The Resus Room

In this episode Rob takes us through a case he saw recently that brought about some invaluable learning. We're not going to give you anymore clues than that! Enjoy! Simon & Rob References & Further Reading (anonymised to keep the anticipation!) Article 1   Article 2   Article 3   Article 4

  Welcome back to April's papers of the month. We've got 3 papers this month that look to challenge our work up strategies for the critically unwell. First up we look at a paper on the Ottawa subarachnoid haemorrhage rule, specifically considering if we can decrease scanning in patients with a suspected SAH and what application of the rule might mean for our practice. Next up we look at a paper that might shine some real doubt on the use of IO access in our patients in cardiac arrest. Lastly we look at a validation paper for the PERC rule for those patients with a suspected pulmonary embolus and this paper brings about some interesting points on external validity Once again we'd really encourage you to have a look at the papers yourself and we've love to hear any thoughts or feedback you have. Enjoy! Simon & Rob  References Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. Perry JJ. CMAJ. 2017   Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Kawano T. Ann Emerg Med. 2018  Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. Freund Y. JAMA. 2018  CORE EM; IO in Cardiac Arrest    

Gaining control of the airway in a critically unwell patient is a key skill of the critical care team and littered with potential for difficulty and complications. NAP4 highlighted the real dangers faced with their review of complications of airway management in the UK, lessons have been learnt and practice has progressed. As always there is room to improve on current practice and a recent paper published in Anaesthesia describes a comprehensive strategy to optimise oxygenation, airway management, and tracheal intubation in critically ill patients in all hospital locations. In this podcast we cover; Why this matters to all involved in critically unwell patients, not just those delivering RSI Recap of RSI, the procedure and its indictions Headlines from NAP4 Strategies highlighted to optimise airway management and oxygenation How this impacts our prehospital and inhospital practive We'd love to hear your thoughts so please leave your comments below or contact us via twitter @TheResusRoom Enjoy! Simon, Rob & James References & Further Reading NAP4 Guidelines for the management of tracheal intubation in critically ill adults. A Higgs B. British Journal of Anaesthesia. 2017 Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study.De Jong A. Am J Respir Crit Care Med. 2013 Introduction to the Vortex; vimeo

How often do you prescribe or give i.v. fluids to your patients? How much thought goes into what's contained in that fluid? What effect will you fluid choice have on your patient? Two trials on crystalloid administration in the acutely unwell patient have occupied a lot of conversation in the research world over the last few weeks, both published in the NEJM and in this podcast we take a look at them. In the podcast we cover the following; Whats the big deal with crystalloids Previous trials on fluid administration NEJM papers on crystalloids Myburgh's editorial Make sure you take a look at the papers yourself and come up with your own conclusions. There are a whole host of superb FOAM resources out there on the topic that are well worth a look and referenced below. We'd love to hear any thoughts and comments below. Enjoy! Simon & Rob References & Further Reading Fluid Na K Cl Ca Mg Lact Acet Glucon Dext Osmol mOsm/L 0.9% N Saline 154 0 154 0 0 0 0 0 0 308 Lactated Ringers 131 5 11 2.7 0 29 0 0 0 273 Hartmanns 129 5 109 4 0 29 0 0 0 278 Plasma Lyte 140 5 98 0 3 0 27 23 0 280 Constituents measured in mEq/L Reference; University Texas  Balanced Crystalloids versus Saline in Critically Ill Adults. Semler MW. N Engl J Med. 2018 Balanced Crystalloids versus Saline in Noncritically Ill Adults. Self WH. N Engl J Med. 2018 Patient-Centered Outcomes and Resuscitation Fluids. Myburgh J. N Engl J Med. 2018 REBEL.EM; Is the Great Debate Between Balanced vs Unbalanced Crystalloids Finally Over? PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation JC: Balanced fluids vs Saline on the ICU. The SMART trial. St Emlyn’s JC: So long Salt and Saline? St Emlyn’s The Bottom Line; SALT-EM The Bottom Line; SMART

