The Resus Room

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

Welcome back to Papers of the Month. March has given us some great papers. We kick off with a couple of papers looking at rib fractures, associated morbidity and mortality and also looks at management of flail segments. We then turn our attention to airway management and look at a paper reviewing the outcomes associated with patients who are intubated during resuscitation from cardiac arrest. As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below. Enjoy Simon & Rob References & Further Reading    Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Andersen LW. JAMA. 2017 Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol. Cordelie E. Trauma Surg & Acute Care Open. 2017   Are first rib fractures a marker for other life-threatening injuries in pa

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. Rhabdomyolysis is caused by a breakdown in skeletal muscle and occurs most commonly following trauma, very often that can be due to a 'long-lie' when a patient is unable to get off a floor until help arrives after a prolonged period. There are other causes including drugs, muscle enzyme deficiencies, electrolyte abnormalities and more. The presentation itself is pretty vague and suspicion of the disease needs to be pretty high. Patients can experience weakness, myalgia and the dark'coca-cola urine', the diagnosis is then confirmed with a serum elevation in CK. The big concern with Rhabdomyolysis is the hit the kidneys take. Acute kidney injury is due to the heme pigment that is released from myoglobin

Epistaxis is an extremely common presentation to both Prehospital Emergency Services and Emergency Departments. The vast majority are benign and self limiting but every once in a while a catastrophic bleed will come our way.  Whilst not necessarily the most attention grabbing of topics a sound understanding of the management is key to excellent care. In this podcast Rob talk us through the management of epistaxis, all the way from causes and presentation, right the way through to resuscitative management and latest evidenced based treatment. Enjoy! References & Further Reading LITFL epistaxis review Geeky medics epistaxis  BMJ overview paper & management flowchart Routine coagulation screening in the management of emergency admission for epistaxis; is it necessary? Thaha MA. J Laryngol Otol 2000 Front-line epistaxis management: let's not forget the basic. E C Ho. J Laryngol Otol 2008 Serious spontaneous epistaxis and hypertension in hospitalized patients.Page C. Eur Arch Otorhinolaryngol. 2011

Welcome back to Papers of the Month. February holds a diverse number of topics on some really interesting areas of practice. We kick off with a snap shot systematic review from the Annals of Emergency Medicine on the effect of Amiodarone or Lignocaine on the outcome from refractory VF or VT arrests, are drugs losing more favour yet again in cardiac arrest. Next up is a pilot study following the surgical theme of minimal intervention for appendicitis, can antibiotics safely be used in a particular cohort of patients to prevent the need for surgery? And moreover could this be even safer than the traditional surgical cure? Last up we cover a paper looking at the survival from traumatic cardiac arrest and consider the bias that may occur by reporting those resuscitation attempts that are of limited duration in with the whole cohort; are we painting a overly negative picture of the prognosis of traumatic cardiac arrest? As ever we would highly encourage you to go and read the papers yourselves, these are only our

Those of us who are a bit longer in the tooth have spent most of our careers not scanning everyone who sustained a head injury on warfarin, but in 2104 NICE published guidance suggesting we do just that. At times, with the huge burden we place on our radiology services, it is difficult not think we're over doing things with all of these scan requests, especially when the patient has no adverse symptoms or signs. Fortunately the AHEAD study has just been published which looks at thousands of patients presenting to ED's on warfarin with a head injury. The paper is open access and deserves a full read, in this podcast I run through some of the main parts of the study and have a think about how it might impact on our practice. This is just one part of the puzzle on the management of patients with anticoagulated head injuries, we had a look previously on what to do if you perform a scan and that appears normal in our Anticoagulation, Head Injury & Delayed Bleeds Podcast. Hope you enjoy the podcast and we'd lov

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

Happy New Year!!! The publishing world seems to have wound down a bit for the festive break, but 4 papers caught out eye that can add some further context to practice in the Resus Room. Firstly we take a look at two papers looking at the conversion from non-shockable to shockable rhythms in cardiac arrest, both the likelihood and the associated prognosis. Next up we have a look at a paper focussing on Cerebral Performance Categories (CPC's) and their reliability as an outcome for studies. Lastly we have a look at the recent Cochrane Review on video laryngoscopy vs direct laryngoscopy for adult intubation. Thanks again to our sponsors ADPRAC for supporting the podcast. References & Further Reading Age-specific differences in prognostic significance of rhythmconversion from initial non-shockable to shockable rhythm and subsequent shock delivery in out-of-hospital cardiac arrest. Funada A. Resuscitation. 2016 Conversion to shockable rhythms during resuscitation and survivalfor out-of hospital cardiac arrest.

As the years tick by our healthcare systems work harder and harder to ensure that acute coronary syndromes are picked up as they present to our Emergency Departments, the evolution of high sensitivity troponins and their application have been key to this. The utility of a test however is dependant upon it's application to the appropriate patient. In a heavily burdened system it can at times seem sensible to front load tests and 'add on a troponin' before we are even sure the history is consistent with a possible acute coronary syndrome. But is this a safe approach for our patients and what are the potential consequences? In this podcast we run through a recent paper from the US on the topic. Whilst not the highest level of evidence and also looking at a system not entirely generalisable to the UK, it does highlight the aforementioned concerns and is a useful reminder to consider our approach to testing in patients with chest pain. We are certainly not berating the use of troponin, we just think the paper serv

So my talk at the ICS SOA 2016 conference on whether ED should be allowed to intubate certainly provoked some discussion, which was fortunate as it was the purpose of the talk! If you haven't listened to it yet, stop listening to this and have a listen to the talk here first. In this quick debrief between Rob and myself we have a think about the feedback and where to go from here. We'd love to hear any feedback in the comments section at the webpage at www.TheResusRoom.co.uk Simon

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.