The Resus Room

Acute cholecystitis is a diagnosis that we make frequently in the Emergency Department. But like all diagnostic work ups there is a lot to know about which parts of the history, examination and bedside tests we can do in the ED that really help either rule in or rule out the disease. In this podcast we run through some of the key bits of information published in the Commissioning Guide Gallstone disease 2016, jointly published by the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland & the Royal College of Surgeons. We then concentrate on a recent systematic review of the diagnostic work up for Acute Cholecystitis. Yet again the evidence base brings up some issues to challenge our traditional teaching on the topic but should help polish our management of patients with a differential of Acute Cholecystitis. Enjoy! References & Further Reading Commissioning Guide Gallstone disease 2016 Up to date; Acute Cholecystitis NICE guidance; Acute Cholecystitis History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis. Jain A. Acad Emerg Med

This month we look at a paper concentrating on the risk of contrast induced nephropathy in contrasted CT scans, looking specifically at the need to hydrate at-risk patients prior to and following CT scans. The use of prehospital blood is also under the spotlight with the ongoing RePHILL trial. We look at a paper reviewing prehospital blood use with the Kent Surrey Sussex prehospital service and the described physiological changes seen in patients receiving blood. Make sure you also go over and check out the podcast episode from PHEMCAST on the RePHILL trial with Jim Hancox. Finally I was lucky enough to catch up with Johannes von Vopelius-Feldt, the lead author of a paper in press on the impact of prehospital critical care teams on out of hospital cardiac arrests. You can find the fantastic opportunity of a scholarship to be an Emergency Nurse Practitioner here from ADPRAC. Enjoy Simon & Rob References & Further Reading Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Nijssen EC. Lancet. 2017 FOAMcast; Contrast-Induced Nephropathy and Genitourinary Trauma RELEL.EM; The AMACING Trial: Prehydration to Prevent Contrast Induced Nephropathy (CIN)? Royal College Radiology; Prevention of Contrast Induced Acute Kidney Injury (CI-AKI) In Adult Patients Pre-hospital transfusion of packed red blood cells in 147 patients from a UK helicopter emergency medical service. Lyon RM. Scand J Trauma Resusc Emerg Med. 2017 PHEMCAST; blood Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest. von Vopelius-Feldt J. Resuscitation. 2017 Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Nijssen EC. Lancet. 2017

So today Rob and I were lucky enough to be asked to attend the Trauma Care Conference 2017, to listen to some of the great talks and catch up with some of the speakers for their take on the highlights of the talks. We managed to catch the following speakers, here are the topics they covered and relevant links to the resources discussed. Speakers Gareth Davies, Consultant Emergency Medicine, Royal London Hospital; Understanding where, when and how people die? Dave Gay, Consultant Radiologist, Derriford Hospital; The Role of Ultrasound in Trauma Fiona Lecky, Professor Emergency Medicine, Salford; Traumatic Brain Injury: recent progress & future challenges Simon Carley, Professor Emergency Medicine, Central Manchester; The Top 10 trauma papers of 2016 St Emlyn's Top 10 +1 Trauma Papers 2016 Tim Rainer, Professor Emergency Medicine, Cardiff; Permissive hypotension in blunt trauma David Raven, Emergency Medicine Consultant, Heart of England Foundation Trust; HECTOR & Elderly Trauma The HECTOR Course (& free online manual!!) Ross Fisher, Consultant Paediatric Surgeon Sheffield Children's Hospital; TARN report for paediatrics p3 presentations TARNlet Database Have a listen to the podcast and again huge thanks to the speakers for taking their time to share their superb talks with a wider audience. Simon

Centralisation of care for specialist services such as stroke, trauma and myocardial infarctions is becoming more and more common place. But where will it stop and what does it mean for the specialty of Emergency Medicine? In this episode we have a look at a recent pilot RCT published in the journal of Resuscitation looking at the feasibility of setting up an bigger RCT to evaluate moving prehospital patients to a cardiac arrest centre. The paper itself is a great piece of work but the bigger discussion around the topic is also a really important point to consider. Have a listen to the podcast, see what you think and please post you comments on the site for us all to see. Enjoy! Simon References A Randomised tRial of Expedited transfer to a cardiac arrest centre for non-ST elevation ventricular fibrillation out-of-hospital cardiac arrest: The ARREST pilot randomised trial. Patterson T. Resuscitation. 2017

Welcome back to Papers of the Month. March has given us some great papers. We kick off with a couple of papers looking at rib fractures, associated morbidity and mortality and also looks at management of flail segments. We then turn our attention to airway management and look at a paper reviewing the outcomes associated with patients who are intubated during resuscitation from cardiac arrest. As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below. Enjoy Simon & Rob References & Further Reading Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Andersen LW. JAMA. 2017 Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol. Cordelie E. Trauma Surg & Acute Care Open. 2017 Are first rib fractures a marker for other life-threatening injuries in patients with major trauma? A cohort study of patients on the UK Trauma Audit and Research Network database. Sammy IA. Emerg Med J. 2017 AIRWAYS-2