Welcome to March's papers of the month. We know we're biased but we've got 3 more superb papers for you this month! First up we review a paper looking at oxygen levels in patient's with a return of spontaneous circulation following cardiac arrest, is hyperoxia bad news for this patient cohort as well as the other areas we've recently covered? Secondly we have a look at a paper reviewing the association between time to i.v. furosemide and outcomes in patients presenting with acute heart failure, you may want to have a listen to our previous podcast on the topic first here. Lastly, when you see a pregnant patient with a suspected thromboembolic event, can you use a negative d-dimer result to rule out the possibility? We review a recent paper looking at biomarker and specifically d-dimers ability to do this.  We'd love to hear from you with any thoughts or feedback you have on the podcast. And we've now launched of Critical Appraisal Lowdown course, so if you want to gain some more skills in critical appraisal make sure you go and check out our online course here. Enjoy! Simon & Rob References & Further Reading Association Between Early Hyperoxia Exposure AfterResuscitation from Cardiac Arrest and Neurological Disability: A Prospective Multi-Center Protocol-Directed Cohort Study. Roberts BW. Circulation. 2018 The DiPEP (Diagnosis of PE in Pregnancy) biomarker study: An observational cohort study augmented with additional cases to determine the diagnostic utility of biomarkers for suspectedvenous thromboembolism during pregnancy and puerperium. Hunt BJ. Br J Haematol. 2018 Time to Furosemide Treatment and Mortality in PatientsHospitalized With Acute Heart Failure. Matsue Y . J Am Coll Cardiol. 2017 MDCALC; Framingham Heart Failure Diagnostic Criteria REBEL.EM; Door to Furosemide in AHF Modified Rankin Scale

So the three of us are back together and going to take on Sepsis! It's vital to have a sound understanding of sepsis. It has a huge morbidity and mortality but importantly there is so much that we can do both prehospital and in hospital to improve patient outcomes. In the podcast we cover the following; Definitions Scale of problem Different bodies; NICE/Sepsis Trust/3rd international consensus definition including qSOFA Handover and pre alerts Treatment; Sepsis 6 The evidence base behind treatment Contentious areas  Prehospital abx Fever control Steroids ETCO2 We hope the podcast helps refresh your knowledge on the topic and brings about some clarity on some contentious points. As always don't just take our word for it, go and have a look at the primary literature referenced below. Enjoy! Simon, Rob & James References & Further Reading Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Kumar. Critical Care Medicine. 2006 Prognostic value of timing of antibiotic administration in patientswith septic shock treated with early quantitative resuscitation. Ryoo SM. Am J Med Sci. 2015  The association between time to antibiotics and relevant clinicaloutcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. de Groot B. Crit Care. 2015 Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Puskarich MA. Crit Care Med. 2011 Early goal-directed therapy in the treatment of severe sepsis and septic shock. Rivers E. N Engl J Med. 2001 Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Nguyen HB. Crit Care Med. 2004  The prognostic value of blood lactate levels relative to that of vitalsigns in the pre-hospital setting: a pilot study. Jansen TC Crit Care. 2008 Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Jones AE. JAMA. 2010 Lower versus higher hemoglobin threshold for transfusion in septic shock. Holst LB. N Engl J Med. 2014 A randomized trial of protocol-based care for early septic shock. ProCESS Investigators. N Engl J Med. 2014 Trial of early, goal-directed resuscitation for septic shock. Mouncey PR. N Engl J Med. 2015 Goal-directed resuscitation for patients with early septic shock. ARISE Investigators. N Engl J Med. 2014 Acetaminophen for Fever in Critically Ill Patients with SuspectedInfection. Young P. N Engl J Med. 2015 NICE; Sepsis: recognition, diagnosis and early management The Sepsis Trust The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer M. JAMA. 2016 NHS E; Improving outcomes for patients with sepsis. A cross-system action plan Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Alam N. Lancet Respir Med. 2018 Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. Venkatesh B. N Engl J Med. 2018 PHEMCAST; End Tidal Carbon Dioxide Current clinical controversies in the management of sepsis. Cohen J. J R Coll Physicians Edinb. 2016 St Emlyns; qSOFA  RCEM; Severe Sepsis and Septic Shock Clinical Audit 2016/2017 National report RCEM & UK Sepsis Trust; Toolkit: Emergency Department management of Sepsis in adults and young people over 12 years- 2016

