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Coda Change

Coda Conference: Clinical Knowledge, Advocacy and Community.Melbourne: 11-14 Sept 2022codachange.org

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Best Emergency Medicine literature of the year 2018/19

Ken Milne the author of skeptics guide to emergency medicine SGEM reviews the hottest critical care literature for 2018 2019. Ken reviews articles from the Lomaghi trial on magnesium for rate control in Atrial fibrillation, Expulsive therapy for renal calculi with Tamulosin, Oxygen therapy in critical illness in the Iota trial and finally aromatherapy for nausea and vomiting.

14mins

9 Dec 2019

Rank #1

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The Great(est) Fluid Debate

Resuscitation fluids save lives in humans with life-threatening hypovolaemia. The fluid of choice should have biochemical characteristics close to the type of fluid lost and replaced at a rate and volume sufficient to correct the severe fluid deficit. Then stop and consider the early use of catecholamines. There are few indications to give critically ill patients resuscitation fluids after 24 hours of admission. There is no place for synthetic colloids of non-physiological crystalloids. The effects of unnecessary fluids last well beyond the initial resuscitation period and are associated with adverse effects and harm to the patient. Fluids are toxic drugs and must be used with great care.

18mins

24 Jan 2020

Rank #2

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Vasopressors in the Emergency room

John Greenwood discusses the use of vasopressors in the emergency room. His talk focuses on three areas. First, he reviews vasopressors and categorises them based on resuscitation end points. Secondly, he addresses the concept of “pressor angst” and how it can significantly impact patient mortality. Finally, he will empower you to start vasopressors early in patients with distributive shock and sepsis. The tale of a 45-year-old lady with sepsis in the context of pneumonia is retold. John asks - what do you do? Initial fluid resuscitation has improved the vitals somewhat, but she is still hypotensive. Continue to give fluids? Sure – it seems to be what happens commonly. Starting vasopressors starts a cascade of events that will consume time and resources. It impacts flow, timing, and ability to see other patients. Often, the clinician knows it the right thing to do but does not want to pull the trigger. This process of having two conflicting beliefs in your brain at the same time is cognitive dissonance. In the context of using vasopressors, John terms this “pressor angst”. The hesitation to use vasopressors even when perhaps you know it is the right thing to do. It is a complex confliction of behaviours, beliefs, goals, and practices. Regarding vasopressors specifically, the clinician will be considering the logistics, bed crunch and procedures amongst other things! Why does the time matter? As John explains with reference to the literature, the time to the decision to commence vasopressors is hugely important in influencing patient mortality. There is a clear mortality benefit to starting vasopressors early. Norepinephrine started early can aid in adjusting preload, cardiac output, and afterload parameters. John steps you through the effect of norepinephrine on all metrics that contribute to. The conclusion is that early norepinephrine administration improves both macro- and microcirculatory function in vasoplegic shock. John wants you to avoid pressor angst! Do not be afraid of vasopressors and pull the trigger early. Finally, consider norepinephrine early in sepsis. For more like this, head to https://codachange.org/podcasts/ 

20mins

14 Dec 2018

Rank #3

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Post-Intubation Sedation: Scott Weingart

Scott Weingart discusses post-intubation sedation – a topic that tends to aggrieve him on a regular basis. Scott explains in simple terms why he is bemused at the lack of understanding surrounding intubated patients who become agitated or aggressive. How would you like a piece of plastic placed down your throat? The problem, as Scott explains, is that sedation does not blunt pain. Sedation without analgesia leads to delirium. In simple terms delirium leads to poor outcomes and death. Moreover, concerningly, the early sedation strategy of intubated patients has long term and far-reaching outcomes during their course of critical illness. So, what can be done? Scott explains that we need patients properly sedated, however not too deeply sedated. The goal needs to be a patient who is oriented, safe and with a normal sleep-wake cycle. Paralysis is not the answer. What is the answer? Scott walks you through A1 sedation – meaning analgesia first. Once pain is controlled, then sedation comes in to play. Scott stresses with analgesia first, the sedation needed is less. He explains how he achieves this in practice in detail. He then provides some clinical examples and how he would approach them including which specific medications he uses in practice. Scott’s main points are simple. Control the pain and very few patients will need a lot of sedation. In addition, if you adequately control the pain, very few patients will have delirium in the Emergency Department. Join Scott as he passionately discusses post-intubation sedation. For more like this, head to our podcast page. #CodaPodcast

