type II respiratory failure

  • Obtain ABG if hypoxic or already on oxygen
    • If a respiratory acidosis consider NIV, address medical condition and senior review. Treat with the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92%
    • If hypercapnia but not acidotic, titrate the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92%. Repeat ABG after change of treatment/deterioration. Consider reducing FiO2 if PO2 on ABG >8kPa
    • If PCO2 < 6 (normal or low) aim to keep SpO2 94-98% and repeat the ABG in 30-60 minutes

Points specific to prehospital oxygen use

  • A sudden reduction in 3% of SpO2 within the target range should prompt a fuller assessment of the patient
  • Pulse oximetry must be available in all locations in which oxygen is being used
  • Some patients over the age of 70 when clinically stable may have SpO2 between 92-94%, these patients don't require O2 therapy unless the SpO2 falls below the level that is known to be normal for that individual
  • Patients with COPD should initially be given oxygen via 24% venturi at 2-4L/min or 28% mask at a flow rate 4L/min, or nasal cannulae at 1-2L/min aiming for 88-92%
  • Patients over 50 years of age and long term smoker with a history of SOB on exertion and no other cause for their breathlessness should be treated as having COPD.
  • Limit O2 driven nebs, if no air driven nebs available, to 6 minutes in duration in patients known to have COPD

In summary....

So the bottom line? Well just like Goldielock's porridge, with oxygen we don't want too little, we don't want too much but we want just the right amount!

There is no doubt that hypoxia kills but beware that too much of anything is bad for you and in the same way we need to be vigilant to targeting oxygen delivery to our patients target SpO2

 

References

BTS Guideline for oxygen use in healthcare and emergency settings

 

May 19, 2017
Troponin Rule Out Strategies
39:52

How many patients are admitted from your ED with suspected cardiac chest pain? What strategy of testing do you employ to rule out acute myocardial infarction? When and why do you send troponins in this process?

In this podcast Ed Carlton, Emergency Medicine Consultant at North Bristol Hospital and Troponin Researcher, talks to us about troponin rule out strategies, recent publications on the topics, where the future of troponin research is heading and most importantly what this all means for our practice.

Our previous podcast on troponins acts as a good introduction to this episode. Have a listen to both and we'd love to hear your comments at the bottom of the page and we hope you found this as useful as we did!

Enjoy

Simon

References

 

Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin TMeasurement Below the Limit of Detection: A Collaborative Meta-analysis. Pickering JW. Ann Intern Med. 2017 

Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial. Poldervaart JM. Ann Intern Med. 2017

May 15, 2017
May 2017; papers of the month
25:07

This month we've got a good variety of topics.

We look at an recent systematic review and meta analysis on the prognostic value of echo in life support, an update from Blyth's paper in 2012. We review a paper looking at testing gin patients presenting to the emergency department in SVT. Finally we cover a paper looking at different methods employed when running an Emergency Department.

As always make sure you go and have a read of the papers yourselves and come up with your own conclusions, we'd love to hear your feedback.

Enjoy!

Simon & Rob

References & Further Reading

Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysisTsou PY. Resuscitation. 2017

Usefulness of laboratory and radiological investigations in the management of supraventricular tachycardiaAshok A. Emerg Med Australas.2017

What do emergency physicians in charge do? A qualitative observational study. Hosking I. Emerg Med J. 2017 

 

May 01, 2017
Top 10 EM papers; 2016-17
24:52

This podcast is taken from a talk I gave at Grand Rounds at The Bristol Royal Infirmary on the Top 10 Papers in EM over the last 12 months.

Many of these have been covered in previous podcasts, but running through them gives a good opportunity for further recap and reflection.

Papers Covered;

Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV1. Injury. 2015 Dec 13. pii: S0020-1383(15)00768-8. doi: 10.1016/j.injury.2015.11.045. [Epub ahead of print]

(more in February'sPapers of the month)

Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Baharoglu MI. Lancet.2016 May 9. pii: S0140-6736(16)30392-0. doi: 10.1016/S0140-6736(16)30392-0. [Epub ahead of print]

(more in July's Papers of the month)

Causes of Elevated Cardiac Troponins in the Emergency Department and Their Associated Mortality. Meigher S. Acad Emerg Med. 2016

(more in our Troponins podcast)

Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. Ferguson I, et al. Ann Emerg Med. 2016.

(more in September's Paper's of the month)

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P. N Engl J Med. 2016

(more in our podcast PE The Controversy)

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Andersen LW. JAMA. 2017

(more in March's Papers of the month)

Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Donaldson L. Emerg Med Australas. 2016 Aug 25

(more in our Stroke Thrombolysis podcast)

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospectiverandomisedphase 3controlledopen-labelnon-inferiority trialNijssen EC. Lancet. 2017

(more in April's Papers podcast)

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Sierink JC. Lancet. 2016 Jun 28

(more in August's Papers podcast)

Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017 

(more coming up in May's Papers podcast!)

Enjoy and we'll be back with our papers of the month next week!

Simon

 

Apr 25, 2017
Acute Cholecystitis; making the diagnosis
19:29

Acute cholecystitis is a diagnosis that we make frequently in the Emergency Department. But like all diagnostic work ups there is a lot to know about which parts of the history, examination and bedside tests we can do in the ED that really help either rule in or rule out the disease.

