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.
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!
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!
This month the literature seems to be focussed on cardiac arrest
In this podcast we'll cover a paper looking at the significance of chest compression rate, ultrasound for prognostication (and to a lesser extent identification of tamponade) and finally a systematic review and meta-analysis of PCI following ROSC.
The PCI paper follows on nicely from our previous podcast on the topic, so make sure you have a listen to that one first.
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
EM Nerd-The Case of the Tell-Tale Heart
JC: Is this the REASON to use USS in cardiac arrest? St.Emlyn’s
Stroke thrombolysis has definitely put the spotlight back on to the topic of stroke over the last few years. Stroke thrombolysis has led to restructuring of stroke care in the UK and has helped drive investment in stroke care.
The evidence base that underpins thrombolysis has been controversial to say the least and can be difficult to comprehend.
The article, published in the the Emergency Medicine Australasia Journal is a great place to start to get to grips with the topic.
In the podcast we run through the paper and hopefully this will shed act as a good recap on the topic and lead you to delve into the primary literature and form your own opinion.
Enjoy!
References
Risk assessment, testing and risk management form the very heart of Emergency Medicine and Critical Care.
Being aware of the evidence surrounding a topic is key to delivering high level care but without an understanding of the underpinning concepts it's application is extremely limited.
Understanding how a test result changes a patient's likelihood of a disease can be described with likelihood ratios, the Royal College of Emergency Medicine has a podcast explaining likelihood ratios in more detail.
But when a test result comes back on the boundary between positive and negative, or at the extremes of positive we can find it difficult to know what this means and that's where interval likelihood ratios comes into play.
Examples include a minimally elevated WCC in a suspected appendicitis, or a dramatically raised d-dimer as compared to a borderline positive result in a suspected pulmonary embolus, this podcast talks through some of those concepts and their application, enjoy!
References
Pulmonary embolism: making sense of the diagnostic evaluation. Wolfe TR. Ann Emerg Med. 2001
This month we cover a paper looking at the role of early craniectomy for raised intracranial pressure, the outcomes associated with advanced airway managements in prehospital cardiac arrest and lastly at the utility on ETCO2 and consider if it's application decreases adverse respiratory events.
This month our great sponsors ADPRAC our giving away a £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 and Links
Capnography for procedural sedation in the ED: a systematic review. Dewdney C, Emerg Med J. 2016
This week the British Thoracic Society have released an updated version of their guidelines on asthma. The document covers all aspects from diagnosis, treatment and follow up, in this podcast we briefly run through some of the aspects covered in the acute management section.
Make sure you have a look at the full document that can be found here https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/
Speak to you soon!
In 2014 NICE updated their guidelines on Head Injury: assessment and early management. This included specific guidance for those patients on warfarin
Guidance regarding the ongoing observation of these patients is not contained within the guideline but as with much of Emergency Medicine variation between departments and regions vary in the threshold to admit patients with a normal CT head due to concerns of these patients developing a delayed bleed.
A recent systematic review and meta analysis on the topic has just been published and we thought it would be worth a look.
The paper gives an interesting take on the risk we are dealing with following a normal scan in presentation to the ED and whilst the papers contained may not be the strongest level of evidence the meta-analysis is probably the best we have to go on at present.
Enjoy and we'd love to hear any of your thoughts!
Here's a look at some of the papers that caught our eye this month.
We cover a paper looking at the the potential benefits of ketofol over propofol for conscious sedation, the role of aggressive blood pressure reduction in haemorrhage stroke and finally a really interesting paper of PE thrombolysis in cardiac arrest.
This month our great sponsors ADPRAC our giving away a £50 iTunes voucher to spend on education/entertainment for you to spend on supporting your work life balance! All you need to do is email through the answer to the following question;
With regards to this September 2016 Papers podcast and The PEA-PETT study, which of the following is correct;
A. The RCT shows a statistically significant benefit in PE thrombolysis intra arrest
B. The paper focussed on peri-arrest thrombolysis
C. The paper was a case series of PE's thrombolysed during arrest
Send your answer via email to contacttheresusroom@gmail.com with your name, answer and iTunes email address, entries close on 15th September and we'll announce the winner in October's podcast.
Enjoy!
References
Where does the role of a chest X-ray lie in major trauma?
With the ever increasing use of CT and ultrasound in the resus room what role does the old school CXR hold? How many injuries will it pick up? How many will it miss? And when is the extra delay justified?
This podcast looks at a recent paper on the topic and some related national guidelines. Enjoy!
References
Burns are a common presentation to the ED and can result in a significant degree or morbidity and mortality.
In this podcast we talk through the approach and treatment of burns along with some controversies in the literature regarding assessment of burn depth and fluid management. Enjoy!
References
SCANRCIT: Pain can’t be used to differentiate between partial and full thickness burns
Here's a look at some of the papers that caught our eye this month.
In this podcast we cover a paper looking at the significance of findings with the history, physical exam and imaging in subarachnoid haemorrhage to inform your work up.
We look at another paper focussing on total body versus selective CT scanning in trauma and lastly a paper looking at the validation of the DECAF score to predict mortality in COPD exacerbations.
We've also got the e book 'ABC of Emergency Radiology' to give away on iTunes thanks to our new sponsors ADPRAC.
All you need to do is answer the following question;
With regards to this August 2016 Papers podcast and REACT-2, which of the following is correct;
A. The use of selective CT scanning in major trauma leads to a dramatic decrease in radiation
B. The use of selective CT scanning in major trauma leads to a decrease in time to diagnosis
C. The use of selective CT scanning in major trauma leads to a decrease in cost per in patient episode
D. The safety of selective CT scanning vs whole body CT scanning was equivocal
Send your answer via email to contacttheresusroom@gmail.com with your name, answer and iTunes email address, entries close on the 15th August and we'll announce the winner in September's podcast.
