REBOA, ECMO, Thoracotomy? Where should we be focussing our attention in the world of Pre-hospital care?
We were lucky enough to be invited to the London Trauma Conference on the Prehospital Day supported by the Norwegian Air Ambulance Foundation. The day focussed on the areas we can make a real impact to the outcomes of our pre-hospital critical care patients. We grabbed a few minutes time of the following speakers to hear their thoughts;
Introosseous Access; Jerry Nolan
Pre-hospital Blood products; Jostein Hagemo
Communication under pressure; Dr Stephen Hearn
Pre-hospital Critical Care - what should the near future look like? Dr Stephen Rashford
Have a listen and as always we’d love to hear any thoughts or comments you have on the website and via twitter, and take a look at the references below to draw your own conclusions. We'll be back in the new year with monthly episodes of Papers of the Month and Roadside to Resus; have a great Christmas and New Year and we'll speak to you soon!
Enjoy!
Simon, Rob & James
Well the year has flown by and it's already time for December's Papers of the Month Podcast!
Head injuries are a huge work load for those of us involved in Emergency Care. Identifying those at risk of deterioration from a traumatic brain injury is a priority, as early intervention and prognostication can make a huge difference to patient outcomes. CT scanning is relatively easy to access and with it investigation creep has lowered our threshold of investigation and use of radiology resources; first up we have a look at a paper that looks at the potential benefits from employing a number of different guidelines in identifying the patients with traumatic brain injury, whilst comparing the risk of over investigation.
Next up we have a look at the commonly made diagnosis of urinary tract infection in the older population and a review paper that will help you make the right diagnosis when it's present and not over diagnose when not.
Finally we have a think about the potential benefit of a fluid bolus during induction of anaesthesia for our patients undergoing RSI; can a 500 mL fluid bolus prevent cardiovascular collapse? And we also hear the authors insights on the great RCT.
Make sure to get in touch with any comments on any of the reviews, and importantly make sure you check out the papers and draw your own conclusions.
Enjoy!
Simon & Rob
Angioedema is something we'll all encounter in the acute setting, whether we recognise it or not...
Understanding the different causes and mechanisms is imperative to ensuring the patients get treatment that is not only effective, but in extremis potentially lifesaving. In this episode we talk through the condition; from clinical presentation, causative agents, mechanisms of action, differentials and the evidence base of treatment.
Get in touch with any comments on the podcast, ensure to read the papers that are referenced yourself and draw your own conclusions.
Enjoy!
Simon & Rob
As care on our emergency and urgent care demand is on an ever upwards course, whilst alongside this the scope of what we can potentially deliver to patients is also increasing. In order to meet this demand and to deliver the best care possible to our patients we will need to look for other solutions.
We were lucky enough to be invited to the First Community Emergency at the Royal Society of Medicine in London, hosted by the Physician's Response Unit. This event looked at the current challenges and explored solutions and opportunities for more collaborative working.
In this podcast you'll hear from Tony Joy about the concept and practice of Community Emergency Medicine. You'll hear from Gareth Davies on the history of Pre Hospital Emergency Medicine, both challenges and achievements. Finally you'll hear from Bill Leaning, PRU clinical manager & HEMS paramedic about how to go about setting up a service.
Please let us know any thoughts or feedback, and we'll be back with another podcast on a clinical topic for you in a few days time.
Enjoy!
Simon & James
We've got some papers this month that focus on our sickest patients!
If you had a patient that you found in cardiac arrest and you believed they had a PE, would you thrombolyse them during the arrest, and how much more likely do you think they would be to survive? Our first paper looks at exactly this question.
Second up we consider the potential harms associated with adrenaline administration to those in traumatic arrest.
Finally, when RSI'ing a patient and considering your pharmacological cocktail, how likely are you to reach for the fentanyl and how much concern would you have over the risk of this rendering the patient haemodynamically unstable? We take a look at a recent review on the topic and get Dr. Ian Ferguson's insights as the lead author.
