Welcome back, this is our last podcast before our short summer break! We start off having a look at the physiological effects of prolonged resuscitation with a supraglottic device compared with endotracheal intubation, which raises some really interesting questions about our ongoing ventilation strategy in resuscitations. Next up we look at an RCT comparing RSI to DSI in critically injured patients and the effect on peri-intubation hypoxia. Finally we take a look at the practice of lateral canthotomy for retrobulbar haemorrhage/orbital compartment syndrome. How effective is the procedure and how competent are EM clinicians compared to Opthalmogists? Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom and we'll see you back in September! Simon &amp; Rob

Welcome back, this is our last podcast before our short summer break! We start off having a look at the physiological effects of prolonged resuscitation with a supraglottic device compared with endotracheal intubation, which raises some really interesting questions about our ongoing ventilation strategy in resuscitations. Next up we look at an RCT comparing RSI to DSI in critically injured patients and the effect on peri-intubation hypoxia. Finally we take a look at the practice of lateral canthotomy for retrobulbar haemorrhage/orbital compartment syndrome. How effective is the procedure and how competent are EM clinicians compared to Opthalmogists? Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom and we'll see you back in September! Simon &amp; Rob

August 2023; papers of the month

So in this episode we’re going to run though the primary survey in trauma. This clinical assessment helps us identify and treat life threatening injuries and to rapidly intervene and correct them, so getting it right really matter1.  How this is done is hugely dependant upon the setting (either pre or in-hospital) as it is affected by the access to the patient, the number of people there to contribute to care and the challenges that the scene or hospital environment might hold. We run through a model of primary survey that looks to gain as much information as possible in a rapid and effective pattern and discuss the slightly different approaches we all take, along with  rationale behind them. Finally we cover the communication of the primary survey to the team, strategies that we can undertake to achieve this and how this can affect the momentum and onwards care of the patient.  We found this a really useful topic to consider in some depth and we hope it's of use to you too! Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James

So in this episode we’re going to run though the primary survey in trauma. This clinical assessment helps us identify and treat life threatening injuries and to rapidly intervene and correct them, so getting it right really matter1.  How this is done is hugely dependant upon the setting (either pre or in-hospital) as it is affected by the access to the patient, the number of people there to contribute to care and the challenges that the scene or hospital environment might hold. We run through a model of primary survey that looks to gain as much information as possible in a rapid and effective pattern and discuss the slightly different approaches we all take, along with  rationale behind them. Finally we cover the communication of the primary survey to the team, strategies that we can undertake to achieve this and how this can affect the momentum and onwards care of the patient.  We found this a really useful topic to consider in some depth and we hope it's of use to you too! Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James

Trauma Primary Survey; Roadside to Resus

There have been some huge trials released over the last month and we've got three brilliant papers to discuss! First up we take a look at an RCT on video versus direct laryngoscopy for patients requiring emergency intubation with the DEVICE trial. The VL versus DL debate has been ongoing for quite some time now, so is this a final nail in the coffin for DL? Next up we take a look at an RCT of prehospital TXA use in patients at risk of bleeding from major trauma in the PATCH trial. The results seen in the trial look at a glance to oppose those seen in CRASH-2, so is this the end of TXA in this cohort of patients? Finally we have a great paper giving us further information on whether we should we be initiating immediate antihypertensive treatment for patients admitted to hospital with asymptomatic hypertension. Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon &amp; Rob

There have been some huge trials released over the last month and we've got three brilliant papers to discuss! First up we take a look at an RCT on video versus direct laryngoscopy for patients requiring emergency intubation with the DEVICE trial. The VL versus DL debate has been ongoing for quite some time now, so is this a final nail in the coffin for DL? Next up we take a look at an RCT of prehospital TXA use in patients at risk of bleeding from major trauma in the PATCH trial. The results seen in the trial look at a glance to oppose those seen in CRASH-2, so is this the end of TXA in this cohort of patients? Finally we have a great paper giving us further information on whether we should we be initiating immediate antihypertensive treatment for patients admitted to hospital with asymptomatic hypertension. Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon &amp; Rob

July 2023; papers of the month

This is the first of two episodes looking at pneumothoraces. In this episode we're going to start out by taking a look at traumatic pneumothoraces. Traumatic pneumothoraces are present in about a fifth of multiple trauma patients, so it's not infrequent to come across them and they can obviously occur in those with isolated chest injury too. Thoracic trauma occurs in around two thirds of multi-trauma cases and is classified as the primary cause of death in a quarter of trauma patients. The clinical assessment carries with it a fair amount of dogma, including looking for tensions with tracheal deviation, so we'll be running through what the signs we should look for actually mean. Then we'll move on to a detailed discussion about investigation strategies before finally looking at the guidelines and evidence on the topic, including which we have to intervene with, which we probably shouldn't and those in which there is much uncertainty... Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James ps; if you’re interested in getting your site involved with the CoMITED Trial then email comited-trial@bristol.ac.uk 

This is the first of two episodes looking at pneumothoraces. In this episode we're going to start out by taking a look at traumatic pneumothoraces. Traumatic pneumothoraces are present in about a fifth of multiple trauma patients, so it's not infrequent to come across them and they can obviously occur in those with isolated chest injury too. Thoracic trauma occurs in around two thirds of multi-trauma cases and is classified as the primary cause of death in a quarter of trauma patients. The clinical assessment carries with it a fair amount of dogma, including looking for tensions with tracheal deviation, so we'll be running through what the signs we should look for actually mean. Then we'll move on to a detailed discussion about investigation strategies before finally looking at the guidelines and evidence on the topic, including which we have to intervene with, which we probably shouldn't and those in which there is much uncertainty... Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James ps; if you’re interested in getting your site involved with the CoMITED Trial then email comited-trial@bristol.ac.uk

Traumatic Pneumothorax; Roadside to Resus

Welcome back to the podcast and to the first episode in collaboration with our new sponsors Zoll, a huge thanks to them in their support of free open access medical education! First off this month we return to the topic of rib fractures; with an apparent shift in practice to the surgical fixation of multiple rib fractures, we take a look at an early vs late approach and consider the impact these results may have on trauma systems. Next up it's a prehospital RCT assessing the use of a prehospital strategy including a single troponin to rule out acute coronary syndrome. Will this prove safe when compared to an in hospital strategy and what impact does it have on prehospital resources? Finally we look at ventilation rates in cardiac arrest management. For as long as we can remember the guidance has been to ventilate at ten breaths per minute, but will a strategy involving a faster ventilatory rate yield better results? Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon &amp; Rob

Welcome back to the podcast and to the first episode in collaboration with our new sponsors Zoll, a huge thanks to them in their support of free open access medical education! First off this month we return to the topic of rib fractures; with an apparent shift in practice to the surgical fixation of multiple rib fractures, we take a look at an early vs late approach and consider the impact these results may have on trauma systems. Next up it's a prehospital RCT assessing the use of a prehospital strategy including a single troponin to rule out acute coronary syndrome. Will this prove safe when compared to an in hospital strategy and what impact does it have on prehospital resources? Finally we look at ventilation rates in cardiac arrest management. For as long as we can remember the guidance has been to ventilate at ten breaths per minute, but will a strategy involving a faster ventilatory rate yield better results? Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon &amp; Rob

June 2023; papers of the month

The last time we took a good look at head injuries was back in 2018 in our Roadside to Resus episodes and for all of the foundational stuff on incidence, assessment, management and loads more  make sure you go and check that episode out.  But this episode is one of our new UPDATES episodes, because we’re pretty old now… and whilst we’ve been having a go at this for a while evidence and guidelines will have progressed, which clearly have implications on how we manage certain cases and that’s where these come in! So they’ll focus mainly on the last 5 years of practice. The new NICE head injury guidance has just been released and it’s the first major overhaul since 2014.  Now we know it’s a UK guideline, but there’s some really key practice updates and evidence in there that’s relevant irrespective of where you find yourself listening this!  So in this episode we're going to be having a look at the most recent TXA evidence, with in terms of indications, timing and dosing. We'll be having a look at the risk of intracerebral injury with regards to anticoagulants and antiplatelet agents and a few other bits and pieces that can help us inform and improve our care. Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James

The last time we took a good look at head injuries was back in 2018 in our Roadside to Resus episodes and for all of the foundational stuff on incidence, assessment, management and loads more  make sure you go and check that episode out.  But this episode is one of our new UPDATES episodes, because we’re pretty old now… and whilst we’ve been having a go at this for a while evidence and guidelines will have progressed, which clearly have implications on how we manage certain cases and that’s where these come in! So they’ll focus mainly on the last 5 years of practice. The new NICE head injury guidance has just been released and it’s the first major overhaul since 2014.  Now we know it’s a UK guideline, but there’s some really key practice updates and evidence in there that’s relevant irrespective of where you find yourself listening this!  So in this episode we're going to be having a look at the most recent TXA evidence, with in terms of indications, timing and dosing. We'll be having a look at the risk of intracerebral injury with regards to anticoagulants and antiplatelet agents and a few other bits and pieces that can help us inform and improve our care. Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James

Head Injury Updates; Roadside to Resus

This month we start off with a paper looking at the first pass success rate of intubation in cardiac arrest when performing continual CPR versus pausing. We then come on to two really interesting diagnostic papers and our prehospital accuracy for identifying certain injuries; we take a look at the accuracy of HEMS clinicians in assessing the stability of a pelvic ring and subsequent application of a pelvic binder. And then we look at the accuracy of prehospital clincians in assessing for all life and limb threatening injuries. Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon &amp; Rob

This month we start off with a paper looking at the first pass success rate of intubation in cardiac arrest when performing continual CPR versus pausing. We then come on to two really interesting diagnostic papers and our prehospital accuracy for identifying certain injuries; we take a look at the accuracy of HEMS clinicians in assessing the stability of a pelvic ring and subsequent application of a pelvic binder. And then we look at the accuracy of prehospital clincians in assessing for all life and limb threatening injuries. Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon &amp; Rob

May 2023; papers of the month

Being in a situation of being unable to intubate and unable to oxygenate is an absolute time critical emergency.  Focus needs to be paid to the techniques and strategy to deal with this situation. But we also need to consider steps to ensure it occurs at a low frequency and our decision making and recognition of the situation happens quickly and simply. In the episode we’re going to be talking about a number of other aspects that are relevant for all emergency providers, irrespective of whether you intubate or not, along with how those aspects translate into everyday practice.  We'll be covering bits around patient positioning, optimising simple ventilation via a BVM &amp; supraglottics, all the way through to needle cricothyroidotomy and surgical airways. Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James

Being in a situation of being unable to intubate and unable to oxygenate is an absolute time critical emergency.  Focus needs to be paid to the techniques and strategy to deal with this situation. But we also need to consider steps to ensure it occurs at a low frequency and our decision making and recognition of the situation happens quickly and simply. In the episode we’re going to be talking about a number of other aspects that are relevant for all emergency providers, irrespective of whether you intubate or not, along with how those aspects translate into everyday practice.  We'll be covering bits around patient positioning, optimising simple ventilation via a BVM &amp; supraglottics, all the way through to needle cricothyroidotomy and surgical airways. Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James

