The Resus Room (Simon Laing, Rob Fenwick & James Yates)

Happy New Year!!!

We hope you've had some time off over the festive period and now we're back to kick start the new year with three more great papers.

Syncope is common presentation to the Emergency Department, accounting for 1% of presentations. Without a clear precipitant of the event it can be challenging to identify those patients who have a higher risk of associated morbidity and mortality, and furthermore those who would benefit from further investigation and observations. Our first paper looks at syncope risk-stratification tools and sheds some light on their utility.

Acute exacerbations of COPD with acute type 2 respiratory failure and frequently treated with non-invasive ventilation (NIV), with high flow nasal oxygenation a treatment normally for patients in type 1 respiratory failure. However our second paper is a fantastic RCT looking at the the application of either NIV or high flow nasal oxygenation in those type 2 COPD exacerbations, are both options for our patients?

Finally, since the advent of trauma networks in the UK, prehospital patients have been triaged to the most relevant centre based upon trauma triage tools. Our third paper looks at the performance of these tools and gives valuable insights for both those clinicians using the tools and those receiving trauma patients in both MTCs and other trauma units.

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

Simon & Rob

Drug ingestion both accidental and intentional accounts for a significant proportion of attendances at UK Emergency Departments and 999 calls.

In 2016 there were >2,500 registered deaths in England and Wales related to drug misuse, which had increased by nearly 60% in a decade.

So without a doubt we are all going to come across critically unwell patients with drug ingestions. But inappropriate drug use is not confined to illicit substances, with many prescription drugs being misused to ill effect and also overdosed in an attempt to end patients lives.

In this podcast we’re going to run through the assessment of patients presenting with a possible drug ingestion, cover the potential toxidromes you may encounter and talk about the management of these presentations. Specifically we take a look at serotonin syndrome, sedative toxidrome and both cholinergic and anti-cholinergic syndrome.

In next months Roadside to Resus we'll take a look at specific medications of overdose; paracetamol, beta blockers, calcium channel blockers and the intricacies of their management along with other key parts of critical care including the management of cardiac arrest due to toxicity.

Make sure to take a look at the references and resources below.

Enjoy!

Simon, Rob & James

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

Evidence-based emergency medicine/skills for evidence-based emergency care. Interval likelihood ratios: another advantage for the evidence-based diagnostician. Brown MD. Ann Emerg Med. 2003

Pulmonary embolism: making sense of the diagnostic evaluation. Wolfe TR. Ann Emerg Med. 2001

Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. Schouten HJ. BMJ. 2013

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!

Prehospital Sodium Bicarbonate Use Could Worsen Long Term Survival with Favorable Neurological Recovery among Patients with Out-of-Hospital Cardiac Arrest. Kawano T, et al. Resuscitation. 2017

Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature. Velissaris D, et al. J Clin Med Res. 2016

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

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

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

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

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

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

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

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

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

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

Rob & James

Being in a situation of being unable to intubate and unable to oxygenate is an absolute time critical emergency. 

Focus needs to be paid to the techniques and strategy to deal with this situation. But we also need to consider steps to ensure it occurs at a low frequency and our decision making and recognition of the situation happens quickly and simply.

In the episode we’re going to be talking about a number of other aspects that are relevant for all emergency providers, irrespective of whether you intubate or not, along with how those aspects translate into everyday practice. 

We'll be covering bits around patient positioning, optimising simple ventilation via a BVM & supraglottics, all the way through to needle cricothyroidotomy and surgical airways.

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

Enjoy!

Simon, Rob & James

Welcome back to October's Papers Podcast, this month we move airway from advanced airway management and bring you a broad array of papers.

First up we have a look at the relative success of a variety of pharmacological strategies for managing the acutely agitated patient in ED. Next up we have look at the well know CURB-65 score and it's ability to predict the need for critical care interventions. Lastly, we may all feel at times that performing a CT head on those well patients solely because they take anticoagulants may be a little on the excessive side, we review a paper that looks at the yield of positive scans in this cohort.

As ever don't just take our word for it, go and have a look at the papers yourself, we would love to hear any comments or feedback you have.

Enjoy!

Simon & Rob

References & Further Reading 

IntramuscularMidazolam, Olanzapine, Ziprasidone, or Haloperidolfor TreatingAcuteAgitationin the Emergency Department. Klein LR. Ann Emerg Med. 2018

Performanceof the CURB-65Scorein PredictingCritical CareInterventionsin PatientsAdmitted With Community-AcquiredPneumonia.Ilg A. Ann Emerg Med.2018

Incidenceof intracranial bleedingin anticoagulatedpatientswith minor head injury: a systematic review and meta-analysis of prospective studies. Minhas H. Br J Haematol.2018

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!

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

Fractures of the pelvis are found reasonably often in major trauma, but they’re a really challenging presentation. They are difficult to assess and accurately diagnose in the prehospital setting, mortality rates are high, particularly in patients with haemodynamic instability and there are often associated injuries. Associated mortality from patients with pelvic fractures who reach hospital is reported to be up to 19%, with mortality rates as high as 37% reported in the presence of haemodynamic instability.

In this episode we'll run through pelvic injuries, all the way from anatomy and mechanisms of injury, to assessment and management.

As always make sure you have a look at the references and supporting material attached in the show notes, and get in touch with any questions or comments and take care of yourselves.

Enjoy!

Simon, Rob and James

We talk a lot about the different skills involved in the management of the critically unwell patient; CPR, airway management, defibrillation, chest drains, RSI etc, etc…..but there is another aspect which is arguably as important and that is the non-technical skills involved in resuscitation.

In this podcast we discuss non-technical skills, followership, leadership and different models of working. What’s really important to remember in this episode is that at the centre of  leadership and follwership is a patient, or patients, that we’re trying to deliver the best care and outcomes for and that effective leadership and followership are key to achieving.

Now leadership and followership comes in a variety of places but for this episode we’re mainly going to look at the importance and way in which leadership and follower ship manifests itself in high acuity cases such as traumas and cardiac arrests but the concepts are translatable to all sorts of cases and parts of healthcare.