Think of rhabdomyolysis and you'll think of an elevated creatine kinase (CK). The condition ranges from an asymptomatic period to a life-threatening condition with a hugely associated rise in CK which can also be accompanied by electrolyte disturbance, renal failure and disseminated intravascular coagulation. Rhabdomyolysis is caused by a breakdown in skeletal muscle and occurs most commonly following trauma, very often that can be due to a 'long-lie' when a patient is unable to get off a floor until help arrives after a prolonged period. There are other causes including drugs, muscle enzyme deficiencies, electrolyte abnormalities and more. The presentation itself is pretty vague and suspicion of the disease needs to be pretty high. Patients can experience weakness, myalgia and the dark'coca-cola urine', the diagnosis is then confirmed with a serum elevation in CK. The big concern with Rhabdomyolysis is the hit the kidneys take. Acute kidney injury is due to the heme pigment that is released from myoglobin and haemoglobin and is nephrotoxic. Early aggressive fluid rehydration aims to minimise ischaemic injury, increase urinary flow rates and thus limit intratubular cast formation. Fluids also help eliminate excess K+ that may be associated. But have a think about the management in your ED, how high does that CK need to be to require i.v. fluids and admission to hospital? Here's a few facts we need to know: Normal CK enzyme levels are 45–260 U/l. CK rises in rhabdomyolysis within 12hours of the onset of muscle injury CK levels peak at 1–3 days, and declines 3–5 days after muscle injury The peak CK level may be predictive of the development of renal failure A CK level of 5000 U/l or greater is related to renal failure Optimal fluid rate administration is unclear, some papers suggest replacement of isotonic saline at rates of 1-2L per hour. , adjusted to 200-300mL per hour to maintain a diuresis. Attention needs to be paid to urine output serum markers and fluid status. A lot of the evidence and knowledge surrounding rhabdomyolysis is from humanitarian disasters; earthquakes, terrorism along with observational cohorts, but at the end of the day we need to work with what we've got. Have a listen to the podcast and see what you think, the application of the evidence base may change your practice. Enjoy! References Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Huerta-Alardín AL. Crit Care. 2005 Creatine kinase MB isoenzyme in dermatomyositis: a noncardiac source. Larca LJ. Ann Intern Med. 1981 Epidemiologic aspects of the Bam earthquake in Iran: the nephrologic perspective. Hatamizadeh P. Am J Kidney Dis. 2006 Prognostic value, kinetics and effect of CVVHDF on serum of the myoglobin and creatine kinase in critically ill patients with rhabdomyolysis. Mikkelsen TS. Acta Anaesthesiol Scand. 2005 Rhabdomyolysis: an evaluation of 475 hospitalized patients. Melli G. Medicine (Baltimore). 2005 Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey. de Meijer AR. Intensive Care Med. 2003 Prevention and treatment of heme pigment-induced acute kidney injury (acute renal failure). Paul M Palevsky. UpToDate. 2015

Epistaxis is an extremely common presentation to both Prehospital Emergency Services and Emergency Departments. The vast majority are benign and self limiting but every once in a while a catastrophic bleed will come our way. Whilst not necessarily the most attention grabbing of topics a sound understanding of the management is key to excellent care. In this podcast Rob talk us through the management of epistaxis, all the way from causes and presentation, right the way through to resuscitative management and latest evidenced based treatment. Enjoy! References & Further Reading LITFL epistaxis review Geeky medics epistaxis BMJ overview paper & management flowchart Routine coagulation screening in the management of emergency admission for epistaxis; is it necessary? Thaha MA. J Laryngol Otol 2000 Front-line epistaxis management: let's not forget the basic. E C Ho. J Laryngol Otol 2008 Serious spontaneous epistaxis and hypertension in hospitalized patients.Page C. Eur Arch Otorhinolaryngol. 2011 Tranexamic acid in epistaxis: a systematic review. Kamhieh Y, et al. Clin Otolaryngol. 2016

Welcome back to Papers of the Month. February holds a diverse number of topics on some really interesting areas of practice. We kick off with a snap shot systematic review from the Annals of Emergency Medicine on the effect of Amiodarone or Lignocaine on the outcome from refractory VF or VT arrests, are drugs losing more favour yet again in cardiac arrest. Next up is a pilot study following the surgical theme of minimal intervention for appendicitis, can antibiotics safely be used in a particular cohort of patients to prevent the need for surgery? And moreover could this be even safer than the traditional surgical cure? Last up we cover a paper looking at the survival from traumatic cardiac arrest and consider the bias that may occur by reporting those resuscitation attempts that are of limited duration in with the whole cohort; are we painting a overly negative picture of the prognosis of traumatic cardiac arrest? As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below. Enjoy Simon & Rob References & Further Reading In Patients With Cardiac Arrest, Does Amiodarone or Lidocaine Increase Meaningful Survival? Hunter BR. Ann Emerg Med Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial AllowingOutpatient Antibiotic Management. Talan DA. Ann Emerg Med. 2016 Dec Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Beck B. Resuscitation 2017 Feb

Those of us who are a bit longer in the tooth have spent most of our careers not scanning everyone who sustained a head injury on warfarin, but in 2104 NICE published guidance suggesting we do just that. At times, with the huge burden we place on our radiology services, it is difficult not think we're over doing things with all of these scan requests, especially when the patient has no adverse symptoms or signs. Fortunately the AHEAD study has just been published which looks at thousands of patients presenting to ED's on warfarin with a head injury. The paper is open access and deserves a full read, in this podcast I run through some of the main parts of the study and have a think about how it might impact on our practice. This is just one part of the puzzle on the management of patients with anticoagulated head injuries, we had a look previously on what to do if you perform a scan and that appears normal in our Anticoagulation, Head Injury & Delayed Bleeds Podcast. Hope you enjoy the podcast and we'd love to hear any of your feedback on social media or on the website. Simon

A lot of our podcasts have focussed on prognostic factors in arrest to help with the decision making of continuing or stopping resuscitation in cardiac arrest. There would appear to be a huge variety in practice as to when resuscitation is ceased, and in that way having explicit guidance to unify practice can at times seem appealing. In this episode we have a look at a recent paper covering the topic, it suggests a group of patients accounting for nearly half of cardiac arrests, that upon recognition could safely lead us to cease efforts. Have a listen to the podcast and let us know what you think! References Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Jabre P. Ann Intern Med. 2016 Resuscitation Council; Recognition of Life Extinct