The Resus Room

Latest Episodes:

Burns; Roadside to Resus Oct 15, 2018

Show notes

With bonfire night approaching we thought it would be a good time to have a think about burns.

However burns are a significant issue at all times of year with around 130,000 presentations to UK EDs annually, 10,000 cases are admitted to hospital, 500 of these have severe burns and 200 of these will die. But most importantly intervention that we make can make a big difference to both morbidity and mortality, really affecting outcomes.

Throughout this episode we'll be covering the essential first responder management, all the way through to the critical care that maybe required for the sickest of burns patients.

In the podcast we cover

Burn type and burn severity
The importance of history
Assessing burn extent
Assessing burn depth
The A-E assessment and specifics regarding the burns patient
NAI, antibiotics, tetanus cover, analgesia, special circumstances eyes & chemicals
Conveyance and destination

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

Enjoy!

Simon, Rob & James

References

British Burn Association First Aid Clinical Practice Guidelines

BBA Clinical Practice Guideline for Management of Burn Blisters

BBA Clinical Practice Guideline for Deroofing Burn Blisters

RCEMLearning; Major Trauma, Burns

National Burn Care Referral Guidance

WHO; fact sheet on burns

NHS Standard Contract for Specialised Burns Care (All Ages) Schedule 2- The Services A. Service Specification

LITFL; burns

Clinical review: The critical care management of the burn patient. Jane A Snell. Crit Care 2013

Fluid resuscitation in major burns. Mitra B ANZ J Surg. 2006

How well does the Parkland formula estimate actual fluid resuscitation volumes? Cartotto RC. J Burn Care Rehabil. 2002

Fluid resuscitation management in patients with burns: update. Guilabert P. Br J Anaesth. 2016

ISBI Practice Guidelines for Burn Care 2016

October 2018; papers of the month Oct 01, 2018

Show notes

Welcome back to October's Papers Podcast, this month we move airway from advanced airway management and bring you a broad array of papers.

First up we have a look at the relative success of a variety of pharmacological strategies for managing the acutely agitated patient in ED. Next up we have look at the well know CURB-65 score and it's ability to predict the need for critical care interventions. Lastly, we may all feel at times that performing a CT head on those well patients solely because they take anticoagulants may be a little on the excessive side, we review a paper that looks at the yield of positive scans in this cohort.

As ever don't just take our word for it, go and have a look at the papers yourself, we would love to hear any comments or feedback you have.

Enjoy!

Simon & Rob

References & Further Reading

IntramuscularMidazolam, Olanzapine, Ziprasidone, or Haloperidolfor TreatingAcuteAgitationin the Emergency Department. Klein LR. Ann Emerg Med. 2018

Performanceof the CURB-65Scorein PredictingCritical CareInterventionsin PatientsAdmitted With Community-AcquiredPneumonia.Ilg A. Ann Emerg Med.2018

Incidenceof intracranial bleedingin anticoagulatedpatientswith minor head injury: a systematic review and meta-analysis of prospective studies. Minhas H. Br J Haematol.2018

September 2018; papers of the month Sep 14, 2018

Show notes

So we're back with September's papers of the month a little later than usual but we wanted to give you a little time to digest AIRWAYS-2... before we give you some more prehospital research on advanced airway management in cardiac arrest!

The American version of AIRWAYS-2, PART, has just been released in JAMA, looking at the laryngeal tube versus endotracheal intubation as a primary strategy for advanced airway management. The paper is fascinating accompaniment to AIRWAYS-2.

Next we have a look at a paper assessing Emergency Medicine clinicians' ability to predict hospital admission at the time of triage, should we be making early calls on the destination of our patients?

Finally we have a look at the potential role of esmolol in cases of refractory VF and a paper that reports twice the survival rates in those that receive it!

As always we strongly suggest you have a look at the papers yourself and come to your own conclusions. Make sure you check out the hyperlinked blogs below that we mention in the podcast that contain some fantastic critiques. We'd also love to hear any comments either at the foot of this page or on twitter to @TheResusRoom.

Enjoy!

Simon & Rob

References & Further Reading

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac ArrestA Randomized Clinical Trial. Henry E. Wang, MD. 2018

Emergency medicinephysicians' abilityto predicthospital admissionat the timeof triage. Vlodaver ZK. Am J Emerg Med.2018

Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patientswith refractory ventricular fibrillation. Driver BE. Resuscitation.2014

King Laryngeal Tube

Intubation or supraglottic airway in cardiac arrest; AIRWAYS-2 Aug 28, 2018

Show notes

So we're back from our summer hiatus with a real treat. The long awaited AIRWAYS-2 paper has just been released and we've been lucky enough to speak with the lead author, Professor Jonathan Benger, about the paper and discuss what the findings mean for cardiac arrest management.

