The Resus Room

We start off this month with a much talked about paper in the pre-hospital services, what benefit does Pre Hospital Critical Care bring to cardiac arrest victims? We are lucky enough to have the inside thoughts of the lead author, this a really interesting piece of work and will no doubt lead to further discussions, for more information from the author take a look at his thesis here. Next up we take a look at the utility of troponins in patients that have suffered cardiac arrest, can we use them to evaluate how likely it was that an MI precipitated the arrest? Last up we have a look at a novel approach of ruling out stroke as the cause of acute dizziness. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob

Following on from our previous Roadside to Resus episode on Stroke, in this episode we look at the rapidly evolving area of stroke management.  In the last 2 decades stroke management has progressed beyond recognition and keeping up with the evidence and available therapies is a significant challenge. We cover the following treatments, looking at the risks and benefits of each, with the goal of being able to offer our patients the best possible outcomes; Aspirin Thrombolysis; both prehospitally and in hospital Thrombectomy Decompressive Hemicraniectomy Normoxia Euglycaemia Acute blood pressure management As always we’d love to hear any thoughts or comments you have on the website and via twitter. Enjoy! Simon, Rob & James References Tissue plasminogen activator for acute ischemic stroke. National Institute of Neurological Disorders and Stroke rt-PA.Stroke Study Group. N Engl J Med. 1995  Aspirin in Stroke;NNT Stroke Thrombolysis; Life in The Fast Lane Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency. Nolte CH. Stroke. 2018 Effect of the use of ambulance based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. Ebinger M. JAMA. 2014 Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee. Mokin M. J Neurointerv Surg. 2019 Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Evans MRB. Pract Neurol. 2017 Extend; The Bottom Line Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline.Published: 1 May 2019 MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial.Fransen PS. Trials. 2014 A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA).Campbell BC. Int J Stroke. 2014 Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. Jeffrey L. Saver. NEJM. 2015  Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging.Gregory W. Albers. NEJM. 2018 Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.Raul G. Nogueira.NEJM. 2018

Well the summer has definitely hit and we hope you get a chance for a break... making sure you spend spend some time listening to our Heat Illness episode on a beach somewhere! It's a wide variety of papers for you this month; Should we be looking to immediately cardiovert acute onset AF in the ED? What difference does glucagon make to clearing oesophageal foreign bodies? How important is our diagnostic accuracy in ED to the patients morbidity and mortality? And finally we cover a paper looking at the requirement for urgent tracheal intubation in trauma patients, and are lucky enough to get some thoughts from the lead author Dr. Kate Crewdson. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob  

Stroke is a common presentation to all Emergency Health care providers, with around 150,000 strokes occurring in the UK each year! Our impact and treatment can be hugely significant and in this podcast we’re going to conver the topic in some depth, and importantly cover some of the new Guidance published by NICE in their ‘Stroke and transient ischaemic attack in the over 16’s diagnosis and initial management’ document that was published in May of this year. We'll be running through Definition Pathophysiology Territories Risk factors Assessment; both prehospitally and in hospital Stroke mimics Investigations As always we’d love to hear any thoughts or comments you have on the website and via twitter. Enjoy! Simon, Rob & James References Stroke & Dizziness; PHEMCAST RCEMLearning; RCEM Belfast Vertigo Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline.Published: 1 May 2019 Acute Stroke Lecture notes; LITFL Stroke Thrombolysis; LITFL Are you at risk of a Stroke; Stroke Association Modifiable Risk Factors for Stroke and Strategies for Stroke Prevention.Hill VA. Semin Neurol. 2017 A systematic review of stroke recognition instruments in hospital and prehospital settings. Rudd M. Emerg Med J. 2016 Acute Stroke Diagnosis.Kenneth S. Yew. Am Fam Physician. 2009 Imaging of acute stroke prior to treatment: current practice and evolving techniques.G Mair. Br J Radiol. 2014 Should CT Angiography be a Routine Component of Acute Stroke Imaging?Vanja Douglas. Neuro hospitalist. 2015 Comparative Sensitivity of Computed Tomography vs. Magnetic Resonance Imaging for Detecting Acute Posterior Fossa Infarct. David Y Hwang. J Emerg Med. 2013 Posterior circulation ischaemic stroke. A Merwick BMJ 2014 Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack (Review)Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. 2019. Cochrane.

