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February 14, 2020
Figures for the year ending September 2019 showed a 7% rise in offences involving knives or sharp instruments recorded by the police (to 44,771 offences). This is 46% higher than when comparable recording began (year ending March 2011) and the highest on record.  The news is sadly littered with cases of knife crime and terror and whilst we may have thought of stabbings as confined to small pockets of the country, sadly it now seems that we all have or all will be dealing with such cases. The variability in injury and severity is vast from stabbings, however in extremis they are completely time critical, and striking the balance between performing only those life saving interventions on scene, during transport and in ED and getting to the final destination of theatre as quickly as possible. In this podcast we discuss our thoughts on dealing with these cases; from the moment we get that call, all the way through to getting them into theatre. As always we’d love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions. Enjoy! Simon, Rob and James
February 1, 2020
Welcome back! Three very different topics and papers for you this month. First up we have a look at the risk/benefit of sending troponins on patients aged 65 years an older when presenting with non-specific complaints; does this help their work up, or is this a classic case of over-testing? Next up we take a look at the causes of our patients presenting to the ED with a reduced level of consciousness, this paper may help inform your differentials and knowledge on the likelihood of different pathologies. Finally, following on from our recent Roadside to Resus episode on Seizures, we take a look at an RCT which compares 3 second line anti epileptics; will this give us the definitive answer over which we should be using? Once again we would love to hear you comments and feedback, and make sure you check out the articles yourselves and come to your own conclusions. Enjoy Simon & Rob
January 15, 2020
Seizures are defined as a “paroxysmal electrical discharge of the neurones in the brain resulting in a change of function or behaviour”. All of us involved in Emergency Care will encounter patients with seizures which can occur for a number of reasons, with Epilepsy affecting 1 in 100 people in the UK. Being able to identify the cause, terminate ongoing seizures and provide ongoing investigation and care is complicated and of paramount importance, as some of these episodes carry with them a high morbidity and mortality rate. In this episode of Roadside to Resus we run through the following; The scale of the problem Causes of seizures Definition of status epilepticus Different forms of seizures Clinical assessment Investigations Antiepileptic’s Management& guidelines; both Pre and In-hospital RSI for status epilepticus Follow up and guidance As always we’d love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions. Enjoy! Simon, Rob & James
January 1, 2020
Happy New Year!! We hope you've all had a great Christmas and New Year and that you managed to get some well earned time off over the festive period.  2019 saw us publish more insights from lead authors of the latest and most influential studies in Emergency Medicine and Critical Care, and we're really excited to say that we'll be delivering you even more in 2020 with some excellent RCTs, international guidelines and much, much more! This month we've got 3 papers to challenge practice across a wide array of practice. We start off with a paper that evaluates if we can change our d-dimer thresholds in suspected PE's and how many unnecessary work ups and scans that might decrease. Next, following on from our previous Hypothermia podcast, we have a look at a paper which looks at the best rewarming rates in patients with hypothermia, which may change your rewarming strategies.... Finally we have a think about our use of CT scanning in patients who gain a ROSC after cardiac arrest, and consider what benefit full body CT scanning might bring. Thanks to all of you for your support with the podcast over the last year and we look forward to bringing you some great stuff in 2020! Enjoy Simon & Rob
December 12, 2019
REBOA, ECMO, Thoracotomy? Where should we be focussing our attention in the world of Pre-hospital care? We were lucky enough to be invited to the London Trauma Conference on the Prehospital Day supported by the Norwegian Air Ambulance Foundation. The day focussed on the areas we can make a real impact to the outcomes of our pre-hospital critical care patients. We grabbed a few minutes time of the following speakers to hear their thoughts; Introosseous Access; Jerry Nolan Pre-hospital Blood products; Jostein Hagemo Communication under pressure; Dr Stephen Hearn Pre-hospital Critical Care - what should the near future look like? Dr Stephen Rashford Have a listen and as always we’d love to hear any thoughts or comments you have on the website and via twitter, and take a look at the references below to draw your own conclusions. We'll be back in the new year with monthly episodes of Papers of the Month and Roadside to Resus; have a great Christmas and New Year and we'll speak to you soon! Enjoy! Simon, Rob & James
December 1, 2019
Well the year has flown by and it's already time for December's Papers of the Month Podcast! Head injuries are a huge work load for those of us involved in Emergency Care. Identifying those at risk of deterioration from a traumatic brain injury is a priority, as early intervention and prognostication can make a huge difference to patient outcomes. CT scanning is relatively easy to access and with it investigation creep has lowered our threshold of investigation and use of radiology resources; first up we have a look at a paper that looks at the potential benefits from employing a number of different guidelines in identifying the patients with traumatic brain injury, whilst comparing the risk of over investigation. Next up we have a look at the commonly made diagnosis of urinary tract infection in the older population and a review paper that will help you make the right diagnosis when it's present and not over diagnose when not. Finally we have a think about the potential benefit of a fluid bolus during induction of anaesthesia for our patients undergoing RSI; can a 500 mL fluid bolus prevent cardiovascular collapse? And we also hear the authors insights on the great RCT. Make sure to get in touch with any comments on any of the reviews, and importantly make sure you check out the papers and draw your own conclusions. Enjoy! Simon & Rob
November 18, 2019
Angioedema is something we'll all encounter in the acute setting, whether we recognise it or not... Understanding the different causes and mechanisms is imperative to ensuring the patients get treatment that is not only effective, but in extremis potentially lifesaving. In this episode we talk through the condition; from clinical presentation, causative agents, mechanisms of action, differentials and the evidence base of treatment. Get in touch with any comments on the podcast, ensure to read the papers that are referenced yourself and draw your own conclusions. Enjoy! Simon & Rob  
November 11, 2019
As care on our emergency and urgent care demand is on an ever upwards course, whilst alongside this the scope of what we can potentially deliver to patients is also increasing. In order to meet this demand and to deliver the best care possible to our patients we will need to look for other solutions. We were lucky enough to be invited to the First Community Emergency at the Royal Society of Medicine in London, hosted by the Physician's Response Unit. This event looked at the current challenges and explored solutions and opportunities for more collaborative working. In this podcast you'll hear from Tony Joy about the concept and practice of Community Emergency Medicine. You'll hear from Gareth Davies on the history of Pre Hospital Emergency Medicine, both challenges and achievements. Finally you'll hear from Bill Leaning, PRU clinical manager & HEMS paramedic about how to go about setting up a service. Please let us know any thoughts or feedback, and we'll be back with another podcast on a clinical topic for you in a few days time. Enjoy! Simon & James
November 1, 2019
We've got some papers this month that focus on our sickest patients! If you had a patient that you found in cardiac arrest and you believed they had a PE, would you thrombolyse them during the arrest, and how much more likely do you think they would be to survive? Our first paper looks at exactly this question. Second up we consider the potential harms associated with adrenaline administration to those in traumatic arrest. Finally, when RSI'ing a patient and considering your pharmacological cocktail, how likely are you to reach for the fentanyl and how much concern would you have over the risk of this rendering the patient haemodynamically unstable? We take a look at a recent review on the topic and get Dr. Ian Ferguson's insights as the lead author. Make sure to get in touch with any comments on any of the reviews, and importantly make sure you check out the papers and draw your own conclusions. Enjoy! Simon & Rob  
October 15, 2019
So an incredibly important paper, CRASH-3 has just been published in the Lancet, which looks at the treatment of head injuries with Tranexamic Acid (TXA). TXA has been shown to save lives in trauma patients at the risk of major haemorrhage, with the notable exclusion of those with head injuries, CRASH-2. TXA has been shown to save lives in those with post parts haemorrhage, WOMAN trial. Time to treatment with TXA has been shown to be hugely influential in it's ability to decrease blood loss and save lives. So has TXA now been shown to save lives in head injuries? In this episode we run through the paper and are lucky enough to have an interview with the lead author, Professor Ian Roberts. Have a listen, read the paper and as always we’d love to hear any thoughts or comments you have on the website and via twitter, and take a look at the references below to draw your own conclusions. Enjoy! Simon, Rob & James References The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.Roberts I. Health Technol Assess. 2013 CRASH-2;The Bottom Line Effectof earlytranexamic acidadministrationon mortality, hysterectomy, and othermorbiditiesin womenwith post-partum haemorrhage(WOMAN): an international, randomised, double-blind, placebo-controlledtrial. WOMANTrialCollaborators.Lancet 2017 WOMAN Trial;The Bottom Line Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients.Gayet-Ageron A. Lancet. 2017 Tranexamic Acid - The Mechanism of Action;Video Tranexamic Acid, Time to Treatment;The Resus Room Does earlier TXA save lives?St Emlyns TXA podcast; PHEMCAST About CRASH-3; LSHTM
October 1, 2019