27mins

3 Mar 2017

Rank #4

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Prehospital Diagnosis and Treatment of Sepsis

Michael Perlmutter guides you through the prehospital diagnosis and treatment of sepsis. Sepsis is a difficult diagnosis to make. Even in the hospital, where a plethora of tests are available to assist the clinician. The diagnosis remains a challenging one, due to the very nature of sepsis. A shadowy shape-shifter notorious for its ability to hide in plain sight. For now, even in-hospital, there is no test with perfect sensitivity or specificity for sepsis. This is especially true in the prehospital environment, where we must rely on tools we can bring into the field: physical exam, point of care tests (lactate/venous gas), assessment of end-tidal CO2, and ultrasound. The aim of prehospital sepsis care is two-fold – early diagnosis and early treatment. First, early diagnosis of cases ranging from early sepsis to septic shock. Point of care testing is essential. Measurement of EtCO2 serves two purposes: as a reasonable surrogate for lactate and providing an accurate respiratory rate. A vital sign that is notoriously poorly assessed. Respiratory rate plays a key role in both SIRS and SOFA/qSOFA criteria for sepsis, making an accurate count essential. Ultrasound should also play a pivotal role in prehospital sepsis management. Much has been made of the prehospital FAST exam, however, the ability of POCUS to gauge fluid responsiveness and cardiac function is far more useful. Assessment of the IVC may aid in determining the value of volume resuscitation by helping to identify patients who are responsive to volume and those who would be better served by early initiation of vasopressors. Similarly, assessment of cardiac function may prove extremely useful in selecting a pressor. POCUS may also assist in differentiating sepsis from other aetiologies by identifying a source, such as pneumonia. The second fundamental aim is treatment equivalent to that available in-hospital. This includes judicious administration of balanced IV fluids guided by POCUS and clinical assessment of fluid responsiveness, early pressors, and early antibiotics, particularly where transport times are significant. When sepsis is diagnosed by EMS, a “sepsis alert” should be communicated to the receiving hospital, to facilitate ongoing early, aggressive care upon arrival of the retrieval team. Advanced prehospital diagnosis and treatment can produce dramatic reductions in mortality from sepsis. For more like this, head to our podcast page. #CodaPodcast

11mins

10 Nov 2016

Rank #5

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Science of Cardiopulmonary Resuscitation

David Halliwell presents the science of cardiopulmonary resuscitation. Resuscitation means lots of things to different people – compression, CPR, mouth to mouth, ventilation, return to normal and reanimation all come to mind. But how and why does resuscitation really work – let David explain. This talk uses a case study approach to discuss why resuscitation practitioners should focus upon technical accuracy when resuscitating, focussing on all the facets of a resuscitation, compression, decompression, trans-thoracic impedance. Two points David would like you to take away: 1) Blood flows from high to low pressure even when the heart stops beating and 2) Blood doesn’t flow through the heart during systole. David talks about the two big theories of cardiopulmonary resuscitation. The first is the heart squeeze theory – that being chest compressions will pump blood out of the heart and around the body. This is as opposed to the thoracic pump theory which states blood flows due to a pressure gradient and by changing the pressure in the thoracic cavity you enable the blood to continue to move. This is enabled by the papillary muscles and valves failing to work in an arrested heart. The truth is probably that both theories hold merit and a combination of both enables a successful resuscitation. David calls this the lung pump theory. After discussing theory, David moves on to the more practical aspects of CPR. Firstly, compression – compressions clear the heart out. Without compressions, the right ventricle fills with blood (due to the pressure gradient) that cannot move through. This splints the right heart against the collapsed left heart. Secondly, ventilation. David warns of the complications caused by improper and inappropriate ventilation which will decrease venous return and make your compressions futile. Finally, defibrillation. There are a few important points here. The critical mass is the left ventricle, so get the pads as close to this as possible. Prepare the skin (which involves knowing how to use the razors in the defibrillator kit) and place the pads appropriately. David concludes with some technical issues that need to be remembered, performed correctly, and watched out for. These include chest compression depth, compression rate, hand placement and consistency. For more like this, head to https://codachange.org/podcasts/ 

