The Resus Room – Details, episodes & analysis

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

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

Happy New Year!

We've got some great topic and in person events lined up for 2024 which we'll be able to share some more details about with you soon.

This month we look at an RCT of conservative airway management in patients with a low GCS following presentation with acute poisoning.

Next up we take a look at paper reviewing our diagnostic ability with dissociative seizures; this gives us some really valuable signs and symptoms to looks for and outlines how we can improve with these presentations.

Lastly we look at prognostic scores following out of hospital cardiac arrests with a study that compares four different scores. If reliable they have significant scope to help us to both prognosticate and give valuable information to family and loved ones on their presentation to ED.

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

We know it's the festive season but we thought we'd try and cover an issue from which there appears to be no escape and is a particular problem at this time of year, queuing!

Whether we like it or not, this has become a factor for all of us working in emergency care, whether its delays getting your patient into the department, queueing down the corridor into ED, a prolonged stay in ED for an appropriate ward, or even in a physical queue to get out of the ED and onto an appropriate bed!

We are looking after our patients for significantly longer than we're used to and this pushes the patient and the clinician into an area of care in which we have limited experience and comfort.

Rather than accepting delays and ignoring their inevitable impact on patient care, we need to move towards equipping ourselves with the skills and knowledge to fill that care vacuum and ensure that excellence in patient care continues throughout their time with the ambulance service.

So with that in mind, in this episode we're going to think about some of the considerations and interventions that are required to ensure our patients remain safe and comfortable throughout their queueing experience. And to do that we're going to draw on the concept of prolonged field care.

An article by Aehbric O'Kelley and Tom Mallinson recently authored a paper published in Journal of paramedic practice entitled "Prolonged field care principles in UK paramedic practice". That article really provided the idea and stimulus for this episode, so thanks to them for all of the hard work and once you've listened to us waffle on you should head across to their paper for a far more eloquent explanation of it all!

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

We've talked about Aortic Dissection before in our Roadside to Resus episode and the huge difficulties in picking out these rare but potentially devastating cases and this month we've got a fantastic paper on the topic! The DAShED study looks at patients presenting with symptoms that could be suggestive of aortic dissection and helps us understand the diagnostic challenge and approach to acute aortic syndrome, along with testing the characteristics of a number of decision tools.

Next up we look at a paper from Bendszus, an RCT of medical versus thrombectomy and medical treatment for acute ischaemic strokes with a large infarct, with some really powerful results.

Finally we look at a paper that shows some staggeringly different ROSC rates for patients in cardiac arrest depending on the size of the ventilation bag used!

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob