The Resus Room

Latest Episodes:

Angioedema Nov 18, 2019

Show notes

Angioedema is something we'll all encounter in the acute setting, whether we recognise it or not...

Understanding the different causes and mechanisms is imperative to ensuring the patients get treatment that is not only effective, but in extremis potentially lifesaving. In this episode we talk through the condition; from clinical presentation, causative agents, mechanisms of action, differentials and the evidence base of treatment.

Get in touch with any comments on the podcast, ensure to read the papers that are referenced yourself and draw your own conclusions.

Enjoy!

Simon & Rob

Community Emergency Medicine Nov 11, 2019

Show notes

As care on our emergency and urgent care demand is on an ever upwards course, whilst alongside this the scope of what we can potentially deliver to patients is also increasing. In order to meet this demand and to deliver the best care possible to our patients we will need to look for other solutions.

We were lucky enough to be invited to the First Community Emergency at the Royal Society of Medicine in London, hosted by the Physician's Response Unit. This event looked at the current challenges and explored solutions and opportunities for more collaborative working.

In this podcast you'll hear from Tony Joy about the concept and practice of Community Emergency Medicine. You'll hear from Gareth Davies on the history of Pre Hospital Emergency Medicine, both challenges and achievements. Finally you'll hear from Bill Leaning, PRU clinical manager & HEMS paramedic about how to go about setting up a service.

Please let us know any thoughts or feedback, and we'll be back with another podcast on a clinical topic for you in a few days time.

Enjoy!

Simon & James

November 2019; papers of the month Nov 01, 2019

Show notes

We've got some papers this month that focus on our sickest patients!

If you had a patient that you found in cardiac arrest and you believed they had a PE, would you thrombolyse them during the arrest, and how much more likely do you think they would be to survive? Our first paper looks at exactly this question.

Second up we consider the potential harms associated with adrenaline administration to those in traumatic arrest.

Finally, when RSI'ing a patient and considering your pharmacological cocktail, how likely are you to reach for the fentanyl and how much concern would you have over the risk of this rendering the patient haemodynamically unstable? We take a look at a recent review on the topic and get Dr. Ian Ferguson's insights as the lead author.

Make sure to get in touch with any comments on any of the reviews, and importantly make sure you check out the papers and draw your own conclusions.

Enjoy!

Simon & Rob

Can TXA save lives in head injuries, CRASH-3; Roadside to Resus Oct 15, 2019

Show notes

So an incredibly important paper, CRASH-3 has just been published in the Lancet, which looks at the treatment of head injuries with Tranexamic Acid (TXA).

TXA has been shown to save lives in trauma patients at the risk of major haemorrhage, with the notable exclusion of those with head injuries, CRASH-2. TXA has been shown to save lives in those with post parts haemorrhage, WOMAN trial. Time to treatment with TXA has been shown to be hugely influential in it's ability to decrease blood loss and save lives. So has TXA now been shown to save lives in head injuries?

In this episode we run through the paper and are lucky enough to have an interview with the lead author, Professor Ian Roberts.

Have a listen, read the paper and as always we'd love to hear any thoughts or comments you have on the website and via twitter, and take a look at the references below to draw your own conclusions.

Enjoy!

Simon, Rob & James

References

The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.Roberts I. Health Technol Assess. 2013

CRASH-2;The Bottom Line

Effectof earlytranexamic acidadministrationon mortality, hysterectomy, and othermorbiditiesin womenwith post-partum haemorrhage(WOMAN): an international, randomised, double-blind, placebo-controlledtrial. WOMANTrialCollaborators.Lancet 2017

WOMAN Trial;The Bottom Line

Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients.Gayet-Ageron A. Lancet. 2017

Tranexamic Acid - The Mechanism of Action;Video

Tranexamic Acid, Time to Treatment;The Resus Room

Does earlier TXA save lives?St Emlyns

TXA podcast; PHEMCAST

About CRASH-3; LSHTM

October 2019; papers of the month Oct 01, 2019

Show notes

Welcome to October '19 papers podcast.

You can't go far without the topic of TXA as a treatment for anything that bleeds being mentioned! With the publication of CRASH-2 and the WOMAN trial practice has crept such that administration in gastro-intestinal bleeding is seen fairly frequently. However, current guidelines don't recommend the use of TXA in GI bleeding, so this month we have a look at a systematic review which looks to answer whether it's administration is supported by the evidence, before we get a definitive answer from the HALT-IT trial.

Next up, following on from our Burns Roadside to Resus podcast, we take a look at a paper that quantifies the potential benefit of thorough first aid in the management of paediatric burns, a really key paper on the topic, with really powerful results.

Finally, we all know that Sepsis is a core area of our practice, but at times it may feel like the attention on those that could possibly have severe sepsis displaces the ability to care for other critically ill patients. We take a look at a great paper developing a prehospital screening tool to focus in on those patients that really do require time-critical care.

Enjoy!

Simon & Rob

Shock in Trauma; Roadside to Resus Sep 16, 2019

Show notes

So as promised, and following on from our previous shock episode, this time we've covered the topic of shock in Trauma. It's a massive topic and one that we all, yet again, can make a huge difference for our patients' outcomes.