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

Enjoy!

Simon, Rob & James

Welcome to November’s papers of the month podcast!

This month we kick things off looking at TXA in trauma and consider in complex scenes and resource limited environments if TXA could be administered effectively in an IM rather than IV route? We also get an authors inside view from Professor Ian Roberts.

Next up; does the anatomical location of a head injury affect the risk of an intracerebral bleed and could this affect those patients that can go without a scan?

And finally we have a look at the importance of a chest X-ray in COVID-19 and consider how accurate the X-ray is at both picking up and ruling out the infection.

Enjoy!

Simon & Rob 

Welcome back! This month we take a look at 3 papers covering the breadth of Emergency Care.

First up we look at a paper evaluating outcomes for patients discharged on scene by an EMS service; how many reattend ED, how many require ICU care and what is the associated mortality rate?

NEXUS and Canadian c-spine rules both incorporate the presence of c-spine tenderness when deciding whether to image the neck as a result of trauma. But what is the prevalence of c-spine tenderness without trauma and how might that affect our clinical assessment?

Finally we take a look at a paper focussing on the risk of laryngospasm in paediatric sedation; what is the risk, which factors make it more likely to occur, and what can we do to mitigate it's risk?

Enjoy!

Simon & Rob

Welcome back to the podcast and to November's Papers Of The Month.

First up we're taking a look at a paper that challenges the current American Heart Association (AHA) and European Society of Cardiology (ESC) guidelines that recommend when right ventricular myocardial infarction, that patients are not administered nitrates due to the risks of compromise of cardiac output. 

Secondly we look at an RCT, with some really clever blinding, that looks at different BP targets for intubated and ventilated patients in ICU who have sustained a cardiac arrest.

Finally we take a look at a paper focussing on healthcare professionals’ perceptions  of interprofessional teamwork in the emergency critical incidents.

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

Simon & Rob

Acute Behavioural Disturbance (ABD), one of the most challenging, dangerous and serious presentations that we will encounter in emergency management of patients.

There is no widely accepted definition of ABD. Really it’s an umbrella term for a patient presenting with a triad of features, secondary to a specific underlying cause, made up of;

• Delirium
• Severe agitation and aggressive behaviour
• Autonomic dysfunction

In this episode we're going to run through ABD, it's causes, the approach and investigation. Excellent management of these cases relies upon high quality team working, planning, communications and strategies to keep all involved safe and we'll be discussing each of those in turn.

Enjoy!

Simon, Rob & James

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!

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

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!

Simon, Rob & James

References & Further Reading

Resuscitation to Recovery Document

Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. Niklas Nielsen. N Engl J Med 2013

Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Dumas F. Circ Cardiovasc Interv. 2010

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

Roadside to Resus; Cardiac Arrest

PCI following ROSC; TRR

C-spine immobilisation is a controversial topic because of a lack of high quality evidence from clinical trials. Historical approaches have been challenged, however NICE guidance continues to recommend 3-point immobilisation for all patients with suspected spinal injury despite considerable clinical equipoise.

So we're back from our summer hiatus with a real treat. The long awaited AIRWAYS-2 paper has just been released and we've been lucky enough to speak with the lead author, Professor Jonathan Benger, about the paper and discuss what the findings mean for cardiac arrest management.

AIRWAYS-2 looks at the initial advanced airway management strategy for paramedics attending out of hospital cardiac arrests, essentially whether or not the aim should be to place a supraglottic airway device or an endotracheal tube when advancing from simple airway techniques. The study was a huge undertaking with many speculating over how the results would change practice, including discussion of how it may affect paramedic's practice of intubation, all of which we cover in the podcast.

Before you listen to the podcast make sure you have a look at the paper yourself, have a listen to PHEMCAST's previous episode which covers the study design and have a look at the infographics on the website which summarise the primary outcome and secondary analysis and which we refer to in the interview with Professor Benger.

In the podcast we refer to Jabre's paper which can be found below and we also covered in May's papers podcast. Have a listen to the interview and let us know any thoughts or feedback you have, we're sure this one will create a lot of discussion!

Simon, Rob & James

References & Further Reading

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. The AIRWAYS-2 Randomized Clinical Trial. Benger J. JAMA. 2018

PHEMCAST; the LMA

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomised Clinical Trial. Jabre P. JAMA. 2018

TEAM Course

Motor vehicle collisions or road traffic collisions are a massive problem worldwide. Data from the World Health Organisation reports that there are around 1.2 million deaths every year and this is the leading cause of death internationally for children and young adults aged 5-29 years. 

In the UK there are around 1,500 deaths annually and also around 60,000 patients with significant and life changing injuries, which is 7 patients every hour!! So anything we can do to improve patient care following an MVC is definitely a worthwhile venture.

We’ve looked at Extrication here on the podcast before but we’re back on it again because today the Faculty of Pre Hospital Care have released their Consensus Statement on Extrication Following a Motor Vehicle Collision. 

The statement builds on the work from the EXIT project and the research that has helped inform our understanding of multiple factors of extrication. The statement will inform a change of practice for both clinicians and non-medical responders and in this episode we run through the statement with two of it’s authors and discuss the practical applications.

Make sure you take a look at the new Consensus Statement itself and the background evidence which is all linked to on the website.

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

Simon, Rob & James

Acute Kidney Injury is common, complicated and holds significant morbidity and mortality. But...if we recognise it, we can make a real difference to our patients' outcomes.

In this episode we run through the anatomy, physiology and aetiologies.

We have a think about the multitude of definitions of AKI and then take each of the pre renal, renal and post renal categories and think about the ways we can optimise our care in each.

We also have a think about who needs to be admitted and who can be safely managed in the community.

This was a hugely valuable episode for us all to research and bring clarity to a complicated topic, we hope it does the same for you too!

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

Simon, Rob & James

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

Welcome back to December’s paper of the month podcast!

In the first paper this month we take a look at a paper that assesses the utility of CT scans for patients presenting with fever of an unknown origin; could this help us identify the source more frequently and if so how often?

