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The Resus Room

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.
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The Resus Room
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Oct 14, 2021

Intubation is a key part of advanced airway management.

Although some of you out there may not intubate, we’ll be covering aspects where the identification of the need for intubation and how contributing as a team to the process can make a real difference to patient outcomes.

Intubation is subject of a considerable amount of evidence and debate. Increasing use of supraglottic airways both in theatre and in cardiac arrest creates a situation in which there are limited opportunities to train and learn the skill. This brings into question who should these limited opportunities to train go to, what defines competence, which patients now would benefit from intubation.

In this episode we’re going to cover these topics and more, including talking through how to fine your intubation technique as much as possible. We’re coming at this episode with our collective neonatal, ED and PHEM practice which all involve advanced airway management and it’s fair to say that we’re all passionate about delivering intubation and advanced airway management to the highest level possible. 

We hope this episode gives a further opportunity to consider the topic in great depth and reflect upon how we can all contribute to improving practice.

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Enjoy!

Simon, Rob & James

Oct 1, 2021

Welcome to October’s papers of the month!

Should patients who gain a ROSC following an out of hospital cardiac arrest go for an immediate angiogram if their ECG does not show an STEMI or Left Bundle Branch Block? We’ve looked at this before with the COACT trial which only looked at those patients with a shockable rhythm but this months paper looks at all ROSCs from all rhythms.

Next up we take a look at a paper that investigates senior paramedics decision making in cessation of cardiac arrests and think further about the decision making that goes into these complex decisions.

Finally we take a look at a huge trial assessing the use of balanced fluids versus Normal Saline in critically ill patients and gain more information about the strategy we should employ.

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Enjoy!

Simon & Rob

Sep 15, 2021

So this time we're going to be looking at the HUGE topic of acute coronary syndrome (ACS)! ACS ranges from patients who appear well at the time of their presentation, to those that have arrhythmias, haemodynamic instability, to those that are in cardiac arrest!

There are around three quarters of a million ED chest pain attendances per year for acute chest pain and it accounts for around 25% of ED medical admissions!!

Some of the treatments we’ll discuss for patients with ACS can have a huge affect on morbidity and mortality and we can make a real difference to our patients. The ESC guidelines are a fantastic resource to take a look at and we've listen the papers that form the evidence we cover in the podcast.

We worry about missing ACS and conversely, with so many ‘suspected ACS patients’, we also worry about overly suspecting it and the subsequent burden of admissions and investigations that it may mean. We’re going to cover the approach to ACS in this episode in our standard format, all the way from definition, patho-physiology, assessment, investigations and management and cover aspects that are both new information and a sound revision of the topic.

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Enjoy!

Simon, Rob & James

Sep 1, 2021

Welcome back after our summer hiatus to September’s Papers Podcast!

Firstly we take a look at two different strategies for managing agitation in the Emergency Department, to achieve rapid control. Is haloperidol and midazolam, or ketamine alone, a better strategy?

Then we take a look at the results from RECOVERY-RS. We covered the design of the trial at it’s conception last year and this trial essentially looks to answer whether a strategy of high flow nasal oxygenation, CPAP or conventional oxygenation is best for our patients with suspected or confirmed COVID-19 when they present with hypoxia.

Lastly we turn to Rob and take a look at his recent publication on the use of cervical collars when dealing with a patient able to self extricate from a motor vehicle collision; how will the application of a collar or commands help with excessive movement?

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Enjoy!

Simon & Rob

Aug 1, 2021

Welcome to August 2021’s papers podcast!

Three more great papers for you this month which have challenged and informed our practice.

First up we look Impact of ambulance deceleration with patients lying flat vs 30 degrees head up on intracranial pressure in patients with a head injury.

Next, is a patient with a refractory VF arrest more likely to have a positive finding on coronary angiography than one with non-refractory VF?

And finally, in patients with blunt chest wall injury, does the presence of a flail chest indicate a worse morbidity and mortality compared to rib fractures alone? And what do the findings mean for our clinical examination focus?

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

We're giving you all a summer break from us and we'll be back again with our Papers of the Month and Roadside to Resus episodes in September.

