Coda Change

Greg Kelly focuses on transferable skills from adult practice applicable to the collapsed neonate, taking us first through a systematic approach to the common underlying causes and the physiology behind them. He outlines a comprehensive approach to the clapped out baby even when the underlying cause isn't immediately clear and reassures us that there are plenty of simple interventions we can undertake.

Allow me to introduce to you this extraordinarily talented doctor. John Hinds became involved in our motorcycle racing medical team as a medical student and progressed to inspirational teacher and natural leader. He had a burning passion for improving the care of the injured and on qualification it was evident he was destined for greatness within the world of critical care. In his role as Delta 7 for the Northern Ireland Ambulance Service and as a travelling doctor at motorcycle races in Ireland Doc John brought the highest standards of care and compassion to the most unfortunate at their hour of greatest need. I took this young man as my pupil teaching him the role of motorcycle doctor and quickly realised this exceptional doctor was truly special. In truth the pupil quickly became the master and I had the privilege of 15 years of working alongside him as his wingman.

Where does the abdominal assessment occur when you manage a paediatric trauma patient? Warwick Teague challenges us to stop just leaving it to the paediatric surgeon as he talks us through his approach to the abdomen in a paediatric trauma, including the key aspects of assessment and treatment - so simple, he says, even a surgeon can do it.

Trish Woods guides you through some clinical pearls in the intensive care management of neonates. The complex physiology of the transitioning required in the journey from foetal life to neonatal presents many challenges and scary moments. Trish helps you to navigate these challenges and to unlock the key to providing quality neonatal intensive care. Many things can go wrong in the neonatal period as babies transition to life in the real world. Trish highlights her thoughts on the use of positive end expiratory pressure (PEEP), how deep to intubate, when to clamp the cord and the use of ultrasound. When babies arrive early their lungs can be full of meconium or fluid. Due to this, Trish recommends using PEEP – without which there is distal airway collapse and fluid accumulation. Aeration of the lungs is vital. To this end, how deep should intubation be aimed? The depth may not be overly important. This is because regional lung aeration triggers widespread, global increase in pulmonary blood flow. There is little definitive evidence to guide clinicians on when to clamp the cord – early or late. Trish recommends considering the physiology of clamping the cord. After clamping the cord there is a massive drop in cardiac output. Ventilatory support will turn this around – something to remember. In a compromised baby, perhaps we should aim to clamp the cord sooner and then initiate ventilation. Finally, Trish highlights the utility of ultrasound. Viewing the heart and lungs provides crucial information for the clinician. Furthermore, Trish discusses actively looking for aeration, collapse, consolidation and pneumothorax in the lungs and thorax. Overall, don’t forget the essentials. Trish reminds you to keep life sweet, warm, and tempting and help neonates to transition into the big world. For more like this, head to our podcast page. #CodaPodcast

Deirdre talks ‘bad blood’ – the complex world of critical care haematology. Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human. When they run riot, or the fine balance between pro- and anti-inflammatory states is shifted, there can be significant morbidity and mortality. Deirdre presents three patients to highlight these issues and what you can do about it. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients. Platelets make up a tiny percentage of blood – just 0.01%. However, they have a crucial role to play. A low platelet count can be due to reduced production or increased destruction. Disseminated Intravascular Coagulation (DIC) is a clinical and laboratory diagnosis that affects about 1% of hospitalised patients. At the most severe end it is associated with bleeding and/or thrombotic complications. Disorders such as thrombotic thrombocytopenia purpura (TTP) and other forms of micro-angiopathic haemolytic anaemia (MAHA) will also be described including the role of ADAMST13. The knowledge of what is what, is critical, as it will dictate treatment. Heparin-Induced Thrombocytopaenia (HIT) is an uncommon but important condition which is difficult to diagnose in a critically ill patient. It is a heparin dependent pro-thrombotic disorder. There is no good test for HIT.  Have you always wondered about NETs (neutrophil extracellular traps) and their importance? If so this whistle-stop tour of non-malignant hematology in the ICU is for you! Deirdre drives home the message that low platelets are common in the critically ill and the causes are multifactorial.  Finally, for more like this head to codachange.org/podcasts/

Mervyn Singer discusses the use of biomarkers in critical care. Multiple biomarkers - physiological, biochemical, biological - can prognosticate early in critical illness, even in the ED. These biomarkers are numerous - lipids, progesterone, troponin, thyroid stimulating hormone, inflammatory cytokines, mitochondrial dysfunction… so on and so forth! Prognostication can happen as early as the Emergency Department. Studies from the States have found high levels of inflammatory cytokines can predict death, separately from clinical presentation. Therefore, we can predict when critically ill patients are destined to die. So, does this mean that we are just prolonging the life of those destined to die in critical care? Perhaps. Mervyn discusses this being the possible reason for many failed ICU studies. Concurrently, the only progress in critical care in the past 20 years may be due only to less iatrogenic harm. Furthermore, he explains his experiments with rats demonstrating the use of cardiovascular parameters, cytokines, troponins and even cholesterol being accurate prognostic biomarkers. Then, Mervyn goes on to identify the use of steroids in sepsis. He talks about research that demonstrates a benefit to steroid use, but only in those patients predicted to die using the aforementioned biomarkers. This could be a key to selecting an appropriate patient group to allocate a specific treatment too. Furthermore, we examine treating sepsis with beta blockers. Giving beta blockers to everyone has no effect at best and a harmful effect at worst. However, giving beta-blockers to those who were predicted to die conferred benefit! In conclusion, we can predict outcome early in disease. This may allow better selection of patients for certain treatments! We thus need to adopt a completely different strategy for such patients predetermined to die. This also applies to trial design, especially where survival is the endpoint. For more like this, head to https://codachange.org/podcasts/ 