Can't Intubate Can't Oxygenate; Roadside to Resus

Welcome back to the podcast! This month we start off thinking about sepsis, specifically fluid management and whether a restrictive approach to fluid resuscitation in combination with earlier vasopressors is advantageous over a liberal approach. Next we have a look at a study evaluating the diagnostic benefit of ultrasound in the prehospital setting. Finally we have a think about the benefit that traumatic brain injury patients may benefit from with regards to beta blocker therapy. Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon &amp; Rob

Welcome back to the podcast! This month we start off thinking about sepsis, specifically fluid management and whether a restrictive approach to fluid resuscitation in combination with earlier vasopressors is advantageous over a liberal approach. Next we have a look at a study evaluating the diagnostic benefit of ultrasound in the prehospital setting. Finally we have a think about the benefit that traumatic brain injury patients may benefit from with regards to beta blocker therapy. Once again we’d love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon &amp; Rob

April 2023; papers of the month

So NOF's aren't the most glamorous of topics to cover on a podcast, but the difference we can make to patients but refining our care is huge.  Neck of femur fractures have a high and increasing incidence. They occur predominantly in frail patients who have the greatest risk of complications, both from the injury and medical interventions.  In this episode we'll be running through their presentation, discuss both the clinical and radiological diagnostics. We'll also be looking in depth about both pharmacological and non-pharmacological methods of pain relief and have a think about where fascia-iliaca compartment blocks sit with regards to pre and in- hospital practice.  Finally we'll move on to the definitive surgical approach and in-hospital care. Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James

So NOF's aren't the most glamorous of topics to cover on a podcast, but the difference we can make to patients but refining our care is huge.  Neck of femur fractures have a high and increasing incidence. They occur predominantly in frail patients who have the greatest risk of complications, both from the injury and medical interventions.  In this episode we'll be running through their presentation, discuss both the clinical and radiological diagnostics. We'll also be looking in depth about both pharmacological and non-pharmacological methods of pain relief and have a think about where fascia-iliaca compartment blocks sit with regards to pre and in- hospital practice.  Finally we'll move on to the definitive surgical approach and in-hospital care. Once again we'd love to hear any comments or questions either via the website or social media. Enjoy! Simon, Rob &amp; James

Neck of Femur Fractures; Roadside to Resus

Emergency Medicine podcasts based on evidence based medicine focussed on practice in and around the resus room.

Great podcast. Really good information, and interesting conversation.

Great podcast

The Resus Room

Think of rhabdomyolysis and you'll think of an elevated creatine kinase (CK). The condition ranges from an asymptomatic period to a life-threatening condition with a hugely associated rise in CK which can also be accompanied by electrolyte disturbance, renal failure and disseminated intravascular coagulation. Rhabdomyolysis is caused by a breakdown in skeletal muscle and occurs most commonly following trauma, very often that can be due to a 'long-lie' when a patient is unable to get off a floor until help arrives after a prolonged period. There are other causes including drugs, muscle enzyme deficiencies, electrolyte abnormalities and more. The presentation itself is pretty vague and suspicion of the disease needs to be pretty high. Patients can experience weakness, myalgia and the dark'coca-cola urine', the diagnosis is then confirmed with a serum elevation in CK. The big concern with Rhabdomyolysis is the hit the kidneys take. Acute kidney injury is due to the heme pigment that is released from myoglobin and haemoglobin and is nephrotoxic. Early aggressive fluid rehydration aims to minimise ischaemic injury, increase urinary flow rates and thus limit intratubular cast formation. Fluids also help eliminate excess K+ that may be associated. But have a think about the management in your ED, how high does that CK need to be to require i.v. fluids and admission to hospital? Here's a few facts we need to know:  Normal CK enzyme levels are 45–260 U/l. CK rises in rhabdomyolysis within 12hours of the onset of muscle injury CK levels peak at 1–3 days, and declines 3–5 days after muscle injury The peak CK level may be predictive of the development of renal failure A CK level of 5000 U/l or greater is related to renal failure Optimal fluid rate administration is unclear, some papers suggest replacement of isotonic saline at rates of 1-2L per hour. , adjusted to 200-300mL per hour to maintain a diuresis. Attention needs to be paid to urine output serum markers and fluid status.  A lot of the evidence and knowledge surrounding rhabdomyolysis is from humanitarian disasters; earthquakes, terrorism along with observational cohorts, but at the end of the day we need to work with what we've got. Have a listen to the podcast and see what you think, the application of the evidence base may change your practice. Enjoy!   References  Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Huerta-Alardín AL. Crit Care. 2005 Creatine kinase MB isoenzyme in dermatomyositis: a noncardiac source. Larca LJ. Ann Intern Med. 1981 Epidemiologic aspects of the Bam earthquake in Iran: the nephrologic perspective. Hatamizadeh P. Am J Kidney Dis. 2006Prognostic value, kinetics and effect of CVVHDF on serum of the myoglobin and creatine kinase in critically ill patients with rhabdomyolysis. Mikkelsen TS. Acta Anaesthesiol Scand. 2005 Rhabdomyolysis: an evaluation of 475 hospitalized patients. Melli G. Medicine (Baltimore). 2005  Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey. de Meijer AR. Intensive Care Med. 2003  Prevention and treatment of heme pigment-induced acute kidney injury (acute renal failure). Paul M Palevsky. UpToDate. 2015

Think of rhabdomyolysis and you'll think of an elevated creatine kinase (CK). The condition ranges from an asymptomatic period to a life-threatening condition with a hugely associated rise in CK which can also be accompanied by electrolyte disturbance, renal failure and disseminated intravascular coagulation. Rhabdomyolysis is caused by a breakdown in skeletal muscle and occurs most commonly following trauma, very often that can be due to a 'long-lie' when a patient is unable to get off a floor until help arrives after a prolonged period. There are other causes including drugs, muscle enzyme deficiencies, electrolyte abnormalities and more. The presentation itself is pretty vague and suspicion of the disease needs to be pretty high. Patients can experience weakness, myalgia and the dark'coca-cola urine', the diagnosis is then confirmed with a serum elevation in CK. The big concern with Rhabdomyolysis is the hit the kidneys take. Acute kidney injury is due to the heme pigment that is released from myoglobin and haemoglobin and is nephrotoxic. Early aggressive fluid rehydration aims to minimise ischaemic injury, increase urinary flow rates and thus limit intratubular cast formation. Fluids also help eliminate excess K+ that may be associated. But have a think about the management in your ED, how high does that CK need to be to require i.v. fluids and admission to hospital? Here's a few facts we need to know: <ul> <li>Normal CK enzyme levels are 45–260 U/l.</li> <li>CK rises in rhabdomyolysis within 12hours of the onset of muscle injury</li> <li>CK levels peak at 1–3 days, and declines 3–5 days after muscle injury</li> <li>The peak CK level may be predictive of the development of renal failure</li> <li>A CK level of 5000 U/l or greater is related to renal failure</li> <li>Optimal fluid rate administration is unclear, some papers suggest replacement of isotonic saline at rates of 1-2L per hour. , adjusted to 200-300mL per hour to maintain a diuresis.</li> <li>Attention needs to be paid to urine output serum markers and fluid status.</li> </ul> A lot of the evidence and knowledge surrounding rhabdomyolysis is from humanitarian disasters; earthquakes, terrorism along with observational cohorts, but at the end of the day we need to work with what we've got. Have a listen to the podcast and see what you think, the application of the evidence base may change your practice. Enjoy!  References <a href="https://www.ncbi.nlm.nih.gov/pubmed/15774072/" rel="nofollow" target="_blank"> Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Huerta-Alardín AL. Crit Care. 2005</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/7224380" rel="nofollow" target="_blank">Creatine kinase MB isoenzyme in dermatomyositis: a noncardiac source. Larca LJ. Ann Intern Med. 1981</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/16490621" rel="nofollow" target="_blank">Epidemiologic aspects of the Bam earthquake in Iran: the nephrologic perspective. Hatamizadeh P. Am J Kidney Dis. 2006</a><a href="https://www.ncbi.nlm.nih.gov/pubmed/15954972" rel="nofollow" target="_blank">Prognostic value, kinetics and effect of CVVHDF on serum of the myoglobin and creatine kinase in critically ill patients with rhabdomyolysis. Mikkelsen TS. Acta Anaesthesiol Scand. 2005</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/16267412" rel="nofollow" target="_blank">Rhabdomyolysis: an evaluation of 475 hospitalized patients. Melli G. Medicine (Baltimore). 2005</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Serum+creatine+kinase+as+predictor+of+clinical+course+in+rhabdomyolysis%3A+a+5-year+intensive+care+survey" rel="nofollow" target="_blank"> Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey. de Meijer AR. Intensive Care Med. 2003</a> <a href="http://www.uptodate.com/contents/prevention-and-treatment-of-heme-pigment-induced-acute-kidney-injury-acute-renal-failure" rel="nofollow" target="_blank"> Prevention and treatment of heme pigment-induced acute kidney injury (acute renal failure). Paul M Palevsky. UpToDate. 2015</a>

Rhabdomyolysis

Rob Fenwick talks to us about this common condition and amongst others throws up a few surprises about the risks of rewarming. Enjoy

Rob Fenwick talks to us about this common condition and amongst others throws up a few surprises about the risks of rewarming. Enjoy

Hypothermia

We talk through some core content on epilepsy, some algorithims for treatment, some of the evidence base that surrounds the topic and some of the difficulties surrounding decision making

We talk through some core content on epilepsy, some algorithims for treatment, some of the evidence base that surrounds the topic and some of the difficulties surrounding decision making

Status Epilepticus

If you're involved in the care of critically unwell patients then you will frequently encounter patients who are shocked. The European Society of Intensive Care Medicine defines shock as; 'Life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen utilization by the cells. It is a state in which the circulation is unable to deliver sufficient oxygen to meet the demands of the tissues, resulting in cellular dysfunction.’ The assessment for shock needs to be part of the routine workup of every potentially unwell patient. Shock carries with it a high mortality rate, a range of meaningful interventions and the potential to make a real difference to our patients' outcomes.  In this podcast we cover  Defining shock in adults Significance of shock What shock looks like A recap of cardiac physiology Causes of shock Ultrasound evaluation Fluid therapy Inotropes and vasopressors  As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you. Enjoy! Simon, Rob &amp; James References Consensuson circulatory shockand hemodynamic monitoring. Task forceof the EuropeanSociety of Intensive Care Medicine. Cecconi M. Intensive Care Med.2014 NICE Intravenous fluid therapy in adults in hospital. Clinical guideline. December 2013 ALIEM; Choosing the right vasopressor agent in hypotension Resus; The Shock Index ALIEM; Shock Index: A Predictor of Morbidity and Mortality? A comparisonof the shockindexand conventionalvital signsto identifyacute, critical illnessin the emergency department. Rady MY. Ann Emerg Med.1994  TheResusRoom; Sepsis RCEM guidance; Noradrenaline Infusion  Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Puskarich MA. Crit Care Med. 2011  Early goal-directed therapy in the treatment of severe sepsis and septic shock.Rivers E. N Engl J Med. 2001  Early lactate clearance is associated with improved outcome in severe sepsis and septic shock.Nguyen HB. Crit Care Med. 2004   Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.Jones AE. JAMA. 2010  A randomized trial of protocol-based care for early septic shock.ProCESS Investigators. N Engl J Med. 2014 Early goal-directed therapyin the treatmentof severe sepsisand septic shock. Rivers E. N Engl J Med.2001  The significance of non-sustained hypotension in emergency department patients with sepsis.Marchick MR. Intensive Care Med. 2009 Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis.Natthida Owattanapanich. Scand J Trauma Resusc Emerg Med. 2018. TheResusRoom; The Crystalloid Debate

