The Resus Room

Happy New Year!! 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! Simon & Rob      

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 los

You've got a critically unwell patient who needs an RSI. You've got lots of things to think about but specifically do you ramp them up or keep them supine, additionally do you use a checklist or are those things a complete waste of time? This month we have a look at 2 papers which should shed some light on the subject. We also look at a systematic review and meta-analysis which hopefully helps us answer a question we've been looking at on the podcast for quite some time: in the the context of a cardiac arrest that has gained a ROSC, if the ECG is not diagnostic of a STEMI but the history is suggestive of a cardiac event, should the patient go straight to the cathlab for PCI? As always don't just take our word for it but go and have a look at the papers yourself and we would love to hear your thoughts. Enjoy! Simon & Rob References & Further Reading A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults. Semler MW. Chest. 2

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 a

If you talk to people about the topic of thrombolysis in PE they'll tell you about the controversy of the submassive category, but there's a universal acceptance that thrombolysing massive PE's is well evidenced and straight forward. In this episode we delve back into the literature and not only explore massive PE thrombolysis, but also the gold standard to which it is judged upon, heparin. Have a listen to the podcast and as always we would love to hear your thoughts. Enjoy! Simon & Rob References & Further Reading 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism British Thoracic Society guidelines for the management of suspected acute pulmonary embolism; 2003 Antithrombotic Therapy for VTE Disease CHEST Guideline and Expert Panel Report; 2016 Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. A Scientific Statement From the American Heart Association. 2011 Ven

Welcome back to November's papers podcast! This month we've got some great topics to discuss. We look at another paper on the topic of oxygen therapy, this time a hug article from JAMA on oxygen therapy in the context of acute stroke and the impact on disability. Next up we look at a fascinating case report of a extradural haematoma that was drained via an I.O. needle prior to surgical evacuation. Lastly we follow up on our previous podcast on PE; the controversy, which looked at the prevalence of PE in those patients presenting with undifferentiated syncope. This paper puts a great counter to the conclusions arrived at in that Prandoni paper. Enjoy! Simon & Rob References & Further Reading   Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke: The Stroke Oxygen Study Randomized Clinical Trial. Roffe C. JAMA. 2017 Temporising extradural haematoma by craniostomy using an intraosseous needle. Bulstrode H. Injury. 2017  Prevalence of pulmonary embolis

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

This podcast covers some highlights from the talks at the BASICS and The Faculty of Pre-Hospital Care 2017 Conference. We were lucky enough to be invited by Caroline Leech to cover the day and managed to grab a couple of minutes with a handful of the superb speakers; Dr. Tom Evens; Elite sports for high performance clinicians Dr. Les Gordon; Pre-hospital management of hypothermia Dr. Helen Milne; Retrieval and transfer medicine Surgeon Commander Kate Prior; The battlefield Dr Chris Press; Prehospital management of diving emergencies Miss Aimee Yarrington; Obstetric Emergencies Professor Mark Wilson; Pre-hospital Care, where are we going?   Thanks to all involved for making the podcast and for a great day at the conference, and to PHEMCAST for the collaboration! Simon, Rob & Clare  

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! Simon & Rob References & Further Reading   Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathingcritically-ill patients. Corl KA. J Crit Care. 2017   Oxygen Therapy in Suspected Acute Myocardial Infarction. Hofmann R. N Engl J Med. 2017  Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an i

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