The Resus Room

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

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

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

So the three of us are back together and going to take on Sepsis! It's vital to have a sound understanding of sepsis. It has a huge morbidity and mortality but importantly there is so much that we can do both prehospital and in hospital to improve patient outcomes. In the podcast we cover the following; Definitions Scale of problem Different bodies; NICE/Sepsis Trust/3rd international consensus definition including qSOFA Handover and pre alerts Treatment; Sepsis 6 The evidence base behind treatment Contentious areas Prehospital abx Fever control Steroids ETCO2 We hope the podcast helps refresh your knowledge on the topic and brings about some clarity on some contentious points. As always don't just take our word for it, go and have a look at the primary literature referenced below. Enjoy! Simon, Rob & James References & Further Reading Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Kumar. Critical Care Medicine. 2006 Prognostic value of timing of antibiotic administration in patientswith septic shock treated with early quantitative resuscitation. Ryoo SM. Am J Med Sci. 2015 The association between time to antibiotics and relevant clinicaloutcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. de Groot B. Crit Care. 2015 Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Puskarich MA. Crit Care Med. 2011 Early goal-directed therapy in the treatment of severe sepsis and septic shock. Rivers E. N Engl J Med. 2001 Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Nguyen HB. Crit Care Med. 2004 The prognostic value of blood lactate levels relative to that of vitalsigns in the pre-hospital setting: a pilot study. Jansen TC Crit Care. 2008 Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. Jones AE. JAMA. 2010 Lower versus higher hemoglobin threshold for transfusion in septic shock. Holst LB. N Engl J Med. 2014 A randomized trial of protocol-based care for early septic shock. ProCESS Investigators. N Engl J Med. 2014 Trial of early, goal-directed resuscitation for septic shock. Mouncey PR. N Engl J Med. 2015 Goal-directed resuscitation for patients with early septic shock. ARISE Investigators. N Engl J Med. 2014 Acetaminophen for Fever in Critically Ill Patients with SuspectedInfection. Young P. N Engl J Med. 2015 NICE; Sepsis: recognition, diagnosis and early management The Sepsis Trust The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer M. JAMA. 2016 NHS E; Improving outcomes for patients with sepsis. A cross-system action plan Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. Alam N. Lancet Respir Med. 2018 Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. Venkatesh B. N Engl J Med. 2018 PHEMCAST; End Tidal Carbon Dioxide Current clinical controversies in the management of sepsis. Cohen J. J R Coll Physicians Edinb. 2016 St Emlyns; qSOFA RCEM; Severe Sepsis and Septic Shock Clinical Audit 2016/2017 National report RCEM & UK Sepsis Trust; Toolkit: Emergency Department management of Sepsis in adults and young people over 12 years- 2016

On a not infrequent basis we will come across patients in hospital who have a CT head scan that appears to show an unsurvivable event. Having sourced opinion from our neurosurgical and neurology colleagues we may well be given the advice to withdraw care for the patient. It has become increasingly recognised that prognosticating in such patients at an early stage is extremely difficult with numerous cases surviving what was initially thought to be an unsurvivable event, with a good neurological outcome. This joint document from the Intensive Care Society, Royal College of Emergency Medicine, Neuro Anaesthesia and Critical Care Society of Great Britain & Ireland and the Welsh Intensive Care Society gives new guidance for such perceived devastating brain injuries and will challenge many peoples thinking on the topic with additional questions being asked on resource utilisation. In this podcast Caroline Leech, EM and PHEM Consultant in Coventry, discusses the guidelines and the implications they hold for our practice. As always make sure you read the document yourself, we would love to hear your thoughts. Enjoy! Simon & Caroline References Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement A case for stopping the early withdrawal of life sustainingtherapies in patients with devastating brain injuries. Manara AR. J Intensive Care Soc. 2016

Welcome back, we've got 3 absolute beauties of papers for you this month! You'll have struggled not to have heard about the ADRENAL trial, a trial of iv steroids in the sickest of patients with septic shock. We also have a look at a trial that many have been quoting as sound evidence for the utility of pH during the prognostication of patients in cardiac arrest. Finally we have a look at a paper that may shed some concern on the use of Double Sequential Defibrillation that we covered recently on the podcast... 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 TheBottomLine; ADRENAL St Emlyns; ADRENAL Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. Venkatesh B. N Engl J Med. 2018 External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose Cardioversion. Gerstein NS. Ann Emerg Med. 2018 Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: a multicenter observational registry-based study. Shin J. Crit Care. 2017

In this episode we cover a paper that you have to know about! The use of tranexamic acid(or TXA) has become widespread in the case of major trauma and post partum haemorrhage. This time we discuss a recent paper that asks us if giving it within 3 hours is enough, or whether we need to be even more specific regarding its urgency of administration in order to save lives from bleeding. There is a superb podcast over at our buddies site PHEMCAST which covers an interview with one of the authors and we'd highly recommend listening to that! Enjoy! Simon & Rob References 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

Prehospital Care is evolving rapidly and is one of the most exciting and dynamic specialties to be involved with at the moment. As a reflection of it's progress the Faculty of Pre Hospital Care held its first scientific conference this week. We were lucky enough to be invited by Caroline Leech, EM & PHEM Consultant and the person responsible for organising this superb event, to interview some of the superb speakers at the event. Here are the speakers we were lucky enough to catch up with and the topics they discuss Matt Thomas – Hyperoxia: when oxygen is harmful Jo Manson – The hyperacute inflammatory response to trauma Rob Moss – FPHC Consensus Statement - Spinal Malcolm Russell – FPHC Consensus Statemnent – External Haemorrhage Tim Nutbeam – Pre-hospital research: what do we not know? David Menzies – Impact brain apnoea & motorsport Stacey Webster – Calcium in pre-hospital blood transfusion: the missing link Rod Mackenzie Injury prevention, control & recovery A huge thanks to all involved in the conference for having us at the conference and we hope to see you all next year! Simon, Rob & James References and links FPHC Consensus statement guidelines Ionised calcium levels in major trauma patients who received blood in the Emergency Department. Webster S. Emerg Med J. 2016 TOP-ART