If you're involved in the care of critically unwell patients then you will frequently encounter patients who are shocked. The European Society of Intensive Care Medicine defines shock as; 'Life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen utilization by the cells. It is a state in which the circulation is unable to deliver sufficient oxygen to meet the demands of the tissues, resulting in cellular dysfunction.’ The assessment for shock needs to be part of the routine workup of every potentially unwell patient. Shock carries with it a high mortality rate, a range of meaningful interventions and the potential to make a real difference to our patients' outcomes.  In this podcast we cover <ul> <li>Defining shock in adults</li> <li>Significance of shock</li> <li>What shock looks like</li> <li>A recap of cardiac physiology</li> <li>Causes of shock</li> <li>Ultrasound evaluation</li> <li>Fluid therapy</li> <li>Inotropes and vasopressors</li> </ul> As always we’d love to hear any thoughts or comments you have on the website and via twitter, we look forward to hearing from you. Enjoy! <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a>, <a href="https://twitter.com/robfenwick" rel="nofollow" target="_blank">Rob</a> &amp; <a href="https://twitter.com/heli_med_james" rel="nofollow" target="_blank">James</a> References Consensuson circulatory shockand hemodynamic monitoring. Task forceof the EuropeanSociety of Intensive Care Medicine. Cecconi M. Intensive Care Med.2014 NICE Intravenous fluid therapy in adults in hospital. Clinical guideline. December 2013 ALIEM; Choosing the right vasopressor agent in hypotension Resus; The Shock Index ALIEM; Shock Index: A Predictor of Morbidity and Mortality? A comparisonof the shockindexand conventionalvital signsto identifyacute, critical illnessin the emergency department. Rady MY. Ann Emerg Med.1994  TheResusRoom; Sepsis RCEM guidance; Noradrenaline Infusion Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Puskarich MA. Crit Care Med. 2011 Early goal-directed therapy in the treatment of severe sepsis and septic shock.Rivers E. N Engl J Med. 2001 Early lactate clearance is associated with improved outcome in severe sepsis and septic shock.Nguyen HB. Crit Care Med. 2004  Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.Jones AE. JAMA. 2010 A randomized trial of protocol-based care for early septic shock.ProCESS Investigators. N Engl J Med. 2014 Early goal-directed therapyin the treatmentof severe sepsisand septic shock. Rivers E. N Engl J Med.2001 The significance of non-sustained hypotension in emergency department patients with sepsis.Marchick MR. Intensive Care Med. 2009 Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis.Natthida Owattanapanich. Scand J Trauma Resusc Emerg Med. 2018. TheResusRoom; The Crystalloid Debate

Shock; Roadside to Resus

Traumatic Cardiac Arrest; for many of us an infrequent presentation and it that lies the problem. In our previous cardiac arrest podcast we talked about the approach to the arresting patient, however in trauma the approach change significantly. We require a different set of skills and priorities and having the whole team on board whilst sharing the same mental model is key. Have a listen to the podcast and let us know your thoughts. The references are below but if you only read one thing take a look at the ERC Guidelines on traumatic cardiac arrest which we refer to. Enjoy! Simon, Rob &amp; James References &amp; Further Reading Resuscitation to Recovery Document Roadside to Resus; Cardiac Arrest  ERC Guidelines; Traumatic Arrest Traumatic cardiac arrest: who are the survivors? Lockey D. Ann Emerg Med. 2006 Conversion to shockable rhythms during resuscitation and survival for out-of hospital cardiac arrest. Wah W. Am J Emerg Med. 2017  Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Beck B. Resuscitation 2017. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. Seamon MJ. J Trauma Acute Care Surg. 2015  EAST guidelines 2015; ED Thoracotomy FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Inaba K. Ann Surg. 2015

Traumatic Cardiac Arrest; for many of us an infrequent presentation and it that lies the problem. In our previous cardiac arrest podcast we talked about the approach to the arresting patient, however in trauma the approach change significantly. We require a different set of skills and priorities and having the whole team on board whilst sharing the same mental model is key. Have a listen to the podcast and let us know your thoughts. The references are below but if you only read one thing take a look at the ERC Guidelines on traumatic cardiac arrest which we refer to. Enjoy! <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a>, <a href="https://twitter.com/robfenwick" rel="nofollow" target="_blank">Rob</a> &amp; <a href="https://twitter.com/heli_med_james" rel="nofollow" target="_blank">James</a> References &amp; Further Reading <a href="https://www.resus.org.uk/publications/resuscitation-to-recovery/" rel="nofollow" target="_blank">Resuscitation to Recovery Document</a> <a href="http://theresusroom.co.uk/cardiac-arrest" rel="nofollow" target="_blank">Roadside to Resus; Cardiac Arrest</a> <a href="https://cprguidelines.eu/sites/573c777f5e61585a053d7ba5/content_entry573c77e35e61585a053d7baf/573c78115e61585a053d7bce/files/S0300-9572_15_00329-9_main.pdf" rel="nofollow" target="_blank"> ERC Guidelines; Traumatic Arrest</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/16934644" rel="nofollow" target="_blank">Traumatic cardiac arrest: who are the survivors?</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/16934644" rel="nofollow" target="_blank">Lockey D.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/16934644" rel="nofollow" target="_blank">Ann Emerg Med.</a> 2006 <a href="https://www.ncbi.nlm.nih.gov/pubmed/27810251" rel="nofollow" target="_blank">Conversion to shockable rhythms during resuscitation and survival for out-of hospital cardiac arrest. Wah W. Am J Emerg Med. 2017 </a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/27914232" rel="nofollow" target="_blank">Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Beck B. Resuscitation 2017</a>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/26091330" rel="nofollow" target="_blank">An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. Seamon MJ. J Trauma Acute Care Surg. 2015</a> <a href="https://www.east.org/education/practice-management-guidelines/emergency-department-thoracotomy" rel="nofollow" target="_blank"> EAST guidelines 2015; ED Thoracotomy</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/26258320" rel="nofollow" target="_blank">FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Inaba K. Ann Surg. 2015</a>

Traumatic Arrest; Roadside to Resus

Carbon Monoxide poisoning is definitely one of those differentials that you consider when the patients books into ED with '?carbon monoxide poisoning'...... but how much do we really think about it in a patient that hasn't been sent down to the ED with this specific thought in mind? Rob Fenwick talks us through the key points of Carbon Monoxide poisoning and some recent evidence on the topic which will probably make us consider the possibility a bit more frequently! This podcast was based around the post Rob wrote for Jonathan Downham's superb Critical Care Practitioner podcast. Go and have a look at the post for a lot more information on the topic.

Carbon Monoxide poisoning is definitely one of those differentials that you consider when the patients books into ED with '?carbon monoxide poisoning'...... but how much do we really think about it in a patient that hasn't been sent down to the ED with this specific thought in mind? Rob Fenwick talks us through the key points of Carbon Monoxide poisoning and some recent evidence on the topic which will probably make us consider the possibility a bit more frequently! This podcast was based around the post Rob wrote for <a href="http://www.jonathandownham.com/carbon-monoxide-poisoning/" rel="nofollow" target="_blank">Jonathan Downham's superb Critical Care Practitioner podcast</a>. Go and have a look at the post for a lot more information on the topic.

Carbon Monoxide

We have a significant way to go with respect to our cardiac arrest management. ‘Cardiopulmoary Resuscitation is attempted in nearly 30,000 people who suffered OHCA in England each year, but survival rates are low and compare unfavourably to a number of other countries’  -  Resuscitation to Recovery 2017 25% of patients get a ROSC with 7-8% of patients surviving to hospital discharge, which as mentioned is hugely below some countries. In this podcast we run through cardiac arrest management and the associated evidence base, right from chest compressions, through to drugs, prognostication and ceasing resuscitation attempts. Make sure you take a look at the papers and references yourself and we would love to hear you feedback! Enjoy! Simon, Rob &amp; James References &amp; Further Reading Resuscitation to Recovery Document "Kids Save Lives": Educating Schoolchildren in Cardiopulmonary Resuscitation Is a Civic DutyThat Needs Support for Implementation. Böttiger BW. J Am Heart Assoc. 2017 Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival.Andersen LW. JAMA. 2017 Double sequential Defibrillation therapy for out-of-hospital cardiac arrests: the London experience. Emmerson AC, et al. Resuscitation. 2017 Dual sequential defibrillation: Does one plus one equal two? Deakin CD. Resuscitation. 2016 Thrombolysis during resuscitation for out-of-hospital cardiac arrest. Böttiger BW. N Engl J Med. 2008 Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Perkins GD. Lancet. 2015 Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Rubertsson S. JAMA. 2014 Effect of epinephrine on survival after cardiac arrest: a systematic review and meta analysis. Patanwala AE. Minerva Anestesiol. 2014 Impact of cardiopulmonary resuscitation duration on survival from paramedic witnessed out-of-hospital cardiac arrests: An observational study. Nehme Z. 2016 Mar;100:25-31. doi: 10.1016/j.resuscitation.2015.12.011. Epub 2016 Jan 13. Predicting in-hospital mortality during cardiopulmonary resuscitation. Schultz SC. Resuscitation. 1996 Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017 End-tidal CO2 as a predictor of survival in out-of-hospital cardiac arrest. Eckstein M. Prehosp Disaster Med. 2011 LITFL; cessation of CPR

We have a significant way to go with respect to our cardiac arrest management. ‘Cardiopulmoary Resuscitation is attempted in nearly 30,000 people who suffered OHCA in England each year, but survival rates are low and compare unfavourably to a number of other countries’ -  Resuscitation to Recovery 2017 25% of patients get a ROSC with 7-8% of patients surviving to hospital discharge, which as mentioned is hugely below some countries. In this podcast we run through cardiac arrest management and the associated evidence base, right from chest compressions, through to drugs, prognostication and ceasing resuscitation attempts. Make sure you take a look at the papers and references yourself and we would love to hear you feedback! Enjoy! <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a>, <a href="https://twitter.com/robfenwick" rel="nofollow" target="_blank">Rob</a> &amp; <a href="https://twitter.com/heli_med_james" rel="nofollow" target="_blank">James</a> References &amp; Further Reading <a href="https://www.resus.org.uk/publications/resuscitation-to-recovery/" rel="nofollow" target="_blank">Resuscitation to Recovery Document</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/28292747" rel="nofollow" target="_blank">"Kids Save Lives": Educating Schoolchildren in Cardiopulmonary Resuscitation Is a Civic DutyThat Needs Support for Implementation. Böttiger BW. J Am Heart Assoc. 2017</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/28118660" rel="nofollow" target="_blank">Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival.Andersen LW. JAMA. 2017</a> <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/28624593/" rel="nofollow" target="_blank">Double sequential Defibrillation therapy for out-of-hospital cardiac arrests: the London experience. Emmerson AC, et al. Resuscitation. 2017</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/27565035" rel="nofollow" target="_blank">Dual sequential defibrillation: Does one plus one equal two? Deakin CD. Resuscitation. 2016</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/19092151" rel="nofollow" target="_blank">Thrombolysis during resuscitation for out-of-hospital cardiac arrest. Böttiger BW. N Engl J Med. 2008</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/25467566" rel="nofollow" target="_blank">Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Perkins GD. Lancet. 2015</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/24240611" rel="nofollow" target="_blank">Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. Rubertsson S. JAMA. 2014</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/24193240" rel="nofollow" target="_blank">Effect of epinephrine on survival after cardiac arrest: a systematic review and meta analysis. Patanwala AE. Minerva Anestesiol. 2014</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/26774172" rel="nofollow" target="_blank">Impact of cardiopulmonary resuscitation duration on survival from paramedic witnessed out-of-hospital cardiac arrests: An observational study. Nehme Z. 2016 Mar;100:25-31. doi: 10.1016/j.resuscitation.2015.12.011. Epub 2016 Jan 13.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/8959768" rel="nofollow" target="_blank">Predicting in-hospital mortality during cardiopulmonary resuscitation. Schultz SC. Resuscitation. 1996</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/28263791" rel="nofollow" target="_blank">Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Tsou PY. Resuscitation. 2017</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/22107764" rel="nofollow" target="_blank">End-tidal CO2 as a predictor of survival in out-of-hospital cardiac arrest. Eckstein M. Prehosp Disaster Med. 2011</a> <a href="https://lifeinthefastlane.com/ccc/cessation-of-cpr/" rel="nofollow" target="_blank">LITFL; cessation of CPR</a>