28mins

16 Oct 2016

Rank #6

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Emerging Toxicology - Steve Aks

Poisons and novel agents are a moving target in the clinical arena. This talk begins with a historical look at decontamination and pitfalls that have been discovered along the way. The advent of intubation and critical care was a major boon in the improvement in mortality from poisoning. The Scandinavian Method is described and is an important lesion to this day. The rise of antidotes is mentioned. Emerging drugs are highlighted in the context of where we have come from. The phenylethylamine compound structure and corresponding variants are described. The importance of the principles of supportive care as learned in the Scandinavian method is emphasized. Other emerging topics including synthetic cannabinoids, and anti-NMDA receptor antagonists are discussed. Emerging interventions of prescription naloxone, and ED ECMO are outlined. High vigilance for new agents, and innovative treatments will enable clinicians deal with these evolving trends.

21mins

14 Mar 2016

Rank #7

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Hardcore EM: How an Emergency Physician Thinks

Hardcore EM: How an Emergency Physician Thinks

32mins

2 Mar 2019

Rank #8

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Prehospital Ketamine – Is there anything it can’t do?

PHARM Physician, Per Bredmose, provides an in-depth look at Ketamine in the prehospital setting. Per discusses the uses, benefits and potential complications of Ketamine, providing tips and tricks from his wealth of experience.

30mins

19 Apr 2016

Rank #9

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Is the Answer Really “Always Ketamine”? - Peter Brindley interrogates: Reuben Strayer

A no-holes barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.

16mins

29 Apr 2018

Rank #10

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Rapid Sequence Airway: Darren Braude

Darren Braude discusses the concept of Rapid Sequence Airway (RSA). The evolution of this concept goes back to the start of the 21st century. Here, the practise of ‘archaic’ airway management was common. This involved getting that plastic tube down the patient’s trachea no matter what. However, gradually, the risks of hypoxaemia during airway management become evident. This led to a movement towards extraglottic airways. If the oxygen saturation was dropping and there had been two failed attempts. This movement continued to involve towards operators deciding to move to other methods when only one attempt had failed. This was largely due to the increased training and skill of clinicians. The thinking being if they could not get it in one shot, they probably weren’t going to get it at all. This evolution was the catalyst for the movement towards faster airways, and less emphasis on intubation. Rapid Sequence Airway is pharmacology and preparation as in RSI, with the planned placement of an extraglottic device, without any intention to intubate. Moreover, in this talk Darren takes you through the advantages and disadvantages of RSA. It is a fast and highly successful technique with minimal airway trauma. On the flip side, some patients are not good candidates for extraglottic devices. RSA necessitates a secondary procedure and it does not provide a ‘definitive’ airway. RSA is an alternative airway management strategy that may be ideal for preoxygenation of hypoxemic patients as well for prehospital and in-flight use. Darren provides the ins and outs of Rapid Sequence Airway in this talk, as well as providing the data and his real world experience of using this concept. Finally, for more like this, head to our podcast page. #CodaPodcast

24mins

3 May 2017

Rank #11

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The Right Ventricle in Pulmonary Hypertension: John Greenwood