Next, we often focus on the specific of medical management in cardiac arrest, but what impact does witnessing a cardiac arrest have on bystanders and could this affect the way we interact and behave on scene?

Lastly we consider those patients that require a prehospital anaesthetic following return of spontaneous circulation from a medical cardiac arrest. Does the choice of induction agent between midazolam and ketamine affect the likelihood of hypotension and other complications?

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

Simon & Rob

This is the first of two episodes looking at pneumothoraces. In this episode we're going to start out by taking a look at traumatic pneumothoraces.

Traumatic pneumothoraces are present in about a fifth of multiple trauma patients, so it's not infrequent to come across them and they can obviously occur in those with isolated chest injury too. Thoracic trauma occurs in around two thirds of multi-trauma cases and is classified as the primary cause of death in a quarter of trauma patients.

The clinical assessment carries with it a fair amount of dogma, including looking for tensions with tracheal deviation, so we'll be running through what the signs we should look for actually mean.

Then we'll move on to a detailed discussion about investigation strategies before finally looking at the guidelines and evidence on the topic, including which we have to intervene with, which we probably shouldn't and those in which there is much uncertainty...

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

Enjoy!

Simon, Rob & James

ps; if you’re interested in getting your site involved with the CoMITED Trial then email comited-trial@bristol.ac.uk 

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!

Simon, Rob & James

References & Further Reading

Resuscitation to Recovery Document

"Kids Save Lives": Educating Schoolchildren in Cardiopulmonary Resuscitation Is a Civic DutyThat Needs Support for Implementation. Böttiger BW. J Am Heart Assoc. 2017

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

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

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

Thrombolysis during resuscitation for out-of-hospital cardiac arrest. Böttiger BW. N Engl J Med. 2008

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

Effect of epinephrine on survival after cardiac arrest: a systematic review and meta analysis. Patanwala AE. Minerva Anestesiol. 2014

Impact of cardiopulmonary resuscitation duration on survival from paramedic witnessed out-of-hospital cardiac arrests: An observational study. Nehme Z. 2016 Mar;100:25-31. doi: 10.1016/j.resuscitation.2015.12.011. Epub 2016 Jan 13.

Predicting in-hospital mortality during cardiopulmonary resuscitation. Schultz SC. Resuscitation. 1996

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

End-tidal CO2 as a predictor of survival in out-of-hospital cardiac arrest. Eckstein M. Prehosp Disaster Med. 2011

LITFL; cessation of CPR

Welcome to February's papers of the month. This time we're talking about decompressing tension pneumothoraces, nasal oxygenation, prognosis of cardiac arrest with respect to duration and more!

Head injury worldwide is a significant cause of morbidity and mortality.

Besides prevention there isn't anything that can be done to improve the results from the primary brain injury, there is however a phenomenal amount that can be done to reduce the secondary brain injury that patients suffer, both from a prehospital and in hospital point of view.

In the podcast we run through head injuries, all the way from initial classification and investigation, to specifics of treatment including neuro protective anaesthesia and hyperosmolar therapy, to give a sound overview of the management of these patients.

As always we welcome feedback via the website or on Twitter and we look forward to hearing from you.

Enjoy!

Simon, Rob & James

References & Further Reading

Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016

Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned? Boone MD. Surg Neurol Int. 2015

Life in the fast lane; hypertonic saline

Life in the fast lane; Traumatic brain injury

Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality. T Lawrence. BMJ Open. 2016

Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. M.Majdan. The Lancet. 2016

The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. Gale SC. J Trauma. 2005

What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population? Rotheray KR. Resuscitation. 2012

NICE Head Injury Guidelines 2014

MDCALC Canadian Head Injury

TheResusRoom; The AHEAD Study

TheResusRoom; Anticoagulation, head injury & delayed bleeds

Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement 

A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries. Manara AR. J Intensive Care Soc. 2016

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 

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?

We've heard a lot about advanced airway management recently, with some really significant publications over the last few months and in the last few weeks in JAMA we've had another!

Cricoid pressure during emergency anaesthesia and for those at high risk of aspiration has been common place for more than half a century. But it's a topic that has caused quite some debate. On one hand it has the potential to reduce aspiration, a very real and potentially very serious complication of RSI. But on the other it has the potential to hinder the view on laryngoscopy and decrease first pass success.

The founding evidence for cricoid pressure has always been a little soft. In this podcast we look at the background of cricoid pressure and then run through this key paper, discussing the implications it holds for both pre and in-hospital advanced airway management.

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

References

Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anaesthesia: The IRIS Randomized Clinical Trial. Birenbaum A. JAMA Surg 2018

Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Sellick BA Lancet.1961

Safer Prehospital Anaesthesia 2017;AAGBI

JC: Cricoid Pressure and RSI, do we still need it?St Emlyn’s

Cricoid: To press, or not to press?(Hinds and May)

This month we're looking at the JAMA paper on the new sepsis definitions, adverse event rates in ED sedation, interventional treatment for the over 80's with ACS and more!

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

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

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

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

Simon & Rob

So we're back with September's papers of the month a little later than usual but we wanted to give you a little time to digest AIRWAYS-2... before we give you some more prehospital research on advanced airway management in cardiac arrest!

The American version of AIRWAYS-2, PART, has just been released in JAMA, looking at the laryngeal tube versus endotracheal intubation as a primary strategy for advanced airway management. The paper is fascinating accompaniment to AIRWAYS-2.

Next we have a look at a paper assessing Emergency Medicine clinicians' ability to predict hospital admission at the time of triage, should we be making early calls on the destination of our patients?

Finally we have a look at the potential role of esmolol in cases of refractory VF and a paper that reports twice the survival rates in those that receive it!

As always we strongly suggest you have a look at the papers yourself and come to your own conclusions. Make sure you check out the hyperlinked blogs below that we mention in the podcast that contain some fantastic critiques. We'd also love to hear any comments either at the foot of this page or on twitter to @TheResusRoom.

Enjoy!

