Neonatal Intensive Care: Trish Woods
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Trish Woods guides you through some clinical pearls in the intensive care management of neonates. The complex physiology of the transitioning required in the journey from foetal life to neonatal presents many challenges and scary moments. Trish helps you to navigate these challenges and to unlock the key to providing quality neonatal intensive care. Many things can go wrong in the neonatal period as babies transition to life in the real world. Trish highlights her thoughts on the use of positive end expiratory pressure (PEEP), how deep to intubate, when to clamp the cord and the use of ultrasound. When babies arrive early their lungs can be full of meconium or fluid. Due to this, Trish recommends using PEEP – without which there is distal airway collapse and fluid accumulation. Aeration of the lungs is vital. To this end, how deep should intubation be aimed? The depth may not be overly important. This is because regional lung aeration triggers widespread, global increase in pulmonary blood flow. There is little definitive evidence to guide clinicians on when to clamp the cord – early or late. Trish recommends considering the physiology of clamping the cord. After clamping the cord there is a massive drop in cardiac output. Ventilatory support will turn this around – something to remember. In a compromised baby, perhaps we should aim to clamp the cord sooner and then initiate ventilation. Finally, Trish highlights the utility of ultrasound. Viewing the heart and lungs provides crucial information for the clinician. Furthermore, Trish discusses actively looking for aeration, collapse, consolidation and pneumothorax in the lungs and thorax. Overall, don’t forget the essentials. Trish reminds you to keep life sweet, warm, and tempting and help neonates to transition into the big world. Neonatal Intensive Care: Trish Woods For more like this, head to our podcast page. #CodaPodcast
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Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion’s opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies.
So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.
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This highlights the importance of all physicians knowing how to deal with these cases.
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Natalie suggests being suspicious of horse-riding children!
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Natalie concludes by discussing the differences in management of injuries, comparing children and adult interventions. She also discusses the outcomes of children with major trauma and the vast implications on the child, the family and society.
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Medicine for Mars - Kevin Fong
Summary by: Kevin Fong
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The management of the transected airway is frightening because it is a rare airway emergency and one that does not fit the usual plan A,B,C airway management algorithms. An approach is presented which considers two principal anatomical distinctions for injuries both above and below the cricoid cartilage.
Secondly, the mechanism of injury is classified according to whether it is either penetrating or blunt trauma. Finally the airway management urgency is described according to either an immediate or semi-urgent approach being required. These three approaches, the location of the injury relative to the cricoid, the mechanism of the injury and thirdly, the urgency of the airway intervention required are then applied together to provide a guide to management of the transected airway.
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If the thought of how Einstein’s theorem on ‘General Relativity’ can help us answer the question of, when to stop resuscitation interests you then don’t miss this.
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Teamwork: The strongest drug in the hospital
Modern acute care medicine is eye-wateringly complex and potentially dangerous. It really can't be delivered safely without deliberately addressing our teamwork (in both acute and chronic situations). Unfortunately, historically, human factors were commonly left to chance, and recently have been threatened by decerebrate checklists and meaningless psychobabble. Practical strategies exist (thank goodness!) and will be reviewed. We have much to learn, but must also avoid overly simple answers to exceedingly complex problems. It's time to get back to basics and away from the BS. Come be part of a practical revolution
Cardiac Arrest and Oxygen: Stephen Bernard
Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients.
Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes.
This is especially true in hospitals where oxygen is used frequently and often without much thought.
Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea.
In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest.
Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge.
The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes in the same way.
Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury.
Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen.
Join Stephen as he makes you think twice about blindly using oxygen for patients following a cardiac arrest.
Deborah Stein - Trauma is Risky Business
Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma.
Stein’s speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?. Stein’s suggests a thorough Risk Benefit Determination will include:
Analysis of best available data
Use of best available judgement
Gathering of different opinions
An understanding that you won’t always make the right decision
To document the 'crap' out of it!
And to remember you’ll never know what you prevented from not occurring.
Stein’s also focuses on the risk to patients due to missed injuries and the processes physicians can take to help ensure that a patient injuries are not missed. Stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases).
