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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: 2020
Dec 14, 2020

So for decades people have talked about Contrast Induced Nephropathy…or Contrast Induced Acute Kidney Injury, depending on the decade and location of discussion. The theory being that diuresis, increased urine viscosity and changes in vasoconstriction and vasodilation leads to a worsening of renal function following iv contrast administration.

It seems to come from the 1950’s where some patients were seen to develop acute kidney injuries following iv contrast. Now times have changed and treatments and contrasts evolved but the discussion around contrast induced nephropathy continues. At times these discussion can mean that some patients wait for scans in the Emergency Department whilst waiting for blood tests to come back first. But is this the right thing to do?

In this episode we take a look at the origins of contrast induced nephropathy, consider some recent publications on the topic and see how this translates to practice and applications of the most recent guidelines.

Reading around the topic has been hugely informative for us and we hope will be of benefit to you too!

Enjoy

Simon & Rob

Dec 1, 2020

Welcome back to December's Papers of The Month Podcast! Three more papers for you which will challenge and inform you practice.

First up we have a look at a systematic review and meta-analysis which considers the fluid choice in resuscitating those patients with suspected traumatic brain injury in the prehospital setting; should we be reaching for the hypertonic solutions, or is an isotonic fluid such as normal saline adequate?

Next we take a look at a paper that has received a lot of online discussion which looks at the two approaches of antibiotics or surgery for an appendicitis. This is a randomised control trial that looks to answer a question that the literature has dipped into over the last few years, but this RCT goes that bit further and will help give patients a good idea of the pro's and con's of each approach.

Finally we take a look at the UK national approach to oxygenation strategies in those patients receiving a prehospital emergency anaesthetic. How many clinicians provide PEEP, how commonly implemented is apnoeic oxygenation and do we all ventilate through apnoea? Gaining an understanding as to where our practice sits compared to others gives us the opportunity to consider the potential benefits and downsides of various strategies and may help unify practice to more streamlined working and better outcomes for our patients. We also get the opportunity to hear thoughts on the subject from one of the authors Dr. Amar Amshru, Emergency Medicine and and Pre Hospital Doctor in London and with Kent Surrey and Sussex Air Ambulance.

Enjoy!

Simon & Rob

Nov 16, 2020

Welcome back to the podcast!

In this episode of Roadside to Resus we're going to take a look Anaphylaxis, which has been highlighted on a national level of concern as NICE state ‘many people do not receive optimal management following their acute anaphylactic reaction’.

Much of the problem lies within a lack of understanding of what actually constitutes an anaphylactic reaction and the knock on effect this has to the treatment provided.

In this episode we'll explore the definition of anaphylaxis and the significant differences that can be seen in the presentation. We have a a think about the pathophysiology and reasons behind the variance in presentations and how this affects the importance of treatments available and their relative importance.

Anaphylaxis is known to have a a number of patients who have a biphasic reaction, it predicates the need to convey patients to hospital and a period of observation; however the frequency and severity of these biphasic reactions can help to inform this further and for that reason we take a look at the literature on it.

We've covered angioedema before in a separate episode, but we briefly cover the similarities and differences and how this affects management.

Lastly we cover the follow up and management that these patients require.

We'd love to hear any comments or feedback you have and make sure to take a look at the references and resources below.

Enjoy!

Simon, Rob & James

Nov 1, 2020

Welcome to November’s papers of the month podcast!

This month we kick things off looking at TXA in trauma and consider in complex scenes and resource limited environments if TXA could be administered effectively in an IM rather than IV route? We also get an authors inside view from Professor Ian Roberts.

Next up; does the anatomical location of a head injury affect the risk of an intracerebral bleed and could this affect those patients that can go without a scan?

And finally we have a look at the importance of a chest X-ray in COVID-19 and consider how accurate the X-ray is at both picking up and ruling out the infection.

Enjoy!

Simon & Rob 

Oct 15, 2020

So in our Toxidrome Roadside to Resus episode we covered the initial management of a poisoned patient, some of the constellation of features to look out for and the specific management. But what about specific agents and circumstances that require particular knowledge and management both in the prehospital environment and in ED?