Welcome to October '19 papers podcast. You can't go far without the topic of TXA as a treatment for anything that bleeds being mentioned! With the publication of CRASH-2 and the WOMAN trial practice has crept such that administration in gastro-intestinal bleeding is seen fairly frequently. However, current guidelines don't recommend the use of TXA in GI bleeding, so this month we have a look at a systematic review which looks to answer whether it's administration is supported by the evidence, before we get a definitive answer from the HALT-IT trial. Next up, following on from our Burns Roadside to Resus podcast, we take a look at a paper that quantifies the potential benefit of thorough first aid in the management of paediatric burns, a really key paper on the topic, with really powerful results. Finally, we all know that Sepsis is a core area of our practice, but at times it may feel like the attention on those that could possibly have severe sepsis displaces the ability to care for other critically ill patients. We take a look at a great paper developing a prehospital screening tool to focus in on those patients that really do require time-critical care. Enjoy! Simon & Rob  
September 16, 2019
So as promised, and following on from our previous shock episode, this time we've covered the topic of shock in Trauma. It's a massive topic and one that we all, yet again, can make a huge difference for our patients' outcomes.  There is some crossover as you'd expect from the concepts and assessment that we covered in our Shock episode, so we'd recommend taking a listen to that one first. Make sure you have a comfy seat and plenty of refreshments to keep you going for this one as we cover the following; Definition Aetiology Hypovolaemic shock Neurogenic shock Obstructive shock Cardiogenic shock Physiology; Traumatic coagulopathy Other diagnostics Controlling external haemorrhage Pelvic binders REBOA Avoiding coagulopathy BP targets & permissive hypotension Fluid choices & supporting evidence TEG/ROTEM Calcium TXA Vasopressors Preventing hypothermia Relieving obstruction Interventional radiology Damage control surgery As always we’d love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions. Enjoy! Simon, Rob & James References Shock;The Resus Room podcast REBOA;The Resus Room podcast External Haemorrhage;The Resus Room podcast Blood;PHEMCAST TEG & ROTEM;FOAMcast Major Trauma guideline;NICE Resuscitative endovascular balloon occlusion of the aorta (REBOA):a population based gap analysis of trauma patients in England and Wales Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. Joseph B. JAMA Surg. 2019 The Pre-hospital Management of Pelvic Fractures: Initial Consensus Statement. I Scott. FPHC. 2012 RePHILL;Birmingham University Trials Assessment and Treatment of Spinal Cord Injuries and Neurogenic Shock;Fox A. JEMS Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. Holcomb JB. JAMA. 2015 Risks and benefitsof hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis. Owattanapanich N. Scand J Trauma Resusc Emerg Med. 2018 The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.Roberts I. Health Technol Assess. 2013 TEG and ROTEM for diagnosing trauma‑induced coagulopathy (disorder of the clotting system) in adult trauma patients with bleeding;Cochrane Review. 2015  Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review.McQuilten ZK. Transfus Med Rev. 2018 Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock.Sperry JL. N Engl J Med. 2018
September 16, 2019
So as promised, and following on from our previous shock episode, this time we've covered the topic of shock in Trauma. It's a massive topic and one that we all, yet again, can make a huge difference for our patients' outcomes.  There is some crossover as you'd expect from the concepts and assessment that we covered in our Shock episode, so we'd recommend taking a listen to that one first. Make sure you have a comfy seat and plenty of refreshments to keep you going for this one as we cover the following; Definition Aetiology Hypovolaemic shock Neurogenic shock Obstructive shock Cardiogenic shock Physiology; Traumatic coagulopathy Other diagnostics Controlling external haemorrhage Pelvic binders REBOA Avoiding coagulopathy BP targets & permissive hypotension Fluid choices & supporting evidence TEG/ROTEM Calcium TXA Vasopressors Preventing hypothermia Relieving obstruction Interventional radiology Damage control surgery As always we’d love to hear any thoughts or comments you have on the website and via twitter, and make sure you take a look at the references and guidelines linked below to draw your own conclusions. Enjoy! Simon, Rob & James References Shock;The Resus Room podcast REBOA;The Resus Room podcast External Haemorrhage;The Resus Room podcast Blood;PHEMCAST TEG & ROTEM;FOAMcast Major Trauma guideline;NICE Resuscitative endovascular balloon occlusion of the aorta (REBOA):a population based gap analysis of trauma patients in England and Wales Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma. Joseph B. JAMA Surg. 2019 The Pre-hospital Management of Pelvic Fractures: Initial Consensus Statement. I Scott. FPHC. 2012 RePHILL;Birmingham University Trials Assessment and Treatment of Spinal Cord Injuries and Neurogenic Shock;Fox A. JEMS Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. Holcomb JB. JAMA. 2015 Risks and benefitsof hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis. Owattanapanich N. Scand J Trauma Resusc Emerg Med. 2018 The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.Roberts I. Health Technol Assess. 2013 TEG and ROTEM for diagnosing trauma‑induced coagulopathy (disorder of the clotting system) in adult trauma patients with bleeding;Cochrane Review. 2015  Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review.McQuilten ZK. Transfus Med Rev. 2018 Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock.Sperry JL. N Engl J Med. 2018
September 1, 2019
We start off this month with a much talked about paper in the pre-hospital services, what benefit does Pre Hospital Critical Care bring to cardiac arrest victims? We are lucky enough to have the inside thoughts of the lead author, this a really interesting piece of work and will no doubt lead to further discussions, for more information from the author take a look at his thesis here. Next up we take a look at the utility of troponins in patients that have suffered cardiac arrest, can we use them to evaluate how likely it was that an MI precipitated the arrest? Last up we have a look at a novel approach of ruling out stroke as the cause of acute dizziness. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob  
August 15, 2019
Following on from our previous Roadside to Resus episode on Stroke, in this episode we look at the rapidly evolving area of stroke management.  In the last 2 decades stroke management has progressed beyond recognition and keeping up with the evidence and available therapies is a significant challenge. We cover the following treatments, looking at the risks and benefits of each, with the goal of being able to offer our patients the best possible outcomes; Aspirin Thrombolysis; both prehospitally and in hospital Thrombectomy Decompressive Hemicraniectomy Normoxia Euglycaemia Acute blood pressure management As always we’d love to hear any thoughts or comments you have on the website and via twitter. Enjoy! Simon, Rob & James References Tissue plasminogen activator for acute ischemic stroke. National Institute of Neurological Disorders and Stroke rt-PA.Stroke Study Group. N Engl J Med. 1995  Aspirin in Stroke;NNT Stroke Thrombolysis; Life in The Fast Lane Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency. Nolte CH. Stroke. 2018 Effect of the use of ambulance based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. Ebinger M. JAMA. 2014 Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee. Mokin M. J Neurointerv Surg. 2019 Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Evans MRB. Pract Neurol. 2017 Extend; The Bottom Line Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline.Published: 1 May 2019 MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial.Fransen PS. Trials. 2014 A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA).Campbell BC. Int J Stroke. 2014 Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. Jeffrey L. Saver. NEJM. 2015  Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging.Gregory W. Albers. NEJM. 2018 Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.Raul G. Nogueira.NEJM. 2018
August 1, 2019
Well the summer has definitely hit and we hope you get a chance for a break... making sure you spend spend some time listening to our Heat Illness episode on a beach somewhere! It's a wide variety of papers for you this month; Should we be looking to immediately cardiovert acute onset AF in the ED? What difference does glucagon make to clearing oesophageal foreign bodies? How important is our diagnostic accuracy in ED to the patients morbidity and mortality? And finally we cover a paper looking at the requirement for urgent tracheal intubation in trauma patients, and are lucky enough to get some thoughts from the lead author Dr. Kate Crewdson. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob  
July 15, 2019
Stroke is a common presentation to all Emergency Health care providers, with around 150,000 strokes occurring in the UK each year! Our impact and treatment can be hugely significant and in this podcast we’re going to conver the topic in some depth, and importantly cover some of the new Guidance published by NICE in their ‘Stroke and transient ischaemic attack in the over 16’s diagnosis and initial management’ document that was published in May of this year. We'll be running through Definition Pathophysiology Territories Risk factors Assessment; both prehospitally and in hospital Stroke mimics Investigations As always we’d love to hear any thoughts or comments you have on the website and via twitter. Enjoy! Simon, Rob & James References Stroke & Dizziness; PHEMCAST RCEMLearning; RCEM Belfast Vertigo Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline.Published: 1 May 2019 Acute Stroke Lecture notes; LITFL Stroke Thrombolysis; LITFL Are you at risk of a Stroke; Stroke Association Modifiable Risk Factors for Stroke and Strategies for Stroke Prevention.Hill VA. Semin Neurol. 2017 A systematic review of stroke recognition instruments in hospital and prehospital settings. Rudd M. Emerg Med J. 2016 Acute Stroke Diagnosis.Kenneth S. Yew. Am Fam Physician. 2009 Imaging of acute stroke prior to treatment: current practice and evolving techniques.G Mair. Br J Radiol. 2014 Should CT Angiography be a Routine Component of Acute Stroke Imaging?Vanja Douglas. Neuro hospitalist. 2015 Comparative Sensitivity of Computed Tomography vs. Magnetic Resonance Imaging for Detecting Acute Posterior Fossa Infarct. David Y Hwang. J Emerg Med. 2013 Posterior circulation ischaemic stroke. A Merwick BMJ 2014 Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack (Review)Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. 2019. Cochrane.