Enjoy!

Simon and Rob

Jul 19, 2021

So welcome back to another Roadside to Resus episode!

Pre alerts are a key part of the interface between pre hospital and in hospital care of the critically unwell patient, when made and received in an effective manner they can really benefit the patient and the system. But too often we hear of friction associated with pre alerts and recent discussions on social media has really highlighted this.

In this episode we explore the pre alert, the guidance that exists already on the topic, the challenges of both making and receiving those pre alerts and our four major questions; why we pre alert, what we should pre alert, how to pre alert and when to pre alert.

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Enjoy!

Simon, Rob & James

Jul 1, 2021

Another month and 3 more papers!

First up we have a look at a paper that has grabbed a lot of recent headlines in the form of TTM2. So we now seem to have the answer to whether comatose patients following out of hospital cardiac arrest benefit from therapeutic hypothermia over maintenance of normothermia.

Next up we take a look at a paper which adds some real value to our assessments of maxillofacial injuries and can help inform our assessment of the likelihood of fracture and need for imaging.

Lastly we take a look at the whether iv vs io access in cardiac arrest might make a difference to outcomes when it comes to the use of adrenaline.

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Enjoy!

Simon and Rob

Jun 16, 2021

So this time we're going to be talking about subarachnoid haemorrhage. So this is going to be a short and punchy look at a really important and interesting topic in subarachnoid haemorrhage.

We run through the approach to headache and then focus on the specific features and findings that we should be looking for with regards subarachnoid haemorrhage. We then consider who we should be investigating further, what value a CT head brings and the sticky subject of who should be going on to have a lumbar puncture.

Finally we consider the the management once the diagnosis of SAH is reached and how we can ensure the best outcomes for our patients.

At the time of recording NICE has published its draft version of Subarachnoid Haemorrhage Caused by a Ruptured Aneurysm; diagnosis and management, which will be a great resource once finalised.

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Enjoy!

Simon, Rob & James

Jun 1, 2021

This month we've got three papers that have challenged our practice both from an in-hospital and pre-hospital perspective.

Firstly we consider a paper that looks at admission saturations for patients with exacerbations of COPD and compare this to the BTS guidance on oxygen therapy, regarding altering oxygen saturations for those proven not to be hypercapnoeic. Should we be aiming for 88-92% or 94-98%?

Next we look at a paper from the team at KSS looking at dispatch to older trauma victims and consider whether current triggers for HEMS dispatch are set at the appropriate level to catch those in this cohort that may benefit from critical care interventions.

Lastly we look at a paper evaluating the QRS width in PEA cardiac arrests and consider firstly whether a broad QRS complex is predictive of hyperkalaemia and secondly whether we would treat patients based off this finding?

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Enjoy!

Simon and Rob

May 5, 2021

So the Resuscitation Council UK have today published new guidelines on resuscitation based on the European Resuscitation Council 2021 Guidelines and recommendations from the International Liaison Committee on Resuscitation.

We were lucky enough to catch up with two key members of both ERC and RCUK, Gavin Perkins and Jasmeet Soar, gaining their valuable insights into the new guidelines.

As well as this Simon, Rob and James pick out some other key points from the guidelines and discuss how these may translate into systems and practice.

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Enjoy!

Simon, Rob & James

May 1, 2021

Welcome back to May's Papers of the Month Podcast!

Three more papers for you on three varied topics. We start off with the use of end tidal carbon dioxide in the content of prehospital head injuries.Taking a look at a paper delving a bit deeper into the utility of end tidal CO2 when compared with arterial CO2 measurements on arrival in ED, in patients having received a prehospital anaesthetic; how accurate is end tidal and what level should we be aiming for?

Next we consider the importance of frailty in the outcomes of our older trauma patients and the ability of three different screening tools in identification of this cohort of high risk patients presenting to our hospitals.

Finally we take a look at a treatment which some prehospital services have already employed and others are considering; the use of CPAP for patients presenting with acute respiratory distress. Does the evidence support its use?