Happy New Year!! Welcome back to the podcast and what we hope will be a superb year. We've got three excellent papers that are extremely relevant to our practice and will have an impact on practice. First up it's a paper looking at the benefit of iv versus oral paracetamol in the Emergency Department, something we do really frequently but what does the evidence say? Next we have a look at the difference that topical TXA could make to epistaxis in terms of bleeding cessation. Lastly we look at a systematic review looking at adenosine versus calcium channel blockers for SVT. Very soon we'll be releasing our Critical Appraisal Lowdown course, so keep an eye out for that. And finally a huge thanks to our sponsors ADPRAC for all of the support with TheResusRoom. Enjoy! Simon & Rob

Handover matters. Handover of patient care occurs at multiple points in the patient's journey and is a crucial point for transference of information and inter professional working. Whether it's the big trauma in Resus with the prehospital services presenting to the big crowd, right the way through to the patient coming to minors who looks like they will be going home shorty, each of these transactions of information needs to be done correctly. Handover can be stressful though and different parties will have different priorities that they are trying to juggle. In this podcast we explore handover, some of the barriers and issues that exist. We have a look at the evidence that exists on it's importance, impact and associated techniques. We also look at tools that exist that can be used to facilitate effective handover. As ever make sure you look at the articles mentioned in the podcast yourself and we would love to hear your thoughts. Enjoy! Simon, Rob & James References & Further Reading Information loss in emergency medical services handover of trauma patients. Carter AJ. Prehosp Emerg Care. 2009 Maintaining eye contact: how to communicate at handover. Dean E. Emerg Nurse. 2012 The handover process and triage of ambulance-borne patients: the experiences of emergency nurses. Bruce K. Nurs Crit Care. 2005 Handover from paramedics: observations and emergency department clinician perceptions. Yong G. Emerg Med Australas. 2008 Review article: Improving the hospital clinical handover between paramedics and emergencydepartment staff in the deteriorating patient. Dawson S. Emerg Med Australas. 2013

You've got a critically unwell patient who needs an RSI. You've got lots of things to think about but specifically do you ramp them up or keep them supine, additionally do you use a checklist or are those things a complete waste of time? This month we have a look at 2 papers which should shed some light on the subject. We also look at a systematic review and meta-analysis which hopefully helps us answer a question we've been looking at on the podcast for quite some time: in the the context of a cardiac arrest that has gained a ROSC, if the ECG is not diagnostic of a STEMI but the history is suggestive of a cardiac event, should the patient go straight to the cathlab for PCI? As always don't just take our word for it but go and have a look at the papers yourself and we would love to hear your thoughts. Enjoy! Simon & Rob References & Further Reading A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults. Semler MW. Chest. 2017 A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults. Janz DR. Chest. 2017 Early coronary angiography in patients resuscitated from out of hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis. Khan MS. Resuscitation. 2017 JC: Should non ST elevation ROSC patients go to cath lab? St.Emlyn's CHECK-UP Checklist; The Bottom Line

Traumatic Cardiac Arrest; for many of us an infrequent presentation and it that lies the problem. In our previous cardiac arrest podcast we talked about the approach to the arresting patient, however in trauma the approach change significantly. We require a different set of skills and priorities and having the whole team on board whilst sharing the same mental model is key. Have a listen to the podcast and let us know your thoughts. The references are below but if you only read one thing take a look at the ERC Guidelines on traumatic cardiac arrest which we refer to. Enjoy! Simon, Rob & James References & Further Reading Resuscitation to Recovery Document Roadside to Resus; Cardiac Arrest ERC Guidelines; Traumatic Arrest Traumatic cardiac arrest: who are the survivors? Lockey D. Ann Emerg Med. 2006 Conversion to shockable rhythms during resuscitation and survival for out-of hospital cardiac arrest. Wah W. Am J Emerg Med. 2017 Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Beck B. Resuscitation 2017. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. Seamon MJ. J Trauma Acute Care Surg. 2015 EAST guidelines 2015; ED Thoracotomy FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Inaba K. Ann Surg. 2015

If you talk to people about the topic of thrombolysis in PE they'll tell you about the controversy of the submassive category, but there's a universal acceptance that thrombolysing massive PE's is well evidenced and straight forward. In this episode we delve back into the literature and not only explore massive PE thrombolysis, but also the gold standard to which it is judged upon, heparin. Have a listen to the podcast and as always we would love to hear your thoughts. Enjoy! Simon & Rob References & Further Reading 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism British Thoracic Society guidelines for the management of suspected acute pulmonary embolism; 2003 Antithrombotic Therapy for VTE Disease CHEST Guideline and Expert Panel Report; 2016 Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. A Scientific Statement From the American Heart Association. 2011 Venous thromboembolic diseases: diagnosis, management and thrombophilia testing; NICE. 2012 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1438862/pdf/jrsocmed00257-0051.pdfValue of anticoagulants in the treatment of pulmonary embolism: a discussion paper. Paul Egermayer. Journal of the Royal Society of Medicine 1981. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. BARRITT DW. Lancet. 1960 Treatment of pulmonary embolism in total hip replacement. Johnson R. Clin Orthop Relat Res. 1977 PAIMS 2: alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen activator Italian multicenter study 2. Dalla-Volta S. J Am Coll Cardiol. 1992 Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Goldhaber SZ. Lancet. 1993 Thrombolysis Compared With Heparin for the Initial Treatment of Pulmonary Embolism. A Meta-Analysis of the Randomized Controlled Trials. Susan Wan. 2004 Massive PE and cardiogenic shock. To thrombolyse or not to thrombolyse, that is the question. Francoise Ticehurst. BestBets. 2004

Welcome back to November's papers podcast! This month we've got some great topics to discuss. We look at another paper on the topic of oxygen therapy, this time a hug article from JAMA on oxygen therapy in the context of acute stroke and the impact on disability. Next up we look at a fascinating case report of a extradural haematoma that was drained via an I.O. needle prior to surgical evacuation. Lastly we follow up on our previous podcast on PE; the controversy, which looked at the prevalence of PE in those patients presenting with undifferentiated syncope. This paper puts a great counter to the conclusions arrived at in that Prandoni paper. Enjoy! Simon & Rob References & Further Reading Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke: The Stroke Oxygen Study Randomized Clinical Trial. Roffe C. JAMA. 2017 Temporising extradural haematoma by craniostomy using an intraosseous needle. Bulstrode H. Injury. 2017 Prevalence of pulmonary embolism in patients presenting with syncope. A systematic review and meta-analysis. Oqab Z. Am J Emerg Med. 2017

