So it’s that time of year when we try and wind down and take stock of what’s gone on over the last 12 months and make plans for the next year ahead….the problem being that workload does anything but decrease over the festive period in Emergency Care!
So we thought we’d save you the hard yards and collate some of the main topics that caught our eye here at TheResusRoom during 2016. Here we go….
‘You’d better keep that anaphylaxis in Obs overnight’
When we have a think about allergic reactions and anaphylaxis, it’s drilled into us to then consider the risk of going on to develop biphasic reactions. We reviewed a paper from Grunau that challenged many peoples beliefs and quoted the risk to be around 1 in 500, and further showed the resultant reactions were also likely to be mild in severity. This paper really challenged current practice, bringing into question the benefit of admitting these patients for a number of hours, something recommended in the current NICE guidelines.
‘Relax, they’ve stopped shaking’
Status epilepticus is a common presentation to EDs, but the awareness of phases 1 and 2 of seizures isn’t quite so common. NICE gives some some useful guidance on the treatment algorithm for status but debate often presents when the external signs of seizure seem to be settling but it is unclear if the seizure has terminated or entered phase 2 (the non-convulsive phase). A great paper from Pang highlights the need to identify these subtle but ongoing seizures and the resultant harm that can occur from failing to do so.
‘No time for an x-ray, get a needle in it’
Classical teaching for needle thoracostomy of a tension pneumothorax had you place you cannula into the 2nd intercostal space, mid clavicular line and wait to hear that oh so satisfying hiss (that can obviously be heard in your silent resus room!). Laan published a review of the literature in Injury and challenged this practice, highlighting that the failure rate may be as much as 3 times higher using the 2nd ICS when compared with 4th or 5th intercostal space in the anterior axillary line.
‘It’s sleepy time, or is it?’
In April BTS and ICS jointly published new guidelines on the ventilatory management of type 2 respiratory failure. The document ran through the entirety of type 2 failure all the way from initial management, to NIV setup, right through to intubation and ventilation. The document highlighted that significant complications of NIV are rare and that vigilance during it’s use can help reduce this even further. They also mentioned that whilst there isn’t the evidence to support the use of absolute values of pH or pCO2 as an indication for intubation and mechanical ventilation, we should use the prompt of a pH below 7.25 to consider it.
‘Balloons becoming the new trend’
It wasn’t possible to navigate FOAM this year without coming across REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta), this technique allows minimally invasive temporary control of haemorrhage via internal occlusion of blood flow through the aorta, buying some time for more definitive control to be achieved. We caught up with Zaf Qasim, lead author of a review paper on the topic which was published in Resuscitation and also Sam Sadek from the Royal London who ran through the education, governance and finer details involved in setting up a REBOA service. One thing is for sure, REBOA has certainly got peoples attention and the progression and application of the technique looks set to escalate!
‘We’ve got a ROSC. Get them to the cath lab, oh wait, what’s on the ECG??’
What do you do with the patient that has a cardiac arrest, you achieve a ROSC and they have no evidence of a cause of their arrest and the ECG is normal? Whilst the ESC guidelines state ‘in survivors of out-of-hospital cardiac arrest, early coronary angiography and PCI—if appropriate—should be performed irrespective of the ECG pattern if no obvious non-cardiac cause of the arrhythmia is present‘, regional practice certainly seems to vary though despite this. We reviewed the strongest paper in the topic, the PROCAT study which has only proven an association between PCI following ROSC and improved outcome rather than a causation of benefit, but with further papers coming out on the topic, common practice is likely to align with the ESC guidelines soon (we hope).
‘CT once and CT again, don’t take the bloody risk’
With NICE’s change in 2014 to scanning all those patients with a head injury on warfarin, practice seems to be creeping towards an even more defensive stance on the topic, with many departments opting to keep patients for observation after an initial normal scan, but what is the risk of a delayed bleed? A paper from Chauny in the Journal of Emergency Medicine looked to answer this question and found the rate to be around 1 in 170 with a risk of neurosurgical intervention at at nearly 1 in 800. Does this warrant observation of these patients for 24 hours, thats for us all to decide?
‘What caused this patient’s collapse, a PE?’
A year of EBM wouldn’t be complete with some controversy on the topic of PE’s and that came in the form of the PESIT trial, published in the NEJM which suggested working patients up presenting with syncope for PE even when an alternative diagnosis had been identified, irrespective of the presence or lack of clinical pointers towards PE. Needless to say the trial suffered a fair amount of criticism from multiple sources and should not be a practice changer.
‘Don’t forget the tube!’
And finally the ICS SoA 2016 Conference gave us a chance to review the current state of play of RSI in UK Emergency Departments. The latest figures from NAP4 showing that in the UK only 20% of ED RSI’s are carried out by EM clinicians. Kerslake’s work from Edinburgh describes a well functioning and performing system, with a collaborative approach for ED airway management. Hopefully further work and enthusiasm throughout the UK in this area will help move us forward, nearer to other ED systems outside the UK.
There were lot of other topics covered throughout the year and make sure you subscribe to the iTunes feed to keep up to date. 2017 promises to be a great year for TheResusRoom, we’re expanding across specialties and into more multidisciplinary areas, with the addition of some great friends and colleagues.
So make sure you try and get some downtime and enjoy some festive cheer over the next few days, we look forward to seeing you on the other side in 2017 and thanks for your support with TheResusRoom!