In this episode Rob takes us through a case he saw recently that brought about some invaluable learning.
We're not going to give you anymore clues than that!
Enjoy!
Welcome back to April's papers of the month.
We've got 3 papers this month that look to challenge our work up strategies for the critically unwell. First up we look at a paper on the Ottawa subarachnoid haemorrhage rule, specifically considering if we can decrease scanning in patients with a suspected SAH and what application of the rule might mean for our practice.
Next up we look at a paper that might shine some real doubt on the use of IO access in our patients in cardiac arrest.
Lastly we look at a validation paper for the PERC rule for those patients with a suspected pulmonary embolus and this paper brings about some interesting points on external validity
Once again we'd really encourage you to have a look at the papers yourself and we've love to hear any thoughts or feedback you have.
Enjoy!
Simon & Rob
References
Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. Perry JJ. CMAJ. 2017
Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Kawano T. Ann Emerg Med. 2018
Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. Freund Y. JAMA. 2018
CORE EM; IO in Cardiac Arrest
Gaining control of the airway in a critically unwell patient is a key skill of the critical care team and littered with potential for difficulty and complications.
NAP4 highlighted the real dangers faced with their review of complications of airway management in the UK, lessons have been learnt and practice has progressed. As always there is room to improve on current practice and a recent paper published in Anaesthesia describes a comprehensive strategy to optimise oxygenation, airway management, and tracheal intubation in critically ill patients in all hospital locations.
In this podcast we cover;
We'd love to hear your thoughts so please leave your comments below or contact us via twitter @TheResusRoom
Enjoy!
References & Further Reading
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!
Handover matters.
Handover of patient care occurs at multiple points in the patient's journey and is a crucial point for transference of information and inter professional working.
Whether it's the big trauma in Resus with the prehospital services presenting to the big crowd, right the way through to the patient coming to minors who looks like they will be going home shorty, each of these transactions of information needs to be done correctly.
Handover can be stressful though and different parties will have different priorities that they are trying to juggle. In this podcast we explore handover, some of the barriers and issues that exist. We have a look at the evidence that exists on it's importance, impact and associated techniques. We also look at tools that exist that can be used to facilitate effective handover.
As ever make sure you look at the articles mentioned in the podcast yourself and we would love to hear your thoughts.
Enjoy!
References & Further Reading
Maintaining eye contact: how to communicate at handover. Dean E. Emerg Nurse. 2012
You've got a critically unwell patient who needs an RSI. You've got lots of things to think about but specifically do you ramp them up or keep them supine, additionally do you use a checklist or are those things a complete waste of time? This month we have a look at 2 papers which should shed some light on the subject.
We also look at a systematic review and meta-analysis which hopefully helps us answer a question we've been looking at on the podcast for quite some time: in the the context of a cardiac arrest that has gained a ROSC, if the ECG is not diagnostic of a STEMI but the history is suggestive of a cardiac event, should the patient go straight to the cathlab for PCI?
As always don't just take our word for it but go and have a look at the papers yourself and we would love to hear your thoughts.
JC: Should non ST elevation ROSC patients go to cath lab? St.Emlyn’s
Traumatic Cardiac Arrest; for many of us an infrequent presentation and it that lies the problem.
In our previous cardiac arrest podcast we talked about the approach to the arresting patient, however in trauma the approach change significantly.
We require a different set of skills and priorities and having the whole team on board whilst sharing the same mental model is key.
Have a listen to the podcast and let us know your thoughts. The references are below but if you only read one thing take a look at the ERC Guidelines on traumatic cardiac arrest which we refer to.
Enjoy!
References & Further Reading
Resuscitation to Recovery Document
Roadside to Resus; Cardiac Arrest
ERC Guidelines; Traumatic Arrest
Traumatic cardiac arrest: who are the survivors? Lockey D. Ann Emerg Med. 2006
If you talk to people about the topic of thrombolysis in PE they'll tell you about the controversy of the submassive category, but there's a universal acceptance that thrombolysing massive PE's is well evidenced and straight forward.
In this episode we delve back into the literature and not only explore massive PE thrombolysis, but also the gold standard to which it is judged upon, heparin.
Have a listen to the podcast and as always we would love to hear your thoughts.
Enjoy!
References & Further Reading
Treatment of pulmonary embolism in total hip replacement. Johnson R. Clin Orthop Relat Res. 1977
Welcome back to November's papers podcast!
This month we've got some great topics to discuss.
We look at another paper on the topic of oxygen therapy, this time a hug article from JAMA on oxygen therapy in the context of acute stroke and the impact on disability.
Next up we look at a fascinating case report of a extradural haematoma that was drained via an I.O. needle prior to surgical evacuation.
Lastly we follow up on our previous podcast on PE; the controversy, which looked at the prevalence of PE in those patients presenting with undifferentiated syncope. This paper puts a great counter to the conclusions arrived at in that Prandoni paper.
Enjoy!
Last time in Roadside to Resus we discussed cardiac arrest with a view to obtaining a return in spontaneous circulation, ROSC.
However gaining a ROSC is just one step along the long road to discharging a patient with a good neurological function back into the community. In fact ROSC is really where all of the hard work really starts!
In this podcast we talk more about the evidence base and algorithms that exist to guide and support practice once a ROSC is achieved. We'd strongly encourage you to go and have a look at the references and resources yourself listed below and would love to hear your feedback in the comments section or via twitter.
