The Resus Room

Drugs in cardiac arrest are controversial. Prehospital research is notoriously difficult to perform. PARAMEDIC2 has just published in the New England Journal of Medicine and is a multi centre randomised placebo controlled trial looking at adrenaline (or epinephrine depending on which side of the pond you reside) in out of hospital cardiac arrest, no mean undertaking and a landmark paper. The paper has gained a huge amount of traction online with multiple blogs discussing the primary outcome which showed a higher survival rate in those receiving adrenaline when compared to placebo. This has been accompanied with a firm debate over the secondary outcomes, which include the rate of survival with a favourable neurological outcome (mRS 0-3), which showed no statistically significant difference between the two treatment arms, but in pure numbers gave a higher proportion of favourable outcomes in the adrenaline group. The trade off for this increased survival is the significant number of survivors with a poor neurol

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: Wha

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. Res

Managing external haemorrhage is easy right?! Then why does haemorrhage remain a major cause of death from trauma worldwide? Ok, some of that is from internal sources, but…. No one should die from compressible external haemorrhage With the right treatment applied in a timely fashion, the vast majority of these bleeds can be stopped. But with new advances like haemostatic agents, changing advice surrounding tourniquet use and practice changing evidence coming out of conflict zones can mean it’s difficult to remain current with the latest best practice. So what options are available to us, how do we use them and what’s the evidence. Here’s the line-up for this months’ podcast: Haemorrhage control ladder Evidence based guidelines on haemorrhage control Direct pressure Enhanced pressure dressings Haemostatic agents and wound packing Tourniquets Case studies As always we welcome feedback via the website or on Twitter and we look forward to your engagement. Enjoy! Simon, Rob & James   References & Further

Welcome back to our monthly round up of the best papers in the resuscitation world. Again we've got 3 great papers covering some really important points of practice. First up we have a look at one of the most talked about diagnostic tests in Emergency Medicine, Troponin. We're are always looking to increase the sensitivity of the assay and test in order to ensure the patient hasn't got Acute Coronary Syndrome, but what are the implications of implementing a high sensitivity test? In our first paper we have a look at this exact scenario, the difference in patient outcomes and some of the resource implications to the service. Next up we have a look at apnoeic oxygeationn. We've covered this a number of times before and most recently in our Roadside to Resus episode on RSI. This time we have a look at the most recent systematic review and meta-analysis on the topic to see if there is more definitive evidence of benefit with this technique. Lastly we've found a paper that suggests a place for prognosticating off

The management of a cardiac arrest can be stressful at the best of times, but add into that the patient being a child and you have the potential for an overwhelmingly stressful situation. Fortunately the major resuscitation bodies have some sound guidance on the management of paediatric arrests. In this episode we run through some of those guidelines and also the evidence base on the topic (scant at best!). We also touch on conveyance of the prehospital paediatric arrest, bringing familiy into the resuscitation area and knowing when to cease resuscitation. We hope the podcast helps you prepare that little bit more for the next case you might see and that it may also ease the stress of such an emotive case. Simon, Rob & James

Professor Simon Carley from St. Emlyns caught up with us at the superb Trauma Care Conference and talked through his top papers in trauma from the last 12 months. There's something for everyone from diagnosing arterial injuries, blood pressure targets in the head injury patient, to i.v. contrast all the way through to imaging in kids. If you haven't already, make sure you go and check out the St Emlyn's blog that underpins the talk that Simon gave. And if you're looking for a great value conference to suit all health care disciplines then make sure to keep an eye out for tickets when they go on sale for Trauma Care 2019. A huge thanks to Simon C for his time recording the podcast and we'd love to hear any comments or feedback. Enjoy! Simon L & Simon C References & Further Reading For all the papers pop over to the St Emlyn's blog for the hyperlinks and abstracts

Dare we say it, we think this month's papers podcast is the best yet, we've got 3 superb papers and topics to consider! The literature has been pretty airway heavy this month so we've got 3 papers on and around the topic for you. First up we have a look at a really interesting paper from London HEMS looking at the risks v benefit of prehospital rapid sequence intubation in patients who are awake but hypotensive, is RSI a much needed move or something we should be looking to avoid prehospitally. Airways-2 will soon be published looking at supraglottic airway management compared to intubation as first line airway management in out of hospital cardiac arrest, but JAMA has just published a paper comparing bag-mask ventilation vs endotracheal intubation in the same situation. It'll be interesting to see if this papers results fall inline with Airways-2. Finally we take a look at a systematic review trying to give us the answer to direct or video laryngoscopy in emergency endotracheal intubation outside the OR. Hav