Simon & Rob

References & Further Reading

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac ArrestA Randomized Clinical Trial. Henry E. Wang, MD. 2018

Emergency medicinephysicians' abilityto predicthospital admissionat the timeof triage. Vlodaver ZK. Am J Emerg Med.2018

Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patientswith refractory ventricular fibrillation. Driver BE. Resuscitation.2014

King Laryngeal Tube

Tranexamic Acid (TXA) has gained a significant amount of attention over the last few years as multiple studies have shown it's utility in decreasing haemorrhage and associated mortality. It has become part of major trauma guidelines, post part haemorrhage protocols and many have adopted it to the management of traumatic brain injury. The findings have been very similar across a spectrum of haemorrhage disease processes and from this further interest in expanding TXA's application to pretty much anything that bleeds. Time from onset of the bleeding has been shown to be important, with it's effect decreasing from time of onset to its administration.

Gastro-intestinal bleeding is a significant cause of morbidity and mortality. Previous meta-analyses have shown favourable outcomes for TXA in GI bleeds and many have already adopted TXA into this area of practice, although guidance from NICE does not yet recommend it.

HALT-IT is a multi centre, international, randomised double blind controlled trial of near 12,000 patients that has just been published in the Lancet. The study was a huge piece of work and looks to definitively answer the question of whether we should be giving TXA to patients with life threatening GI bleeds. In this podcast we run through the ins and outs of the paper ad are lucky enough to speak to the lead author Ian Roberts about the findings, some of the intricacies of the trial and what the results mean for practice.

Enjoy!

Simon, Rob & James

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

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

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

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

Simon & Rob

So the Resuscitation Council UK have today published new guidelines on resuscitation based on the European Resuscitation Council 2021 Guidelines and recommendations from the International Liaison Committee on Resuscitation.

We were lucky enough to catch up with two key members of both ERC and RCUK, Gavin Perkins and Jasmeet Soar, gaining their valuable insights into the new guidelines.

As well as this Simon, Rob and James pick out some other key points from the guidelines and discuss how these may translate into systems and practice.

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

Enjoy!

Simon, Rob & James

So this time we're going to be talking about subarachnoid haemorrhage. So this is going to be a short and punchy look at a really important and interesting topic in subarachnoid haemorrhage.

We run through the approach to headache and then focus on the specific features and findings that we should be looking for with regards subarachnoid haemorrhage. We then consider who we should be investigating further, what value a CT head brings and the sticky subject of who should be going on to have a lumbar puncture.

Finally we consider the the management once the diagnosis of SAH is reached and how we can ensure the best outcomes for our patients.

At the time of recording NICE has published its draft version of Subarachnoid Haemorrhage Caused by a Ruptured Aneurysm; diagnosis and management, which will be a great resource once finalised.

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

Enjoy!

Simon, Rob & James

Well if last month was based on cardiac arrest, this month takes a deeper look at airways!

First up we take a look at a paper that benchmarks the use of video laryngoscopy, specifically with the C-MAC and gives some really useful information from a Swiss HEMS service on first-pass success, the relevance of operator experience on success and factors that alter intubation success.

Next up we're looking at blood in the airway with epistaxis...okay it's a tenuous link, but it pretty much works! The NOPAC study looks at the use of TXA in atraumatic epistaxis and compare it to placebo use, will TXA come up trumps in this setting?

Finally we take a look at the use of scalpel cricothyroidotomy within the London HEMS service over a 20 year period, with a number of things we can learn from this experience.

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

Simon & Rob

The last time we took a good look at head injuries was back in 2018 in our Roadside to Resus episodes and for all of the foundational stuff on incidence, assessment, management and loads more  make sure you go and check that episode out. 

But this episode is one of our new UPDATES episodes, because we’re pretty old now… and whilst we’ve been having a go at this for a while evidence and guidelines will have progressed, which clearly have implications on how we manage certain cases and that’s where these come in! So they’ll focus mainly on the last 5 years of practice.

The new NICE head injury guidance has just been released and it’s the first major overhaul since 2014.  Now we know it’s a UK guideline, but there’s some really key practice updates and evidence in there that’s relevant irrespective of where you find yourself listening this! 

So in this episode we're going to be having a look at the most recent TXA evidence, with in terms of indications, timing and dosing. We'll be having a look at the risk of intracerebral injury with regards to anticoagulants and antiplatelet agents and a few other bits and pieces that can help us inform and improve our care.

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

Enjoy!

Simon, Rob & James

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

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

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!

We have been wanting to do an episode on aortic dissections for quite a while now but you will see that what we’ve actually gone and done is created an episode on acute aortic syndromes…so we’ve done a great job of staying on point straight from the off!

In fairness, we’ve done this because it turns out that there are actually a few different potentially life threatening acute aortic conditions which we need to know about and getting them all into one episode seemed achievable, so let’s see how we get on with that!

Hopefully in this podcast we will try and improve your knowledge of these conditions and we’ll also discuss a couple of cases to bring out some key points.

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

Enjoy!

Simon, Rob & James

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!

Simon, Rob & James

References & Further Reading

Information loss in emergency medical services handover of trauma patients. Carter AJ. Prehosp Emerg Care. 2009

Maintaining eye contact: how to communicate at handover. Dean E. Emerg Nurse. 2012

The handover process and triage of ambulance-borne patients: the experiences of emergency nurses. Bruce K. Nurs Crit Care. 2005

Handover from paramedics: observations and emergency department clinician perceptions. Yong G. Emerg Med Australas. 2008 

Review article: Improving the hospital clinical handover between paramedics and emergencydepartment staff in the deteriorating patient. Dawson S. Emerg Med Australas. 2013

So in this short podcast we're going to run over the summary of recommendations just published by the British Thoracic Society and the Intensive Care society on the Ventilatory Management of Acute Hypercapnia Respiratory Failure in Adults. This isn't in anyway intended as a replacement for reading the document itself so please make sure you take the time to do that.

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.

Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Huerta-Alardín AL. Crit Care. 2005

We were delighted to be back to cover the joint Faculty of Prehospital Care and BASICS conference, day 2,  held at the Royal College of Surgeons of Edinburgh. Again we were absolutely spoilt for choice when it came to content for the podcasts but we managed to catch up with:

• Dr Anne Weaver – a consultant in Emergency Medicine and Prehospital Care working for the Royal London Hospital and London HEMS. She talked to us about chemical burns and a novel treatment for managing these injuries.
• Dr Virginia Beckett – an Obstetrics and Gynaecology consultant who is a member of the mMOET working group and has recently published on the topic of cardiac arrest in pregnancy. She was talking on the topic of resuscitative hysterotomy.
• Sam Cooper – a Critical Care Paramedic from Derbyshire, Leicestershire and Rutland Air Ambulance who discussed a case of prehospital amputation and the learning points that arose from it.
• Dr Rob Lloyd – an Emergency Medicine trainee, blogger and fellow podcaster who has an interest in performance psychology. He talked about Mental Toughness, framed by his experiences working in a hospital deep in a South African township.

Once again, our thanks to Caroline Leech for being instrumental in the organisation of today and inviting us up. We’re already looking forward to next year….

Enjoy!

Simon, Rob & James

References

PonderMed

Diphoterine

A video showing a similar demonstration to the one at the conference showing why Diphoterine works and the limitations of water

Pre-hospital Obstetric Emergency Training; POET

VA Beckett, M Knight, P Sharpe, 2017, 'The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study', BJOG: An International Journal of Obstetrics & Gynaecology, vol. 124, no. 9, pp. 1374-1381

Realtime simulation of peri-mortem c-section; Bradford Teaching Hospital

K. M. Porter, 2010, 'Prehospital amputation', Emergency Medicine Journal, vol. 27, no. 12, pp. 940-942

Caroline Leech, Keith Porter, 2016, 'Man or machine? An experimental study of prehospital emergency amputation', Emergency Medicine Journal, vol. 33, no. 9, pp. 641-644

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;

• Definition
• Aetiology
• Hypovolaemic shock
• Neurogenic shock
• Obstructive shock
• Cardiogenic shock
• Physiology; Traumatic coagulopathy
• Other diagnostics
• Controlling external haemorrhage
• Pelvic binders
• REBOA
• Avoiding coagulopathy
• BP targets & permissive hypotension
• Fluid choices & supporting evidence
• TEG/ROTEM
• Calcium
• TXA
• Vasopressors
• Preventing hypothermia
• Relieving obstruction
• Interventional radiology
• Damage control surgery

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

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!

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.

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!

Association Between Early Hyperoxia Exposure AfterResuscitation from Cardiac Arrest and Neurological Disability: A Prospective Multi-Center Protocol-Directed Cohort Study. Roberts BW. Circulation. 2018

The DiPEP (Diagnosis of PE in Pregnancy) biomarker study: An observational cohort study augmented with additional cases to determine the diagnostic utility of biomarkers for suspectedvenous thromboembolism during pregnancy and puerperium. Hunt BJ. Br J Haematol. 2018

Time to Furosemide Treatment and Mortality in PatientsHospitalized With Acute Heart Failure. Matsue Y . J Am Coll Cardiol. 2017

MDCALC; Framingham Heart Failure Diagnostic Criteria

REBEL.EM; Door to Furosemide in AHF

Modified Rankin Scale

So this is the first of a pregnancy related double-header, with the focus being firmly set on the mother this month and next month we’ll focus in on NLS.

This month though we’re going to be discussing maternal emergencies. Now many conditions that could fall into this category but, as much as we love a good yarn, we really can’t be here all day, so we’ve decided to focus on are the conditions that we are more likely to come across in either prehospital or EM practice. Those conditions in which we can make a really big difference to either the mum or the baby.

We’re talking antepartum haemorrhage, postpartum haemorrhage, cord prolapse, breech presentation and shoulder dystocia, all after we've set the scene on assisting with an uncomplicated delivery.

So what would be really good is if we could find someone to bring in some prehospital maternal experience too. Ideally, someone qualified as a midwidfe and paramedic…and we're incredibly lucky to have just that in Aimee Yarrington, who has joined us for the podcast!

As a background; PPH is the third leading cause of maternal death in the UK and the most common cause of obstetric-related intensive care admissions. APH complicates 3–5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide. Cord prolapse ranges from 0.1% to 0.6%. Breech presentation occurs in 3–4% of term deliveries. Shoulder dystocia has a reported incidence of around 0.70%. And the incidence of primary PPH continues to rise progressively in the UK, reaching as high as 13.8% in 2012–2013. So there's a good reason for us to be experts on these topics.

Let us know any thought and comments you have on the podcast.

Enjoy!

Simon, James & Aimee

Welcome to October’s papers of the month!

Should patients who gain a ROSC following an out of hospital cardiac arrest go for an immediate angiogram if their ECG does not show an STEMI or Left Bundle Branch Block? We’ve looked at this before with the COACT trial which only looked at those patients with a shockable rhythm but this months paper looks at all ROSCs from all rhythms.

Next up we take a look at a paper that investigates senior paramedics decision making in cessation of cardiac arrests and think further about the decision making that goes into these complex decisions.

Finally we take a look at a huge trial assessing the use of balanced fluids versus Normal Saline in critically ill patients and gain more information about the strategy we should employ.

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

Enjoy!

Simon & Rob

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

A look at the headlines from the newly released guidance from NICE. Some bits of this may prove tricky to implement with current systems including the time to RSI....

Despite all the improvements that we have seen in trauma care over the past 20 or more years RTCs are still, sadly, a really common cause of both death and disability, with the number of deaths annually in the UK sitting somewhere between 1500-1900 per annum.

Survivors, who have serious injuries and are left with ongoing disabilities, total 22,000 people per year.

So anything we can do to improve care to these patients is definitely worth looking at and learning about!

Extrication is the process of injured (or potentially injured) patients being removed from vehicles involved in road traffic collisions. The fundamentals behind extrication have been based upon protecting the spine and not worsening an injury of it, but at the potential cost of other time critical injuries and with limited to no sound evidence base.

The EXIT project brings evidence to the practice of extrication and in this podcast we discuss the findings and implications for practice with the lead author Tim Nutbeam, Clare Bosanko (an EM & PHEM consultant) along with the three of us.

