The Resus Room

Patients frequently present to the Emergency Department either with direct concern following an upper gastro intestinal bleed, or with a history that points towards the diagnosis. When these patients are haemodynamically unstable or with ongoing high volume bleeding the decision to admit or discharge becomes simple. But when the episode has settled, deciding whether they are safe to be discharged and continue with outpatient follow up can be difficult. Lots of us use scoring systems such as the Glasgow-Batchford Score or the Rockall Score but how much do we actually understand regarding the 'positive' and 'negative' outcomes of those scores? A recent paper on the topic helps to cast some light on the topic and forms the basis of this podcast. One of the frequently used scoring systems is the Glasgow-Blatchford score below that bases it's score upon historical, physiological and laboratory findings. mdcalc GBS scoring calculator Probably the other most frequently used score in ED is the Rockall score, which in its full form utilises endoscopy findings, however for use in the ED (pre-endoscopy) it has been modified and utilised. mdcalc pre-endoscopy Rockall Score Have a listen to how these scores fare in the paper and it may inform your risk stratification in the ED. Enjoy! References and Further Reading   The Predictive Value of Pre-Endoscopic Risk Scores to Predict Adverse Outcomes in Emergency Department Patients with Upper Gastrointestinal Bleeding - A Systematic Review. Ramaekers R. Acad Emerg Med. 2016 Upper Gastro Intestinal Bleeding at St.Emlyn’s

It's never long before the topic of pulmonary embolism makes it back into the controversial lime light and a recent paper on the association of PE with syncope is the lastest reason. The PESIT trial, just published in the New England Journal of Medicine certainly grabs your attention when you read the abstract, with the implication that PE's are a major and hugely missed cause of the presentation of syncope. It also highlights a diagnostic work up that consists of blanket Well's scoring +/- d-dimer to decide who should be worked up further for the potential diagnosis, for every single patient presenting with syncope, including those with no appropriate symptoms or signs! As always to read the abstract and draw a conclusion is to fall at the first hurdle, so take a listen to the podcast as we dive a bit deeper into the paper and topic, and of course make sure you take a look at the paper yourself and see what you make of the headline grabbing article Enjoy! References and Further Reading Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P. N Engl J Med. 2016 Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. Schultz DJ.J Trauma. 2004 Apr  Prospective evaluation of unsuspected pulmonary embolism on contrast enhanced multidetector CT (MDCT) scanning. Ritchie G. Thorax. 2007 Jun. EM Nerd-The Case of the Incidental Bystander JC: Prevalence of PE in patients with syncope. St.Emlyn’s

This month the literature seems to be focussed on cardiac arrest In this podcast we'll cover a paper looking at the significance of chest compression rate, ultrasound for prognostication (and to a lesser extent identification of tamponade) and finally a systematic review and meta-analysis of PCI following ROSC. The PCI paper follows on nicely from our previous podcast on the topic, so make sure you have a listen to that one first. Our sponsors ADPRAC are giving away another £30 iTunes voucher to spend on education/entertainment to support your work life balance! All you need to do is click the link on our home page through to the ADPRAC website and answer the question relating to the podcast, good luck! References & Further Reading Association between chest compression rates and clinical outcomes following in-hospital cardiac arrest at an academic tertiary hospital. Kilgannon JH. Resuscitation. 2016  Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Gaspari R. Resuscitation. 2016  Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: A systematic review and meta-analysis. Millin MG. Resuscitation. 2016 Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Gaspari R. Resuscitation 2016 EM Nerd-The Case of the Tell-Tale Heart JC: Is this the REASON to use USS in cardiac arrest? St.Emlyn’s

Stroke thrombolysis has definitely put the spotlight back on to the topic of stroke over the last few years. Stroke thrombolysis has led to restructuring of stroke care in the UK and has helped drive investment in stroke care. The evidence base that underpins thrombolysis has been controversial to say the least and can be difficult to comprehend. Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Donaldson L. Emerg Med Australas. 2016 Aug 25 The article, published in the the Emergency Medicine Australasia Journal is a great place to start to get to grips with the topic. In the podcast we run through the paper and hopefully this will shed act as a good recap on the topic and lead you to delve into the primary literature and form your own opinion. Enjoy! References Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Donaldson L. Emerg Med Australas. 2016 Aug 25 Royal College of Physicians; National clinical guideline for stroke, Prepared by the Intercollegiate Stroke Working Party, Fifth Edition 2016 (accredited by NICE)