July 1, 2019
Welcome back! This month we're finishing off our theme of syncope with a paper that looks to answer the big question; in those with undifferentiated syncope, does hospitalisation result in better outcomes when compared to discharge? We have a look at a paper reviewing the feasibility of live streaming video from scene using the 999 caller's mobile phone, a fantastic utilisation of technology and a really exciting area; we also get the thoughts of one of the co-authors, Richard Lyon, Associate Medical Director for KSS. Finally we take a look at a paper reviewing the time on scene in cardiac arrests, that suggests if no ROSC is gained, rapidly getting off scene is in our patients' interest. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob
June 17, 2019
If you live in the UK you may be fooled in to thinking that Heat Illness isn't really something we need to worry about...but you'd be wrong! Each year there are 800 deaths due to Heat Illness and figures in more temperate climates are significantly more. In this podcast we tackle the topic of Heat Illness, all the way through Heat Cramps, Heat Syncope, Heat Exhaustion and to Heat Stroke. We'll cover the following; Definition, clinical spectrum and categories Scale of the problem Thermoregulatory physiology Impact of hyperthermia Clinical findings Those at greatest risk Acclimatisation Differentials Management As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you, and most importantly, we hope we haven't missed the summer heat wave...! Enjoy Simon, Rob & James 
June 1, 2019
Status Epilepticus in children, lying and standing blood pressures in syncope or presyncope and decompressing paediatric tension pneumothoraces. You'll no doubt have seen and heard about the two papers published this month in the Lancet, both Consept and Eclipse look at the use of keppra vs phenytoin as a second line anti convulsant therapy for children in status epilepticus. We take a look at both papers, and have a think about what this means for practice. There has been a large amount of focus on the optimal position for needle decompression of tension pneumothoraces in adults, but an open access paper from SJTREM looks at the best position in children, take a look at the paper here. Finally, should all patients with a presentation of syncope/presyncope be getting a lying and standing blood pressure, or is it an ineffective test? Make sure you take a look at the papers yourself, remembering that the paper from SJTREM on paediatric pneumothoraces is totally open access. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob  
May 15, 2019
Drowning is a huge worldwide problem, and here in the UK there are around 350 accidental deaths from drowning each year. From the patient who is potentially well enough for discharge on scene, all the way through to the resuscitation and prognostication of a cardiac arrest due to drowning, the topic carries a number of unique questions and challenges. In this podcast we run through; The scale of the problem Modes of drowning Prognostic factors Extrication Advanced Life Support in Drowning Termination of resuscitation Medical management As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you. Enjoy! Simon, Rob & James  
May 1, 2019
So first up a huge welcome to SJTREM, the free open access journal who we've teamed up with in the delivery of the podcast, every paper they publish is available online to read for free. Each month we'll be covering one of their papers in our Papers of the Month episodes, giving you the opportunity to review the literature yourself, come to your own conclusions and join the conversation. SJTREM have made our podcast a sustainable venture and together we look forward to promoting review and discussion of the best evidence and education, to all, for free! This month we'll be looking at an analysis of REBOA and having a think about whether it is benefiting those patients that are receiving it. We take a look at paper that reviews what we really know about the use of ETCO2 in cardiac arrest and have a think about how much importance we should put on it. Finally we take a look at the utility of prehospital blood gases; should this be the standard of care, or is it a step too far?Make sure you take a look at the papers yourself, remembering that the paper from SJTREM on prehospital blood gases is totally open access. We'd love to hear your thoughts and comments. Enjoy! Simon & Rob
April 15, 2019
'Patients with GCS scores of 8 or less require prompt intubation', that's what ATLS tells us. The mantra of GCS 8, intubate has pervaded teaching for those involved in the management of patients with a reduced GCS (Glasgow Coma Scale). But on reflection it would seem slightly odd that the gain or loss of a single point on the Glasgow Coma Scale could simply account for a change in the decision as to whether a patient would benefit from intubation and ventilation. So should the patient with a GCS of 9 be best managed without a definitive airway, but when that slips to 8 we should reach for the portex®? In this podcast we take a deeper look at the GCS, we have a think about the role that it was designed to perform and consider how it should best be applied to acutely ill patients when considering protecting their airway. The podcast is based upon the blog from the TEAM Course blog(Training in Emergency Airway Management), make sure to go and have a look at the post and other resources available on that site. Enjoy! Simon, Rob & James References GCS 8 intubate; TEAMcourse Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.2013;74(5):1363-6.Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4. Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G.The Glasgow Coma Scale at 40 years: standing the test of time.Lancet Neurol. 2014;13(8):844-54. Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-5. Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale.Ann Emerg Med. 2011;58(5):427-30. Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor.J Trauma. 2003;54(4):671-8. Isbister GK, Downes F, Sibbritt D, Dawson AH, Whyte IM. Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes.Crit Care Med. 2004;32(1):88-93. Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia.Lancet. 1996;348(9020):123-4. Kulig K, Rumack BH, Rosen P. Gag reflex in assessing level of consciousness.Lancet. 1982;1(8271):565. Rotheray KR, Cheung PS, Cheung CS, et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?.Resuscitation. 2012;83(1):86-9. Moulton C, Pennycook A, Makower R. Relation between Glasgow coma scale and the gag reflex.BMJ. 1991;303(6812):1240-1.
April 1, 2019
So we've got a massively important paper that we're going to kick off April's Papers of the Month podcast with, which is the RCT we've been waiting for; whether patients who have a ROSC should go to the cath lab, without a stemi, if the presumed cause is a coronary event? We've covered this topic in the past, for a background take a listen to PCI following ROSC and our December '17 papers of the month podcast. Next up, on the topic of over-testing, we have a look if we should be sending troponins and BNP's on our patients attending with syncope. Lastly, having spoken recently about the importance of ED airway registry's, we take a look at an open access paper from SJTREM that describes the practice, success and complication rates of ED advanced airway management. As always make sure you take a look at the papers yourselves and draw you own conclusions, we'd love to hear your thoughts. Enjoy! Simon & Rob References & Further Reading Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. Lemkes JS. N Engl J Med.2019 Do High-sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope? Clark CL. Acad Emerg Med.2019 Airway Management in the Emergency Department(The OcEAN-Study) - a prospective single centre observational cohort study. Bernhard M. Scand J Trauma Resusc Emerg Med.2019 PCI following ROSC podcast December 2017; Papers of the Month Podcast
March 18, 2019
We were lucky enough to be back at the fantastic TraumaCare Conference last week. There were a whole host of fantastic talks on offer and the Emergency Medicine stream, arranged by our very own Rob Fenwick, included a pro/con debate on whether Emergency Medicine should be managing the trauma airway. During that debate a number of important papers were raised on the evolution and improvement in advanced airway management. In this podcast we'll run through some of the most important points from that talk. Make sure you take a look at the papers yourself and come to your own conclusions. Enjoy! Simon & Rob    
March 1, 2019
We've got a broad array of topics and papers for you this month! First up we look at a paper from the NEJM assessing the potential benefits in providing ventilations to patients undergoing an RSI. Next we look at patients presenting with both syncope and pre-syncope to the emergency department, this paper quantifies the risk that we should be apportioning to these two different presentations. Finally, we look at a paper that suggests the manual pulse check in CPR is dead, and that the time has come for doppler and ultrasound to replace it! As always make sure you take a look at the papers yourselves and draw you own conclusions, we'd love to hear your thoughts. Enjoy! Simon & Rob References & Further Reading Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. Casey JD. N Engl J Med.2019  Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope. Bastani A. Ann Emerg Med.2019 Comparison of manual pulse palpation, cardiac ultrasonography and Doppler ultrasonography to check the pulse in cardiopulmonary arrest patients. Zengin S. Resuscitation.2018  
February 14, 2019
Hypothermia is a common problem for both pre and in-hospital clinicians. Understanding the underpinning physiology helps us deliver first class care to our patients, decreasing associated morbidity and mortality. There is some extremely difficult decision making to be done in severe cases of hypothermia and the podcast gives us an opportunity to explore them further. We'll cover the subject in depth with particular reference to the following categories of hypothermia; treatment, modifications in cardiac arrest and prognostication. Enjoy! Simon, Rob & James References ERC 2015; Cariac arrest in specialist circumstances LITFL; hypothermia RCEMLearning; hypothermia Up to Date; Hypothermia At the bedside, out of the cold: management of hypothermia and frostbite.BiemJ.CMAJ. 2003 The prehospital management of hypothermia - An up-to-date overview. Haverkamp FJC. Injury. 2018  Accidentalhypothermia-an update: The content of this review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Paal P. Scand J Trauma Resusc Emerg Med. 2016 Accidental hypothermia. Brown DJ. 2012 N Engl J Med.