We also get the opportunity to hear from Freddie, a patient extricated from a high energy RTC and hear his perspective on Extrication.

Enjoy!

Simon, Rob & James

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;

• Why this matters to all involved in critically unwell patients, not just those delivering RSI
• Recap of RSI, the procedure and its indictions
• Headlines from NAP4
• Strategies highlighted to optimise airway management and oxygenation
• How this impacts our prehospital and inhospital practive

We'd love to hear your thoughts so please leave your comments below or contact us via twitter @TheResusRoom

Enjoy!

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

In this episode we’re going to be running through adrenal presentations; both Adrenal insufficiency and Adrenal Crisis. There are some parts of these that aren’t completely understood and a lack of a universal definition of Adrenal Crisis, but both insufficiency and a crisis are similar problems at different points on a spectrum and solid understanding of the endocrinology and physiology can really help to improve care in this area. There is huge potential for improving current morbidity and mortality.

We’ll run through both primary and central adrenal insufficiency, describe how this leads to different effects on mineralocorticoids and glucocorticoids and the signs and symptoms that will occurs as a result. 

Many of the patients presenting to the department will be unknown to have adrenal insufficiency and we’ll run through those who are at higher risk, including a huge group due to ongoing medication, who may be those on steroid doses much lower than you would previously have considered as significant. 

NICE published their most recent guidance on Adrenal Insufficiency in August this year and we’ll be referring to a lot of this as we run through the episode. 

We’ll finish up looking at the critical presentation of Adrenal Crisis and the emergency and ongoing management, along with how we support patients with insufficiency to prevent a crisis occurring. 

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

Simon, Rob & James

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

Cardiac arrest management is core business of a resuscitationist and practice is constantly evolving in the pursuit of improving patient outcomes. 

We were lucky enough to be invited to the London Trauma Conference's Cardiac Arrest Masterclass stream, where Matt Thomas put on a superb array of talks around all things cardiac arrest. 

We managed to borrow a bit of time from some of the speakers and caught up with some of the topics covered including; airway management, ECGs pre/post arrest, POCUS, CRM and breaking bad news. We found the day hugely useful and we hope the podcast sums up some of the great points from the day.

Enjoy!

Simon, Rob & James

References

London Trauma Conference

AIRWAYS-2; podcast

SPIKES Protocol

LITFL; Killer ECG Patterns

Beyondprognostication: ambulancepersonnel's livedexperiencesof cardiacarrestdecision-making. Anderson NE. Emerg Med J.2018

Zero Talent Battle

Welcome back to November's Papers Podcast! We've got 3 great papers for you again this month.

First up we take a look at a paper that looks to quantify the amount of experience needed to be a proficient intubator, in this case in arrest. Next we have a look at a paper which shows a significant difference in mortality in cardiac arrest dependant on the intravascular access route used. Finally we have a look a really interesting paper in the dispatch method of a HEMS service which we be of real interest to all those involved in paramedicine and prehospital critical care.

Make sure you take a look at the papers themselves and form your own opinions. We'd love to hear any thoughts and feedback you have.

Enjoy!

Simon & Rob

References & Further Reading

How much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation? Kim SY. Resuscitation.2018

A novel method of non-clinical dispatch is associated with a higher rate of criticalHelicopter Emergency Medical Service intervention. Munro S .Scand J Trauma Resusc Emerg Med.2018

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

Welcome back to March '22 Papers Podcast!

This month we have a think about causes and coping strategies for Emergency Clinicians involved in stressful cases; what can trigger us and more importantly what can we do to mitigate these circumstances?

In our other two papers we have a think about ECMO-CPR and Resuscitative Thoracotomy, both relatively low frequency but high skill interventions. The papers look at outcomes and case selection and can give us more information about service setups and challenges, and also offer us an opportunity to mentally mode how we can best prepare and decision make in these cases.

Simon & Rob

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 prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Nijssen 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

Rob Fenwick talks to us about this common condition and amongst others throws up a few surprises about the risks of rewarming. Enjoy

Happy New Year!

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

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

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

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

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

Simon & Rob

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

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

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

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

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

Simon, Rob & James

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

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

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;

• Whats the big deal with crystalloids
• Previous trials on fluid administration
• NEJM papers on crystalloids
• Myburgh's editorial

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!

Welcome back to the podcast and to November's Papers of the Month!

We start off looking at the rate of pneumothoraces in patients following ROSC after a medical cardiac arrest. What is the incidence? Are there any risk factors? And how might this affect our index of suspicion and imaging practice?

We've spoken before about how difficult vertigo can be as a presentation to the Emergency Department; really common, often benign but with differentials that include posterior circulatory strokes, tumours and infections. Our second paper looks at a clinical risk score for patients presenting with vertigo to the ED and consider how this might affect practice.

And finally we take a look at a great paper focussing on pre-alerts to the ED; consider current barriers, understanding and ways that we could improve the process both for the patients and staff.

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

Simon & Rob

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

Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study. Langdorf MI. Ann Emerg Med. 2015 Dec

NICE 2016: Major trauma; assessment and initial management

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

Evidence based medicine (EBM) allows us to deliver the best care to our patients and understanding the concepts involved is crucial.

Over the last 18 month we've been building an online course to give people a sound understanding of EBM and we thought we'd give you a free taster of what it's all about.

Have a listen to one of our episodes here on statistics and if you want to find out more have a read below about the full course at www.CriticalAppraisalLowdown.co.uk

Enjoy!

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

So in this episode we’re going to have a deeper think about advanced airway management and specifically supraglottic use in the prehospital and ED environment. 

Many prehospital service have seen the removal of intubation from their scope of practice, and that’s understandably been received with mixed thoughts.

But this isn’t the end of ‘expert advanced airway care for all; in fact far, far from it… we’ve all heard people talking about ‘whacking in an i-gel’, but really utilising a supraglottic device to its maximal potential can make a huge difference to our critically unwell patients. 

We'll be running through an overview of supraglottic devices, the evidence surrounding their use, patient selection, patient positioning and size selection, placing a supraglottic device, troubleshooting and finally ongoing ventilation with a supraglottic device.

