How often do you prescribe or give i.v. fluids to your patients? How much thought goes into what's contained in that fluid? What effect will you fluid choice have on your patient?
Two trials on crystalloid administration in the acutely unwell patient have occupied a lot of conversation in the research world over the last few weeks, both published in the NEJM and in this podcast we take a look at them.
In the podcast we cover the following;
Make sure you take a look at the papers yourself and come up with your own conclusions. There are a whole host of superb FOAM resources out there on the topic that are well worth a look and referenced below.
We'd love to hear any thoughts and comments below.
Enjoy!
References & Further Reading
| Fluid | Na | K | Cl | Ca | Mg | Lact | Acet | Glucon | Dext | Osmol mOsm/L |
| 0.9% N Saline | 154 | 0 | 154 | 0 | 0 | 0 | 0 | 0 | 0 | 308 |
| Lactated Ringers | 131 | 5 | 11 | 2.7 | 0 | 29 | 0 | 0 | 0 | 273 |
| Hartmanns | 129 | 5 | 109 | 4 | 0 | 29 | 0 | 0 | 0 | 278 |
| Plasma Lyte | 140 | 5 | 98 | 0 | 3 | 0 | 27 | 23 | 0 | 280 |
Constituents measured in mEq/L Reference; University Texas
Balanced Crystalloids versus Saline in Critically Ill Adults. Semler MW. N Engl J Med. 2018
Balanced Crystalloids versus Saline in Noncritically Ill Adults. Self WH. N Engl J Med. 2018
Patient-Centered Outcomes and Resuscitation Fluids. Myburgh J. N Engl J Med. 2018
REBEL.EM; Is the Great Debate Between Balanced vs Unbalanced Crystalloids Finally Over?
PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation
JC: Balanced fluids vs Saline on the ICU. The SMART trial. St Emlyn’s
Welcome to March's papers of the month. We know we're biased but we've got 3 more superb papers for you this month!
First up we review a paper looking at oxygen levels in patient's with a return of spontaneous circulation following cardiac arrest, is hyperoxia bad news for this patient cohort as well as the other areas we've recently covered?
Secondly we have a look at a paper reviewing the association between time to i.v. furosemide and outcomes in patients presenting with acute heart failure, you may want to have a listen to our previous podcast on the topic first here.
Lastly, when you see a pregnant patient with a suspected thromboembolic event, can you use a negative d-dimer result to rule out the possibility? We review a recent paper looking at biomarker and specifically d-dimers ability to do this.
We'd love to hear from you with any thoughts or feedback you have on the podcast. And we've now launched of Critical Appraisal Lowdown course, so if you want to gain some more skills in critical appraisal make sure you go and check out our online course here.
Enjoy!
MDCALC; Framingham Heart Failure Diagnostic Criteria
So the three of us are back together and going to take on Sepsis!
It's vital to have a sound understanding of sepsis. It has a huge morbidity and mortality but importantly there is so much that we can do both prehospital and in hospital to improve patient outcomes.
In the podcast we cover the following;
We hope the podcast helps refresh your knowledge on the topic and brings about some clarity on some contentious points. As always don't just take our word for it, go and have a look at the primary literature referenced below.
Enjoy!
Trial of early, goal-directed resuscitation for septic shock. Mouncey PR. N Engl J Med. 2015
NICE; Sepsis: recognition, diagnosis and early management
NHS E; Improving outcomes for patients with sepsis. A cross-system action plan
Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. Venkatesh B. N Engl J Med. 2018
PHEMCAST; End Tidal Carbon Dioxide
Current clinical controversies in the management of sepsis. Cohen J. J R Coll Physicians Edinb. 2016
RCEM; Severe Sepsis and Septic Shock Clinical Audit 2016/2017 National report
On a not infrequent basis we will come across patients in hospital who have a CT head scan that appears to show an unsurvivable event. Having sourced opinion from our neurosurgical and neurology colleagues we may well be given the advice to withdraw care for the patient.
It has become increasingly recognised that prognosticating in such patients at an early stage is extremely difficult with numerous cases surviving what was initially thought to be an unsurvivable event, with a good neurological outcome.
This joint document from the Intensive Care Society, Royal College of Emergency Medicine, Neuro Anaesthesia and Critical Care Society of Great Britain & Ireland and the Welsh Intensive Care Society gives new guidance for such perceived devastating brain injuries and will challenge many peoples thinking on the topic with additional questions being asked on resource utilisation.
In this podcast Caroline Leech, EM and PHEM Consultant in Coventry, discusses the guidelines and the implications they hold for our practice.
As always make sure you read the document yourself, we would love to hear your thoughts.
Enjoy!
Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement
Welcome back, we've got 3 absolute beauties of papers for you this month!
You'll have struggled not to have heard about the ADRENAL trial, a trial of iv steroids in the sickest of patients with septic shock. We also have a look at a trial that many have been quoting as sound evidence for the utility of pH during the prognostication of patients in cardiac arrest. Finally we have a look at a paper that may shed some concern on the use of Double Sequential Defibrillation that we covered recently on the podcast...
We'd love to hear from you with any thoughts or feedback you have on the podcast. And we've now launched of Critical Appraisal Lowdown course, so if you want to gain some more skills in critical appraisal make sure you go and check out our online course here.
Enjoy!
Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. Venkatesh B. N Engl J Med. 2018
In this episode we cover a paper that you have to know about!
The use of tranexamic acid(or TXA) has become widespread in the case of major trauma and post partum haemorrhage. This time we discuss a recent paper that asks us if giving it within 3 hours is enough, or whether we need to be even more specific regarding its urgency of administration in order to save lives from bleeding.
There is a superb podcast over at our buddies site PHEMCAST which covers an interview with one of the authors and we'd highly recommend listening to that!
Enjoy!
Prehospital Care is evolving rapidly and is one of the most exciting and dynamic specialties to be involved with at the moment.
As a reflection of it's progress the Faculty of Pre Hospital Care held its first scientific conference this week. We were lucky enough to be invited by Caroline Leech, EM & PHEM Consultant and the person responsible for organising this superb event, to interview some of the superb speakers at the event.
Here are the speakers we were lucky enough to catch up with and the topics they discuss
Matt Thomas – Hyperoxia: when oxygen is harmful
Jo Manson – The hyperacute inflammatory response to trauma
Rob Moss – FPHC Consensus Statement - Spinal
Malcolm Russell – FPHC Consensus Statemnent – External Haemorrhage
Tim Nutbeam – Pre-hospital research: what do we not know?
David Menzies – Impact brain apnoea & motorsport
Stacey Webster – Calcium in pre-hospital blood transfusion: the missing link
Rod Mackenzie Injury prevention, control & recovery
A huge thanks to all involved in the conference for having us at the conference and we hope to see you all next year!
Happy New Year!!
Welcome back to the podcast and what we hope will be a superb year. We've got three excellent papers that are extremely relevant to our practice and will have an impact on practice.
First up it's a paper looking at the benefit of iv versus oral paracetamol in the Emergency Department, something we do really frequently but what does the evidence say? Next we have a look at the difference that topical TXA could make to epistaxis in terms of bleeding cessation. Lastly we look at a systematic review looking at adenosine versus calcium channel blockers for SVT.
Very soon we'll be releasing our Critical Appraisal Lowdown course, so keep an eye out for that.
And finally a huge thanks to our sponsors ADPRAC for all of the support with TheResusRoom.
Enjoy!