In this podcast we run through some of the key bits of information published in the Commissioning Guide Gallstone disease 2016, jointly published by the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland & the Royal College of Surgeons.

We then concentrate on a recent systematic review of the diagnostic work up for Acute Cholecystitis. Yet again the evidence base brings up some issues to challenge our traditional teaching on the topic but should help polish our management of patients with a differential of Acute Cholecystitis.

Enjoy!

References & Further Reading

Commissioning Guide Gallstone disease 2016

Up to date; Acute Cholecystitis

NICE guidance; Acute Cholecystitis

History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis. Jain A. Acad Emerg Med

Apr 15, 2017
April 2017; papers of the month
31:39

This month we look at a paper concentrating on the risk of contrast induced nephropathy in contrasted CT scans, looking specifically at the need to hydrate at-risk patients prior to and following CT scans.

The use of prehospital blood is also under the spotlight with the ongoing RePHILL trial. We look at a paper reviewing prehospital blood use with the Kent Surrey Sussex prehospital service and the described physiological changes seen in patients receiving blood. Make sure you also go over and check out the podcast episode from PHEMCAST on the RePHILL trial with Jim Hancox.

Finally I was lucky enough to catch up with Johannes von Vopelius-Feldt, the lead author of a paper in press on the impact of prehospital critical care teams on out of hospital cardiac arrests.

You can find the fantastic opportunity of a scholarship to be an Emergency Nurse Practitioner here from ADPRAC.

Enjoy

Simon & Rob

References & Further Reading

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospectiverandomisedphase 3controlledopen-labelnon-inferiority trialNijssen EC. Lancet. 2017

FOAMcast; Contrast-Induced Nephropathy and Genitourinary Trauma

RELEL.EM; The AMACING Trial: Prehydration to Prevent Contrast Induced Nephropathy (CIN)?

Royal College Radiology; Prevention of Contrast Induced Acute Kidney Injury (CI-AKI) In Adult Patients

Pre-hospital transfusion of packed red blood cells in 147 patients from a UK helicopter emergency medical service. Lyon RM. Scand J Trauma Resusc Emerg Med. 2017

PHEMCAST; blood

Apr 01, 2017
Trauma in the ED '17
41:40

So today Rob and I were lucky enough to be asked to attend the Trauma Care Conference 2017, to listen to some of the great talks and catch up with some of the speakers for their take on the highlights of the talks.

We managed to catch the following speakers, here are the topics they covered and relevant links to the resources discussed.

Speakers

Gareth Davies, Consultant Emergency Medicine, Royal London Hospital; Understanding where, when and how people die?

Dave Gay, Consultant Radiologist, Derriford Hospital; The Role of Ultrasound in Trauma

Fiona Lecky, Professor Emergency Medicine, Salford; Traumatic Brain Injury: recent progress & future challenges

Simon Carley, Professor Emergency Medicine, Central Manchester; The Top 10 trauma papers of 2016

St Emlyn's Top 10 +1 Trauma Papers 2016

Tim Rainer,  Professor Emergency Medicine, Cardiff; Permissive hypotension in blunt trauma

David Raven, Emergency Medicine Consultant, Heart of England Foundation Trust; HECTOR & Elderly Trauma

The HECTOR Course (& free online manual!!)

Ross Fisher, Consultant Paediatric Surgeon Sheffield Children’s Hospital; TARN report for paediatrics

p3 presentations

TARNlet Database

 

Have a listen to the podcast and again huge thanks to the speakers for taking their time to share their superb talks with a wider audience.

Simon

Mar 18, 2017
Cardiac Arrest Centres
19:17

Centralisation of care for specialist services such as stroke, trauma and myocardial infarctions is becoming more and more common place. But where will it stop and what does it mean for the specialty of Emergency Medicine?

In this episode we have a look at a recent pilot RCT published in the journal of Resuscitation looking at the feasibility of setting up an bigger RCT to evaluate moving prehospital patients to a cardiac arrest centre. The paper itself is a great piece of work but the bigger discussion around the topic is also a really important point to consider.

Have a listen to the podcast, see what you think and please post you comments on the site for us all to see.

Enjoy!

Simon

References
 

A Randomised tRial of Expedited transfer to a cardiac arrest centre for non-ST elevation ventricular fibrillation out-of-hospital cardiac arrest: The ARREST pilot randomised trial. Patterson T. Resuscitation. 2017

Mar 08, 2017
March 2017; papers of the month
30:03

Welcome back to Papers of the Month. March has given us some great papers.

We kick off with a couple of papers looking at rib fractures, associated morbidity and mortality and also looks at management of flail segments.

We then turn our attention to airway management and look at a paper reviewing the outcomes associated with patients who are intubated during resuscitation from cardiac arrest.

As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below.

Enjoy

Simon & Rob

References & Further Reading
  

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Andersen LW. JAMA. 2017

 

AIRWAYS-2

 

Mar 01, 2017
Rhabdomyolysis
11:50

Think of rhabdomyolysis and you'll think of an elevated creatine kinase (CK). The condition ranges from an asymptomatic period to a life-threatening condition with a hugely associated rise in CK which can also be accompanied by electrolyte disturbance, renal failure and disseminated intravascular coagulation.

