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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: Page 8
Jul 1, 2017

We're back with 3 superb topics this month!

First off we have a look at the utility of ultrasound for the detection of pneumothoraces in the context of blunt trauma.

Next we look at the need to scan facial bones when scanning a patient's head following trauma.

Last of all we look at a paper reviewing the association between the use of a bougie and the first pass success when performing ED RSI.

Have a listen to the podcast and most importantly make sure you have a look at the references and critically appraise the papers yourself. We'd love to hear your thoughts and comments at the bottom of the page.

Enjoy!

Jun 21, 2017

Guidelines. Algorithms. Evidence based medicine. These all play a significant part in the safe and effective management of the majority of our patients. As a result there is a danger that treatment pathways are followed blindly without critiquing their use and there is real risk we can loose sight of what’s best for the patient in front of us. Guidelines encourage inflexible decision making, which creates further challenge when we are met by patients who do not fit standard treatment pathways.

If this is the case then the management of cardiac arrest, which is taught and delivered in a didactic and protocol driven fashion, is surely the pinnacle of the problem. Standard Advanced Life Support (ALS) is totally appropriate for the majority of cardiac arrests, but what happens when it fails our patients? Refractory ventricular fibrillation (rVF) is, by its very nature, defined by the failure of ALS, but frustratingly there is very little evidence, or guidance, surrounding how to manage this patient group.

I was faced with this situation when called to support an ambulance crew who were resuscitating an out-of-hospital VF arrest. When benchmarked against the ALS guidelines their management had been exemplary, but the patient remained in VF after eight shocks. So what now? The UK Resuscitation Council doesn’t specifically discuss rVF, but offers the advice that it is “usually worthwhile continuing” if the patient remains in VF. Not a particularly controversial statement, but not much help either. They do discuss the potential for ECMO use, but this is currently a very rare option in UK practice, or thrombolysis for known or suspected pulmonary embolism.

Other potential interventions not in the guidelines include IV magnesium and placing defibrillator pads in the anterior-posterior orientation. PCI can also be considered if there is a suitable receiving centre available and the patient can be delivered in a safe and timely fashion.

A final option is the use of double sequential defibrillation (DSD), using two defibrillators, charged to their maximum energy setting, to deliver two shocks in an almost simultaneous fashion.DSD was first described in human subjects in 1994 when it was used to successfully defibrillate five patients who entered rVF during routine electrophysiologic testing. These patients were otherwise refractory to between seven and twenty single shocks. Looking at the available literature there has been little interest in DSD since then, until the last two to three years when it appears to have undergone a small revival. Sadly, there is no evidence for its use beyond case reports and small case series. The case reports appear to show good results with four in the last two years reporting survival to discharge with good neurological outcome. There are also a handful of other cases discussed in online blogs and articles with good outcomes. But these case reports and articles almost certainly represent an excellent example of publication bias. The most recent case series reviewed the use of DSD by an American ambulance service over a period of four years. During this time DSD was written into their refractory VF protocol, with rVF defined as failure of five single shocks. The study included twelve patients, three of whom survived to discharge with two of these demonstrating a cerebral performance score of 1. Despite appearing to demonstrate reasonable outcomes for DSD, sadly this study has a number of significant limitations. One important point the authors fail to discuss is that the two neurologically intact survivors received their DSD shocks after two and three single shocks respectively, not after five shocks which would have been per-protocol and consistent with the authors definition of refractory VF.

This highlights a further problem with analysing the use of DSD. Not only is there a dearth of high-level evidence, but the literature that is available is highly inconsistent. There are a range of definitions for refractory VF, different orientations for the second set of pads, variable interventions prior to using DSD, a variety of timings between the shocks and so on. This means that comparison between studies and drawing meaningful conclusions is nearly impossible. Given these challenges, what are the explanations for why DSD might work?

The first theory is that by using DSD the myocardium is defibrillated with a broader energy vector compared to a single set of pads resulting in a more complete depolarisation of the myocardium. A second theory is that the first shock reduces the ventricular defibrillation threshold meaning that the second shock is more effective. A third explanation may simply be the large amount of energy delivered to the myocardium. These theories should be tempered by the fact that studies have demonstrated increasing defibrillation energy to result in increased defibrillation success, but only up to a plateau. After this the success of defibrillation drops sharply. Increased energy use has also been demonstrated to cause an increase in A-V block but without an associated increase in shock success or patient outcome.

The use of double sequential defibrillation is clearly an area that would benefit from further research, but despite this it is interesting to note that London Ambulance Service have enabled their Advanced Paramedic Practitioners to use DSD and some American EMS systems have written DSD into their protocols.

So returning to the case in point what did I choose to do with my patient?

