Coda Change

The arrested heart surgery patient is a unique beast in surgery and critical care. Dr Nikki Stamp gives a whirlwind tour of post cardiac surgery resuscitation. She will discuss how to spot the potential arrest, how to manage it and some special situations to be aware of in this special group of patients Post cardiac surgery resuscitation is complex. Nikki describes them as "brown trouser moments". She highlights this with three cases. A15-year-old girl who exsanguinated on Day 12 after dissection repair in the community. A 40-year-old female arrested within an hour of a re-do aortic root procedure. A 72-year-old lady who arrested after a bradycardic arrest following an aortic valve replacement. Only one survived – this is serious business. Cardiac arrest post cardiac surgery is relatively uncommon. The survival rate is also quite high. This is due to it being recognised and treated early with a high proportion of reversible causes. The key is to think of these causes and treat them as a team. Nikki breaks the causes into four groups. Ischemia, mechanical, arrhythmia and unknown. It is important to recognise that cardiac arrest in this population is differs to a typical scenario of cardiac arrest. As such, there is a different algorithm. This hinges on assessing the rhythm in the first instance and consider defibrillation fist if appropriate. One should also consider the use of pacing wires if they are still in post-operatively. Nikki provides a great number of clinical pearls, discussing care of the right heart, use of chest compressions and cardiac massage, use of ECMO and considerations if a left ventricular assistance device is in place. Her take home points include being alert to these situations but not alarmed! Practice these resuscitations as a team. Shock early and pace early and remember most people should not die with a closed chest!

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Management of Status Epilepticus in Neuro Critical care Brandon Foreman talk about the management of status epilepticus in neuro critical care. What are seizures? Why is this important? There are 1 million ED visits due to seizures every year with a quarter getting admitted to the hospital. 1 in 10 people will have a seizure in their lifetime. It is common. Status epilepticus is defined as seizures lasting greater than 5 minutes or recurrent seizures without interval recovery back to baseline. Practically speaking, if the person is seizing when you walk into the room or they remain comatose after they just seized, assume they are in status epilepticus. A key point - the longer the seizure, the greater the mortality. So early and effective management is critical. The first line of defence is benzodiazepines. Give it however you want, give it fast and give it in the correct dose. Brendon stresses dosage is really important. This treatment is effective, with one study showing by following a status epilepticus protocol, 74% of status epilepticus patients had resolution compared to only 29% without adequate treatment. After 20 minutes, the patient is still seizing. Now what? This condition is now defined as established status epilepticus, and you must move to second line treatments. In this category there are a lot of choices. They are of course all intravenous drugs. They all have pros and cons so use what you have available and what you are comfortable with. Again, whatever you chose, use the right dose. If after 40 minutes you are still not winning, move to the next step. At this stage the seizure might look like it is controlled due to electromechanical dissociation. However, this is commonly non-convulsive seizure activity. Get started on the third line of defence… do not muck around with more benzodiazepines or second line agents. You now move to starting an anaesthetic and securing the airway. Use whatever is available and whatever you are most comfortable with. By treating and controlling status epilepticus in under 60 minutes and you have a real chance of reducing mortality and morbidity in these patients.

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Maaret Castren passionately delivers her take on how to improve outcomes from out-of-hospital cardiac arrests. Maaret brings resuscitation back to the basics. Using science, education and local organisation factored together, we can drastically improve the chance of survival in out-of-hospital cardiac arrest. Currently, the best systems in the world only garner 20% survival rates in these situations. Mareet explains that quite simply, education is lacking. She believes the first step is to know your patient. 50% of cardiac arrest patients have signs and symptoms in the preceding weeks before their arrests. However, there is no current sudden cardiac arrest risk prediction tool available! Maaret explains the concept of precision medicine – the idea that medicine practised in a one size fits all manner provides successful treatments to some patients but not all. One must consider individual differences in people's genes, environments and lifestyles. In resuscitation medicine this can simply mean altering hand position based on a patient's size. Developing a culture of excellence is crucial in improving survival rates. Maaret challenges you to make the decision to not allow anyone suffering a cardiac arrest to die. She challenges you to not accept failure – and if it is to occur then to scrutinise why. Maaret goes on to assert that while people have been trained and equipped with skills to deal with a cardiac arrest, health professionals have been found wanting research. Doctors and nurses have been shown to have less survivors when calling emergency numbers. She wants this to improve through ongoing education and training. Currently there is a huge variation in outcomes for cardiac arrest patients. Measuring your results makes it possible for you to know what to improve. Benchmarking shows you where you need to learn. You need to build a culture of excellence in your own system. Patients are not the same, so we need to also individualise resuscitation. Maaret implores you to make the jump from the current culture to the desired culture and in doing so improve the resuscitation outcomes from out-of-hospital cardiac arrests.