Make sure to get in touch with any comments on any of the reviews, and importantly make sure you check out the papers and draw your own conclusions.
Enjoy!
Simon & Rob
So an incredibly important paper, CRASH-3 has just been published in the Lancet, which looks at the treatment of head injuries with Tranexamic Acid (TXA).
TXA has been shown to save lives in trauma patients at the risk of major haemorrhage, with the notable exclusion of those with head injuries, CRASH-2. TXA has been shown to save lives in those with post parts haemorrhage, WOMAN trial. Time to treatment with TXA has been shown to be hugely influential in it's ability to decrease blood loss and save lives. So has TXA now been shown to save lives in head injuries?
In this episode we run through the paper and are lucky enough to have an interview with the lead author, Professor Ian Roberts.
Have a listen, read the paper and as always we’d love to hear any thoughts or comments you have on the website and via twitter, and take a look at the references below to draw your own conclusions.
Enjoy!
Simon, Rob & James
References
The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.Roberts I. Health Technol Assess. 2013
CRASH-2;The Bottom Line
Effectof earlytranexamic acidadministrationon mortality, hysterectomy, and othermorbiditiesin womenwith post-partum haemorrhage(WOMAN): an international, randomised, double-blind, placebo-controlledtrial. WOMANTrialCollaborators.Lancet 2017
WOMAN Trial;The Bottom Line
Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients.Gayet-Ageron A. Lancet. 2017
Tranexamic Acid - The Mechanism of Action;Video
Tranexamic Acid, Time to Treatment;The Resus Room
Does earlier TXA save lives?St Emlyns
TXA podcast; PHEMCAST
About CRASH-3; LSHTM
Welcome to October '19 papers podcast.
You can't go far without the topic of TXA as a treatment for anything that bleeds being mentioned! With the publication of CRASH-2 and the WOMAN trial practice has crept such that administration in gastro-intestinal bleeding is seen fairly frequently. However, current guidelines don't recommend the use of TXA in GI bleeding, so this month we have a look at a systematic review which looks to answer whether it's administration is supported by the evidence, before we get a definitive answer from the HALT-IT trial.
Next up, following on from our Burns Roadside to Resus podcast, we take a look at a paper that quantifies the potential benefit of thorough first aid in the management of paediatric burns, a really key paper on the topic, with really powerful results.
Finally, we all know that Sepsis is a core area of our practice, but at times it may feel like the attention on those that could possibly have severe sepsis displaces the ability to care for other critically ill patients. We take a look at a great paper developing a prehospital screening tool to focus in on those patients that really do require time-critical care.
Enjoy!
Simon & Rob
So as promised, and following on from our previous shock episode, this time we've covered the topic of shock in Trauma. It's a massive topic and one that we all, yet again, can make a huge difference for our patients' outcomes.
There is some crossover as you'd expect from the concepts and assessment that we covered in our Shock episode, so we'd recommend taking a listen to that one first. Make sure you have a comfy seat and plenty of refreshments to keep you going for this one as we cover the following;
As always we’d love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions.
Enjoy!
Simon, Rob & James
References
Shock;The Resus Room podcast
REBOA;The Resus Room podcast
External Haemorrhage;The Resus Room podcast
Blood;PHEMCAST
TEG & ROTEM;FOAMcast
Major Trauma guideline;NICE
Resuscitative endovascular balloon occlusion of the aorta (REBOA):a population based gap analysis of trauma patients in England and Wales
Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. Joseph B. JAMA Surg. 2019
The Pre-hospital Management of Pelvic Fractures: Initial Consensus Statement. I Scott. FPHC. 2012
RePHILL;Birmingham University Trials
Assessment and Treatment of Spinal Cord Injuries and Neurogenic Shock;Fox A. JEMS
Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. Holcomb JB. JAMA. 2015
Risks and benefitsof hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis. Owattanapanich N. Scand J Trauma Resusc Emerg Med. 2018
The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.Roberts I. Health Technol Assess. 2013
TEG and ROTEM for diagnosing trauma‑induced coagulopathy (disorder of the clotting system) in adult trauma patients with bleeding;Cochrane Review. 2015
Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review.McQuilten ZK. Transfus Med Rev. 2018
Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock.Sperry JL. N Engl J Med. 2018
We start off this month with a much talked about paper in the pre-hospital services, what benefit does Pre Hospital Critical Care bring to cardiac arrest victims? We are lucky enough to have the inside thoughts of the lead author, this a really interesting piece of work and will no doubt lead to further discussions, for more information from the author take a look at his thesis here.
