Drugs in cardiac arrest are controversial. Prehospital research is notoriously difficult to perform. PARAMEDIC2 has just published in the New England Journal of Medicine and is a multi centre randomised placebo controlled trial looking at adrenaline (or epinephrine depending on which side of the pond you reside) in out of hospital cardiac arrest, no mean undertaking and a landmark paper.
The paper has gained a huge amount of traction online with multiple blogs discussing the primary outcome which showed a higher survival rate in those receiving adrenaline when compared to placebo. This has been accompanied with a firm debate over the secondary outcomes, which include the rate of survival with a favourable neurological outcome (mRS 0-3), which showed no statistically significant difference between the two treatment arms, but in pure numbers gave a higher proportion of favourable outcomes in the adrenaline group.
The trade off for this increased survival is the significant number of survivors with a poor neurological outcome.
The question on everyone's lips then being; should we continue to administer adrenaline in cardiac arrest given the findings from this study?
In the podcast we run over the main findings of the paper and are lucky enough to speak to the lead author Professor Gavin Perkins about the paper and some of the questions we and you have had following publication of the paper. A huge thanks to Gavin for taking the time to do this.
Have a listen, enjoy, and let us know any thoughts or feedback you have
Simon, Rob & James
References & Further Reading
PARAMEDIC2; Warwick University Clinical Trials Unit
A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. Perkins GD. N Engl J Med. 2018
PARAMEDIC2 Protocol
Testing Epinephrine for Out-of-Hospital Cardiac Arrest. Callaway CW. N Engl J Med. 2018
First10EMParamedic 2: Epinephrine harms/helps in out of hospital cardiac arrest
REBEL Cast Ep56 PARAMEDIC-2: Time to Abandon Epinephrine in OHCA?
Head injury worldwide is a significant cause of morbidity and mortality.
Besides prevention there isn't anything that can be done to improve the results from the primary brain injury, there is however a phenomenal amount that can be done to reduce the secondary brain injury that patients suffer, both from a prehospital and in hospital point of view.
In the podcast we run through head injuries, all the way from initial classification and investigation, to specifics of treatment including neuro protective anaesthesia and hyperosmolar therapy, to give a sound overview of the management of these patients.
As always we welcome feedback via the website or on Twitter and we look forward to hearing from you.
Enjoy!
Simon, Rob & James
References & Further Reading
Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016
Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned? Boone MD. Surg Neurol Int. 2015
Life in the fast lane; hypertonic saline
Life in the fast lane; Traumatic brain injury
Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality. T Lawrence. BMJ Open. 2016
Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. M.Majdan. The Lancet. 2016
The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. Gale SC. J Trauma. 2005
What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population? Rotheray KR. Resuscitation. 2012
NICE Head Injury Guidelines 2014
MDCALC Canadian Head Injury
TheResusRoom; The AHEAD Study
TheResusRoom; Anticoagulation, head injury & delayed bleeds
Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement
A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries. Manara AR. J Intensive Care Soc. 2016
Welcome to July's papers podcast.
There has been a plethora of superb and thought provoking papers published this month and we've got the best 3 that caught our eye for you.
In this episode we look at the potential benefit of early vs late endoscopy in patients presenting with an acute upper GI bleed. Next we look at both intra and post ROSC hyperoxia and the associated outcomes. Finally we have a look at the utility of straight leg raise as a test to rule out potential pelvicfractures in out trauma patients.
We strongly suggest you source the papers and come to your own conclusions and we'd love to hear any comments either at the foot of this page or on twitter to @TheResusRoom.
Enjoy!
Simon & Rob
References & Further Reading
Delayed endoscopy is associated with increased mortality in upper gastrointestinal hemorrhage. Jeong N. Am J Emerg Med. 2018
Association between intra- and post-arrest hyperoxia on mortality in adults with cardiac arrest: A systematic review and meta-analysis. Patel JK. Resuscitation. 2018
Straight leg elevation to rule out pelvic injury. Bolt C. Injury. 2018