Once again we'd love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Simon & Rob

Apr 15, 2021

So last month we considered Maternal Emergencies and the approach and interventions we can make in order to minimise complications during pregnancy and during childbirth. As promised this month we're looking at the next step along the process and focussing on Newborn Life Support.

Dealing with newborns has the potential to be really stressful but hopefully by concentrating on the fundamentals and guidelines we'll all be able to approach the situation with greater confidence.

Let us know any thought and comments you have on the podcast.

Enjoy!

Simon, Rob & James

Apr 1, 2021

Well if last month was based on cardiac arrest, this month takes a deeper look at airways!

First up we take a look at a paper that benchmarks the use of video laryngoscopy, specifically with the C-MAC and gives some really useful information from a Swiss HEMS service on first-pass success, the relevance of operator experience on success and factors that alter intubation success.

Next up we're looking at blood in the airway with epistaxis...okay it's a tenuous link, but it pretty much works! The NOPAC study looks at the use of TXA in atraumatic epistaxis and compare it to placebo use, will TXA come up trumps in this setting?

Finally we take a look at the use of scalpel cricothyroidotomy within the London HEMS service over a 20 year period, with a number of things we can learn from this experience.

Once again we'd love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Simon & Rob

Mar 15, 2021

So this is the first of a pregnancy related double-header, with the focus being firmly set on the mother this month and next month we’ll focus in on NLS.

This month though we’re going to be discussing maternal emergencies. Now many conditions that could fall into this category but, as much as we love a good yarn, we really can’t be here all day, so we’ve decided to focus on are the conditions that we are more likely to come across in either prehospital or EM practice. Those conditions in which we can make a really big difference to either the mum or the baby.

We’re talking antepartum haemorrhage, postpartum haemorrhage, cord prolapse, breech presentation and shoulder dystocia, all after we've set the scene on assisting with an uncomplicated delivery.

So what would be really good is if we could find someone to bring in some prehospital maternal experience too. Ideally, someone qualified as a midwidfe and paramedic…and we're incredibly lucky to have just that in Aimee Yarrington, who has joined us for the podcast!

As a background; PPH is the third leading cause of maternal death in the UK and the most common cause of obstetric-related intensive care admissions. APH complicates 3–5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide. Cord prolapse ranges from 0.1% to 0.6%. Breech presentation occurs in 3–4% of term deliveries. Shoulder dystocia has a reported incidence of around 0.70%. And the incidence of primary PPH continues to rise progressively in the UK, reaching as high as 13.8% in 2012–2013. So there's a good reason for us to be experts on these topics.

Let us know any thought and comments you have on the podcast.

Enjoy!

Simon, James & Aimee

Mar 1, 2021

So this month we've got a cardiac-arrest-fest for you! With 3 papers centered on the management of cardiac arrest, with some key points that will help inform and improve our practice.

First up we have a think about where patients with a presumed cardiac cause of their arrest should be transported to. Trauma networks in the UK have changed destinations for patients, but is there a patient benefit transporting this patients to a cardiac arrest centre and if so how much?

Next we look at the potential benefit to nurse-led cardiac arrests with a study that might change some thoughts on how we best run and collaborate our cardiac arrests.

Finally we take a look at an open access paper from SJTREM, looking at the use of serum markers to help us prognosticate in hypothermic cardiac arrest and in these really challenging cases there is some great stuff to take from the paper.

Once again we'd love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Simon & Rob

Feb 15, 2021

Welcome back to the podcast and our next Roadside to Resus episode, this time we’re taking a look at Diabetic Ketoacidosis, DKA.

In this episode we’ll be getting our heads around the pathophysiology that underpins DKA, consider the clinical picture and severity of patients that present and look at both the in-hospital and pre-hospital management of these patients including topics such at fluid choice, insulin boluses and nasal ETCO2 for diagnosis of DKA.

Let us know any thought and comments you have.

Enjoy!

SimonRob & James

Feb 1, 2021

So three very different papers for you this month...

We start off having a look at a paper on the HINTS examination. This exam came to prominence a few years ago as a way to distinguish between central and peripheral causes of vertigo with a pretty amazing sensitivity and specificity. Since then many EM clinicians have brought it onto their practice and this paper seeks to assess how good the test is at the bedside in real life practice.

