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St Emlyn's October 2019 Round-Up: Key Insights from Conferences and Research October 2019 was a bustling month for the St Emlyn's team, filled with important conferences, groundbreaking research, and engaging discussions in emergency medicine. This round-up covers the highlights, from tactical trauma insights to controversial trial results, providing a comprehensive overview of the month’s most significant developments. Tactical Trauma Conference in Sundsvall, Sweden The month started with the Tactical Trauma Conference in Sundsvall, Sweden, where Pete Hume, a colleague from Virchester, presented on the response to the Manchester Arena bombing. This tragic event, involving many pediatric casualties, posed significant challenges in managing a high volume of injured children. Pete’s presentation highlighted the crucial lessons learned during the response, emphasizing the importance of preparedness and efficient resource management. A standout talk at the conference was given by Geoff Yost, who discussed the 2017 Las Vegas shooting. A key takeaway from his presentation was the importance of utilizing bystanders during mass casualty incidents. Bystanders are often the first to respond, and their actions can significantly influence outcomes. This was exemplified by the recent London Bridge attack, where members of the public intervened using improvised weapons like a narwhal tusk. Pete also provided insights into leadership in crisis situations, a topic covered by Kate Pryor at the conference. Overall, the Tactical Trauma Conference underscored the need for collaboration with bystanders and the importance of effective leadership during emergencies. R.CEM Annual Scientific Conference in Gateshead The R.CEM Annual Scientific Conference, held in Gateshead at the end of October, brought together emergency clinicians, nurses, paramedics, and researchers to discuss the latest developments in emergency medicine. Chris Gray, a member of the St Emlyn's team, attended and shared his experiences through a series of blog posts. One of the most anticipated studies discussed at the conference was the NOPE PAX study on the use of tranexamic acid for treating nosebleeds. Although the results are not yet publicly available, the study is expected to provide valuable insights into this increasingly popular treatment. Another key study was the CAP-IT study, which focuses on the use of antibiotics in pediatric pneumonia—a topic of ongoing debate in the context of antibiotic stewardship. The conference also featured discussions on the CRASH-3 trial, particularly concerning the use of tranexamic acid in traumatic brain injury. Ian Roberts delivered a compelling presentation on the mechanisms of tranexamic acid and the significant differences in its use across various regions, including the UK, the US, and Australasia. The TERN Network and the TIRED Study A major highlight of the R.CEM conference was the presentation of the TIRED study, the first major project from the Trainees Emergency Research Network (TERN). Led by Dan Horner, the study surveyed the levels of fatigue among emergency physicians across the UK, using the Need for Recovery Score to assess recovery time after shifts. The study revealed concerning results, with emergency clinicians scoring an average of 73 on the Need for Recovery Score, significantly higher than the previous highest score of 55 recorded for Iranian miners. This suggests that emergency clinicians are under immense pressure, leading to high levels of fatigue. Interestingly, older clinicians had lower scores, indicating either greater resilience or better workload management. However, the study raises the controversial question of whether the job’s demands are causing some clinicians to leave the profession early. The TERN network is continuing to explore critical questions in emergency medicine, with upcoming studies on subarachnoid hemorrhage and the necessity of lumbar punctures. European Resuscitation Council Meeting in Slovenia The European Resuscitation Council meeting in Slovenia was another key event in October. The chain of survival—early recognition, CPR, defibrillation, and post-resuscitation care—was a major focus of the conference. While much attention is often given to post-resuscitation care, the most significant impact on survival comes from the early stages of the chain. The GoodSAM app, which allows trained responders to be notified of nearby emergencies, plays a crucial role in this early response. The app has already made a significant difference in several cases, including cardiac arrests. Another important discussion at the conference was the use of hypothermia in post-cardiac arrest care. Following the TTM1 trial, which suggested that hypothermia might not be as beneficial as once thought, some clinicians have stopped temperature management altogether. However, evidence presented at the ERC meeting indicates that this may have led to an increase in post-arrest mortality. The ongoing TTM2 trial aims to provide more clarity on the role of hypothermia in post-cardiac arrest care. Thromboprophylaxis in Lower Limb Immobilization Dan Horner’s study on thromboprophylaxis in lower limb immobilization is another significant piece of research published this month. The study, a systematic review, highlighted that the incidence of significant deep vein thrombosis (DVT) in patients with lower limb immobilization is around 2%, and anticoagulation almost certainly