After changing the pad position, administering magnesium and continuing defibrillation they remained in VF.  I considered transport to a hospital with interventional cardiology but the patient was several stories up in a property with an inherently complex extrication. So I chose to use DSD because I felt that all other avenues had been explored. The patient had suffered a witnessed arrest, received bystander CPR immediately and throughout the resuscitation they had maintained a high end tidal CO2 and a coarse VF. I felt that this was a patient who could still respond to non-standard cardiac arrest management in the absence of a response to guideline directed treatment. After two DSD shocks a return of spontaneous circulation was achieved and the patient survived to hospital admission, but sadly didn’t survive to hospital discharge.

We’re left with a even bigger question: if we accept that DSD is a potentially useful intervention in rVF, when should we consider using it? Would the outcome for this patient have been different if DSD had been used earlier?

The European Resuscitation Council states that the use of double sequential defibrillation cannot be recommended for routine use. But treating rVF is not routine and the guidelines have otherwise failed our patient. It is said that insanity is defined as doing the same thing over and over again, without changing anything, and expecting a different result. Is this not what the guidelines preach in rVF? It is up to you, the clinician, to determine whether DSD is appropriate for each rVF case you encounter. But I urge you to consider the patient in front of you and tailor your resuscitation to their needs, whether that includes DSD or an alternative option. Personally, I believe DSD does have a place in the management of rVF patients, after considering the other interventions previously discussed. Given that shock success declines over time, DSD could be used as early as the sixth shock, because at this point the guidelines have nothing further to add. Or maybe it’s me who’s insane…

James Yates (Critical Care Paramedic GWAAC)

References

Double sequential Defibrillation therapy for out-of-hospital cardiac arrests: the London experience. Emmerson AC, et al. Resuscitation. 2017 

A Case Series of Double Sequence Defibrillation. Merlin MA. Prehosp Emerg Care. 2016

Double sequential external shocks for refractory ventricular fibrillation. Hoch DH. J Am Coll Cardiol. 1994

Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Reportof Ten Cases. Cabañas JG. Prehosp Emerg Care. 2015

Double Sequential Defibrillation for Refractory Ventricular Fibrillation: A Case Report. Lybeck AM. Prehosp Emerg Care. 2015

Double simultaneous defibrillators for refractory ventricular fibrillation. Leacock BW. J Emerg Med. 2014

Simultaneous use of two defibrillators for the conversion of refractory ventricular fibrillation. Gerstein NS. J Cardiothorac Vasc Anesth. 2015

Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Cortez E. Resuscitation. 2016 

Double Sequential External Defibrillation and Survival from Out-of-Hospital Cardiac Arrest: A CaseReport. Johnston M. Prehosp Emerg Care. 2016

Dual defibrillation in out-of-hospital cardiac arrest: A retrospectivecohort analysis. Ross EM. Resuscitation. 2016

Refractory Ventricular Fibrillation Successfully Cardioverted With Dual Sequential Defibrillation. Sena RC. J Emerg Med. 2016

Dual sequential defibrillation: Does one plus one equal two? Deakin CD. Resuscitation. 2016

Magnesium therapy for refractory ventricular fibrillation. Baraka A. J Cardiothorac Vasc Anesth. 2000 

Jun 15, 2017

High quality manual cardiopulmonary resuscitation (CPR) with minimal delays has been shown to improve outcomes following out-of-hospital cardiac arrest (OHCA). There are concerns that the quality of CPR can diminish over time and as little as 1 minute of CPR can lead to fatigue and deviation from the current recommended rate and depth of compressions.

With this in mind, a mechanical device to provide chest compressions at a constant rate, depth and without tiring has considerable theoretical benefits to patients, yet clinical equipoise remains about the role for this treatment modality.

In this podcast, we discuss and critically appraise 2 randomised controlled trials (RCTs) set out to answer exactly that question and give our take on the role for mechanical CPR devices in the future

Hope you enjoy and feel free to leave any feedback below!

Rob

References 

Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Perkins GD. Lancet. 2015

Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Rubertsson S. JAMA. 2014

Jun 1, 2017

We're back with another look at the papers most relevant to our practice in and around The Resus Room.

The WOMAN trial was a huge trial that looked at tranexamic acid in post partum haemorrhage, it's gained a lot of attention online and we kick things off having a look at the paper ourselves.

Next up, and following on nicely from our previous Cardiac Arrest Centres podcast, we have a look at a systematic review and meta-analysis on whether prolonged transfer times in patients following cardiac arrest affects outcomes.

Finally we have a look at a paper on management of PEs in cardiac arrest which draws some very interesting conclusions on the management of such cases and the associated outcomes!

Please make sure you go and have a look at the papers yourself and as ever huge thanks to our sponsors ADPRAC for making this all possible.

