The Resus Room

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 Trach

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! Simon &  Rob References & Further Reading 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 Effect of Sodium Bicarbonate on A

So we're back with some superb topics this month; Early or late intubation in ICU patients, which is associated with worse outcomes? What are the predictors of a poor outcome in patients presenting with syncope? Does a cervical collar result in a demonstrable raise in ICP viewed by ultrasound? Make sure you take a look at the papers yourself, they certainly provide food for thought and raise important questions in our practice Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast Enjoy! Simon & Rob References & Further Reading Association between timing of intubation and outcome in critically ill patients: A secondary analysis of the ICON audit. Bauer PR. J Crit Care. 2017   Increase in intracranial pressure by application of a rigid cervical collar: a pilot study in healthy volunteers. Maissan IM. Eur J Emerg Med. 2017   Predicting Short-Term Risk of Arrhythmia among Patients with Syncope: The Canadian Syncope Arrhythmia Risk Score. Thirugan

This is the second part of the Roadside to Resus discussion on asthma. Make sure you’ve listened to part 1 before delving into this one! Part 2 covers Ketamine Ultrasound in asthma NIV in asthma Asthma related cardiac arrest Imaging Management Discharge We hope you enjoy the episode and would love to hear your feedback! Simon, Rob & James   References & Further Reading BTS Asthma Guidelines 2016 Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Goodacre S. Lancet Respir Med. 2013  Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017 Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV. Injury. 2016 TheResusRoom; Needle Thoracostomy podcast TheResusRoom; BTS Asthma Guidelines 2016 podcast LITFL; Non-invasive ventilation (NIV) a

Asthma is a common disease and presents to acute healthcare services extremely frequently. The majority of presentations are mild exacerbations of a known diagnosis and are relatively simple to assess and treat, many being completely appropriate for out patient treatment. On the other hand around 200 deaths per year are attributable in the UK to asthma, and therefore in the relatively young group of patients there is a real potential for critical illness with catastrophic consequence if not treated effectively. The majority of these deaths occur prior to the patient making it to hospital making the prehospital phase extremely important and hugely stressful in these cases. It is also worth noting that of the deaths reported that many were associated with inadequate inhaled corticosteroids or steroid tablets and inadequate follow up, meaning that our encounter with these patients at all stages of their care even if not that severe at the point of assessment is a key opportunity to discuss and educate about trea

We're back with more great papers for you this month, hot off the press! There's been a lot of talk over the last few years about apnoeic oxygenation and whether it really holds any benefit to patients undergoing RSI, we have a look at a systematic review that may help answer that question. Next up we have a look at the choice of sedation agent used in the Emergency Department and how this correlates with patient satisfaction. Finally, following on from our recent podcast on Double Sequential Defibrillation, we have a look at a paper published looking at the results of DSD from the London prehospital service. Will this reveal a patient benefit? Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast. Enjoy! Simon & Rob References & Further Reading Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. Pavlov I. Am J Emerg Med. 2017 Patient satisfaction with procedural sedation in the

This is the first of a new series of Roadside to Resus podcasts. We've been joined by James Yates, a Critical Care Paramedic with the Great Western Air Ambulance to make it a truly multidisciplinary team. Each monthly episode we'll be discussing acute presentations, including the latest and most influential evidence base surrounding them. We really want  to break down some barriers between pre-hospital and in hospital teams and it soon becomes evident in this first podcast that many of the problems we face are shared throughout the patient journey and across disciplines! We're starting off with Acute Heart Failure and in the podcast we run through; The underlying physiology and help explain the different problems we may find in each subset The keys to diagnosis, including the most predictive parts of history and examination We discuss the evidence base for treatment and the trends of use both pre and in-hospital We talk about CPAP and whether the evidence supports it's use Finally, the direction that further

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. In this episode we discuss the complexities of balancing the risks and harms when trying to provide a patient centred approach, rather than a “one-size fits all” model.   As always, there are a number of papers, guidelines and resources that you should have a look at (it’s not exhaustive, but a good place to start!)   Enjoy!   Rob References & Further Reading     NICE Guidance   Major trauma   Spinal injury    Faculty of prehospital care consensus statements   Spinal immobilisation   Minimal patient handling   Cochrane reviews   Spinal Immobilisation for Trauma   Papers of interest   Cowley et al 2017   Dixon et al 2015   Benger & Blackham 2009   Hauswald 2015   Hauswald 2013   Michaleff e

We're back with 3 superb topics this month! First off we have a look at the utility of ultrasound for the detection of pneumothoraces in the context of blunt trauma. Next we look at the need to scan facial bones when scanning a patient's head following trauma. Last of all we look at a paper reviewing the association between the use of a bougie and the first pass success when performing ED RSI. Have a listen to the podcast and most importantly make sure you have a look at the references and critically appraise the papers yourself. We'd love to hear your thoughts and comments at the bottom of the page. Enjoy! Simon & Rob References & Further Reading Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017 Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury. Huang LK. Injury. 2017  The Bougie and First-Pass Success in the Emergency Department. Driver B. Ann Emer