Touching on the processes designed to prevent missed injuries such as;
Territory Trauma Survey
Roles of clinical decision rules
To scan the living ‘crap’ out of them - whole body CT scans (can decrease mortality but comes attached with its own risks).
Stein’s then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital the likelihood of being sued reduces.
Stein’s also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers.
Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.
Ultrasound Improves Resuscitation Outcomes: Resa Lewiss
Resa Lewis tells you how ultrasound improves resuscitation outcomes in critical care.
Ultrasound helps you make more accurate diagnoses. It allows you to perform procedures with fewer complications, and ultrasound enables you to be more time and cost efficient.
However, there may be more to ultrasound - Resa enlightens you.
The ultrasound allows the clinician to interact with their patients.
Further, Ultrasound enables patients to be integrated into their own care and it allows for an element of creativity.
Moreover, Resa explores the idea of reciprocal illumination – the process of exchange and education between clinician and patient. It is the dialogue that occurs between the two and allows for different and deep thinking.
Evidently, what underpins these thoughts is the idea of creativity. Resa asks you to consider how you are creative with your hands. It may be gardening, knitting, playing a musical instrument, writing, or even washing the dishes.
Working with your hands is the gateway to creativity. Working with your hands in an intentional and purposeful way, on a regular basis elevates your mood and decreases stress and anxiety. The science supports this.
Furthermore, a hand-brain interaction is stimulated, fostering creativity. In bringing these ideas back to the Emergency Room, Resa explains that by using your hands through ultrasound, you are enabling creativity and open communication with your patients.
Moreover, Reciprocal illumination – enhancing both care and outcomes. Resa describes the evidence behind this idea. Patient’s overwhelming welcome ultrasound at the bedside in the Emergency Department. They agree that it improves patient care and increases efficiency of their treatment.
Finally, Resa concludes by pondering the idea that ultrasound may also lead to great benefits for the clinicians themselves.
For more like this, head to our podcast page. #CodaPodcast
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
Transfusion Thresholds in Acute Brain Injury
A bare knuckle pit fight between Oli Flower & Simon Finfer over when to transfuse in acute brain injury...
Oli argues that the transfusion threshold should be 90 g/L, whereas Simon takes 70 g/L to be a more appropriate trigger to transfuse blood in the context of acute brain injury.
The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives crit care professionals mad - surely there must be a ""right"" number. Unfortunately there isn't, which is where understanding all the relevant aspects to the argument becomes important.
Enjoy listening to these two duke it out and then make up your mind - what will your number be?
When to Stop Resuscitation in Critical Care: Patricia Gerritsen
The document discusses different degrees of death, from soon-to-be dead to irreversibly dead. It explores categories such as reversibly dead, irreversibly dead, and almost dead. Examples are given of people who were considered dead but later revived, such as cases of extreme hypothermia, hyperkalemia, acidosis, and hypercapnia. The document suggests that not everything that appears dead is irreversibly dead, and questions are posed about determining degrees of death.
Myths in ICU: BUSTED by Team Thomas
Thomas & Kass bust some common ICU Myths in a classic Podcast for Intensive Care Network (ICN). Here's the slide deck and references to go with it.
Shoes, Sex and Secrets: Stress in EMS -Ashley liebig
This very short document consists of only 3 words - "shoes", "sex", and "secrets" - with no other context provided. It gives a minimal amount of information that is open to interpretation without more details from the full source text.
Spiders and Stingers
A clinical overview of four important Australian envenomings: Redback spider, Funnelweb spider, Box jellyfish and Irukandji Syndrome. The talk was given at the Bedside Critical Care 2012 conference in the Whitsunday Islands.
Estrategia de pulmón abierto
The document discusses strategies for ventilating patients using transpulmonary pressures (Ptp). It begins by reviewing normal lung mechanics and how stresses are placed on the lungs and alveoli during breathing. Forces like gravity and airway pressures can overdistend or collapse alveoli. The optimal ventilatory strategy aims to keep alveoli in a "safe window" by applying enough pressure to recruit collapsed alveoli but not enough to cause overdistension. Maintaining the right Ptp is important, especially in patients with diseased lungs or high chest wall pressures, as it more directly reflects the pressure experienced by the alveoli.