We'd love to hear any comments or feedback you have and make sure to take a look at the references and resources below.

Enjoy!

Simon, Rob & James

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

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

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

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

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

Simon & Rob

Welcome back to the podcast!

This month we start off thinking about sepsis, specifically fluid management and whether a restrictive approach to fluid resuscitation in combination with earlier vasopressors is advantageous over a liberal approach.

Next we have a look at a study evaluating the diagnostic benefit of ultrasound in the prehospital setting.

Finally we have a think about the benefit that traumatic brain injury patients may benefit from with regards to beta blocker therapy.

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

Simon & Rob

Welcome back to the first Roadside to Resus episode for 2025!!

In this episode, we’re diving into a seasonally appropriate, and really paediatric common presentation for anyone involved in emergency care….Bronchiolitis. 

Now although it’s one of the most common respiratory illnesses affecting kids, bronchiolitis can easily cause confusion and concern around the severity of illness, whether to convey/admit/discharge, and also which treatments are indicated and which aren’t, including the perennially hot topic of bronchodilators.

In this episode we’re going to and delve into all of those aspects & explore the evidence and guidelines that are out there for bronchiolitis, including the NICE guidelines on the topic.

So, whether you're on the frontlines of paediatric emergency medicine or just brushing up on your knowledge, this episode…hopefully…will be packed with practical insights to enhance your care in those patients with bronchiolitis or even the differentials!

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

Simon, Rob & James

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!

Simon, Rob & James

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

Conversion to shockable rhythms during resuscitation and survival for out-of hospital cardiac arrest. Wah W. Am J Emerg Med. 2017 

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

An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. Seamon MJ. J Trauma Acute Care Surg. 2015

EAST guidelines 2015; ED Thoracotomy

Seizures are defined as a “paroxysmal electrical discharge of the neurones in the brain resulting in a change of function or behaviour”. All of us involved in Emergency Care will encounter patients with seizures which can occur for a number of reasons, with Epilepsy affecting 1 in 100 people in the UK.

Being able to identify the cause, terminate ongoing seizures and provide ongoing investigation and care is complicated and of paramount importance, as some of these episodes carry with them a high morbidity and mortality rate.

In this episode of Roadside to Resus we run through the following;

• The scale of the problem
• Causes of seizures
• Definition of status epilepticus
• Different forms of seizures
• Clinical assessment
• Investigations
• Antiepileptic’s
• Management& guidelines; both Pre and In-hospital
• RSI for status epilepticus
• Follow up and guidance

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

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.

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

The Parkland formula under fire: is the criticism justified? Blumetti J, et al. J Burn Care Res. 2008 Jan-Feb.

Mersey Burns for calculating fluid resuscitation volume when managing burns: NICE advice [MIB58] Published date: March 2016

SCANRCIT: Pain can’t be used to differentiate between partial and full thickness burns

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

Resuscitative endovascular balloon occlusion of the aorta: a gap analysis of severely injured UK combat casualties. Morrison JJ. . Shock. 2014 May;41(5):388-93. doi: 10.1097/SHK.0000000000000136.

Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis. Inoue J. J Trauma Acute Care Surg. 2016 Apr;80(4):559-67. doi: 10.1097/TA.0000000000000968.

The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. Morrison JJ. J Surg Res. 2014 Oct;191(2):423-31. doi: 10.1016/j.jss.2014.04.012. Epub 2014 Apr 13.

Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales. Barnard EB. Emerg Med J. 2015 Dec;32(12):926-32. doi: 10.1136/emermed-2015-205217.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Rossaint R. Crit Care. 2016 Apr 12;20(1):100. doi: 10.1186/s13054-016-1265-x.

Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. Moore LJ. J Trauma Acute Care Surg. 2015 Oct;79(4):523-30; discussion 530-2. doi: 10.1097/TA.0000000000000809.

The AAST Prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). DuBose JJ. J Trauma Acute Care Surg. 2016 Apr 5. [Epub ahead of print]

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!

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!

TheBottomLine; ADRENAL

St Emlyns; ADRENAL

Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. Venkatesh B. N Engl J Med. 2018

External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose Cardioversion. Gerstein NS. Ann Emerg Med. 2018

Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study. Shin J. Crit Care. 2017

Welcome back after the summer break!

Three more papers for you to feast your ears on this month and as always make sure you go and check them out yourselves after you've had a listen!

First up, following on really nicely from the DOSE-VF paper on dual sequential defibrillation we take a look at the paper that looks at the association between shock interval and VF termination. We might be biased but this shines a light on an area that could make a huge difference to the outcomes for patients with refractory VF!

Next; when you're seeing a patient with an upper GI bleed, which scoring/prognostication tool do you use and is it the best? We cover a paper that looks at exactly this question.

Finally we look at whether TXA predisposes patients to a higher risk of venous thromboembolism and whether it might affect our practice patterns.

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

Simon & Rob

A really strong line up of papers to bring this year's evidence round up to a close!

First up we take a look at a paper evaluating the utility of pulse oximetry (along with several other diagnostic tests) in identifying vascular injury following trauma, a really interesting look at an approach we didn't know much about.

Next up we run through PARAMEDIC-3, a huge RCT looking at the best vascular access strategy for patients in cardiac arrest, will the result of this paper change our approach?

And finally we look at a paper focussing on intubation success rate in US EMS services according to intubation rate.

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

Simon & Rob

So for decades people have talked about Contrast Induced Nephropathy…or Contrast Induced Acute Kidney Injury, depending on the decade and location of discussion. The theory being that diuresis, increased urine viscosity and changes in vasoconstriction and vasodilation leads to a worsening of renal function following iv contrast administration.

It seems to come from the 1950’s where some patients were seen to develop acute kidney injuries following iv contrast. Now times have changed and treatments and contrasts evolved but the discussion around contrast induced nephropathy continues. At times these discussion can mean that some patients wait for scans in the Emergency Department whilst waiting for blood tests to come back first. But is this the right thing to do?

In this episode we take a look at the origins of contrast induced nephropathy, consider some recent publications on the topic and see how this translates to practice and applications of the most recent guidelines.