Welcome back! This month we're finishing off our theme of syncope with a paper that looks to answer the big question; in those with undifferentiated syncope, does hospitalisation result in better outcomes when compared to discharge? We have a look at a paper reviewing the feasibility of live streaming video from scene using the 999 caller's mobile phone, a fantastic utilisation of technology and a really exciting area; we also get the thoughts of one of the co-authors, Richard Lyon, Associate Medical Director for KSS. Finally we take a look at a paper reviewing the time on scene in cardiac arrests, that suggests if no ROSC is gained, rapidly getting off scene is in our patients' interest. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob

Exploring the impact of Heat Illness, from milder forms like Heat Cramps to severe Heat Stroke, discussing clinical findings, risk factors, and management. Emphasis on early recognition and differentiation between conditions, along with cooling strategies and holistic care approaches.

Status Epilepticus in children, lying and standing blood pressures in syncope or presyncope and decompressing paediatric tension pneumothoraces. You'll no doubt have seen and heard about the two papers published this month in the Lancet, both Consept and Eclipse look at the use of keppra vs phenytoin as a second line anti convulsant therapy for children in status epilepticus. We take a look at both papers, and have a think about what this means for practice. There has been a large amount of focus on the optimal position for needle decompression of tension pneumothoraces in adults, but an open access paper from SJTREM looks at the best position in children, take a look at the paper here. Finally, should all patients with a presentation of syncope/presyncope be getting a lying and standing blood pressure, or is it an ineffective test? Make sure you take a look at the papers yourself, remembering that the paper from SJTREM on paediatric pneumothoraces is totally open access. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob  

Exploring the challenges of drowning, from initial assessment to resuscitation and prognostication. Discussions on modes of drowning, prognostic factors, extrication, ALS, and termination of resuscitation. The importance of quick rescue efforts and proper clinical management in drowning cases. Optimizing airway management and ventilation in CPR, along with challenges in resuscitating drowning patients.

So first up a huge welcome to SJTREM, the free open access journal who we've teamed up with in the delivery of the podcast, every paper they publish is available online to read for free. Each month we'll be covering one of their papers in our Papers of the Month episodes, giving you the opportunity to review the literature yourself, come to your own conclusions and join the conversation. SJTREM have made our podcast a sustainable venture and together we look forward to promoting review and discussion of the best evidence and education, to all, for free! This month we'll be looking at an analysis of REBOA and having a think about whether it is benefiting those patients that are receiving it. We take a look at paper that reviews what we really know about the use of ETCO2 in cardiac arrest and have a think about how much importance we should put on it. Finally we take a look at the utility of prehospital blood gases; should this be the standard of care, or is it a step too far?Make sure you take a look at the papers yourself, remembering that the paper from SJTREM on prehospital blood gases is totally open access. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob

'Patients with GCS scores of 8 or less require prompt intubation', that's what ATLS tells us. The mantra of GCS 8, intubate has pervaded teaching for those involved in the management of patients with a reduced GCS (Glasgow Coma Scale). But on reflection it would seem slightly odd that the gain or loss of a single point on the Glasgow Coma Scale could simply account for a change in the decision as to whether a patient would benefit from intubation and ventilation. So should the patient with a GCS of 9 be best managed without a definitive airway, but when that slips to 8 we should reach for the portex®? In this podcast we take a deeper look at the GCS, we have a think about the role that it was designed to perform and consider how it should best be applied to acutely ill patients when considering protecting their airway. The podcast is based upon the blog from the TEAM Course blog(Training in Emergency Airway Management), make sure to go and have a look at the post and other resources available on that site. Enjoy! Simon, Rob & James References GCS 8 intubate; TEAMcourse Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.2013;74(5):1363-6.Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4. Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G.The Glasgow Coma Scale at 40 years: standing the test of time.Lancet Neurol. 2014;13(8):844-54. Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-5. Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale.Ann Emerg Med. 2011;58(5):427-30. Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor.J Trauma. 2003;54(4):671-8. Isbister GK, Downes F, Sibbritt D, Dawson AH, Whyte IM. Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes.Crit Care Med. 2004;32(1):88-93. Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia.Lancet. 1996;348(9020):123-4. Kulig K, Rumack BH, Rosen P. Gag reflex in assessing level of consciousness.Lancet. 1982;1(8271):565. Rotheray KR, Cheung PS, Cheung CS, et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?.Resuscitation. 2012;83(1):86-9. Moulton C, Pennycook A, Makower R. Relation between Glasgow coma scale and the gag reflex.BMJ. 1991;303(6812):1240-1.