Well in this episode we’ll cover these by running through;

  • Paracetamol poisoning and treatment
  • Calcium channel blocker overdose
  • Beta blocker overdose
  • High dose insulin euglycaemic therapy
  • Activated charcoal
  • Intralipid therapy
  • Cardiac arrest due to toxicology

We'd love to hear any comments or feedback you have and make sure to take a look at the references and resources below.

Enjoy!

Simon, Rob & James

Oct 1, 2020

Welcome back to the Papers of the Month podcast, once again we've got 3 more papers to inform, discuss and hopefully improve our practice.

First up we have a look at a paper which looks to quantify the prognostic utility of lactate in our sick Resus patients; we often look at the initial lactates and draw conclusions for what they mean, but this paper helps us understand the results a bit further.

For our patients that sustain a head injury, the NICE guidelines advocate that all patients on direct oral anticoagulants should have a CT head scan, irrespective of clinical findings or other high risk features of the patients history. Quantifying the risk that these patients have for an intracranial bleed is really important, as to date it isn't fully understood. Our second paper looks at this directly and can help inform practice, guidelines and discussions with patients.

Finally; we often think about how we can improve resuscitation of our patients in cardiac arrest, look for the latest treatment and evidence, but it can be easy to overlook how our actions can significantly affect their loved ones who may be present at this time. We take a look at a fascinating study looking at the impact of inviting patients in to witness the resuscitation in its entirety and the effect that this has in regards too PTSD. In our opinion this paper holds a huge amount to think about and is a game changer!

Finally keep an eye out for our CPD portal and app which is in the final stages of testing and will be out very shortly!! We'll be keeping you up to date on twitter @TheResusRoom with its launch

Enjoy!

Simon & Rob

Sep 15, 2020

Drug ingestion both accidental and intentional accounts for a significant proportion of attendances at UK Emergency Departments and 999 calls.

In 2016 there were >2,500 registered deaths in England and Wales related to drug misuse, which had increased by nearly 60% in a decade.

So without a doubt we are all going to come across critically unwell patients with drug ingestions. But inappropriate drug use is not confined to illicit substances, with many prescription drugs being misused to ill effect and also overdosed in an attempt to end patients lives.

In this podcast we’re going to run through the assessment of patients presenting with a possible drug ingestion, cover the potential toxidromes you may encounter and talk about the management of these presentations. Specifically we take a look at serotonin syndrome, sedative toxidrome and both cholinergic and anti-cholinergic syndrome.

In next months Roadside to Resus we'll take a look at specific medications of overdose; paracetamol, beta blockers, calcium channel blockers and the intricacies of their management along with other key parts of critical care including the management of cardiac arrest due to toxicity.

Make sure to take a look at the references and resources below.

Enjoy!

Simon, Rob & James

Sep 1, 2020

Welcome back!!

So we've had a small summer hiatus and are now back with another Papers of The Month and a jam packed line up of episodes for the rest of the year!

We start off this month with a paper which looks to evaluate if there is any benefit on mortality with the use of checklists for endotracheal intubation.

Next up we take a look at the factors in cardiac arrest that are most important with regards to prognostication; what should your attention and handover be most focussed upon?

Finally we take a look at a paper suggesting that blood gases following ROSC can help us prognosticate for our patient and how this might this affect our practice.

Finally keep an eye out for our CPD portal and app which is in the final stages of testing and will be out very shortly!! We'll be keeping you up to date on twitter @TheResusRoom with its launch

All references can be found on our webpage at TheResusRoom.co.uk

Enjoy!

Simon & Rob

Aug 1, 2020

So this is our last episode before a small summer hiatus, so it better be a good one!

Journals are littered with some great articles at the moment, so we've chosen 3 great papers that cover a number of really important EM topics.

Over the last few years more emphasis has been put on a more conservative management on pneumothoraces and following that trend we take a look at a paper evaluating the safety of using a small bore chest drain for the delayed management of haemothoraces, compared with large bore.

Next up we take a look at the Injury Severity Score and how well it correlates with the need for life saving interventions in trauma.

