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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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Jul 1, 2024

There's a huge paper to talk about this month in the PREOXI trial, a multi centre RCT looking at the pre oxygenation strategy in critically unwell patients undergoing RSI, with patients either getting high flow oxygen through a facemask or NIV. The results are pretty remarkable and may well be practice changing as we'll discuss in the podcast!

Next up we take a look at a feasibility of lidocaine patches for older patients with rib fractures and the potential benefit in terms of pain and respiratory complications.

Lastly we take a look at the benefit of performing a CT head scan in the Emergency Department for patients with a first fit. At times this can feel like a significant utilisation of resources, but what is the yield of positive scans and impact on patient care?

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

Jun 18, 2024

So this month we’re looking at major incidents and specifically the triage process that is now coming into play in the UK and further afield that you need to know about!

We normally stick pretty strongly to clinical topics; they’re pretty easy to focus on because you can imagine how extra knowledge in a certain clinical area could make a difference to presentations that we see pretty commonly. And being brutally honest, making the effort to prepare and rehearse what we might do, on the off chance that we ever come across a major incident, can be difficult to motivate yourself to do.

But this is probably an area that investing a bit of time in, really thinking about how you would act in a major incident, could make a phenomenal difference to what may be one of the most, if not the most challenging clinical days of your career.

In the episode we run through Ten Second Triage (TST) and the Major Incident Triage Tool (MITT). They replace the previous triage methodologies and are to be implemented by the end of this month. We also cover some other aspects of planning and approach for being the first responder at a major incident, and we were lucky enough to gain some insights to the new triage process from Phil Cowburn, an EM & PHEM consultant who was involved in their development.

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

Jun 1, 2024

Welcome back to June's Papers of the month!

We kick off this month looking at the work up of patients with a first episode of psychosis. With these patients there is a chance of a psychosis secondary to an underlying structural cause. Getting neuro-imaging to look for this prior to psychiatric assessment is tricky though, often with a need for sedation and then the subsequent delay for psychiatric assessment. Our first paper looks at the yield of positive scans for these patients and helps us to understand a bit more about the need for this.

Secondly; sepsis screening tools are commonplace in most emergency services and departments, but how do they compare against senior clinician gestalt?

Finally we look at the association of gastric distension in cardiac arrest and the rates of ROSC, should we be concentrating more on decompression of gastric volume intra-arrest?

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

May 15, 2024

We’ve covered Cardiac Arrest management (as in the medical delivery of it) in a previous Roadside to Resusepsiode. Since then we've had some updates with Paramedic-2, Refractory VF, Airways-2  and a whole host of other papers. But what we haven't talked much about is the art of creating the environment, space & workflow to deliver the best medical care possible. 

Whilst these might seem like less exciting and important parts of the package, they probably require a greater degree of skill and knowledge than running the medical aspects of the arrest. To do them with excellence you need to anticipate every single objective/obstacle that could stand in your way, including the medical interventions involved and the challenges of that unique case and environment. 

In this episode we run through the aspects of a cardiac arrest right from the initiation of the case to the clearing/transfer to onwards care. We talk about the use of immediate, urgent and definitive plans and then run through how these translate into both in-hospital and prehospital arrests.

We personally got a lot out of preparing and thinking about this episode, so we hope you find it useful too!

We’d love to hear any thoughts or feedback on this slightly different style of episode either on the website or via X @TheResusRoom!

Simon & James

May 1, 2024

Welcome back to the podcast and three great papers for May's episode!

First up we take a pretty deep look into refractory VF. This follows on from our our review of DOSE-VF in December '22's papers of the month and our recent Roadside to Resus on the topic. In that we discussed the possibility that many of the cases we see at pulse checks as being refractory VF may actually have had 5 seconds or more, post shock, where they jumped out of VF but then reverted back into it. This paper is a secondary analysis of DOSE-VF and reveals what really happen to these 'refractory VFs' by interrogating the defibrillators. What difference will it make to our strategy for recurrent and refractory VF?

Next up we take a look at elderly patients presenting to the Emergency Department with abdominal pain with an analysis of the features that predict a serious abdominal condition.

Lastly we look at the how different pressures exerted to the facemask when ventilating neonates can make in terms of bradycardia and apnoea.

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

Apr 15, 2024

Lower back pain is a really common cause for patients to present to primary care, urgent care and emergency care.

Thankfully many of these cases are self limiting, but somewhere in the region of 1:300 patients with back pain in the ED will have Cauda Equina Syndrome.