Sleep apnea
Sleep apnea is a serious sleep disorder where a person's breathing is interrupted during sleep. There are two main types - obstructive sleep apnea caused by blockage of the airway, and central sleep apnea caused by problems in the brain's respiratory control center. Symptoms include loud snoring, waking with gasping sensations, and daytime sleepiness. Risk factors include obesity, large neck size, and family history. Diagnosis involves an overnight sleep study to monitor breathing, brain waves, muscle activity and more. Treatment options include lifestyle changes, oral devices, ventilation with CPAP machines, and in some cases surgery.
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Phil hyde: Paeds Sim - Not for Dummies
This document discusses pediatric simulation training and critical care education. It acknowledges contributors to the field and emphasizes integration and collaboration across specialties. The document outlines the patient journey from injury to rehabilitation and stresses the importance of multi-professional education from undergraduate to post-graduate levels. It promotes using simulated pediatric patients and families to engage clinicians and advocates for primary injury prevention. The document poses questions and challenges educators to train healthcare professionals in teams using simulated patients from the start of their education.
Minor Injuries and Major Trauma in Paediatrics: Natalie May
Natalie May gives you the break down of paediatric trauma.
Paediatric trauma is relatively rare but terrifying. However, there are many ways we can think about paediatric trauma to make these challenging situations easier to face.
Children are inherently portable. This means that they often turn up at peripheral, non-paediatric centres that are not major trauma centres.
This highlights the importance of all physicians knowing how to deal with these cases.
Anatomy and physiology of children is different to adults. Their ability to compensate is remarkable. This means the index of suspicion of serious injury should be higher.
For instance, their ribs are a lot more pliable than those of adults, meaning hollow viscous organ injuries are more common following trauma.
Similarly, their vital signs can be more confounding. Tachycardia could simply mean fear or pain.
On the other hand, it could indicate a major internal bleed. This leads to children being under and over triaged at a high rate.
Teenagers also present challenges. Does the surly, teenage girl with limited verbal responses have a serious head injury..? Or is she being a stereotypical teenage girl?
The mechanism of children trauma differs from that of adults.
Polytrauma is rare in children without adult involvement, such as a motor vehicle accident. However, as children develop through adolescence, the mechanisms of injury begin to resemble those of adults.
Quad bike accidents, stabbings and even shootings become more common. Isolated thoracic injuries become the second most common cause of trauma in adolescents 16 years and older.
Toddlers by comparison get isolated limb injuries more commonly. They are mobile, curious and have no sense of danger. Their height to the ground is less, making head trauma less common, and less serious.
Under one’s however are more often carried by adults and lack protective reflexes making skull fractures more common. Polytrauma in this age group should also raise suspicion of non-accidental injury. External factors often need to be involved for more serious polytrauma.
Natalie suggests being suspicious of horse-riding children!
Once a child is in your department, the assessment differs slightly to that of an adult. Specifically, scanning protocols are different with less use of pan scanning and more focussed scanning. CT for heads and penetrating chest trauma and abdomen, and plain films for C-spine, limbs, pelvis, and blunt trauma to the chest.
Natalie concludes by discussing the differences in management of injuries, comparing children and adult interventions. She also discusses the outcomes of children with major trauma and the vast implications on the child, the family and society.
Minor Injuries and Major Trauma in Paediatrics: Natalie May
For more like this, head to our podcast page. #CodaPodcast
Andy Sloas - Are we Masters of the Paediatric Airway?
One of the many things that we, as intensivists or emergency physicians, do better than anyone in the business is obtain the emergent airway. We are usually introduced to our patients on the worst days of their lives and even though we may sometimes wish for it, we do not have the option to reschedule our intubations. Smashed, bloody, distorted, edematous airways secondary to trauma, anaphylaxis, and GI bleeds are the commonality not the exception. We manage those airways routinely with nary a complaint or even a hither for a better look at the glottis than what we can obtain. We often feel lucky to even get a glimpse of the arytenoids much less something that actually resembles normal laryngeal anatomy. Personally, if I knew that I would need to be intubated today, that my airway would be a bloody, edematous, traumatic mess and there was only chance for one person to take a shot at placing the tube, then I would pray to God that the last face I saw before the Roc and Ketamine pushed me asunder was the familiar grill of one of my EM/critical care colleagues. Who better to bet all my chips on then someone who deals with the most difficult airways on the face of the planet as part of their daily routine? The EM doc or critical care provider can not only get that airway, but is so relaxed about it that they will often casually check on the patient in the next bed before and after the intubation. That’s the confidence I’m looking for when it comes to the fast-paced life and death world of emergency airway. Now put a child’s life on the line. Are you ready to intubate what was a perfectly healthy three year old two hours before trauma threatened their life and placed their airway in your hands? You will be...