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 f

High quality manual cardiopulmonary resuscitation (CPR) with minimal delays has been shown to improve outcomes following out-of-hospital cardiac arrest (OHCA). There are concerns that the quality of CPR can diminish over time and as little as 1 minute of CPR can lead to fatigue and deviation from the current recommended rate and depth of compressions. With this in mind, a mechanical device to provide chest compressions at a constant rate, depth and without tiring has considerable theoretical benefits to patients, yet clinical equipoise remains about the role for this treatment modality. In this podcast, we discuss and critically appraise 2 randomised controlled trials (RCTs) set out to answer exactly that question and give our take on the role for mechanical CPR devices in the future Hope you enjoy and feel free to leave any feedback below! Rob References  Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Perkins GD. L

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! Simon & Rob References & Further Reading Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum

Oxygen is probably the drug that we give the most but possibly has the least governance over.  More has got to be good except in those at high risk of type II respiratory failure right?? Well as we know the evidence base has swung to challenge that idea in recent years and the new BTS guidelines for Oxygen use in Healthcare and Emergency Settings has just been published with a few things that are worth reviewing since the original publication in 2008. No apologies that this may be predominantly old ground here, this is an area we're all involved with day in and day out that is simple to correct and affects mortality Historically oxygen has been given without prescription; 42% of patients in the 2015 BTS audit had no accompanying prescription When it is prescribed this doesn't always correlate with delivery 1/3 of patients were outside of target SpO2 range (10% below & 22% above) If nothing else is taken from this document then reinforcement of the fact that we need to keep oxygen saturations normal/nea

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 Emerge

This month we've got a good variety of topics. We look at an recent systematic review and meta analysis on the prognostic value of echo in life support, an update from Blyth's paper in 2012. We review a paper looking at testing gin patients presenting to the emergency department in SVT. Finally we cover a paper looking at different methods employed when running an Emergency Department. As always make sure you go and have a read of the papers yourselves and come up with your own conclusions, we'd love to hear your feedback. Enjoy! Simon & Rob References & Further Reading Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017 Usefulness of laboratory and radiological investigations in the management of supraventricular tachycardia. Ashok A. Emerg Med Australas.2017 What do emergency physicians in charge do? A qualitative observational study. Hosking I. Emerg Med J. 2017   

This podcast is taken from a talk I gave at Grand Rounds at The Bristol Royal Infirmary on the Top 10 Papers in EM over the last 12 months. Many of these have been covered in previous podcasts, but running through them gives a good opportunity for further recap and reflection. Papers Covered; Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV1. Injury. 2015 Dec 13. pii: S0020-1383(15)00768-8. doi: 10.1016/j.injury.2015.11.045. [Epub ahead of print] (more in February'sPapers of the month) Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Baharoglu MI. Lancet.2016 May 9. pii: S0140-6736(16)30392-0. doi: 10.1016/S0140-6736(16)30392-0. [Epub ahead of print] (more in July's Papers of the month) Causes of Elevated Cardiac Troponins in the Emergency Department and Their Associated Morta

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 Examina

This month we look at a paper concentrating on the risk of contrast induced nephropathy in contrasted CT scans, looking specifically at the need to hydrate at-risk patients prior to and following CT scans. The use of prehospital blood is also under the spotlight with the ongoing RePHILL trial. We look at a paper reviewing prehospital blood use with the Kent Surrey Sussex prehospital service and the described physiological changes seen in patients receiving blood. Make sure you also go over and check out the podcast episode from PHEMCAST on the RePHILL trial with Jim Hancox. Finally I was lucky enough to catch up with Johannes von Vopelius-Feldt, the lead author of a paper in press on the impact of prehospital critical care teams on out of hospital cardiac arrests. You can find the fantastic opportunity of a scholarship to be an Emergency Nurse Practitioner here from ADPRAC. Enjoy Simon & Rob References & Further Reading Prophylactic hydration to protect renal function from intravascular iodinated cont

So today Rob and I were lucky enough to be asked to attend the Trauma Care Conference 2017, to listen to some of the great talks and catch up with some of the speakers for their take on the highlights of the talks. We managed to catch the following speakers, here are the topics they covered and relevant links to the resources discussed. Speakers Gareth Davies, Consultant Emergency Medicine, Royal London Hospital; Understanding where, when and how people die? Dave Gay, Consultant Radiologist, Derriford Hospital; The Role of Ultrasound in Trauma Fiona Lecky, Professor Emergency Medicine, Salford; Traumatic Brain Injury: recent progress & future challenges Simon Carley, Professor Emergency Medicine, Central Manchester; The Top 10 trauma papers of 2016 St Emlyn's Top 10 +1 Trauma Papers 2016 Tim Rainer,  Professor Emergency Medicine, Cardiff; Permissive hypotension in blunt trauma David Raven, Emergency Medicine Consultant, Heart of England Foundation Trust; HECTOR & Elderly Trauma The HECTOR Course (&

Centralisation of care for specialist services such as stroke, trauma and myocardial infarctions is becoming more and more common place. But where will it stop and what does it mean for the specialty of Emergency Medicine? In this episode we have a look at a recent pilot RCT published in the journal of Resuscitation looking at the feasibility of setting up an bigger RCT to evaluate moving prehospital patients to a cardiac arrest centre. The paper itself is a great piece of work but the bigger discussion around the topic is also a really important point to consider. Have a listen to the podcast, see what you think and please post you comments on the site for us all to see. Enjoy! Simon References   A Randomised tRial of Expedited transfer to a cardiac arrest centre for non-ST elevation ventricular fibrillation out-of-hospital cardiac arrest: The ARREST pilot randomised trial. Patterson T. Resuscitation. 2017