Rhabdomyolysis is caused by a breakdown in skeletal muscle and occurs most commonly following trauma, very often that can be due to a 'long-lie' when a patient is unable to get off a floor until help arrives after a prolonged period. There are other causes including drugs, muscle enzyme deficiencies, electrolyte abnormalities and more.

The presentation itself is pretty vague and suspicion of the disease needs to be pretty high. Patients can experience weakness, myalgia and the dark'coca-cola urine', the diagnosis is then confirmed with a serum elevation in CK.

The big concern with Rhabdomyolysis is the hit the kidneys take. Acute kidney injury is due to the heme pigment that is released from myoglobin and haemoglobin and is nephrotoxic. Early aggressive fluid rehydration aims to minimise ischaemic injury, increase urinary flow rates and thus limit intratubular cast formation. Fluids also help eliminate excess K+ that may be associated. But have a think about the management in your ED, how high does that CK need to be to require i.v. fluids and admission to hospital?

Here's a few facts we need to know:

  • Normal CK enzyme levels are 45–260 U/l.
  • CK rises in rhabdomyolysis within 12hours of the onset of muscle injury
  • CK levels peak at 1–3 days, and declines 3–5 days after muscle injury
  • The peak CK level may be predictive of the development of renal failure
  • A CK level of 5000 U/l or greater is related to renal failure
  • Optimal fluid rate administration is unclear, some papers suggest replacement of isotonic saline at rates of 1-2L per hour. , adjusted to 200-300mL per hour to maintain a diuresis.
  • Attention needs to be paid to urine output serum markers and fluid status.

A lot of the evidence and knowledge surrounding rhabdomyolysis is from humanitarian disasters; earthquakes, terrorism along with observational cohorts, but at the end of the day we need to work with what we've got.

Have a listen to the podcast and see what you think, the application of the evidence base may change your practice.

Enjoy!

 References

Bench-to-bedside reviewRhabdomyolysis -- an overview for cliniciansHuerta-Alardín AL. Crit Care. 2005

 
Feb 21, 2017
Epistaxis
22:54

Epistaxis is an extremely common presentation to both Prehospital Emergency Services and Emergency Departments. The vast majority are benign and self limiting but every once in a while a catastrophic bleed will come our way. 

Whilst not necessarily the most attention grabbing of topics a sound understanding of the management is key to excellent care.

In this podcast Rob talk us through the management of epistaxis, all the way from causes and presentation, right the way through to resuscitative management and latest evidenced based treatment.

Enjoy!

References & Further Reading

Serious spontaneous epistaxis and hypertension in hospitalized patients.Page C. Eur Arch Otorhinolaryngol. 2011

Feb 15, 2017
February 2017; papers of the month
26:56

Welcome back to Papers of the Month. February holds a diverse number of topics on some really interesting areas of practice.

We kick off with a snap shot systematic review from the Annals of Emergency Medicine on the effect of Amiodarone or Lignocaine on the outcome from refractory VF or VT arrests, are drugs losing more favour yet again in cardiac arrest.

Next up is a pilot study following the surgical theme of minimal intervention for appendicitis, can antibiotics safely be used in a particular cohort of patients to prevent the need for surgery? And moreover could this be even safer than the traditional surgical cure?

Last up we cover a paper looking at the survival from traumatic cardiac arrest and consider the bias that may occur by reporting those resuscitation attempts that are of limited duration in with the whole cohort; are we painting a overly negative picture of the prognosis of traumatic cardiac arrest?

As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below.

Enjoy

Simon & Rob

References & Further Reading

In Patients With Cardiac Arrest, Does Amiodarone or Lidocaine Increase Meaningful Survival? Hunter BR. Ann Emerg Med

Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial AllowingOutpatient Antibiotic Management. Talan DA. Ann Emerg Med. 2016 Dec

Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Beck B. Resuscitation 2017 Feb

Feb 01, 2017
The AHEAD Study; scan all head injuries on warfarin??
16:45

Those of us who are a bit longer in the tooth have spent most of our careers not scanning everyone who sustained a head injury on warfarin, but in 2104 NICE published guidance suggesting we do just that.

At times, with the huge burden we place on our radiology services, it is difficult not think we're over doing things with all of these scan requests, especially when the patient has no adverse symptoms or signs. Fortunately the AHEAD study has just been published which looks at thousands of patients presenting to ED's on warfarin with a head injury.

The paper is open access and deserves a full read, in this podcast I run through some of the main parts of the study and have a think about how it might impact on our practice.

This is just one part of the puzzle on the management of patients with anticoagulated head injuries, we had a look previously on what to do if you perform a scan and that appears normal in our Anticoagulation, Head Injury & Delayed Bleeds Podcast.

Hope you enjoy the podcast and we'd love to hear any of your feedback on social media or on the website.

Simon

Jan 16, 2017
Cardiac Arrest; when to stop?
17:31

A lot of our podcasts have focussed on prognostic factors in arrest to help with the decision making of continuing or stopping resuscitation in cardiac arrest. There would appear to be a huge variety in practice as to when resuscitation is ceased, and in that way having explicit guidance to unify practice can at times seem appealing.