Enjoy!

May 19, 2017

Oxygen is probably the drug that we give the most but possibly has the least governance over.  More has got to be good except in those at high risk of type II respiratory failure right?? Well as we know the evidence base has swung to challenge that idea in recent years and the new BTS guidelines for Oxygen use in Healthcare and Emergency Settings has just been published with a few things that are worth reviewing since the original publication in 2008. No apologies that this may be predominantly old ground here, this is an area we're all involved with day in and day out that is simple to correct and affects mortality

Historically oxygen has been given without prescription;

  • 42% of patients in the 2015 BTS audit had no accompanying prescription
  • When it is prescribed this doesn't always correlate with delivery
  • 1/3 of patients were outside of target SpO2 range (10% below & 22% above)

If nothing else is taken from this document then reinforcement of the fact that we need to keep oxygen saturations normal/near normal for all patients, except groups at risk of type II respiratory failure

Prescribe and delivery oxygen by target oxygen saturations

What is normal?

  • Normal Oxygen saturations for healthy young adults is approximately 96-98%, there is minor decrease with increasing age.
  • Healthy subjects desaturate to 90% SpO2 during night time; be cautious interpreting a single oximetry reading from a sleeping patient, short duration overnight dips are normal

 

Will mental status give me an early indication of hypoxaemia?

  • No, impaired mental function at a mean value of SaO2 64%, no evidence above SaO2 84%
  • Loss of consciousness at a mean SaO2 56%

 

Aims of oxygen therapy

  • Correct potentially harmful hypoxia
  • Alleviate breathlessness only in those hypoxic

 

Why the fuss about hyperoxia?

Hyperoxia has been shown to be associated with

  • Risk to COPD patients and those at risk of type II respiratory failure
  • Increased CK level in STEMI and increased infarct size on MR scan at 3 months
  • Association of hyperoxaemia with increased mortality in several ITU studies
  • Worsens systolic myocardial performance
  • Absorption Atelectasis even at FIO2 30-50%
  • Intrapulmonary shunting
  • Post-operative hypoxaemia
  • Coronary vasoconstriction
  • Increased Systemic Vascular Resistance
  • Reduced Cardiac Index
  • Possible reperfusion injury post MI

In patients with COPD studies have showed most hypercapnia patients arriving at hospital with the equivalent of SpO2 > 92% were acidotic, high concentration O2has been associated with more than double the mortality rate in those with acute exacerbations of COPD. Titrate O2 delivery down smoothly

 

Which patients are at risk of CO2 retention and acidosis if given high dose oxygen?

  • Chronic hypoxic lung disease
    • COPD/CF/Bronchiectasis
  • Chest wall disease
    • Kyphoscoliosis
    • Thoracoplasty
  • Neuromuscular disease
  • Morbid obesity with hypo ventilatory syndrome

 

What is the oxygen target?

Oxygen titrated to an SpO2 of 94-98%

Except in those at risk of hypercapnia respiratory failure, then 88-92%(or specific SpO2 on patient's alert card)

 

What about in Palliative Care?

Most breathlessness in cancer patients is caused by airflow obstruction, infections or pleural effusions and in these cases the issues need to be addressed. Oxygen does relieve breathlessness in hyperaemic cancer patients but not if SpO2 >90%. Midazolam and morphine also relieve breathlessness and are more likely to be effective.

 

Delivery Devices

  • Reservior masks can deliver O2 concentrations between 60-80%
  • Nasal cannualae at 1-6L/min can deliver 24-50%
  • Venturi masks allow accurate delivery of O2
  • If tachypnoeic over 30 breaths per minute an increase over the marked flow rate should be delivered, note this won't increase the FiO2!

Equivalent doses of O2

24% venturi = 1L O2

28 % venturi = 2L O2

35% venturi = 4L O2

40% venturi = nasal/facemask 5-6LO2

60% venturi = 7-10L simple face mask

 

Approach to oxygen delivery

Firstly determine if at risk of type II respiratory failure

If not;

  • SpO2 < 94%, deliver oxygen
  • Perform an ABG
    • If high PCO2 consider invasive ventilation, in the interim aim SpO2 94-98%
    • If PCO2 normal or low aim SpO2 94-98% and repeat ABG in 30-60 minutes

If at risk of type II respiratory failure

  • Obtain ABG if hypoxic or already on oxygen
    • If a respiratory acidosis consider NIV, address medical condition and senior review. Treat with the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92%
    • If hypercapnia but not acidotic, titrate the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92%. Repeat ABG after change of treatment/deterioration. Consider reducing FiO2 if PO2 on ABG >8kPa
    • If PCO2 < 6 (normal or low) aim to keep SpO2 94-98% and repeat the ABG in 30-60 minutes