Cardiac Arrest; Roadside to Resus

This is the first of a new series of Roadside to Resus podcasts. We've been joined by James Yates, a Critical Care Paramedic with the Great Western Air Ambulance to make it a truly multidisciplinary team. Each monthly episode we'll be discussing acute presentations, including the latest and most influential evidence base surrounding them. We really want  to break down some barriers between pre-hospital and in hospital teams and it soon becomes evident in this first podcast that many of the problems we face are shared throughout the patient journey and across disciplines! We're starting off with Acute Heart Failure and in the podcast we run through;  The underlying physiology and help explain the different problems we may find in each subset The keys to diagnosis, including the most predictive parts of history and examination We discuss the evidence base for treatment and the trends of use both pre and in-hospital We talk about CPAP and whether the evidence supports it's use Finally, the direction that further treatment in the UK may move      Once again we hope you find the podcast useful. Get in touch with any comments, questions or suggestions for further topics. Most of all don't take our word for it, but make sure you delve into the references yourself and make up your own mind. Enjoy! Simon, Rob &amp; James References &amp; Further Reading Recommendations on pre-hospital &amp; early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine Understanding cardiac output. Jean-Louis Vincent. Crit Care. 2008.  2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure The pathophysiology of hypertensive acute heart failure. Viau DM. Heart. 2015 Meta-analysis: Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema. Weng. Annals Int Med. 2010  Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S.JAMA 2005 Diagnosing Acute Heart Failure in the Emergency Department; A Systematic Review and Meta-analysis. Martindale. Academic Emergency Medicine. 2016 Noninvasive ventilation in acute cardiogenic pulmonary edema. Gray A. N Engl J Med. 2008  Life in the Fast Lane; severe heart failure management  Emergency Medicine Cases; acute congestive heart failure  REBEL.EM; morphine kills in acute decompensated heart failure  EMCRIT 1; Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

This is the first of a new series of Roadside to Resus podcasts. We've been joined by James Yates, a Critical Care Paramedic with the Great Western Air Ambulance to make it a truly multidisciplinary team. Each monthly episode we'll be discussing acute presentations, including the latest and most influential evidence base surrounding them. We really want  to break down some barriers between pre-hospital and in hospital teams and it soon becomes evident in this first podcast that many of the problems we face are shared throughout the patient journey and across disciplines! We're starting off with Acute Heart Failure and in the podcast we run through; <ul> <li>The underlying physiology and help explain the different problems we may find in each subset</li> <li>The keys to diagnosis, including the most predictive parts of history and examination</li> <li>We discuss the evidence base for treatment and the trends of use both pre and in-hospital</li> <li>We talk about CPAP and whether the evidence supports it's use</li> <li>Finally, the direction that further treatment in the UK may move</li> </ul> Once again we hope you find the podcast useful. Get in touch with any comments, questions or suggestions for further topics. Most of all don't take our word for it, but make sure you delve into the references yourself and make up your own mind. Enjoy! <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a>, <a href="https://twitter.com/robfenwick" rel="nofollow" target="_blank">Rob</a> &amp; <a href="https://twitter.com/heli_med_james" rel="nofollow" target="_blank">James</a> References &amp; Further Reading <a href="http://onlinelibrary.wiley.com/doi/10.1002/ejhf.289/full" rel="nofollow" target="_blank">Recommendations on pre-hospital &amp; early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575587/" rel="nofollow" target="_blank">Understanding cardiac output. Jean-Louis Vincent. Crit Care. 2008.</a> <a href="https://academic.oup.com/eurheartj/article/37/27/2129/1748921/2016-ESC-Guidelines-for-the-diagnosis-and#86355040" rel="nofollow" target="_blank"> 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/26123135" rel="nofollow" target="_blank">The pathophysiology of hypertensive acute heart failure. Viau DM. Heart. 2015</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/20439577" rel="nofollow" target="_blank">Meta-analysis: Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema. Weng. Annals Int Med. 2010 </a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/16234501" rel="nofollow" target="_blank">Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S.JAMA 2005</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/26910112" rel="nofollow" target="_blank">Diagnosing Acute Heart Failure in the Emergency Department; A Systematic Review and Meta-analysis. Martindale. Academic Emergency Medicine. 2016</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/19615296" rel="nofollow" target="_blank">Noninvasive ventilation in acute cardiogenic pulmonary edema. Gray A. </a><a href="https://www.ncbi.nlm.nih.gov/pubmed/19615296" rel="nofollow" target="_blank">N Engl J Med.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/19615296" rel="nofollow" target="_blank">2008</a> <a href="https://lifeinthefastlane.com/ccc/severe-heart-failure-management/" rel="nofollow" target="_blank"> Life in the Fast Lane; severe heart failure management</a> <a href="https://emergencymedicinecases.com/episode-4-acute-congestive-heart-failure/" rel="nofollow" target="_blank"> Emergency Medicine Cases; acute congestive heart failure</a> <a href="http://rebelem.com/morphine-kills-in-acute-decompensated-heart-failure/" rel="nofollow" target="_blank"> REBEL.EM; morphine kills in acute decompensated heart failure</a> <a href="https://emcrit.org/emcrit/scape/" rel="nofollow" target="_blank">EMCRIT 1; Sympathetic Crashing Acute Pulmonary Edema (SCAPE)</a>

Acute Heart Failure; Roadside to Resus

Bicarbonate use in cardiac arrest. The topic still provokes debate and multiple publications on the topic still hit the press reels. People talk of the increased rate of ROSC and the improvement in metabolic state, whilst others talk of the increase in mortality and worsening of intracellular acidosis. A recent paper in Resuscitation looked at a huge cohort of patients receiving bicarbonate in arrest prehospitally. In this episode we take a look at the paper, review the guidelines and give our take on the current situation with regards bicarb in arrest We hope you enjoy it and would love to hear your feedback! Simon &amp;  Rob References &amp; Further Reading Prehospital Sodium Bicarbonate Use Could Worsen Long Term Survival with Favorable Neurological Recovery among Patients with Out-of-Hospital Cardiac Arrest. Kawano T, et al. Resuscitation. 2017 Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature. Velissaris D, et al. J Clin Med Res. 2016 Effect of Sodium Bicarbonate on Advanced Cardiac Life Support. Jungyoup Lee. Circulation 2014  Advanced Life Support; Bicarbonate guidance

Bicarbonate use in cardiac arrest. The topic still provokes debate and multiple publications on the topic still hit the press reels. People talk of the increased rate of ROSC and the improvement in metabolic state, whilst others talk of the increase in mortality and worsening of intracellular acidosis. A recent paper in Resuscitation looked at a huge cohort of patients receiving bicarbonate in arrest prehospitally. In this episode we take a look at the paper, review the guidelines and give our take on the current situation with regards bicarb in arrest We hope you enjoy it and would love to hear your feedback! <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a> &amp;  <a href="https://twitter.com/robfenwick" rel="nofollow" target="_blank">Rob</a> References &amp; Further Reading <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/28802878/" rel="nofollow" target="_blank">Prehospital Sodium Bicarbonate Use Could Worsen Long Term Survival with Favorable Neurological Recovery among Patients with Out-of-Hospital Cardiac Arrest. Kawano T, et al. Resuscitation. 2017</a> <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/26985247/" rel="nofollow" target="_blank">Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature. Velissaris D, et al. J Clin Med Res. 2016</a> <a href="http://circ.ahajournals.org/content/130/Suppl_2/A114" rel="nofollow" target="_blank">Effect of Sodium Bicarbonate on Advanced Cardiac Life Support. Jungyoup Lee. Circulation 2014</a> <a href="https://www.google.co.uk/url?sa=t&amp;rct=j&amp;q=&amp;esrc=s&amp;source=web&amp;cd=2&amp;ved=0ahUKEwixtr6y9_XVAhUkCMAKHfo8CxYQFggzMAE&amp;url=https%3A%2F%2Fwww.resus.org.uk%2FEasySiteWeb%2FGatewayLink.aspx%3FalId%3D807&amp;usg=AFQjCNEYHyfxVtvH6ify3nsCLZnUIUoZMA" rel="nofollow" target="_blank"> Advanced Life Support; Bicarbonate guidance</a>

Bicarbonate in arrest

So an incredibly important paper, CRASH-3 has just been published in the Lancet, which looks at the treatment of head injuries with Tranexamic Acid (TXA). TXA has been shown to save lives in trauma patients at the risk of major haemorrhage, with the notable exclusion of those with head injuries, CRASH-2. TXA has been shown to save lives in those with post parts haemorrhage, WOMAN trial. Time to treatment with TXA has been shown to be hugely influential in it's ability to decrease blood loss and save lives. So has TXA now been shown to save lives in head injuries? In this episode we run through the paper and are lucky enough to have an interview with the lead author, Professor Ian Roberts. Have a listen, read the paper and as always we’d love to hear any thoughts or comments you have on the website and via twitter, and take a look at the references below to draw your own conclusions. Enjoy! Simon, Rob &amp; James References The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.Roberts I. Health Technol Assess. 2013 CRASH-2;The Bottom Line Effectof earlytranexamic acidadministrationon mortality, hysterectomy, and othermorbiditiesin womenwith post-partum haemorrhage(WOMAN): an international, randomised, double-blind, placebo-controlledtrial. WOMANTrialCollaborators.Lancet 2017 WOMAN Trial;The Bottom Line Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients.Gayet-Ageron A. Lancet. 2017 Tranexamic Acid - The Mechanism of Action;Video Tranexamic Acid, Time to Treatment;The Resus Room Does earlier TXA save lives?St Emlyns TXA podcast; PHEMCAST About CRASH-3; LSHTM

