The Resus Room

Angioedema is something we'll all encounter in the acute setting, whether we recognise it or not... Understanding the different causes and mechanisms is imperative to ensuring the patients get treatment that is not only effective, but in extremis potentially lifesaving. In this episode we talk through the condition; from clinical presentation, causative agents, mechanisms of action, differentials and the evidence base of treatment. Get in touch with any comments on the podcast, ensure to read the papers that are referenced yourself and draw your own conclusions. Enjoy! Simon & Rob

As care on our emergency and urgent care demand is on an ever upwards course, whilst alongside this the scope of what we can potentially deliver to patients is also increasing. In order to meet this demand and to deliver the best care possible to our patients we will need to look for other solutions. We were lucky enough to be invited to the First Community Emergency at the Royal Society of Medicine in London, hosted by the Physician's Response Unit. This event looked at the current challenges and explored solutions and opportunities for more collaborative working. In this podcast you'll hear from Tony Joy about the concept and practice of Community Emergency Medicine. You'll hear from Gareth Davies on the history of Pre Hospital Emergency Medicine, both challenges and achievements. Finally you'll hear from Bill Leaning, PRU clinical manager & HEMS paramedic about how to go about setting up a service. Please let us know any thoughts or feedback, and we'll be back with another podcast on a clinical topic for you in a few days time. Enjoy! Simon & James

We've got some papers this month that focus on our sickest patients! If you had a patient that you found in cardiac arrest and you believed they had a PE, would you thrombolyse them during the arrest, and how much more likely do you think they would be to survive? Our first paper looks at exactly this question. Second up we consider the potential harms associated with adrenaline administration to those in traumatic arrest. Finally, when RSI'ing a patient and considering your pharmacological cocktail, how likely are you to reach for the fentanyl and how much concern would you have over the risk of this rendering the patient haemodynamically unstable? We take a look at a recent review on the topic and get Dr. Ian Ferguson's insights as the lead author. Make sure to get in touch with any comments on any of the reviews, and importantly make sure you check out the papers and draw your own conclusions. Enjoy! Simon & Rob

The podcast explores the potential of Tranexamic Acid (TXA) to save lives in head injuries, as shown in the CRASH-3 paper. They discuss TXA's effectiveness in trauma patients and postpartum hemorrhage, emphasizing the crucial role of early treatment. The episode includes an interview with lead author, Professor Ian Roberts, and references key trials like CRASH-2 and WOMAN.

Welcome to October '19 papers podcast. You can't go far without the topic of TXA as a treatment for anything that bleeds being mentioned! With the publication of CRASH-2 and the WOMAN trial practice has crept such that administration in gastro-intestinal bleeding is seen fairly frequently. However, current guidelines don't recommend the use of TXA in GI bleeding, so this month we have a look at a systematic review which looks to answer whether it's administration is supported by the evidence, before we get a definitive answer from the HALT-IT trial. Next up, following on from our Burns Roadside to Resus podcast, we take a look at a paper that quantifies the potential benefit of thorough first aid in the management of paediatric burns, a really key paper on the topic, with really powerful results. Finally, we all know that Sepsis is a core area of our practice, but at times it may feel like the attention on those that could possibly have severe sepsis displaces the ability to care for other critically ill patients. We take a look at a great paper developing a prehospital screening tool to focus in on those patients that really do require time-critical care. Enjoy! Simon & Rob

So as promised, and following on from our previous shock episode, this time we've covered the topic of shock in Trauma. It's a massive topic and one that we all, yet again, can make a huge difference for our patients' outcomes. There is some crossover as you'd expect from the concepts and assessment that we covered in our Shock episode, so we'd recommend taking a listen to that one first. Make sure you have a comfy seat and plenty of refreshments to keep you going for this one as we cover the following; Definition Aetiology Hypovolaemic shock Neurogenic shock Obstructive shock Cardiogenic shock Physiology; Traumatic coagulopathy Other diagnostics Controlling external haemorrhage Pelvic binders REBOA Avoiding coagulopathy BP targets & permissive hypotension Fluid choices & supporting evidence TEG/ROTEM Calcium TXA Vasopressors Preventing hypothermia Relieving obstruction Interventional radiology Damage control surgery As always we'd love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions. Enjoy! Simon, Rob & James References Shock;The Resus Room podcast REBOA;The Resus Room podcast External Haemorrhage;The Resus Room podcast Blood;PHEMCAST TEG & ROTEM;FOAMcast Major Trauma guideline;NICE Resuscitative endovascular balloon occlusion of the aorta (REBOA):a population based gap analysis of trauma patients in England and Wales Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. Joseph B. JAMA Surg. 2019 The Pre-hospital Management of Pelvic Fractures: Initial Consensus Statement. I Scott. FPHC. 2012 RePHILL;Birmingham University Trials Assessment and Treatment of Spinal Cord Injuries and Neurogenic Shock;Fox A. JEMS Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. Holcomb JB. JAMA. 2015 Risks and benefitsof hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis. Owattanapanich N. Scand J Trauma Resusc Emerg Med. 2018 The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.Roberts I. Health Technol Assess. 2013 TEG and ROTEM for diagnosing trauma‑induced coagulopathy (disorder of the clotting system) in adult trauma patients with bleeding;Cochrane Review. 2015 Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review.McQuilten ZK. Transfus Med Rev. 2018 Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock.Sperry JL. N Engl J Med. 2018

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.