Andrew Sloas DO, RDMS, FACEP, FAAEM, FAAP Editor-in-Chief: The PEM ED Podcast www.pemed.org
Meditation Performance and Critical Care: Scott Weingart
The document discusses the results of a study on the impact of COVID-19 lockdowns on air pollution. Researchers found that lockdowns led to significant short-term reductions in nitrogen dioxide and fine particulate matter pollution globally as economic activities slowed. However, the impacts on greenhouse gases and long-term air quality improvements remain uncertain without permanent behavior and economic changes.
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.
Managing the Transected Airway by Georgie Harris
The management of the transected airway is frightening because it is a rare airway emergency and one that does not fit the usual plan A,B,C airway management algorithms. An approach is presented which considers two principal anatomical distinctions for injuries both above and below the cricoid cartilage.
Secondly, the mechanism of injury is classified according to whether it is either penetrating or blunt trauma. Finally the airway management urgency is described according to either an immediate or semi-urgent approach being required. These three approaches, the location of the injury relative to the cricoid, the mechanism of the injury and thirdly, the urgency of the airway intervention required are then applied together to provide a guide to management of the transected airway.
Heroism vs Safety in Healthcare by Peter Brindley
The battle is on...who will win out: the heroic healthcare individual or the faceless safety checklist? Well, obviously, it's not that simple...but, then again, nor is it that complicated. We need to harness the best of both and this talk hopes to strike that balance. This requires a discussion of human strengths and weaknesses, and ditto for computers and checklists. This talk hopes to ensure that the Human Factor is always a factor, and to suggest what can be learnt if we understand healthcare in sociology and psychology terms. It also hopes to explain why a team of experts is not necessarily an expert team, and why our verbal dexterity is likely our greatest skill or liability. This talk offers practical examples of how to improve teamwork, communication, situational awareness, resource utilization and decision making, in other words, our crisis management skills. While it is time to stop searching for simple answers to complex problems, it is also time to stop ignoring all those lessons that can be learnt from others. Above all this talk hopes to put the patient's needs back where they belong: at the very centre of a complex, beguiling, but also magnificent health system. If this talks fails in that noble goal then the speaker wants to hear from you: he doesn't want to be wrong a moment longer than is absolutely necessary
When to STOP Resuscitation by Roger Harris
When to stop resuscitation in probably the biggest question challenging Critical Care and it's a challenge that many of us face virtually every clinical shift. The main problem is that there is little good data to guide us, leaving us to navigate this situation with few coordinates to plot a path forward. When to stop resuscitation explores this problem and suggests some landmarks we can use to navigate by. It examines the inter-relationship between the pillars of our medical ethics Autonomy, Beneficence, Non-Maleficence and Justice. To better understand the clinical challenges we face, the talk also uses a framework provided by modern physics and the 'Space Time Continuum' theorem. Hence the title might more appropriately be – “The will to Live – The courage to die and the space-time continuum”.
If the thought of how Einstein’s theorem on ‘General Relativity’ can help us answer the question of, when to stop resuscitation interests you then don’t miss this.
Penetrating Injuries to the Neck
Penetrating injuries to the neck is a great summary of how to assess and manage neck wounds from lacerations to the airway to gunshot wounds. The talk covers relevant anatomy, the zones of the neck and how to investigate vascular, tracheal and oesophageal injuries. A comprehensive understanding of the relevat anatomy is essential to recognising associated injury patterns. The improvements in the accuracy of helical CTA scans has meant that the delineation of the zones of the neck has become less relevant to the further investigation and management of pemetrating neck wounds. Oesphageal injuries remain difficult to detect and require a high level of clinical suspicion to identify these.
