The St.Emlyn’s Podcast

Chest pain that sounds like indigestion, feels mild or seems “atypical” can still be myocardial infarction. The difficult question is not whether troponin is useful, but which patients actually need testing — and how much weight we should give symptoms, cardiovascular risk factors and clinical judgement. Professor Rick Body looks at the evidence behind those decisions, drawing on his own research and other studies of patients with suspected acute coronary syndromes. He explores which clinical features genuinely change the probability of myocardial infarction, which are less useful than we might think, and how to balance the risks of missing MI against unnecessary investigation. In this podcast: Why “heavy” or “crushing” chest pain only modestly increased the probability of myocardial infarction in Rick’s study population. Why indigestion-like pain should not automatically reassure us, and why apparently “atypical” symptoms cannot safely exclude acute coronary syndrome. The diagnostic significance of associated features such as vomiting and, particularly, sweating observed by the clinician. Why dividing chest pain into “typical” and “atypical” presentations has limited discriminatory value. Why having no recognised hypertension, hyperlipidaemia, diabetes, smoking history or family history does not rule out acute myocardial infarction. How clinician gestalt does track with risk, but is not sufficiently reliable on its own to rule myocardial infarction in or out. Why none of this means testing everyone: Rick’s practical approach is to seek a convincing alternative explanation and use troponin when MI remains a plausible diagnosis that has not otherwise been adequately explained. The numerical probabilities discussed come from populations already selected for investigation of suspected myocardial infarction, so they should not simply be transferred to every patient presenting with chest pain. About Rick Body Rick Body is Professor of Emergency Medicine at the University of Manchester and an Honorary Consultant in Emergency Medicine at Manchester University NHS Foundation Trust. His research has focused extensively on diagnostics in acute coronary syndromes, including cardiac troponin and strategies for the early rule-out of myocardial infarction. Timestamps 00:00 – Which patients with chest pain need a troponin? 02:00 – What individual symptoms do to pre-test probability 05:00 – Vomiting and observed sweating 08:00 – The problem with “typical” and “atypical” symptoms 10:00 – Do traditional cardiovascular risk factors help? 13:00 – How reliable is clinical judgement or gestalt? 16:00 – Avoiding both under-investigation and over-investigation 17:00 – Rick’s practical approach to deciding when to test Links and resources The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes Examining the signs and symptoms experienced by individuals with suspected acute coronary syndrome in the Asia-Pacific region ‘Chest pain typicality’ in suspected acute coronary syndromes and the impact of clinical experience Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department? Can Emergency Physician Gestalt “Rule In” or “Rule Out” Acute Coronary Syndrome? Multicentre validation study More from St Emlyn’s St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources. If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you. Learning from podcasts? If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

Traumatic cardiac arrest demands rapid treatment, but one of the hardest decisions is whether a resuscitative thoracotomy is likely to help. Can the location of a penetrating injury and the rhythm on the monitor give us better information than an uncertain history of when the patient arrested? Recorded at Trauma 2030 at the Royal College of Surgeons of England, Iain Beardsell speaks with Laura Kocierz about a data-driven approach developed from London’s Air Ambulance experience. They discuss distinguishing cardiac tamponade from exsanguination, using ECG rhythm as a surrogate for arrest duration, and why thoracotomy should target the underlying pathology rather than simply the diagnosis of traumatic cardiac arrest. In this podcast: Why traumatic cardiac arrest is better thought of as a clinical low-output state rather than relying on a simple binary definition. How the surface location of a penetrating injury can help estimate whether cardiac tamponade or exsanguination is the more likely cause. Why a wound within the cardiac box or epigastrium was associated with more than a 30% chance of isolated tamponade in the London data. Why treating presumed exsanguination should not stop the team actively looking for concurrent tamponade, including with ultrasound. How the presenting ECG rhythm may provide useful physiological information when the reported duration of traumatic cardiac arrest is uncertain. The observed progression from organised sinus rhythm through bradycardia and agonal complexes to asystole as arrest duration increases — and why these are population-derived timings rather than precise clocks for an individual patient. Why an organised rhythm in a patient with suspected tamponade may support immediate resuscitative thoracotomy even when the reported arrest time appears prolonged. Why resuscitative thoracotomy is not, in itself, a treatment for exsanguination, where haemorrhage control, blood transfusion and rapid movement towards definitive care may need to take priority. About Laura Kocierz Laura Kocierz is a consultant in intensive care medicine and anaesthesia in Worcester and a consultant with London’s Air Ambulance. Her work includes research examining how clinical information available at the scene can support decision-making in traumatic cardiac arrest. Timestamps 00:00 – Defining traumatic cardiac arrest 02:00 – Injury location, tamponade and exsanguination 05:00 – When should resuscitative thoracotomy be considered? 07:00 – Using the ECG as a surrogate for arrest duration 11:00 – Combining likely pathology with presenting rhythm 13:00 – Moving beyond a simple 15-minute rule 14:00 – Why thoracotomy is not the treatment for exsanguination Links and resources Read the paper: Improving decision-making for prehospital Resuscitative Thoracotomy in traumatic cardiac arrest Read the London’s Air Ambulance study of 601 prehospital resuscitative thoracotomies Find out more about Trauma 2030 More from St Emlyn’s St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources. If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you. Learning from podcasts? If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD. Subscribe to the St Emlyn’s Podcast wherever you get your podcasts. Trauma 2030 TRAUMA 2030 united experts and innovators to shape the future of trauma care. Over two days, it explored breakthroughs in science, systems, and frontline practice, fostering collaboration across disciplines. The symposium aimed to inspire research, inform policy, and build a bold roadmap for trauma care worldwide.

