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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: 2017
Dec 11, 2017

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 1, 2017

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 

Nov 20, 2017

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 10, 2017

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 1, 2017

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 

Oct 16, 2017

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 6, 2017

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 1, 2017

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!

Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence? Krage R. Emerg Med J. 2017

iSepsis – Vena Caval Ultrasonography – Just Don’t Do It!; EMCrit

The Bottom Line; DETO2X-AMI

JC: Oxygen in ACS. A fuss about nothing? The DETO2X Trial at St.Emlyn’s

Sep 21, 2017

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 11, 2017

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 1, 2017

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!

 
Aug 14, 2017

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 1, 2017

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!

Jul 20, 2017

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 10, 2017

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
 
Major trauma
 
Spinal injury 
 
Faculty of prehospital care consensus statements
 
Spinal immobilisation
 
Minimal patient handling
 
Cochrane reviews
 
Spinal Immobilisation for Trauma
 
Papers of interest
 
Cowley et al 2017
 
Dixon et al 2015
 
Benger & Blackham 2009
 
Hauswald 2015
 
Hauswald 2013
 
Michaleff et al 2012
 
Podcasts
 
RCEM Learning
 
EMCrit
Jul 1, 2017

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!

Jun 21, 2017

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 15, 2017

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 1, 2017

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!

May 19, 2017

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 15, 2017

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 1, 2017

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 

 

Apr 25, 2017

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 15, 2017

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

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