In this episode we have a look at a recent paper covering the topic, it suggests a group of patients accounting for nearly half of cardiac arrests, that upon recognition could safely lead us to cease efforts.

Have a listen to the podcast and let us know what you think!

References

Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Jabre P. Ann Intern Med. 2016

Resuscitation Council; Recognition of Life Extinct

Jan 14, 2017
January 2017; papers of the month
30:22

Happy New Year!!!

The publishing world seems to have wound down a bit for the festive break, but 4 papers caught out eye that can add some further context to practice in the Resus Room.

Firstly we take a look at two papers looking at the conversion from non-shockable to shockable rhythms in cardiac arrest, both the likelihood and the associated prognosis.

Next up we have a look at a paper focussing on Cerebral Performance Categories (CPC's) and their reliability as an outcome for studies.

Lastly we have a look at the recent Cochrane Review on video laryngoscopy vs direct laryngoscopy for adult intubation.

Thanks again to our sponsors ADPRAC for supporting the podcast.

References & Further Reading

Age-specific differences in prognostic significance of rhythmconversion from initial non-shockable to shockable rhythm and subsequent shock delivery in out-of-hospital cardiac arrest. Funada A. Resuscitation. 2016

Conversion to shockable rhythms during resuscitation and survivalfor out-of hospital cardiac arrestWah W. Am J Emerg Med. 2016 

Inter-rater reliability of post-arrest cerebral performance category(CPCscoresGrossestreuer AV. Resuscitation. 2016

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubationLewis SR. Cochrane Database Syst Rev. 2016 

Jan 01, 2017
Troponins replacing history taking?
16:22

As the years tick by our healthcare systems work harder and harder to ensure that acute coronary syndromes are picked up as they present to our Emergency Departments, the evolution of high sensitivity troponins and their application have been key to this.

The utility of a test however is dependant upon it's application to the appropriate patient. In a heavily burdened system it can at times seem sensible to front load tests and 'add on a troponin' before we are even sure the history is consistent with a possible acute coronary syndrome. But is this a safe approach for our patients and what are the potential consequences?

In this podcast we run through a recent paper from the US on the topic. Whilst not the highest level of evidence and also looking at a system not entirely generalisable to the UK, it does highlight the aforementioned concerns and is a useful reminder to consider our approach to testing in patients with chest pain.

We are certainly not berating the use of troponin, we just think the paper serves a great reminder that testing must be appropriately applied.

Enjoy, and as ever we'd love to hear your feedback!

References

SIGN ACS Guidelines 2016

RCEMFOAMed SIGN ACS Guidelines

Causes of Elevated Cardiac Troponins in the Emergency Department and Their Associated Mortality. Meigher S. Acad Emerg Med. 2016

Cardiac Troponin: The basics from St. Emlyn’s

Rick Body via St Emlyns; One high sensitivity troponin test to rule out acute myocardial infarction

 

Dec 15, 2016
RSI Debate; the aftermath..
09:01

So my talk at the ICS SOA 2016 conference on whether ED should be allowed to intubate certainly provoked some discussion, which was fortunate as it was the purpose of the talk!

If you haven't listened to it yet, stop listening to this and have a listen to the talk here first.

In this quick debrief between Rob and myself we have a think about the feedback and where to go from here.

We'd love to hear any feedback in the comments section at the webpage at www.TheResusRoom.co.uk

Simon

Dec 10, 2016
Should EM clinicians be allowed to RSI?
22:40

RSI delivered by EM clinicians is common place throughout the globe, in the UK however it still seems a contentious topic, with recent data showing only 20% of ED RSIs being performed by EM clinicians.

I was lucky enough to be asked to talk at the ICS SoA 2016 conference on the topic of EM doctors carrying out RSI's in the UK and this podcast is a copy of that talk.

I hope it provides some context both to UK practitioners and also to those from other countries, who may not understand what the big deal is all about.

Simon

References

A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance.Randomized controlled trial. Kovacs G, et al. Ann Emerg Med. 2000

Acute airway management in the emergency department by non-anesthesiologists. Review article. Kovacs G, et al. Can J Anaesth. 2004

Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Mayo PH, et al. Crit Care Med. 2004

The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Reid C, et al. Emerg Med J. 2004

Rapid sequence induction of anaesthesia in UK emergency departments: a national census. Benger J, et al. Emerg Med J. 2011.

Tracheal intubation in an urban emergency department in Scotland: a prospective, observational study of 3738 intubations. Kerslake D, et al. Resuscitation. 2015

Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care. Park L, et al. Emerg Med Australas. 2016

Scottish Intensive Care Society: RSI

Difficult Airway Society Guidelines

RCOA Anaesthesia in the Emergency Department Guidelines; Chapter 6.1

John Hinds on RSI at RCEM 2015 Belfast

Draft; AAGBI Guidelines: Safer pre-hospital anaesthesia 2016

AAGBI Pre-hospital Anaesthesia Guideline 2009

Dec 05, 2016
December 2016; papers of the month
28:15

Welcome to December's Papers of the month where we'll be looking at the papers recently published that have caught our eye.

First up, what happens when clinicians override clinical decision rules for PE? Are we better than the the rules?

