Welcome back to October's Papers of the Month. We've been really spoilt with three fantastic papers to discuss this month!

First up we take a look at the accuracy of non-invasive blood pressure readings in critically unwell patients in the prehospital environment and see how they could falsely reassure in both hypotension and hypertension.

Next up we take a look at the superb SHED study, which looks to evaluate the accuracy of a plain CT head in identifying subarachnoid haemorrhage at different time frames. Currently NICE recommend an LP after a negative scan if the scan was performed more than 6 hours from onset. But what does this significant dataset show and importantly how likely are you to 'miss' an aneurysmal subarachnoid haemorrhage if scanned within the first 24 hours and not following up with an LP?

Lastly we look at a paper that highlight the potential benefit of naloxone in out of hospital cardiac arrest in opioid overdose. This delves into priorities in resuscitation, the fundamentals and some possible unexpected physiological effects from naloxone.

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

Simon & Rob

PE’s (or Pulmonary Emboli) are a key part of Emergency Care, something that many of us will consider as a differential diagnosis multiple times of a daily basis, in a similar way to acute coronary syndrome, so we need to be absolute experts on the topic!

A PE normally occurs when a Deep Vein Thrombosis shoots off to the pulmonary arterial tree, occurring in 60-120 per 100,000 of the population per year

The inhospital mortality is 14% and the 90 day mortality is around 20%. But this is proportional to its size, and risk stratifying PE’s once we’ve got the diagnosis is really important.

PE is a real diagnostic challenge and less than 1 in 10 who are investigated for a PE end up with the diagnosis, so knowing the risk factors, associated features and thresholds for work up are really important.

There are some key concepts in risk stratification and particularly in test thresholds that we’ll cover in this episode that are applicable to all of our practice…..we’re excited! Getting these right helps us to avoid missing the diagnosis and equally importantly ensure we aren’t ‘over testing’ & ‘over diagnosing’ because investigation and treatment for a PE isn’t without it’s own risks.

In the episode we’ll talk in depth about factors associated with presentation, risk factors, investigations and finally onto treatments, covering the whole spectrum from low risk PE’s up to those with massive PE’s and cardiac arrest. The evidence base behind the work up and treatments is truly fascinating and we hope you find this episode as eye-opening as we did to prepare for!

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

Simon, Rob & James

Welcome back after the summer break!

Three more papers for you to feast your ears on this month and as always make sure you go and check them out yourselves after you've had a listen!

First up, following on really nicely from the DOSE-VF paper on dual sequential defibrillation we take a look at the paper that looks at the association between shock interval and VF termination. We might be biased but this shines a light on an area that could make a huge difference to the outcomes for patients with refractory VF!

Next; when you're seeing a patient with an upper GI bleed, which scoring/prognostication tool do you use and is it the best? We cover a paper that looks at exactly this question.

Finally we look at whether TXA predisposes patients to a higher risk of venous thromboembolism and whether it might affect our practice patterns.

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

Simon & Rob

The UK REBOA trial left many with doubts over its utility for trauma patients in ED. The time from injury to its use was around 90 minutes and the trial was stopped when it didn't reduce and maybe even increased mortality compared to standard care alone.

But what effect does REBOA have when used prehospitally and how feasible is it? Our first paper, from London HEMS, looks at this and gives a fascinating insight into it's use and the physiological response seen with it.

We've recently looked at dual sequential defibrillation for refractory VF with the DOSE-VF trial. Our second paper this month looks at how a double defibrillator strategy, in the context of cardioversion for AF, may affect restoration of sinus rhythm in obese patients.

Finally we take a look at the use of video livestreaming from scene to EMS, in a feasibility RCT. How can it affect accurate dispatch of the most appropriate resources and what impact does it have on those that use it?

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

Simon & Rob

Acute Kidney Injury is common, complicated and holds significant morbidity and mortality. But...if we recognise it, we can make a real difference to our patients' outcomes.

In this episode we run through the anatomy, physiology and aetiologies.

We have a think about the multitude of definitions of AKI and then take each of the pre renal, renal and post renal categories and think about the ways we can optimise our care in each.

We also have a think about who needs to be admitted and who can be safely managed in the community.

This was a hugely valuable episode for us all to research and bring clarity to a complicated topic, we hope it does the same for you too!

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

Simon, Rob & James

There's a huge paper to talk about this month in the PREOXI trial, a multi centre RCT looking at the pre oxygenation strategy in critically unwell patients undergoing RSI, with patients either getting high flow oxygen through a facemask or NIV. The results are pretty remarkable and may well be practice changing as we'll discuss in the podcast!

Next up we take a look at a feasibility of lidocaine patches for older patients with rib fractures and the potential benefit in terms of pain and respiratory complications.

Lastly we take a look at the benefit of performing a CT head scan in the Emergency Department for patients with a first fit. At times this can feel like a significant utilisation of resources, but what is the yield of positive scans and impact on patient care?

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

Simon & Rob

So this month we’re looking at major incidents and specifically the triage process that is now coming into play in the UK and further afield that you need to know about!

We normally stick pretty strongly to clinical topics; they’re pretty easy to focus on because you can imagine how extra knowledge in a certain clinical area could make a difference to presentations that we see pretty commonly. And being brutally honest, making the effort to prepare and rehearse what we might do, on the off chance that we ever come across a major incident, can be difficult to motivate yourself to do.

But this is probably an area that investing a bit of time in, really thinking about how you would act in a major incident, could make a phenomenal difference to what may be one of the most, if not the most challenging clinical days of your career.

In the episode we run through Ten Second Triage (TST) and the Major Incident Triage Tool (MITT). They replace the previous triage methodologies and are to be implemented by the end of this month. We also cover some other aspects of planning and approach for being the first responder at a major incident, and we were lucky enough to gain some insights to the new triage process from Phil Cowburn, an EM & PHEM consultant who was involved in their development.

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

Simon, Rob & James

Welcome back to June's Papers of the month!

We kick off this month looking at the work up of patients with a first episode of psychosis. With these patients there is a chance of a psychosis secondary to an underlying structural cause. Getting neuro-imaging to look for this prior to psychiatric assessment is tricky though, often with a need for sedation and then the subsequent delay for psychiatric assessment. Our first paper looks at the yield of positive scans for these patients and helps us to understand a bit more about the need for this.

Secondly; sepsis screening tools are commonplace in most emergency services and departments, but how do they compare against senior clinician gestalt?

Finally we look at the association of gastric distension in cardiac arrest and the rates of ROSC, should we be concentrating more on decompression of gastric volume intra-arrest?

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

Simon & Rob