Jim Manning presents the how and why of adrenaline in cardiac arrest. The use of adrenaline in cardiac arrest resuscitation has been popular since the 1960s. Laboratory studies and anecdotal experience showed improved rates of return of spontaneous circulation (ROSC) with the use of adrenaline at small dosages. This led to the widespread adoption of adrenaline administration during cardiac arrest into every resuscitation guideline for decades to come. Extensive laboratory studies characterised the beneficial physiological effects of adrenaline during cardiac arrest and closed-chest cardiopulmonary resuscitation (CC-CPR). Adrenaline administered during CC-CPR results in peripheral arterial vasoconstriction that raises the aortic pressure. Particularly during the relaxation phase of CC-CPR. This increase in aortic pressure results in an increased aortic to right atrial pressure gradient that drives blood flow to the myocardium during CC-CPR. This pressure gradient is known as the coronary perfusion pressure (CPP) and this correlates with ROSC in laboratory investigations and clinical studies. During the 1990s, the use of “high-dose” adrenaline showed increased rates of ROSC compared to “standard-dose” adrenaline. However, larger doses of adrenaline did not result in improved survival. Recent meta-analyses have raised serious questions about the value of adrenaline. Notably, showing a benefit for achieving ROSC but no clear evidence of improved long-term survival. Controlled clinical trials to address this question are now underway. However, there is another important issue that needs to be addressed: the “route” of administration. With the growing interest in endovascular resuscitation, the use of intra-aortic adrenaline titration offers a means of rapidly and effectively delivering adrenaline to peripheral arterial effector sites while providing arterial pressure and CPP monitoring to guide titration of adrenaline doses to achieve an optimal hemodynamic effect while avoiding excessive adrenaline doses. For more like this, head to https://codachange.org/podcasts/ 

Congenital heart disease isn't just diagnosed in the antenatal period and during post-natal examination. Nick Pigott takes us through the three main presentations of congenital heart disease (shock, cyanosis and heart failure) and reassures us that treating these patients is simpler than we think, urging us to consider cardiac disease in the sick newborn. He covers duct-dependent lesions, structural obstructive lesions, immediate resuscitation, the usefulness of physical examination, a deeper dive into hyperplastic left heart syndrome, the known cardiac patients (and what to do with them) and the paediatric cardiology wonder-drug: Prostaglandin infusion.

Working in a Paediatric Emergency Department that has 52,000 attendances per year, means that at this point I have fallen into almost every possible pitfall associated with communicating with children and their parents, whether it be the seriously ill or the efficient disposition of the worried well and everything in between. The art of appearing to take all the time in the world whilst managing large volumes of patients can be challenging at times. It can be difficult to separate your emotional response to a patient and their parents from your professional assessment. I hope that by hightlighting mistakes I have encountered along the way that others will learn from them.

John Glasheen discusses the importance and challenges of trade-offs in prehospital critical care. Every Pre Hospital and Retrieval Medicine (PHARM) mission involves a series of complex decisions. These are made rapidly in a high-pressure environment. Excellent PHARM clinicians are invariably expert decision makers. The ability to identify, accept and manage trade-offs is a key skill in prehospital and retrieval medicine. Some of these trade-offs are obvious, and the best options are clear. For example, aircraft and crew safety cannot be compromised regardless of the clinical situation on scene. Other choices are far more complex. These require rapid and accurate cognitive appraisal of a dynamic and often incomplete information set. Moreover, interventions performed on scene, involve a balance of the patient’s immediate requirements against time and risk. During a mission, each decision to do something leads to how and where it should be done. This often results in a trade off between principle and preference. Decisions on which team member should perform a particular procedure must balance competence, training opportunity and the concurrent performance of other tasks. Every mission is a continuous efficiency-thoroughness trade-off, and each individual decision must be made to positively affect overall patient care. Furthermore, there is often no single ideal solution to these trade-offs. We must tailor decisions to circumstances. The way in which the clinician manages these trade offs is vital both for effective patient care the overall performance of the mission. Excellence in PHARM is a function of training and experience, with expert clinicians operating within a robust system that allows for flexibility. Protocols are powerful but individual insight is indispensable. For more like this, head to our podcast page. #CodaPodcast