Next we have a look at a review article that runs through the back ground literature on subsegmental PE's, their diagnosis and management.

And finally we have a look at a paper that helps to benchmark ED airway management with regards first pass success rate.

Our sponsors ADPRAC are giving away another £30 iTunes voucher to spend on education/entertainment to support your work life balance! All you need to do is click the link on our home page through to the ADPRAC website and answer the question relating to the podcast, good luck!

References & Further Reading

Yield of CT Pulmonary Angiography in the Emergency Department When Providers Override Evidence-based Clinical Decision Support. Yan Z. Radiology. 2016

Best Clinical Practice: Current Controversies in Pulmonary Embolism Imaging and Treatment of Subsegmental Thromboembolic Disease. Long B. J Emerg Med. 2016

Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care. Park L. Emerg Med Australas. 2016

Dec 01, 2016
Upper GI Bleeding, what's the risk?
18:56

Patients frequently present to the Emergency Department either with direct concern following an upper gastro intestinal bleed, or with a history that points towards the diagnosis.

When these patients are haemodynamically unstable or with ongoing high volume bleeding the decision to admit or discharge becomes simple.

But when the episode has settled, deciding whether they are safe to be discharged and continue with outpatient follow up can be difficult. Lots of us use scoring systems such as the Glasgow-Batchford Score or the Rockall Score but how much do we actually understand regarding the 'positive' and 'negative' outcomes of those scores?

A recent paper on the topic helps to cast some light on the topic and forms the basis of this podcast.

One of the frequently used scoring systems is the Glasgow-Blatchford score below that bases it's score upon historical, physiological and laboratory findings.

mdcalc GBS scoring calculator

Probably the other most frequently used score in ED is the Rockall score, which in its full form utilises endoscopy findings, however for use in the ED (pre-endoscopy) it has been modified and utilised.

mdcalc pre-endoscopy Rockall Score

Have a listen to how these scores fare in the paper and it may inform your risk stratification in the ED.

Enjoy!

References and Further Reading
 

The Predictive Value of Pre-Endoscopic Risk Scores to Predict Adverse Outcomes in Emergency Department Patients with Upper Gastrointestinal Bleeding - A Systematic Review. Ramaekers R. Acad Emerg Med. 2016

Upper Gastro Intestinal Bleeding at St.Emlyn’s

Nov 17, 2016
PE; the latest controversy
19:55

It's never long before the topic of pulmonary embolism makes it back into the controversial lime light and a recent paper on the association of PE with syncope is the lastest reason.

The PESIT trial, just published in the New England Journal of Medicine certainly grabs your attention when you read the abstract, with the implication that PE's are a major and hugely missed cause of the presentation of syncope. It also highlights a diagnostic work up that consists of blanket Well's scoring +/- d-dimer to decide who should be worked up further for the potential diagnosis, for every single patient presenting with syncope, including those with no appropriate symptoms or signs!

As always to read the abstract and draw a conclusion is to fall at the first hurdle, so take a listen to the podcast as we dive a bit deeper into the paper and topic, and of course make sure you take a look at the paper yourself and see what you make of the headline grabbing article

Enjoy!

References and Further Reading
Nov 10, 2016
November 2016; papers of the month
29:25

This month the literature seems to be focussed on cardiac arrest

In this podcast we'll cover a paper looking at the significance of chest compression rate, ultrasound for prognostication (and to a lesser extent identification of tamponade) and finally a systematic review and meta-analysis of PCI following ROSC.

The PCI paper follows on nicely from our previous podcast on the topic, so make sure you have a listen to that one first.

Our sponsors ADPRAC are giving away another £30 iTunes voucher to spend on education/entertainment to support your work life balance! All you need to do is click the link on our home page through to the ADPRAC website and answer the question relating to the podcast, good luck!

References & Further Reading

Association between chest compression rates and clinical outcomes following in-hospital cardiac arrest at an academic tertiary hospital. Kilgannon JH. Resuscitation. 2016 

Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Gaspari R. Resuscitation. 2016 

Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Gaspari R. Resuscitation 2016

EM Nerd-The Case of the Tell-Tale Heart

JC: Is this the REASON to use USS in cardiac arrest? St.Emlyn’s

Nov 01, 2016
Stroke thrombolysis
16:57

Stroke thrombolysis has definitely put the spotlight back on to the topic of stroke over the last few years. Stroke thrombolysis has led to restructuring of stroke care in the UK and has helped drive investment in stroke care.

The evidence base that underpins thrombolysis has been controversial to say the least and can be difficult to comprehend.

Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Donaldson L. Emerg Med Australas. 2016 Aug 25

The article, published in the the Emergency Medicine Australasia Journal is a great place to start to get to grips with the topic.

In the podcast we run through the paper and hopefully this will shed act as a good recap on the topic and lead you to delve into the primary literature and form your own opinion.

Enjoy!

References

Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Donaldson L. Emerg Med Australas. 2016 Aug 25

Royal College of Physicians; National clinical guideline for stroke, Prepared by the Intercollegiate Stroke Working Party, Fifth Edition 2016 (accredited by NICE)

Oct 22, 2016
One for the geeks; interval likelihood ratios
14:58

Risk assessment, testing and risk management form the very heart of Emergency Medicine and Critical Care.

