The Resus Room

This month the literature seems to be focussed on cardiac arrest In this podcast we'll cover a paper looking at the significance of chest compression rate, ultrasound for prognostication (and to a lesser extent identification of tamponade) and finally a systematic review and meta-analysis of PCI following ROSC. The PCI paper follows on nicely from our previous podcast on the topic, so make sure you have a listen to that one first. 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 Association between chest compression rates and clinical outcomes following in-hospital cardiac arrest at an academic tertiary hospital. Kilgannon JH. Resuscitation. 2016 Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Gaspari R. Resuscitation. 2016 Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: A systematic review and meta-analysis. Millin MG. Resuscitation. 2016 Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Gaspari R. Resuscitation 2016 EM Nerd-The Case of the Tell-Tale Heart JC: Is this the REASON to use USS in cardiac arrest? St.Emlyn's

Stroke thrombolysis has definitely put the spotlight back on to the topic of stroke over the last few years. Stroke thrombolysis has led to restructuring of stroke care in the UK and has helped drive investment in stroke care. The evidence base that underpins thrombolysis has been controversial to say the least and can be difficult to comprehend. 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 The article, published in the the Emergency Medicine Australasia Journal is a great place to start to get to grips with the topic. In the podcast we run through the paper and hopefully this will shed act as a good recap on the topic and lead you to delve into the primary literature and form your own opinion. Enjoy! References 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 Royal College of Physicians; National clinical guideline for stroke, Prepared by the Intercollegiate Stroke Working Party, Fifth Edition 2016 (accredited by NICE)

Risk assessment, testing and risk management form the very heart of Emergency Medicine and Critical Care. Being aware of the evidence surrounding a topic is key to delivering high level care but without an understanding of the underpinning concepts it's application is extremely limited. Understanding how a test result changes a patient's likelihood of a disease can be described with likelihood ratios, the Royal College of Emergency Medicine has a podcast explaining likelihood ratios in more detail. But when a test result comes back on the boundary between positive and negative, or at the extremes of positive we can find it difficult to know what this means and that's where interval likelihood ratios comes into play. Examples include a minimally elevated WCC in a suspected appendicitis, or a dramatically raised d-dimer as compared to a borderline positive result in a suspected pulmonary embolus, this podcast talks through some of those concepts and their application, enjoy! References Evidence-based emergency medicine/skills for evidence-based emergency care. Interval likelihood ratios: another advantage for the evidence-based diagnostician. Brown MD. Ann Emerg Med. 2003 Pulmonary embolism: making sense of the diagnostic evaluation. Wolfe TR. Ann Emerg Med. 2001 Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. Schouten HJ. BMJ. 2013

This month we cover a paper looking at the role of early craniectomy for raised intracranial pressure, the outcomes associated with advanced airway managements in prehospital cardiac arrest and lastly at the utility on ETCO2 and consider if it's application decreases adverse respiratory events. This month our great sponsors ADPRAC our giving away a £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 and Links Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. Hutchinson PJ, N Engl J Med. 2016 Sep Capnography for procedural sedation in the ED: a systematic review. Dewdney C, Emerg Med J. 2016 The role of prehospital advanced airway management on outcomes for out-of-hospital cardiac arrest patients: a meta-analysis. Jeong S. Am J Emerg Med. 2016 Jul TheBottomLine - RESCUEicp ICS State of the Art Conference 2016: Find out more here

This week the British Thoracic Society have released an updated version of their guidelines on asthma. The document covers all aspects from diagnosis, treatment and follow up, in this podcast we briefly run through some of the aspects covered in the acute management section. Make sure you have a look at the full document that can be found here https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/ Speak to you soon!