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! Simon, Rob & James  

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

In this episode Rob takes us through a case he saw recently that brought about some invaluable learning. We're not going to give you anymore clues than that! Enjoy! Simon & Rob References & Further Reading (anonymised to keep the anticipation!) Article 1   Article 2   Article 3   Article 4  

  Welcome back to April's papers of the month. We've got 3 papers this month that look to challenge our work up strategies for the critically unwell. First up we look at a paper on the Ottawa subarachnoid haemorrhage rule, specifically considering if we can decrease scanning in patients with a suspected SAH and what application of the rule might mean for our practice. Next up we look at a paper that might shine some real doubt on the use of IO access in our patients in cardiac arrest. Lastly we look at a validation paper for the PERC rule for those patients with a suspected pulmonary embolus and this paper brings about some interesting points on external validity Once again we'd really encourage you to have a look at the papers yourself and we've love to hear any thoughts or feedback you have. Enjoy! Simon & Rob  References Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. Perry JJ. CMAJ. 2017   Intraosseous Vascular Access Is Associated With Lower Survival and Neur

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! Simon, Rob 

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! Simon & Rob References & Further Reading Fluid Na K Cl Ca Mg Lact Acet Glucon Dext Osmol mOsm/L 0.9% N Saline 154 0 154 0 0 0 0 0 0 308 Lactated Ringers 131 5 11 2.7 0 2

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 m

So the three of us are back together and going to take on Sepsis! It's vital to have a sound understanding of sepsis. It has a huge morbidity and mortality but importantly there is so much that we can do both prehospital and in hospital to improve patient outcomes. In the podcast we cover the following; Definitions Scale of problem Different bodies; NICE/Sepsis Trust/3rd international consensus definition including qSOFA Handover and pre alerts Treatment; Sepsis 6 The evidence base behind treatment Contentious areas  Prehospital abx Fever control Steroids ETCO2 We hope the podcast helps refresh your knowledge on the topic and brings about some clarity on some contentious points. As always don't just take our word for it, go and have a look at the primary literature referenced below. Enjoy! Simon, Rob & James References & Further Reading Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Kumar. Critical C

On a not infrequent basis we will come across patients in hospital who have a CT head scan that appears to show an unsurvivable event. Having sourced opinion from our neurosurgical and neurology colleagues we may well be given the advice to withdraw care for the patient. It has become increasingly recognised that prognosticating in such patients at an early stage is extremely difficult with numerous cases surviving what was initially thought to be an unsurvivable event, with a good neurological outcome. This joint document from the Intensive Care Society, Royal College of Emergency Medicine, Neuro Anaesthesia and Critical Care Society of Great Britain & Ireland and the Welsh Intensive Care Society gives new guidance for such perceived devastating brain injuries and will challenge many peoples thinking on the topic with additional questions being asked on resource utilisation. In this podcast Caroline Leech, EM and PHEM Consultant in Coventry, discusses the guidelines and the implications they hold for our

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! Simon & Rob References & Further Reading 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 Attem

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! Simon & Rob References 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

Prehospital Care is evolving rapidly and is one of the most exciting and dynamic specialties to be involved with at the moment. As a reflection of it's progress the Faculty of Pre Hospital Care held  its first scientific conference this week. We were lucky enough to be invited by Caroline Leech, EM & PHEM Consultant and the person responsible for organising this superb event, to interview some of the superb speakers at the event. Here are the speakers we were lucky enough to catch up with and the topics they discuss Matt Thomas – Hyperoxia: when oxygen is harmful Jo Manson – The hyperacute inflammatory response to trauma Rob Moss – FPHC Consensus Statement - Spinal Malcolm Russell – FPHC Consensus Statemnent – External Haemorrhage Tim Nutbeam – Pre-hospital research: what do we not know?  David Menzies – Impact brain apnoea & motorsport Stacey Webster – Calcium in pre-hospital blood transfusion: the missing link Rod Mackenzie Injury prevention, control & recovery A huge thanks to all involved in