The Resus Room

Motor vehicle collisions or road traffic collisions are a massive problem worldwide. Data from the World Health Organisation reports that there are around 1.2 million deaths every year and this is the leading cause of death internationally for children and young adults aged 5-29 years.  In the UK there are around 1,500 deaths annually and also around 60,000 patients with significant and life changing injuries, which is 7 patients every hour!! So anything we can do to improve patient care following an MVC is definitely a worthwhile venture. We’ve looked at Extrication here on the podcast before but we’re back on it again because today the Faculty of Pre Hospital Care have released their Consensus Statement on Extrication Following a Motor Vehicle Collision.  The statement builds on the work from the EXIT project and the research that has helped inform our understanding of multiple factors of extrication. The statement will inform a change of practice for both clinicians and non-medical responders and in this episode we run through the statement with two of it’s authors and discuss the practical applications. Make sure you take a look at the new Consensus Statement itself and the background evidence which is all linked to on the website. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome back to the podcast and to November's Papers of the Month! We start off looking at the rate of pneumothoraces in patients following ROSC after a medical cardiac arrest. What is the incidence? Are there any risk factors? And how might this affect our index of suspicion and imaging practice? We've spoken before about how difficult vertigo can be as a presentation to the Emergency Department; really common, often benign but with differentials that include posterior circulatory strokes, tumours and infections. Our second paper looks at a clinical risk score for patients presenting with vertigo to the ED and consider how this might affect practice. And finally we take a look at a great paper focussing on pre-alerts to the ED; consider current barriers, understanding and ways that we could improve the process both for the patients and staff. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

In this episode we’re going to be running through adrenal presentations; both Adrenal insufficiency and Adrenal Crisis. There are some parts of these that aren’t completely understood and a lack of a universal definition of Adrenal Crisis, but both insufficiency and a crisis are similar problems at different points on a spectrum and solid understanding of the endocrinology and physiology can really help to improve care in this area. There is huge potential for improving current morbidity and mortality. We’ll run through both primary and central adrenal insufficiency, describe how this leads to different effects on mineralocorticoids and glucocorticoids and the signs and symptoms that will occurs as a result.  Many of the patients presenting to the department will be unknown to have adrenal insufficiency and we’ll run through those who are at higher risk, including a huge group due to ongoing medication, who may be those on steroid doses much lower than you would previously have considered as significant.  NICE published their most recent guidance on Adrenal Insufficiency in August this year and we’ll be referring to a lot of this as we run through the episode.  We’ll finish up looking at the critical presentation of Adrenal Crisis and the emergency and ongoing management, along with how we support patients with insufficiency to prevent a crisis occurring.  Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome back to October's Papers of the Month. We've been really spoilt with three fantastic papers to discuss this month! First up we take a look at the accuracy of non-invasive blood pressure readings in critically unwell patients in the prehospital environment and see how they could falsely reassure in both hypotension and hypertension. Next up we take a look at the superb SHED study, which looks to evaluate the accuracy of a plain CT head in identifying subarachnoid haemorrhage at different time frames. Currently NICE recommend an LP after a negative scan if the scan was performed more than 6 hours from onset. But what does this significant  dataset show and importantly how likely are you to 'miss' an aneurysmal subarachnoid haemorrhage if scanned within the first 24 hours and not following up with an LP? Lastly we look at a paper that highlight the potential benefit of naloxone in out of hospital cardiac arrest in opioid overdose. This delves into priorities in resuscitation, the fundamentals and some possible unexpected physiological effects from naloxone. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