Reading around the topic has been hugely informative for us and we hope will be of benefit to you too!

Enjoy

Simon & Rob

For this episode we’ve been lucky enough to catch a number of the speakers from the traumacare conference.

First up, conference organiser Caroline Leech (EM + PHEM consultant) gave us a few minutes of her time to talk about the latest major trauma key performance indicators from NICE.

Nicola Curry (Consultant Haematologist) spoke about transfusion in trauma and the use of massive haemorrhage protocols. Importantly, she covers the evidence behind the current strategies and where future research opportunities exist.

Stuart Reid (EM + PHEM consultant) covered the ways of optimising timely transfer of major trauma patients. This had an inter-hospital focus, but there were certainly some elements which can be applied to a primary patient transfer.

David Raven (EM consultant) provided an update to the ongoing work with the HECTOR project. We’ve previously heard about their amazing course but this time he was able to let us know about the “silver trauma safety net” which is being used by the ambulance service in the West Midlands. This aims to provide appropriate recognition and triage of trauma in the elderly population.

Finally, Elspeth Hulse (anaesthetic SpR) gave us a timely reminder about the identification and management of organophosphate poisoning - really useful from both and EM and PHEM perspective.

Thanks again to Caroline for the invite to the conference and keep and eye out for a special podcast in the next few weeks where Simon Carley will be running through his top 10 trauma papers of 2017/18 (we were going to try and condense it, but there was way too much good stuff!)

Enjoy!

Trauma Care

St Emlyns

HECTOR

The UK REBOA trial left many with doubts over its utility for trauma patients in ED. The time from injury to its use was around 90 minutes and the trial was stopped when it didn't reduce and maybe even increased mortality compared to standard care alone.

But what effect does REBOA have when used prehospitally and how feasible is it? Our first paper, from London HEMS, looks at this and gives a fascinating insight into it's use and the physiological response seen with it.

We've recently looked at dual sequential defibrillation for refractory VF with the DOSE-VF trial. Our second paper this month looks at how a double defibrillator strategy, in the context of cardioversion for AF, may affect restoration of sinus rhythm in obese patients.

Finally we take a look at the use of video livestreaming from scene to EMS, in a feasibility RCT. How can it affect accurate dispatch of the most appropriate resources and what impact does it have on those that use it?

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

Simon & Rob

So when people talk about patients having a high lactate we think about them being sick, it can at times be easy to slip into thinking that this equals sepsis or maybe ischaemia. And whilst the presence of a high lactate in the context of infection and ischaemia is important to note, there is a lot more to interpreting a raised lactate than may first be apparent...

So in this episode we’re going to delve down into lactate, have a think about what it is, what normal and raised levels are, consider the mechanisms behind it’s formation and breakdown and think about the causes of raised lactate. We'll then put this all together and have a think about how we can interpret and lactate levels ensuring we give the best treatment to our patients!

Enjoy!

Simon, Rob & James

Welcome back to June's Papers of the month!

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

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

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

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

Simon & Rob

We talk through some core content on epilepsy, some algorithims for treatment, some of the evidence base that surrounds the topic and some of the difficulties surrounding decision making

There are more great pieces of research to enjoy this month!

We start off with a paper following on nicely from our Roadside to Resus episode on Stabbing, which looks at the ability of prehospital providers to predict whether stab injuries penetrate to deep structures, or are purely superficial from clinical assessment.

Next up we take a look at a paper using high sensitivity troponin and their limit of detection, to assess whether we could be safely discharging patients earlier from the emergency department.

Finally we have a look at the results from the RECOVERY group on dexamethasone use in COVID-19, have we got a treatment that can help improve survival in patients admitted with the virus?

We'd love to hear any thought or comments you have either on the website or via twitter @TheResusRoom.

Enjoy!

Simon & Rob

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

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

Welcome back to the papers of the month podcast!

First up we take a look at a paper assessing the importance of symptoms and sings in suspected Cauda Equina cases and consider which factors we should be giving weight to, including whether a PR is appropriate.

Next up we take a look at a paper looking at electrical injuries presenting to the Emergency Department, the risk of significant injury and the appropriate investigations to perform on both high and low energy voltage injuries.

Lastly we take a look a paper looking at the use of vasopressin and steroids in in-hospital cardiac arrest and see what effect in has in the latest RCT.

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

Enjoy!

Simon & Rob

This is an episode we've been wanting to cover for a long time now! In it we explore the challenges in entering and developing in prehospital critical care, which translate into pretty much developing in any new role both in and out of health care.

We cover some pretty personally challenging experiences and the strategies that both clinicians new to prehospital critical care may find useful to employ. We also discuss how supervisors can use these techniques to both guide and support new clinicians. 

The four main areas discussed are;

• Decision making
• Prioritisation of tasks
• Leadership
• Incorporating evidence based medicine into practice

We wrap up exploring how reflection can be used to accelerate growth as a clinician but also the risks of over-reflection!

We really hope you enjoy the episode and would love to hear any thoughts or feedback on the episode both on the website and via social media.

Simon & James

Welcome to July's papers podcast. 

There has been a plethora of superb and thought provoking papers published this month and we've got the best 3 that caught our eye for you.

In this episode we look at the potential benefit of early vs late endoscopy in patients presenting with an acute upper GI bleed.  Next we look at both intra and post ROSC hyperoxia and the associated outcomes. Finally we have a look at the utility of straight leg raise as a test to rule out potential pelvicfractures in out trauma patients.

We strongly suggest you source the papers and come to your own conclusions and we'd love to hear any comments either at the foot of this page or on twitter to @TheResusRoom.

Enjoy!

Simon & Rob

References & Further Reading

Delayed endoscopy is associated with increased mortality in upper gastrointestinal hemorrhage. Jeong N. Am J Emerg Med. 2018 

Association between intra- and post-arrest hyperoxia on mortality in adults with cardiac arrest: A systematic review and meta-analysis. Patel JK. Resuscitation. 2018

Straight leg elevation to rule out pelvic injury. Bolt C. Injury. 2018