AIRWAYS-2 looks at the initial advanced airway management strategy for paramedics attending out of hospital cardiac arrests, essentially whether or not the aim should be to place a supraglottic airway device or an endotracheal tube when advancing from simple airway techniques. The study was a huge undertaking with many speculating over how the results would change practice, including discussion of how it may affect paramedic's practice of intubation, all of which we cover in the podcast.

Before you listen to the podcast make sure you have a look at the paper yourself, have a listen to PHEMCAST's previous episode which covers the study design and have a look at the infographics on the website which summarise the primary outcome and secondary analysis and which we refer to in the interview with Professor Benger.

In the podcast we refer to Jabre's paper which can be found below and we also covered in May's papers podcast. Have a listen to the interview and let us know any thoughts or feedback you have, we're sure this one will create a lot of discussion!

Simon, Rob & James

References & Further Reading

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. The AIRWAYS-2 Randomized Clinical Trial. Benger J. JAMA. 2018

PHEMCAST; the LMA

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomised Clinical Trial. Jabre P. JAMA. 2018

TEAM Course

August 2018; papers of the month Aug 01, 2018

Show notes

Welcome to August's papers of the month.

So this is our last offering for the summer until whilst we take a short break until September, so we had to finish off we 3 great papers!

First up we look at the drug of the moment (or decade...) in tranexamic acid and the effect that it has on outcomes in primary intracerebral haemorrhage.

Next, what role does point of care ultrasound (POCUS) hold in the patient presenting with undifferentiated shock? We look at a randomised control trial of POCUS in this patient cohort that assesses the ability to translate POCUS into a mortality benefit.

Finally we look at a delphi study published in the EMJ which explores expert opinion upon multiple aspects of paediatric traumatic arrests. The results are fascinating and may inform some of the CRM used in the next case you see.

Enjoy!

Simon & Rob

References & Further Reading

Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Sprigg N. Lancet. 2018

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With UndifferentiatedHypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Atkinson PR. Ann Emerg Med. 2018

Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management. Rickard AC. Emerg Med J. 2018

St Emlyns JC; Tich Tich Boom?

First10EM; TXA in ICH (TICH-2)

Adrenaline in Cardiac Arrest; PARAMEDIC2 Jul 25, 2018

Show notes

Drugs in cardiac arrest are controversial. Prehospital research is notoriously difficult to perform. PARAMEDIC2 has just published in the New England Journal of Medicine and is a multi centre randomised placebo controlled trial looking at adrenaline (or epinephrine depending on which side of the pond you reside) in out of hospital cardiac arrest, no mean undertaking and a landmark paper.

The paper has gained a huge amount of traction online with multiple blogs discussing the primary outcome which showed a higher survival rate in those receiving adrenaline when compared to placebo. This has been accompanied with a firm debate over the secondary outcomes, which include the rate of survival with a favourable neurological outcome (mRS 0-3), which showed no statistically significant difference between the two treatment arms, but in pure numbers gave a higher proportion of favourable outcomes in the adrenaline group.

The trade off for this increased survival is the significant number of survivors with a poor neurological outcome.

The question on everyone's lips then being; should we continue to administer adrenaline in cardiac arrest given the findings from this study?

In the podcast we run over the main findings of the paper and are lucky enough to speak to the lead author Professor Gavin Perkins about the paper and some of the questions we and you have had following publication of the paper. A huge thanks to Gavin for taking the time to do this.

Have a listen, enjoy, and let us know any thoughts or feedback you have

Simon, Rob & James

References & Further Reading

PARAMEDIC2; Warwick University Clinical Trials Unit

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. Perkins GD. N Engl J Med. 2018

PARAMEDIC2 Protocol

Testing Epinephrine for Out-of-Hospital Cardiac Arrest. Callaway CW. N Engl J Med. 2018

First10EMParamedic 2: Epinephrine harms/helps in out of hospital cardiac arrest

REBEL Cast Ep56 PARAMEDIC-2: Time to Abandon Epinephrine in OHCA?

Head Injury; Roadside to Resus Jul 16, 2018

Show notes

Head injury worldwide is a significant cause of morbidity and mortality.

Besides prevention there isn't anything that can be done to improve the results from the primary brain injury, there is however a phenomenal amount that can be done to reduce the secondary brain injury that patients suffer, both from a prehospital and in hospital point of view.

In the podcast we run through head injuries, all the way from initial classification and investigation, to specifics of treatment including neuro protective anaesthesia and hyperosmolar therapy, to give a sound overview of the management of these patients.

As always we welcome feedback via the website or on Twitter and we look forward to hearing from you.

Enjoy!