Lastly there is another great paper on the management of acute atrial fibrillation; comparing electrical cardioversion with the potential use of procainamide prior to shocking. Does it result in fewer patients requiring a shock, and when it comes to the shock is AP pad positioning more effective that anterolateral?

We'll be taking a small break over the summer and will be back in September for our next Papers Podcast and keep an eye out for the launch of our FREE CPD app and web platform this summer.

Enjoy!
 
Simon & Rob
 

 

Jul 20, 2020

The more you delve into cardiac arrest, the more it seems that delivering the essentials well is the key to great outcomes; timely recognition, high quality chest compressions, with early and appropriate defibrillation.

But is ultrasound in cardiac arrest a layer that we should all be adding in as a standard. It holds the potential to not only prognose outcomes from cardiac arrest, both medical and traumatic, but also to add a level of diagnosis of potentially reversible causes.

In this podcast we chat through the evidence surrounding ultrasound in cardiac arrest and consider the practicalities of application during delivery of patient care.

Make sure to take a look at the references and resources below.

Enjoy!

Simon, Rob & James

Jul 1, 2020

There are more great pieces of research to enjoy this month!

We start off with a paper following on nicely from our Roadside to Resus episode on Stabbing, which looks at the ability of prehospital providers to predict whether stab injuries penetrate to deep structures, or are purely superficial from clinical assessment.

Next up we take a look at a paper using high sensitivity troponin and their limit of detection, to assess whether we could be safely discharging patients earlier from the emergency department.

Finally we have a look at the results from the RECOVERY group on dexamethasone use in COVID-19, have we got a treatment that can help improve survival in patients admitted with the virus?

We'd love to hear any thought or comments you have either on the website or via twitter @TheResusRoom.

Enjoy!

Simon & Rob

Jun 18, 2020

Tranexamic Acid (TXA) has gained a significant amount of attention over the last few years as multiple studies have shown it's utility in decreasing haemorrhage and associated mortality. It has become part of major trauma guidelines, post part haemorrhage protocols and many have adopted it to the management of traumatic brain injury. The findings have been very similar across a spectrum of haemorrhage disease processes and from this further interest in expanding TXA's application to pretty much anything that bleeds. Time from onset of the bleeding has been shown to be important, with it's effect decreasing from time of onset to its administration.

Gastro-intestinal bleeding is a significant cause of morbidity and mortality. Previous meta-analyses have shown favourable outcomes for TXA in GI bleeds and many have already adopted TXA into this area of practice, although guidance from NICE does not yet recommend it.

HALT-IT is a multi centre, international, randomised double blind controlled trial of near 12,000 patients that has just been published in the Lancet. The study was a huge piece of work and looks to definitively answer the question of whether we should be giving TXA to patients with life threatening GI bleeds. In this podcast we run through the ins and outs of the paper ad are lucky enough to speak to the lead author Ian Roberts about the findings, some of the intricacies of the trial and what the results mean for practice.

Enjoy!

Simon, Rob & James

 

Jun 1, 2020

Welcome back to June’s Papers Podcast!

Traditionally when you’re taught about working a patient up for a potential diagnosis you’ll find a list of signs, symptoms and tests that you need to perform in order to obtain your diagnosis. What that teaching doesn’t tell you is how important each of those aspects is and this month we take a deeper look at this for pneumonia. We look two papers, one focussing on the clinical findings both in signs and symptoms and then a further paper on the importance of biomarker in the diagnosis.

We also have a look at a paper which focusses on decreasing time on scene for prehospital patients and the potential benefit of regular time prompts, an idea that may be applicable irrespective of your place and role of work.

We’d love to hear any thought or comments you have either on the website or via twitter @TheResusRoom.

Enjoy!

Simon & Rob

May 25, 2020

Transfers of patients happen all the time. It's easy to think about transfers as only those that involve an ambulance and moving patients from one hospital to the next, but in reality it's far more extensive than that. We all move patients all the time, whether that be the unwell patient in the upstairs of their house to the ambulance, the patient in the Emergency Department to the CT scanner or another ward, or the more traditional interhosptal transfer.