In 2014 NICE updated their guidelines on Head Injury: assessment and early management. This included specific guidance for those patients on warfarin Guidance regarding the ongoing observation of these patients is not contained within the guideline but as with much of Emergency Medicine variation between departments and regions vary in the threshold to admit patients with a normal CT head due to concerns of these patients developing a delayed bleed. A recent systematic review and meta analysis on the topic has just been published and we thought it would be worth a look. Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016 The paper gives an interesting take on the risk we are dealing with following a normal scan in presentation to the ED and whilst the papers contained may not be the strongest level of evidence the meta-analysis is probably the best we have to go on at present. Enjoy and we'd love to hear any of your thoughts!

Here's a look at some of the papers that caught our eye this month. We cover a paper looking at the the potential benefits of ketofol over propofol for conscious sedation, the role of aggressive blood pressure reduction in haemorrhage stroke and finally a really interesting paper of PE thrombolysis in cardiac arrest. This month our great sponsors ADPRAC our giving away a £50 iTunes voucher to spend on education/entertainment for you to spend on supporting your work life balance! All you need to do is email through the answer to the following question; With regards to this September 2016 Papers podcast and The PEA-PETT study, which of the following is correct; A. The RCT shows a statistically significant benefit in PE thrombolysis intra arrest B. The paper focussed on peri-arrest thrombolysis C. The paper was a case series of PE's thrombolysed during arrest Send your answer via email to [email protected] with your name, answer and iTunes email address, entries close on 15th September and we'll announce the winner in October's podcast. Enjoy! References 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. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. Qureshi AI, et al. N Engl J Med. 2016 Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the "PEAPETT" study). Sharifi M. Am J Emerg Med. 2016 Jun 30.

Where does the role of a chest X-ray lie in major trauma? With the ever increasing use of CT and ultrasound in the resus room what role does the old school CXR hold? How many injuries will it pick up? How many will it miss? And when is the extra delay justified? This podcast looks at a recent paper on the topic and some related national guidelines. Enjoy! References Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study. Langdorf MI. Ann Emerg Med. 2015 Dec NICE 2016: Major trauma; assessment and initial management The Royal College of Radiologists 2011; Standards of practice and guidance for trauma radiology in severely injured patients

Burns are a common presentation to the ED and can result in a significant degree or morbidity and mortality. In this podcast we talk through the approach and treatment of burns along with some controversies in the literature regarding assessment of burn depth and fluid management. Enjoy! References The Parkland formula under fire: is the criticism justified? Blumetti J, et al. J Burn Care Res. 2008 Jan-Feb. Mersey Burns for calculating fluid resuscitation volume when managing burns: NICE advice [MIB58] Published date: March 2016 SCANRCIT: Pain can't be used to differentiate between partial and full thickness burns

Here's a look at some of the papers that caught our eye this month. In this podcast we cover a paper looking at the significance of findings with the history, physical exam and imaging in subarachnoid haemorrhage to inform your work up. We look at another paper focussing on total body versus selective CT scanning in trauma and lastly a paper looking at the validation of the DECAF score to predict mortality in COPD exacerbations. We've also got the e book 'ABC of Emergency Radiology' to give away on iTunes thanks to our new sponsors ADPRAC. All you need to do is answer the following question; With regards to this August 2016 Papers podcast and REACT-2, which of the following is correct; A. The use of selective CT scanning in major trauma leads to a dramatic decrease in radiation B. The use of selective CT scanning in major trauma leads to a decrease in time to diagnosis C. The use of selective CT scanning in major trauma leads to a decrease in cost per in patient episode D. The safety of selective CT scanning vs whole body CT scanning was equivocal Send your answer via email to [email protected] with your name, answer and iTunes email address, entries close on the 15th August and we'll announce the winner in September's podcast. Enjoy!