Cauda Equina Syndrome is something that is challenging for all clinicians because many patients with simple lower back pain may have many similar symptoms,  but if we miss it, or if there is a delay to surgery that can lead to potentially avoidable long-term disability for our patients and on top of that its a major cause of healthcare litigation.

And we’re not talking about a delay in weeks being a problem here, we’re talking about hours to days, with big  potential complications like impaired bowel/bladder/sexual dysfunction or lower limb paralysis - so you can see why litigation is a big part of some missed cases.

In this episode we run through the the signs, symptoms, investigations and treatment with a strong reference back to the underlying anatomy and disruption.

We also cover the recently published national Cauda Equina Pathway, which is a great resource but poses some real challenges in it’s implementation!

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

Apr 1, 2024

Welcome back to the podcast! Three more papers covering topics that are relevant to all of our practice.

The importance of removing wet clothes from patients is often discussed, both to prevent hypothermia and increase patient comfort. But how important is it to get wet clothes off and is it something we can defer to a different point? We start off taking a look at an RCT on this very question.

Next up another RCT, this time looking at the efficacy of morphine, ibuprofen and paracetamol for patients with closed limb injuries. Which one, or combination, would you think would be most efficacious…

Lastly, following on from our most recent Roadside to Resus episode, we take a look at a paper on the association between end tidal CO2 levels and mortality in prehospital patients with suspected traumatic brain injury. This paper highlights really well the need understand the fundamentals that contribute to ETCO2 when applying to clinical practice. 

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

Mar 14, 2024

End Tidal CO2, or ETCO2 for short, is something that’s talked about pretty often in Emergency and Critical Care and that’s because it’s used a lot in the assessment and treatment of patients!

It’s got a big part to play in airway management, resuscitation, sedation and is also increasingly used in other situations. Some of these applications have some pretty strong evidence to back them up but others are definitely worth a deeper thought, because without a sound understanding of ETCO2 we can fall foul of some traps…

ETCO2 is a non-invasive measurement of the partial pressure of CO2 in expired gas at the end of exhalation. Ideally we’d like to know what’s really going on arterially with the partial pressure of arterial CO2 but we can use the end tidal because that’s an easy reading to get from exhaled breath, when it will most closely resemble the alveolar CO2 concentration.

Its value is reflective of ventilation but also really importantly is affected by the circulation, the circuit and how it’s applied. In the podcast we run through all of these aspects, its application to clinical care and also some of its pitfalls. 

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

Mar 1, 2024

Welcome back to the podcast, a new month, three more papers and discussion around the topics.

We kick off with a paper comparing mechanical ventilation in CPR compared to the more traditional hand ventilation; what difference does the machine make to ventilation in arrest and should we be changing to this strategy as a standard?

We've talked about aneurysmal subarachnoid haemorrhage a fair amount on the podcast and the second paper looks at the effectiveness of lumbar CSF drain compared to standard care with some pretty staggering results!

Lastly we take a look at a paper exploring decision making in prehospital trauma, specifically with regard to blood transfusion. This is a great paper to focus on the complexities of decision making, understand decision making strategies, recognise areas of weakness and consider how aspects of these can be used educationally and to improve emergency care for our patients.

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

Feb 14, 2024

As we all know, rapid and effective resuscitation makes a huge difference to the chance of survival from a cardiac arrest.

If you’re going to pick a rhythm to have as the patient or as the Resuscitationist, then it’s going to be a shockable rhythm, so VF or pulseless VT as they hold the greatest chance of survival. You'll find an initial shockable rhythm in around 20% of cases & defibrillation alone may lead to a ROSC. So it’s absolutely imperative to get the immediate management spot on!

Whilst current practice is good, there are some aspects of care that we can improve on and make a real difference to outcomes in these patients, with those first on scene or at the bedside in a phenomenally important position to deliver life saving care.

In this episode we’ll be talking predominantly about refractory VF but the strategy will transfer to how we can also deal with refractory VT cardiac arrests. 

We'll be running through all of the following;

  • VF incidence
  • Mechanisms behind VF
  • Refractory and recurrent VF
  • Defibrillation strategies
  • Pharmacological strategies
  • PCI in arrest
  • ECMO

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

Feb 1, 2024

Welcome back to February's papers of the month.

Syncope is a really common presentation to the Emergency Department and it can be complicated to tease out those with a concerning precipitant from the others with a more benign cause. The first paper gives us some context to the management of these undifferentiated syncopes and provides a barometer for how stringently ESC guidance on the topic is followed.