reduces this risk. However, the study also pointed out that there is no clear consensus on which risk stratification tool is best for identifying patients at risk of DVT. The GemNet guidelines from R.CEM are a solid option, but more research is needed in this area. The study also discussed the choice of anticoagulant, noting that while low-molecular-weight heparin is the most commonly used, the use of DOACs, such as rivaroxaban, is on the rise. As an emergency physician, the balance between preventing life-threatening complications like pulmonary embolism and avoiding significant bleeding events remains a critical consideration in patient care. Top 10 Papers from 2018-2019 The R.CEM Annual Scientific Conference also featured a presentation on the top 10 papers from the past year, covering a wide range of topics in emergency medicine. One key study explored whether early or delayed cardioversion should be performed in recent-onset atrial fibrillation, with the conclusion leaning towards not immediately intervening. Another study examined whether ventilation should continue during RSI (rapid sequence induction), with evidence suggesting that it should. The debate over cricoid pressure during RSI continues, with recent evidence indicating that it may not be necessary and could even be harmful in some cases. Magnesium in atrial fibrillation was also discussed, with the evidence supporting its use, particularly when combined with other treatments. The presentation also covered the use of vasopressors in hemorrhagic shock, with early evidence suggesting they might be beneficial, though more research is needed. Finally, the discussion touched on diagnosing pulmonary embolism in pregnancy using the YEARS score, a promising but still developing area of research. The CRASH-3 Trial: A Controversial Conclusion The CRASH-3 trial, focusing on the use of tranexamic acid in traumatic brain injury, has generated significant debate in the emergency medicine community. While the trial’s findings have already started to influence practice in the UK, the way the results were interpreted and publicized has been controversial. The debate centres around two main camps: one that argues the trial didn’t conclusively prove that tranexamic acid reduces mortality in traumatic brain injury and another that believes the evidence strongly suggests a benefit in certain subgroups. While not the final word on the subject, the CRASH-3 trial provides enough evidence to justify the use of tranexamic acid in specific scenarios. Looking Ahead As October ends and November begins, there’s much to look forward to. The Asian Conference of Emergency Medicine in India promises to be an exciting event, and the Resuscitology Conference in December is already sold out, with plans to run it again in 2020. Emergency medicine is more intense than ever, with record numbers of patients and some of the toughest days experienced in the field. Despite these challenges, the St Emlyn's team continues to provide exceptional care and remain at the forefront of emergency medicine research and practice. Thank you for following along with this month’s round-up. Stay tuned for more updates from St Emlyn's as we continue to explore, learn, and share the latest in emergency medicine.     4o

Simon and Zaf talk about the practicalities of REBOA and discuss whether it's ready for prime time in the UK. Introduction Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a minimally invasive technique designed to control hemorrhage in patients with life-threatening bleeding and offers a bridge to definitive surgical intervention. Here at St Emlyn’s, we are committed to exploring innovative solutions that enhance patient outcomes in emergency medicine. In this post, we delve into the essentials of REBOA, its clinical application, benefits, and challenges. Understanding REBOA REBOA involves the insertion of a balloon catheter into the aorta via the femoral artery. By inflating the balloon, we can occlude the aorta, thus controlling bleeding below the point of occlusion. This procedure is particularly useful in cases of non-compressible torso haemorrhage, where traditional methods of haemorrhage control are inadequate. Indications and Contraindications Indications: Hemorrhagic shock from pelvic fractures or abdominal bleeding. Trauma patients with signs of severe hemorrhage unresponsive to fluid resuscitation. As a temporary measure until surgical control of bleeding is achieved. Contraindications: Patients with known aortic pathology (e.g., aortic dissection). Significant injury above the diaphragm. Prolonged transport times where REBOA may not be beneficial. The Procedure Preparation Before performing REBOA, it is crucial to ensure that the patient is appropriately resuscitated and stabilized as much as possible. This includes securing the airway, ensuring adequate ventilation, and achieving initial hemodynamic stabilization. Insertion and Inflation Vascular Access: Gain access to the common femoral artery using ultrasound guidance to minimize complications. Catheter Insertion: Insert the REBOA catheter through a sheath into the femoral artery. Advance the catheter under fluoroscopic or ultrasound guidance to the desired level in the aorta (Zone I: above the celiac artery for abdominal hemorrhage, Zone III: above the bifurcation of the iliac arteries for pelvic hemorrhage). Balloon Inflation: Inflate the balloon to occlude the aorta. This temporarily controls bleeding and allows time for definitive