If you've had an MI with a STEMI or a new LBBB the decision to go to the cath lab is pretty straight forward. If you've collapsed with a cardiac arrest of presumed cardiac aetiology (the majority of them) and gained a ROSC (return in spontaneous circulation) then the decision to go the the lab immediately is pretty variable and can depend of the clinicians involved, the ECG or the system within which you work. The Resus Council and the European Society of Cardiology have some guidance on the topic and that is a must read. Today we have a look at a commonly quoted paper in the literature, The PROCAT database, to see if we can shed some light on the topic. We'd love to hear feedback and comments on the podcast in the comments section. Enjoy! References 2014 ESC/EACTS Guidelines on myocardial revascularization; page 2585 Resus Council; Post Resus Care section 6 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 Jun 1;3(3):200-7. doi: 10.1161/CIRCINTERVENTIONS.109.913665. Epub 2010 May 18.

I haven't always read papers and with the time pressures of training and life it's impossible for us to be on top of all of the literature. But over the last few years I've come across some papers that I wish others had told me about. For some of you this will all be a recap but for others hopefully it will spark an interest and get you to have a look at the papers yourself. We all know that it is extremely rare that one paper alone will or should change our practice but hopefully it's the interest and further questions into a topic that can come out of these papers. Enjoy! 5 References Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Scheuermeyer FX. Ann Emerg Med. 2015 May Thrombolysis during resuscitation for out-of-hospital cardiac arrest. Böttiger BW. N Engl J Med. 2008 Dec 18 Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Appelboam A. Lancet. 2015 Oct Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Martindale JL. Acad Emerg Med. 2016 Mar Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Blyth L. Acad Emerg Med. 2012 Oct

So the long awaited new NICE Guidelines on Sepsis have just been released. I'm no sepsis expert, I'm not on a panel involved with the guidelines but I am someone who is going to be trying to use these guidelines everyday at work with multiple patients and I'm not the only one....we all are! In this podcast we run through some of the main points brought up in the new guidelines. Talk about some potential difficulties and join toward some useful resources such as the brilliant flow charts developed by the Sepsis Trust. Let us know your thought and feedback either via the site www.TheResusRoom.co.uk or on twitter @TheResusRoom. Enjoy!

We have a look at papers covering platelet transfusions for patients on antiplatelets who suffer intracerebral bleeds, the optimal dose for procedural sedation with ketamine in children, a new meta-analysis on the sensitivity of early CT in suspected sub arachnoid haemorrhage and finish up with an amazing case report regarding a hypothermic cardiac arrest Make sure you go and have a look at the papers yourself to see what the evidence means to you. Optimal dosing of intravenous ketamine for procedural sedation in children in the ED-a randomized controlled trial. Kannikeswaran N. Am J Emerg Med. 2016 Apr 2. pii: S0735-6757(16)30011-0. doi: 10.1016/j.ajem.2016.03.064. [Epub ahead of print] 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] Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Dubosh NM. Stroke. 2016 Mar;47(3):750-5. doi: 10.1161/STROKEAHA.115.011386. Epub 2016 Jan 21. HEMS advanced trauma team retrieval of a patient with accidental hypothermic cardiac arrest for ECMO therapy. McCormack J. Resuscitation. 2016 May 30

Sedation is becoming an ever more significant part of our work in the Emergency Department. At the end of May 2016 the Royal College of Emergency Medicine Published the RCEM Sedation Audit of 2015-2016 that covered more than 8,000 ED sedations throughout the UK (involving more than 190 ED's). There are some pearls to take out of this great piece of work in which there would seem to be some significant scope to improve. The document not only benchmarks our practice but helps give us a feel for the risks involved. Have a listen and check out the resources mentioned via the hyperlinks below, most importantly make sure you have a look at the document itself. Relevant Resources RCEM Sedation Audit ACPeducate iTunes feed TEAM course

Carbon Monoxide poisoning is definitely one of those differentials that you consider when the patients books into ED with '?carbon monoxide poisoning'...... but how much do we really think about it in a patient that hasn't been sent down to the ED with this specific thought in mind? Rob Fenwick talks us through the key points of Carbon Monoxide poisoning and some recent evidence on the topic which will probably make us consider the possibility a bit more frequently! This podcast was based around the post Rob wrote for Jonathan Downham's superb Critical Care Practitioner podcast. Go and have a look at the post for a lot more information on the topic.

