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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
Apr 1, 2017

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

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

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

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

Enjoy

Simon & Rob

References & Further Reading

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

FOAMcast; Contrast-Induced Nephropathy and Genitourinary Trauma

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

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

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

PHEMCAST; blood

Mar 18, 2017

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

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

Speakers

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

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

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

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

St Emlyn's Top 10 +1 Trauma Papers 2016

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

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

The HECTOR Course (& free online manual!!)

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

p3 presentations

TARNlet Database

 

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

Simon

Mar 8, 2017

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

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

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

Enjoy!

Simon

References
 

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

Mar 1, 2017

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

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

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

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

Enjoy

Simon & Rob

References & Further Reading
  

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

 

AIRWAYS-2

 

Feb 21, 2017

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

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

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

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

Here's a few facts we need to know:

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

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

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

Enjoy!

 References

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

 
Feb 15, 2017

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

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

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

Enjoy!

References & Further Reading

LITFL epistaxis review

Geeky medics epistaxis 

BMJ overview paper & management flowchart

Routine coagulation screening in the management of emergency admission for epistaxis; is it necessary? Thaha MA. J Laryngol Otol 2000

Front-line epistaxis management: let's not forget the basic. E C Ho. J Laryngol Otol 2008

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

 Tranexamic acid in epistaxis: a systematic review. Kamhieh Y, et al. Clin Otolaryngol. 2016

Feb 1, 2017

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

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

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

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

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

Enjoy

Simon & Rob

References & Further Reading

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

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

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

Jan 16, 2017

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

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

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

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

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

Simon

Jan 14, 2017

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

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

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

References

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

Resuscitation Council; Recognition of Life Extinct

Jan 1, 2017

Happy New Year!!!

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

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

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

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

Thanks again to our sponsors ADPRAC for supporting the podcast.

References & Further Reading

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

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

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

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

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