February 1, 2019
Ketamine and trauma are the topics for this months papers. The three papers we cover are really important for all of us involved in the care of critically unwell patients. Hypotensive resuscitation in the context of trauma has been an evolving area of practice in the treatment of our acute trauma victims. A paper published in SJTREM this month meta-analyses the data that exists out there on the topic and looks to give us an idea of the benefits and potential risks associated with such an approach, the paper is available here and is well worth a full read. Morphine has been a mainstay of the treatment of acute severe pain in the Emergency Department for decades, but as the popularity of ketamine grows we take a look at another meta-analysis, this time comparing the efficacy of ketamine versus morphine in this setting and group of patients. And lastly, if you have ever had a patient become severely agitated with ketamine sedation, you'll be keen to avoid that happening again! The last paper we look at is a randomised control trial looking at the potential benefits of using either midazolam or haloperidol to achieve that. We hope you find the podcast useful, as ever please go and take a look at the papers yourself and we'd love to hear any thought or comments you have either rat the bottom of the page, or via twitter @TheResusRoom. Enjoy! Simon & Rob References Risks and benefits of hypotensive resuscitation in patientswith traumatic hemorrhagic shock: a meta-analysis. Owattanapanich N. Scand J Trauma Resusc Emerg Med.2018  A Systematic Review and Meta-analysisof Ketamine as an Alternativeto Opioids for Acute Pain in the Emergency Department. Karlow N. Acad Emerg Med.2018 Premedication With Midazolamor Haloperidolt o Prevent Recovery Agitation in Adults Undergoing Procedural Sedation With Ketamine: A Randomized Double Blind Clinical Trial. Akhlaghi N. Ann Emerg Med.2019  St Emlyns; JC: Should we premedicate for ketamine sedation?  
January 14, 2019
If you're involved in the care of critically unwell patients then you will frequently encounter patients who are shocked. The European Society of Intensive Care Medicine defines shock as; 'Life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen utilization by the cells. It is a state in which the circulation is unable to deliver sufficient oxygen to meet the demands of the tissues, resulting in cellular dysfunction.’ The assessment for shock needs to be part of the routine workup of every potentially unwell patient. Shock carries with it a high mortality rate, a range of meaningful interventions and the potential to make a real difference to our patients' outcomes.  In this podcast we cover Defining shock in adults Significance of shock What shock looks like A recap of cardiac physiology Causes of shock Ultrasound evaluation Fluid therapy Inotropes and vasopressors As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you. Enjoy! Simon, Rob & James References Consensuson circulatory shockand hemodynamic monitoring. Task forceof the EuropeanSociety of Intensive Care Medicine. Cecconi M. Intensive Care Med.2014 NICE Intravenous fluid therapy in adults in hospital. Clinical guideline. December 2013 ALIEM; Choosing the right vasopressor agent in hypotension Resus; The Shock Index ALIEM; Shock Index: A Predictor of Morbidity and Mortality? A comparisonof the shockindexand conventionalvital signsto identifyacute, critical illnessin the emergency department. Rady MY. Ann Emerg Med.1994  TheResusRoom; Sepsis RCEM guidance; Noradrenaline Infusion 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  Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.Jones AE. JAMA. 2010 A randomized trial of protocol-based care for early septic shock.ProCESS Investigators. N Engl J Med. 2014 Early goal-directed therapyin the treatmentof severe sepsisand septic shock. Rivers E. N Engl J Med.2001 The significance of non-sustained hypotension in emergency department patients with sepsis.Marchick MR. Intensive Care Med. 2009 Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis.Natthida Owattanapanich. Scand J Trauma Resusc Emerg Med. 2018. TheResusRoom; The Crystalloid Debate
January 1, 2019
Happy New Year!! Hopefully you got a bit of downtime over the festive period and are feeling suitably refreshed and ready to attack 2019! We've got 3 great papers to kick off the year. First up we look at the recent PReVENT trial which looks at ventilator strategies in patients without ARDS with respect to tidal volumes. This paper continues the work from the much cited ARDSNet paper from 2000, and we'd highly recommend you go and have a look at that paper first. Next we look at another paper from JAMA which compares Thrombolysis to Aspirin in minor non-disabling strokes. We say enough about this one in the podcast, but for a bit of background to our thoughts and the evidence surrounding stroke, check out our previous Stroke Thrombolysis podcast. Lastly we have a look at a paper investigating their systems use of push-dose-pressors, which whilst not the most methodologically sound piece of research, certainly brings out some interesting thoughts and points. As always make sure you take a look at the papers yourselves and we'd love to hear and comments or feedback you've got. Enjoy! Simon & Rob References & Further Reading Effectof a LowvsIntermediateTidalVolumeStrategyon Ventilator-FreeDaysin IntensiveCareUnitPatientsWithout ARDS: A Randomized Clinical Trial. JAMA.2018 Writing Group for the PReVENT Investigators Ventilationwith lowertidal volumesas comparedwith traditionaltidal volumesfor acute lung injury and the acute respiratory distress syndrome. Acute Respiratory Distress SyndromeNetwork. N Engl J Med.2000 PReVENT; The Bottom Line EMCrit; Vent and Prevent, an update Effectof AlteplasevsAspirinon FunctionalOutcomefor PatientsWith AcuteIschemicStrokeand MinorNondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. Khatri P. JAMA.2018 TheResusRoom; Stroke Thrombolysis podcast Push dose pressors: Experience in critically ill patients outside of the operating room. Rotando A. Am J Emerg Med.2018
December 20, 2018
Festive greetings to all! We hope you've had a fantastic 2018 and have some time off over Xmas and New Year to celebrate with friends and family. We thought we'd bring you some of the most influential papers that we've read over the last 12 months, that haven't necessarily fitted in that closely with some of the topics we've covered...we hope you enjoy! Thanks for all of your support with the podcast throughout 2018 and we wish you a very happy 2019. Simon, Rob & James References Pediatric golf cart trauma: Not par for the course. Tracy BM. J Pediatr Surg. 2018 What to eat and drink in the festive season: a pan-European, observational, cross-sectional study. Parker HL, et al. Eur J Gastroenterol Hepatol. 2017. Work of Breathing into Snow in the Presence versus Absence of an Artificial Air Pocket Affects Hypoxia and Hypercapnia of a Victim Covered with Avalanche Snow: A Randomized Double Blind Crossover Study. Karel Roubík. PLoS One. 2015.