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Resuscitation is complicated, but the solutions don't have to be. Chris Hicks brings you four psychological strategies that will help you manage complex resuscitations. It is a fascinating time to be a resuscitationist with ROBOA, ECMO and EPR. Chris explains that as we learn more about critical illness, we learn more about the complexities of resuscitation. Therefore, we need ways to manage and constrain complexity and to simplify and organise problems that will see us through. Chris's lessons are founded on a case. A 22-year-old female is brought into the Emergency Department. She was an unrestrained driver in a motor vehicle accident. She is agitated, has multiple facial smash injuries, burns to her torso and neck, a right sided flail segment, and a mechanically unstable pelvis. Also, when you ultrasound her abdomen, you realise she is well into the third trimester of a pregnancy. Chris discusses four strategies to cope in a complex situation. The first is grounded in habits. Habits have a lot to do with whether or not we succeed at a given enterprise. They can help break down complex problems into simpler parts. Once a habit has been practiced and rehearsed, it becomes harder to not execute the habit than it is to execute it. Next Chris advises to foster emergent organisation in the team. This is self-organisation in teams whereby individual simplicity can create organised complexity. During periods of high task loads it makes sense to create smaller teams to create divisional lines. This allows semi-autonomous teams to function independently towards a specific goal. Thereafter, try to factor down complex problems. Take a problem as you see it and lead it in a direction you'd like to see it. By simplifying a problem into a few sentences, you assert that you understand it, and you can then begin to manage it. Finally, Chris talks about limiting variability. This is in order to constrain chaos. Eliminate variables and thereby eliminate unnecessary steps. This can sometimes mean cutting down team size – Chris conjects most teams are too big! Join Chris as he takes you through four strategies to manage complexity in a complex resuscitation. Lean on habit. Foster emergence. Factor down the problem and limit the variables.

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Neurologic airway manipulation is unforgiving; errors lead to hypoxia and secondary injury. Managing the airway with an eye towards success, the first time, every time, without allowing sats to drop below 90% is the holy grail of neuro airways. Selection of RSI techniques, DSI techniques, and pharmacologic management is critical for success. The TBI airway with ICP issues and the post tPA airway present unique problems and the failed extubation in the neurologic patient is as common as the day is long. We will explore the latest theories and data (if there are any) and debunk some common myths together during this session.

Interprofessional issues in critical care

Meeting of the Tribes brings together clinicians from a broad range of health professions, including medicine, nursing, social work and physiotherapy, to explore interprofessional issues in critical care.

In addition to their clinical work, panelists have unique perspectives on education, simulation and resilience in healthcare.

In discussing issues related to tribalism and their implications for interprofessional practice, the panel explore what it will take to overcome a tribal mentality in the service of improved patient care.

Tune in to this discussion as the panel strive to:

(a) present a snapshot of the status quo

(b) explore key issues and their implications for clinical practice

(c) envision of future of enhanced interprofessional collaborative practice.

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Ronan O'Leary discusses reversing coagulopathy in traumatic brain injury. The PATCH trial was a trial look at the use of platelets to reverse the effects of aspirin and clopidogrel in patients with spontaneous cerebral haemorrhage. Ronan asserts that overall platelets are harming patients. Through his talk he highlights many studies that have been inconclusive about the benefits of giving platelets in traumatic intracerebral haemorrhage. As one study eloquently described, "It was not possible to determine if platelet transfusion was superior, inferior or not different from control interventions." So why are platelets given at all? In haemorrhage, reduced platelet activity is associated with adverse outcomes. This is demonstrated with larger haematoma size in patients with lower platelet counts. So, it would make sense that replacing platelets should lead to better outcomes. However, this is not the case. Furthermore, as Ronan articulates, sometimes it just feels better to do something over nothing. The aetiology of the condition probably has nothing to do with platelets in the first place. Instead, non-traumatic intracerebral haemorrhages are likely caused by atherosclerotic disease, with changes in microvascular anatomy and brittle vessels leading to haemorrhage. Further, transfusing a patient with intracerebral haemorrhage with platelets may lead to secondary ischaemic change. Platelets have many proinflammatory and prothrombotic properties. So are the harms of platelets outweighed by the benefits… probably not. Ronan will go on to discuss the potential to extrapolate this evidence to traumatic brain injury patients. He concludes, probably not, mainly due to the mechanism of haemorrhage being the transmission of kinetic energy which is at odds with that of spontaneous intracerebral haemorrhage.

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Moderate panel discussion on FOAM Open Access Medical Publishing Data sharing

The door to needle time for acute stroke in Critical Care is a key variable when striving for good outcomes. Rhonda Cadena answers the question - Who should pull the trigger on tPA for acute ischemic stroke? Medical management of acute strokes has changed dramatically over the years. We used to rely on clinical exams for diagnosis, prescribe strange medications and undertake interventions that were scary! This has changed in recent times. We have now evolved to advanced imaging techniques, new medications and interventions including endovascular treatments. These advances have dramatically increased the likelihood of positive outcomes in stroke patients. The new problem coming to light is time. All the modern treatments that exist do wonderfully well in achieving what they are supposed to. However, the longer it takes for a stroke patient to be get the treatment equates to more deficits and less chance of having a complete recovery. The process as it currently exists can take time. A patient will notice symptoms. They then call emergency service. An ambulance is dispatched, the patient undergoes an initial assessment and is then transferred to the hospital. Here they will be triaged, connected to monitoring, have bloods drawn, have a history taken, be examined… all taking time! Stroke guidelines say the door to treatment time should be 60 minutes or less. Rhonda explains that the focus should be on reducing the time that the process takes. She highlights that most of the time savings should occur before the patient hits the door. That is in the pre-hospital setting. We should be focusing on emergent treatment in the pre-hospital period. Rhonda runs through practical examples of time saving techniques utilising technology and a few simple changes to processes to cut time and improve outcomes. The basics of tPA are spelled out and Rhonda steps you through how a lot of the steps can be expedited along the patient's early treatment journey. So, who pulls the trigger? Rhonda explains it does not matter! So long as we are saving time in the pre-hospital period, the door to needle time for acute stroke can be reduced and outcomes improved.

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