The Resus Room

Bicarbonate use in cardiac arrest. The topic still provokes debate and multiple publications on the topic still hit the press reels. People talk of the increased rate of ROSC and the improvement in metabolic state, whilst others talk of the increase in mortality and worsening of intracellular acidosis. A recent paper in Resuscitation looked at a huge cohort of patients receiving bicarbonate in arrest prehospitally. In this episode we take a look at the paper, review the guidelines and give our take on the current situation with regards bicarb in arrest We hope you enjoy it and would love to hear your feedback! Simon &  Rob References & Further Reading Prehospital Sodium Bicarbonate Use Could Worsen Long Term Survival with Favorable Neurological Recovery among Patients with Out-of-Hospital Cardiac Arrest. Kawano T, et al. Resuscitation. 2017 Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature. Velissaris D, et al. J Clin Med Res. 2016 Effect of Sodium Bicarbonate on Advanced Cardiac Life Support. Jungyoup Lee. Circulation 2014 Advanced Life Support; Bicarbonate guidance

So we're back with some superb topics this month; Early or late intubation in ICU patients, which is associated with worse outcomes? What are the predictors of a poor outcome in patients presenting with syncope? Does a cervical collar result in a demonstrable raise in ICP viewed by ultrasound? Make sure you take a look at the papers yourself, they certainly provide food for thought and raise important questions in our practice Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast Enjoy! Simon & Rob References & Further Reading Association between timing of intubation and outcome in critically ill patients: A secondary analysis of the ICON audit. Bauer PR. J Crit Care. 2017   Increase in intracranial pressure by application of a rigid cervical collar: a pilot study in healthy volunteers. Maissan IM. Eur J Emerg Med. 2017   Predicting Short-Term Risk of Arrhythmia among Patients with Syncope: The Canadian Syncope Arrhythmia Risk Score. Thiruganasambandamoorthy V. Acad Emerg Med. 2017 

This podcast discusses topics such as the use of ketamine and ultrasound in asthma, NIV in asthma management, challenges in intubating severe asthmatic patients, management of cardiac arrest in asthma patients, the use of T-piece nebulization in cardiac arrest, IV salbutamol in asthma treatment, and criteria for discharging patients.

The podcast discusses the presentation and severity of asthma, the criteria for assessing asthma severity, differential diagnosis of asthma and conditions that mimic it, identifying and treating asthma attacks, and the management of severe asthma cases with IV hydrocortisone and magnesium.

We're back with more great papers for you this month, hot off the press! There's been a lot of talk over the last few years about apnoeic oxygenation and whether it really holds any benefit to patients undergoing RSI, we have a look at a systematic review that may help answer that question. Next up we have a look at the choice of sedation agent used in the Emergency Department and how this correlates with patient satisfaction. Finally, following on from our recent podcast on Double Sequential Defibrillation, we have a look at a paper published looking at the results of DSD from the London prehospital service. Will this reveal a patient benefit? Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast. Enjoy! Simon & Rob References & Further Reading Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. Pavlov I. Am J Emerg Med. 2017 Patient satisfaction with procedural sedation in the emergency department. Johnson OG. Emerg Med Australas. 2017 Double sequential defibrillation therapy for out-of-hospitalcardiac arrests: The London experience. Emmerson AC. Resuscitation. 2017

This is the first of a new series of Roadside to Resus podcasts. We've been joined by James Yates, a Critical Care Paramedic with the Great Western Air Ambulance to make it a truly multidisciplinary team. Each monthly episode we'll be discussing acute presentations, including the latest and most influential evidence base surrounding them. We really want  to break down some barriers between pre-hospital and in hospital teams and it soon becomes evident in this first podcast that many of the problems we face are shared throughout the patient journey and across disciplines! We're starting off with Acute Heart Failure and in the podcast we run through; The underlying physiology and help explain the different problems we may find in each subset The keys to diagnosis, including the most predictive parts of history and examination We discuss the evidence base for treatment and the trends of use both pre and in-hospital We talk about CPAP and whether the evidence supports it's use Finally, the direction that further treatment in the UK may move     Once again we hope you find the podcast useful. Get in touch with any comments, questions or suggestions for further topics. Most of all don't take our word for it, but make sure you delve into the references yourself and make up your own mind. Enjoy! Simon, Rob & James References & Further Reading Recommendations on pre-hospital & early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine Understanding cardiac output. Jean-Louis Vincent. Crit Care. 2008. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure The pathophysiology of hypertensive acute heart failure. Viau DM. Heart. 2015 Meta-analysis: Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema. Weng. Annals Int Med. 2010  Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S.JAMA 2005 Diagnosing Acute Heart Failure in the Emergency Department; A Systematic Review and Meta-analysis. Martindale. Academic Emergency Medicine. 2016 Noninvasive ventilation in acute cardiogenic pulmonary edema. Gray A. N Engl J Med. 2008 Life in the Fast Lane; severe heart failure management Emergency Medicine Cases; acute congestive heart failure REBEL.EM; morphine kills in acute decompensated heart failure  EMCRIT 1; Sympathetic Crashing Acute Pulmonary Edema (SCAPE)  