So an incredibly important paper, CRASH-3 has just been published in the Lancet, which looks at the treatment of head injuries with Tranexamic Acid (TXA). TXA has been shown to save lives in trauma patients at the risk of major haemorrhage, with the notable exclusion of those with head injuries, CRASH-2. TXA has been shown to save lives in those with post parts haemorrhage, WOMAN trial. Time to treatment with TXA has been shown to be hugely influential in it's ability to decrease blood loss and save lives. So has TXA now been shown to save lives in head injuries? In this episode we run through the paper and are lucky enough to have an interview with the lead author, Professor Ian Roberts. Have a listen, read the paper and as always we’d love to hear any thoughts or comments you have on the website and via twitter, and take a look at the references below to draw your own conclusions. Enjoy! Simon, Rob &amp; James References The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.Roberts I. Health Technol Assess. 2013 CRASH-2;The Bottom Line Effectof earlytranexamic acidadministrationon mortality, hysterectomy, and othermorbiditiesin womenwith post-partum haemorrhage(WOMAN): an international, randomised, double-blind, placebo-controlledtrial. WOMANTrialCollaborators.Lancet 2017 WOMAN Trial;The Bottom Line Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients.Gayet-Ageron A. Lancet. 2017 Tranexamic Acid - The Mechanism of Action;Video Tranexamic Acid, Time to Treatment;The Resus Room Does earlier TXA save lives?St Emlyns TXA podcast; PHEMCAST About CRASH-3; LSHTM

Can TXA save lives in head injuries, CRASH-3; Roadside to Resus

A lot of our podcasts have focussed on prognostic factors in arrest to help with the decision making of continuing or stopping resuscitation in cardiac arrest. There would appear to be a huge variety in practice as to when resuscitation is ceased, and in that way having explicit guidance to unify practice can at times seem appealing. In this episode we have a look at a recent paper covering the topic, it suggests a group of patients accounting for nearly half of cardiac arrests, that upon recognition could safely lead us to cease efforts. Have a listen to the podcast and let us know what you think! References Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Jabre P. Ann Intern Med. 2016  Resuscitation Council; Recognition of Life Extinct

A lot of our podcasts have focussed on prognostic factors in arrest to help with the decision making of continuing or stopping resuscitation in cardiac arrest. There would appear to be a huge variety in practice as to when resuscitation is ceased, and in that way having explicit guidance to unify practice can at times seem appealing. In this episode we have a look at a recent paper covering the topic, it suggests a group of patients accounting for nearly half of cardiac arrests, that upon recognition could safely lead us to cease efforts. Have a listen to the podcast and let us know what you think! References <a href="http://27618681" rel="nofollow" target="_blank">Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Jabre P. Ann Intern Med. 2016</a> <a href="https://www.resus.org.uk/resuscitation-guidelines/prehospital-resuscitation/#role" rel="nofollow" target="_blank"> Resuscitation Council; Recognition of Life Extinct</a>

Cardiac Arrest; when to stop?

Guideline

Oxygen is probably the drug that we give the most but possibly has the least governance over.  More has got to be good except in those at high risk of type II respiratory failure right?? Well as we know the evidence base has swung to challenge that idea in recent years and the new  BTS guidelines for Oxygen use in Healthcare and Emergency Settings has just been published with a few things that are worth reviewing since the original publication in 2008. No apologies that this may be predominantly old ground here, this is an area we're all involved with day in and day out that is simple to correct and affects mortality Historically oxygen has been given without prescription;  42% of patients in the 2015 BTS audit had no accompanying prescription When it is prescribed this doesn't always correlate with delivery 1/3 of patients were outside of target SpO2 range (10% below &amp; 22% above)  If nothing else is taken from this document then reinforcement of the fact that we need to keep oxygen saturations normal/near normal for all patients, except groups at risk of type II respiratory failure Prescribe and delivery oxygen by target oxygen saturations What is normal?  Normal Oxygen saturations for healthy young adults is approximately 96-98%, there is minor decrease with increasing age. Healthy subjects desaturate to 90% SpO2 during night time; be cautious interpreting a single oximetry reading from a sleeping patient, short duration overnight dips are normal    Will mental status give me an early indication of hypoxaemia?  No, impaired mental function at a mean value of SaO2 64%, no evidence above SaO2 84% Loss of consciousness at a mean SaO2 56%    Aims of oxygen therapy  Correct potentially harmful hypoxia Alleviate breathlessness only in those hypoxic    Why the fuss about hyperoxia? Hyperoxia has been shown to be associated with  Risk to COPD patients and those at risk of type II respiratory failure Increased CK level in STEMI and increased infarct size on MR scan at 3 months Association of hyperoxaemia with increased mortality in several ITU studies Worsens systolic myocardial performance Absorption Atelectasis even at FIO2 30-50% Intrapulmonary shunting Post-operative hypoxaemia Coronary vasoconstriction Increased Systemic Vascular Resistance Reduced Cardiac Index Possible reperfusion injury post MI  In patients with COPD studies have showed most hypercapnia patients arriving at hospital with the equivalent of SpO2 &gt; 92% were acidotic, high concentration O2has been associated with more than double the mortality rate in those with acute exacerbations of COPD. Titrate O2 delivery down smoothly   Which patients are at risk of CO2 retention and acidosis if given high dose oxygen?  Chronic hypoxic lung disease  COPD/CF/Bronchiectasis   Chest wall disease  Kyphoscoliosis Thoracoplasty   Neuromuscular disease Morbid obesity with hypo ventilatory syndrome    What is the oxygen target? Oxygen titrated to an SpO2 of 94-98% Except in those at risk of hypercapnia respiratory failure, then 88-92%(or specific SpO2 on patient's alert card)   What about in Palliative Care? Most breathlessness in cancer patients is caused by airflow obstruction, infections or pleural effusions and in these cases the issues need to be addressed. Oxygen does relieve breathlessness in hyperaemic cancer patients but not if SpO2 &gt;90%. Midazolam and morphine also relieve breathlessness and are more likely to be effective.   Delivery Devices  Reservior masks can deliver O2 concentrations between 60-80% Nasal cannualae at 1-6L/min can deliver 24-50% Venturi masks allow accurate delivery of O2 If tachypnoeic over 30 breaths per minute an increase over the marked flow rate should be delivered, note this won't increase the FiO2!  Equivalent doses of O2 24% venturi = 1L O2 28 % venturi = 2L O2 35% venturi = 4L O2 40% venturi = nasal/facemask 5-6LO2 60% venturi = 7-10L simple face mask   Approach to oxygen delivery Firstly determine if at risk of type II respiratory failure If not;  SpO2 &lt; 94%, deliver oxygen Perform an ABG  If high PCO2 consider invasive ventilation, in the interim aim SpO2 94-98% If PCO2 normal or low aim SpO2 94-98% and repeat ABG in 30-60 minutes    If at risk of type II respiratory failure  Obtain ABG if hypoxic or already on oxygen  If a respiratory acidosis consider NIV, address medical condition and senior review. Treat with the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92% If hypercapnia but not acidotic, titrate the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92%. Repeat ABG after change of treatment/deterioration. Consider reducing FiO2 if PO2 on ABG &gt;8kPa If PCO2 &lt; 6 (normal or low) aim to keep SpO2 94-98% and repeat the ABG in 30-60 minutes    Points specific to prehospital oxygen use  A sudden reduction in 3% of SpO2 within the target range should prompt a fuller assessment of the patient Pulse oximetry must be available in all locations in which oxygen is being used Some patients over the age of 70 when clinically stable may have SpO2 between 92-94%, these patients don't require O2 therapy unless the SpO2 falls below the level that is known to be normal for that individual Patients with COPD should initially be given oxygen via 24% venturi at 2-4L/min or 28% mask at a flow rate 4L/min, or nasal cannulae at 1-2L/min aiming for 88-92% Patients over 50 years of age and long term smoker with a history of SOB on exertion and no other cause for their breathlessness should be treated as having COPD. Limit O2 driven nebs, if no air driven nebs available, to 6 minutes in duration in patients known to have COPD  In summary.... So the bottom line? Well just like Goldielock's porridge, with oxygen we don't want too little, we don't want too much but we want just the right amount! There is no doubt that hypoxia kills but beware that too much of anything is bad for you and in the same way we need to be vigilant to targeting oxygen delivery to our patients target SpO2    References  BTS Guideline for oxygen use in healthcare and emergency settings

