The Resus Room

Latest Episodes:

Paediatric Arrest; Roadside to Resus May 21, 2018

Show notes

The management of a cardiac arrest can be stressful at the best of times, but add into that the patient being a child and you have the potential for an overwhelmingly stressful situation.

Fortunately the major resuscitation bodies have some sound guidance on the management of paediatric arrests. In this episode we run through some of those guidelines and also the evidence base on the topic (scant at best!). We also touch on conveyance of the prehospital paediatric arrest, bringing familiy into the resuscitation area and knowing when to cease resuscitation.

We hope the podcast helps you prepare that little bit more for the next case you might see and that it may also ease the stress of such an emotive case.

Simon, Rob & James

Top 10 Trauma Papers 2018 May 10, 2018

Show notes

Professor Simon Carley from St. Emlyns caught up with us at the superb Trauma Care Conference and talked through his top papers in trauma from the last 12 months.

There's something for everyone from diagnosing arterial injuries, blood pressure targets in the head injury patient, to i.v. contrast all the way through to imaging in kids.

If you haven't already, make sure you go and check out the St Emlyn's blog that underpins the talk that Simon gave. And if you're looking for a great value conference to suit all health care disciplines then make sure to keep an eye out for tickets when they go on sale for Trauma Care 2019.

A huge thanks to Simon C for his time recording the podcast and we'd love to hear any comments or feedback.

Enjoy!

Simon L & Simon C

References & Further Reading

For all the papers pop over to the St Emlyn's blog for the hyperlinks and abstracts

May 2018; papers of the month May 01, 2018

Show notes

Dare we say it, we think this month's papers podcast is the best yet, we've got 3 superb papers and topics to consider!

The literature has been pretty airway heavy this month so we've got 3 papers on and around the topic for you.

First up we have a look at a really interesting paper from London HEMS looking at the risks v benefit of prehospital rapid sequence intubation in patients who are awake but hypotensive, is RSI a much needed move or something we should be looking to avoid prehospitally.

Airways-2 will soon be published looking at supraglottic airway management compared to intubation as first line airway management in out of hospital cardiac arrest, but JAMA has just published a paper comparing bag-mask ventilation vs endotracheal intubation in the same situation. It'll be interesting to see if this papers results fall inline with Airways-2.

Finally we take a look at a systematic review trying to give us the answer to direct or video laryngoscopy in emergency endotracheal intubation outside the OR.

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

Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental? Crewdson K. Acta Anaesthesiol Scand. 2018

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

Videolaryngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside the operating room: a systematic review and meta-analysis. Arulkumaran N. Br J Anaesth. 2018

Statistics Demystified Apr 23, 2018

Show notes

Evidence based medicine (EBM) allows us to deliver the best care to our patients and understanding the concepts involved is crucial.

Over the last 18 month we've been building an online course to give people a sound understanding of EBM and we thought we'd give you a free taster of what it's all about.

Have a listen to one of our episodes here on statistics and if you want to find out more have a read below about the full course at www.CriticalAppraisalLowdown.co.uk

Enjoy!

Simon, Rob & James

Trauma Care 2018 Apr 18, 2018

Show notes

For this episode we've been lucky enough to catch a number of the speakers from the traumacare conference.

First up, conference organiser Caroline Leech (EM + PHEM consultant) gave us a few minutes of her time to talk about the latest major trauma key performance indicators from NICE.

Nicola Curry (Consultant Haematologist) spoke about transfusion in trauma and the use of massive haemorrhage protocols. Importantly, she covers the evidence behind the current strategies and where future research opportunities exist.

Stuart Reid (EM + PHEM consultant) covered the ways of optimising timely transfer of major trauma patients. This had an inter-hospital focus, but there were certainly some elements which can be applied to a primary patient transfer.

David Raven (EM consultant) provided an update to the ongoing work with the HECTOR project. We've previously heard about their amazing course but this time he was able to let us know about the "silver trauma safety net" which is being used by the ambulance service in the West Midlands. This aims to provide appropriate recognition and triage of trauma in the elderly population.

Finally, Elspeth Hulse (anaesthetic SpR) gave us a timely reminder about the identification and management of organophosphate poisoning - really useful from both and EM and PHEM perspective.

Thanks again to Caroline for the invite to the conference and keep and eye out for a special podcast in the next few weeks where Simon Carley will be running through his top 10 trauma papers of 2017/18 (we were going to try and condense it, but there was way too much good stuff!)

Enjoy!

Simon, Rob & James

References & Further Reading

Trauma Care

St Emlyns

HECTOR

A case to make you think... Apr 08, 2018

Show notes

In this episode Rob takes us through a case he saw recently that brought about some invaluable learning.

We're not going to give you anymore clues than that!

Enjoy!

Simon & Rob

References & Further Reading

(anonymised to keep the anticipation!)

Article 1 Article 2 Article 3 Article 4

April 2018; papers of the month Apr 01, 2018

Show notes

Welcome back to April's papers of the month.

We've got 3 papers this month that look to challenge our work up strategies for the critically unwell. First up we look at a paper on the Ottawa subarachnoid haemorrhage rule, specifically considering if we can decrease scanning in patients with a suspected SAH and what application of the rule might mean for our practice.

Next up we look at a paper that might shine some real doubt on the use of IO access in our patients in cardiac arrest.