Points specific to prehospital oxygen use

  • A sudden reduction in 3% of SpO2 within the target range should prompt a fuller assessment of the patient
  • Pulse oximetry must be available in all locations in which oxygen is being used
  • Some patients over the age of 70 when clinically stable may have SpO2 between 92-94%, these patients don't require O2 therapy unless the SpO2 falls below the level that is known to be normal for that individual
  • Patients with COPD should initially be given oxygen via 24% venturi at 2-4L/min or 28% mask at a flow rate 4L/min, or nasal cannulae at 1-2L/min aiming for 88-92%
  • Patients over 50 years of age and long term smoker with a history of SOB on exertion and no other cause for their breathlessness should be treated as having COPD.
  • Limit O2 driven nebs, if no air driven nebs available, to 6 minutes in duration in patients known to have COPD

In summary....

So the bottom line? Well just like Goldielock's porridge, with oxygen we don't want too little, we don't want too much but we want just the right amount!

There is no doubt that hypoxia kills but beware that too much of anything is bad for you and in the same way we need to be vigilant to targeting oxygen delivery to our patients target SpO2

 

References

BTS Guideline for oxygen use in healthcare and emergency settings

 

May 15, 2017

How many patients are admitted from your ED with suspected cardiac chest pain? What strategy of testing do you employ to rule out acute myocardial infarction? When and why do you send troponins in this process?

In this podcast Ed Carlton, Emergency Medicine Consultant at North Bristol Hospital and Troponin Researcher, talks to us about troponin rule out strategies, recent publications on the topics, where the future of troponin research is heading and most importantly what this all means for our practice.

Our previous podcast on troponins acts as a good introduction to this episode. Have a listen to both and we'd love to hear your comments at the bottom of the page and we hope you found this as useful as we did!

Enjoy

Simon

References

 

Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin TMeasurement Below the Limit of Detection: A Collaborative Meta-analysis. Pickering JW. Ann Intern Med. 2017 

Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial. Poldervaart JM. Ann Intern Med. 2017

May 1, 2017

This month we've got a good variety of topics.

We look at an recent systematic review and meta analysis on the prognostic value of echo in life support, an update from Blyth's paper in 2012. We review a paper looking at testing gin patients presenting to the emergency department in SVT. Finally we cover a paper looking at different methods employed when running an Emergency Department.

As always make sure you go and have a read of the papers yourselves and come up with your own conclusions, we'd love to hear your feedback.

Enjoy!

Simon & Rob

References & Further Reading

Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysisTsou PY. Resuscitation. 2017

Usefulness of laboratory and radiological investigations in the management of supraventricular tachycardiaAshok A. Emerg Med Australas.2017

What do emergency physicians in charge do? A qualitative observational study. Hosking I. Emerg Med J. 2017 

 

Apr 25, 2017

This podcast is taken from a talk I gave at Grand Rounds at The Bristol Royal Infirmary on the Top 10 Papers in EM over the last 12 months.

Many of these have been covered in previous podcasts, but running through them gives a good opportunity for further recap and reflection.

Papers Covered;

Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV1. Injury. 2015 Dec 13. pii: S0020-1383(15)00768-8. doi: 10.1016/j.injury.2015.11.045. [Epub ahead of print]

(more in February'sPapers of the month)

Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Baharoglu MI. Lancet.2016 May 9. pii: S0140-6736(16)30392-0. doi: 10.1016/S0140-6736(16)30392-0. [Epub ahead of print]

(more in July's Papers of the month)

Causes of Elevated Cardiac Troponins in the Emergency Department and Their Associated Mortality. Meigher S. Acad Emerg Med. 2016

(more in our Troponins podcast)

Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. Ferguson I, et al. Ann Emerg Med. 2016.

(more in September's Paper's of the month)

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P. N Engl J Med. 2016

(more in our podcast PE The Controversy)

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Andersen LW. JAMA. 2017

(more in March's Papers of the month)

Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Donaldson L. Emerg Med Australas. 2016 Aug 25

(more in our Stroke Thrombolysis podcast)

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospectiverandomisedphase 3controlledopen-labelnon-inferiority trialNijssen EC. Lancet. 2017

(more in April's Papers podcast)

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Sierink JC. Lancet. 2016 Jun 28

(more in August's Papers podcast)

Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017 

(more coming up in May's Papers podcast!)

Enjoy and we'll be back with our papers of the month next week!

Simon

 

Apr 15, 2017

Acute cholecystitis is a diagnosis that we make frequently in the Emergency Department. But like all diagnostic work ups there is a lot to know about which parts of the history, examination and bedside tests we can do in the ED that really help either rule in or rule out the disease.