Next up we take a look a huge RCT of transfusion thresholds in patients presenting with a myocardial infarction. Should we be restrictive in our approach, saving a valuable resource, or is it validated to transfuse more liberally in terms of the patients outcome?

Finally we take a look at a paper looking to tease out the predictors of post intubation hypotension in those getting a prehospital anaesthetic following trauma, with some interesting associations and factors to looks out for.

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

Jan 15, 2024

Fever is an incredibly effective mechanism to fight off pathogens.

Clearly, whilst many illnesses that cause a fever don’t require anything more than the body’s natural response, there are some patients in which a fever might represent a serious illness. Differentiating those serious illnesses from self-limiting presentations can be tricky at times, but can also be anxiety provoking for clinicians and parents, or carers of that child. 

In children the limited communication can make the diagnostic challenge of the origin of the fever a real challenge, along with the added difficult of gaining some tests. Differentiating those with a benign disease from those with a life threatening presentation can be a daunting challenge.

The numbers of presentations to healthcare providers are staggering. Paediatric fever has been reported to represent as high as 15-25% of all presentations in primary care and emergency departments, so massive numbers. Thankfully the prevalence of serious infections in children is low and is estimated at <1% in primary care settings in industrialised countries, although it has been suggested that for ED attendances the prevalence of serious illness could be as high as 25%.

So we thought with this common but tricky presentation that it was about time we tackled the topic. We'll be running through;

  • A definition
  • Patholphysiology
  • Relevance of the severity of the fever
  • Febrile seizures
  • Clinical assessment
  • NICE guidelines
  • Duration of fever
  • Management
  • Antipyretics

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

Jan 1, 2024

Happy New Year!

We've got some great topic and in person events lined up for 2024 which we'll be able to share some more details about with you soon.

This month we look at an RCT of conservative airway management in patients with a low GCS following presentation with acute poisoning.

Next up we take a look at paper reviewing our diagnostic ability with dissociative seizures; this gives us some really valuable signs and symptoms to looks for and outlines how we can improve with these presentations.

Lastly we look at prognostic scores following out of hospital cardiac arrests with a study that compares four different scores. If reliable they have significant scope to help us to both prognosticate and give valuable information to family and loved ones on their presentation to ED.

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

Dec 14, 2023

We know it's the festive season but we thought we’d try and cover an issue from which there appears to be no escape and is a particular problem at this time of year, queuing!

Whether we like it or not, this has become a factor for all of us working in emergency care, whether its delays getting your patient into the department, queueing down the corridor into ED, a prolonged stay in ED for an appropriate ward, or even in a physical queue to get out of the ED and onto an appropriate bed!

We are looking after our patients for significantly longer than we’re used to and this pushes the patient and the clinician into an area of care in which we have limited experience and comfort.

Rather than accepting delays and ignoring their inevitable impact on patient care, we need to move towards equipping ourselves with the skills and knowledge to fill that care vacuum and ensure that excellence in patient care continues throughout their time with the ambulance service.

So with that in mind, in this episode we’re going to think about some of the considerations and interventions that are required to ensure our patients remain safe and comfortable throughout their queueing experience. And to do that we’re going to draw on the concept of prolonged field care.

An article by Aehbric O’Kelley and Tom Mallinson recently authored a paper published in Journal of paramedic practice entitled “Prolonged field care principles in UK paramedic practice”. That article really provided the idea and stimulus for this episode, so thanks to them for all of the hard work and once you’ve listened to us waffle on you should head across to their paper for a far more eloquent explanation of it all!

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

Dec 1, 2023

We've talked about Aortic Dissection before in our Roadside to Resus episode and the huge difficulties in picking out these rare but potentially devastating cases and this month we've got a fantastic paper on the topic! The DAShED study looks at patients presenting with symptoms that could be suggestive of aortic dissection and helps us understand the diagnostic challenge and approach to acute aortic syndrome, along with testing the characteristics of a number of decision tools.

Next up we look at a paper from Bendszus, an RCT of medical versus thrombectomy and medical treatment for acute ischaemic strokes with a large infarct, with some really powerful results.

Finally we look at a paper that shows some staggeringly different ROSC rates for patients in cardiac arrest depending on the size of the ventilation bag used!

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

Nov 15, 2023

Blood gases are really commonly used in ED, Critical Care, Respiratory Medicine and Prehospitally. In fact, you’d do well to walk 10 meters in an ED without being given one to sign off! But it’s for good reason, because they give you additional information about what’s going on from a respiratory and metabolic perspective in the patient.