Simon, Rob & James

References & Further Reading

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

Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned? Boone MD. Surg Neurol Int. 2015

Life in the fast lane; hypertonic saline

Life in the fast lane; Traumatic brain injury

Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality. T Lawrence. BMJ Open. 2016

Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. M.Majdan. The Lancet. 2016

The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. Gale SC. J Trauma. 2005

What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population? Rotheray KR. Resuscitation. 2012

NICE Head Injury Guidelines 2014

MDCALC Canadian Head Injury

TheResusRoom; The AHEAD Study

TheResusRoom; Anticoagulation, head injury & delayed bleeds

Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement

A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries. Manara AR. J Intensive Care Soc. 2016

July 2018; papers of the month Jul 02, 2018

Show notes

Welcome to July's papers podcast.

There has been a plethora of superb and thought provoking papers published this month and we've got the best 3 that caught our eye for you.

In this episode we look at the potential benefit of early vs late endoscopy in patients presenting with an acute upper GI bleed. Next we look at both intra and post ROSC hyperoxia and the associated outcomes. Finally we have a look at the utility of straight leg raise as a test to rule out potential pelvicfractures in out trauma patients.

We strongly suggest you source the papers and come to your own conclusions and we'd love to hear any comments either at the foot of this page or on twitter to @TheResusRoom.

Enjoy!

Simon & Rob

References & Further Reading

Delayed endoscopy is associated with increased mortality in upper gastrointestinal hemorrhage. Jeong N. Am J Emerg Med. 2018

Association between intra- and post-arrest hyperoxia on mortality in adults with cardiac arrest: A systematic review and meta-analysis. Patel JK. Resuscitation. 2018

Straight leg elevation to rule out pelvic injury. Bolt C. Injury. 2018

External Haemorrhage; Roadside to Resus Jun 20, 2018

Show notes

Managing external haemorrhage is easy right?! Then why does haemorrhage remain a major cause of death from trauma worldwide? Ok, some of that is from internal sources, but….

No one should die from compressible external haemorrhage

With the right treatment applied in a timely fashion, the vast majority of these bleeds can be stopped. But with new advances like haemostatic agents, changing advice surrounding tourniquet use and practice changing evidence coming out of conflict zones can mean it's difficult to remain current with the latest best practice.

So what options are available to us, how do we use them and what's the evidence. Here's the line-up for this months' podcast:

Haemorrhage control ladder
Evidence based guidelines on haemorrhage control
Direct pressure
Enhanced pressure dressings
Haemostatic agents and wound packing
Tourniquets
Case studies

As always we welcome feedback via the website or on Twitter and we look forward to your engagement.

Enjoy!

Simon, Rob & James

References & Further Reading

Bennett, B. L & Littlejohn, L. (2014) Review of new topical hemostatic dressings for combat casualty care. Military Medicine. Volume 179, number 5, pp497-514.

Lee, C., Porter, K. M & Hodgetts, T. J. (2007) Tourniquet use in the civilian prehospital setting. Emergency Medicine Journal. Volume 24, pp584-7.

Nutbeam, T & Boylan, M. (2013) ABC of prehospital emergency medicine. Wiley Blackwell. London.

Shokrollahi, K., Sharma, H & Gakhar, H. (2008) A technique for temporary control of haemorrhage. The Journal of Emergency Medicine. Volume 34, number 3, pp319-20.

Trauma! Extremity Arterial Hemorrhage; LITFL

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Rolf Rossaint. Critical Care 2016.

NICE 2016. Major Trauma; Assessment and Initial Management

FPHC 2017; Position statement on the application of Tourniquets

June 2018; papers of the month Jun 01, 2018

Show notes

Welcome back to our monthly round up of the best papers in the resuscitation world.

Again we've got 3 great papers covering some really important points of practice. First up we have a look at one of the most talked about diagnostic tests in Emergency Medicine, Troponin. We're are always looking to increase the sensitivity of the assay and test in order to ensure the patient hasn't got Acute Coronary Syndrome, but what are the implications of implementing a high sensitivity test? In our first paper we have a look at this exact scenario, the difference in patient outcomes and some of the resource implications to the service.

Next up we have a look at apnoeic oxygeationn. We've covered this a number of times before and most recently in our Roadside to Resus episode on RSI. This time we have a look at the most recent systematic review and meta-analysis on the topic to see if there is more definitive evidence of benefit with this technique.

Lastly we've found a paper that suggests a place for prognosticating off pH in cardiac arrest, is this something we should be adopting?

Have a listen but most importantly have a look at the papers yourself and let us know your thoughts.

Enjoy!

Simon & Rob

References & Further Reading

Low-level troponin elevations following a reduced troponin I cutoff: Increased resource utilization without improved outcomes. Becker BA. Am J Emerg Med. 2018

Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-Analysis. Oliveira J E Silva L. Ann Emerg Med. 2017

Association between acidosis and outcome in out-of-hospital cardiac arrest patients. Lin CC. Am J Emerg Med. 2018.