Oxygen is probably the drug that we give the most but possibly has the least governance over.  More has got to be good except in those at high risk of type II respiratory failure right?? Well as we know the evidence base has swung to challenge that idea in recent years and the new <a href="https://www.brit-thoracic.org.uk/document-library/clinical-information/oxygen/2017-emergency-oxygen-guideline/bts-guideline-for-oxygen-use-in-adults-in-healthcare-and-emergency-settings/" rel="nofollow" target="_blank"> BTS guidelines for Oxygen use in Healthcare and Emergency Settings</a> has just been published with a few things that are worth reviewing since the original publication in 2008. No apologies that this may be predominantly old ground here, this is an area we're all involved with day in and day out that is simple to correct and affects mortality Historically oxygen has been given without prescription; <ul> <li>42% of patients in the 2015 BTS audit had no accompanying prescription</li> <li>When it is prescribed this doesn't always correlate with delivery</li> <li>1/3 of patients were outside of target SpO2 range (10% below &amp; 22% above)</li> </ul> If nothing else is taken from this document then reinforcement of the fact that we need to keep oxygen saturations normal/near normal for all patients, except groups at risk of type II respiratory failure Prescribe and delivery oxygen by target oxygen saturations What is normal? <ul> <li>Normal Oxygen saturations for healthy young adults is approximately 96-98%, there is minor decrease with increasing age.</li> <li>Healthy subjects desaturate to 90% SpO2 during night time; be cautious interpreting a single oximetry reading from a sleeping patient, short duration overnight dips are normal</li> </ul> Will mental status give me an early indication of hypoxaemia? <ul> <li>No, impaired mental function at a mean value of SaO2 64%, no evidence above SaO2 84%</li> <li>Loss of consciousness at a mean SaO2 56%</li> </ul> Aims of oxygen therapy <ul> <li>Correct potentially harmful hypoxia</li> <li>Alleviate breathlessness only in those hypoxic</li> </ul> Why the fuss about hyperoxia? Hyperoxia has been shown to be associated with <ul> <li>Risk to COPD patients and those at risk of type II respiratory failure</li> <li>Increased CK level in STEMI and increased infarct size on MR scan at 3 months</li> <li>Association of hyperoxaemia with increased mortality in several ITU studies</li> <li>Worsens systolic myocardial performance</li> <li>Absorption Atelectasis even at FIO2 30-50%</li> <li>Intrapulmonary shunting</li> <li>Post-operative hypoxaemia</li> <li>Coronary vasoconstriction</li> <li>Increased Systemic Vascular Resistance</li> <li>Reduced Cardiac Index</li> <li>Possible reperfusion injury post MI</li> </ul> In patients with COPD studies have showed most hypercapnia patients arriving at hospital with the equivalent of SpO2 &gt; 92% were acidotic, high concentration O2has been associated with more than double the mortality rate in those with acute exacerbations of COPD. Titrate O2 delivery down smoothly Which patients are at risk of CO2 retention and acidosis if given high dose oxygen? <ul> <li>Chronic hypoxic lung disease <ul> <li>COPD/CF/Bronchiectasis</li> </ul> </li> <li>Chest wall disease <ul> <li>Kyphoscoliosis</li> <li>Thoracoplasty</li> </ul> </li> <li>Neuromuscular disease</li> <li>Morbid obesity with hypo ventilatory syndrome</li> </ul> What is the oxygen target? Oxygen titrated to an SpO2 of 94-98% Except in those at risk of hypercapnia respiratory failure, then 88-92%(or specific SpO2 on patient's alert card) What about in Palliative Care? Most breathlessness in cancer patients is caused by airflow obstruction, infections or pleural effusions and in these cases the issues need to be addressed. Oxygen does relieve breathlessness in hyperaemic cancer patients but not if SpO2 &gt;90%. Midazolam and morphine also relieve breathlessness and are more likely to be effective. Delivery Devices <ul> <li>Reservior masks can deliver O2 concentrations between 60-80%</li> <li>Nasal cannualae at 1-6L/min can deliver 24-50%</li> <li>Venturi masks allow accurate delivery of O2</li> <li>If tachypnoeic over 30 breaths per minute an increase over the marked flow rate should be delivered, note this won't increase the FiO2!</li> </ul> Equivalent doses of O2 24% venturi = 1L O2 28 % venturi = 2L O2 35% venturi = 4L O2 40% venturi = nasal/facemask 5-6LO2 60% venturi = 7-10L simple face mask Approach to oxygen delivery Firstly determine if at risk of type II respiratory failure If not; <ul> <li>SpO2 &lt; 94%, deliver oxygen</li> <li>Perform an ABG <ul> <li>If high PCO2 consider invasive ventilation, in the interim aim SpO2 94-98%</li> <li>If PCO2 normal or low aim SpO2 94-98% and repeat ABG in 30-60 minutes</li> </ul> </li> </ul> If at risk of type II respiratory failure <ul> <li>Obtain ABG if hypoxic or already on oxygen <ul> <li>If a respiratory acidosis consider NIV, address medical condition and senior review. Treat with the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92%</li> <li>If hypercapnia but not acidotic, titrate the lowest FiO2 via venturi or nasal specs to maintain an SpO2 88-92%. Repeat ABG after change of treatment/deterioration. Consider reducing FiO2 if PO2 on ABG &gt;8kPa</li> <li>If PCO2 &lt; 6 (normal or low) aim to keep SpO2 94-98% and repeat the ABG in 30-60 minutes</li> </ul> </li> </ul> Points specific to prehospital oxygen use <ul> <li>A sudden reduction in 3% of SpO2 within the target range should prompt a fuller assessment of the patient</li> <li>Pulse oximetry must be available in all locations in which oxygen is being used</li> <li>Some patients over the age of 70 when clinically stable may have SpO2 between 92-94%, these patients don't require O2 therapy unless the SpO2 falls below the level that is known to be normal for that individual</li> <li>Patients with COPD should initially be given oxygen via 24% venturi at 2-4L/min or 28% mask at a flow rate 4L/min, or nasal cannulae at 1-2L/min aiming for 88-92%</li> <li>Patients over 50 years of age and long term smoker with a history of SOB on exertion and no other cause for their breathlessness should be treated as having COPD.</li> <li>Limit O2 driven nebs, if no air driven nebs available, to 6 minutes in duration in patients known to have COPD</li> </ul> In summary.... So the bottom line? Well just like Goldielock's porridge, with oxygen we don't want too little, we don't want too much but we want just the right amount! There is no doubt that hypoxia kills but beware that too much of anything is bad for you and in the same way we need to be vigilant to targeting oxygen delivery to our patients target SpO2 References <a href="https://www.brit-thoracic.org.uk/document-library/clinical-information/oxygen/2017-emergency-oxygen-guideline/bts-guideline-for-oxygen-use-in-adults-in-healthcare-and-emergency-settings/" rel="nofollow" target="_blank"> BTS Guideline for oxygen use in healthcare and emergency settings</a>

BTS 2017 Oxygen Guideline; pre and in-hospital

So this is a talk I gave atthe EMCEF 22 conference.This covers a few of the papers we've discussed in the last 6months on the podcast but a bit of spaced repetition is never a badthing! We'll be running through topics on heartfailure, sedation, intubation, anaphylaxis and duration of cardiacarrest. The papers are well worth a look and whilst not all highquality evidence they do bring to the front some really interestingquestions about are practice and prompt us to challenge our habits.Enjoy! References Diagnosing AcuteHeart Failure in the Emergency Department: A Systematic Review andMeta-analysis. Martindale JL. Acad Emerg Med. 2016Mar;23(3):223-42. doi: 10.1111/acem.12878. Epub 2016 Feb13.Martinda Incidence ofAdverse Events in Adults Undergoing Procedural Sedation in theEmergency Department: A Systematic Review and Meta-analysis.Bellolio MF. Acad Emerg Med. 2016 Feb;23(2):119-34.doi: 10.1111/acem.12875. Epub 2016 Jan 22. Utility ofgum-elastic bougie for tracheal intubation during chestcompressions in a manikin: a randomized crossover trial. KomasawaN. Am J Emerg Med. 2016 Jan;34(1):54-6. doi:10.1016/j.ajem.2015.09.016. Epub 2015 Sep 21. Defining thelearning curve for endotracheal intubation using directlaryngoscopy: A systematic review. BuisML. Resuscitation. 2016 Feb;99:63-71. doi:10.1016/j.resuscitation.2015.11.005. Epub 2015 Dec 19. Incidence ofclinically important biphasic reactions in emergency departmentpatients with allergic reactions or anaphylaxis. GrunauBE. Ann Emerg Med. 2014 Jun;63(6):736-44.e2. doi:10.1016/j.annemergmed.2013.10.017. Epub 2013 Nov 13. Impact ofcardiopulmonary resuscitation duration on survival from paramedicwitnessed out-of-hospital cardiac arrests: An observational study.Nehme Z. Resuscitation. 2016 Mar;100:25-31. doi:10.1016/j.resuscitation.2015.12.011. Epub 2016 Jan 13.

So this is a talk I gave at the <a href="http://EBM%20UPDATES%20IN%20RESUS" rel="nofollow" target="_blank">EMCEF</a> 22 conference. This covers a few of the papers we've discussed in the last 6 months on the podcast but a bit of spaced repetition is never a bad thing! We'll be running through topics on heart failure, sedation, intubation, anaphylaxis and duration of cardiac arrest. The papers are well worth a look and whilst not all high quality evidence they do bring to the front some really interesting questions about are practice and prompt us to challenge our habits. Enjoy! References <a href="https://www.ncbi.nlm.nih.gov/pubmed/26910112" rel="nofollow" target="_blank">Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Martindale JL. Acad Emerg Med. 2016 Mar;23(3):223-42. doi: 10.1111/acem.12878. Epub 2016 Feb 13.Martinda</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/26801209" rel="nofollow" target="_blank">Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Bellolio MF. Acad Emerg Med. 2016 Feb;23(2):119-34. doi: 10.1111/acem.12875. Epub 2016 Jan 22.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/26456492" rel="nofollow" target="_blank">Utility of gum-elastic bougie for tracheal intubation during chest compressions in a manikin: a randomized crossover trial. Komasawa N. Am J Emerg Med. 2016 Jan;34(1):54-6. doi: 10.1016/j.ajem.2015.09.016. Epub 2015 Sep 21.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/26711127" rel="nofollow" target="_blank">Defining the learning curve for endotracheal intubation using direct laryngoscopy: A systematic review. Buis ML. Resuscitation. 2016 Feb;99:63-71. doi: 10.1016/j.resuscitation.2015.11.005. Epub 2015 Dec 19.</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/24239340" rel="nofollow" target="_blank">Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis. Grunau BE. Ann Emerg Med. 2014 Jun;63(6):736-44.e2. doi: 10.1016/j.annemergmed.2013.10.017. Epub 2013 Nov 13.</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/26774172" rel="nofollow" target="_blank">Impact of cardiopulmonary resuscitation duration on survival from paramedic witnessed out-of-hospital cardiac arrests: An observational study. Nehme Z. Resuscitation. 2016 Mar;100:25-31. doi: 10.1016/j.resuscitation.2015.12.011. Epub 2016 Jan 13.</a>

Heart failure, sedation, intubation, anaphylaxis & cardiac arrest; EBM updates in Resuscitation 

'Patients with GCS scores of 8 or less require prompt intubation', that's what ATLS tells us. The mantra of GCS 8, intubate has pervaded teaching for those involved in the management of patients with a reduced GCS (Glasgow Coma Scale). But on reflection it would seem slightly odd that the gain or loss of a single point on the Glasgow Coma Scale could simply account for a change in the decision as to whether a patient would benefit from intubation and ventilation. So should the patient with a GCS of 9 be best managed without a definitive airway, but when that slips to 8 we should reach for the portex®? In this podcast we take a deeper look at the GCS, we have a think about the role that it was designed to perform and consider how it should best be applied to acutely ill patients when considering protecting their airway. The podcast is based upon the blog from the TEAM Course blog(Training in Emergency Airway Management), make sure to go and have a look at the post and other resources available on that site. Enjoy! Simon, Rob &amp; James References GCS 8 intubate; TEAMcourse Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.2013;74(5):1363-6.Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4. Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G.The Glasgow Coma Scale at 40 years: standing the test of time.Lancet Neurol. 2014;13(8):844-54. Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-5. Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale.Ann Emerg Med. 2011;58(5):427-30. Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor.J Trauma. 2003;54(4):671-8. Isbister GK, Downes F, Sibbritt D, Dawson AH, Whyte IM. Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes.Crit Care Med. 2004;32(1):88-93. Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia.Lancet. 1996;348(9020):123-4. Kulig K, Rumack BH, Rosen P. Gag reflex in assessing level of consciousness.Lancet. 1982;1(8271):565. Rotheray KR, Cheung PS, Cheung CS, et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?.Resuscitation. 2012;83(1):86-9. Moulton C, Pennycook A, Makower R. Relation between Glasgow coma scale and the gag reflex.BMJ. 1991;303(6812):1240-1.

'Patients with GCS scores of 8 or less require prompt intubation', that's what ATLS tells us. The mantra of GCS 8, intubate has pervaded teaching for those involved in the management of patients with a reduced GCS (Glasgow Coma Scale). But on reflection it would seem slightly odd that the gain or loss of a single point on the Glasgow Coma Scale could simply account for a change in the decision as to whether a patient would benefit from intubation and ventilation. So should the patient with a GCS of 9 be best managed without a definitive airway, but when that slips to 8 we should reach for the portex®? In this podcast we take a deeper look at the GCS, we have a think about the role that it was designed to perform and consider how it should best be applied to acutely ill patients when considering protecting their airway. The podcast is based upon the blog from the <a href="http://www.teamcourse.co.uk/" rel="nofollow" target="_blank">TEAM Course blog</a>(Training in Emergency Airway Management), make sure to go and have a look at the post and other resources available on that site. Enjoy! <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a>, <a href="https://twitter.com/robfenwick" rel="nofollow" target="_blank">Rob</a> &amp; <a href="https://twitter.com/heli_med_james" rel="nofollow" target="_blank">James</a> References <a href="https://teamcourse.co.uk/blog-test-2" rel="nofollow" target="_blank">GCS 8 intubate; TEAMcourse</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/23609291" rel="nofollow" target="_blank">Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.2013;74(5):1363-6.</a><a href="https://www.ncbi.nlm.nih.gov/pubmed/4136544" rel="nofollow" target="_blank">Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/25030516" rel="nofollow" target="_blank">Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G.The Glasgow Coma Scale at 40 years: standing the test of time.Lancet Neurol. 2014;13(8):844-54.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/19272743" rel="nofollow" target="_blank">Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-5.</a> <a href="https://www.ncbi.nlm.nih.gov/21803447" rel="nofollow" target="_blank">Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale.Ann Emerg Med. 2011;58(5):427-30.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/12707528" rel="nofollow" target="_blank">Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor.J Trauma. 2003;54(4):671-8.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/14707564" rel="nofollow" target="_blank">Isbister GK, Downes F, Sibbritt D, Dawson AH, Whyte IM. Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes.Crit Care Med. 2004;32(1):88-93.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/8676684" rel="nofollow" target="_blank">Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia.Lancet. 1996;348(9020):123-4.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/6120419" rel="nofollow" target="_blank">Kulig K, Rumack BH, Rosen P. Gag reflex in assessing level of consciousness.Lancet. 1982;1(8271):565.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/21787740" rel="nofollow" target="_blank">Rotheray KR, Cheung PS, Cheung CS, et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?.Resuscitation. 2012;83(1):86-9.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/1747645" rel="nofollow" target="_blank">Moulton C, Pennycook A, Makower R. Relation between Glasgow coma scale and the gag reflex.BMJ. 1991;303(6812):1240-1.</a>

GCS 8, intubate?

