Mile High Anaesthesia by Healy
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Geoff Healy rises above traditional views on the use of anaesthesia, highlighting the unique challenges and key role it plays in the pre-hospital environment.
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Medicine for Mars - Kevin Fong
Medicine for Mars - Kevin Fong
Summary by: Kevin Fong
Kevin Fong is an astrophysicist, astronaut and anaesthetist who gives an incredibly entertaining talk about human space exploration and our dreams of a manned mission to MARS. This is a mission that stands on the boundary between science fiction and science fact. A mission that would be a minimum of 1000 days in length and which would be twice as long as any previous manned space mission.
Fong focuses on the the incredibly destructive effects of such prolonged weightlessness on the human body. He outlines the somewhat predictable effects of this on the muscles and bones, but surprises us with the changes in vestibular balance, linear acceleronomy, baroreceptor calibration and probably most frighteningly the psychological effects of prolonged isolation in space. Despite considerable work in the area of human adaptation for space and the ongoing development of counter-measures these physiological challenges remain largely unsolved.
In essence Fong explains, to overcome the detrimental physiological effects of prolonged weightlessness engineers need to design a craft capeable of generating 1G of gravitational force to mimick earth’s gravity. This could require a craft the size of the London EYE rotating four times per minute. Perhaps if this can be achieved, astronauts might arrive at MARS after 30 months in space in a physcial state capeable of allowing them to stand upright and walk from the landing craft.
Pat Croskerry - Making Transitions of Care Safe
It is now well recognized that transferring the care of a patient from one caregiver to another is a vulnerable point in a patient’s care and a potential threat to patient safety. There may be many intra-disciplinary and inter-disciplinary transition points in the ED during an individual patient’s care. The process requires that each participant communicates well with others to establish an accurate shared mental representation of the important issues.
To minimize transition failures, the process should be trained and standardized, recognized as a multiprofessional activity, defined by who should be present, where and when it should occur, and have an end-point that is a clear plan for the ongoing care of the patient. The reliabilility, consistency, and efficacy of the transition should be a hallmark of departmental culture.
Training should be provided in how the process works and how it fails. The broad distinction between the transfer of poor information (unwarranted opinions, stereotyping, stigmatization, gratuitous comments, overconfidence, and other cognitive biases) and poor transfer of information (unstructured, casual setting, rushed/fatigued, interruptions/distractions, limited input from others, verbal only, degraded narrative skills) should be recognized. It is important to reliably express the amount of certainty attached to what is actually known at transfer so that recipients clearly understand what is expected of them.
The vulnerability of human memory should be recognized and strategies used to deal with it (SBAR, I-PASS and others). There should be awareness of particular biases in communication at transition time. Serial position effects describe how primacy (information presented at the beginning) and recency (the last information to be presented) may influence what is perceived and retained. It is important to be aware of specific biases that operate at transition time: framing, fundamental attribution error, search satisficing and others) and consider strategies to mitigate them.
Teaching About Medical Error
Teach your medical students and residents to identify and avoid four common medical errors made in training.
Medical Safety: Lessons from Space by Kevin Fong
Kevin Fong is an astrophysicist, astronaut and anaesthetist with an interest in medical error and safety. In this talk he focuses on lessons learnt from his time at NASA which can be applied to medical practice. Fong believes that key to safer practice is in the collection of accurate data. He outlines some aspects of the famous communications between Sully Sullenberger (pilot) and the Le Gardia air-traffic control tower as Sullenberger miraculously lands a commercial airline on New York's Hudson River - Fong's point is not in the words said or in the calmness of the communications, but that we can go back and analyse every word spoken because the data is collected so accurately.
He goes on to discuss some of the failures surrounding both the Space Shuttle Challenger and Columbia accident's. More importantly he stresses not so much the lessons learnt but the lessons forgotten and the need to ensure organisational memory. We only protect ourselves and our patients through technology and the systems of operation we create.