December 17, 2018
Cardiac arrest management is core business of a resuscitationist and practice is constantly evolving in the pursuit of improving patient outcomes.  We were lucky enough to be invited to the London Trauma Conference's Cardiac Arrest Masterclass stream, where Matt Thomas put on a superb array of talks around all things cardiac arrest.  We managed to borrow a bit of time from some of the speakers and caught up with some of the topics covered including; airway management, ECGs pre/post arrest, POCUS, CRM and breaking bad news. We found the day hugely useful and we hope the podcast sums up some of the great points from the day. Enjoy! Simon, Rob & James References London Trauma Conference AIRWAYS-2; podcast SPIKES Protocol LITFL; Killer ECG Patterns Beyondprognostication: ambulancepersonnel's livedexperiencesof cardiacarrestdecision-making. Anderson NE. Emerg Med J.2018 Zero Talent Battle
December 1, 2018
Well the year maybe coming to a close but the high quality papers keep on coming out! We've got 3 great articles to cover in this episode which have some key points to reflect on in our practice. First up we take a look at the application of Canadian c-spine rules by ED triage nurses and the potential impact this approach could hold. Next up we have a look at the addition of magnesium to current ED rate control of uncompromised patients presenting with rapid AF. Lastly we look at a paper on the conservative management of traumatic pneumothoraces, including those undergoing positive pressure ventilation, which reviews the complication rate of this approach. As always make sure you take a look at the papers yourselves and form your own opinions, we would love to hear you comments and feedback. Enjoy! Simon & Rob References & Further Reading Ian G. Stiell, Catherine M. Clement, Maureen Lowe, Connor Sheehan, Jacqueline Miller, Sherry Armstrong, Brenda Bailey, Kerry Posselwhite, Jannick Langlais, Karin Ruddy, Susan Thorne, Alison Armstrong, Catherine Dain, Jeffrey J. Perry, Christian Vaillancourt, 2018, 'A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses', Annals of Emergency Medicine, vol. 72, no. 4, pp. 333-341 Wahid Bouida, Kaouthar Beltaief, Mohamed Amine Msolli, Noussaiba Azaiez, Houda Ben Soltane, Adel Sekma, Imen Trabelsi, Hamdi Boubaker, Mohamed Habib Grissa, Mehdi Methemem, Riadh Boukef, Zohra Dridi, Asma Belguith, Semir Nouira, 2018, 'Low‐dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double‐blind Study (LOMAGHI Study)', Academic Emergency Medicine Steven P. Walker, Shaney L. Barratt, Julian Thompson, Nick A. Maskell, 2018, 'Conservative Management in Traumatic Pneumothoraces', Chest, vol. 153, no. 4, pp. 946-953 SGEM#232: I Can See Clearly Now the Collar is Gone – Thanks to the Triage Nurse London Trauma Conference; Cardiac Arrest Masterclass
November 23, 2018
We were delighted to be back to cover the joint Faculty of Prehospital Care and BASICS conference, day 2,  held at the Royal College of Surgeons of Edinburgh. Again we were absolutely spoilt for choice when it came to content for the podcasts but we managed to catch up with: • Dr Anne Weaver – a consultant in Emergency Medicine and Prehospital Care working for the Royal London Hospital and London HEMS. She talked to us about chemical burns and a novel treatment for managing these injuries. • Dr Virginia Beckett – an Obstetrics and Gynaecology consultant who is a member of the mMOET working group and has recently published on the topic of cardiac arrest in pregnancy. She was talking on the topic of resuscitative hysterotomy. • Sam Cooper – a Critical Care Paramedic from Derbyshire, Leicestershire and Rutland Air Ambulance who discussed a case of prehospital amputation and the learning points that arose from it. • Dr Rob Lloyd – an Emergency Medicine trainee, blogger and fellow podcaster who has an interest in performance psychology. He talked about Mental Toughness, framed by his experiences working in a hospital deep in a South African township. Once again, our thanks to Caroline Leech for being instrumental in the organisation of today and inviting us up. We’re already looking forward to next year…. Enjoy! Simon, Rob & James References PonderMed Diphoterine A video showing a similar demonstration to the one at the conference showing why Diphoterine works and the limitations of water Pre-hospital Obstetric Emergency Training; POET VA Beckett, M Knight, P Sharpe, 2017, 'The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study', BJOG: An International Journal of Obstetrics & Gynaecology, vol. 124, no. 9, pp. 1374-1381 Realtime simulation of peri-mortem c-section; Bradford Teaching Hospital K. M. Porter, 2010, 'Prehospital amputation', Emergency Medicine Journal, vol. 27, no. 12, pp. 940-942 Caroline Leech, Keith Porter, 2016, 'Man or machine? An experimental study of prehospital emergency amputation', Emergency Medicine Journal, vol. 33, no. 9, pp. 641-644  
November 20, 2018
We were delighted to be invited to cover the joint Faculty of Prehospital Care and BASICS conference held at the Royal College of Surgeons of Edinburgh. This two-day prehospital extravaganza covered a broad range of topics and the content was delivered by some excellent speakers. As such, we were absolutely spoilt for choice when it came to content for the podcasts but we managed to catch up with: Dr Abi Hoyle – a paediatric emergency medicine consultant with a background in military and retrieval services. She gave us some key tips when dealing with paediatric patients. Ian Dunbar – a technical and medical rescue consultant with years of experience in the UK Fire and Rescue Service and ongoing involvement with British Touring Car Championship and the FIA. He did some myth busting around extrication from vehicles. Professor Mike Tipton – a leading figure in extreme physiology who is the Associate Head of Research at the Extreme Environments Laboratory in Portsmouth, is trustee/director of Surf Life Saving GB, sits on the medical committee for the RNLI and was awarded an MBE for services to physiological research in extreme environments. Mike spoke on the topic of drowning. Massive thanks to Dr Caroline Leech who put together this brilliant programme and extended the invitation to us. We hope you enjoy the podcast and extract some learning to inform your practice. Enjoy! Simon, Rob & James References Resus Council UK; Prehospital Resuscitation Michael J. Shattock, Michael J. Tipton, 2012, '‘Autonomic conflict’: a different way to die during cold water immersion?',The Journal of Physiology, vol. 590, no. 14, pp. 3219-3230  Faculty of Pre-Hospital Care and Basics Conference
November 8, 2018
We've heard a lot about advanced airway management recently, with some really significant publications over the last few months and in the last few weeks in JAMA we've had another! Cricoid pressure during emergency anaesthesia and for those at high risk of aspiration has been common place for more than half a century. But it's a topic that has caused quite some debate. On one hand it has the potential to reduce aspiration, a very real and potentially very serious complication of RSI. But on the other it has the potential to hinder the view on laryngoscopy and decrease first pass success. The founding evidence for cricoid pressure has always been a little soft. In this podcast we look at the background of cricoid pressure and then run through this key paper, discussing the implications it holds for both pre and in-hospital advanced airway management. As always we'd love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you. Enjoy! Simon, Rob & James References Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anaesthesia: The IRIS Randomized Clinical Trial. Birenbaum A. JAMA Surg 2018 Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Sellick BA Lancet.1961 Safer Prehospital Anaesthesia 2017;AAGBI JC: Cricoid Pressure and RSI, do we still need it?St Emlyn’s Cricoid: To press, or not to press?(Hinds and May)  
November 1, 2018
Welcome back to November's Papers Podcast! We've got 3 great papers for you again this month. First up we take a look at a paper that looks to quantify the amount of experience needed to be a proficient intubator, in this case in arrest. Next we have a look at a paper which shows a significant difference in mortality in cardiac arrest dependant on the intravascular access route used. Finally we have a look a really interesting paper in the dispatch method of a HEMS service which we be of real interest to all those involved in paramedicine and prehospital critical care. Make sure you take a look at the papers themselves and form your own opinions. We'd love to hear any thoughts and feedback you have. Enjoy! Simon & Rob References & Further Reading How much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation? Kim SY. Resuscitation.2018 A novel method of non-clinical dispatch is associated with a higher rate of criticalHelicopter Emergency Medical Service intervention. Munro S .Scand J Trauma Resusc Emerg Med.2018 Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Kawano T. Ann Emerg Med.2018
October 15, 2018