PE’s (or Pulmonary Emboli) are a key part of Emergency Care, something that many of us will consider as a differential diagnosis multiple times of a daily basis, in a similar way to acute coronary syndrome, so we need to be absolute experts on the topic! A PE normally occurs when a Deep Vein Thrombosis shoots off to the pulmonary arterial tree, occurring in 60-120 per 100,000 of the population per year The inhospital mortality is 14% and the 90 day mortality is around 20%. But this is proportional to its size, and risk stratifying PE’s once we’ve got the diagnosis is really important. PE is a real diagnostic challenge and less than 1 in 10 who are investigated for a PE end up with the diagnosis, so knowing the risk factors, associated features and thresholds for work up are really important. There are some key concepts in risk stratification and particularly in test thresholds that we’ll cover in this episode that are applicable to all of our practice…..we’re excited! Getting these right helps us to avoid missing the diagnosis and equally importantly ensure we aren’t ‘over testing’ & ‘over diagnosing’ because investigation and treatment for a PE isn’t without it’s own risks. In the episode we’ll talk in depth about factors associated with presentation, risk factors, investigations and finally onto treatments, covering the whole spectrum from low risk PE’s up to those with massive PE’s and cardiac arrest. The evidence base behind the work up and treatments is truly fascinating and we hope you find this episode as eye-opening as we did to prepare for! Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome back after the summer break! Three more papers for you to feast your ears on this month and as always make sure you go and check them out yourselves after you've had a listen! First up, following on really nicely from the DOSE-VF paper on dual sequential defibrillation we take a look at the paper that looks at the association between shock interval and VF termination. We might be biased but this shines a light on an area that could make a huge difference to the outcomes for patients with refractory VF! Next; when you're seeing a patient with an upper GI bleed, which scoring/prognostication tool do you use and is it the best? We cover a paper that looks at exactly this question. Finally we look at whether TXA predisposes patients to a higher risk of venous thromboembolism and whether it might affect our practice patterns. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

The UK REBOA trial left many with doubts over its utility for trauma patients in ED. The time from injury to its use was around 90 minutes and the trial was stopped when it didn't reduce and maybe even increased mortality compared to standard care alone. But what effect does REBOA have when used prehospitally and how feasible is it? Our first paper, from London HEMS, looks at this and gives a fascinating insight into it's use and the physiological response seen with it. We've recently looked at dual sequential defibrillation for refractory VF with the DOSE-VF trial. Our second paper this month looks at how a double defibrillator strategy, in the context of cardioversion for AF, may affect restoration of sinus rhythm in obese patients. Finally we take a look at the use of video livestreaming from scene to EMS, in a feasibility RCT. How can it affect accurate dispatch of the most appropriate resources and what impact does it have on those that use it? Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

Acute Kidney Injury is common, complicated and holds significant morbidity and mortality. But...if we recognise it, we can make a real difference to our patients' outcomes. In this episode we run through the anatomy, physiology and aetiologies. We have a think about the multitude of definitions of AKI and then take each of the pre renal, renal and post renal categories and think about the ways we can optimise our care in each. We also have a think about who needs to be admitted and who can be safely managed in the community. This was a hugely valuable episode for us all to research and bring clarity to a complicated topic, we hope it does the same for you too! Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

There's a huge paper to talk about this month in the PREOXI trial, a multi centre RCT looking at the pre oxygenation strategy in critically unwell patients undergoing RSI, with patients either getting high flow oxygen through a facemask or NIV. The results are pretty remarkable and may well be practice changing as we'll discuss in the podcast! Next up we take a look at a feasibility of lidocaine patches for older patients with rib fractures and the potential benefit in terms of pain and respiratory complications. Lastly we take a look at the benefit of performing a CT head scan in the Emergency Department for patients with a first fit. At times this can feel like a significant utilisation of resources, but what is the yield of positive scans and impact on patient care? Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

So this month we’re looking at major incidents and specifically the triage process that is now coming into play in the UK and further afield that you need to know about! We normally stick pretty strongly to clinical topics; they’re pretty easy to focus on because you can imagine how extra knowledge in a certain clinical area could make a difference to presentations that we see pretty commonly. And being brutally honest, making the effort to prepare and rehearse what we might do, on the off chance that we ever come across a major incident, can be difficult to motivate yourself to do. But this is probably an area that investing a bit of time in, really thinking about how you would act in a major incident, could make a phenomenal difference to what may be one of the most, if not the most challenging clinical days of your career. In the episode we run through Ten Second Triage (TST) and the Major Incident Triage Tool (MITT). They replace the previous triage methodologies and are to be implemented by the end of this month. We also cover some other aspects of planning and approach for being the first responder at a major incident, and we were lucky enough to gain some insights to the new triage process from Phil Cowburn, an EM & PHEM consultant who was involved in their development. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome back to June's Papers of the month! We kick off this month looking at the work up of patients with a first episode of psychosis. With these patients there is a chance of a psychosis secondary to an underlying structural cause. Getting neuro-imaging to look for this prior to psychiatric assessment is tricky though, often with a need for sedation and then the subsequent delay for psychiatric assessment. Our first paper looks at the yield of positive scans for these patients and helps us to understand a bit more about the need for this. Secondly; sepsis screening tools are commonplace in most emergency services and departments, but how do they compare against senior clinician gestalt? Finally we look at the association of gastric distension in cardiac arrest and the rates of ROSC, should we be concentrating more on decompression of gastric volume intra-arrest? Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