Drugs in cardiac arrest are controversial. Prehospital research is notoriously difficult to perform. PARAMEDIC2 has just published in the New England Journal of Medicine and is a multi centre randomised placebo controlled trial looking at adrenaline (or epinephrine depending on which side of the pond you reside) in out of hospital cardiac arrest, no mean undertaking and a landmark paper. The paper has gained a huge amount of traction online with multiple blogs discussing the primary outcome which showed a higher survival rate in those receiving adrenaline when compared to placebo. This has been accompanied with a firm debate over the secondary outcomes, which include the rate of survival with a favourable neurological outcome (mRS 0-3), which showed no statistically significant difference between the two treatment arms, but in pure numbers gave a higher proportion of favourable outcomes in the adrenaline group. The trade off for this increased survival is the significant number of survivors with a poor neurological outcome. The question on everyone's lips then being; should we continue to administer adrenaline in cardiac arrest given the findings from this study? In the podcast we run over the main findings of the paper and are lucky enough to speak to the lead author Professor Gavin Perkins about the paper and some of the questions we and you have had following publication of the paper. A huge thanks to Gavin for taking the time to do this. Have a listen, enjoy, and let us know any thoughts or feedback you have Simon, Rob &amp; James References &amp; Further Reading PARAMEDIC2; Warwick University Clinical Trials Unit A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. Perkins GD. N Engl J Med. 2018 PARAMEDIC2 Protocol Testing Epinephrine for Out-of-Hospital Cardiac Arrest. Callaway CW. N Engl J Med. 2018  First10EMParamedic 2: Epinephrine harms/helps in out of hospital cardiac arrest  REBEL Cast Ep56 PARAMEDIC-2: Time to Abandon Epinephrine in OHCA?

Drugs in cardiac arrest are controversial. Prehospital research is notoriously difficult to perform. PARAMEDIC2 has just published in the New England Journal of Medicine and is a multi centre randomised placebo controlled trial looking at adrenaline (or epinephrine depending on which side of the pond you reside) in out of hospital cardiac arrest, no mean undertaking and a landmark paper. The paper has gained a huge amount of traction online with multiple blogs discussing the primary outcome which showed a higher survival rate in those receiving adrenaline when compared to placebo. This has been accompanied with a firm debate over the secondary outcomes, which include the rate of survival with a favourable neurological outcome (mRS 0-3), which showed no statistically significant difference between the two treatment arms, but in pure numbers gave a higher proportion of favourable outcomes in the adrenaline group. The trade off for this increased survival is the significant number of survivors with a poor neurological outcome. The question on everyone's lips then being; should we continue to administer adrenaline in cardiac arrest given the findings from this study? In the podcast we run over the main findings of the paper and are lucky enough to speak to the lead author Professor Gavin Perkins about the paper and some of the questions we and you have had following publication of the paper. A huge thanks to Gavin for taking the time to do this. Have a listen, enjoy, and let us know any thoughts or feedback you have Simon, Rob &amp; James References &amp; Further Reading PARAMEDIC2; Warwick University Clinical Trials Unit A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. Perkins GD. N Engl J Med. 2018 PARAMEDIC2 Protocol Testing Epinephrine for Out-of-Hospital Cardiac Arrest. Callaway CW. N Engl J Med. 2018 First10EMParamedic 2: Epinephrine harms/helps in out of hospital cardiac arrest REBEL Cast Ep56 PARAMEDIC-2: Time to Abandon Epinephrine in OHCA?

Adrenaline in Cardiac Arrest; PARAMEDIC2 

So today Rob and I were lucky enough to be asked to attend the Trauma Care Conference 2017, to listen to some of the great talks and catch up with some of the speakers for their take on the highlights of the talks. We managed to catch the following speakers, here are the topics they covered and relevant links to the resources discussed. Speakers Gareth Davies, Consultant Emergency Medicine, Royal London Hospital; Understanding where, when and how people die? Dave Gay, Consultant Radiologist, Derriford Hospital; The Role of Ultrasound in Trauma Fiona Lecky, Professor Emergency Medicine, Salford; Traumatic Brain Injury: recent progress &amp; future challenges Simon Carley, Professor Emergency Medicine, Central Manchester; The Top 10 trauma papers of 2016 St Emlyn's Top 10 +1 Trauma Papers 2016 Tim Rainer,  Professor Emergency Medicine, Cardiff; Permissive hypotension in blunt trauma David Raven, Emergency Medicine Consultant, Heart of England Foundation Trust; HECTOR &amp; Elderly Trauma The HECTOR Course (&amp; free online manual!!) Ross Fisher, Consultant Paediatric Surgeon Sheffield Children’s Hospital; TARN report for paediatrics p3 presentations TARNlet Database   Have a listen to the podcast and again huge thanks to the speakers for taking their time to share their superb talks with a wider audience. Simon

So today Rob and I were lucky enough to be asked to attend the <a href="https://www.traumacare.org.uk/Conference" rel="nofollow" target="_blank">Trauma Care Conference 2017</a>, to listen to some of the great talks and catch up with some of the speakers for their take on the highlights of the talks. We managed to catch the following speakers, here are the topics they covered and relevant links to the resources discussed. Speakers Gareth Davies, Consultant Emergency Medicine, Royal London Hospital; Understanding where, when and how people die? Dave Gay, Consultant Radiologist, Derriford Hospital; The Role of Ultrasound in Trauma Fiona Lecky, Professor Emergency Medicine, Salford; Traumatic Brain Injury: recent progress &amp; future challenges Simon Carley, Professor Emergency Medicine, Central Manchester; The Top 10 trauma papers of 2016 <a href="http://stemlynsblog.org/top-10-trauma-papers-2016-st-emlyns/" rel="nofollow" target="_blank">St Emlyn's Top 10 +1 Trauma Papers 2016</a> Tim Rainer,  Professor Emergency Medicine, Cardiff; Permissive hypotension in blunt trauma David Raven, Emergency Medicine Consultant, Heart of England Foundation Trust; HECTOR &amp; Elderly Trauma <a href="http://www.heftemcast.co.uk/the-hector-course-manual-foamed/" rel="nofollow" target="_blank">The HECTOR Course (&amp; free online manual!!)</a> Ross Fisher, Consultant Paediatric Surgeon Sheffield Children’s Hospital; TARN report for paediatrics <a href="http://ffolliet.com" rel="nofollow" target="_blank">p3 presentations</a> <a href="https://www.tarn.ac.uk/Content.aspx?ca=7" rel="nofollow" target="_blank">TARNlet Database</a> Have a listen to the podcast and again huge thanks to the speakers for taking their time to share their superb talks with a wider audience. <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a>

Trauma in the ED '17

Asthma is a common disease and presents to acute healthcare services extremely frequently. The majority of presentations are mild exacerbations of a known diagnosis and are relatively simple to assess and treat, many being completely appropriate for out patient treatment. On the other hand around 200 deaths per year are attributable in the UK to asthma, and therefore in the relatively young group of patients there is a real potential for critical illness with catastrophic consequence if not treated effectively. The majority of these deaths occur prior to the patient making it to hospital making the prehospital phase extremely important and hugely stressful in these cases. It is also worth noting that of the deaths reported that many were associated with inadequate inhaled corticosteroids or steroid tablets and inadequate follow up, meaning that our encounter with these patients at all stages of their care even if not that severe at the point of assessment is a key opportunity to discuss and educate about treatment plans and reasons to return. In part 1 of this podcast we will run through  Pathophysiology How patients present Guidelines Treatment  Salbutamol Ipratropium Steroids Magnesium    Part 2 will be out shortly, we hope you enjoy the episode and would love to hear your feedback! Simon, Rob &amp; James References &amp; Further Reading  BTS Asthma Guidelines 2016 Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Goodacre S. Lancet Respir Med. 2013  Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. Emerg Med J. 2017 Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV. Injury. 2016 TheResusRoom; Needle Thoracostomy podcast TheResusRoom; BTS Asthma Guidelines 2016 podcast  LITFL; Non-invasive ventilation (NIV) and asthma Intensiveblog; Asthma mechanical Ventilation Pitfalls BestBets; In a severe Exacerbation of asthma can Ketamine be used to avoid the need for mechanical ventilation in adults?

Asthma is a common disease and presents to acute healthcare services extremely frequently. The majority of presentations are mild exacerbations of a known diagnosis and are relatively simple to assess and treat, many being completely appropriate for out patient treatment. On the other hand around 200 deaths per year are attributable in the UK to asthma, and therefore in the relatively young group of patients there is a real potential for critical illness with catastrophic consequence if not treated effectively. The majority of these deaths occur prior to the patient making it to hospital making the prehospital phase extremely important and hugely stressful in these cases. It is also worth noting that of the deaths reported that many were associated with inadequate inhaled corticosteroids or steroid tablets and inadequate follow up, meaning that our encounter with these patients at all stages of their care even if not that severe at the point of assessment is a key opportunity to discuss and educate about treatment plans and reasons to return. In part 1 of this podcast we will run through <ul> <li>Pathophysiology</li> <li>How patients present</li> <li>Guidelines</li> <li>Treatment <ul> <li>Salbutamol</li> <li>Ipratropium</li> <li>Steroids</li> <li>Magnesium</li> </ul> </li> </ul> Part 2 will be out shortly, we hope you enjoy the episode and would love to hear your feedback! <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a>, <a href="https://twitter.com/robfenwick" rel="nofollow" target="_blank">Rob</a> &amp; <a href="https://twitter.com/heli_med_james" rel="nofollow" target="_blank">James</a> References &amp; Further Reading <a href="https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/" rel="nofollow" target="_blank"> BTS Asthma Guidelines 2016</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/24731521" rel="nofollow" target="_blank">Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Goodacre S. Lancet Respir Med. 2013 </a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/28500086" rel="nofollow" target="_blank">Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST. Sauter TC. </a><a href="https://www.ncbi.nlm.nih.gov/pubmed/28500086" rel="nofollow" target="_blank">Emerg Med J.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/28500086" rel="nofollow" target="_blank">2017</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/26724173" rel="nofollow" target="_blank">Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Laan DV. Injury. 2016</a> <a href="http://theresusroom.co.uk/needle-thoracostomy" rel="nofollow" target="_blank">TheResusRoom; Needle Thoracostomy podcast</a> <a href="http://theresusroom.co.uk/asthma-2016-bts-guideline" rel="nofollow" target="_blank">TheResusRoom; BTS Asthma Guidelines 2016 podcast</a> <a href="https://lifeinthefastlane.com/ccc/non-invasive-ventilation-niv-and-asthma/" rel="nofollow" target="_blank"> LITFL; Non-invasive ventilation (NIV) and asthma</a> <a>Intensiveblog; Asthma mechanical Ventilation Pitfalls</a> <a href="http://www.bestbets.org/bets/bet.php?id=2741" rel="nofollow" target="_blank">BestBets; In a severe Exacerbation of asthma can Ketamine be used to avoid the need for mechanical ventilation in adults?</a>