surgical repair. Monitoring and Maintenance Continuous monitoring of vital signs and catheter position is essential. The occlusion time should be minimized to reduce ischemic complications. Ideally, REBOA should serve as a bridge to definitive surgical intervention within 30-60 minutes. Benefits and Challenges Benefits Rapid Hemorrhage Control: REBOA can quickly control bleeding, buying crucial time for surgical intervention. Less Invasive: Compared to traditional open thoracotomy with aortic cross-clamping, REBOA is less invasive, reducing associated morbidity. Improved Survival Rates: Emerging evidence suggests that REBOA can improve survival rates in appropriately selected trauma patients. Challenges Technical Expertise: REBOA requires specific training and expertise. Improper technique can lead to significant complications. Ischemic Complications: Prolonged aortic occlusion can lead to ischemia of distal organs and tissues, necessitating careful monitoring and timely deflation. Resource Intensive: REBOA demands resources such as fluoroscopy, ultrasound, and trained personnel, which may not be available in all settings. Conclusion REBOA represents a promising advancement in trauma care, offering a vital tool in the management of life-threatening haemorrhage, but it's utility in the Emergency Department is uncertain. Further reading EMCrit guest post - the good, the bad, the ugly of the (original) Joint Statement https://emcrit.org/emcrit/good-bad-ugly-of-joint-statement-reboa/   Updated 2019 Joint Statement from the ACS-COT, ACEP, NAEMSP, and NAEMT: https://tsaco.bmj.com/content/4/1/e000376.info   London Air Ambulance Prehospital REBOA Case series: https://linkinghub.elsevier.com/retrieve/pii/S0300-9572(18)31110-9

A Month in Review: Key Takeaways from St Emlyn's September 2019 Content Welcome to a detailed overview of the latest content from St Emlyn's, focusing on the valuable insights and educational resources we shared throughout September 2019. This month’s offerings span a wide range of topics, from the evolving concept of the "resuscitationist" to the increasing challenges posed by decompensated liver disease, and the ongoing development of emergency medicine education. Here’s a look at the most important takeaways. The Resuscitationist: More Than Just a Title The term "resuscitationist" has become a buzzword within the emergency medicine (EM) and critical care communities, especially following its emergence from the SMACC (Social Media and Critical Care) conferences. Dan Horner delved into this concept in a recent presentation, sparking a broader discussion about what it truly means to identify as a resuscitationist. At its core, being a resuscitationist isn’t just about having an interest in the resuscitation room. It requires a blend of sharp clinical skills, deep knowledge of resuscitation science, and the ability to apply evidence-based practices effectively. But beyond technical expertise, leadership and teamwork are crucial. A resuscitationist must excel in managing high-stakes, chaotic situations where decisions are made with limited information and under intense time pressure. Moreover, Dan highlights the importance of humility and collaboration. The best resuscitationists are those who recognize their own limitations and are skilled at drawing on the strengths of others, whether from different specialties or professions. This collaborative approach not only enhances patient care but also builds stronger, more effective resuscitation teams. Decompensated Liver Disease: A Growing Concern in the ED Liver disease is on the rise, particularly due to lifestyle factors like alcohol consumption and obesity. Gareth Roberts tackled this pressing issue in his blog post on decompensated liver disease, which is becoming increasingly common in emergency departments (EDs) across the UK and beyond. Gareth outlines a comprehensive care bundle designed to manage patients with decompensated liver disease effectively. This bundle includes seven key points: Thorough Investigation: Quick and accurate investigations are essential, particularly for detecting complications like spontaneous bacterial peritonitis (SBP), which can be life-threatening. Infection Management: Aggressive treatment of infections is critical, with a focus on using appropriate antibiotics and monitoring for SBP. Acute Kidney Injury (AKI) and Hyponatremia: These complications are common in liver disease patients and must be managed carefully. Gareth discusses the potential benefits of human albumin in these cases. GI Bleeding: Gastrointestinal bleeding, especially from varices, poses a significant risk. Gareth directs readers to additional resources on St Emlyn’s, including a presentation by Chris Gray on managing GI bleeding. Hepatic Encephalopathy: This condition can severely alter a patient’s mental status and requires careful management. With the increasing prevalence of liver disease, understanding and managing hepatic encephalopathy is more important than ever. Gareth’s post is a must-read for anyone dealing with liver disease in the ED, providing both practical advice and links to further resources. Expanding Education: The MSc in Emergency Medicine Education is a cornerstone of St Emlyn’s, and we’re excited to announce the expansion of the MSc in Emergency Medicine at Manchester Metropolitan University. This program has been running successfully for several years and is now broadening its scope to include paramedics, making it a truly multi-professional and multi-disciplinary course. The MSc program offers a variety of modules tailored to the specific needs of different healthcare professionals. Whether you’re looking to deepen your clinical knowledge, enhance your leadership skills, or explore new areas of emergency medicine, this program has something to offer. For more details, visit our website or reach out directly. Supporting St Emlyn’s: Keep Our Content Free and Accessible St Emlyn’s remains committed to providing free and open-access content to the global emergency medicine community. However, maintaining and expanding our offerings requires resources. If you find value in what we provide, please consider supporting us financially. Even a small contribution can help us continue to deliver high-quality content to healthcare professionals worldwide. Introducing Coda: The Next Evolution After SMACC Coda is the latest evolution in the SMACC legacy, aiming to broaden the scope of its predecessor by incorporating a wider range of specialties, including oncology, public health, and surgery. As a member of the Coda executive team, I can attest to the ambitious goals of this new conference series. Coda retains the clinical excellence that SMACC was known for, but with an added emphasis on advocacy. Each year, Coda will tackle a significant global health issue, with the inaugural theme focusing on climate change and its impact on medical practice. It’s important to note that while climate change is a key focus, it won’t dominate the entire conference. Only about 25% of the program will be dedicated to this theme, with the remaining 75% featuring the high-quality clinical content you’ve come to expect from SMACC. The first Coda conference is set to take place in Melbourne in 2020, and we encourage you to participate, whether in person or remotely. The Zero Point Survey: A Game-Changer in Resuscitation The Zero Point Survey, a concept championed by Cliff Reid, is gaining widespread recognition for its transformative impact on resuscitation practices. The idea shifts the focus of the primary survey in resuscitation from when you first encounter the patient to what you do before you even meet them. This approach emphasizes the importance of preparation—both mental and environmental. By optimizing everything you can control before the patient arrives, you set the stage for delivering high-quality care when it matters most. Feedback from the EM community has been overwhelmingly positive, with many clinicians reporting that the Zero Point Survey has changed how they manage the resuscitation room. It’s not just a theoretical concept; it’s a practical tool that’s making a real difference in patient outcomes. If you’re not yet familiar with the Zero Point Survey, I strongly encourage you to explore the resources available on the St Emlyn’s website, including an excellent video by Cliff Reid that outlines the key elements of this approach. Looking Ahead: What’s Next for St Emlyn’s? As we wrap up our review of September’s content, it’s clear that the St Emlyn’s team has been hard at work bringing you the latest in emergency medicine education and clinical practice. But there’s much more to come. In the coming months, we’ll be covering exciting topics at upcoming conferences, including the ArchiEM conference in Gateshead and the Slovenia ERC conference. These events promise to bring fresh insights and new perspectives that we’ll be sharing with you through our blog posts and podcasts. In the meantime, keep doing the incredible work you do in emergency medicine. It’s a challenging field, but it’s also incredibly rewarding, and you’re making a difference every day. Thank you for being part of the St Emlyn’s community, and I look forward to continuing this journey with you. Stay tuned for more great content, and as always, keep pushing the boundaries of what’s possible in emergency care.

The CRASH-3 Trial: Revolutionizing Head Injury Management with Tranexamic Acid The CRASH-3 trial, a landmark study in the field of emergency medicine, has brought significant attention to the potential role of tranexamic acid (TXA) in managing traumatic brain injury (TBI). As one of the largest randomized controlled trials ever conducted on head injury patients, its findings could reshape clinical practices globally, particularly in the pre-hospital and emergency department settings. Overview of the CRASH-3 Trial The CRASH-3 trial was designed to assess the efficacy of TXA in reducing mortality among patients with traumatic brain injury. TXA is an antifibrinolytic agent commonly used to prevent excessive bleeding in various medical scenarios, such as trauma, surgery, and postpartum hemorrhage. The question posed by CRASH-3 was whether TXA could also reduce deaths in patients who had suffered a TBI, a question that had remained unanswered despite the success of the CRASH-2 trial in managing extracranial bleeding. Patient Population and Inclusion Criteria The trial focused on adults aged 16 years and older who had sustained a traumatic brain injury. To be included, patients needed to have either a Glasgow Coma Scale (GCS) score of 12 or lower or a positive CT scan indicating intracranial bleeding. Notably, patients with significant extracranial bleeding were excluded from the trial to specifically measure the effect of TXA on TBI outcomes. A critical aspect of the trial was the timing of TXA administration. Initially, the protocol allowed TXA to be administered within eight hours of injury. However, as data from