Next up we take a look at the utility of troponins in patients that have suffered cardiac arrest, can we use them to evaluate how likely it was that an MI precipitated the arrest?
Last up we have a look at a novel approach of ruling out stroke as the cause of acute dizziness.
We'd love to hear your thoughts and comments.
Enjoy!
Simon & Rob
Following on from our previous Roadside to Resus episode on Stroke, in this episode we look at the rapidly evolving area of stroke management.
In the last 2 decades stroke management has progressed beyond recognition and keeping up with the evidence and available therapies is a significant challenge. We cover the following treatments, looking at the risks and benefits of each, with the goal of being able to offer our patients the best possible outcomes;
As always we’d love to hear any thoughts or comments you have on the website and via twitter.
Enjoy!
References
Well the summer has definitely hit and we hope you get a chance for a break... making sure you spend spend some time listening to our Heat Illness episode on a beach somewhere!
It's a wide variety of papers for you this month;
Should we be looking to immediately cardiovert acute onset AF in the ED? What difference does glucagon make to clearing oesophageal foreign bodies? How important is our diagnostic accuracy in ED to the patients morbidity and mortality? And finally we cover a paper looking at the requirement for urgent tracheal intubation in trauma patients, and are lucky enough to get some thoughts from the lead author Dr. Kate Crewdson.
We'd love to hear your thoughts and comments.
Enjoy!
Simon & Rob
Stroke is a common presentation to all Emergency Health care providers, with around 150,000 strokes occurring in the UK each year! Our impact and treatment can be hugely significant and in this podcast we’re going to conver the topic in some depth, and importantly cover some of the new Guidance published by NICE in their ‘Stroke and transient ischaemic attack in the over 16’s diagnosis and initial management’ document that was published in May of this year.
We'll be running through
As always we’d love to hear any thoughts or comments you have on the website and via twitter.
Enjoy!
References
RCEMLearning; RCEM Belfast Vertigo
Acute Stroke Lecture notes; LITFL
Are you at risk of a Stroke; Stroke Association
Modifiable Risk Factors for Stroke and Strategies for Stroke Prevention.Hill VA. Semin Neurol. 2017
A systematic review of stroke recognition instruments in hospital and prehospital settings. Rudd M. Emerg Med J. 2016
Acute Stroke Diagnosis.Kenneth S. Yew. Am Fam Physician. 2009
Welcome back!
This month we're finishing off our theme of syncope with a paper that looks to answer the big question; in those with undifferentiated syncope, does hospitalisation result in better outcomes when compared to discharge?
We have a look at a paper reviewing the feasibility of live streaming video from scene using the 999 caller's mobile phone, a fantastic utilisation of technology and a really exciting area; we also get the thoughts of one of the co-authors, Richard Lyon, Associate Medical Director for KSS.
Finally we take a look at a paper reviewing the time on scene in cardiac arrests, that suggests if no ROSC is gained, rapidly getting off scene is in our patients' interest.
We'd love to hear your thoughts and comments.
Enjoy!
Simon & Rob
If you live in the UK you may be fooled in to thinking that Heat Illness isn't really something we need to worry about...but you'd be wrong! Each year there are 800 deaths due to Heat Illness and figures in more temperate climates are significantly more.