John Greenwood takes a broad view on pulmonary hypertension and explores the heart-lung interactions that occur in this disease process. Pulmonary hypertension commonly occurs when managing a patient with an acute critical illness. Pulmonary hypertension has a devastating impact on cardiac function. Whilst we recognise the disease itself, we don't recognise the ‘upstream’ effects. John explains how it is these effects that may be causing the patient to crash. John, in this talk, helps you to understand the clinical heart-lung interactions affected by pulmonary hypertension and the effect on the right ventricle. He educates you on identifying patients at high risk for pulmonary hypertension, and finally he discusses critical management strategies for patients with pulmonary hypertension. In the ICU, causes of acute pulmonary hypertension are evident daily.  Microcirculatory of the lung has a strong impact on what the pulmonary pressures are. Therefore, conditions such as pneumonia, ARDS and pulmonary oedema will all lead to pulmonary hypertension. The condition can then be exacerbated by the treatments offered – namely mechanical ventilation! This brings John to the right ventricle. John explains why he feels the right ventricle is too often overlooked. He describes the form and function of the right ventricle and how it often fails in the case of pulmonary hypertension. The pumping function of the muscle does not have the necessary components to overcome high pressures as they are encountered in this disease. Finally, John provides his thoughts on the management of pulmonary hypertension, keeping in mind the importance of the right ventricle. Through his presentation he will convince you that pulmonary hypertension is common. By remembering that the right ventricle is sensitive, by judicious use of echocardiography and by proper resuscitation, John will help you treat patients with pulmonary hypertension. Finally, for more like this, head to https://codachange.org/podcasts/ 

29mins

3 Jan 2017

Rank #12

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Defending Bawa-Garba: When Healthcare Becomes a Crime

Delivery of safe healthcare currently faces unprecedented challenges in the UK and globally. This arises, at least partly, from a rising involvement of the criminal law in the investigation of medical errors apparently conflicting with the need to respect a "duty of candour". As a result, doctors face enormous pressures in fear of being blamed for medical errors. David Sellu is a consultant surgeon who was convicted for gross negligence manslaughter in late 2013 after the death of a patient in a private hospital. I (@DrJennyVaughan) was the medical lead for a group of David Sellu's friends as we launched a campaign to overturn his conviction. There has never been a successful 'out of time' appeal in this area of the law so we were dealing with almost impossible odds from the start. The positive result was extraordinary, both for David and our whole profession (www.medicalmanslaughter.co.uk). Since these events, I have supported other doctors facing criminal conviction, such as the paediatrician Dr Hadiza Bawa-Garba, through my work with the Doctors Association UK (DAUK, @TheDA_UK). Thousands of doctors crowd-funded a campaign and successfully overturned a court decision to erase her from the UK medical register. Her case proved to be a lightning rod in the UK for a profession at breaking point. Many healthcare staff are working on critically under-staffed wards and in under-resourced departments, with an increasingly unmanageable workload. DAUK have since launched a "Learn Not Blame" campaign to improve safety for patients and healthcare professionals. We believe that the involvement of the criminal justice system in these cases often does not allow an appreciation of the interplay of individuals within complex health systems. We also remain particularly concerned that a recent analysis of conviction trends shows an excessive conviction rate of black and minority ethnic (BME) healthcare staff.

25mins

18 Dec 2019

Rank #13

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Clot retrieval for stroke in the extended time window

A case example of a large vessel obstruction of the brain and our current techniques available to treat it. How we make decisions on endovascular treatment and management points for emergency and intensive care colleagues.

20mins

22 Jan 2020

Rank #14

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Anyone Can Intubate, or Not: Teaching airway skills the antifragile way - George Kovacs

Becoming competent in airway management requires good decision making and and technical skills. Ultimately what matters is how your clinical performance impacts patient outcomes. For this we need to have a clear understanding of what defines success ensuring that its more than just 'getting the tube'. Come to this talk and you'll experience a Canadian take on Guinness, adventure sports, flying a plane and how other factors including failure influence airway management outcomes.