Last time in Roadside to Resus we discussed cardiac arrest with a view to obtaining a return in spontaneous circulation, ROSC. However gaining a ROSC is just one step along the long road to discharging a patient with a good neurological function back into the community. In fact ROSC is really where all of the hard work really starts! In this podcast we talk more about the evidence base and algorithms that exist to guide and support practice once a ROSC is achieved. We'd strongly encourage you to go and have a look at the references and resources yourself listed below and would love to hear your feedback in the comments section or via twitter. Enjoy! Simon, Rob & James References & Further Reading Resuscitation to Recovery Document Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. Niklas Nielsen. N Engl J Med 2013 Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Dumas F. Circ Cardiovasc Interv. 2010 Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia. Sandroni C. Resuscitation. 2013 Roadside to Resus; Cardiac Arrest PCI following ROSC; TRR

This podcast covers some highlights from the talks at the BASICS and The Faculty of Pre-Hospital Care 2017 Conference. We were lucky enough to be invited by Caroline Leech to cover the day and managed to grab a couple of minutes with a handful of the superb speakers; Dr. Tom Evens; Elite sports for high performance clinicians Dr. Les Gordon; Pre-hospital management of hypothermia Dr. Helen Milne; Retrieval and transfer medicine Surgeon Commander Kate Prior; The battlefield Dr Chris Press; Prehospital management of diving emergencies Miss Aimee Yarrington; Obstetric Emergencies Professor Mark Wilson; Pre-hospital Care, where are we going? Thanks to all involved for making the podcast and for a great day at the conference, and to PHEMCAST for the collaboration! Simon, Rob & Clare

Welcome back to October's papers podcast! This month we have a look at a paper that shines further light on the use of ultrasound in predicting fluid responsiveness in the spontaneously ventilating patient. We look at a paper that sets to challenge the concerns over hyperoxia in presumed myocardial infarction. And lastly we look at how stress impacts in a cardiac arrest situation on the team leader's performance. Make sure you have a look at the papers yourself and we would love to hear any feedback and alternative thoughts on the ones we cover! Lastly thanks for your support with the podcast Enjoy! Simon & Rob References & Further Reading Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathingcritically-ill patients. Corl KA. J Crit Care. 2017 Oxygen Therapy in Suspected Acute Myocardial Infarction. Hofmann R. N Engl J Med. 2017 Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence? Krage R. Emerg Med J. 2017 iSepsis – Vena Caval Ultrasonography – Just Don't Do It!; EMCrit The Bottom Line; DETO2X-AMI JC: Oxygen in ACS. A fuss about nothing? The DETO2X Trial at St.Emlyn's

We have a significant way to go with respect to our cardiac arrest management. 'Cardiopulmoary Resuscitation is attempted in nearly 30,000 people who suffered OHCA in England each year, but survival rates are low and compare unfavourably to a number of other countries' - Resuscitation to Recovery 2017 25% of patients get a ROSC with 7-8% of patients surviving to hospital discharge, which as mentioned is hugely below some countries. In this podcast we run through cardiac arrest management and the associated evidence base, right from chest compressions, through to drugs, prognostication and ceasing resuscitation attempts. Make sure you take a look at the papers and references yourself and we would love to hear you feedback! Enjoy! Simon, Rob & James References & Further Reading Resuscitation to Recovery Document "Kids Save Lives": Educating Schoolchildren in Cardiopulmonary Resuscitation Is a Civic DutyThat Needs Support for Implementation. Böttiger BW. J Am Heart Assoc. 2017 Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival.Andersen LW. JAMA. 2017 Double sequential Defibrillation therapy for out-of-hospital cardiac arrests: the London experience. Emmerson AC, et al. Resuscitation. 2017 Dual sequential defibrillation: Does one plus one equal two? Deakin CD. Resuscitation. 2016 Thrombolysis during resuscitation for out-of-hospital cardiac arrest. Böttiger BW. N Engl J Med. 2008 Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Perkins GD. Lancet. 2015 Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Rubertsson S. JAMA. 2014 Effect of epinephrine on survival after cardiac arrest: a systematic review and meta analysis. Patanwala AE. Minerva Anestesiol. 2014 Impact of cardiopulmonary resuscitation duration on survival from paramedic witnessed out-of-hospital cardiac arrests: An observational study. Nehme Z. 2016 Mar;100:25-31. doi: 10.1016/j.resuscitation.2015.12.011. Epub 2016 Jan 13. Predicting in-hospital mortality during cardiopulmonary resuscitation. Schultz SC. Resuscitation. 1996 Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017 End-tidal CO2 as a predictor of survival in out-of-hospital cardiac arrest. Eckstein M. Prehosp Disaster Med. 2011 LITFL; cessation of CPR

Bicarbonate use in cardiac arrest. The topic still provokes debate and multiple publications on the topic still hit the press reels. People talk of the increased rate of ROSC and the improvement in metabolic state, whilst others talk of the increase in mortality and worsening of intracellular acidosis. A recent paper in Resuscitation looked at a huge cohort of patients receiving bicarbonate in arrest prehospitally. In this episode we take a look at the paper, review the guidelines and give our take on the current situation with regards bicarb in arrest We hope you enjoy it and would love to hear your feedback! Simon & Rob References & Further Reading Prehospital Sodium Bicarbonate Use Could Worsen Long Term Survival with Favorable Neurological Recovery among Patients with Out-of-Hospital Cardiac Arrest. Kawano T, et al. Resuscitation. 2017 Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature. Velissaris D, et al. J Clin Med Res. 2016 Effect of Sodium Bicarbonate on Advanced Cardiac Life Support. Jungyoup Lee. Circulation 2014 Advanced Life Support; Bicarbonate guidance

So we're back with some superb topics this month; Early or late intubation in ICU patients, which is associated with worse outcomes? What are the predictors of a poor outcome in patients presenting with syncope? Does a cervical collar result in a demonstrable raise in ICP viewed by ultrasound? Make sure you take a look at the papers yourself, they certainly provide food for thought and raise important questions in our practice Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast Enjoy! Simon & Rob References & Further Reading Association between timing of intubation and outcome in critically ill patients: A secondary analysis of the ICON audit. Bauer PR. J Crit Care. 2017 Increase in intracranial pressure by application of a rigid cervical collar: a pilot study in healthy volunteers. Maissan IM. Eur J Emerg Med. 2017 Predicting Short-Term Risk of Arrhythmia among Patients with Syncope: The Canadian Syncope Arrhythmia Risk Score. Thiruganasambandamoorthy V. Acad Emerg Med. 2017