Being aware of the evidence surrounding a topic is key to delivering high level care but without an understanding of the underpinning concepts it's application is extremely limited.

Understanding how a test result changes a patient's likelihood of a disease can be described with likelihood ratios, the Royal College of Emergency Medicine has a podcast explaining likelihood ratios in more detail.

But when a test result comes back on the boundary between positive and negative, or at the extremes of positive we can find it difficult to know what this means and that's where interval likelihood ratios comes into play. 

Examples include a minimally elevated WCC in a suspected appendicitis, or a dramatically raised d-dimer as compared to a borderline positive result in a suspected pulmonary embolus, this podcast talks through some of those concepts and their application, enjoy!

References

Evidence-based emergency medicine/skills for evidence-based emergency care. Interval likelihood ratios: another advantage for the evidence-based diagnostician. Brown MD. Ann Emerg Med. 2003

Pulmonary embolism: making sense of the diagnostic evaluation. Wolfe TR. Ann Emerg Med. 2001

Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. Schouten HJ. BMJ. 2013

Oct 11, 2016
October 2016; papers of the month
28:54

This month we cover a paper looking at the role of early craniectomy for raised intracranial pressure, the outcomes associated with advanced airway managements in prehospital cardiac arrest and lastly at the utility on ETCO2 and consider if it's application decreases adverse respiratory events.

This month our great sponsors ADPRAC our giving away a £30 iTunes voucher to spend on education/entertainment to support your work life balance! All you need to do is click the link on our home page through to the ADPRAC website and answer the question relating to the podcast, good luck!

References and Links

Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. Hutchinson PJ, N Engl J Med. 2016 Sep

Capnography for procedural sedation in the ED: a systematic review. Dewdney C, Emerg Med J. 2016 

The role of prehospital advanced airway management on outcomes for out-of-hospital cardiac arrest patients: a meta-analysis. Jeong S. Am J Emerg Med. 2016 Jul

TheBottomLine - RESCUEicp

ICS State of the Art Conference 2016: Find out more here

Oct 01, 2016
Asthma; New 2016 BTS Guidelines
10:03

This week the British Thoracic Society have released an updated version of their guidelines on asthma. The document covers all aspects from diagnosis, treatment and follow up, in this podcast we briefly run through some of the aspects covered in the acute management section.

Make sure you have a look at the full document that can be found here https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/

Speak to you soon!

Sep 29, 2016
Anti coagulated head injuries and delayed bleeds....
15:14

In 2014 NICE updated their guidelines on Head Injury: assessment and early management. This included specific guidance for those patients on warfarin

Guidance regarding the ongoing observation of these patients is not contained within the guideline but as with much of Emergency Medicine variation between departments and regions vary in the threshold to admit patients with a normal CT head due to concerns of these patients developing a delayed bleed.

A recent systematic review and meta analysis on the topic has just been published and we thought it would be worth a look.

Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016

The paper gives an interesting take on the risk we are dealing with following a normal scan in presentation to the ED and whilst the papers contained may not be the strongest level of evidence the meta-analysis is probably the best we have to go on at present.

Enjoy and we'd love to hear any of your thoughts!

Sep 15, 2016
September 2016; papers of the month
24:42

Here's a look at some of the papers that caught our eye this month.

We cover a paper looking at the the potential benefits of ketofol over propofol for conscious sedation, the role of aggressive blood pressure reduction in haemorrhage stroke and finally a really interesting paper of PE thrombolysis in cardiac arrest.

This month our great sponsors ADPRAC our giving away a £50 iTunes voucher to spend on education/entertainment for you to spend on supporting your work life balance! All you need to do is email through the answer to the following question;

With regards to this September 2016 Papers podcast and The PEA-PETT study, which of the following is correct;

A. The RCT shows a statistically significant benefit in PE thrombolysis intra arrest

B. The paper focussed on peri-arrest thrombolysis

C. The paper was a case series of PE's thrombolysed during arrest

Send your answer via email to contacttheresusroom@gmail.com with your name, answer and iTunes email address, entries close on 15th September and we'll announce the winner in October's podcast.

Enjoy!

 

References

Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. Ferguson I, et al. Ann Emerg Med. 2016.

Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. Qureshi AI, et al. N Engl J Med. 2016

Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the "PEAPETT" study). Sharifi M. Am J Emerg Med. 2016 Jun 30.

 

Sep 01, 2016
CXR in Blunt Trauma
17:28

Where does the role of a chest X-ray lie in major trauma?

With the ever increasing use of CT and ultrasound in the resus room what role does the old school CXR hold? How many injuries will it pick up? How many will it miss? And when is the extra delay justified?

This podcast looks at a recent paper on the topic and some related national guidelines. Enjoy!

References

Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study. Langdorf MI. Ann Emerg Med. 2015 Dec

NICE 2016: Major trauma; assessment and initial management

Aug 22, 2016
Burns
30:51

Burns are a common presentation to the ED and can result in a significant degree or morbidity and mortality.

In this podcast we talk through the approach and treatment of burns along with some controversies in the literature regarding assessment of burn depth and fluid management. Enjoy!

References

The Parkland formula under fire: is the criticism justified? Blumetti J, et al. J Burn Care Res. 2008 Jan-Feb.