Rethinking Adrenaline in Cardiac Arrest
The use of adrenaline in cardiac arrest resuscitation has been advocated since the 1960s. Laboratory studies and anecdotal experience showed improved rates of return of spontaneous circulation (ROSC) with the use of adrenaline at a dosage of approximately 0.01 mg/kg. This led to the widespread adoption of adrenaline administration during cardiac arrest into every resuscitation guideline for decades to come. Extensive laboratory studies characterized the beneficial physiological effects of adrenaline during cardiac arrest and closed-chest cardiopulmonary resuscitation (CC-CPR). Adrenaline administered during CC-CPR results in peripheral arterial vasoconstriction that raises the aortic pressure, particularly during the relaxation phase of CC-CPR. This increase in aortic pressure results in an increased aortic to right atrial pressure gradient that drives blood flow to the myocardium during CC-CPR. This pressure gradient is known as the coronary perfusion pressure (CPP) and has been shown to correlate with ROSC in both laboratory investigations and clinical studies. During the 1990s, the use of “high-dose” adrenaline showed increased rates of ROSC compared to “standard-dose” adrenaline. However, it was subsequently recognized that larger doses of adrenaline did not result in improved survival. Furthermore, questions have been raised as to whether or not “standard-dose” adrenaline improves survival from cardiac arrest. Recent meta-analyses have raised serious questions about the value of adrenaline, showing a benefit for achieving ROSC but no clear evidence of improved long-term survival. Controlled clinical trials to address this question are now underway. However, there is another important issue that needs to be addressed: the “route” of administration. With the growing interest in endovascular resuscitation, the use of intra-aortic adrenaline titration offers a means of rapidly and effectively delivering adrenaline to peripheral arterial effector sites while providing arterial pressure and CPP monitoring to guide titration of adrenaline doses to achieve an optimal hemodynamic effects while avoiding excessive adrenaline doses.
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Teamwork: The strongest drug in the hospital
Modern acute care medicine is eye-wateringly complex and potentially dangerous. It really can't be delivered safely without deliberately addressing our teamwork (in both acute and chronic situations). Unfortunately, historically, human factors were commonly left to chance, and recently have been threatened by decerebrate checklists and meaningless psychobabble. Practical strategies exist (thank goodness!) and will be reviewed. We have much to learn, but must also avoid overly simple answers to exceedingly complex problems. It's time to get back to basics and away from the BS. Come be part of a practical revolution
Cardiac Arrest and Oxygen: Stephen Bernard
Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients.
Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes.
This is especially true in hospitals where oxygen is used frequently and often without much thought.
Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea.
In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest.
Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge.
The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes in the same way.
Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury.
Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen.
Join Stephen as he makes you think twice about blindly using oxygen for patients following a cardiac arrest.
Deborah Stein - Trauma is Risky Business
Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma.
Stein’s speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?. Stein’s suggests a thorough Risk Benefit Determination will include:
Analysis of best available data
Use of best available judgement
Gathering of different opinions
An understanding that you won’t always make the right decision
To document the 'crap' out of it!
And to remember you’ll never know what you prevented from not occurring.
Stein’s also focuses on the risk to patients due to missed injuries and the processes physicians can take to help ensure that a patient injuries are not missed. Stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases).
Touching on the processes designed to prevent missed injuries such as;
Territory Trauma Survey
Roles of clinical decision rules
To scan the living ‘crap’ out of them - whole body CT scans (can decrease mortality but comes attached with its own risks).
Stein’s then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital the likelihood of being sued reduces.
Stein’s also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers.
Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.
Ultrasound Improves Resuscitation Outcomes: Resa Lewiss
Resa Lewis tells you how ultrasound improves resuscitation outcomes in critical care.
Ultrasound helps you make more accurate diagnoses. It allows you to perform procedures with fewer complications, and ultrasound enables you to be more time and cost efficient.
However, there may be more to ultrasound - Resa enlightens you.
The ultrasound allows the clinician to interact with their patients.
Further, Ultrasound enables patients to be integrated into their own care and it allows for an element of creativity.
Moreover, Resa explores the idea of reciprocal illumination – the process of exchange and education between clinician and patient. It is the dialogue that occurs between the two and allows for different and deep thinking.