other studies like the WOMAN trial and CRASH-2 became available, suggesting that the benefits of TXA diminish after three hours, the protocol was adjusted. This change meant that the majority of patients received TXA within three hours of injury, a key factor in the study's final analysis. Key Findings of the CRASH-3 Trial The CRASH-3 trial enrolled 12,737 patients across 29 countries, making it one of the most extensive studies of its kind. The primary outcome measured was all-cause mortality at 28 days post-injury. The results showed that overall mortality was slightly lower in the TXA group (18.5%) compared to the placebo group (19.8%), although this difference was not statistically significant. However, a pre-specified subgroup analysis provided more compelling evidence. When patients with a GCS of 3 and bilateral unreactive pupils (indicating very severe brain injury) were excluded, TXA demonstrated a more significant benefit. In this subgroup, the mortality rate was 12.5% in the TXA group versus 14% in the placebo group, a statistically significant reduction with a relative risk of 0.89. This finding suggests that TXA is particularly beneficial for patients with moderate head injuries (GCS 9-15) who are more likely to survive if bleeding is controlled. Number Needed to Treat (NNT) One of the critical metrics for evaluating the effectiveness of a treatment is the number needed to treat (NNT). In the CRASH-3 trial, the NNT was 67, meaning that 67 patients would need to be treated with TXA to save one additional life at 28 days post-injury. For comparison, the NNT for aspirin in acute myocardial infarction is about 42, which is widely regarded as highly effective. An NNT of 67 is therefore quite favorable in the context of emergency medicine, particularly for a condition as serious as traumatic brain injury. Timing of Administration The CRASH-3 trial strongly reinforced the importance of administering TXA as early as possible after a head injury. The data indicated a 10% reduction in TXA’s effectiveness for every 20-minute delay in patients with mild to moderate head injury. This underscores the need for TXA to be administered in the pre-hospital setting, ideally by paramedics at the scene or en route to the hospital. Delaying treatment until after arrival at the emergency department or after conducting a CT scan may significantly reduce the drug's benefits. Implications for Clinical Practice The results of the CRASH-3 trial suggest that TXA should be considered for all patients with moderate traumatic brain injury, particularly those with a GCS of 9 to 15 and confirmed intracranial bleeding. For patients with severe head injuries (GCS of 8 or less, or with bilateral unreactive pupils), the benefits of TXA are less clear, likely due to the severity of the primary brain injury. Given the trial’s findings, it is recommended that TXA be integrated into clinical protocols for the management of head injuries. This is especially relevant in pre-hospital care, where early intervention is possible. TXA should be administered as soon as possible after the injury occurs, particularly in cases where a significant delay in getting to the hospital is expected. Cost-Effectiveness and Accessibility Another important aspect of TXA is its cost-effectiveness. In the UK, a 1-gram dose of TXA costs approximately £1, making it an affordable treatment option for healthcare systems worldwide. This low cost makes TXA a viable option not only in high-income countries but also in low- and middle-income countries where healthcare resources are often limited. Given its affordability and the potential to save lives, TXA is an attractive option for widespread use in managing traumatic brain injury globally. Considerations for Special Populations Although the CRASH-3 trial focused on adults, there is a strong rationale for extending its findings to pediatric patients. The physiology of traumatic brain injury in children is similar to that in adults, and there is no evidence to suggest that TXA would act differently in a younger population. As such, it would be reasonable to use TXA in children with TBI, following the same dosing guidelines adjusted for body weight. Future Directions: Intramuscular TXA and Beyond While CRASH-3 has provided valuable insights, research into TXA’s potential uses continues. One area of interest is the development of intramuscular (IM) TXA, which could be particularly useful in pre-hospital settings where intravenous (IV) access is challenging. The possibility of an auto-injector for TXA is also being explored, which could simplify administration and further broaden its use, especially in resource-limited settings. Conclusion: Implementing CRASH-3 Findings in Practice The CRASH-3 trial marks a significant advancement in our approach to treating traumatic brain injury. The evidence strongly supports the use of TXA, particularly in patients with moderate head injuries who receive the drug within three hours of injury. TXA is safe, cost-effective, and easy to administer, making it a valuable tool in both pre-hospital and hospital settings. The implementation of CRASH-3’s findings into clinical practice could save thousands of lives annually, particularly in settings where early intervention is possible. As the emergency medicine community, we must act swiftly to incorporate these findings into our protocols and training, ensuring that TXA is used effectively to improve outcomes for patients with traumatic brain injury worldwide.

