The Resus Room

Welcome back to the podcast and to November's Papers of the Month! We start off looking at the rate of pneumothoraces in patients following ROSC after a medical cardiac arrest. What is the incidence? Are there any risk factors? And how might this affect our index of suspicion and imaging practice? We've spoken before about how difficult vertigo can be as a presentation to the Emergency Department; really common, often benign but with differentials that include posterior circulatory strokes, tumours and infections. Our second paper looks at a clinical risk score for patients presenting with vertigo to the ED and consider how this might affect practice. And finally we take a look at a great paper focussing on pre-alerts to the ED; consider current barriers, understanding and ways that we could improve the process both for the patients and staff. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

In this episode we’re going to be running through adrenal presentations; both Adrenal insufficiency and Adrenal Crisis. There are some parts of these that aren’t completely understood and a lack of a universal definition of Adrenal Crisis, but both insufficiency and a crisis are similar problems at different points on a spectrum and solid understanding of the endocrinology and physiology can really help to improve care in this area. There is huge potential for improving current morbidity and mortality. We’ll run through both primary and central adrenal insufficiency, describe how this leads to different effects on mineralocorticoids and glucocorticoids and the signs and symptoms that will occurs as a result.  Many of the patients presenting to the department will be unknown to have adrenal insufficiency and we’ll run through those who are at higher risk, including a huge group due to ongoing medication, who may be those on steroid doses much lower than you would previously have considered as significant.  NICE published their most recent guidance on Adrenal Insufficiency in August this year and we’ll be referring to a lot of this as we run through the episode.  We’ll finish up looking at the critical presentation of Adrenal Crisis and the emergency and ongoing management, along with how we support patients with insufficiency to prevent a crisis occurring.  Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James

Welcome back to October's Papers of the Month. We've been really spoilt with three fantastic papers to discuss this month! First up we take a look at the accuracy of non-invasive blood pressure readings in critically unwell patients in the prehospital environment and see how they could falsely reassure in both hypotension and hypertension. Next up we take a look at the superb SHED study, which looks to evaluate the accuracy of a plain CT head in identifying subarachnoid haemorrhage at different time frames. Currently NICE recommend an LP after a negative scan if the scan was performed more than 6 hours from onset. But what does this significant  dataset show and importantly how likely are you to 'miss' an aneurysmal subarachnoid haemorrhage if scanned within the first 24 hours and not following up with an LP? Lastly we look at a paper that highlight the potential benefit of naloxone in out of hospital cardiac arrest in opioid overdose. This delves into priorities in resuscitation, the fundamentals and some possible unexpected physiological effects from naloxone. Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon & Rob

PE’s (or Pulmonary Emboli) are a key part of Emergency Care, something that many of us will consider as a differential diagnosis multiple times of a daily basis, in a similar way to acute coronary syndrome, so we need to be absolute experts on the topic! A PE normally occurs when a Deep Vein Thrombosis shoots off to the pulmonary arterial tree, occurring in 60-120 per 100,000 of the population per year The inhospital mortality is 14% and the 90 day mortality is around 20%. But this is proportional to its size, and risk stratifying PE’s once we’ve got the diagnosis is really important. PE is a real diagnostic challenge and less than 1 in 10 who are investigated for a PE end up with the diagnosis, so knowing the risk factors, associated features and thresholds for work up are really important. There are some key concepts in risk stratification and particularly in test thresholds that we’ll cover in this episode that are applicable to all of our practice…..we’re excited! Getting these right helps us to avoid missing the diagnosis and equally importantly ensure we aren’t ‘over testing’ & ‘over diagnosing’ because investigation and treatment for a PE isn’t without it’s own risks. In the episode we’ll talk in depth about factors associated with presentation, risk factors, investigations and finally onto treatments, covering the whole spectrum from low risk PE’s up to those with massive PE’s and cardiac arrest. The evidence base behind the work up and treatments is truly fascinating and we hope you find this episode as eye-opening as we did to prepare for! Once again we’d love to hear any thoughts or feedback either on the website or via X @TheResusRoom! Simon, Rob & James