The Fifth Universal Definition of Myocardial Infarction changes some familiar language around MI and puts new emphasis on how we interpret troponin, myocardial injury and imaging. For emergency clinicians, these changes affect both how we describe what is happening and how confidently we can make the diagnosis. Iain Beardsell introduces Rick Body, Professor of Emergency Medicine at the University of Manchester, who works through what has changed and what it means in practice. In this podcast: Why the familiar type 1–5 classification has been replaced by primary, secondary and procedure-related myocardial infarction. How conditions including plaque rupture, spontaneous coronary artery dissection, coronary vasospasm and embolism now fit within primary MI. Why the definition now supports sex-specific 99th percentile high-sensitivity troponin thresholds, and what this may mean for commonly used assays. How coronary or cardiac imaging has become more important when moving from a likely MI diagnosis towards confirmation and defining the underlying mechanism. Why a raised troponin is not synonymous with myocardial infarction, and how acute myocardial injury may result from inflammation, haemodynamic stress, physiological stress, catecholamine excess, toxicity or trauma. The challenge of diagnosing chronic myocardial injury in the emergency department when the definition describes assessment in a stable clinical setting. Why interpreting a troponin delta remains nuanced: absolute versus relative change, time from symptom onset and the interval between samples all matter. Where occlusive myocardial infarction (OMI) now sits: the terminology has not replaced STEMI/NSTEMI, but recognised occlusion patterns including de Winter T waves, Wellens syndrome, Sgarbossa criteria and posterior MI are explicitly discussed. About Rick Body Rick Body is Professor of Emergency Medicine at the University of Manchester and an honorary consultant at Manchester Foundation Trust. He is also Editor-in-Chief of the Emergency Medicine Journal and chairs the NICE Interventional Procedures Advisory Committee. Timestamps 00:00 – Introduction and why the new definition matters 02:00 – Primary, secondary and procedure-related MI 04:00 – Sex-specific troponin thresholds 05:00 – Imaging and confirmation of myocardial infarction 06:00 – Acute myocardial injury and its causes 09:00 – Chronic myocardial injury in the ED 11:00 – Absolute versus relative troponin deltas 15:00 – OMI, STEMI and NSTEMI terminology Links and resources Read the accompanying St Emlyn’s article Read the Fifth Universal Definition of Myocardial Infarction View the IFCC high-sensitivity cardiac troponin assay reference tables More from St Emlyn’s St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources. If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you. Learning from podcasts? If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

Small decisions in the resus room can save minutes; badly designed systems can waste thousands of hours. In the April 2026 St Emlyn’s round-up, Iain Beardsell and Simon Carley move between both ends of that spectrum, from external haemorrhage control and chest drains before CT to ED crowding, clinician productivity and the reflex to solve safety problems with more mandatory training. There is also new evidence on smoking cessation in the emergency department and HI-PEITHO, a randomised trial of catheter-directed thrombolysis for higher-risk pulmonary embolism. In this podcast: A practical escalation approach to external haemorrhage control: why accurate direct pressure still matters, when to escalate, and why a tourniquet should not automatically be the first intervention. Chest drains before trauma CT: when physiological compromise makes drainage necessary and when inserting one first may simply delay definitive imaging. How Stevan Bruijns’ idea of a cognitive bridge can help clinicians explain ED crowding to colleagues who do not experience the problem themselves. Why asking how many patients per hour a clinician sees can be misleading if staffing, crowding, IT, physical environment and workflow are ignored. Jesse Spurr’s challenge to healthcare’s instinct to respond to errors with another training module, and why systems thinking may identify more useful solutions. What a systematic review tells us about smoking cessation interventions in the ED, including the difference between behavioural advice alone and interventions incorporating nicotine replacement therapy. The HI-PEITHO trial of ultrasound-facilitated catheter-directed fibrinolysis plus anticoagulation for intermediate-high-risk pulmonary embolism, and why the composite outcome and balance of benefit and harm need careful interpretation. Why putting a major trauma patient straight onto a portable monitor, checking transfer oxygen and preparing equipment early can remove avoidable delays on the way to CT or theatre. Links and resources Read TTL Tip 8: External Haemorrhage Control Read TTL Tip 9: Chest Drain Before CT? Think, Decide, Communicate Read Explaining Emergency Department Crowding Using a Cognitive Bridge Read Marching Backwards into the Future: Why Healthcare Needs Fewer Modules and More Systems Thinking Read How Many Patients Should We See Per Hour? Read Fit to Quit? The Trial Evidence for Smoking Cessation Interventions in ED Read the Emergency Medicine Journal systematic review of ED smoking cessation interventions Read the St Emlyn’s review of HI-PEITHO Read the original HI-PEITHO trial in the New England Journal of Medicine Read TTL Tip 10: Put the Trauma Patient Straight onto the Portable Monitor More from St Emlyn’s St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources. If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you. Learning from podcasts? If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

In this month’s St Emlyn’s podcast, Iain Beardsell and Simon Carley work through some of the most interesting recent posts and papers from the blog. The conversation ranges from the latest pulmonary embolism guidance to the persistent problem of emergency department crowding, and from pre-hospital whole blood to the uneven availability of enhanced critical care across the UK. They also look at whether TOE might help us deliver more effective CPR, why arterial pressure may be a more useful resuscitation target than simply watching compressions, and a remarkable report from Gaza that challenges some long-held assumptions about pericardiocentesis in traumatic tamponade. As ever, the focus is less on simply repeating what the papers say and more on what they mean in practice. Some of the evidence is reassuring, some of it is uncomfortable, and several of the studies raise as many questions as they answer. It is a discussion about uncertainty, physiology, systems and the importance of being willing to change your mind when the evidence does not fit what feels intuitively right. Learning from podcasts? If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.