This is the second part of the Roadside to Resus discussion on asthma. Make sure you've listened to part 1 before delving into this one! Part 2 covers Ketamine Ultrasound in asthma NIV in asthma Asthma related cardiac arrest Imaging Management Discharge We hope you enjoy the episode and would love to hear your feedback! Simon, Rob & James References & Further Reading BTS Asthma Guidelines 2016 Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Goodacre S. Lancet Respir Med. 2013 Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017 Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV. Injury. 2016 TheResusRoom; Needle Thoracostomy podcast TheResusRoom; BTS Asthma Guidelines 2016 podcast LITFL; Non-invasive ventilation (NIV) and asthma Intensiveblog; Asthma mechanical Ventilation Pitfalls BestBets; In a severe Exacerbation of asthma can Ketamine be used to avoid the need for mechanical ventilation in adults?

Asthma is a common disease and presents to acute healthcare services extremely frequently. The majority of presentations are mild exacerbations of a known diagnosis and are relatively simple to assess and treat, many being completely appropriate for out patient treatment. On the other hand around 200 deaths per year are attributable in the UK to asthma, and therefore in the relatively young group of patients there is a real potential for critical illness with catastrophic consequence if not treated effectively. The majority of these deaths occur prior to the patient making it to hospital making the prehospital phase extremely important and hugely stressful in these cases. It is also worth noting that of the deaths reported that many were associated with inadequate inhaled corticosteroids or steroid tablets and inadequate follow up, meaning that our encounter with these patients at all stages of their care even if not that severe at the point of assessment is a key opportunity to discuss and educate about treatment plans and reasons to return. In part 1 of this podcast we will run through Pathophysiology How patients present Guidelines Treatment Salbutamol Ipratropium Steroids Magnesium Part 2 will be out shortly, we hope you enjoy the episode and would love to hear your feedback! Simon, Rob & James References & Further Reading BTS Asthma Guidelines 2016 Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Goodacre S. Lancet Respir Med. 2013 Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017 Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV. Injury. 2016 TheResusRoom; Needle Thoracostomy podcast TheResusRoom; BTS Asthma Guidelines 2016 podcast LITFL; Non-invasive ventilation (NIV) and asthma Intensiveblog; Asthma mechanical Ventilation Pitfalls BestBets; In a severe Exacerbation of asthma can Ketamine be used to avoid the need for mechanical ventilation in adults?

We're back with more great papers for you this month, hot off the press! There's been a lot of talk over the last few years about apnoeic oxygenation and whether it really holds any benefit to patients undergoing RSI, we have a look at a systematic review that may help answer that question. Next up we have a look at the choice of sedation agent used in the Emergency Department and how this correlates with patient satisfaction. Finally, following on from our recent podcast on Double Sequential Defibrillation, we have a look at a paper published looking at the results of DSD from the London prehospital service. Will this reveal a patient benefit? Let us know any thoughts and feedback you have on the podcast and thanks for your support with the podcast. Enjoy! Simon & Rob References & Further Reading Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. Pavlov I. Am J Emerg Med. 2017 Patient satisfaction with procedural sedation in the emergency department. Johnson OG. Emerg Med Australas. 2017 Double sequential defibrillation therapy for out-of-hospitalcardiac arrests: The London experience. Emmerson AC. Resuscitation. 2017

This is the first of a new series of Roadside to Resus podcasts. We've been joined by James Yates, a Critical Care Paramedic with the Great Western Air Ambulance to make it a truly multidisciplinary team. Each monthly episode we'll be discussing acute presentations, including the latest and most influential evidence base surrounding them. We really want to break down some barriers between pre-hospital and in hospital teams and it soon becomes evident in this first podcast that many of the problems we face are shared throughout the patient journey and across disciplines! We're starting off with Acute Heart Failure and in the podcast we run through; The underlying physiology and help explain the different problems we may find in each subset The keys to diagnosis, including the most predictive parts of history and examination We discuss the evidence base for treatment and the trends of use both pre and in-hospital We talk about CPAP and whether the evidence supports it's use Finally, the direction that further treatment in the UK may move Once again we hope you find the podcast useful. Get in touch with any comments, questions or suggestions for further topics. Most of all don't take our word for it, but make sure you delve into the references yourself and make up your own mind. Enjoy! Simon, Rob & James References & Further Reading Recommendations on pre-hospital & early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine Understanding cardiac output. Jean-Louis Vincent. Crit Care. 2008. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure The pathophysiology of hypertensive acute heart failure. Viau DM. Heart. 2015 Meta-analysis: Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema. Weng. Annals Int Med. 2010 Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S.JAMA 2005 Diagnosing Acute Heart Failure in the Emergency Department; A Systematic Review and Meta-analysis. Martindale. Academic Emergency Medicine. 2016 Noninvasive ventilation in acute cardiogenic pulmonary edema. Gray A. N Engl J Med. 2008 Life in the Fast Lane; severe heart failure management Emergency Medicine Cases; acute congestive heart failure REBEL.EM; morphine kills in acute decompensated heart failure EMCRIT 1; Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

C-spine immobilisation is a controversial topic because of a lack of high quality evidence from clinical trials. Historical approaches have been challenged, however NICE guidance continues to recommend 3-point immobilisation for all patients with suspected spinal injury despite considerable clinical equipoise. In this episode we discuss the complexities of balancing the risks and harms when trying to provide a patient centred approach, rather than a "one-size fits all" model. As always, there are a number of papers, guidelines and resources that you should have a look at (it's not exhaustive, but a good place to start!) Enjoy! Rob References & Further Reading NICE Guidance Major trauma Spinal injury Faculty of prehospital care consensus statements Spinal immobilisation Minimal patient handling Cochrane reviews Spinal Immobilisation for Trauma Papers of interest Cowley et al 2017 Dixon et al 2015 Benger & Blackham 2009 Hauswald 2015 Hauswald 2013 Michaleff et al 2012 Podcasts RCEM Learning EMCrit