In this podcast we run through some of the key bits of information published in the Commissioning Guide Gallstone disease 2016, jointly published by the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland & the Royal College of Surgeons.

We then concentrate on a recent systematic review of the diagnostic work up for Acute Cholecystitis. Yet again the evidence base brings up some issues to challenge our traditional teaching on the topic but should help polish our management of patients with a differential of Acute Cholecystitis.

Enjoy!

References & Further Reading

Commissioning Guide Gallstone disease 2016

Up to date; Acute Cholecystitis

NICE guidance; Acute Cholecystitis

History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis. Jain A. Acad Emerg Med

Apr 1, 2017

This month we look at a paper concentrating on the risk of contrast induced nephropathy in contrasted CT scans, looking specifically at the need to hydrate at-risk patients prior to and following CT scans.

The use of prehospital blood is also under the spotlight with the ongoing RePHILL trial. We look at a paper reviewing prehospital blood use with the Kent Surrey Sussex prehospital service and the described physiological changes seen in patients receiving blood. Make sure you also go over and check out the podcast episode from PHEMCAST on the RePHILL trial with Jim Hancox.

Finally I was lucky enough to catch up with Johannes von Vopelius-Feldt, the lead author of a paper in press on the impact of prehospital critical care teams on out of hospital cardiac arrests.

You can find the fantastic opportunity of a scholarship to be an Emergency Nurse Practitioner here from ADPRAC.

Enjoy

Simon & Rob

References & Further Reading

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospectiverandomisedphase 3controlledopen-labelnon-inferiority trialNijssen EC. Lancet. 2017

FOAMcast; Contrast-Induced Nephropathy and Genitourinary Trauma

RELEL.EM; The AMACING Trial: Prehydration to Prevent Contrast Induced Nephropathy (CIN)?

Royal College Radiology; Prevention of Contrast Induced Acute Kidney Injury (CI-AKI) In Adult Patients

Pre-hospital transfusion of packed red blood cells in 147 patients from a UK helicopter emergency medical service. Lyon RM. Scand J Trauma Resusc Emerg Med. 2017

PHEMCAST; blood

Mar 18, 2017

So today Rob and I were lucky enough to be asked to attend the Trauma Care Conference 2017, to listen to some of the great talks and catch up with some of the speakers for their take on the highlights of the talks.

We managed to catch the following speakers, here are the topics they covered and relevant links to the resources discussed.

Speakers

Gareth Davies, Consultant Emergency Medicine, Royal London Hospital; Understanding where, when and how people die?

Dave Gay, Consultant Radiologist, Derriford Hospital; The Role of Ultrasound in Trauma

Fiona Lecky, Professor Emergency Medicine, Salford; Traumatic Brain Injury: recent progress & future challenges

Simon Carley, Professor Emergency Medicine, Central Manchester; The Top 10 trauma papers of 2016

St Emlyn's Top 10 +1 Trauma Papers 2016

Tim Rainer,  Professor Emergency Medicine, Cardiff; Permissive hypotension in blunt trauma

David Raven, Emergency Medicine Consultant, Heart of England Foundation Trust; HECTOR & Elderly Trauma

The HECTOR Course (& free online manual!!)

Ross Fisher, Consultant Paediatric Surgeon Sheffield Children’s Hospital; TARN report for paediatrics

p3 presentations

TARNlet Database

 

Have a listen to the podcast and again huge thanks to the speakers for taking their time to share their superb talks with a wider audience.

Simon

Mar 8, 2017

Centralisation of care for specialist services such as stroke, trauma and myocardial infarctions is becoming more and more common place. But where will it stop and what does it mean for the specialty of Emergency Medicine?

In this episode we have a look at a recent pilot RCT published in the journal of Resuscitation looking at the feasibility of setting up an bigger RCT to evaluate moving prehospital patients to a cardiac arrest centre. The paper itself is a great piece of work but the bigger discussion around the topic is also a really important point to consider.

Have a listen to the podcast, see what you think and please post you comments on the site for us all to see.

Enjoy!

Simon

References
 

A Randomised tRial of Expedited transfer to a cardiac arrest centre for non-ST elevation ventricular fibrillation out-of-hospital cardiac arrest: The ARREST pilot randomised trial. Patterson T. Resuscitation. 2017

Mar 1, 2017

Welcome back to Papers of the Month. March has given us some great papers.

We kick off with a couple of papers looking at rib fractures, associated morbidity and mortality and also looks at management of flail segments.

We then turn our attention to airway management and look at a paper reviewing the outcomes associated with patients who are intubated during resuscitation from cardiac arrest.

As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below.

