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