In this podcast we tackle the topic of Heat Illness, all the way through Heat Cramps, Heat Syncope, Heat Exhaustion and to Heat Stroke.
We'll cover the following;
As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you, and most importantly, we hope we haven't missed the summer heat wave...!
Enjoy
Simon, Rob & James
Status Epilepticus in children, lying and standing blood pressures in syncope or presyncope and decompressing paediatric tension pneumothoraces.
You'll no doubt have seen and heard about the two papers published this month in the Lancet, both Consept and Eclipse look at the use of keppra vs phenytoin as a second line anti convulsant therapy for children in status epilepticus. We take a look at both papers, and have a think about what this means for practice.
There has been a large amount of focus on the optimal position for needle decompression of tension pneumothoraces in adults, but an open access paper from SJTREM looks at the best position in children, take a look at the paper here.
Finally, should all patients with a presentation of syncope/presyncope be getting a lying and standing blood pressure, or is it an ineffective test?
Make sure you take a look at the papers yourself, remembering that the paper from SJTREM on paediatric pneumothoraces is totally open access.
We'd love to hear your thoughts and comments.
Enjoy!
Simon & Rob
Drowning is a huge worldwide problem, and here in the UK there are around 350 accidental deaths from drowning each year.
From the patient who is potentially well enough for discharge on scene, all the way through to the resuscitation and prognostication of a cardiac arrest due to drowning, the topic carries a number of unique questions and challenges.
In this podcast we run through;
As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you.
Enjoy!
Simon, Rob & James
So first up a huge welcome to SJTREM, the free open access journal who we've teamed up with in the delivery of the podcast, every paper they publish is available online to read for free.
Each month we'll be covering one of their papers in our Papers of the Month episodes, giving you the opportunity to review the literature yourself, come to your own conclusions and join the conversation. SJTREM have made our podcast a sustainable venture and together we look forward to promoting review and discussion of the best evidence and education, to all, for free!
This month we'll be looking at an analysis of REBOA and having a think about whether it is benefiting those patients that are receiving it. We take a look at paper that reviews what we really know about the use of ETCO2 in cardiac arrest and have a think about how much importance we should put on it. Finally we take a look at the utility of prehospital blood gases; should this be the standard of care, or is it a step too far?Make sure you take a look at the papers yourself, remembering that the paper from SJTREM on prehospital blood gases is totally open access.
We'd love to hear your thoughts and comments.
Enjoy!
Simon & Rob
'Patients with GCS scores of 8 or less require prompt intubation', that's what ATLS tells us.
The mantra of GCS 8, intubate has pervaded teaching for those involved in the management of patients with a reduced GCS (Glasgow Coma Scale). But on reflection it would seem slightly odd that the gain or loss of a single point on the Glasgow Coma Scale could simply account for a change in the decision as to whether a patient would benefit from intubation and ventilation. So should the patient with a GCS of 9 be best managed without a definitive airway, but when that slips to 8 we should reach for the portex®?
In this podcast we take a deeper look at the GCS, we have a think about the role that it was designed to perform and consider how it should best be applied to acutely ill patients when considering protecting their airway.
The podcast is based upon the blog from the TEAM Course blog(Training in Emergency Airway Management), make sure to go and have a look at the post and other resources available on that site.
Enjoy!
References
Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.2013;74(5):1363-6.Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4.
So we've got a massively important paper that we're going to kick off April's Papers of the Month podcast with, which is the RCT we've been waiting for; whether patients who have a ROSC should go to the cath lab, without a stemi, if the presumed cause is a coronary event? We've covered this topic in the past, for a background take a listen to PCI following ROSC and our December '17 papers of the month podcast.
Next up, on the topic of over-testing, we have a look if we should be sending troponins and BNP's on our patients attending with syncope.
Lastly, having spoken recently about the importance of ED airway registry's, we take a look at an open access paper from SJTREM that describes the practice, success and complication rates of ED advanced airway management.
As always make sure you take a look at the papers yourselves and draw you own conclusions, we'd love to hear your thoughts.
Enjoy!
Simon & Rob
References & Further Reading
Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. Lemkes JS. N Engl J Med.2019
Do High-sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope? Clark CL. Acad Emerg Med.2019
Airway Management in the Emergency Department(The OcEAN-Study) - a prospective single centre observational cohort study. Bernhard M. Scand J Trauma Resusc Emerg Med.2019
PCI following ROSC podcast
December 2017; Papers of the Month Podcast
We were lucky enough to be back at the fantastic TraumaCare Conference last week.
There were a whole host of fantastic talks on offer and the Emergency Medicine stream, arranged by our very own Rob Fenwick, included a pro/con debate on whether Emergency Medicine should be managing the trauma airway. During that debate a number of important papers were raised on the evolution and improvement in advanced airway management. In this podcast we'll run through some of the most important points from that talk.
Make sure you take a look at the papers yourself and come to your own conclusions.
Enjoy!
Simon & Rob
We've got a broad array of topics and papers for you this month!
First up we look at a paper from the NEJM assessing the potential benefits in providing ventilations to patients undergoing an RSI. Next we look at patients presenting with both syncope and pre-syncope to the emergency department, this paper quantifies the risk that we should be apportioning to these two different presentations. Finally, we look at a paper that suggests the manual pulse check in CPR is dead, and that the time has come for doppler and ultrasound to replace it!
As always make sure you take a look at the papers yourselves and draw you own conclusions, we'd love to hear your thoughts.
Enjoy!
Simon & Rob
References & Further Reading
Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. Casey JD. N Engl J Med.2019
Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope. Bastani A. Ann Emerg Med.2019
Comparison of manual pulse palpation, cardiac ultrasonography and Doppler ultrasonography to check the pulse in cardiopulmonary arrest patients. Zengin S. Resuscitation.2018
Hypothermia is a common problem for both pre and in-hospital clinicians. Understanding the underpinning physiology helps us deliver first class care to our patients, decreasing associated morbidity and mortality.
There is some extremely difficult decision making to be done in severe cases of hypothermia and the podcast gives us an opportunity to explore them further.
We'll cover the subject in depth with particular reference to the following categories of hypothermia; treatment, modifications in cardiac arrest and prognostication.
Enjoy!
Simon, Rob & James
References
ERC 2015; Cariac arrest in specialist circumstances
LITFL; hypothermia
RCEMLearning; hypothermia
Up to Date; Hypothermia
At the bedside, out of the cold: management of hypothermia and frostbite.BiemJ.CMAJ. 2003
The prehospital management of hypothermia - An up-to-date overview. Haverkamp FJC. Injury. 2018
Accidentalhypothermia-an update: The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Paal P. Scand J Trauma Resusc Emerg Med. 2016
Accidental hypothermia. Brown DJ. 2012 N Engl J Med.
Ketamine and trauma are the topics for this months papers.
The three papers we cover are really important for all of us involved in the care of critically unwell patients. Hypotensive resuscitation in the context of trauma has been an evolving area of practice in the treatment of our acute trauma victims. A paper published in SJTREM this month meta-analyses the data that exists out there on the topic and looks to give us an idea of the benefits and potential risks associated with such an approach, the paper is available here and is well worth a full read.
Morphine has been a mainstay of the treatment of acute severe pain in the Emergency Department for decades, but as the popularity of ketamine grows we take a look at another meta-analysis, this time comparing the efficacy of ketamine versus morphine in this setting and group of patients.
And lastly, if you have ever had a patient become severely agitated with ketamine sedation, you'll be keen to avoid that happening again! The last paper we look at is a randomised control trial looking at the potential benefits of using either midazolam or haloperidol to achieve that.
We hope you find the podcast useful, as ever please go and take a look at the papers yourself and we'd love to hear any thought or comments you have either rat the bottom of the page, or via twitter @TheResusRoom.
Enjoy!
Simon & Rob
References
Risks and benefits of hypotensive resuscitation in patientswith traumatic hemorrhagic shock: a meta-analysis. Owattanapanich N. Scand J Trauma Resusc Emerg Med.2018
A Systematic Review and Meta-analysisof Ketamine as an Alternativeto Opioids for Acute Pain in the Emergency Department. Karlow N. Acad Emerg Med.2018
Premedication With Midazolamor Haloperidolt o Prevent Recovery Agitation in Adults Undergoing Procedural Sedation With Ketamine: A Randomized Double Blind Clinical Trial. Akhlaghi N. Ann Emerg Med.2019
St Emlyns; JC: Should we premedicate for ketamine sedation?
If you're involved in the care of critically unwell patients then you will frequently encounter patients who are shocked. The European Society of Intensive Care Medicine defines shock as;
'Life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen utilization by the cells. It is a state in which the circulation is unable to deliver sufficient oxygen to meet the demands of the tissues, resulting in cellular dysfunction.’
The assessment for shock needs to be part of the routine workup of every potentially unwell patient. Shock carries with it a high mortality rate, a range of meaningful interventions and the potential to make a real difference to our patients' outcomes.
In this podcast we cover
As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you.
Enjoy!
References
Consensuson circulatory shockand hemodynamic monitoring. Task forceof the EuropeanSociety of Intensive Care Medicine. Cecconi M. Intensive Care Med.2014
NICE Intravenous fluid therapy in adults in hospital. Clinical guideline. December 2013
ALIEM; Choosing the right vasopressor agent in hypotension
Resus; The Shock Index
ALIEM; Shock Index: A Predictor of Morbidity and Mortality?
A comparisonof the shockindexand conventionalvital signsto identifyacute, critical illnessin the emergency department. Rady MY. Ann Emerg Med.1994
TheResusRoom; Sepsis
RCEM guidance; Noradrenaline Infusion
Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Puskarich MA. Crit Care Med. 2011
Early goal-directed therapy in the treatment of severe sepsis and septic shock.Rivers E. N Engl J Med. 2001
Early lactate clearance is associated with improved outcome in severe sepsis and septic shock.Nguyen HB. Crit Care Med. 2004
Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.Jones AE. JAMA. 2010
A randomized trial of protocol-based care for early septic shock.ProCESS Investigators. N Engl J Med. 2014
Early goal-directed therapyin the treatmentof severe sepsisand septic shock. Rivers E. N Engl J Med.2001
The significance of non-sustained hypotension in emergency department patients with sepsis.Marchick MR. Intensive Care Med. 2009
Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis.Natthida Owattanapanich. Scand J Trauma Resusc Emerg Med. 2018.
TheResusRoom; The Crystalloid Debate
Happy New Year!! Hopefully you got a bit of downtime over the festive period and are feeling suitably refreshed and ready to attack 2019!
We've got 3 great papers to kick off the year. First up we look at the recent PReVENT trial which looks at ventilator strategies in patients without ARDS with respect to tidal volumes. This paper continues the work from the much cited ARDSNet paper from 2000, and we'd highly recommend you go and have a look at that paper first.
Next we look at another paper from JAMA which compares Thrombolysis to Aspirin in minor non-disabling strokes. We say enough about this one in the podcast, but for a bit of background to our thoughts and the evidence surrounding stroke, check out our previous Stroke Thrombolysis podcast.
Lastly we have a look at a paper investigating their systems use of push-dose-pressors, which whilst not the most methodologically sound piece of research, certainly brings out some interesting thoughts and points.
As always make sure you take a look at the papers yourselves and we'd love to hear and comments or feedback you've got.
Enjoy!
Simon & Rob
References & Further Reading
EMCrit; Vent and Prevent, an update