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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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Now displaying: 2016
Dec 15, 2016

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 10, 2016

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 5, 2016

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 1, 2016

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

Nov 17, 2016

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 10, 2016

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

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

Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. Schultz DJ.Trauma. 2004 Apr 

Prospective evaluation of unsuspected pulmonary embolism on contrast enhanced multidetector CT (MDCT) scanning. Ritchie G. Thorax. 2007 Jun.

EM Nerd-The Case of the Incidental Bystander

JC: Prevalence of PE in patients with syncope. St.Emlyn’s

Nov 1, 2016

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

Oct 22, 2016

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 11, 2016

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 1, 2016

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

Sep 29, 2016

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 15, 2016

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 1, 2016

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.

 

Aug 22, 2016

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 10, 2016

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 1, 2016

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!

Jul 25, 2016

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 20, 2016

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 13, 2016

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!

Jun 17, 2016

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 12, 2016

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.

May 4, 2016

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

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