Enjoy

Simon & Rob

References & Further Reading
  

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Andersen LW. JAMA. 2017

 

AIRWAYS-2

 

Feb 21, 2017

Think of rhabdomyolysis and you'll think of an elevated creatine kinase (CK). The condition ranges from an asymptomatic period to a life-threatening condition with a hugely associated rise in CK which can also be accompanied by electrolyte disturbance, renal failure and disseminated intravascular coagulation.

Rhabdomyolysis is caused by a breakdown in skeletal muscle and occurs most commonly following trauma, very often that can be due to a 'long-lie' when a patient is unable to get off a floor until help arrives after a prolonged period. There are other causes including drugs, muscle enzyme deficiencies, electrolyte abnormalities and more.

The presentation itself is pretty vague and suspicion of the disease needs to be pretty high. Patients can experience weakness, myalgia and the dark'coca-cola urine', the diagnosis is then confirmed with a serum elevation in CK.

The big concern with Rhabdomyolysis is the hit the kidneys take. Acute kidney injury is due to the heme pigment that is released from myoglobin and haemoglobin and is nephrotoxic. Early aggressive fluid rehydration aims to minimise ischaemic injury, increase urinary flow rates and thus limit intratubular cast formation. Fluids also help eliminate excess K+ that may be associated. But have a think about the management in your ED, how high does that CK need to be to require i.v. fluids and admission to hospital?

Here's a few facts we need to know:

  • Normal CK enzyme levels are 45–260 U/l.
  • CK rises in rhabdomyolysis within 12hours of the onset of muscle injury
  • CK levels peak at 1–3 days, and declines 3–5 days after muscle injury
  • The peak CK level may be predictive of the development of renal failure
  • A CK level of 5000 U/l or greater is related to renal failure
  • Optimal fluid rate administration is unclear, some papers suggest replacement of isotonic saline at rates of 1-2L per hour. , adjusted to 200-300mL per hour to maintain a diuresis.
  • Attention needs to be paid to urine output serum markers and fluid status.

A lot of the evidence and knowledge surrounding rhabdomyolysis is from humanitarian disasters; earthquakes, terrorism along with observational cohorts, but at the end of the day we need to work with what we've got.

Have a listen to the podcast and see what you think, the application of the evidence base may change your practice.

Enjoy!

 References

Bench-to-bedside reviewRhabdomyolysis -- an overview for cliniciansHuerta-Alardín AL. Crit Care. 2005

 
Feb 15, 2017

Epistaxis is an extremely common presentation to both Prehospital Emergency Services and Emergency Departments. The vast majority are benign and self limiting but every once in a while a catastrophic bleed will come our way. 

Whilst not necessarily the most attention grabbing of topics a sound understanding of the management is key to excellent care.

In this podcast Rob talk us through the management of epistaxis, all the way from causes and presentation, right the way through to resuscitative management and latest evidenced based treatment.

Enjoy!

References & Further Reading

LITFL epistaxis review

Geeky medics epistaxis 

BMJ overview paper & management flowchart

Routine coagulation screening in the management of emergency admission for epistaxis; is it necessary? Thaha MA. J Laryngol Otol 2000

Front-line epistaxis management: let's not forget the basic. E C Ho. J Laryngol Otol 2008

Serious spontaneous epistaxis and hypertension in hospitalized patients.Page C. Eur Arch Otorhinolaryngol. 2011

 Tranexamic acid in epistaxis: a systematic review. Kamhieh Y, et al. Clin Otolaryngol. 2016

Feb 1, 2017

Welcome back to Papers of the Month. February holds a diverse number of topics on some really interesting areas of practice.

We kick off with a snap shot systematic review from the Annals of Emergency Medicine on the effect of Amiodarone or Lignocaine on the outcome from refractory VF or VT arrests, are drugs losing more favour yet again in cardiac arrest.

Next up is a pilot study following the surgical theme of minimal intervention for appendicitis, can antibiotics safely be used in a particular cohort of patients to prevent the need for surgery? And moreover could this be even safer than the traditional surgical cure?

Last up we cover a paper looking at the survival from traumatic cardiac arrest and consider the bias that may occur by reporting those resuscitation attempts that are of limited duration in with the whole cohort; are we painting a overly negative picture of the prognosis of traumatic cardiac arrest?

As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below.

Enjoy

Simon & Rob

References & Further Reading

In Patients With Cardiac Arrest, Does Amiodarone or Lidocaine Increase Meaningful Survival? Hunter BR. Ann Emerg Med

Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial AllowingOutpatient Antibiotic Management. Talan DA. Ann Emerg Med. 2016 Dec

Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Beck B. Resuscitation 2017 Feb

Jan 16, 2017

Those of us who are a bit longer in the tooth have spent most of our careers not scanning everyone who sustained a head injury on warfarin, but in 2104 NICE published guidance suggesting we do just that.