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Medicine for Mars - Kevin Fong
Medicine for Mars - Kevin Fong
Summary by: Kevin Fong
Kevin Fong is an astrophysicist, astronaut and anaesthetist who gives an incredibly entertaining talk about human space exploration and our dreams of a manned mission to MARS. This is a mission that stands on the boundary between science fiction and science fact. A mission that would be a minimum of 1000 days in length and which would be twice as long as any previous manned space mission.
Fong focuses on the the incredibly destructive effects of such prolonged weightlessness on the human body. He outlines the somewhat predictable effects of this on the muscles and bones, but surprises us with the changes in vestibular balance, linear acceleronomy, baroreceptor calibration and probably most frighteningly the psychological effects of prolonged isolation in space. Despite considerable work in the area of human adaptation for space and the ongoing development of counter-measures these physiological challenges remain largely unsolved.
In essence Fong explains, to overcome the detrimental physiological effects of prolonged weightlessness engineers need to design a craft capeable of generating 1G of gravitational force to mimick earth’s gravity. This could require a craft the size of the London EYE rotating four times per minute. Perhaps if this can be achieved, astronauts might arrive at MARS after 30 months in space in a physcial state capeable of allowing them to stand upright and walk from the landing craft.
Pat Croskerry - Making Transitions of Care Safe
It is now well recognized that transferring the care of a patient from one caregiver to another is a vulnerable point in a patient’s care and a potential threat to patient safety. There may be many intra-disciplinary and inter-disciplinary transition points in the ED during an individual patient’s care. The process requires that each participant communicates well with others to establish an accurate shared mental representation of the important issues.
To minimize transition failures, the process should be trained and standardized, recognized as a multiprofessional activity, defined by who should be present, where and when it should occur, and have an end-point that is a clear plan for the ongoing care of the patient. The reliabilility, consistency, and efficacy of the transition should be a hallmark of departmental culture.
Training should be provided in how the process works and how it fails. The broad distinction between the transfer of poor information (unwarranted opinions, stereotyping, stigmatization, gratuitous comments, overconfidence, and other cognitive biases) and poor transfer of information (unstructured, casual setting, rushed/fatigued, interruptions/distractions, limited input from others, verbal only, degraded narrative skills) should be recognized. It is important to reliably express the amount of certainty attached to what is actually known at transfer so that recipients clearly understand what is expected of them.
The vulnerability of human memory should be recognized and strategies used to deal with it (SBAR, I-PASS and others). There should be awareness of particular biases in communication at transition time. Serial position effects describe how primacy (information presented at the beginning) and recency (the last information to be presented) may influence what is perceived and retained. It is important to be aware of specific biases that operate at transition time: framing, fundamental attribution error, search satisficing and others) and consider strategies to mitigate them.
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Teach your medical students and residents to identify and avoid four common medical errors made in training.
Medical Safety: Lessons from Space by Kevin Fong
Kevin Fong is an astrophysicist, astronaut and anaesthetist with an interest in medical error and safety. In this talk he focuses on lessons learnt from his time at NASA which can be applied to medical practice. Fong believes that key to safer practice is in the collection of accurate data. He outlines some aspects of the famous communications between Sully Sullenberger (pilot) and the Le Gardia air-traffic control tower as Sullenberger miraculously lands a commercial airline on New York's Hudson River - Fong's point is not in the words said or in the calmness of the communications, but that we can go back and analyse every word spoken because the data is collected so accurately.
He goes on to discuss some of the failures surrounding both the Space Shuttle Challenger and Columbia accident's. More importantly he stresses not so much the lessons learnt but the lessons forgotten and the need to ensure organisational memory. We only protect ourselves and our patients through technology and the systems of operation we create.
How to Think Straight- Cognitive Debiasing Pat Croskerry
"How to think straight: Cognitive de-biasing by Pat Croskerry
The number of preventable deaths of hospitalized patients in the US each year is estimated at 40,000- 80,000. The figure for the ICU alone is estimated at 40,000 so the death rate must be in the higher end of the range. When settings outside the hospital are taken into account (ED, primary care), the overall number must be considerably higher.