Transfers of patients are inherently high risk times for the patient and having some background knowledge on transfers and a structured approach helps us ensure the best possible care for our patients. In this episode we run through transfers with the help of an expert on the topic, Scott Grier a Consultant in Intensive Care Medicine and Anaesthesia at Southmead Hospital in Bristol, the South West Critical Care Network Lead for Transfer, and a PreHospital Critical Care Doctor with GWAAC.

Enjoy!

Simon, Rob and James

May 1, 2020

Welcome to May's papers of the month podcast. Hope you are all well and keeping safe.

This month James joins Simon to discuss some of the great work published following the London Trauma Conference, all available in the hyperlinks on the website.

First up we have a look at the incidence of prehospital hypotension and hypoxia in patients with suspected traumatic brain injury and the ways in which we might look to mitigate against these complications. Next we have a think about end-tidal CO2 levels and the correlation between these and arterial CO2 readings and discuss what the findings might mean for our practice. Finally we have a look at the incidence of hyperoxia in patients receiving a prehospital emergency anaesthetic in the context of trauma, and consider the effect this might have on our patients and again practice.

We'd love to hear any thought or comments you have either on the website or via twitter @TheResusRoom.

Enjoy!

Simon & James

Apr 20, 2020

Fractures of the pelvis are found reasonably often in major trauma, but they’re a really challenging presentation. They are difficult to assess and accurately diagnose in the prehospital setting, mortality rates are high, particularly in patients with haemodynamic instability and there are often associated injuries. Associated mortality from patients with pelvic fractures who reach hospital is reported to be up to 19%, with mortality rates as high as 37% reported in the presence of haemodynamic instability.

In this episode we'll run through pelvic injuries, all the way from anatomy and mechanisms of injury, to assessment and management.

As always make sure you have a look at the references and supporting material attached in the show notes, and get in touch with any questions or comments and take care of yourselves.

Enjoy!

Simon, Rob and James

Apr 10, 2020

So COVID-19 has produced a multitude of challenges to healthcare providers, the response to these challenges has been phenomenal.

One uncertainty is the strategy we should employ for hypoxic respiratory failure and several high quality guidelines have presented conflicting advice for the severely hypoxic patient.

The Warwick Clinical Trials Unit has already begun recruiting patients to their RECOVERY-RS trial, which is open for hospitals in the UK to sign up for. This looks at 3 different strategies of respiratory support for patients admitted with suspected or known COVID-19 and hypoxia; namely CPAP, High-flow nasal oxygen and standard care. The trial is funded by the NIHR and supported by the Intensive Care Society.

In this episode we get a chance to speak to Bronwen Connolly, one of the investigators of the RECOVERY-RS trial; we discuss the background evidence, the trial design, and when results will be available.

As always we’d love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the protocol yourself.

Enjoy!

Simon, Rob & James

Apr 1, 2020

First we hope you're all well. The world has changed dramatically over the the last few weeks and you are all doing a phenomenal job of providing healthcare under extremely challenging circumstances.

We are determined to add a bit of normality to life with a non-COVID-19 papers of the month, full of bad jokes and some EBM. This month we're looking at intubation of acute alcohol intoxication in ED. We take a look at a paper that tries to quantify the risk of patients developing an intracerebral injury when taking antiplatelets and anticoagulants. Finally we have a look at the value of clinical examination and imaging findings in patients with elevated intracranial pressure, how valuable are individual findings?

Most importantly take care of yourselves and loved ones and keep fighting the good fight!

Simon & Rob

Mar 17, 2020

Excellent practice is led by following the high quality evidence based medicine, and there have been a lot of great papers published in the last 12 months!

We were kindly invited to the Faculty of Pre Hospital Care Annual Scientific Conference to give a talk on the top 10 papers over the last year.

Sadly, but completely understandably, the conference had to be cancelled due to COVID-19. In this podcast we cover the talk which is based on 2 cases that are common to PHEM;a major trauma and a cardiac arrest, and discuss how we can optimise outcomes for our patients in view of the recent evidence on these areas.

As always we’d love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions.

Enjoy!

Simon, Rob & James

Mar 1, 2020

We've got a great spread of topics for you this month, stretching all the way from Prehospital Critical Care, to core Emergency Medicine topics.