There is some crossover as you'd expect from the concepts and assessment that we covered in our Shock episode, so we'd recommend taking a listen to that one first. Make sure you have a comfy seat and plenty of refreshments to keep you going for this one as we cover the following;

Definition
Aetiology
Hypovolaemic shock
Neurogenic shock
Obstructive shock
Cardiogenic shock
Physiology; Traumatic coagulopathy
Other diagnostics
Controlling external haemorrhage
Pelvic binders
REBOA
Avoiding coagulopathy
BP targets & permissive hypotension
Fluid choices & supporting evidence
TEG/ROTEM
Calcium
TXA
Vasopressors
Preventing hypothermia
Relieving obstruction
Interventional radiology
Damage control surgery

As always we'd love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions.

Enjoy!

Simon, Rob & James

References

Shock;The Resus Room podcast

REBOA;The Resus Room podcast

External Haemorrhage;The Resus Room podcast

Blood;PHEMCAST

TEG & ROTEM;FOAMcast

Major Trauma guideline;NICE

Resuscitative endovascular balloon occlusion of the aorta (REBOA):a population based gap analysis of trauma patients in England and Wales

Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. Joseph B. JAMA Surg. 2019

The Pre-hospital Management of Pelvic Fractures: Initial Consensus Statement. I Scott. FPHC. 2012

RePHILL;Birmingham University Trials

Assessment and Treatment of Spinal Cord Injuries and Neurogenic Shock;Fox A. JEMS

Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. Holcomb JB. JAMA. 2015

Risks and benefitsof hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis. Owattanapanich N. Scand J Trauma Resusc Emerg Med. 2018

TEG and ROTEM for diagnosing trauma‑induced coagulopathy (disorder of the clotting system) in adult trauma patients with bleeding;Cochrane Review. 2015

Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review.McQuilten ZK. Transfus Med Rev. 2018

Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock.Sperry JL. N Engl J Med. 2018

September 2019; papers of the month Sep 01, 2019

Show notes

We start off this month with a much talked about paper in the pre-hospital services, what benefit does Pre Hospital Critical Care bring to cardiac arrest victims? We are lucky enough to have the inside thoughts of the lead author, this a really interesting piece of work and will no doubt lead to further discussions, for more information from the author take a look at his thesis here.

Next up we take a look at the utility of troponins in patients that have suffered cardiac arrest, can we use them to evaluate how likely it was that an MI precipitated the arrest?

Last up we have a look at a novel approach of ruling out stroke as the cause of acute dizziness.

We'd love to hear your thoughts and comments.

Enjoy!

Simon & Rob

Stroke Management; Roadside to Resus Aug 15, 2019

Show notes

Following on from our previous Roadside to Resus episode on Stroke, in this episode we look at the rapidly evolving area of stroke management.

In the last 2 decades stroke management has progressed beyond recognition and keeping up with the evidence and available therapies is a significant challenge. We cover the following treatments, looking at the risks and benefits of each, with the goal of being able to offer our patients the best possible outcomes;

Aspirin
Thrombolysis; both prehospitally and in hospital
Thrombectomy
Decompressive Hemicraniectomy
Normoxia
Euglycaemia
Acute blood pressure management

As always we'd love to hear any thoughts or comments you have on the website and via twitter.

Enjoy!

Simon, Rob & James

References

Tissue plasminogen activator for acute ischemic stroke. National Institute of Neurological Disorders and Stroke rt-PA.Stroke Study Group. N Engl J Med. 1995

Aspirin in Stroke;NNT

Stroke Thrombolysis; Life in The Fast Lane

Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency. Nolte CH. Stroke. 2018

Effect of the use of ambulance based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. Ebinger M. JAMA. 2014

Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee. Mokin M. J Neurointerv Surg. 2019

Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Evans MRB. Pract Neurol. 2017

Extend; The Bottom Line

Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline.Published: 1 May 2019

MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial.Fransen PS. Trials. 2014

A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA).Campbell BC. Int J Stroke. 2014

Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. Jeffrey L. Saver. NEJM. 2015

Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging.Gregory W. Albers. NEJM. 2018

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.Raul G. Nogueira.NEJM. 2018

August 2019; papers of the month Aug 01, 2019

Show notes

Well the summer has definitely hit and we hope you get a chance for a break... making sure you spend spend some time listening to our Heat Illness episode on a beach somewhere!

It's a wide variety of papers for you this month;

Should we be looking to immediately cardiovert acute onset AF in the ED? What difference does glucagon make to clearing oesophageal foreign bodies? How important is our diagnostic accuracy in ED to the patients morbidity and mortality? And finally we cover a paper looking at the requirement for urgent tracheal intubation in trauma patients, and are lucky enough to get some thoughts from the lead author Dr. Kate Crewdson.

We'd love to hear your thoughts and comments.

Enjoy!

Simon & Rob

Stroke; Roadside to Resus Jul 15, 2019

Show notes

Stroke is a common presentation to all Emergency Health care providers, with around 150,000 strokes occurring in the UK each year! Our impact and treatment can be hugely significant and in this podcast we're going to conver the topic in some depth, and importantly cover some of the new Guidance published by NICE in their 'Stroke and transient ischaemic attack in the over 16's diagnosis and initial management' document that was published in May of this year.

We'll be running through