Designer repair: fixing systems not reinventing

In this (rather delayed!) October round-up, Iain Beardsell and Simon Carley catch up on recent St Emlyn’s blog posts and papers that continue to shape emergency and resuscitation practice.

The discussion moves across trauma, analgesia, cardiac arrest physiology, emergency department systems, and antimicrobial stewardship—less about novelty, more about what actually holds up on shift.

Trauma and haemorrhage

The episode opens with a discussion of the FIRST-2 trial, examining fibrinogen concentrate and prothrombin complex concentrate versus fresh frozen plasma in severe traumatic haemorrhage.
Despite promising physiological theory, the trial shows no meaningful reduction in blood product use compared with standard care, reinforcing the ongoing role of FFP in early trauma resuscitation.

Upper limb injuries and regional anaesthesia

The team explore the SUPERB trial comparing supraclavicular brachial plexus blocks with Bier’s blocks for upper limb reductions.
Both techniques provide excellent analgesia. The conversation reflects on changing practice, procedural sedation pressures, ultrasound access, and how physical space—not evidence—often dictates what we do.

Cardiac arrest: signals worth paying attention to

Three recent cardiac arrest papers are reviewed, focusing on physiological markers rather than new devices:

• End-tidal CO₂ as a CPR quality target

• Ventilation strategies during arrest, including chest-compression-synchronised ventilation

• Cerebral oximetry as a potential prognostic signal

These are not definitive answers, but they point towards cardiac arrest management that is more physiological and less ritualistic.

Emergency department systems: repair, not reinvention

A reflective discussion on “designer repair” challenges the idea that emergency departments need constant transformation.
Instead, the focus shifts to recognising and supporting the clinicians quietly holding fragile systems together every day—and why fixing small, broken things often matters more than grand redesigns.

Sepsis and antibiotics

The episode closes with a critical look at broad-spectrum antibiotic use in suspected sepsis.
Observational data suggest significant overtreatment and real harm, reinforcing the need to pause, think, and choose the right antibiotic—not just the fastest one.

This episode is a reminder that good emergency medicine is rarely about silver bullets.
It’s about judgement, physiology, and paying attention to what actually works in the real world.

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