Those of us seeing 'non-specific' complaints will appreciate how difficult they can be to diagnose and manage effectively. We have a look at a paper that helps characterise this group and give some context to their mortality risk. This may well help inform conversations and decision making with this patient group.

Recent literature has looked at a more conservative management for traumatic pneumothoraces, but what about those that are spontaneous? The British Thoracic Society has guidelines for how we should deal with them but a recent RCT in the New England Journal of Medicine looks at an even more conservative approach for our patients; can we decrease the number of aspirations and drains that we are performing?

Finally we've covered recently a paper on the topic of Prehospital Critical Care on the outcomes for patients in cardiac arrest, in this episode we have a look on their impact in trauma patients and hear from the lead author Ali Maddock on the implications of the study's findings.

Enjoy!

Simon & Rob

Feb 14, 2020

Figures for the year ending September 2019 showed a 7% rise in offences involving knives or sharp instruments recorded by the police (to 44,771 offences). This is 46% higher than when comparable recording began (year ending March 2011) and the highest on record. 

The news is sadly littered with cases of knife crime and terror and whilst we may have thought of stabbings as confined to small pockets of the country, sadly it now seems that we all have or all will be dealing with such cases.

The variability in injury and severity is vast from stabbings, however in extremis they are completely time critical, and striking the balance between performing only those life saving interventions on scene, during transport and in ED and getting to the final destination of theatre as quickly as possible.

In this podcast we discuss our thoughts on dealing with these cases; from the moment we get that call, all the way through to getting them into theatre.

As always we’d love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions.

Enjoy!

Simon, Rob and James

Feb 1, 2020

Welcome back!

Three very different topics and papers for you this month. First up we have a look at the risk/benefit of sending troponins on patients aged 65 years an older when presenting with non-specific complaints; does this help their work up, or is this a classic case of over-testing?

Next up we take a look at the causes of our patients presenting to the ED with a reduced level of consciousness, this paper may help inform your differentials and knowledge on the likelihood of different pathologies.

Finally, following on from our recent Roadside to Resus episode on Seizures, we take a look at an RCT which compares 3 second line anti epileptics; will this give us the definitive answer over which we should be using?

Once again we would love to hear you comments and feedback, and make sure you check out the articles yourselves and come to your own conclusions.

Enjoy

Simon & Rob

Jan 15, 2020

Seizures are defined as a “paroxysmal electrical discharge of the neurones in the brain resulting in a change of function or behaviour”. All of us involved in Emergency Care will encounter patients with seizures which can occur for a number of reasons, with Epilepsy affecting 1 in 100 people in the UK.

Being able to identify the cause, terminate ongoing seizures and provide ongoing investigation and care is complicated and of paramount importance, as some of these episodes carry with them a high morbidity and mortality rate.

In this episode of Roadside to Resus we run through the following;

  • The scale of the problem
  • Causes of seizures
  • Definition of status epilepticus
  • Different forms of seizures
  • Clinical assessment
  • Investigations
  • Antiepileptic’s
  • Management& guidelines; both Pre and In-hospital
  • RSI for status epilepticus
  • Follow up and guidance

As always we’d love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions.

Enjoy!

Simon, Rob & James

Jan 1, 2020

Happy New Year!!

We hope you've all had a great Christmas and New Year and that you managed to get some well earned time off over the festive period. 

2019 saw us publish more insights from lead authors of the latest and most influential studies in Emergency Medicine and Critical Care, and we're really excited to say that we'll be delivering you even more in 2020 with some excellent RCTs, international guidelines and much, much more!

This month we've got 3 papers to challenge practice across a wide array of practice. We start off with a paper that evaluates if we can change our d-dimer thresholds in suspected PE's and how many unnecessary work ups and scans that might decrease. Next, following on from our previous Hypothermia podcast, we have a look at a paper which looks at the best rewarming rates in patients with hypothermia, which may change your rewarming strategies.... Finally we have a think about our use of CT scanning in patients who gain a ROSC after cardiac arrest, and consider what benefit full body CT scanning might bring.

Thanks to all of you for your support with the podcast over the last year and we look forward to bringing you some great stuff in 2020!

Enjoy

Simon & Rob

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