At times, with the huge burden we place on our radiology services, it is difficult not think we're over doing things with all of these scan requests, especially when the patient has no adverse symptoms or signs. Fortunately the AHEAD study has just been published which looks at thousands of patients presenting to ED's on warfarin with a head injury.

The paper is open access and deserves a full read, in this podcast I run through some of the main parts of the study and have a think about how it might impact on our practice.

This is just one part of the puzzle on the management of patients with anticoagulated head injuries, we had a look previously on what to do if you perform a scan and that appears normal in our Anticoagulation, Head Injury & Delayed Bleeds Podcast.

Hope you enjoy the podcast and we'd love to hear any of your feedback on social media or on the website.

Simon

Jan 14, 2017

A lot of our podcasts have focussed on prognostic factors in arrest to help with the decision making of continuing or stopping resuscitation in cardiac arrest. There would appear to be a huge variety in practice as to when resuscitation is ceased, and in that way having explicit guidance to unify practice can at times seem appealing.

In this episode we have a look at a recent paper covering the topic, it suggests a group of patients accounting for nearly half of cardiac arrests, that upon recognition could safely lead us to cease efforts.

Have a listen to the podcast and let us know what you think!

References

Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Jabre P. Ann Intern Med. 2016

Resuscitation Council; Recognition of Life Extinct

Jan 1, 2017

Happy New Year!!!

The publishing world seems to have wound down a bit for the festive break, but 4 papers caught out eye that can add some further context to practice in the Resus Room.

Firstly we take a look at two papers looking at the conversion from non-shockable to shockable rhythms in cardiac arrest, both the likelihood and the associated prognosis.

Next up we have a look at a paper focussing on Cerebral Performance Categories (CPC's) and their reliability as an outcome for studies.

Lastly we have a look at the recent Cochrane Review on video laryngoscopy vs direct laryngoscopy for adult intubation.

Thanks again to our sponsors ADPRAC for supporting the podcast.

References & Further Reading

Age-specific differences in prognostic significance of rhythmconversion from initial non-shockable to shockable rhythm and subsequent shock delivery in out-of-hospital cardiac arrest. Funada A. Resuscitation. 2016

Conversion to shockable rhythms during resuscitation and survivalfor out-of hospital cardiac arrestWah W. Am J Emerg Med. 2016 

Inter-rater reliability of post-arrest cerebral performance category(CPCscoresGrossestreuer AV. Resuscitation. 2016

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubationLewis SR. Cochrane Database Syst Rev. 2016 

Dec 15, 2016

As the years tick by our healthcare systems work harder and harder to ensure that acute coronary syndromes are picked up as they present to our Emergency Departments, the evolution of high sensitivity troponins and their application have been key to this.

The utility of a test however is dependant upon it's application to the appropriate patient. In a heavily burdened system it can at times seem sensible to front load tests and 'add on a troponin' before we are even sure the history is consistent with a possible acute coronary syndrome. But is this a safe approach for our patients and what are the potential consequences?

In this podcast we run through a recent paper from the US on the topic. Whilst not the highest level of evidence and also looking at a system not entirely generalisable to the UK, it does highlight the aforementioned concerns and is a useful reminder to consider our approach to testing in patients with chest pain.

We are certainly not berating the use of troponin, we just think the paper serves a great reminder that testing must be appropriately applied.

Enjoy, and as ever we'd love to hear your feedback!

References

SIGN ACS Guidelines 2016

RCEMFOAMed SIGN ACS Guidelines

Causes of Elevated Cardiac Troponins in the Emergency Department and Their Associated Mortality. Meigher S. Acad Emerg Med. 2016

Cardiac Troponin: The basics from St. Emlyn’s

Rick Body via St Emlyns; One high sensitivity troponin test to rule out acute myocardial infarction

 

Dec 10, 2016

So my talk at the ICS SOA 2016 conference on whether ED should be allowed to intubate certainly provoked some discussion, which was fortunate as it was the purpose of the talk!

If you haven't listened to it yet, stop listening to this and have a listen to the talk here first.

In this quick debrief between Rob and myself we have a think about the feedback and where to go from here.

We'd love to hear any feedback in the comments section at the webpage at www.TheResusRoom.co.uk

Simon

Dec 5, 2016

RSI delivered by EM clinicians is common place throughout the globe, in the UK however it still seems a contentious topic, with recent data showing only 20% of ED RSIs being performed by EM clinicians.

I was lucky enough to be asked to talk at the ICS SoA 2016 conference on the topic of EM doctors carrying out RSI's in the UK and this podcast is a copy of that talk.

I hope it provides some context both to UK practitioners and also to those from other countries, who may not understand what the big deal is all about.