Mersey Burns for calculating fluid resuscitation volume when managing burns: NICE advice [MIB58] Published date: March 2016

SCANRCIT: Pain can’t be used to differentiate between partial and full thickness burns

 

Aug 10, 2016
August 2016; papers of the month
31:51

Here's a look at some of the papers that caught our eye this month.

In this podcast we cover a paper looking at the significance of findings with the history, physical exam and imaging in subarachnoid haemorrhage to inform your work up. 

We look at another paper focussing on total body versus selective CT scanning in trauma and lastly a paper looking at the validation of the DECAF score to predict mortality in COPD exacerbations.

We've also got the e book 'ABC of Emergency Radiology' to give away on iTunes thanks to our new sponsors ADPRAC.

All you need to do is answer the following question;

With regards to this August 2016 Papers podcast and REACT-2, which of the following is correct;

A. The use of selective CT scanning in major trauma leads to a dramatic decrease in radiation

B. The use of selective CT scanning in major trauma leads to a decrease in time to diagnosis

C. The use of selective CT scanning in major trauma leads to a decrease in cost per in patient episode

D. The safety of selective CT scanning vs whole body CT scanning was equivocal

Send your answer via email to contacttheresusroom@gmail.com with your name, answer and iTunes email address, entries close on the 15th August and we'll announce the winner in September's podcast. 

Enjoy!

Aug 01, 2016
PCI following ROSC
22:39

If you've had an MI with a STEMI or a new LBBB the decision to go to the cath lab is pretty straight forward. If you've collapsed with a cardiac arrest of presumed cardiac aetiology (the majority of them) and gained a ROSC (return in spontaneous circulation) then the decision to go the the lab immediately is pretty variable and can depend of the clinicians involved, the ECG or the system within which you work.

The Resus Council and the European Society of Cardiology have some guidance on the topic and that is a must read. Today we have a look at a commonly quoted paper in the literature, The PROCAT database, to see if we can shed some light on the topic.

We'd love to hear feedback and comments on the podcast in the comments section. Enjoy!

References

Jul 25, 2016
5 Essential Papers
24:29

I haven't always read papers and with the time pressures of training and life it's impossible for us to be on top of all of the literature. But over the last few years I've come across some papers that I wish others had told me about.

For some of you this will all be a recap but for others hopefully it will spark an interest and get you to have a look at the papers yourself. We all know that it is extremely rare that one paper alone will or should change our practice but hopefully it's the interest and further questions into a topic that can come out of these papers. Enjoy!

5 References

Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Scheuermeyer FX. Ann Emerg Med. 2015 May

Thrombolysis during resuscitation for out-of-hospital cardiac arrest. Böttiger BW. N Engl J Med. 2008 Dec 18

Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Appelboam A. Lancet. 2015 Oct

Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Martindale JL. Acad Emerg Med. 2016 Mar

Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Blyth L. Acad Emerg Med. 2012 Oct

Jul 20, 2016
Sepsis: NICE 2016 Guideline Summary
19:14

So the long awaited new NICE Guidelines on Sepsis have just been released. I'm no sepsis expert, I'm not on a panel involved with the guidelines but I am someone who is going to be trying to use these guidelines everyday at work with multiple patients and I'm not the only one....we all are!

In this podcast we run through some of the main points brought up in the new guidelines. Talk about some potential difficulties and join toward some useful resources such as the brilliant flow charts developed by the Sepsis Trust.

Let us know your thought and feedback either via the site www.TheResusRoom.co.uk or on twitter @TheResusRoom. Enjoy!

Jul 13, 2016
July 2016; papers of the month
36:28
Jul 01, 2016
How safe is ED sedation?
17:39

Sedation is becoming an ever more significant part of our work in the Emergency Department. At the end of May 2016 the Royal College of Emergency Medicine Published the RCEM Sedation Audit of 2015-2016 that covered more than 8,000 ED sedations throughout the UK (involving more than 190 ED's).

There are some pearls to take out of this great piece of work in which there would seem to be some significant scope to improve. The document not only benchmarks our practice but helps give us a feel for the risks involved.

Have a listen and check out the resources mentioned via the hyperlinks below, most importantly make sure you have a look at the document itself.

Relevant Resources

RCEM Sedation Audit

ACPeducate iTunes feed

TEAM course

Jun 17, 2016
Carbon Monoxide
14:16

Carbon Monoxide poisoning is definitely one of those differentials that you consider when the patients books into ED with '?carbon monoxide poisoning'...... but how much do we really think about it in a patient that hasn't been sent down to the ED with this specific thought in mind?

Rob Fenwick talks us through the key points of Carbon Monoxide poisoning and some recent evidence on the topic which will probably make us consider the possibility a bit more frequently! This podcast was based around the post Rob wrote for Jonathan Downham's superb Critical Care Practitioner podcast. Go and have a look at the post for a lot more information on the topic.

Jun 12, 2016
June 2016; papers of the month
25:59
Jun 01, 2016
May 2016; papers of the month
16:30
May 15, 2016
Heart failure, sedation, intubation, anaphylaxis & cardiac arrest; EBM updates in Resuscitation
33:13

So this is a talk I gave at the EMCEF 22 conference. This covers a few of the papers we've discussed in the last 6 months on the podcast but a bit of spaced repetition is never a bad thing!