With bonfire night approaching we thought it would be a good time to have a think about burns. However burns are a significant issue at all times of year with around 130,000 presentations to UK EDs annually, 10,000 cases are admitted to hospital, 500 of these have severe burns and 200 of these will die. But most importantly intervention that we make can make a big difference to both morbidity and mortality, really affecting outcomes.  Throughout this episode we'll be covering the essential first responder management, all the way through to the critical care that maybe required for the sickest of burns patients.  In the podcast we cover Burn type and burn severity The importance of history Assessing burn extent Assessing burn depth The A-E assessment and specifics regarding the burns patient NAI, antibiotics, tetanus cover, analgesia, special circumstances eyes & chemicals Conveyance and destination As always we'd love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you. Enjoy! Simon, Rob & James    References British Burn Association First Aid Clinical Practice Guidelines BBA Clinical Practice Guideline for Management of Burn Blisters BBA Clinical Practice Guideline for Deroofing Burn Blisters RCEMLearning; Major Trauma, Burns National Burn Care Referral Guidance WHO; fact sheet on burns NHS Standard Contract for Specialised Burns Care (All Ages) Schedule 2- The Services A. Service Specification LITFL; burns Clinical review: The critical care management of the burn patient. Jane A Snell. Crit Care 2013 Fluid resuscitation in major burns. Mitra B ANZ J Surg. 2006 How well does the Parkland formula estimate actual fluid resuscitation volumes? Cartotto RC. J Burn Care Rehabil. 2002 Fluid resuscitation management in patients with burns: update. Guilabert P. Br J Anaesth. 2016 ISBI Practice Guidelines for Burn Care 2016  
October 1, 2018
Welcome back to October's Papers Podcast, this month we move airway from advanced airway management and bring you a broad array of papers. First up we have a look at the relative success of a variety of pharmacological strategies for managing the acutely agitated patient in ED. Next up we have look at the well know CURB-65 score and it's ability to predict the need for critical care interventions. Lastly, we may all feel at times that performing a CT head on those well patients solely because they take anticoagulants may be a little on the excessive side, we review a paper that looks at the yield of positive scans in this cohort. As ever don't just take our word for it, go and have a look at the papers yourself, we would love to hear any comments or feedback you have. Enjoy! Simon & Rob References & Further Reading  IntramuscularMidazolam, Olanzapine, Ziprasidone, or Haloperidolfor TreatingAcuteAgitationin the Emergency Department. Klein LR. Ann Emerg Med. 2018 Performanceof the CURB-65Scorein PredictingCritical CareInterventionsin PatientsAdmitted With Community-AcquiredPneumonia.Ilg A. Ann Emerg Med.2018 Incidenceof intracranial bleedingin anticoagulatedpatientswith minor head injury: a systematic review and meta-analysis of prospective studies. Minhas H. Br J Haematol.2018
September 14, 2018
So we're back with September's papers of the month a little later than usual but we wanted to give you a little time to digest AIRWAYS-2... before we give you some more prehospital research on advanced airway management in cardiac arrest! The American version of AIRWAYS-2, PART, has just been released in JAMA, looking at the laryngeal tube versus endotracheal intubation as a primary strategy for advanced airway management. The paper is fascinating accompaniment to AIRWAYS-2. Next we have a look at a paper assessing Emergency Medicine clinicians' ability to predict hospital admission at the time of triage, should we be making early calls on the destination of our patients? Finally we have a look at the potential role of esmolol in cases of refractory VF and a paper that reports twice the survival rates in those that receive it! As always we strongly suggest you have a look at the papers yourself and come to your own conclusions. Make sure you check out the hyperlinked blogs below that we mention in the podcast that contain some fantastic critiques. We'd also love to hear any comments either at the foot of this page or on twitter to @TheResusRoom. Enjoy! Simon & Rob References & Further Reading Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac ArrestA Randomized Clinical Trial. Henry E. Wang, MD. 2018 Emergency medicinephysicians' abilityto predicthospital admissionat the timeof triage. Vlodaver ZK. Am J Emerg Med.2018 Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patientswith refractory ventricular fibrillation. Driver BE. Resuscitation.2014 King Laryngeal Tube  
August 28, 2018
So we're back from our summer hiatus with a real treat. The long awaited AIRWAYS-2 paper has just been released and we've been lucky enough to speak with the lead author, Professor Jonathan Benger, about the paper and discuss what the findings mean for cardiac arrest management. AIRWAYS-2 looks at the initial advanced airway management strategy for paramedics attending out of hospital cardiac arrests, essentially whether or not the aim should be to place a supraglottic airway device or an endotracheal tube when advancing from simple airway techniques. The study was a huge undertaking with many speculating over how the results would change practice, including discussion of how it may affect paramedic's practice of intubation, all of which we cover in the podcast. Before you listen to the podcast make sure you have a look at the paper yourself, have a listen to PHEMCAST's previous episode which covers the study design and have a look at the infographics on the website which summarise the primary outcome and secondary analysis and which we refer to in the interview with Professor Benger. In the podcast we refer to Jabre's paper which can be found below and we also covered in May's papers podcast. Have a listen to the interview and let us know any thoughts or feedback you have, we're sure this one will create a lot of discussion! Simon, Rob & James References & Further Reading Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. The AIRWAYS-2 Randomized Clinical Trial. Benger J. JAMA. 2018 PHEMCAST; the LMA Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomised Clinical Trial. Jabre P. JAMA. 2018 TEAM Course
August 1, 2018
Welcome to August's papers of the month. So this is our last offering for the summer until whilst we take a short break until September, so we had to finish off we 3 great papers! First up we look at the drug of the moment (or decade...) in tranexamic acid and the effect that it has on outcomes in primary intracerebral haemorrhage. Next, what role does point of care ultrasound (POCUS) hold in the patient presenting with undifferentiated shock? We look at a randomised control trial of POCUS in this patient cohort that assesses the ability to translate POCUS into a mortality benefit. Finally we look at a delphi study published in the EMJ which explores expert opinion upon multiple aspects of paediatric traumatic arrests. The results are fascinating and may inform some of the CRM used in the next case you see. As always we strongly suggest you have a look at the papers yourself and come to your own conclusions. Make sure you check out the hyperlinked blogs below that we mention in the podcast that contain some fantastic critiques. We'd also love to hear any comments either at the foot of this page or on twitter to @TheResusRoom. Enjoy!   Simon & Rob References & Further Reading Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Sprigg N. Lancet. 2018 Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With UndifferentiatedHypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Atkinson PR. Ann Emerg Med. 2018 Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management. Rickard AC. Emerg Med J. 2018 St Emlyns JC; Tich Tich Boom? First10EM; TXA in ICH (TICH-2) 
July 25, 2018
Drugs in cardiac arrest are controversial. Prehospital research is notoriously difficult to perform. PARAMEDIC2 has just published in the New England Journal of Medicine and is a multi centre randomised placebo controlled trial looking at adrenaline (or epinephrine depending on which side of the pond you reside) in out of hospital cardiac arrest, no mean undertaking and a landmark paper. The paper has gained a huge amount of traction online with multiple blogs discussing the primary outcome which showed a higher survival rate in those receiving adrenaline when compared to placebo. This has been accompanied with a firm debate over the secondary outcomes, which include the rate of survival with a favourable neurological outcome (mRS 0-3), which showed no statistically significant difference between the two treatment arms, but in pure numbers gave a higher proportion of favourable outcomes in the adrenaline group. The trade off for this increased survival is the significant number of survivors with a poor neurological outcome. The question on everyone's lips then being; should we continue to administer adrenaline in cardiac arrest given the findings from this study? In the podcast we run over the main findings of the paper and are lucky enough to speak to the lead author Professor Gavin Perkins about the paper and some of the questions we and you have had following publication of the paper. A huge thanks to Gavin for taking the time to do this. Have a listen, enjoy, and let us know any thoughts or feedback you have Simon, Rob & James References & Further Reading PARAMEDIC2; Warwick University Clinical Trials Unit A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. Perkins GD. N Engl J Med. 2018 PARAMEDIC2 Protocol Testing Epinephrine for Out-of-Hospital Cardiac Arrest. Callaway CW. N Engl J Med. 2018 First10EMParamedic 2: Epinephrine harms/helps in out of hospital cardiac arrest REBEL Cast Ep56 PARAMEDIC-2: Time to Abandon Epinephrine in OHCA?