Enjoy!
If you've had an MI with a STEMI or a new LBBB the decision to go to the cath lab is pretty straight forward. If you've collapsed with a cardiac arrest of presumed cardiac aetiology (the majority of them) and gained a ROSC (return in spontaneous circulation) then the decision to go the the lab immediately is pretty variable and can depend of the clinicians involved, the ECG or the system within which you work.
The Resus Council and the European Society of Cardiology have some guidance on the topic and that is a must read. Today we have a look at a commonly quoted paper in the literature, The PROCAT database, to see if we can shed some light on the topic.
We'd love to hear feedback and comments on the podcast in the comments section. Enjoy!
References
I haven't always read papers and with the time pressures of training and life it's impossible for us to be on top of all of the literature. But over the last few years I've come across some papers that I wish others had told me about.
For some of you this will all be a recap but for others hopefully it will spark an interest and get you to have a look at the papers yourself. We all know that it is extremely rare that one paper alone will or should change our practice but hopefully it's the interest and further questions into a topic that can come out of these papers. Enjoy!
5 References
So the long awaited new NICE Guidelines on Sepsis have just been released. I'm no sepsis expert, I'm not on a panel involved with the guidelines but I am someone who is going to be trying to use these guidelines everyday at work with multiple patients and I'm not the only one....we all are!
In this podcast we run through some of the main points brought up in the new guidelines. Talk about some potential difficulties and join toward some useful resources such as the brilliant flow charts developed by the Sepsis Trust.
Let us know your thought and feedback either via the site www.TheResusRoom.co.uk or on twitter @TheResusRoom. Enjoy!
We have a look at papers covering platelet transfusions for patients on antiplatelets who suffer intracerebral bleeds, the optimal dose for procedural sedation with ketamine in children, a new meta-analysis on the sensitivity of early CT in suspected sub arachnoid haemorrhage and finish up with an amazing case report regarding a hypothermic cardiac arrest
Make sure you go and have a look at the papers yourself to see what the evidence means to you.
Sedation is becoming an ever more significant part of our work in the Emergency Department. At the end of May 2016 the Royal College of Emergency Medicine Published the RCEM Sedation Audit of 2015-2016 that covered more than 8,000 ED sedations throughout the UK (involving more than 190 ED's).
There are some pearls to take out of this great piece of work in which there would seem to be some significant scope to improve. The document not only benchmarks our practice but helps give us a feel for the risks involved.
Have a listen and check out the resources mentioned via the hyperlinks below, most importantly make sure you have a look at the document itself.
Relevant Resources
Carbon Monoxide poisoning is definitely one of those differentials that you consider when the patients books into ED with '?carbon monoxide poisoning'...... but how much do we really think about it in a patient that hasn't been sent down to the ED with this specific thought in mind?
Rob Fenwick talks us through the key points of Carbon Monoxide poisoning and some recent evidence on the topic which will probably make us consider the possibility a bit more frequently! This podcast was based around the post Rob wrote for Jonathan Downham's superb Critical Care Practitioner podcast. Go and have a look at the post for a lot more information on the topic.
For June we have a look at papers covering CT head imaging in delayed trauma presentations, risk stratifying TIAs, early administration of fluids in severe sepsis and most importantly the utility of a biro in a surgical airway.......
Make sure you go and have a look at the papers yourself to see what the evidence means to you.
References
Here's a look at some of the papers that caught our eye this month. We have a look at patient positioning for RSI, the implication of hypothermia on arrival in the ED and the reliability of clinical assessment of syncope in our elderly patients.
Make sure you go and have a look at the papers yourself to see what the evidence means to you.
So this is a talk I gave at the EMCEF 22 conference. This covers a few of the papers we've discussed in the last 6 months on the podcast but a bit of spaced repetition is never a bad thing!
We'll be running through topics on heart failure, sedation, intubation, anaphylaxis and duration of cardiac arrest. The papers are well worth a look and whilst not all high quality evidence they do bring to the front some really interesting questions about are practice and prompt us to challenge our habits. Enjoy!
References
In this episode we were lucky enough to catch up with Sam Sadek, EM Consultant at The Royal London hospital and HEMS doctor and also Zaf Qasim EM Consultant in Delaware in the United States. Both have been heavily involved in the setup and delivery of REBOA service in their respective posts.
In this podcast they share their experience and expertise on the topic of setting up a REBOA service. A huge thanks to both of them as this is a superb podcast for anybody considering getting involved in REBOA.
Recent podcasts on REBOA on ERCAST and EMCrit are essential listening and serve as great preludes to our discussion so make sure you check them out.
Please pop any comments or questions at the bottom of the page and we will come back with a Q&A podcast on the topic really soon!
References
So we were lucky enough to be asked to cover the Trauma Care Conference and specifically today's day focussing on Major Trauma in the Emergency Department. We managed to to get a few minutes of time from some of the superb speakers and get their take home messages from their talks. Enjoy!
Relevant Resources
Rob Fenwick talks to us about this common condition and amongst others throws up a few surprises about the risks of rewarming. Enjoy
Here's a look at some of the papers that caught our eye this month. We cover the best way to diagnose heart failure, the risks associated with hyperopia and the utility of ETCO2. Take the time to have a look at the papers yourself and leave any feed back or comments at the bottom of the page, enjoy!