Risk assessment, testing and risk management form the very heart of Emergency Medicine and Critical Care. Being aware of the evidence surrounding a topic is key to delivering high level care but without an understanding of the underpinning concepts it's application is extremely limited. Understanding how a test result changes a patient's likelihood of a disease can be described with likelihood ratios, the Royal College of Emergency Medicine has a podcast explaining likelihood ratios in more detail. But when a test result comes back on the boundary between positive and negative, or at the extremes of positive we can find it difficult to know what this means and that's where interval likelihood ratios comes into play.  Examples include a minimally elevated WCC in a suspected appendicitis, or a dramatically raised d-dimer as compared to a borderline positive result in a suspected pulmonary embolus, this podcast talks through some of those concepts and their application, enjoy! References Evidence-based emergency medicine/skills for evidence-based emergency care. Interval likelihood ratios: another advantage for the evidence-based diagnostician. Brown MD. Ann Emerg Med. 2003 Pulmonary embolism: making sense of the diagnostic evaluation. Wolfe TR. Ann Emerg Med. 2001 Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. Schouten HJ. BMJ. 2013

This month we cover a paper looking at the role of early craniectomy for raised intracranial pressure, the outcomes associated with advanced airway managements in prehospital cardiac arrest and lastly at the utility on ETCO2 and consider if it's application decreases adverse respiratory events. This month our great sponsors ADPRAC our giving away a £30 iTunes voucher to spend on education/entertainment to support your work life balance! All you need to do is click the link on our home page through to the ADPRAC website and answer the question relating to the podcast, good luck! References and Links Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. Hutchinson PJ, N Engl J Med. 2016 Sep Capnography for procedural sedation in the ED: a systematic review. Dewdney C, Emerg Med J. 2016  The role of prehospital advanced airway management on outcomes for out-of-hospital cardiac arrest patients: a meta-analysis. Jeong S. Am J Emerg Med. 2016 Jul TheBottomLine - RESCUEicp ICS State of the Art Conference 2016: Find out more here

This week the British Thoracic Society have released an updated version of their guidelines on asthma. The document covers all aspects from diagnosis, treatment and follow up, in this podcast we briefly run through some of the aspects covered in the acute management section. Make sure you have a look at the full document that can be found here https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/ Speak to you soon!

In 2014 NICE updated their guidelines on Head Injury: assessment and early management. This included specific guidance for those patients on warfarin Guidance regarding the ongoing observation of these patients is not contained within the guideline but as with much of Emergency Medicine variation between departments and regions vary in the threshold to admit patients with a normal CT head due to concerns of these patients developing a delayed bleed. A recent systematic review and meta analysis on the topic has just been published and we thought it would be worth a look. Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016 The paper gives an interesting take on the risk we are dealing with following a normal scan in presentation to the ED and whilst the papers contained may not be the strongest level of evidence the meta-analysis is probably the best we have to go on at present. Enjoy and we'd love to hear any of your thoughts!

Here's a look at some of the papers that caught our eye this month. We cover a paper looking at the the potential benefits of ketofol over propofol for conscious sedation, the role of aggressive blood pressure reduction in haemorrhage stroke and finally a really interesting paper of PE thrombolysis in cardiac arrest. This month our great sponsors ADPRAC our giving away a £50 iTunes voucher to spend on education/entertainment for you to spend on supporting your work life balance! All you need to do is email through the answer to the following question; With regards to this September 2016 Papers podcast and The PEA-PETT study, which of the following is correct; A. The RCT shows a statistically significant benefit in PE thrombolysis intra arrest B. The paper focussed on peri-arrest thrombolysis C. The paper was a case series of PE's thrombolysed during arrest Send your answer via email to contacttheresusroom@gmail.com with your name, answer and iTunes email address, entries close on 15th September and we'll announce the winner in October's podcast. Enjoy!   References Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. Ferguson I, et al. Ann Emerg Med. 2016. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. Qureshi AI, et al. N Engl J Med. 2016 Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the "PEAPETT" study). Sharifi M. Am J Emerg Med. 2016 Jun 30.  

Where does the role of a chest X-ray lie in major trauma? With the ever increasing use of CT and ultrasound in the resus room what role does the old school CXR hold? How many injuries will it pick up? How many will it miss? And when is the extra delay justified? This podcast looks at a recent paper on the topic and some related national guidelines. Enjoy! References Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study. Langdorf MI. Ann Emerg Med. 2015 Dec NICE 2016: Major trauma; assessment and initial management The Royal College of Radiologists 2011; Standards of practice and guidance for trauma radiology in severely injured patients