A Comprehensive Review of St Emlyn’s Blog: August 2019 Highlights Welcome to St Emlyn’s blog and podcast, where we reflect on the key topics and research from August 2019. In this review, we’ll explore the most impactful discussions and studies, providing valuable insights for emergency medicine professionals. From managing lower GI bleeding and addressing climate change in anaesthesia to examining PTSD in emergency services and the future of diagnostics, this post summarizes essential takeaways that are shaping our field. Managing Lower GI Bleeding in the Emergency Department One of the significant topics covered was the management of acute lower gastrointestinal (GI) bleeding, a common but challenging condition in the emergency department (ED). The complexity of managing these cases often lies in determining the correct priority of care, appropriate management strategies, and even the correct speciality for handling these patients. We reviewed a consensus guideline from the British Society of Gastroenterology and Hepatology, published in Gut, which offers practical recommendations for the diagnosis and management of acute lower GI bleeds. The guideline emphasizes the importance of using stratification tools to distinguish between stable and unstable patients, which can help streamline management in the ED. For stable patients, the Oakland score is recommended. This scoring system helps identify which patients can be safely managed on an outpatient basis, reducing unnecessary hospital admissions. Conversely, patients with a major bleed should be admitted and scheduled for a colonoscopy at the earliest opportunity. The guideline also highlights the value of CT angiography for hemodynamically unstable patients, a practice increasingly integrated into emergency care. Transfusion thresholds, set at 70 grams per litre, align with standard practices in other clinical settings, with adjustments for patients with cardiovascular disease. The guideline also recommends having dedicated GI bleed leads within trusts to ensure seamless coordination with emergency services. Sustainability and Climate Change in Anesthesia Another crucial discussion from August focused on the environmental impact of healthcare, particularly in anaesthesia. In the UK, healthcare is a significant contributor to climate change, driven by factors like travel, disposable materials, and the use of anaesthetic gases such as nitrous oxide and desflurane. A key paper by Cliff Shelton and colleagues underscores the need to adopt more sustainable practices in anaesthesia. For example, desflurane is approximately 3,000 times more potent as a greenhouse gas than carbon dioxide. The paper advocates for reducing the use of high-polluting gases and considering greener alternatives where possible. This shift towards sustainability in healthcare is essential, although challenging, given the nature of medical practice. However, small changes, such as reducing nitrous oxide use in departments where alternatives exist, can collectively make a significant difference. The paper serves as a call to action for healthcare professionals to be more mindful of their environmental impact and to seek sustainable solutions in their practices. Pre-Hospital Care: Comparing Macintosh and McGrath Laryngoscopes The debate over the best laryngoscope for pre-hospital rapid sequence intubation (RSI) is ongoing, and in August, we reviewed a study that contributed valuable data to this discussion. Published in Critical Care Medicine, the study compared the Macintosh and McGrath laryngoscopes in pre-hospital settings, involving 514 adult emergency patients. The study found that both devices were equally effective for pre-hospital RSI. Notably, it also revealed that switching to a different device after a failed intubation attempt was more successful than repeating the attempt with the same device. This finding aligns with the 30-second RSI drills many practitioners use, which advocate for changing the approach after a failed attempt. These findings have practical implications for both pre-hospital and in-hospital care. In the ED, switching to a video laryngoscope, such as the McGrath, after a failed intubation attempt could improve patient outcomes. As video laryngoscopes become more accessible in emergency departments, integrating them into RSI protocols could be a beneficial strategy. PTSD in Emergency Services: Rusty Carroll’s Series Rusty Carroll’s ongoing series on PTSD within the ambulance service continues to be one of the most impactful contributions to the St Emlyn’s blog. The August instalment focused on the aftermath of PTSD, exploring the journey towards understanding what “normal” looks like after such an experience. Rusty’s candid reflections resonate with many in the emergency services community, highlighting the mental health challenges prevalent in our field. The series has received positive feedback, with many readers finding comfort and validation in Rusty’s experiences. However, the widespread relatability of this series also underscores a concerning reality: many emergency service professionals are struggling with similar issues. As a community, we need to support one another, promote mental health awareness, and advocate for resources to address the psychological toll of our work. Revisiting Rusty’s previous installments in this series is highly recommended for a deeper understanding of the complex emotions associated with PTSD in emergency services. The Realities of Packed Red Cell Transfusions Another fascinating topic from August was the metabolic and biochemical characteristics of packed red cell transfusions, which have significant implications for trauma care in the ED. This discussion was sparked by a conversation on Twitter, leading to critical reflections