We're back with 3 superb topics this month! First off we have a look at the utility of ultrasound for the detection of pneumothoraces in the context of blunt trauma. Next we look at the need to scan facial bones when scanning a patient's head following trauma. Last of all we look at a paper reviewing the association between the use of a bougie and the first pass success when performing ED RSI. Have a listen to the podcast and most importantly make sure you have a look at the references and critically appraise the papers yourself. We'd love to hear your thoughts and comments at the bottom of the page. Enjoy! Simon & Rob References & Further Reading Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017 Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury. Huang LK. Injury. 2017 The Bougie and First-Pass Success in the Emergency Department. Driver B. Ann Emerg Med. 2017

Guidelines. Algorithms. Evidence based medicine. These all play a significant part in the safe and effective management of the majority of our patients. As a result there is a danger that treatment pathways are followed blindly without critiquing their use and there is real risk we can loose sight of what's best for the patient in front of us. Guidelines encourage inflexible decision making, which creates further challenge when we are met by patients who do not fit standard treatment pathways. If this is the case then the management of cardiac arrest, which is taught and delivered in a didactic and protocol driven fashion, is surely the pinnacle of the problem. Standard Advanced Life Support (ALS) is totally appropriate for the majority of cardiac arrests, but what happens when it fails our patients? Refractory ventricular fibrillation (rVF) is, by its very nature, defined by the failure of ALS, but frustratingly there is very little evidence, or guidance, surrounding how to manage this patient group. I was faced with this situation when called to support an ambulance crew who were resuscitating an out-of-hospital VF arrest. When benchmarked against the ALS guidelines their management had been exemplary, but the patient remained in VF after eight shocks. So what now? The UK Resuscitation Council doesn't specifically discuss rVF, but offers the advice that it is "usually worthwhile continuing" if the patient remains in VF. Not a particularly controversial statement, but not much help either. They do discuss the potential for ECMO use, but this is currently a very rare option in UK practice, or thrombolysis for known or suspected pulmonary embolism. Other potential interventions not in the guidelines include IV magnesium and placing defibrillator pads in the anterior-posterior orientation. PCI can also be considered if there is a suitable receiving centre available and the patient can be delivered in a safe and timely fashion. A final option is the use of double sequential defibrillation (DSD), using two defibrillators, charged to their maximum energy setting, to deliver two shocks in an almost simultaneous fashion.DSD was first described in human subjects in 1994 when it was used to successfully defibrillate five patients who entered rVF during routine electrophysiologic testing. These patients were otherwise refractory to between seven and twenty single shocks. Looking at the available literature there has been little interest in DSD since then, until the last two to three years when it appears to have undergone a small revival. Sadly, there is no evidence for its use beyond case reports and small case series. The case reports appear to show good results with four in the last two years reporting survival to discharge with good neurological outcome. There are also a handful of other cases discussed in online blogs and articles with good outcomes. But these case reports and articles almost certainly represent an excellent example of publication bias. The most recent case series reviewed the use of DSD by an American ambulance service over a period of four years. During this time DSD was written into their refractory VF protocol, with rVF defined as failure of five single shocks. The study included twelve patients, three of whom survived to discharge with two of these demonstrating a cerebral performance score of 1. Despite appearing to demonstrate reasonable outcomes for DSD, sadly this study has a number of significant limitations. One important point the authors fail to discuss is that the two neurologically intact survivors received their DSD shocks after two and three single shocks respectively, not after five shocks which would have been per-protocol and consistent with the authors definition of refractory VF. This highlights a further problem with analysing the use of DSD. Not only is there a dearth of high-level evidence, but the literature that is available is highly inconsistent. There are a range of definitions for refractory VF, different orientations for the second set of pads, variable interventions prior to using DSD, a variety of timings between the shocks and so on. This means that comparison between studies and drawing meaningful conclusions is nearly impossible. Given these challenges, what are the explanations for why DSD might work? The first theory is that by using DSD the myocardium is defibrillated with a broader energy vector compared to a single set of pads resulting in a more complete depolarisation of the myocardium. A second theory is that the first shock reduces the ventricular defibrillation threshold meaning that the second shock is more effective. A third explanation may simply be the large amount of energy delivered to the myocardium. These theories should be tempered by the fact that studies have demonstrated increasing defibrillation energy to result in increased defibrillation success, but only up to a plateau. After this the success of defibrillation drops sharply. Increas

High quality manual cardiopulmonary resuscitation (CPR) with minimal delays has been shown to improve outcomes following out-of-hospital cardiac arrest (OHCA). There are concerns that the quality of CPR can diminish over time and as little as 1 minute of CPR can lead to fatigue and deviation from the current recommended rate and depth of compressions. With this in mind, a mechanical device to provide chest compressions at a constant rate, depth and without tiring has considerable theoretical benefits to patients, yet clinical equipoise remains about the role for this treatment modality. In this podcast, we discuss and critically appraise 2 randomised controlled trials (RCTs) set out to answer exactly that question and give our take on the role for mechanical CPR devices in the future Hope you enjoy and feel free to leave any feedback below! Rob References Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Perkins GD. Lancet. 2015 Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Rubertsson S. JAMA. 2014

We're back with another look at the papers most relevant to our practice in and around The Resus Room. The WOMAN trial was a huge trial that looked at tranexamic acid in post partum haemorrhage, it's gained a lot of attention online and we kick things off having a look at the paper ourselves. Next up, and following on nicely from our previous Cardiac Arrest Centres podcast, we have a look at a systematic review and meta-analysis on whether prolonged transfer times in patients following cardiac arrest affects outcomes. Finally we have a look at a paper on management of PEs in cardiac arrest which draws some very interesting conclusions on the management of such cases and the associated outcomes! Please make sure you go and have a look at the papers yourself and as ever huge thanks to our sponsors ADPRAC for making this all possible. Enjoy! Simon & Rob References & Further Reading Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. WOMAN Trial Collaborators.Lancet 2017 Does transport time of out-of-hospital cardiac arrest patients matter? A systematic review and meta-analysis. Geri G. Resuscitation 2017 Pulmonary embolism related sudden cardiac arrest admitted alive at hospital: Management and outcomes. Bougouin W. Resuscitation. 2017 The Woman Trial; The Bottom Line