We’ve covered Cardiac Arrest management (as in the medical delivery of it) in a previous Roadside to Resusepsiode. Since then we've had some updates with Paramedic-2, Refractory VF, Airways-2  and a whole host of other papers. But what we haven't talked much about is the art of creating the environment, space & workflow to deliver the best medical care possible.  Whilst these might seem like less exciting and important parts of the package, they probably require a greater degree of skill and knowledge than running the medical aspects of the arrest. To do them with excellence you need to anticipate every single objective/obstacle that could stand in your way, including the medical interventions involved and the challenges of that unique case and environment.  In this episode we run through the aspects of a cardiac arrest right from the initiation of the case to the clearing/transfer to onwards care. We talk about the use of immediate, urgent and definitive plans and then run through how these translate into both in-hospital and prehospital arrests. We personally got a lot out of preparing and thinking about this episode, so we hope you find it useful too! We’d love to hear any thoughts or feedback on this slightly different style of episode either on the website or via X @TheResusRoom! Simon & James

Welcome back to the podcast and three great papers for May's episode! First up we take a pretty deep look into refractory VF. This follows on from our our review of DOSE-VF in December '22's papers of the month and our recent Roadside to Resus on the topic. In that we discussed the possibility that many of the cases we see at pulse checks as being refractory VF may actually have had 5 seconds or more, post shock, where they jumped out of VF but then reverted back into it. This paper is a secondary analysis of DOSE-VF and reveals what really happen to these 'refractory VFs' by interrogating the defibrillators. What difference will it make to our strategy for recurrent and refractory VF? Next up we take a look at elderly patients presenting to the Emergency Department with abdominal pain with an analysis of the features that predict a serious abdominal condition. Lastly we look at the how different pressures exerted to the facemask when ventilating neonates can make in terms of bradycardia and apnoea. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

Lower back pain is a really common cause for patients to present to primary care, urgent care and emergency care. Thankfully many of these cases are self limiting, but somewhere in the region of 1:300 patients with back pain in the ED will have Cauda Equina Syndrome. Cauda Equina Syndrome is something that is challenging for all clinicians because many patients with simple lower back pain may have many similar symptoms,  but if we miss it, or if there is a delay to surgery that can lead to potentially avoidable long-term disability for our patients and on top of that its a major cause of healthcare litigation. And we’re not talking about a delay in weeks being a problem here, we’re talking about hours to days, with big  potential complications like impaired bowel/bladder/sexual dysfunction or lower limb paralysis - so you can see why litigation is a big part of some missed cases. In this episode we run through the the signs, symptoms, investigations and treatment with a strong reference back to the underlying anatomy and disruption. We also cover the recently published national Cauda Equina Pathway, which is a great resource but poses some real challenges in it’s implementation! Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome back to the podcast! Three more papers covering topics that are relevant to all of our practice. The importance of removing wet clothes from patients is often discussed, both to prevent hypothermia and increase patient comfort. But how important is it to get wet clothes off and is it something we can defer to a different point? We start off taking a look at an RCT on this very question. Next up another RCT, this time looking at the efficacy of morphine, ibuprofen and paracetamol for patients with closed limb injuries. Which one, or combination, would you think would be most efficacious… Lastly, following on from our most recent Roadside to Resus episode, we take a look at a paper on the association between end tidal CO2 levels and mortality in prehospital patients with suspected traumatic brain injury. This paper highlights really well the need understand the fundamentals that contribute to ETCO2 when applying to clinical practice.  Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