Enjoy!
References & Further Reading
Resuscitation to Recovery Document
Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia. Sandroni C. Resuscitation. 2013
This podcast covers some highlights from the talks at the BASICS and The Faculty of Pre-Hospital Care 2017 Conference.
We were lucky enough to be invited by Caroline Leech to cover the day and managed to grab a couple of minutes with a handful of the superb speakers;
Dr. Tom Evens; Elite sports for high performance clinicians
Dr. Les Gordon; Pre-hospital management of hypothermia
Dr. Helen Milne; Retrieval and transfer medicine
Surgeon Commander Kate Prior; The battlefield
Dr Chris Press; Prehospital management of diving emergencies
Miss Aimee Yarrington; Obstetric Emergencies
Professor Mark Wilson; Pre-hospital Care, where are we going?
Thanks to all involved for making the podcast and for a great day at the conference, and to PHEMCAST for the collaboration!
Simon, Rob & Clare
Welcome back to October's papers podcast!
This month we have a look at a paper that shines further light on the use of ultrasound in predicting fluid responsiveness in the spontaneously ventilating patient. We look at a paper that sets to challenge the concerns over hyperoxia in presumed myocardial infarction. And lastly we look at how stress impacts in a cardiac arrest situation on the team leader's performance.
Make sure you have a look at the papers yourself and we would love to hear any feedback and alternative thoughts on the ones we cover! Lastly thanks for your support with the podcast
Enjoy!
References & Further Reading
We have a significant way to go with respect to our cardiac arrest management.
‘Cardiopulmoary Resuscitation is attempted in nearly 30,000 people who suffered OHCA in England each year, but survival rates are low and compare unfavourably to a number of other countries’
- Resuscitation to Recovery 2017
25% of patients get a ROSC with 7-8% of patients surviving to hospital discharge, which as mentioned is hugely below some countries.
In this podcast we run through cardiac arrest management and the associated evidence base, right from chest compressions, through to drugs, prognostication and ceasing resuscitation attempts.
Make sure you take a look at the papers and references yourself and we would love to hear you feedback!
Enjoy!
References & Further Reading
Resuscitation to Recovery Document
Dual sequential defibrillation: Does one plus one equal two? Deakin CD. Resuscitation. 2016
Bicarbonate use in cardiac arrest.
The topic still provokes debate and multiple publications on the topic still hit the press reels. People talk of the increased rate of ROSC and the improvement in metabolic state, whilst others talk of the increase in mortality and worsening of intracellular acidosis.
A recent paper in Resuscitation looked at a huge cohort of patients receiving bicarbonate in arrest prehospitally. In this episode we take a look at the paper, review the guidelines and give our take on the current situation with regards bicarb in arrest
We hope you enjoy it and would love to hear your feedback!
So we're back with some superb topics this month;
Make sure you take a look at the papers yourself, they certainly provide food for thought and raise important questions in our practice
Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast
Enjoy!
References & Further Reading
This is the second part of the Roadside to Resus discussion on asthma. Make sure you’ve listened to part 1 before delving into this one!
Part 2 covers
We hope you enjoy the episode and would love to hear your feedback!
References & Further Reading
Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017
TheResusRoom; Needle Thoracostomy podcast
TheResusRoom; BTS Asthma Guidelines 2016 podcast
LITFL; Non-invasive ventilation (NIV) and asthma
Intensiveblog; Asthma mechanical Ventilation Pitfalls
Asthma is a common disease and presents to acute healthcare services extremely frequently.
The majority of presentations are mild exacerbations of a known diagnosis and are relatively simple to assess and treat, many being completely appropriate for out patient treatment.
On the other hand around 200 deaths per year are attributable in the UK to asthma, and therefore in the relatively young group of patients there is a real potential for critical illness with catastrophic consequence if not treated effectively. The majority of these deaths occur prior to the patient making it to hospital making the prehospital phase extremely important and hugely stressful in these cases.
It is also worth noting that of the deaths reported that many were associated with inadequate inhaled corticosteroids or steroid tablets and inadequate follow up, meaning that our encounter with these patients at all stages of their care even if not that severe at the point of assessment is a key opportunity to discuss and educate about treatment plans and reasons to return.
In part 1 of this podcast we will run through
Part 2 will be out shortly, we hope you enjoy the episode and would love to hear your feedback!
Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017
TheResusRoom; Needle Thoracostomy podcast
TheResusRoom; BTS Asthma Guidelines 2016 podcast
LITFL; Non-invasive ventilation (NIV) and asthma
We're back with more great papers for you this month, hot off the press!
There's been a lot of talk over the last few years about apnoeic oxygenation and whether it really holds any benefit to patients undergoing RSI, we have a look at a systematic review that may help answer that question.
Next up we have a look at the choice of sedation agent used in the Emergency Department and how this correlates with patient satisfaction.
Finally, following on from our recent podcast on Double Sequential Defibrillation, we have a look at a paper published looking at the results of DSD from the London prehospital service. Will this reveal a patient benefit?
Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast.
Enjoy!
References & Further Reading
Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. Pavlov I. Am J Emerg Med. 2017
Double sequential defibrillation therapy for out-of-hospitalcardiac arrests: The London experience. Emmerson AC. Resuscitation. 2017