For June we have a look at papers covering CT head imaging in delayed trauma presentations, risk stratifying TIAs, early administration of fluids in severe sepsis and most importantly the utility of a biro in a surgical airway....... Make sure you go and have a look at the papers yourself to see what the evidence means to you. References Validation of ABCD2 scores ascertained by referring clinicians: a retrospective transient ischaemic attack clinic cohort study. Dutta D. Emerg Med J. 2016 Apr 7. pii: emermed-2015-205519. doi: 10.1136/emermed-2015-205519. [Epub ahead of print] Bystander cricothyrotomy with ballpoint pen: a fresh cadaveric feasibility study. Kisser U. Emerg Med J. 2016 Apr 19. pii: emermed-2015-205659. doi: 10.1136/emermed-2015-205659. [Epub ahead of print] Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Leisman D. Ann Emerg Med. 2016 Apr 14. pii: S0196-0644(16)00148-7. doi: 10.1016/j.annemergmed.2016.02.044. [Epub ahead of print] CT head imaging in patients with head injury who present after 24 h of injury: a retrospective cohort study. Marincowitz C. Emerg Med J. 2016 Apr 13. pii: emermed-2015-205370. doi: 10.1136/emermed-2015-205370. [Epub ahead of print]

Here's a look at some of the papers that caught our eye this month. We have a look at patient positioning for RSI, the implication of hypothermia on arrival in the ED and the reliability of clinical assessment of syncope in our elderly patients. Make sure you go and have a look at the papers yourself to see what the evidence means to you. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Khandelwal N. Anesth Analg. 2016 Apr;122(4):1101-7. doi: 10.1213/ANE.0000000000001184. Reliability of clinical assessments in older adults with syncope or near syncope. Nishijima DK. Acad Emerg Med. 2016 Mar 29. doi: 10.1111/acem.12977. [Epub ahead of print] Effects of prehospital hypothermia on transfusion requirements and outcomes: a retrospective observatory trial. Klauke N. BMJ Open. 2016 Mar 30;6(3):e009913. doi: 10.1136/bmjopen-2015-009913.

So this is a talk I gave at the EMCEF 22 conference. This covers a few of the papers we've discussed in the last 6 months on the podcast but a bit of spaced repetition is never a bad thing! We'll be running through topics on heart failure, sedation, intubation, anaphylaxis and duration of cardiac arrest. The papers are well worth a look and whilst not all high quality evidence they do bring to the front some really interesting questions about are practice and prompt us to challenge our habits. Enjoy! References Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Martindale JL. Acad Emerg Med. 2016 Mar;23(3):223-42. doi: 10.1111/acem.12878. Epub 2016 Feb 13.Martinda Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Bellolio MF. Acad Emerg Med. 2016 Feb;23(2):119-34. doi: 10.1111/acem.12875. Epub 2016 Jan 22. Utility of gum-elastic bougie for tracheal intubation during chest compressions in a manikin: a randomized crossover trial. Komasawa N. Am J Emerg Med. 2016 Jan;34(1):54-6. doi: 10.1016/j.ajem.2015.09.016. Epub 2015 Sep 21. Defining the learning curve for endotracheal intubation using direct laryngoscopy: A systematic review. Buis ML. Resuscitation. 2016 Feb;99:63-71. doi: 10.1016/j.resuscitation.2015.11.005. Epub 2015 Dec 19. Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis. Grunau BE. Ann Emerg Med. 2014 Jun;63(6):736-44.e2. doi: 10.1016/j.annemergmed.2013.10.017. Epub 2013 Nov 13. Impact of cardiopulmonary resuscitation duration on survival from paramedic witnessed out-of-hospital cardiac arrests: An observational study. Nehme Z. Resuscitation. 2016 Mar;100:25-31. doi: 10.1016/j.resuscitation.2015.12.011. Epub 2016 Jan 13.