July 16, 2018
Head injury worldwide is a significant cause of morbidity and mortality. Besides prevention there isn't anything that can be done to improve the results from the primary brain injury, there is however a phenomenal amount that can be done to reduce the secondary brain injury that patients suffer, both from a prehospital and in hospital point of view. In the podcast we run through head injuries, all the way from initial classification and investigation, to specifics of treatment including neuro protective anaesthesia and hyperosmolar therapy, to give a sound overview of the management of these patients. As always we welcome feedback via the website or on Twitter and we look forward to hearing from you. Enjoy! Simon, Rob & James References & Further Reading Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016 Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned? Boone MD. Surg Neurol Int. 2015 Life in the fast lane; hypertonic saline Life in the fast lane; Traumatic brain injury Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality. T Lawrence. BMJ Open. 2016 Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. M.Majdan. The Lancet. 2016 The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. Gale SC. J Trauma. 2005 What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population? Rotheray KR. Resuscitation. 2012 NICE Head Injury Guidelines 2014 MDCALC Canadian Head Injury TheResusRoom; The AHEAD Study TheResusRoom; Anticoagulation, head injury & delayed bleeds Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement  A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries. Manara AR. J Intensive Care Soc. 2016
July 2, 2018
Welcome to July's papers podcast.  There has been a plethora of superb and thought provoking papers published this month and we've got the best 3 that caught our eye for you. In this episode we look at the potential benefit of early vs late endoscopy in patients presenting with an acute upper GI bleed.  Next we look at both intra and post ROSC hyperoxia and the associated outcomes. Finally we have a look at the utility of straight leg raise as a test to rule out potential pelvicfractures in out trauma patients. We strongly suggest you source the papers and come to your own conclusions and we'd love to hear any comments either at the foot of this page or on twitter to @TheResusRoom. Enjoy! Simon & Rob References & Further Reading Delayed endoscopy is associated with increased mortality in upper gastrointestinal hemorrhage. Jeong N. Am J Emerg Med. 2018  Association between intra- and post-arrest hyperoxia on mortality in adults with cardiac arrest: A systematic review and meta-analysis. Patel JK. Resuscitation. 2018 Straight leg elevation to rule out pelvic injury. Bolt C. Injury. 2018
June 20, 2018
Managing external haemorrhage is easy right?! Then why does haemorrhage remain a major cause of death from trauma worldwide? Ok, some of that is from internal sources, but…. No one should die from compressible external haemorrhage With the right treatment applied in a timely fashion, the vast majority of these bleeds can be stopped. But with new advances like haemostatic agents, changing advice surrounding tourniquet use and practice changing evidence coming out of conflict zones can mean it’s difficult to remain current with the latest best practice. So what options are available to us, how do we use them and what’s the evidence. Here’s the line-up for this months’ podcast: Haemorrhage control ladder Evidence based guidelines on haemorrhage control Direct pressure Enhanced pressure dressings Haemostatic agents and wound packing Tourniquets Case studies As always we welcome feedback via the website or on Twitter and we look forward to your engagement. Enjoy! Simon, Rob & James   References & Further Reading Bennett, B. L & Littlejohn, L. (2014) Review of new topical hemostatic dressings for combat casualty care. Military Medicine. Volume 179, number 5, pp497-514. Lee, C., Porter, K. M & Hodgetts, T. J. (2007) Tourniquet use in the civilian prehospital setting. Emergency Medicine Journal. Volume 24, pp584-7.  Nutbeam, T & Boylan, M. (2013) ABC of prehospital emergency medicine. Wiley Blackwell. London. Shokrollahi, K., Sharma, H & Gakhar, H. (2008) A technique for temporary control of haemorrhage. The Journal of Emergency Medicine. Volume 34, number 3, pp319-20. Trauma! Extremity Arterial Hemorrhage; LITFL  The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Rolf Rossaint. Critical Care 2016. NICE 2016. Major Trauma; Assessment and Initial Management FPHC 2017; Position statement on the application of Tourniquets    
June 1, 2018
Welcome back to our monthly round up of the best papers in the resuscitation world. Again we've got 3 great papers covering some really important points of practice. First up we have a look at one of the most talked about diagnostic tests in Emergency Medicine, Troponin. We're are always looking to increase the sensitivity of the assay and test in order to ensure the patient hasn't got Acute Coronary Syndrome, but what are the implications of implementing a high sensitivity test? In our first paper we have a look at this exact scenario, the difference in patient outcomes and some of the resource implications to the service. Next up we have a look at apnoeic oxygeationn. We've covered this a number of times before and most recently in our Roadside to Resus episode on RSI. This time we have a look at the most recent systematic review and meta-analysis on the topic to see if there is more definitive evidence of benefit with this technique. Lastly we've found a paper that suggests a place for prognosticating off pH in cardiac arrest, is this something we should be adopting? Have a listen but most importantly have a look at the papers yourself and let us know your thoughts. Enjoy! Simon & Rob References & Further Reading Low-level troponin elevations following a reduced troponin I cutoff: Increased resource utilization without improved outcomes. Becker BA. Am J Emerg Med. 2018  Effectiveness of Apneic Oxygenation During Intubation: A Systematic Review and Meta-Analysis. Oliveira J E Silva L. Ann Emerg Med. 2017  Association between acidosis and outcome in out-of-hospital cardiac arrest patients. Lin CC. Am J Emerg Med. 2018.
May 21, 2018
The management of a cardiac arrest can be stressful at the best of times, but add into that the patient being a child and you have the potential for an overwhelmingly stressful situation. Fortunately the major resuscitation bodies have some sound guidance on the management of paediatric arrests. In this episode we run through some of those guidelines and also the evidence base on the topic (scant at best!). We also touch on conveyance of the prehospital paediatric arrest, bringing familiy into the resuscitation area and knowing when to cease resuscitation. We hope the podcast helps you prepare that little bit more for the next case you might see and that it may also ease the stress of such an emotive case. Simon, Rob & James
May 10, 2018
Professor Simon Carley from St. Emlyns caught up with us at the superb Trauma Care Conference and talked through his top papers in trauma from the last 12 months. There's something for everyone from diagnosing arterial injuries, blood pressure targets in the head injury patient, to i.v. contrast all the way through to imaging in kids. If you haven't already, make sure you go and check out the St Emlyn's blog that underpins the talk that Simon gave. And if you're looking for a great value conference to suit all health care disciplines then make sure to keep an eye out for tickets when they go on sale for Trauma Care 2019. A huge thanks to Simon C for his time recording the podcast and we'd love to hear any comments or feedback. Enjoy! Simon L & Simon C References & Further Reading For all the papers pop over to the St Emlyn's blog for the hyperlinks and abstracts
May 1, 2018
Dare we say it, we think this month's papers podcast is the best yet, we've got 3 superb papers and topics to consider! The literature has been pretty airway heavy this month so we've got 3 papers on and around the topic for you. First up we have a look at a really interesting paper from London HEMS looking at the risks v benefit of prehospital rapid sequence intubation in patients who are awake but hypotensive, is RSI a much needed move or something we should be looking to avoid prehospitally. Airways-2 will soon be published looking at supraglottic airway management compared to intubation as first line airway management in out of hospital cardiac arrest, but JAMA has just published a paper comparing bag-mask ventilation vs endotracheal intubation in the same situation. It'll be interesting to see if this papers results fall inline with Airways-2. Finally we take a look at a systematic review trying to give us the answer to direct or video laryngoscopy in emergency endotracheal intubation outside the OR. Have a listen but most importantly have a look at the papers yourself and let us know your thoughts. Enjoy! Simon & Rob References & Further Reading Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental? Crewdson K. Acta Anaesthesiol Scand. 2018  Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome AfterOut-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial. Jabre P. JAMA. 2018  Videolaryngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside the operating room: a systematic review and meta-analysis. Arulkumaran N. Br J Anaesth. 2018
April 23, 2018
Evidence based medicine (EBM) allows us to deliver the best care to our patients and understanding the concepts involved is crucial. Over the last 18 month we've been building an online course to give people a sound understanding of EBM and we thought we'd give you a free taster of what it's all about. Have a listen to one of our episodes here on statistics and if you want to find out more have a read below about the full course at www.CriticalAppraisalLowdown.co.uk Enjoy! Simon, Rob & James  
April 18, 2018
For this episode we’ve been lucky enough to catch a number of the speakers from the traumacare conference. First up, conference organiser Caroline Leech (EM + PHEM consultant) gave us a few minutes of her time to talk about the latest major trauma key performance indicators from NICE. Nicola Curry (Consultant Haematologist) spoke about transfusion in trauma and the use of massive haemorrhage protocols. Importantly, she covers the evidence behind the current strategies and where future research opportunities exist. Stuart Reid (EM + PHEM consultant) covered the ways of optimising timely transfer of major trauma patients. This had an inter-hospital focus, but there were certainly some elements which can be applied to a primary patient transfer. David Raven (EM consultant) provided an update to the ongoing work with the HECTOR project. We’ve previously heard about their amazing course but this time he was able to let us know about the “silver trauma safety net” which is being used by the ambulance service in the West Midlands. This aims to provide appropriate recognition and triage of trauma in the elderly population. Finally, Elspeth Hulse (anaesthetic SpR) gave us a timely reminder about the identification and management of organophosphate poisoning - really useful from both and EM and PHEM perspective. Thanks again to Caroline for the invite to the conference and keep and eye out for a special podcast in the next few weeks where Simon Carley will be running through his top 10 trauma papers of 2017/18 (we were going to try and condense it, but there was way too much good stuff!) Enjoy! Simon, Rob & James References & Further Reading Trauma Care St Emlyns HECTOR