Next up we take a look at a paper assessing the injury patterns in trapped patients and consider the prevalence of injuries both with regard to spinal and other injury patterns and then consider the impact that this holds with respect to extrication.

Finally we have a look at a paper focussing on the inhospitable management of hypertension; the treatment strategies and the outcomes comparing those being treated during their inpatient stay versus this left untreated with some surprising outcomes...

Once again we'd love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Simon & Rob

Jan 18, 2021

So in this episode we’re going to have a deeper think about advanced airway management and specifically supraglottic use in the prehospital and ED environment. 

Many prehospital service have seen the removal of intubation from their scope of practice, and that’s understandably been received with mixed thoughts.

But this isn’t the end of ‘expert advanced airway care for all; in fact far, far from it… we’ve all heard people talking about ‘whacking in an i-gel’, but really utilising a supraglottic device to its maximal potential can make a huge difference to our critically unwell patients. 

We'll be running through an overview of supraglottic devices, the evidence surrounding their use, patient selection, patient positioning and size selection, placing a supraglottic device, troubleshooting and finally ongoing ventilation with a supraglottic device.

We'd love to hear any comments or feedback you have and make sure to take a look at the references and resources below.

Enjoy!

Simon, Rob & James

Jan 1, 2021

Happy New Year!

Well 2020 certainly wasn't what we were all expecting, so here's hoping for a phenomenally better 2021. We've got some really exciting episodes for you this year including Supraglottic Airways, Neonatal Resuscitation, Diabetic Emergencies, New Resuscitation guidelines and much much more!

We're kicking off the podcast year with three really interesting papers!

First up we consider the importance of first pass success of both supraglottic airways and endotracheal intubation in the context of cardiac arrest; a lot of attention has been shone recently on question of which approach we should consider after bag valve mask ventilation, but how important is the first pass of either of the approaches to the outcomes of our patients?

Next up we have a look at a paper that challenges the use of TXA in our patients with a severe traumatic brain injury after the publication of CRASH 3.

Finally we have another look at the mantra of 'GCS 8-intubate' with a systematic review which draws together all of the evidence across the age ranges and both traumatic and non-traumatic presentations.

Make sure you take a look at our new CPD apps on both Android and iOS to log your time listening to this episode.

Enjoy!

Simon & Rob

 

Dec 14, 2020

So for decades people have talked about Contrast Induced Nephropathy…or Contrast Induced Acute Kidney Injury, depending on the decade and location of discussion. The theory being that diuresis, increased urine viscosity and changes in vasoconstriction and vasodilation leads to a worsening of renal function following iv contrast administration.

It seems to come from the 1950’s where some patients were seen to develop acute kidney injuries following iv contrast. Now times have changed and treatments and contrasts evolved but the discussion around contrast induced nephropathy continues. At times these discussion can mean that some patients wait for scans in the Emergency Department whilst waiting for blood tests to come back first. But is this the right thing to do?

In this episode we take a look at the origins of contrast induced nephropathy, consider some recent publications on the topic and see how this translates to practice and applications of the most recent guidelines.

Reading around the topic has been hugely informative for us and we hope will be of benefit to you too!

Enjoy

Simon & Rob

Dec 1, 2020

Welcome back to December's Papers of The Month Podcast! Three more papers for you which will challenge and inform you practice.

First up we have a look at a systematic review and meta-analysis which considers the fluid choice in resuscitating those patients with suspected traumatic brain injury in the prehospital setting; should we be reaching for the hypertonic solutions, or is an isotonic fluid such as normal saline adequate?

Next we take a look at a paper that has received a lot of online discussion which looks at the two approaches of antibiotics or surgery for an appendicitis. This is a randomised control trial that looks to answer a question that the literature has dipped into over the last few years, but this RCT goes that bit further and will help give patients a good idea of the pro's and con's of each approach.