We'll be running through topics on heart failure, sedation, intubation, anaphylaxis and duration of cardiac arrest. The papers are well worth a look and whilst not all high quality evidence they do bring to the front some really interesting questions about are practice and prompt us to challenge our habits. Enjoy!

References

May 04, 2016
REBOA; setting up a service with Sam Sadek & Zaf Qasim
50:47

In this episode we were lucky enough to catch up with Sam Sadek, EM Consultant at The Royal London hospital and HEMS doctor and also Zaf Qasim EM Consultant in Delaware in the United States. Both have been heavily involved in the setup and delivery of REBOA service in their respective posts.

In this podcast they share their experience and expertise on the topic of setting up a REBOA service. A huge thanks to both of them as this is a superb podcast for anybody considering getting involved in REBOA.

Recent podcasts on REBOA on ERCAST and EMCrit are essential listening and serve as great preludes to our discussion so make sure you check them out.

Please pop any comments or questions at the bottom of the page and we will come back with a Q&A podcast on the topic really soon!

References

Resuscitative endovascular balloon occlusion of the aorta: a gap analysis of severely injured UK combat casualties. Morrison JJ. . Shock. 2014 May;41(5):388-93. doi: 10.1097/SHK.0000000000000136.

Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis. Inoue J. J Trauma Acute Care Surg. 2016 Apr;80(4):559-67. doi: 10.1097/TA.0000000000000968.

The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. Morrison JJ. J Surg Res. 2014 Oct;191(2):423-31. doi: 10.1016/j.jss.2014.04.012. Epub 2014 Apr 13.

Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales. Barnard EB. Emerg Med J. 2015 Dec;32(12):926-32. doi: 10.1136/emermed-2015-205217.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Rossaint R. Crit Care. 2016 Apr 12;20(1):100. doi: 10.1186/s13054-016-1265-x.

Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. Moore LJ. J Trauma Acute Care Surg. 2015 Oct;79(4):523-30; discussion 530-2. doi: 10.1097/TA.0000000000000809.

The AAST Prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). DuBose JJ. J Trauma Acute Care Surg. 2016 Apr 5. [Epub ahead of print]

Apr 24, 2016
Brohi, Nutbeam, Appleyard, Jones, Parsons & Newton; TraumaCare2016, Major Trauma in the ED
24:21

So we were lucky enough to be asked to cover the Trauma Care Conference and specifically today's day focussing on Major Trauma in the Emergency Department. We managed to to get a few minutes of time from some of the superb speakers and get their  take home messages from their talks. Enjoy!

Relevant Resources

TraumaCare

PHEMCAST 

KIDS Calculator

Perimortem C-section

Apr 20, 2016
Hypothermia
26:43

Rob Fenwick talks to us about this common condition and amongst others throws up a few surprises about the risks of rewarming. Enjoy

Apr 06, 2016
April 2016; papers of the month
23:49

Here's a look at some of the papers that caught our eye this month. We cover the best way to diagnose heart failure, the risks associated with hyperopia and the utility of ETCO2.  Take the time to have a look at the papers yourself and leave any feed back or comments at the bottom of the page, enjoy!

Mar 30, 2016
Type II Respiratory Failure
20:05

So in this short podcast we're going to run over the summary of recommendations just published by the British Thoracic Society and the Intensive Care society on the Ventilatory Management of Acute Hypercapnia Respiratory Failure in Adults. This isn't in anyway intended as a replacement for reading the document itself so please make sure you take the time to do that.

Mar 21, 2016
Needle Thoracostomy
25:02

Needle decompression of a pneumothorax is a time critical and life saving procedure. Classical teaching is to perform this in the 2nd ICS midclavicular line but is this the easiest and most effective place to perform it?

In this podcast I speak with Zaf Qasim, an EM physician in the US about the topic and the underpinning EBM. Below are some of the papers we'll be discussing. Enjoy!

Simon

Mar 12, 2016
March 2016; papers of the month
23:32

This month we're looking at the JAMA paper on the new sepsis definitions, adverse event rates in ED sedation, interventional treatment for the over 80's with ACS and more!

Mar 05, 2016
Major Trauma; NICE guideline 2016
12:41

A look at the headlines from the newly released guidance from NICE. Some bits of this may prove tricky to implement with current systems including the time to RSI....

Mar 05, 2016
Status Epilepticus
16:38

We talk through some core content on epilepsy, some algorithims for treatment, some of the evidence base that surrounds the topic and some of the difficulties surrounding decision making

Mar 05, 2016
February 2016; papers of the month
28:36

Welcome to February's papers of the month. This time we're talking about decompressing tension pneumothoraces, nasal oxygenation, prognosis of cardiac arrest with respect to duration and more!

Mar 05, 2016
Anaphylaxis
28:36

Rob Fenwick talks us through some key points regarding anaphylaxis and some recent literature which may be a surprise regarding biphasic reactions, enjoy!

Mar 05, 2016
January 2016; papers of the month
17:27

Here are the papers that caught our eye this month including direct vs video laryngoscopy, ultrasound for shortness of breath, ecg findings in PE and more!

Mar 05, 2016