While many factors contribute to diagnostic failure, a variety of sources suggest that physician’s thinking has a lot to do with it. Dual Process Theory describes how the brain makes decisions in one of two modes: through fast, unconscious, intuitive processes (System 1) or through slower, conscious, analytical processes (System 2). Mental short-cuts (heuristics) and biases are predominantly located in the intuitive mode where we spend most of our conscious time, and this is where the majority of decision failures occur. Thinking straight essentially means achieving a good balance between System 1 and System 2 decision making, and much of our cognitive effort needs to go into monitoring what our unconscious brains are doing in System 1. This is referred to by a variety of terms: metacognition, reflection, mindfulness, and others. They all involve cognitive de-coupling from System 1 and characterize the process of cognitive de-biasing. This is not easily accomplished in the ED or any environment where decision density is often high, throughput pressure exists, resources may be limited, and where decision makers may be fatigued and/or sleep deprived.
While medicine has acquired a variety of strategies over the years for de-biasing clinicians, added benefits can be obtained by developing specific mindware to tackle particular biases. Clinicians need to be aware of the operating characteristics of the dual process model of decision making, of the prevalence and nature of biases, and of how to apply and sustain de-biasing mindware in their decision making.
"
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Nikki Black provides an insight into critical care in humanitarian emergencies.
Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons.
She shares these from the SMACC stage.
Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations.
Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation.
Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition.
Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold!
On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges.
Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment.
Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help.
She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Finally, for more like this, head to our podcast page. #CodaPodcast
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You don’t have to be Bear Grylls to stay alive in the wild. Remember the rule of three - you can live 3 minutes without air, 3 hours without shelter, 3 days without water and 3 weeks without food.
The two biggest killers in the wild are cold and heat. Justin discusses the physiology of our body’s responses to cold and heat and the pathophysiology of hypo- and hyperthermia. He also talks about the simple of ways of preventing cold and heat injury, including staying dry, adding layers, drink any water you can get your hands on - just not sea water.
Lastly - don’t panic.
Forgotten Cardiovascular Physiology by Myburgh
The human circulation is a complex system that has evolved over millenia, primarily designed to promptly respond to conditions of stress - the fight and flight response. The traditional physiological approach focuses on the heart as a pump, adapting to changes in volume and metabolic states.
These principles are underpinned by the Starling equation and incorporated into an adaptation of Ohm\'s law. These principles have been maladapted, punctuated by an increasing reliance on surrogate and derived variables that have little to do with teleological haemodyanamic responses. Insights into the central role of the autonomic nervous system are provided by Guytonian theory that in part explain the physiological fallacy germane to many clinical protocols and practices. These fallacies have been amplified by commercial studies directed at short-term physiological improvements that have little to do with patient-centred outcomes in the medium and longer term. Such effects have been demonstrated in recent high-quality RCTs that force a re-appraisal of seductive short-term physiologically-based gratification.
The Wrong Stuff: Prehospital Dogma - Cliff Reid
The Wrong Stuff: Prehospital Dogma
Summary by: Cliff Reid
The master of Dogmalysis himself, Cliff Reid, challenges current practices in prehospital and emergency medicine. Warning listeners to be skeptical, Cliff dissects the dogma of acute crush injuries and spinal immobilization. He also explores the false dichotomy of “scoop and run vs. stay and play”. Cliff reminds us that “not to challenge current practice is intellectually lazy”.
The Right Stuff: Training in PHARM - Bill Hinckley
Improved patient outcomes as the goal of training. With this philosophy in mind, Bill Hinkley shares his three pillars of training; train yourself, train as a team, train others.
Advice from an inspiring educator on how to build a personal learning network, tips on training as a team and how influential passionate educators are to teaching others.
Rich Levitan - Extreme Airways
Rich Levitan’s talk on difficult airway management is part science, part philosophy and part pep talk.
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
CSD by Jeffcote Coda 22.pdf
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Subdural Haemorrhage and MMA embolisation
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical care
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
The BONANZA Trial and PbTO2 Monitoring
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
Dilating the Dogma of Vasospasm
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
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By Catherine Bell and Andrew Udy
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
TBI Debate - Mild, moderate and severe categories work
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
TBI: when to stop and when to give time
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.