Oxygen is probably the drug that we give the most but possibly has the least governance over. More has got to be good except in those at high risk of type II respiratory failure right?? Well as we know the evidence base has swung to challenge that idea in recent years and the new BTS guidelines for Oxygen use in Healthcare and Emergency Settings has just been published with a few things that are worth reviewing since the original publication in 2008. No apologies that this may be predominantly old ground here, this is an area we're all involved with day in and day out that is simple to correct and affects mortality Historically oxygen has been given without prescription; 42% of patients in the 2015 BTS audit had no accompanying prescription When it is prescribed this doesn't always correlate with delivery 1/3 of patients were outside of target SpO2 range (10% below & 22% above) If nothing else is taken from this document then reinforcement of the fact that we need to keep oxygen saturations normal/near normal for all patients, except groups at risk of type II respiratory failure Prescribe and delivery oxygen by target oxygen saturations What is normal? Normal Oxygen saturations for healthy young adults is approximately 96-98%, there is minor decrease with increasing age. Healthy subjects desaturate to 90% SpO2 during night time; be cautious interpreting a single oximetry reading from a sleeping patient, short duration overnight dips are normal Will mental status give me an early indication of hypoxaemia? No, impaired mental function at a mean value of SaO2 64%, no evidence above SaO2 84% Loss of consciousness at a mean SaO2 56% Aims of oxygen therapy Correct potentially harmful hypoxia Alleviate breathlessness only in those hypoxic Why the fuss about hyperoxia? Hyperoxia has been shown to be associated with Risk to COPD patients and those at risk of type II respiratory failure Increased CK level in STEMI and increased infarct size on MR scan at 3 months Association of hyperoxaemia with increased mortality in several ITU studies Worsens systolic myocardial performance Absorption Atelectasis even at FIO2 30-50% Intrapulmonary shunting Post-operative hypoxaemia Coronary vasoconstriction Increased Systemic Vascular Resistance Reduced Cardiac Index Possible reperfusion injury post MI In patients with COPD studies have showed most hypercapnia patients arriving at hospital with the equivalent of SpO2 > 92% were acidotic, high concentration O2has been associated with more than double the mortality rate in those with acute exacerbations of COPD. Titrate O2 delivery down smoothly Which patients are at risk of CO2 retention and acidosis if given high dose oxygen? Chronic hypoxic lung disease COPD/CF/Bronchiectasis Chest wall disease Kyphoscoliosis Thoracoplasty Neuromuscular disease Morbid obesity with hypo ventilatory syndrome What is the oxygen target? Oxygen titrated to an SpO2 of 94-98% Except in those at risk of hypercapnia respiratory failure, then 88-92%(or specific SpO2 on patient's alert card) What about in Palliative Care? Most breathlessness in cancer patients is caused by airflow obstruction, infections or pleural effusions and in these cases the issues need to be addressed. Oxygen does relieve breathlessness in hyperaemic cancer patients but not if SpO2 >90%. Midazolam and morphine also relieve breathlessness and are more likely to be effective. Delivery Devices Reservior masks can deliver O2 concentrations between 60-80% Nasal cannualae at 1-6L/min can deliver 24-50% Venturi masks allow accurate delivery of O2 If tachypnoeic over 30 breaths per minute an increase over the marked flow rate should be delivered, note this won't increase the FiO2! Equivalent doses of O2 24% venturi = 1L O2 28 % venturi = 2L O2 35% venturi = 4L O2 40% venturi = nasal/facemask 5-6LO2 60% venturi = 7-10L simple face mask Approach to oxygen delivery Firstly determine if at risk of type II respiratory failure If not; SpO2 Perform an ABG If high PCO2 consider invasive ventilation, in the interim aim SpO2 94-98% If PCO2 normal or low aim SpO2 94-98% and repeat ABG in 30-60 minutes If at risk of type II respiratory failure Obtain ABG if hypoxic or already on oxygen If a respiratory acidosis consider NIV, address medical condition and senior review. Treat with the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92% If hypercapnia but not acidotic, titrate the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92%. Repeat ABG after change of treatment/deterioration. Consider reducing FiO2 if PO2 on ABG >8kPa If PCO2 Points specific to prehospital oxygen use A sudden reduction in 3% of SpO2 within the target range should prompt a fuller assessment of the patient Pulse oximetry must be available in all locations in which oxygen is being used Some patients over the age of 70 when clinically stable may have SpO2 between 92-94%, these patients don't require O2 therapy unless the SpO2 falls below the level that is k

How many patients are admitted from your ED with suspected cardiac chest pain? What strategy of testing do you employ to rule out acute myocardial infarction? When and why do you send troponins in this process? In this podcast Ed Carlton, Emergency Medicine Consultant at North Bristol Hospital and Troponin Researcher, talks to us about troponin rule out strategies, recent publications on the topics, where the future of troponin research is heading and most importantly what this all means for our practice. Our previous podcast on troponins acts as a good introduction to this episode. Have a listen to both and we'd love to hear your comments at the bottom of the page and we hope you found this as useful as we did! Enjoy Simon References Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin TMeasurement Below the Limit of Detection: A Collaborative Meta-analysis. Pickering JW. Ann Intern Med. 2017 Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial. Poldervaart JM. Ann Intern Med. 2017 Comparison of the Efficacy and Safety of Early Rule-Out Pathways for Acute Myocardial Infarction. Chapman AR. Circulation. 2017

This month we've got a good variety of topics. We look at an recent systematic review and meta analysis on the prognostic value of echo in life support, an update from Blyth's paper in 2012. We review a paper looking at testing gin patients presenting to the emergency department in SVT. Finally we cover a paper looking at different methods employed when running an Emergency Department. As always make sure you go and have a read of the papers yourselves and come up with your own conclusions, we'd love to hear your feedback. Enjoy! Simon & Rob References & Further Reading Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017 Usefulness of laboratory and radiological investigations in the management of supraventricular tachycardia. Ashok A. Emerg Med Australas.2017 What do emergency physicians in charge do? A qualitative observational study. Hosking I. Emerg Med J. 2017