Asthma; Roadside to Resus Part 1

So we're back from our summer hiatus with a real treat. The long awaited AIRWAYS-2 paper has just been released and we've been lucky enough to speak with the lead author, Professor Jonathan Benger, about the paper and discuss what the findings mean for cardiac arrest management. AIRWAYS-2 looks at the initial advanced airway management strategy for paramedics attending out of hospital cardiac arrests, essentially whether or not the aim should be to place a supraglottic airway device or an endotracheal tube when advancing from simple airway techniques. The study was a huge undertaking with many speculating over how the results would change practice, including discussion of how it may affect paramedic's practice of intubation, all of which we cover in the podcast. Before you listen to the podcast make sure you have a look at the paper yourself, have a listen to PHEMCAST's previous episode which covers the study design and have a look at the infographics on the website which summarise the primary outcome and secondary analysis and which we refer to in the interview with Professor Benger. In the podcast we refer to Jabre's paper which can be found below and we also covered in May's papers podcast. Have a listen to the interview and let us know any thoughts or feedback you have, we're sure this one will create a lot of discussion! Simon, Rob &amp; James References &amp; Further Reading Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. The AIRWAYS-2 Randomized Clinical Trial. Benger J. JAMA. 2018 PHEMCAST; the LMA Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomised Clinical Trial. Jabre P. JAMA. 2018 TEAM Course

So we're back from our summer hiatus with a real treat. The long awaited AIRWAYS-2 paper has just been released and we've been lucky enough to speak with the lead author, Professor Jonathan Benger, about the paper and discuss what the findings mean for cardiac arrest management. AIRWAYS-2 looks at the initial advanced airway management strategy for paramedics attending out of hospital cardiac arrests, essentially whether or not the aim should be to place a supraglottic airway device or an endotracheal tube when advancing from simple airway techniques. The study was a huge undertaking with many speculating over how the results would change practice, including discussion of how it may affect paramedic's practice of intubation, all of which we cover in the podcast. Before you listen to the podcast make sure you have a look at the paper yourself, have a listen to PHEMCAST's previous episode which covers the study design and have a look at the infographics on the website which summarise the primary outcome and secondary analysis and which we refer to in the interview with Professor Benger. In the podcast we refer to Jabre's paper which can be found below and we also covered in May's papers podcast. Have a listen to the interview and let us know any thoughts or feedback you have, we're sure this one will create a lot of discussion! Simon, Rob &amp; James References &amp; Further Reading Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. The AIRWAYS-2 Randomized Clinical Trial. Benger J. JAMA. 2018 PHEMCAST; the LMA Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomised Clinical Trial. Jabre P. JAMA. 2018 <a href="https://teamcourse.co.uk" rel="nofollow" target="_blank">TEAM Course</a>

Intubation or supraglottic airway in cardiac arrest; AIRWAYS-2

If you talk to people about the topic of thrombolysis in PE they'll tell you about the controversy of the submassive category, but there's a universal acceptance that thrombolysing massive PE's is well evidenced and straight forward. In this episode we delve back into the literature and not only explore massive PE thrombolysis, but also the gold standard to which it is judged upon, heparin. Have a listen to the podcast and as always we would love to hear your thoughts. Enjoy! Simon &amp; Rob References &amp; Further Reading  2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism  British Thoracic Society guidelines for the management of suspected acute pulmonary embolism; 2003  Antithrombotic Therapy for VTE Disease CHEST Guideline and Expert Panel Report; 2016 Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. A Scientific Statement From the American Heart Association. 2011  Venous thromboembolic diseases: diagnosis, management and thrombophilia testing; NICE. 2012  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1438862/pdf/jrsocmed00257-0051.pdfValue of anticoagulants in the treatment of pulmonary embolism: a discussion paper. Paul Egermayer. Journal of the Royal Society of Medicine 1981. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. BARRITT DW. Lancet. 1960 Treatment of pulmonary embolism in total hip replacement. Johnson R. Clin Orthop Relat Res. 1977 PAIMS 2: alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen activator Italian multicenter study 2. Dalla-Volta S. J Am Coll Cardiol. 1992  Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Goldhaber SZ. Lancet. 1993 Thrombolysis Compared With Heparin for the Initial Treatment of Pulmonary Embolism.  A Meta-Analysis of the Randomized Controlled Trials. Susan Wan. 2004 Massive PE and cardiogenic shock. To thrombolyse or not to thrombolyse, that is the question. Francoise Ticehurst. BestBets. 2004

If you talk to people about the topic of thrombolysis in PE they'll tell you about the controversy of the submassive category, but there's a universal acceptance that thrombolysing massive PE's is well evidenced and straight forward. In this episode we delve back into the literature and not only explore massive PE thrombolysis, but also the gold standard to which it is judged upon, heparin. Have a listen to the podcast and as always we would love to hear your thoughts. Enjoy! <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a> &amp; <a href="https://twitter.com/robfenwick" rel="nofollow" target="_blank">Rob</a> References &amp; Further Reading <a href="https://academic.oup.com/eurheartj/article/35/43/3033/503581/2014-ESC-Guidelines-on-the-diagnosis-and" rel="nofollow" target="_blank"> 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism</a> <a href="https://www.brit-thoracic.org.uk/document-library/clinical-information/pulmonary-embolism/bts-guideline-for-the-management-of-suspected-acute-pulmonary-embolism/" rel="nofollow" target="_blank"> British Thoracic Society guidelines for the management of suspected acute pulmonary embolism; 2003</a> <a href="http://journal.chestnet.org/article/S0012-3692(15)00335-9/fulltext" rel="nofollow" target="_blank"> Antithrombotic Therapy for VTE Disease CHEST Guideline and Expert Panel Report; 2016</a> <a href="http://circ.ahajournals.org/content/123/16/1788" rel="nofollow" target="_blank">Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension. A Scientific Statement From the American Heart Association. 2011</a> <a href="https://www.nice.org.uk/guidance/cg144/resources/venous-thromboembolic-diseases-diagnosis-management-and-thrombophilia-testing-pdf-35109570835141" rel="nofollow" target="_blank"> Venous thromboembolic diseases: diagnosis, management and thrombophilia testing; NICE. 2012</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1438862/pdf/jrsocmed00257-0051.pdf" rel="nofollow" target="_blank"> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1438862/pdf/jrsocmed00257-0051.pdfValue of anticoagulants in the treatment of pulmonary embolism: a discussion paper. Paul Egermayer. Journal of the Royal Society of Medicine 1981.</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/13797091" rel="nofollow" target="_blank">Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. BARRITT DW. Lancet. 1960</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/598069" rel="nofollow" target="_blank">Treatment of pulmonary embolism in total hip replacement. Johnson R. Clin Orthop Relat Res. 1977</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/1512328" rel="nofollow" target="_blank">PAIMS 2: alteplase combined with heparin versus heparin in the treatment of acute pulmonary embolism. Plasminogen activator Italian multicenter study 2. Dalla-Volta S. J Am Coll Cardiol. 1992 </a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/8094768" rel="nofollow" target="_blank">Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Goldhaber SZ. Lancet. 1993</a> <a href="http://circ.ahajournals.org/content/110/6/744" rel="nofollow" target="_blank">Thrombolysis Compared With Heparin for the Initial Treatment of Pulmonary Embolism.  A Meta-Analysis of the Randomized Controlled Trials. Susan Wan. 2004</a> <a href="http://bestbets.org/bets/bet.php?id=771" rel="nofollow" target="_blank">Massive PE and cardiogenic shock. To thrombolyse or not to thrombolyse, that is the question. Francoise Ticehurst. BestBets. 2004</a>

Massive PE Thrombolysis

Last time in Roadside to Resus we discussed cardiac arrest with a view to obtaining a return in spontaneous circulation, ROSC. However gaining a ROSC is just one step along the long road to discharging a patient with a good neurological function back into the community. In fact ROSC is really where all of the hard work really starts! In this podcast we talk more about the evidence base and algorithms that exist to guide and support practice once a ROSC is achieved. We'd strongly encourage you to go and have a look at the references and resources yourself listed below and would love to hear your feedback in the comments section or via twitter. Enjoy! Simon, Rob &amp; James References &amp; Further Reading Resuscitation to Recovery Document  Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. Niklas Nielsen. N Engl J Med 2013 Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Dumas F. Circ Cardiovasc Interv. 2010 Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia. Sandroni C. Resuscitation. 2013 Roadside to Resus; Cardiac Arrest PCI following ROSC; TRR

Last time in Roadside to Resus we discussed <a href="http://theresusroom.co.uk/cardiac-arrest" rel="nofollow" target="_blank">cardiac arrest</a> with a view to obtaining a return in spontaneous circulation, ROSC. However gaining a ROSC is just one step along the long road to discharging a patient with a good neurological function back into the community. In fact ROSC is really where all of the hard work really starts! In this podcast we talk more about the evidence base and algorithms that exist to guide and support practice once a ROSC is achieved. We'd strongly encourage you to go and have a look at the references and resources yourself listed below and would love to hear your feedback in the comments section or via twitter. Enjoy! <a href="https://twitter.com/laing_simon" rel="nofollow" target="_blank">Simon</a>, <a href="https://twitter.com/robfenwick" rel="nofollow" target="_blank">Rob</a> &amp; <a href="https://twitter.com/heli_med_james" rel="nofollow" target="_blank">James</a> References &amp; Further Reading <a href="https://www.resus.org.uk/publications/resuscitation-to-recovery/" rel="nofollow" target="_blank">Resuscitation to Recovery Document</a> <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1310519#t=article" rel="nofollow" target="_blank"> Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. Niklas Nielsen. N Engl J Med 2013</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/20484098" rel="nofollow" target="_blank">Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Dumas F. Circ Cardiovasc Interv. 2010</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/23831242" rel="nofollow" target="_blank">Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia.</a><a href="https://www.ncbi.nlm.nih.gov/pubmed/23831242" rel="nofollow" target="_blank"> Sandroni C. Resuscitation. 2013</a> <a href="http://theresusroom.co.uk/cardiac-arrest" rel="nofollow" target="_blank">Roadside to Resus; Cardiac Arrest</a> <a href="http://theresusroom.co.uk/pci-following-rosc" rel="nofollow" target="_blank">PCI following ROSC; TRR</a>

Return in spontaneous circulation; Roadside to Resus

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