C-spine immobilisation is a controversial topic because of a lack of high quality evidence from clinical trials. Historical approaches have been challenged, however NICE guidance continues to recommend 3-point immobilisation for all patients with suspected spinal injury despite considerable clinical equipoise. In this episode we discuss the complexities of balancing the risks and harms when trying to provide a patient centred approach, rather than a “one-size fits all” model.   As always, there are a number of papers, guidelines and resources that you should have a look at (it’s not exhaustive, but a good place to start!)   Enjoy!   Rob References & Further Reading     NICE Guidance   Major trauma   Spinal injury    Faculty of prehospital care consensus statements   Spinal immobilisation   Minimal patient handling   Cochrane reviews   Spinal Immobilisation for Trauma   Papers of interest   Cowley et al 2017   Dixon et al 2015   Benger & Blackham 2009   Hauswald 2015   Hauswald 2013   Michaleff et al 2012   Podcasts   RCEM Learning   EMCrit

We're back with 3 superb topics this month! First off we have a look at the utility of ultrasound for the detection of pneumothoraces in the context of blunt trauma. Next we look at the need to scan facial bones when scanning a patient's head following trauma. Last of all we look at a paper reviewing the association between the use of a bougie and the first pass success when performing ED RSI. Have a listen to the podcast and most importantly make sure you have a look at the references and critically appraise the papers yourself. We'd love to hear your thoughts and comments at the bottom of the page. Enjoy! Simon & Rob References & Further Reading Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017 Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury. Huang LK. Injury. 2017  The Bougie and First-Pass Success in the Emergency Department. Driver B. Ann Emerg Med. 2017