Simon

References

A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance.Randomized controlled trial. Kovacs G, et al. Ann Emerg Med. 2000

Acute airway management in the emergency department by non-anesthesiologists. Review article. Kovacs G, et al. Can J Anaesth. 2004

Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Mayo PH, et al. Crit Care Med. 2004

The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Reid C, et al. Emerg Med J. 2004

Rapid sequence induction of anaesthesia in UK emergency departments: a national census. Benger J, et al. Emerg Med J. 2011.

Tracheal intubation in an urban emergency department in Scotland: a prospective, observational study of 3738 intubations. Kerslake D, et al. Resuscitation. 2015

Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care. Park L, et al. Emerg Med Australas. 2016

Scottish Intensive Care Society: RSI

Difficult Airway Society Guidelines

RCOA Anaesthesia in the Emergency Department Guidelines; Chapter 6.1

John Hinds on RSI at RCEM 2015 Belfast

Draft; AAGBI Guidelines: Safer pre-hospital anaesthesia 2016

AAGBI Pre-hospital Anaesthesia Guideline 2009

Dec 1, 2016

Welcome to December's Papers of the month where we'll be looking at the papers recently published that have caught our eye.

First up, what happens when clinicians override clinical decision rules for PE? Are we better than the the rules?

Next we have a look at a review article that runs through the back ground literature on subsegmental PE's, their diagnosis and management.

And finally we have a look at a paper that helps to benchmark ED airway management with regards first pass success rate.

Our sponsors ADPRAC are giving away another £30 iTunes voucher to spend on education/entertainment to support your work life balance! All you need to do is click the link on our home page through to the ADPRAC website and answer the question relating to the podcast, good luck!

References & Further Reading

Yield of CT Pulmonary Angiography in the Emergency Department When Providers Override Evidence-based Clinical Decision Support. Yan Z. Radiology. 2016

Best Clinical Practice: Current Controversies in Pulmonary Embolism Imaging and Treatment of Subsegmental Thromboembolic Disease. Long B. J Emerg Med. 2016

Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care. Park L. Emerg Med Australas. 2016

Nov 17, 2016

Patients frequently present to the Emergency Department either with direct concern following an upper gastro intestinal bleed, or with a history that points towards the diagnosis.

When these patients are haemodynamically unstable or with ongoing high volume bleeding the decision to admit or discharge becomes simple.

But when the episode has settled, deciding whether they are safe to be discharged and continue with outpatient follow up can be difficult. Lots of us use scoring systems such as the Glasgow-Batchford Score or the Rockall Score but how much do we actually understand regarding the 'positive' and 'negative' outcomes of those scores?

A recent paper on the topic helps to cast some light on the topic and forms the basis of this podcast.

One of the frequently used scoring systems is the Glasgow-Blatchford score below that bases it's score upon historical, physiological and laboratory findings.

mdcalc GBS scoring calculator

Probably the other most frequently used score in ED is the Rockall score, which in its full form utilises endoscopy findings, however for use in the ED (pre-endoscopy) it has been modified and utilised.

mdcalc pre-endoscopy Rockall Score

Have a listen to how these scores fare in the paper and it may inform your risk stratification in the ED.

Enjoy!

References and Further Reading
 

The Predictive Value of Pre-Endoscopic Risk Scores to Predict Adverse Outcomes in Emergency Department Patients with Upper Gastrointestinal Bleeding - A Systematic Review. Ramaekers R. Acad Emerg Med. 2016

Upper Gastro Intestinal Bleeding at St.Emlyn’s

Nov 10, 2016

It's never long before the topic of pulmonary embolism makes it back into the controversial lime light and a recent paper on the association of PE with syncope is the lastest reason.

The PESIT trial, just published in the New England Journal of Medicine certainly grabs your attention when you read the abstract, with the implication that PE's are a major and hugely missed cause of the presentation of syncope. It also highlights a diagnostic work up that consists of blanket Well's scoring +/- d-dimer to decide who should be worked up further for the potential diagnosis, for every single patient presenting with syncope, including those with no appropriate symptoms or signs!

As always to read the abstract and draw a conclusion is to fall at the first hurdle, so take a listen to the podcast as we dive a bit deeper into the paper and topic, and of course make sure you take a look at the paper yourself and see what you make of the headline grabbing article

Enjoy!

References and Further Reading

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P. N Engl J Med. 2016

Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. Schultz DJ.Trauma. 2004 Apr 

Prospective evaluation of unsuspected pulmonary embolism on contrast enhanced multidetector CT (MDCT) scanning. Ritchie G. Thorax. 2007 Jun.

EM Nerd-The Case of the Incidental Bystander

JC: Prevalence of PE in patients with syncope. St.Emlyn’s

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