Coda Change

Des Gorman talks about real-world outcomes and controversies following traumatic brain injury. His extensive research and experience in this area give a unique insight into what actually happens to the patients we care for.

Hallie Prescott tells us about why the back-end of sepsis matters and is a neglected aspect of our management. This sub-acute phase can really affect long term outcomes. Long term exposure to broad-spectrum antibiotics and too much fluid are aspects that matter and that we can modify.

Peter Brindley interviews Khairil Musa and they discuss Khairils passion outside of medicine: dance. This Pacific Island Playlist chosen by Khairil opens with Medicine by Daughter: https://vimeo.com/215106696 and closes with Momma's Prayers by JP Cooper: https://vimeo.com/237966073

Kat takes us through the reality of managing pre-eclampsia in South Africa, highlighting what we mustn't miss.

Andrew Dixon from Radiopaedia covers the common pathology seen on CT scans in critical care. He covers basic anatomy and important areas not to miss, strokes, trauma, herniation syndromes, hypoxic brain injury and diffuse axonal injury

Adam gives practical pearls about managing the unexpected difficult airway. He uses a good example, emphasises the importance of effective teamwork and draws from the Vortex approach and the DAS guidelines. Watch out for more from Adam via the Safe Airway Society.

Treating pain is important. Treating pain in a vulnerable population like infants, who cannot speak for themselves, is especially important. Unfortunately, there is a great deal of evidence, from many clinical settings, that suggests that we don't do a great job treating pediatric pain. Recognizing this problem, and based on a large number of randomized controlled trials, many experts recommended the use of sucrose to manage infants' pain. I question this approach and suggest we are safer to assume that sucrose is not a pain medication. Unfortunately, we can't measure pain in infants. The experience is entirely subjective. However, sucrose has been studied in populations who can report their pain (older children and adults) and does not work. Sucrose changes behavioural scores in infants, but those scores do not measure pain. Even if they did, observation is inaccurate for estimating pain in older populations who are able to report pain scores, so we should be skeptical of their accuracy in infants. Furthermore, in brain imaging studies, despite looking calmer, infants‚ brains still react as if they are in pain when sucrose is given. Therefore, I think the safest approach is to assume that sucrose is not a pain medication, and focus on other analgesic options (with proven effect in patient populations that can report their pain). Instead of relying on sucrose, I offer my top five tips for pediatric pain control. 1) Limit painful procedures whenever possible. (Think carefully about whether tests will actually change management. Use oral meds instead of IM or IV. Group painful procedures together.) 2) Think topical. EMLA is a proven option, but amethocaine works faster, and therefore might be a better option. 3) Consider using nerve blocks. 4) Remember the intranasal route. Fentanyl, ketamine, and midazolam are all excellent agents that can be used intranasally to help with pediatric pain and anxiety. 5) Think about distress, not just pain.

John Myburgh gives a philosophical talk about what life (and death) is really about and what the new challenges are in critical care. Modern critical care has so many potential interventions. John challenges whether doing more is always the right thing to do and gives a good argument for doing less being best.

Liz Crowe gives sage advice about dealing with grief and loss in the critical care setting, for both relatives and health care professionals.

There are many ways to skin a cat. Rhonda Cadena discusses management of intracranial hypertension, specifically substantial practice variation, what the evidence shows and what she does in reality.