And it’s probably worth mentioning at this point, this episode is going to be pretty ‘science-heavy’, there should be something in here for everyone; from the clinician that's been looking at these things for the last 30 years, to those that haven't started interpreting gases.

So arterial blood gases can tell you about the efficacy of the patients ventilation in terms of their partial pressures of oxygen and carbon dioxide levels and also from a metabolic perspective about other disorders of their acid-base balance. 

In the episode we'll be covering the following;

-Overview of blood gases

-Respiratory & metabolic sides of the gas

-Acidaemia

-Alkalaemia

-Bicarbonate or base excess?

-Compensation

-Oxygenation

-Anion gaps

-System of interpretation

-Venous gases

-Clinical application & examples of interpretation

We'll be referring to the equation listed on our webpage, so make sure you go and have a look at that and all the references listed.

Once you've listened to the podcast make sure you run through the quiz below to consolidate the concepts covered with some more gas examples and of course get you free CPD certificate for your TheResusRoom portfolio!

Once again we'd love to hear any comments or questions either via the website or social media.

Enjoy!

Simon, Rob & James

Nov 1, 2023

Well this has been a huge month for Emergency Medicine and Critical Care in terms of papers!

We start off looking at REBOA; many resuscitationist's favourite concept or device with the much awaited UK-REBOA trial. What does the paper mean for practice in our Resus Rooms? Is this about to become a key part of trauma management? The paper is fascinating and one of the most though provoking we've discussed in a while.

Next up we look at CROYSTAT-2, another such anticipated trial looking at whether survival could be improved by administering an early and empirical high dose of cryoprecipitate to all patients with trauma and bleeding that required activation of a major hemorrhage protocol.

Finally we look at a paper which describes a taxonomy of key performance errors in intubation and may inform our review and improvement of intubation in the ED.

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

Oct 16, 2023

In this episode we’re going to cover the ‘atraumatic’ or ‘spontaneous’ pneumothoraces and focus on some new key guidelines from the British Thoracic Society which came out in July this year and also look at the relevant evidence on the topic.

There are pretty significant changes in the BTS guidance, it’s no longer about finding a pneumothorax, working out if it’s primary or secondary and then acting dependant on the size. It's now moved more towards looking at how the patient is clinically, taking into account the symptomatology, any big risk characteristics, whether it’s primary or secondary and then thinking about the patients wishes and priorities and nuancing the management plan towards those. 

This episode builds on some of the concepts we discussed in our Traumatic Pneumothorax podcast, so make sure you give that one a listen before clicking play on this one!

We'll be looking at the presentation, evidence, management and follow up, along with some trials that you can get involved in to help develop practice even further.

Once again we'd love to hear any comments or questions either via the website or social media.

Enjoy!

Simon, Rob & James

Oct 1, 2023

Welcome back!

This month we kick off looking at an RCT which looks at whether we should convey patients with a ROSC from a likely cardiac cause (without a STEMI in their ECG) to a cardiac arrest centre, or whether they would be as well served at their local Emergency Department. This paper has huge potential implications for service design for cardiac arrest patients.

Next up we look at another RCT evaluating if patients with a suspected uncomplicated appendicitis who have urgent surgical intervention benefit in terms of a reduced perforation rate, when compared with those who have surgery within 24 hours.

Lastly we take a look at the use of bicarbonate, calcium and magnesium in cardiac arrest and see if there use is supported in a huge cardiac arrest registry.

Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

Sep 19, 2023

Delivering excellent End of Life Care in the Emergency Care is a real challenge but also a huge privilege and has formed some of the most rewarding parts of our careers to date.

We've been really keen to End of Life Care as a topic for a while now. Many, if not all of you, will have been out to these patients or received them in your ED. 

They aren’t simple cases to manage, with lots of issues around scope of practice, lack of alternative care pathways, confusion surrounding legal documentation and many studies have identified a lack of education around palliative care.

In this episode we’ll do our best to demystify those medico-legal terms, talk about care pathways and options that may be available to us, have a think about how we can talk with patients about death and then go on to discuss the clinical care we might need to deliver and the wider holistic nature of caring for these patients and their loved ones.

We're lucky enough to be joined by Ed Presswood, who's a palliative care consultant and clearly an expert on the topic. We gained a massive amount from this episode and we hope you find it really useful too.

You'll find the hyperlinks to some fantastic resources on the topic over on the webpage at TheResusRoom.

Once again we'd love to hear any comments or questions either via the website or social media.

Enjoy!

Simon, Rob & James

Sep 15, 2023

Welcome back to the podcast, coming to you all the way from Australia!

Rob and James were fortunate enough to be invited to deliver the keynote and an airway masterclass at this year's Australian College of Paramedicine International Conference.

At what was an amazing meeting, they were lucky enough to be able to catch up with some of the fantastic speakers to hear the key parts of their talks. In this episode you'll hear from;

Richard Armour, Mobile Intensive Care Ambulance Paramedic at Ambulance Victoria and PhD Candidate at Monash University; Identifying patients requiring chest compressions at overdose prevention sites

Nick Roder, MICA Flight Paramedic Educator, Ambulance Victoria and Teaching Associate, Monash University; Intubation in the setting of airways and inhalation burns

Dr Tegwyn McManamny, Intensive Care Paramedic and Lead Patient Review Specialist, Ambulance Victoria; Care of the Older Person - Delirium and Paramedic Detective

Olivia Hedges, Palliative Care Connect Lead, Ambulance Victoria; Palliative Care Connect Program

Chelsea Lanos, Advanced Care & Community Paramedic Researcher; Organ donation after out-of-hospital cardiac arrest in Canada - a potential role for paramedics

A huge thanks to ACP for the invite, Zoll for the support of the podcast and conference and to the fantastic speakers for giving ip their time to talk to us. We'll be back with another Roadside to Resus episode for you next week on End of Life Care.

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom and we'll see you back in September!

Rob & James

Sep 1, 2023

Welcome back to the podcast!

We're back with three really interesting papers after our summer break, with some great points to think about with regards to our practice and patient outcomes.

First up we take a look at the CT FIRST study which looks at the benefit of whole body CT in patients presenting with a ROSC after their out of hospital cardiac arrest with no obvious cause. Should we be more liberal in our imaging requests in this patient cohort?

Next up we have a think about thrombolysis for massive PEs. When it comes to these patients we have to consider the very real potential complications of thrombolysis and that can often dissuade us from treating them. This paper looks at an alternative dose in thrombolysis and describes some really interesting results.

Finally we take a look at a CT study which is scanning trauma patients after they have died. What injury patterns do they find, which injuries would have been amenable to treatment and are there any lessons on practice to be learnt?

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom and we'll see you back in September!

Simon & Rob

Aug 1, 2023

Welcome back, this is our last podcast before our short summer break!

We start off having a look at the physiological effects of prolonged resuscitation with a supraglottic device compared with endotracheal intubation, which raises some really interesting questions about our ongoing ventilation strategy in resuscitations.

Next up we look at an RCT comparing RSI to DSI in critically injured patients and the effect on peri-intubation hypoxia.

Finally we take a look at the practice of lateral canthotomy for retrobulbar haemorrhage/orbital compartment syndrome. How effective is the procedure and how competent are EM clinicians compared to Opthalmogists?

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom and we'll see you back in September!

Simon & Rob

Jul 14, 2023

So in this episode we’re going to run though the primary survey in trauma. This clinical assessment helps us identify and treat life threatening injuries and to rapidly intervene and correct them, so getting it right really matter1. 

How this is done is hugely dependant upon the setting (either pre or in-hospital) as it is affected by the access to the patient, the number of people there to contribute to care and the challenges that the scene or hospital environment might hold.

We run through a model of primary survey that looks to gain as much information as possible in a rapid and effective pattern and discuss the slightly different approaches we all take, along with  rationale behind them.

Finally we cover the communication of the primary survey to the team, strategies that we can undertake to achieve this and how this can affect the momentum and onwards care of the patient. 

We found this a really useful topic to consider in some depth and we hope it's of use to you too!

Once again we'd love to hear any comments or questions either via the website or social media.

Enjoy!

Simon, Rob & James

Jul 1, 2023

There have been some huge trials released over the last month and we've got three brilliant papers to discuss!

First up we take a look at an RCT on video versus direct laryngoscopy for patients requiring emergency intubation with the DEVICE trial. The VL versus DL debate has been ongoing for quite some time now, so is this a final nail in the coffin for DL?

Next up we take a look at an RCT of prehospital TXA use in patients at risk of bleeding from major trauma in the PATCH trial. The results seen in the trial look at a glance to oppose those seen in CRASH-2, so is this the end of TXA in this cohort of patients?

Finally we have a great paper giving us further information on whether we should we be initiating immediate antihypertensive treatment for patients admitted to hospital with asymptomatic hypertension.

Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom.

Simon & Rob

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