In this episode we were lucky enough to catch up with Sam Sadek, EM Consultant at The Royal London hospital and HEMS doctor and also Zaf Qasim EM Consultant in Delaware in the United States. Both have been heavily involved in the setup and delivery of REBOA service in their respective posts. In this podcast they share their experience and expertise on the topic of setting up a REBOA service. A huge thanks to both of them as this is a superb podcast for anybody considering getting involved in REBOA. Recent podcasts on REBOA on ERCAST and EMCrit are essential listening and serve as great preludes to our discussion so make sure you check them out. Please pop any comments or questions at the bottom of the page and we will come back with a Q&A podcast on the topic really soon! References Resuscitative endovascular balloon occlusion of the aorta: a gap analysis of severely injured UK combat casualties. Morrison JJ. . Shock. 2014 May;41(5):388-93. doi: 10.1097/SHK.0000000000000136. Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis. Inoue J. J Trauma Acute Care Surg. 2016 Apr;80(4):559-67. doi: 10.1097/TA.0000000000000968. The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. Morrison JJ. J Surg Res. 2014 Oct;191(2):423-31. doi: 10.1016/j.jss.2014.04.012. Epub 2014 Apr 13. Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales. Barnard EB. Emerg Med J. 2015 Dec;32(12):926-32. doi: 10.1136/emermed-2015-205217. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Rossaint R. Crit Care. 2016 Apr 12;20(1):100. doi: 10.1186/s13054-016-1265-x. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. Moore LJ. J Trauma Acute Care Surg. 2015 Oct;79(4):523-30; discussion 530-2. doi: 10.1097/TA.0000000000000809. The AAST Prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). DuBose JJ. J Trauma Acute Care Surg. 2016 Apr 5. [Epub ahead of print]

So we were lucky enough to be asked to cover the Trauma Care Conference and specifically today's day focussing on Major Trauma in the Emergency Department. We managed to to get a few minutes of time from some of the superb speakers and get their take home messages from their talks. Enjoy! Relevant Resources TraumaCare PHEMCAST KIDS Calculator Perimortem C-section

Rob Fenwick talks to us about this common condition and amongst others throws up a few surprises about the risks of rewarming. Enjoy

Here's a look at some of the papers that caught our eye this month. We cover the best way to diagnose heart failure, the risks associated with hyperopia and the utility of ETCO2. Take the time to have a look at the papers yourself and leave any feed back or comments at the bottom of the page, enjoy!

So in this short podcast we're going to run over the summary of recommendations just published by the British Thoracic Society and the Intensive Care society on the Ventilatory Management of Acute Hypercapnia Respiratory Failure in Adults. This isn't in anyway intended as a replacement for reading the document itself so please make sure you take the time to do that.

Needle decompression of a pneumothorax is a time critical and life saving procedure. Classical teaching is to perform this in the 2nd ICS midclavicular line but is this the easiest and most effective place to perform it? In this podcast I speak with Zaf Qasim, an EM physician in the US about the topic and the underpinning EBM. Below are some of the papers we'll be discussing. Enjoy! Simon

This month we're looking at the JAMA paper on the new sepsis definitions, adverse event rates in ED sedation, interventional treatment for the over 80's with ACS and more!

A look at the headlines from the newly released guidance from NICE. Some bits of this may prove tricky to implement with current systems including the time to RSI....

We talk through some core content on epilepsy, some algorithims for treatment, some of the evidence base that surrounds the topic and some of the difficulties surrounding decision making

Welcome to February's papers of the month. This time we're talking about decompressing tension pneumothoraces, nasal oxygenation, prognosis of cardiac arrest with respect to duration and more!

Rob Fenwick talks us through some key points regarding anaphylaxis and some recent literature which may be a surprise regarding biphasic reactions, enjoy!

Here are the papers that caught our eye this month including direct vs video laryngoscopy, ultrasound for shortness of breath, ecg findings in PE and more!