April 8, 2018
In this episode Rob takes us through a case he saw recently that brought about some invaluable learning. We're not going to give you anymore clues than that! Enjoy! Simon & Rob References & Further Reading (anonymised to keep the anticipation!) Article 1   Article 2   Article 3   Article 4  
April 1, 2018
  Welcome back to April's papers of the month. We've got 3 papers this month that look to challenge our work up strategies for the critically unwell. First up we look at a paper on the Ottawa subarachnoid haemorrhage rule, specifically considering if we can decrease scanning in patients with a suspected SAH and what application of the rule might mean for our practice. Next up we look at a paper that might shine some real doubt on the use of IO access in our patients in cardiac arrest. Lastly we look at a validation paper for the PERC rule for those patients with a suspected pulmonary embolus and this paper brings about some interesting points on external validity Once again we'd really encourage you to have a look at the papers yourself and we've love to hear any thoughts or feedback you have. Enjoy! Simon & Rob  References Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. Perry JJ. CMAJ. 2017   Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Kawano T. Ann Emerg Med. 2018  Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. Freund Y. JAMA. 2018  CORE EM; IO in Cardiac Arrest    
March 20, 2018
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
March 12, 2018
How often do you prescribe or give i.v. fluids to your patients? How much thought goes into what's contained in that fluid? What effect will you fluid choice have on your patient? Two trials on crystalloid administration in the acutely unwell patient have occupied a lot of conversation in the research world over the last few weeks, both published in the NEJM and in this podcast we take a look at them. In the podcast we cover the following; Whats the big deal with crystalloids Previous trials on fluid administration NEJM papers on crystalloids Myburgh's editorial Make sure you take a look at the papers yourself and come up with your own conclusions. There are a whole host of superb FOAM resources out there on the topic that are well worth a look and referenced below. We'd love to hear any thoughts and comments below. Enjoy! Simon & Rob References & Further Reading Fluid Na K Cl Ca Mg Lact Acet Glucon Dext Osmol mOsm/L 0.9% N Saline 154 0 154 0 0 0 0 0 0 308 Lactated Ringers 131 5 11 2.7 0 29 0 0 0 273 Hartmanns 129 5 109 4 0 29 0 0 0 278 Plasma Lyte 140 5 98 0 3 0 27 23 0 280 Constituents measured in mEq/L Reference; University Texas  Balanced Crystalloids versus Saline in Critically Ill Adults. Semler MW. N Engl J Med. 2018 Balanced Crystalloids versus Saline in Noncritically Ill Adults. Self WH. N Engl J Med. 2018 Patient-Centered Outcomes and Resuscitation Fluids. Myburgh J. N Engl J Med. 2018 REBEL.EM; Is the Great Debate Between Balanced vs Unbalanced Crystalloids Finally Over? PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation JC: Balanced fluids vs Saline on the ICU. The SMART trial. St Emlyn’s JC: So long Salt and Saline? St Emlyn’s The Bottom Line; SALT-EM The Bottom Line; SMART
March 1, 2018
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
February 22, 2018
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
February 12, 2018
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
February 1, 2018
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  
January 22, 2018
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
January 12, 2018
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
January 1, 2018
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      
December 11, 2017
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
December 1, 2017
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 
November 20, 2017
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
November 10, 2017
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  
November 1, 2017
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 
October 16, 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
October 6, 2017
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  
October 1, 2017
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
September 21, 2017
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
September 11, 2017
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
September 1, 2017
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 
August 21, 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?  
August 14, 2017
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?
August 1, 2017
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  
July 20, 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)  
July 10, 2017
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
July 1, 2017
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
June 21, 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. Increased energy use has also been demonstrated to cause an increase in A-V block but without an associated increase in shock success or patient outcome. The use of double sequential defibrillation is clearly an area that would benefit from further research, but despite this it is interesting to note that London Ambulance Service have enabled their Advanced Paramedic Practitioners to use DSD and some American EMS systems have written DSD into their protocols. So returning to the case in point what did I choose to do with my patient? After changing the pad position, administering magnesium and continuing defibrillation they remained in VF.  I considered transport to a hospital with interventional cardiology but the patient was several stories up in a property with an inherently complex extrication. So I chose to use DSD because I felt that all other avenues had been explored. The patient had suffered a witnessed arrest, received bystander CPR immediately and throughout the resuscitation they had maintained a high end tidal CO2 and a coarse VF. I felt that this was a patient who could still respond to non-standard cardiac arrest management in the absence of a response to guideline directed treatment. After two DSD shocks a return of spontaneous circulation was achieved and the patient survived to hospital admission, but sadly didn’t survive to hospital discharge. We’re left with a even bigger question: if we accept that DSD is a potentially useful intervention in rVF, when should we consider using it? Would the outcome for this patient have been different if DSD had been used earlier? The European Resuscitation Council states that the use of double sequential defibrillation cannot be recommended for routine use. But treating rVF is not routine and the guidelines have otherwise failed our patient. It is said that insanity is defined as doing the same thing over and over again, without changing anything, and expecting a different result. Is this not what the guidelines preach in rVF? It is up to you, the clinician, to determine whether DSD is appropriate for each rVF case you encounter. But I urge you to consider the patient in front of you and tailor your resuscitation to their needs, whether that includes DSD or an alternative option. Personally, I believe DSD does have a place in the management of rVF patients, after considering the other interventions previously discussed. Given that shock success declines over time, DSD could be used as early as the sixth shock, because at this point the guidelines have nothing further to add. Or maybe it’s me who’s insane… James Yates (Critical Care Paramedic GWAAC) References Double sequential Defibrillation therapy for out-of-hospital cardiac arrests: the London experience. Emmerson AC, et al. Resuscitation. 2017  A Case Series of Double Sequence Defibrillation. Merlin MA. Prehosp Emerg Care. 2016 Double sequential external shocks for refractory ventricular fibrillation. Hoch DH. J Am Coll Cardiol. 1994 Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Reportof Ten Cases. Cabañas JG. Prehosp Emerg Care. 2015 Double Sequential Defibrillation for Refractory Ventricular Fibrillation: A Case Report. Lybeck AM. Prehosp Emerg Care. 2015 Double simultaneous defibrillators for refractory ventricular fibrillation. Leacock BW. J Emerg Med. 2014 Simultaneous use of two defibrillators for the conversion of refractory ventricular fibrillation. Gerstein NS. J Cardiothorac Vasc Anesth. 2015 Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Cortez E. Resuscitation. 2016  Double Sequential External Defibrillation and Survival from Out-of-Hospital Cardiac Arrest: A CaseReport. Johnston M. Prehosp Emerg Care. 2016 Dual defibrillation in out-of-hospital cardiac arrest: A retrospectivecohort analysis. Ross EM. Resuscitation. 2016 Refractory Ventricular Fibrillation Successfully Cardioverted With Dual Sequential Defibrillation. Sena RC. J Emerg Med. 2016 Dual sequential defibrillation: Does one plus one equal two? Deakin CD. Resuscitation. 2016 Magnesium therapy for refractory ventricular fibrillation. Baraka A. J Cardiothorac Vasc Anesth. 2000 
June 15, 2017
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
June 1, 2017
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
May 19, 2017
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 < 94%, deliver oxygen 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 < 6 (normal or low) aim to keep SpO2 94-98% and repeat the ABG in 30-60 minutes 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 known to be normal for that individual Patients with COPD should initially be given oxygen via 24% venturi at 2-4L/min or 28% mask at a flow rate 4L/min, or nasal cannulae at 1-2L/min aiming for 88-92% Patients over 50 years of age and long term smoker with a history of SOB on exertion and no other cause for their breathlessness should be treated as having COPD. Limit O2 driven nebs, if no air driven nebs available, to 6 minutes in duration in patients known to have COPD In summary.... So the bottom line? Well just like Goldielock's porridge, with oxygen we don't want too little, we don't want too much but we want just the right amount! There is no doubt that hypoxia kills but beware that too much of anything is bad for you and in the same way we need to be vigilant to targeting oxygen delivery to our patients target SpO2   References BTS Guideline for oxygen use in healthcare and emergency settings  
May 15, 2017
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
May 1, 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   
April 25, 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  
April 15, 2017
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
April 1, 2017
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  
March 18, 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
March 8, 2017
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
March 1, 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  
February 21, 2017
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  
February 15, 2017
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
February 1, 2017
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
January 16, 2017
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
January 14, 2017
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
January 1, 2017
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 
December 15, 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  
December 10, 2016
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
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