The Resus Room

Happy New Year!!! The publishing world seems to have wound down a bit for the festive break, but 4 papers caught out eye that can add some further context to practice in the Resus Room. Firstly we take a look at two papers looking at the conversion from non-shockable to shockable rhythms in cardiac arrest, both the likelihood and the associated prognosis. Next up we have a look at a paper focussing on Cerebral Performance Categories (CPC's) and their reliability as an outcome for studies. Lastly we have a look at the recent Cochrane Review on video laryngoscopy vs direct laryngoscopy for adult intubation. Thanks again to our sponsors ADPRAC for supporting the podcast. References & Further Reading Age-specific differences in prognostic significance of rhythmconversion from initial non-shockable to shockable rhythm and subsequent shock delivery in out-of-hospital cardiac arrest. Funada A. Resuscitation. 2016 Conversion to shockable rhythms during resuscitation and survivalfor out-of hospital cardiac arrest. Wah W. Am J Emerg Med. 2016 Inter-rater reliability of post-arrest cerebral performance category(CPC) scores. Grossestreuer AV. Resuscitation. 2016 Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Lewis SR. Cochrane Database Syst Rev. 2016

As the years tick by our healthcare systems work harder and harder to ensure that acute coronary syndromes are picked up as they present to our Emergency Departments, the evolution of high sensitivity troponins and their application have been key to this. The utility of a test however is dependant upon it's application to the appropriate patient. In a heavily burdened system it can at times seem sensible to front load tests and 'add on a troponin' before we are even sure the history is consistent with a possible acute coronary syndrome. But is this a safe approach for our patients and what are the potential consequences? In this podcast we run through a recent paper from the US on the topic. Whilst not the highest level of evidence and also looking at a system not entirely generalisable to the UK, it does highlight the aforementioned concerns and is a useful reminder to consider our approach to testing in patients with chest pain. We are certainly not berating the use of troponin, we just think the paper serves a great reminder that testing must be appropriately applied. Enjoy, and as ever we'd love to hear your feedback! References SIGN ACS Guidelines 2016 RCEMFOAMed SIGN ACS Guidelines Causes of Elevated Cardiac Troponins in the Emergency Department and Their Associated Mortality. Meigher S. Acad Emerg Med. 2016 Cardiac Troponin: The basics from St. Emlyn's Rick Body via St Emlyns; One high sensitivity troponin test to rule out acute myocardial infarction

So my talk at the ICS SOA 2016 conference on whether ED should be allowed to intubate certainly provoked some discussion, which was fortunate as it was the purpose of the talk! If you haven't listened to it yet, stop listening to this and have a listen to the talk here first. In this quick debrief between Rob and myself we have a think about the feedback and where to go from here. We'd love to hear any feedback in the comments section at the webpage at www.TheResusRoom.co.uk Simon

RSI delivered by EM clinicians is common place throughout the globe, in the UK however it still seems a contentious topic, with recent data showing only 20% of ED RSIs being performed by EM clinicians. I was lucky enough to be asked to talk at the ICS SoA 2016 conference on the topic of EM doctors carrying out RSI's in the UK and this podcast is a copy of that talk. I hope it provides some context both to UK practitioners and also to those from other countries, who may not understand what the big deal is all about. Simon References A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance.Randomized controlled trial. Kovacs G, et al. Ann Emerg Med. 2000 Acute airway management in the emergency department by non-anesthesiologists. Review article. Kovacs G, et al. Can J Anaesth. 2004 Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Mayo PH, et al. Crit Care Med. 2004 The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Reid C, et al. Emerg Med J. 2004 Rapid sequence induction of anaesthesia in UK emergency departments: a national census. Benger J, et al. Emerg Med J. 2011. Tracheal intubation in an urban emergency department in Scotland: a prospective, observational study of 3738 intubations. Kerslake D, et al. Resuscitation. 2015 Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care. Park L, et al. Emerg Med Australas. 2016 Scottish Intensive Care Society: RSI Difficult Airway Society Guidelines RCOA Anaesthesia in the Emergency Department Guidelines; Chapter 6.1 John Hinds on RSI at RCEM 2015 Belfast Draft; AAGBI Guidelines: Safer pre-hospital anaesthesia 2016 AAGBI Pre-hospital Anaesthesia Guideline 2009

Welcome to December's Papers of the month where we'll be looking at the papers recently published that have caught our eye. First up, what happens when clinicians override clinical decision rules for PE? Are we better than the the rules? Next we have a look at a review article that runs through the back ground literature on subsegmental PE's, their diagnosis and management. And finally we have a look at a paper that helps to benchmark ED airway management with regards first pass success rate. 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 Yield of CT Pulmonary Angiography in the Emergency Department When Providers Override Evidence-based Clinical Decision Support. Yan Z. Radiology. 2016 Best Clinical Practice: Current Controversies in Pulmonary Embolism Imaging and Treatment of Subsegmental Thromboembolic Disease. Long B. J Emerg Med. 2016 Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care. Park L. Emerg Med Australas. 2016

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