This podcast is taken from a talk I gave at Grand Rounds at The Bristol Royal Infirmary on the Top 10 Papers in EM over the last 12 months. Many of these have been covered in previous podcasts, but running through them gives a good opportunity for further recap and reflection. Papers Covered; Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV1. Injury. 2015 Dec 13. pii: S0020-1383(15)00768-8. doi: 10.1016/j.injury.2015.11.045. [Epub ahead of print] (more in February'sPapers of the month) Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Baharoglu MI. Lancet.2016 May 9. pii: S0140-6736(16)30392-0. doi: 10.1016/S0140-6736(16)30392-0. [Epub ahead of print] (more in July's Papers of the month) Causes of Elevated Cardiac Troponins in the Emergency Department and Their Associated Mortality. Meigher S. Acad Emerg Med. 2016 (more in our Troponins podcast) Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. Ferguson I, et al. Ann Emerg Med. 2016. (more in September's Paper's of the month) Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P. N Engl J Med. 2016 (more in our podcast PE The Controversy) Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Andersen LW. JAMA. 2017 (more in March's Papers of the month) 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 (more in our Stroke Thrombolysis podcast) Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Nijssen EC. Lancet. 2017 (more in April's Papers podcast) Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Sierink JC. Lancet. 2016 Jun 28 (more in August's Papers podcast) Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017 (more coming up in May's Papers podcast!) Enjoy and we'll be back with our papers of the month next week! Simon

Acute cholecystitis is a diagnosis that we make frequently in the Emergency Department. But like all diagnostic work ups there is a lot to know about which parts of the history, examination and bedside tests we can do in the ED that really help either rule in or rule out the disease. In this podcast we run through some of the key bits of information published in the Commissioning Guide Gallstone disease 2016, jointly published by the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland & the Royal College of Surgeons. We then concentrate on a recent systematic review of the diagnostic work up for Acute Cholecystitis. Yet again the evidence base brings up some issues to challenge our traditional teaching on the topic but should help polish our management of patients with a differential of Acute Cholecystitis. Enjoy! References & Further Reading Commissioning Guide Gallstone disease 2016 Up to date; Acute Cholecystitis NICE guidance; Acute Cholecystitis History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis. Jain A. Acad Emerg Med

This month we look at a paper concentrating on the risk of contrast induced nephropathy in contrasted CT scans, looking specifically at the need to hydrate at-risk patients prior to and following CT scans. The use of prehospital blood is also under the spotlight with the ongoing RePHILL trial. We look at a paper reviewing prehospital blood use with the Kent Surrey Sussex prehospital service and the described physiological changes seen in patients receiving blood. Make sure you also go over and check out the podcast episode from PHEMCAST on the RePHILL trial with Jim Hancox. Finally I was lucky enough to catch up with Johannes von Vopelius-Feldt, the lead author of a paper in press on the impact of prehospital critical care teams on out of hospital cardiac arrests. You can find the fantastic opportunity of a scholarship to be an Emergency Nurse Practitioner here from ADPRAC. Enjoy Simon & Rob References & Further Reading Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Nijssen EC. Lancet. 2017 FOAMcast; Contrast-Induced Nephropathy and Genitourinary Trauma RELEL.EM; The AMACING Trial: Prehydration to Prevent Contrast Induced Nephropathy (CIN)? Royal College Radiology; Prevention of Contrast Induced Acute Kidney Injury (CI-AKI) In Adult Patients Pre-hospital transfusion of packed red blood cells in 147 patients from a UK helicopter emergency medical service. Lyon RM. Scand J Trauma Resusc Emerg Med. 2017 PHEMCAST; blood Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest. von Vopelius-Feldt J. Resuscitation. 2017 Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Nijssen EC. Lancet. 2017

So today Rob and I were lucky enough to be asked to attend the Trauma Care Conference 2017, to listen to some of the great talks and catch up with some of the speakers for their take on the highlights of the talks. We managed to catch the following speakers, here are the topics they covered and relevant links to the resources discussed. Speakers Gareth Davies, Consultant Emergency Medicine, Royal London Hospital; Understanding where, when and how people die? Dave Gay, Consultant Radiologist, Derriford Hospital; The Role of Ultrasound in Trauma Fiona Lecky, Professor Emergency Medicine, Salford; Traumatic Brain Injury: recent progress & future challenges Simon Carley, Professor Emergency Medicine, Central Manchester; The Top 10 trauma papers of 2016 St Emlyn's Top 10 +1 Trauma Papers 2016 Tim Rainer, Professor Emergency Medicine, Cardiff; Permissive hypotension in blunt trauma David Raven, Emergency Medicine Consultant, Heart of England Foundation Trust; HECTOR & Elderly Trauma The HECTOR Course (& free online manual!!) Ross Fisher, Consultant Paediatric Surgeon Sheffield Children's Hospital; TARN report for paediatrics p3 presentations TARNlet Database Have a listen to the podcast and again huge thanks to the speakers for taking their time to share their superb talks with a wider audience. Simon

Centralisation of care for specialist services such as stroke, trauma and myocardial infarctions is becoming more and more common place. But where will it stop and what does it mean for the specialty of Emergency Medicine? In this episode we have a look at a recent pilot RCT published in the journal of Resuscitation looking at the feasibility of setting up an bigger RCT to evaluate moving prehospital patients to a cardiac arrest centre. The paper itself is a great piece of work but the bigger discussion around the topic is also a really important point to consider. Have a listen to the podcast, see what you think and please post you comments on the site for us all to see. Enjoy! Simon References A Randomised tRial of Expedited transfer to a cardiac arrest centre for non-ST elevation ventricular fibrillation out-of-hospital cardiac arrest: The ARREST pilot randomised trial. Patterson T. Resuscitation. 2017

Welcome back to Papers of the Month. March has given us some great papers. We kick off with a couple of papers looking at rib fractures, associated morbidity and mortality and also looks at management of flail segments. We then turn our attention to airway management and look at a paper reviewing the outcomes associated with patients who are intubated during resuscitation from cardiac arrest. As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below. Enjoy Simon & Rob References & Further Reading Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. Andersen LW. JAMA. 2017 Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol. Cordelie E. Trauma Surg & Acute Care Open. 2017 Are first rib fractures a marker for other life-threatening injuries in patients with major trauma? A cohort study of patients on the UK Trauma Audit and Research Network database. Sammy IA. Emerg Med J. 2017 AIRWAYS-2