Finally we take a look at the UK national approach to oxygenation strategies in those patients receiving a prehospital emergency anaesthetic. How many clinicians provide PEEP, how commonly implemented is apnoeic oxygenation and do we all ventilate through apnoea? Gaining an understanding as to where our practice sits compared to others gives us the opportunity to consider the potential benefits and downsides of various strategies and may help unify practice to more streamlined working and better outcomes for our patients. We also get the opportunity to hear thoughts on the subject from one of the authors Dr. Amar Amshru, Emergency Medicine and and Pre Hospital Doctor in London and with Kent Surrey and Sussex Air Ambulance.

Enjoy!

Simon & Rob

Nov 16, 2020

Welcome back to the podcast!

In this episode of Roadside to Resus we're going to take a look Anaphylaxis, which has been highlighted on a national level of concern as NICE state ‘many people do not receive optimal management following their acute anaphylactic reaction’.

Much of the problem lies within a lack of understanding of what actually constitutes an anaphylactic reaction and the knock on effect this has to the treatment provided.

In this episode we'll explore the definition of anaphylaxis and the significant differences that can be seen in the presentation. We have a a think about the pathophysiology and reasons behind the variance in presentations and how this affects the importance of treatments available and their relative importance.

Anaphylaxis is known to have a a number of patients who have a biphasic reaction, it predicates the need to convey patients to hospital and a period of observation; however the frequency and severity of these biphasic reactions can help to inform this further and for that reason we take a look at the literature on it.

We've covered angioedema before in a separate episode, but we briefly cover the similarities and differences and how this affects management.

Lastly we cover the follow up and management that these patients require.

We'd love to hear any comments or feedback you have and make sure to take a look at the references and resources below.

Enjoy!

Simon, Rob & James

Nov 1, 2020

Welcome to November’s papers of the month podcast!

This month we kick things off looking at TXA in trauma and consider in complex scenes and resource limited environments if TXA could be administered effectively in an IM rather than IV route? We also get an authors inside view from Professor Ian Roberts.

Next up; does the anatomical location of a head injury affect the risk of an intracerebral bleed and could this affect those patients that can go without a scan?

And finally we have a look at the importance of a chest X-ray in COVID-19 and consider how accurate the X-ray is at both picking up and ruling out the infection.

Enjoy!

Simon & Rob 

Oct 15, 2020

So in our Toxidrome Roadside to Resus episode we covered the initial management of a poisoned patient, some of the constellation of features to look out for and the specific management. But what about specific agents and circumstances that require particular knowledge and management both in the prehospital environment and in ED?

Well in this episode we’ll cover these by running through;

  • Paracetamol poisoning and treatment
  • Calcium channel blocker overdose
  • Beta blocker overdose
  • High dose insulin euglycaemic therapy
  • Activated charcoal
  • Intralipid therapy
  • Cardiac arrest due to toxicology

We'd love to hear any comments or feedback you have and make sure to take a look at the references and resources below.

Enjoy!

Simon, Rob & James

Oct 1, 2020

Welcome back to the Papers of the Month podcast, once again we've got 3 more papers to inform, discuss and hopefully improve our practice.

First up we have a look at a paper which looks to quantify the prognostic utility of lactate in our sick Resus patients; we often look at the initial lactates and draw conclusions for what they mean, but this paper helps us understand the results a bit further.

For our patients that sustain a head injury, the NICE guidelines advocate that all patients on direct oral anticoagulants should have a CT head scan, irrespective of clinical findings or other high risk features of the patients history. Quantifying the risk that these patients have for an intracranial bleed is really important, as to date it isn't fully understood. Our second paper looks at this directly and can help inform practice, guidelines and discussions with patients.

Finally; we often think about how we can improve resuscitation of our patients in cardiac arrest, look for the latest treatment and evidence, but it can be easy to overlook how our actions can significantly affect their loved ones who may be present at this time. We take a look at a fascinating study looking at the impact of inviting patients in to witness the resuscitation in its entirety and the effect that this has in regards too PTSD. In our opinion this paper holds a huge amount to think about and is a game changer!

Finally keep an eye out for our CPD portal and app which is in the final stages of testing and will be out very shortly!! We'll be keeping you up to date on twitter @TheResusRoom with its launch

Enjoy!

Simon & Rob

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