On a not infrequent basis we will come across patients in hospital who have a CT head scan that appears to show an unsurvivable event. Having sourced opinion from our neurosurgical and neurology colleagues we may well be given the advice to withdraw care for the patient. It has become increasingly recognised that prognosticating in such patients at an early stage is extremely difficult with numerous cases surviving what was initially thought to be an unsurvivable event, with a good neurological outcome. This joint document from the Intensive Care Society, Royal College of Emergency Medicine, Neuro Anaesthesia and Critical Care Society of Great Britain & Ireland and the Welsh Intensive Care Society gives new guidance for such perceived devastating brain injuries and will challenge many peoples thinking on the topic with additional questions being asked on resource utilisation. In this podcast Caroline Leech, EM and PHEM Consultant in Coventry, discusses the guidelines and the implications they hold for our practice. As always make sure you read the document yourself, we would love to hear your thoughts. Enjoy! Simon & Caroline References Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement  A case for stopping the early withdrawal of life sustainingtherapies in patients with devastating brain injuries. Manara AR. J Intensive Care Soc. 2016

Welcome back, we've got 3 absolute beauties of papers for you this month! You'll have struggled not to have heard about the ADRENAL trial, a trial of iv steroids in the sickest of patients with septic shock. We also have a look at a trial that many have been quoting as sound evidence for the utility of pH during the prognostication of patients in cardiac arrest. Finally we have a look at a paper that may shed some concern on the use of Double Sequential Defibrillation that we covered recently on the podcast... We'd love to hear from you with any thoughts or feedback you have on the podcast. And we've now launched of Critical Appraisal Lowdown course, so if you want to gain some more skills in critical appraisal make sure you go and check out our online course here. Enjoy! Simon & Rob References & Further Reading TheBottomLine; ADRENAL St Emlyns; ADRENAL Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. Venkatesh B. N Engl J Med. 2018 External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose Cardioversion. Gerstein NS. Ann Emerg Med. 2018 Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study. Shin J. Crit Care. 2017  

In this episode we cover a paper that you have to know about! The use of tranexamic acid(or TXA) has become widespread in the case of major trauma and post partum haemorrhage. This time we discuss a recent paper that asks us if giving it within 3 hours is enough, or whether we need to be even more specific regarding its urgency of administration in order to save lives from bleeding. There is a superb podcast over at our buddies site PHEMCAST which covers an interview with one of the authors and we'd highly recommend listening to that! Enjoy! Simon & Rob References Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Gayet-Ageron A. Lancet. 2017

Prehospital Care is evolving rapidly and is one of the most exciting and dynamic specialties to be involved with at the moment. As a reflection of it's progress the Faculty of Pre Hospital Care held  its first scientific conference this week. We were lucky enough to be invited by Caroline Leech, EM & PHEM Consultant and the person responsible for organising this superb event, to interview some of the superb speakers at the event. Here are the speakers we were lucky enough to catch up with and the topics they discuss Matt Thomas – Hyperoxia: when oxygen is harmful Jo Manson – The hyperacute inflammatory response to trauma Rob Moss – FPHC Consensus Statement - Spinal Malcolm Russell – FPHC Consensus Statemnent – External Haemorrhage Tim Nutbeam – Pre-hospital research: what do we not know?  David Menzies – Impact brain apnoea & motorsport Stacey Webster – Calcium in pre-hospital blood transfusion: the missing link Rod Mackenzie Injury prevention, control & recovery A huge thanks to all involved in the conference for having us at the conference and we hope to see you all next year! Simon, Rob & James   References and links     FPHC Consensus statement guidelines   Ionised calcium levels in major trauma patients who received blood in the Emergency Department. Webster S. Emerg Med J. 2016 TOP-ART