Lastly we look at a validation paper for the PERC rule for those patients with a suspected pulmonary embolus and this paper brings about some interesting points on external validity

Once again we'd really encourage you to have a look at the papers yourself and we've love to hear any thoughts or feedback you have.

Enjoy!

Simon & Rob

References

Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. Perry JJ. CMAJ. 2017

Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Kawano T. Ann Emerg Med. 2018

Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. Freund Y. JAMA. 2018

CORE EM; IO in Cardiac Arrest

RSI; Roadside to Resus Mar 20, 2018

Show notes

Gaining control of the airway in a critically unwell patient is a key skill of the critical care team and littered with potential for difficulty and complications.

NAP4 highlighted the real dangers faced with their review of complications of airway management in the UK, lessons have been learnt and practice has progressed. As always there is room to improve on current practice and a recent paper published in Anaesthesia describes a comprehensive strategy to optimise oxygenation, airway management, and tracheal intubation in critically ill patients in all hospital locations.

In this podcast we cover;

Why this matters to all involved in critically unwell patients, not just those delivering RSI
Recap of RSI, the procedure and its indictions
Headlines from NAP4
Strategies highlighted to optimise airway management and oxygenation
How this impacts our prehospital and inhospital practive

We'd love to hear your thoughts so please leave your comments below or contact us via twitter @TheResusRoom

Enjoy!

Simon, Rob & James

References & Further Reading

NAP4

Guidelines for the management of tracheal intubation in critically ill adults. A Higgs B. British Journal of Anaesthesia. 2017

Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study.De Jong A. Am J Respir Crit Care Med. 2013

Introduction to the Vortex; vimeo

The Crystalloid Debate Mar 12, 2018

Show notes

How often do you prescribe or give i.v. fluids to your patients? How much thought goes into what's contained in that fluid? What effect will you fluid choice have on your patient?

Two trials on crystalloid administration in the acutely unwell patient have occupied a lot of conversation in the research world over the last few weeks, both published in the NEJM and in this podcast we take a look at them.

In the podcast we cover the following;

Whats the big deal with crystalloids
Previous trials on fluid administration
NEJM papers on crystalloids
Myburgh's editorial

Make sure you take a look at the papers yourself and come up with your own conclusions. There are a whole host of superb FOAM resources out there on the topic that are well worth a look and referenced below.

We'd love to hear any thoughts and comments below.

Enjoy!

Simon & Rob

References & Further Reading

Fluid Na K Cl Ca Mg Lact Acet Glucon Dext

Osmol

mOsm/L

0.9% N Saline 154 0 154 0 0 0 0 0 0 308 Lactated Ringers 131 5 11 2.7 0 29 0 0 0 273 Hartmanns 129 5 109 4 0 29 0 0 0 278 Plasma Lyte 140 5 98 0 3 0 27 23 0 280

Constituents measured in mEq/L Reference; University Texas

Balanced Crystalloids versus Saline in Critically Ill Adults. Semler MW. N Engl J Med. 2018

Balanced Crystalloids versus Saline in Noncritically Ill Adults. Self WH. N Engl J Med. 2018

Patient-Centered Outcomes and Resuscitation Fluids. Myburgh J. N Engl J Med. 2018

REBEL.EM; Is the Great Debate Between Balanced vs Unbalanced Crystalloids Finally Over?

PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation

JC: Balanced fluids vs Saline on the ICU. The SMART trial. St Emlyn's

JC: So long Salt and Saline? St Emlyn's

The Bottom Line; SALT-EM

The Bottom Line; SMART

March 2018; papers of the month Mar 01, 2018

Show notes

Welcome to March's papers of the month. We know we're biased but we've got 3 more superb papers for you this month!

First up we review a paper looking at oxygen levels in patient's with a return of spontaneous circulation following cardiac arrest, is hyperoxia bad news for this patient cohort as well as the other areas we've recently covered?

Secondly we have a look at a paper reviewing the association between time to i.v. furosemide and outcomes in patients presenting with acute heart failure, you may want to have a listen to our previous podcast on the topic first here.

Lastly, when you see a pregnant patient with a suspected thromboembolic event, can you use a negative d-dimer result to rule out the possibility? We review a recent paper looking at biomarker and specifically d-dimers ability to do this.

We'd love to hear from you with any thoughts or feedback you have on the podcast. And we've now launched of Critical Appraisal Lowdown course, so if you want to gain some more skills in critical appraisal make sure you go and check out our online course here.

Enjoy!

Simon & Rob

References & Further Reading

Association Between Early Hyperoxia Exposure AfterResuscitation from Cardiac Arrest and Neurological Disability: A Prospective Multi-Center Protocol-Directed Cohort Study. Roberts BW. Circulation. 2018

The DiPEP (Diagnosis of PE in Pregnancy) biomarker study: An observational cohort study augmented with additional cases to determine the diagnostic utility of biomarkers for suspectedvenous thromboembolism during pregnancy and puerperium. Hunt BJ. Br J Haematol. 2018

Time to Furosemide Treatment and Mortality in PatientsHospitalized With Acute Heart Failure. Matsue Y . J Am Coll Cardiol. 2017

MDCALC; Framingham Heart Failure Diagnostic Criteria

REBEL.EM; Door to Furosemide in AHF

Modified Rankin Scale