Guidelines. Algorithms. Evidence based medicine. These all play a significant part in the safe and effective management of the majority of our patients. As a result there is a danger that treatment pathways are followed blindly without critiquing their use and there is real risk we can loose sight of what’s best for the patient in front of us. Guidelines encourage inflexible decision making, which creates further challenge when we are met by patients who do not fit standard treatment pathways. If this is the case then the management of cardiac arrest, which is taught and delivered in a didactic and protocol driven fashion, is surely the pinnacle of the problem. Standard Advanced Life Support (ALS) is totally appropriate for the majority of cardiac arrests, but what happens when it fails our patients? Refractory ventricular fibrillation (rVF) is, by its very nature, defined by the failure of ALS, but frustratingly there is very little evidence, or guidance, surrounding how to manage this patient group. I was faced with this situation when called to support an ambulance crew who were resuscitating an out-of-hospital VF arrest. When benchmarked against the ALS guidelines their management had been exemplary, but the patient remained in VF after eight shocks. So what now? The UK Resuscitation Council doesn’t specifically discuss rVF, but offers the advice that it is “usually worthwhile continuing” if the patient remains in VF. Not a particularly controversial statement, but not much help either. They do discuss the potential for ECMO use, but this is currently a very rare option in UK practice, or thrombolysis for known or suspected pulmonary embolism. Other potential interventions not in the guidelines include IV magnesium and placing defibrillator pads in the anterior-posterior orientation. PCI can also be considered if there is a suitable receiving centre available and the patient can be delivered in a safe and timely fashion. A final option is the use of double sequential defibrillation (DSD), using two defibrillators, charged to their maximum energy setting, to deliver two shocks in an almost simultaneous fashion.DSD was first described in human subjects in 1994 when it was used to successfully defibrillate five patients who entered rVF during routine electrophysiologic testing. These patients were otherwise refractory to between seven and twenty single shocks. Looking at the available literature there has been little interest in DSD since then, until the last two to three years when it appears to have undergone a small revival. Sadly, there is no evidence for its use beyond case reports and small case series. The case reports appear to show good results with four in the last two years reporting survival to discharge with good neurological outcome. There are also a handful of other cases discussed in online blogs and articles with good outcomes. But these case reports and articles almost certainly represent an excellent example of publication bias. The most recent case series reviewed the use of DSD by an American ambulance service over a period of four years. During this time DSD was written into their refractory VF protocol, with rVF defined as failure of five single shocks. The study included twelve patients, three of whom survived to discharge with two of these demonstrating a cerebral performance score of 1. Despite appearing to demonstrate reasonable outcomes for DSD, sadly this study has a number of significant limitations. One important point the authors fail to discuss is that the two neurologically intact survivors received their DSD shocks after two and three single shocks respectively, not after five shocks which would have been per-protocol and consistent with the authors definition of refractory VF. This highlights a further problem with analysing the use of DSD. Not only is there a dearth of high-level evidence, but the literature that is available is highly inconsistent. There are a range of definitions for refractory VF, different orientations for the second set of pads, variable interventions prior to using DSD, a variety of timings between the shocks and so on. This means that comparison between studies and drawing meaningful conclusions is nearly impossible. Given these challenges, what are the explanations for why DSD might work? The first theory is that by using DSD the myocardium is defibrillated with a broader energy vector compared to a single set of pads resulting in a more complete depolarisation of the myocardium. A second theory is that the first shock reduces the ventricular defibrillation threshold meaning that the second shock is more effective. A third explanation may simply be the large amount of energy delivered to the myocardium. These theories should be tempered by the fact that studies have demonstrated increasing defibrillation energy to result in increased defibrillation success, but only up to a plateau. After this the success of defibrillation drops sharply. Increased energy use has also been demonstrated to cause an increase in A-V block but without an associated increase in shock success or patient outcome. The use of double sequential defibrillation is clearly an area that would benefit from further research, but despite this it is interesting to note that London Ambulance Service have enabled their Advanced Paramedic Practitioners to use DSD and some American EMS systems have written DSD into their protocols. So returning to the case in point what did I choose to do with my patient? After changing the pad position, administering magnesium and continuing defibrillation they remained in VF.  I considered transport to a hospital with interventional cardiology but the patient was several stories up in a property with an inherently complex extrication. So I chose to use DSD because I felt that all other avenues had been explored. The patient had suffered a witnessed arrest, received bystander CPR immediately and throughout the resuscitation they had maintained a high end tidal CO2 and a coarse VF. I felt that this was a patient who could still respond to non-standard cardiac arrest management in the absence of a response to guideline directed treatment. After two DSD shocks a return of spontaneous circulation was achieved and the patient survived to hospital admission, but sadly didn’t survive to hospital discharge. We’re left with a even bigger question: if we accept that DSD is a potentially useful intervention in rVF, when should we consider using it? Would the outcome for this patient have been different if DSD had been used earlier? The European Resuscitation Council states that the use of double sequential defibrillation cannot be recommended for routine use. But treating rVF is not routine and the guidelines have otherwise failed our patient. It is said that insanity is defined as doing the same thing over and over again, without changing anything, and expecting a different result. Is this not what the guidelines preach in rVF? It is up to you, the clinician, to determine whether DSD is appropriate for each rVF case you encounter. But I urge you to consider the patient in front of you and tailor your resuscitation to their needs, whether that includes DSD or an alternative option. Personally, I believe DSD does have a place in the management of rVF patients, after considering the other interventions previously discussed. Given that shock success declines over time, DSD could be used as early as the sixth shock, because at this point the guidelines have nothing further to add. Or maybe it’s me who’s insane… James Yates (Critical Care Paramedic GWAAC) References Double sequential Defibrillation therapy for out-of-hospital cardiac arrests: the London experience. Emmerson AC, et al. Resuscitation. 2017  A Case Series of Double Sequence Defibrillation. Merlin MA. Prehosp Emerg Care. 2016 Double sequential external shocks for refractory ventricular fibrillation. Hoch DH. J Am Coll Cardiol. 1994 Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Reportof Ten Cases. Cabañas JG. Prehosp Emerg Care. 2015 Double Sequential Defibrillation for Refractory Ventricular Fibrillation: A Case Report. Lybeck AM. Prehosp Emerg Care. 2015 Double simultaneous defibrillators for refractory ventricular fibrillation. Leacock BW. J Emerg Med. 2014 Simultaneous use of two defibrillators for the conversion of refractory ventricular fibrillation. Gerstein NS. J Cardiothorac Vasc Anesth. 2015 Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Cortez E. Resuscitation. 2016  Double Sequential External Defibrillation and Survival from Out-of-Hospital Cardiac Arrest: A CaseReport. Johnston M. Prehosp Emerg Care. 2016 Dual defibrillation in out-of-hospital cardiac arrest: A retrospectivecohort analysis. Ross EM. Resuscitation. 2016 Refractory Ventricular Fibrillation Successfully Cardioverted With Dual Sequential Defibrillation. Sena RC. J Emerg Med. 2016 Dual sequential defibrillation: Does one plus one equal two? Deakin CD. Resuscitation. 2016 Magnesium therapy for refractory ventricular fibrillation. Baraka A. J Cardiothorac Vasc Anesth. 2000 

High quality manual cardiopulmonary resuscitation (CPR) with minimal delays has been shown to improve outcomes following out-of-hospital cardiac arrest (OHCA). There are concerns that the quality of CPR can diminish over time and as little as 1 minute of CPR can lead to fatigue and deviation from the current recommended rate and depth of compressions. With this in mind, a mechanical device to provide chest compressions at a constant rate, depth and without tiring has considerable theoretical benefits to patients, yet clinical equipoise remains about the role for this treatment modality. In this podcast, we discuss and critically appraise 2 randomised controlled trials (RCTs) set out to answer exactly that question and give our take on the role for mechanical CPR devices in the future Hope you enjoy and feel free to leave any feedback below! Rob References  Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Perkins GD. Lancet. 2015 Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Rubertsson S. JAMA. 2014