End Tidal CO2, or ETCO2 for short, is something that’s talked about pretty often in Emergency and Critical Care and that’s because it’s used a lot in the assessment and treatment of patients! It’s got a big part to play in airway management, resuscitation, sedation and is also increasingly used in other situations. Some of these applications have some pretty strong evidence to back them up but others are definitely worth a deeper thought, because without a sound understanding of ETCO2 we can fall foul of some traps… ETCO2 is a non-invasive measurement of the partial pressure of CO2 in expired gas at the end of exhalation. Ideally we’d like to know what’s really going on arterially with the partial pressure of arterial CO2 but we can use the end tidal because that’s an easy reading to get from exhaled breath, when it will most closely resemble the alveolar CO2 concentration. Its value is reflective of ventilation but also really importantly is affected by the circulation, the circuit and how it’s applied. In the podcast we run through all of these aspects, its application to clinical care and also some of its pitfalls.  Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome back to the podcast, a new month, three more papers and discussion around the topics. We kick off with a paper comparing mechanical ventilation in CPR compared to the more traditional hand ventilation; what difference does the machine make to ventilation in arrest and should we be changing to this strategy as a standard? We've talked about aneurysmal subarachnoid haemorrhage a fair amount on the podcast and the second paper looks at the effectiveness of lumbar CSF drain compared to standard care with some pretty staggering results! Lastly we take a look at a paper exploring decision making in prehospital trauma, specifically with regard to blood transfusion. This is a great paper to focus on the complexities of decision making, understand decision making strategies, recognise areas of weakness and consider how aspects of these can be used educationally and to improve emergency care for our patients. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

As we all know, rapid and effective resuscitation makes a huge difference to the chance of survival from a cardiac arrest. If you’re going to pick a rhythm to have as the patient or as the Resuscitationist, then it’s going to be a shockable rhythm, so VF or pulseless VT as they hold the greatest chance of survival. You'll find an initial shockable rhythm in around 20% of cases & defibrillation alone may lead to a ROSC. So it’s absolutely imperative to get the immediate management spot on! Whilst current practice is good, there are some aspects of care that we can improve on and make a real difference to outcomes in these patients, with those first on scene or at the bedside in a phenomenally important position to deliver life saving care. In this episode we’ll be talking predominantly about refractory VF but the strategy will transfer to how we can also deal with refractory VT cardiac arrests.  We'll be running through all of the following; VF incidence Mechanisms behind VF Refractory and recurrent VF Defibrillation strategies Pharmacological strategies PCI in arrest ECMO Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome back to February's papers of the month. Syncope is a really common presentation to the Emergency Department and it can be complicated to tease out those with a concerning precipitant from the others with a more benign cause. The first paper gives us some context to the management of these undifferentiated syncopes and provides a barometer for how stringently ESC guidance on the topic is followed. Next up we take a look a huge RCT of transfusion thresholds in patients presenting with a myocardial infarction. Should we be restrictive in our approach, saving a valuable resource, or is it validated to transfuse more liberally in terms of the patients outcome? Finally we take a look at a paper looking to tease out the predictors of post intubation hypotension in those getting a prehospital anaesthetic following trauma, with some interesting associations and factors to looks out for. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

Fever is an incredibly effective mechanism to fight off pathogens. Clearly, whilst many illnesses that cause a fever don’t require anything more than the body’s natural response, there are some patients in which a fever might represent a serious illness. Differentiating those serious illnesses from self-limiting presentations can be tricky at times, but can also be anxiety provoking for clinicians and parents, or carers of that child.  In children the limited communication can make the diagnostic challenge of the origin of the fever a real challenge, along with the added difficult of gaining some tests. Differentiating those with a benign disease from those with a life threatening presentation can be a daunting challenge. The numbers of presentations to healthcare providers are staggering. Paediatric fever has been reported to represent as high as 15-25% of all presentations in primary care and emergency departments, so massive numbers. Thankfully the prevalence of serious infections in children is low and is estimated at <1% in primary care settings in industrialised countries, although it has been suggested that for ED attendances the prevalence of serious illness could be as high as 25%. So we thought with this common but tricky presentation that it was about time we tackled the topic. We'll be running through; A definition Patholphysiology Relevance of the severity of the fever Febrile seizures Clinical assessment NICE guidelines Duration of fever Management Antipyretics Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James