Think of rhabdomyolysis and you'll think of an elevated creatine kinase (CK). The condition ranges from an asymptomatic period to a life-threatening condition with a hugely associated rise in CK which can also be accompanied by electrolyte disturbance, renal failure and disseminated intravascular coagulation. Rhabdomyolysis is caused by a breakdown in skeletal muscle and occurs most commonly following trauma, very often that can be due to a 'long-lie' when a patient is unable to get off a floor until help arrives after a prolonged period. There are other causes including drugs, muscle enzyme deficiencies, electrolyte abnormalities and more. The presentation itself is pretty vague and suspicion of the disease needs to be pretty high. Patients can experience weakness, myalgia and the dark'coca-cola urine', the diagnosis is then confirmed with a serum elevation in CK. The big concern with Rhabdomyolysis is the hit the kidneys take. Acute kidney injury is due to the heme pigment that is released from myoglobin and haemoglobin and is nephrotoxic. Early aggressive fluid rehydration aims to minimise ischaemic injury, increase urinary flow rates and thus limit intratubular cast formation. Fluids also help eliminate excess K+ that may be associated. But have a think about the management in your ED, how high does that CK need to be to require i.v. fluids and admission to hospital? Here's a few facts we need to know: Normal CK enzyme levels are 45–260 U/l. CK rises in rhabdomyolysis within 12hours of the onset of muscle injury CK levels peak at 1–3 days, and declines 3–5 days after muscle injury The peak CK level may be predictive of the development of renal failure A CK level of 5000 U/l or greater is related to renal failure Optimal fluid rate administration is unclear, some papers suggest replacement of isotonic saline at rates of 1-2L per hour. , adjusted to 200-300mL per hour to maintain a diuresis. Attention needs to be paid to urine output serum markers and fluid status. A lot of the evidence and knowledge surrounding rhabdomyolysis is from humanitarian disasters; earthquakes, terrorism along with observational cohorts, but at the end of the day we need to work with what we've got. Have a listen to the podcast and see what you think, the application of the evidence base may change your practice. Enjoy! References Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Huerta-Alardín AL. Crit Care. 2005 Creatine kinase MB isoenzyme in dermatomyositis: a noncardiac source. Larca LJ. Ann Intern Med. 1981 Epidemiologic aspects of the Bam earthquake in Iran: the nephrologic perspective. Hatamizadeh P. Am J Kidney Dis. 2006 Prognostic value, kinetics and effect of CVVHDF on serum of the myoglobin and creatine kinase in critically ill patients with rhabdomyolysis. Mikkelsen TS. Acta Anaesthesiol Scand. 2005 Rhabdomyolysis: an evaluation of 475 hospitalized patients. Melli G. Medicine (Baltimore). 2005 Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey. de Meijer AR. Intensive Care Med. 2003 Prevention and treatment of heme pigment-induced acute kidney injury (acute renal failure). Paul M Palevsky. UpToDate. 2015

Epistaxis is an extremely common presentation to both Prehospital Emergency Services and Emergency Departments. The vast majority are benign and self limiting but every once in a while a catastrophic bleed will come our way. Whilst not necessarily the most attention grabbing of topics a sound understanding of the management is key to excellent care. In this podcast Rob talk us through the management of epistaxis, all the way from causes and presentation, right the way through to resuscitative management and latest evidenced based treatment. Enjoy! References & Further Reading LITFL epistaxis review Geeky medics epistaxis BMJ overview paper & management flowchart Routine coagulation screening in the management of emergency admission for epistaxis; is it necessary? Thaha MA. J Laryngol Otol 2000 Front-line epistaxis management: let's not forget the basic. E C Ho. J Laryngol Otol 2008 Serious spontaneous epistaxis and hypertension in hospitalized patients.Page C. Eur Arch Otorhinolaryngol. 2011 Tranexamic acid in epistaxis: a systematic review. Kamhieh Y, et al. Clin Otolaryngol. 2016

Welcome back to Papers of the Month. February holds a diverse number of topics on some really interesting areas of practice. We kick off with a snap shot systematic review from the Annals of Emergency Medicine on the effect of Amiodarone or Lignocaine on the outcome from refractory VF or VT arrests, are drugs losing more favour yet again in cardiac arrest. Next up is a pilot study following the surgical theme of minimal intervention for appendicitis, can antibiotics safely be used in a particular cohort of patients to prevent the need for surgery? And moreover could this be even safer than the traditional surgical cure? Last up we cover a paper looking at the survival from traumatic cardiac arrest and consider the bias that may occur by reporting those resuscitation attempts that are of limited duration in with the whole cohort; are we painting a overly negative picture of the prognosis of traumatic cardiac arrest? As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below. Enjoy Simon & Rob References & Further Reading In Patients With Cardiac Arrest, Does Amiodarone or Lidocaine Increase Meaningful Survival? Hunter BR. Ann Emerg Med Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial AllowingOutpatient Antibiotic Management. Talan DA. Ann Emerg Med. 2016 Dec Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Beck B. Resuscitation 2017 Feb

Those of us who are a bit longer in the tooth have spent most of our careers not scanning everyone who sustained a head injury on warfarin, but in 2104 NICE published guidance suggesting we do just that. At times, with the huge burden we place on our radiology services, it is difficult not think we're over doing things with all of these scan requests, especially when the patient has no adverse symptoms or signs. Fortunately the AHEAD study has just been published which looks at thousands of patients presenting to ED's on warfarin with a head injury. The paper is open access and deserves a full read, in this podcast I run through some of the main parts of the study and have a think about how it might impact on our practice. This is just one part of the puzzle on the management of patients with anticoagulated head injuries, we had a look previously on what to do if you perform a scan and that appears normal in our Anticoagulation, Head Injury & Delayed Bleeds Podcast. Hope you enjoy the podcast and we'd love to hear any of your feedback on social media or on the website. Simon

A lot of our podcasts have focussed on prognostic factors in arrest to help with the decision making of continuing or stopping resuscitation in cardiac arrest. There would appear to be a huge variety in practice as to when resuscitation is ceased, and in that way having explicit guidance to unify practice can at times seem appealing. In this episode we have a look at a recent paper covering the topic, it suggests a group of patients accounting for nearly half of cardiac arrests, that upon recognition could safely lead us to cease efforts. Have a listen to the podcast and let us know what you think! References Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Jabre P. Ann Intern Med. 2016 Resuscitation Council; Recognition of Life Extinct

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