on the assumptions we hold about blood transfusions. In trauma care, blood is often regarded as a superior alternative to crystalloids. However, the reality of what we’re transfusing—packed red cells—is quite different from whole blood. A study we reviewed highlighted some surprising statistics about the contents of packed red cells, including a pH of 6.79, a potassium level of 20, and a lactate level of 9.4. These figures reveal that packed red cells are far from the idealized image of whole blood. The metabolic implications of these characteristics are significant, particularly in the context of massive transfusions. For instance, packed red cells have low levels of 2,3-DPG, which affects their ability to release oxygen to tissues. This raises important questions about how we use blood in trauma resuscitation and whether our current practices are truly optimal. There’s also an ongoing pre-hospital trial in the UK, known as the RePHILL trial, which is examining the outcomes of patients randomized to receive either blood or no blood in pre-hospital settings. The results of this trial are eagerly anticipated and could challenge the assumption that blood is always better. This could lead to more nuanced transfusion practices in the future. The Future of Diagnostics: Insights from Rick Body Finally, we explored the future of diagnostics with insights from Rick Body. His presentation, originally given at the St Emlyn’s Live conference, offers a compelling vision of where diagnostics in the ED is heading. With the rise of machine learning, artificial intelligence (AI), and personalized diagnostics, the landscape of emergency medicine is rapidly evolving. These technologies are already being integrated into diagnostic processes, but they bring new challenges. The data generated by AI and machine learning can be complex, requiring a shift in how we interpret diagnostic results. We must move away from binary thinking and embrace a more nuanced understanding that includes probabilities, uncertainties, and complexities. As emergency medicine professionals, we need to prepare for this shift by engaging with these new technologies and incorporating them into our clinical practice. The future of diagnostics is exciting, but it will require ongoing education and adaptation to fully harness its potential. Conclusion August 2019 was a month rich with insightful discussions and important research that continue to influence our practice in emergency medicine. From managing lower GI bleeding and the environmental impact of anaesthesia to the complexities of blood transfusions and the future of diagnostics, these topics highlight the diverse challenges and opportunities we face in the ED. The St Emlyn’s blog and podcast aim to keep you informed and engaged with the latest developments in our field. This review has provided valuable insights that can be applied in your practice, helping you stay ahead in the ever-evolving landscape of emergency medicine. Stay tuned for more updates, and as always, feel free to share your thoughts and experiences with us. Until next time, take care and continue to push the boundaries of what’s possible in emergency medicine.

A vox pop round up of the best of the ERC19 conference in Slovenia.

Our latest podcast from the #stemlynsLIVE conference last year. Dan Horner talks on the concept and potential role of the UK Resuscitationist.

St Emlyn’s July 2019: Key Highlights Welcome back to St Emlyn’s, where we continue to share the latest insights, discussions, and advancements in emergency medicine. July 2019 was particularly rich in content, covering a wide range of topics from practical clinical advice to deeper reflections on the ethics and philosophy of emergency medicine. Here, we summarize the key points from the month’s posts, optimized for clarity and relevance. Upcoming Events: Resuscitology Course and MSc in Emergency Medicine Before diving into the content highlights, there are two important announcements: Resuscitology Course – December 2019 On December 14th, 2019, the Resuscitology course will be held in Manchester. This course, led by Cliff Reid, offers an in-depth exploration of why certain resuscitation techniques work and how they can be improved in high-stakes scenarios. This is a must-attend for anyone involved in emergency or critical care. Registration details are available on our blog. MSc in Emergency Medicine – 2019-2020 Cohort Recruitment is now open for the 2019-2020 cohort of the MSc in Emergency Medicine. This three-year online program, available to both doctors and nurses, offers an advanced curriculum in emergency medicine. Alumni like Janus Bae, Alan Grace, and Natalie May have found it immensely beneficial. By 2020, we hope to extend the program to paramedics as well, broadening its reach and impact. July 2019 Blog Highlights This month’s content ranged from clinical insights and research updates to philosophical discussions about the practice of emergency medicine. Disaster Medicine in Pakistan: Lessons Learned Zaf Kasim, now practicing in the United States, and Rashid Akhil from Pakistan collaborated on a blog post discussing the management of natural disasters, terrorist attacks, and major incidents in Pakistan. Zaf, who trained with us in Verchester, has become an authority in endovascular resuscitation, REBOA, and ECMO. This post sheds light on the expertise developed by medical professionals in Pakistan, particularly in response to large-scale disasters like the 2005 Kashmir earthquake. It’s a crucial read for anyone interested in global health or disaster medicine, as it demonstrates how effective disaster response systems can be developed even in resource-limited settings. Managing Major GI Hemorrhage: Practical Insights Chris Gray revisited a talk he