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"How to think straight: Cognitive de-biasing by Pat Croskerry
The number of preventable deaths of hospitalized patients in the US each year is estimated at 40,000- 80,000. The figure for the ICU alone is estimated at 40,000 so the death rate must be in the higher end of the range. When settings outside the hospital are taken into account (ED, primary care), the overall number must be considerably higher.
While many factors contribute to diagnostic failure, a variety of sources suggest that physician’s thinking has a lot to do with it. Dual Process Theory describes how the brain makes decisions in one of two modes: through fast, unconscious, intuitive processes (System 1) or through slower, conscious, analytical processes (System 2). Mental short-cuts (heuristics) and biases are predominantly located in the intuitive mode where we spend most of our conscious time, and this is where the majority of decision failures occur. Thinking straight essentially means achieving a good balance between System 1 and System 2 decision making, and much of our cognitive effort needs to go into monitoring what our unconscious brains are doing in System 1. This is referred to by a variety of terms: metacognition, reflection, mindfulness, and others. They all involve cognitive de-coupling from System 1 and characterize the process of cognitive de-biasing. This is not easily accomplished in the ED or any environment where decision density is often high, throughput pressure exists, resources may be limited, and where decision makers may be fatigued and/or sleep deprived.
While medicine has acquired a variety of strategies over the years for de-biasing clinicians, added benefits can be obtained by developing specific mindware to tackle particular biases. Clinicians need to be aware of the operating characteristics of the dual process model of decision making, of the prevalence and nature of biases, and of how to apply and sustain de-biasing mindware in their decision making.
"
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Nikki Black provides an insight into critical care in humanitarian emergencies.
Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons.
She shares these from the SMACC stage.
Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations.
Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation.
Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition.
Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold!
On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges.
Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment.
Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help.
She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Finally, for more like this, head to our podcast page. #CodaPodcast
Surviving in the Wild - Justin Hensley
You don’t have to be Bear Grylls to stay alive in the wild. Remember the rule of three - you can live 3 minutes without air, 3 hours without shelter, 3 days without water and 3 weeks without food.
The two biggest killers in the wild are cold and heat. Justin discusses the physiology of our body’s responses to cold and heat and the pathophysiology of hypo- and hyperthermia. He also talks about the simple of ways of preventing cold and heat injury, including staying dry, adding layers, drink any water you can get your hands on - just not sea water.
Lastly - don’t panic.
Forgotten Cardiovascular Physiology by Myburgh
The human circulation is a complex system that has evolved over millenia, primarily designed to promptly respond to conditions of stress - the fight and flight response. The traditional physiological approach focuses on the heart as a pump, adapting to changes in volume and metabolic states.
These principles are underpinned by the Starling equation and incorporated into an adaptation of Ohm\'s law. These principles have been maladapted, punctuated by an increasing reliance on surrogate and derived variables that have little to do with teleological haemodyanamic responses. Insights into the central role of the autonomic nervous system are provided by Guytonian theory that in part explain the physiological fallacy germane to many clinical protocols and practices. These fallacies have been amplified by commercial studies directed at short-term physiological improvements that have little to do with patient-centred outcomes in the medium and longer term. Such effects have been demonstrated in recent high-quality RCTs that force a re-appraisal of seductive short-term physiologically-based gratification.
The Wrong Stuff: Prehospital Dogma - Cliff Reid
The Wrong Stuff: Prehospital Dogma
Summary by: Cliff Reid
The master of Dogmalysis himself, Cliff Reid, challenges current practices in prehospital and emergency medicine. Warning listeners to be skeptical, Cliff dissects the dogma of acute crush injuries and spinal immobilization. He also explores the false dichotomy of “scoop and run vs. stay and play”. Cliff reminds us that “not to challenge current practice is intellectually lazy”.
The Right Stuff: Training in PHARM - Bill Hinckley
Improved patient outcomes as the goal of training. With this philosophy in mind, Bill Hinkley shares his three pillars of training; train yourself, train as a team, train others.
Advice from an inspiring educator on how to build a personal learning network, tips on training as a team and how influential passionate educators are to teaching others.
Rich Levitan - Extreme Airways
Rich Levitan’s talk on difficult airway management is part science, part philosophy and part pep talk.