27mins

2 May 2017

Rank #15

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Critical Care Haematology

Deirdre talks ‘bad blood’ – the complex world of critical care haematology. Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human. When they run riot, or the fine balance between pro- and anti-inflammatory states is shifted, there can be significant morbidity and mortality. Deirdre presents three patients to highlight these issues and what you can do about it. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients. Platelets make up a tiny percentage of blood – just 0.01%. However, they have a crucial role to play. A low platelet count can be due to reduced production or increased destruction. Disseminated Intravascular Coagulation (DIC) is a clinical and laboratory diagnosis that affects about 1% of hospitalised patients. At the most severe end it is associated with bleeding and/or thrombotic complications. Disorders such as thrombotic thrombocytopenia purpura (TTP) and other forms of micro-angiopathic haemolytic anaemia (MAHA) will also be described including the role of ADAMST13. The knowledge of what is what, is critical, as it will dictate treatment. Heparin-Induced Thrombocytopaenia (HIT) is an uncommon but important condition which is difficult to diagnose in a critically ill patient. It is a heparin dependent pro-thrombotic disorder. There is no good test for HIT.  Have you always wondered about NETs (neutrophil extracellular traps) and their importance? If so this whistle-stop tour of non-malignant hematology in the ICU is for you! Deirdre drives home the message that low platelets are common in the critically ill and the causes are multifactorial.  Finally, for more like this head to codachange.org/podcasts/

23mins

25 Oct 2016

Rank #16

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A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat

Haney Mallemat discusses the treatment for PEA cardiac arrest. Patients who present with pulseless electrical activity (PEA) arrest have a high mortality. The treatment of PEA requires finding and reversing the underlying cause; therefore a simple and rapid approach is required. Traditionally we were taught to use the H’s and the T’s, but this diagnostic tool is cumbersome and of questionable utility overall. Haney discusses the problems with the traditional H’s and T’s as well as focusing on newer approaches to PEA arrest. Haney makes the point that PEA is not a diagnosis, but a ‘waste basket term’ for a lot of possible diagnoses. Rather than assisting a clinician in the assessment and treatment of a patient, it acts on to lead to pontification. To that end, Haney wants us to do away with the H’s and T’s. The problem with the algorithm of diagnosing a PEA, as Haney explains, is the reliance on feeling a pulse. It lacks sensitivity and specificity, largely linked to using fingers. They should not be used in resuscitation scenarios – as the guidelines say we should. Haney makes the point that despite all the advances in medicine, resuscitation has stayed essentially the same for decades. He describes two ways in which he thinks we can advance our care. The first involves the QRS complex. Ask the question – is the QRS complex narrow or wide. Narrow (< 0.12 seconds) leads you to consider mechanical problems, such as tension pneumothorax or tamponade. If it is wide (> 0.12 seconds), then consider metabolic problems such as hypokalaemia. If the QRS is narrow, and you are thinking a mechanical problem then there is electrical activity, and the heart is still beating underneath. The step should be to use ultrasound immediately to find the focused cause. If it is wide, and you are considering metabolic causes, this is more aligned with a true PEA. Calcium bicarbonate should be considered in the first instance. Haney describes the limitations with the algorithm that includes the trauma patient or those with underlying cardiac conditions. Next Haney describes a second algorithm - PREM (pulseless with rhythm and echo motion) and PRES (pulseless with a rhythm and echo standstill). The use of ultrasound is central to this pathway. In PREM the left ventricle is not strong enough to produce a pulse. Does this patient get adrenaline or chest compressions? Haney discusses the options. In PRES there is electrical activity, but the heart is not squeezing. Maybe these people should get adrenaline and compressions! The ECG should still play a part in this algorithm. Haney puts it all together for you and takes you through the algorithm he uses when faced with a patient with PEA. He includes some tips for using the ultrasound probe during cardiac arrest resuscitation scenarios. A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat For more like this, head to our podcast page. #CodaPodcast

23mins

4 Jan 2017

Rank #17

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Muscle wasting in ICU: Fat, Feed and Futility

Muscle wasting in intensive care is the thief of future health. Hugh Montgomery shows us what a big issue this is and what can be done to mitigate the problem.

20mins

24 Jan 2020

Rank #18

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Scott Weingart - Emergent Intubation Resequenced

Pretty much everything I learned as a resident in terms of the sequencing of airway management in ED has changed over the past 15 years. No longer is there simply RSI or stick a laryngoscope in with nothing and use pure brute force to intubate a patient; we have a host of different options and pathways when approaching airway management in the emergency department. This lecture discusses some of these updated ways of getting from a sick patient requiring airway management to a tube between the cords…with only minor technical mishaps.

27mins

5 Apr 2016

Rank #19