gave at the St Emlyn’s Live Conference, focusing on the challenges of managing major gastrointestinal (GI) hemorrhage. Patients presenting with significant upper or lower GI bleeds pose unique challenges, particularly regarding airway management. Chris offers practical advice, emphasizing the importance of resuscitating before intubation and considering video laryngoscopy in difficult cases. The post also highlights the SALAD (Suction Assisted Laryngoscopy and Airway Decontamination) technique, which is particularly useful in managing patients with large amounts of gastric contents. Additionally, Chris touches on the use of PPIs, tranexamic acid (TXA), and terlipressin, although he advises caution until more evidence is available. The ongoing HALT-IT trial in the UK, investigating TXA in GI bleeds, is something to watch closely. Listeriosis: A Rare but Serious Infection Listeriosis, though uncommon, can have severe consequences, particularly for vulnerable populations like the elderly, pregnant women, newborns, and the immunocompromised. This blog post was prompted by a recent outbreak in the UK linked to contaminated hospital food. The post emphasizes the importance of considering listeriosis in differential diagnoses, particularly for patients presenting with unexplained gastrointestinal symptoms. Blood cultures are essential for diagnosis, making it important to include them in the workup for high-risk patients. Early diagnosis is key to improving outcomes in these cases. The Procedure Paradox: Ethical Reflections in Emergency Medicine “The Great Day Paradox” delves into the ethical and emotional challenges of emergency medicine. Inspired by a talk at the Don’t Forget the Bubbles conference, this post explores the contrast between the excitement clinicians feel during life-saving procedures and the often devastating impact these events have on patients. The post encourages clinicians to reflect on their motivations and maintain a patient-centered approach. Drawing on the teachings of John Hinds, it emphasizes that every procedure should be justified by both clinical need and appropriateness for the patient. This blog is a reminder of the importance of balancing clinical enthusiasm with compassion and ethical care. Inferior Vena Cava Filters in Major Trauma: An Evidence-Based Review Rich Carden reviewed the use of inferior vena cava (IVC) filters in major trauma patients, a topic that has been debated for years. IVC filters are intended to prevent pulmonary embolism (PE) in high-risk patients, such as those with significant lower limb or pelvic fractures. Rich discusses a recent randomized controlled trial published in the New England Journal of Medicine, which found that early prophylactic use of IVC filters did not reduce the incidence of symptomatic pulmonary embolism or death at 90 days. This finding suggests that IVC filters should not be used routinely in major trauma patients, though there may be specific cases where they are warranted. Psychological Performance in the Resus Room: Insights from Texas Ashley Leibig’s presentation at St Emlyn’s Live focused on psychological performance in the resus room, drawing on her experience with StarFlight in Texas. Her blog post explores key concepts such as human factors, crew resource management, and self-awareness in high-pressure situations. Ashley’s practical advice on managing oneself, the team, and the environment in emergency medicine is invaluable. This post is essential reading for anyone looking to improve their performance under pressure, whether in emergency medicine or other high-stress fields. The Resuscitative Care Unit: A New Model for Emergency Departments The concept of the resuscitative care unit (RCU) or ED-based critical care units was the focus of our final post of the month. Inspired by a paper published in the Emergency Medicine Journal (EMJ), this blog discusses the idea of creating RCUs to serve as a bridge between the emergency department and intensive care. RCUs are proposed as a solution for managing critically ill patients who require short-term intensive care but may not need full ICU admission. The post also references a JAMA study showing that ED-based ICUs can improve survival rates for critically ill patients. As emergency departments continue to evolve, integrating critical care capabilities is becoming increasingly important. Conclusion July 2019 was a month filled with rich, varied content at St Emlyn’s, offering practical advice, research updates, and philosophical reflections on emergency medicine. Whether you’re interested in disaster management, GI haemorrhage, or the ethical challenges of our profession, this month’s highlights provide valuable insights. We encourage you to engage with our content, share your thoughts, and continue learning. Don’t forget to check out our upcoming events, including the Resuscitology course and the MSc in Emergency Medicine. If you find our content valuable, please consider supporting us through a small donation to help keep St Emlyn’s free and accessible to all. Thank you for being part of the St Emlyn’s community. We look forward to bringing you more valuable content in the coming months.

Prof. Rick Body is an internationally recognised expert in diagnostic testing. In this podcast he takes us through diagnostics today and also the near future which may change almost everything.  You can read more and see the slides/video at http://www.stemlynsblog.com

This talk focuses on how we can optimise our psychological performance in critical care situations, the type of situations that Simon describes as Time Critical, Information light. The Audio is available below, or watch the full presentation above. Don't forget to watch the video on the St Emlyn's site http://www.stemlynsblog.org vb S