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
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CSD by Jeffcote Coda 22.pdf
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Subdural Haemorrhage and MMA embolisation
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical care
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
The BONANZA Trial and PbTO2 Monitoring
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
Dilating the Dogma of Vasospasm
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
EVD Tips and Tricks
By Catherine Bell and Andrew Udy
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
TBI Debate - Mild, moderate and severe categories work
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
TBI: when to stop and when to give time
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.
Ketamine in Brain Injury by Toby Jeffcote
Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics.
However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.
Managing Complications of Chronic SCI by Bonne Lee
20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort.
These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia
Do look at the NeuroResus section on this and listen to Spinal Rehab Specialist Bonne Lee talk about this side of SCI care.
Keywords
SCI, spinal, spinal cord injury, autonomic dysreflexia, pressure areas, infection, peri-operative care, baclofen pump, syringomyelia, chronic SCI, spinal trauma, spinal rehab, incomplete SCI
EEG and Status Eplilepticus by Tania Farrar
Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus.
So why do we do cEEGs for patients with suspected SE?
To confirm the diagnosis
To see if patient just post ictal or still seizing
To establish that the clinical and electric seizures have stopped
To see if burst suppression is achieved
To exclude other differential diagnoses
She makes a good argument for why cEEG is such an important tool in managing SE.
In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.
Browne Neuro symposium.pptx
Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means.
Severe disability is more common than many realise - about 6% of the Australian population.
Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated.
He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being.
Stuart also covers how severely disabled people face various forms of discrimination.
Paediatric Stroke by Shree Basu
Shree Basu is a Paediatirc Intensivist in Sydney. These slides from the Brain Symposium 2023 accompany the talk she gave. She discusses how Paediatric stroke presents, what neuroimaging is required and what interventions are available, including thrombolysis and the role of endovascular thrombectomy.
Hypertensing Spinal Cord Injury - gold standard or wacky?
After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference.
Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways.
Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions.
Hypertensive therapy is relatively safe and easy to implement but not without risk.
Tessa discusses the pros and cons, how this is managed practically and what the future may hold in this area.
Optimal Cerebral Perfusion Pressure
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.
The Power of Words - Death and Language.ppt
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
Appropriate use of antimicrobials is primarily a patient safety issue, and is the key aim of an effective antimicrobial stewardship program. We discuss the challenges in the management of a patient with sepsis, and how decision-making is usually done in the absence of effective diagnostics. Time dependent protocols and the knowledge that undertreatment of a patient with sepsis will lead to poor outcomes will lead to prescribing that may be driven by fear. Antimicrobial resistance is associated with over-use of antimicrobials but is usually not the immediate concern. Antimicrobial stewardship programs should work closely with sepsis teams to ensure that sepsis pathways are implemented across the whole hospital, and that key principles of judicious use are embedded within the clinical pathway.
Brain injury outcomes and predictors
Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources.
However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task.
Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome.
Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models.
There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases.
We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.
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TBI Debate - Mild, moderate and severe categories work
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Hypertensing Spinal Cord Injury - gold standard or wacky?
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
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O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
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Study Resources:
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2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Mile High Anaesthesia by Healy
- 1. Mile High Anaesthesia Geoff Healy
- 3. 3 1% 11% 13% 35% 40% XXX Funny pictures/videos of Cats People taking pictures of their food Gangnam Style Videos FOAMeD Healy, G (unpublished) 2013
- 4. “Don’t believe everything you read on the internet” -ABRAHAM LINCOLN
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- 8. “Gentleman, this is no humbug” 7 - Dr John Collins Warren (October 17, 1846)
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- 12. RSI 11
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- 21. You gotta listen to your gut feeling
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- 29. Delays getting the patient to hospital care 27
- 30. Delays getting the patient to hospital care 27
- 31. Airway audits • KPI is 15mins 28
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- 40. Safety of Prehospital RSI 35
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- 43. PTSD • Anaesthetic awareness vs major trauma 38
- 44. 39 Rehab begins at the roadside
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- 48. 43 Thank you @drgeoffhealy
- 49. 43 Thank you @drgeoffhealy
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