Evidently, what underpins these thoughts is the idea of creativity. Resa asks you to consider how you are creative with your hands. It may be gardening, knitting, playing a musical instrument, writing, or even washing the dishes.
Working with your hands is the gateway to creativity. Working with your hands in an intentional and purposeful way, on a regular basis elevates your mood and decreases stress and anxiety. The science supports this.
Furthermore, a hand-brain interaction is stimulated, fostering creativity. In bringing these ideas back to the Emergency Room, Resa explains that by using your hands through ultrasound, you are enabling creativity and open communication with your patients.
Moreover, Reciprocal illumination – enhancing both care and outcomes. Resa describes the evidence behind this idea. Patient’s overwhelming welcome ultrasound at the bedside in the Emergency Department. They agree that it improves patient care and increases efficiency of their treatment.
Finally, Resa concludes by pondering the idea that ultrasound may also lead to great benefits for the clinicians themselves.
For more like this, head to our podcast page. #CodaPodcast
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
Transfusion Thresholds in Acute Brain Injury
A bare knuckle pit fight between Oli Flower & Simon Finfer over when to transfuse in acute brain injury...
Oli argues that the transfusion threshold should be 90 g/L, whereas Simon takes 70 g/L to be a more appropriate trigger to transfuse blood in the context of acute brain injury.
The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives crit care professionals mad - surely there must be a ""right"" number. Unfortunately there isn't, which is where understanding all the relevant aspects to the argument becomes important.
Enjoy listening to these two duke it out and then make up your mind - what will your number be?
When to Stop Resuscitation in Critical Care: Patricia Gerritsen
The document discusses different degrees of death, from soon-to-be dead to irreversibly dead. It explores categories such as reversibly dead, irreversibly dead, and almost dead. Examples are given of people who were considered dead but later revived, such as cases of extreme hypothermia, hyperkalemia, acidosis, and hypercapnia. The document suggests that not everything that appears dead is irreversibly dead, and questions are posed about determining degrees of death.
Myths in ICU: BUSTED by Team Thomas
Thomas & Kass bust some common ICU Myths in a classic Podcast for Intensive Care Network (ICN). Here's the slide deck and references to go with it.
Shoes, Sex and Secrets: Stress in EMS -Ashley liebig
This very short document consists of only 3 words - "shoes", "sex", and "secrets" - with no other context provided. It gives a minimal amount of information that is open to interpretation without more details from the full source text.
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Estrategia de pulmón abierto
The document discusses strategies for ventilating patients using transpulmonary pressures (Ptp). It begins by reviewing normal lung mechanics and how stresses are placed on the lungs and alveoli during breathing. Forces like gravity and airway pressures can overdistend or collapse alveoli. The optimal ventilatory strategy aims to keep alveoli in a "safe window" by applying enough pressure to recruit collapsed alveoli but not enough to cause overdistension. Maintaining the right Ptp is important, especially in patients with diseased lungs or high chest wall pressures, as it more directly reflects the pressure experienced by the alveoli.
Sleep apnea
Sleep apnea is a serious sleep disorder where a person's breathing is interrupted during sleep. There are two main types - obstructive sleep apnea caused by blockage of the airway, and central sleep apnea caused by problems in the brain's respiratory control center. Symptoms include loud snoring, waking with gasping sensations, and daytime sleepiness. Risk factors include obesity, large neck size, and family history. Diagnosis involves an overnight sleep study to monitor breathing, brain waves, muscle activity and more. Treatment options include lifestyle changes, oral devices, ventilation with CPAP machines, and in some cases surgery.
Is sleep sixth sense
Sleep-disordered breathing (SDB) refers to repetitive episodes of cessation of respiration or reductions in airflow during sleep that are associated with sleep fragmentation and reductions in blood oxygen levels. The most common form is obstructive sleep apnea, which is caused by collapse of the upper airway during sleep and affects 4-9% of adult men and 2-4% of adult women. Risk factors include male gender, obesity, large neck size, and specific anatomical features of the upper airway. Clinical presentation includes loud snoring, witnessed breathing pauses during sleep, daytime sleepiness, impaired cognitive function, and increased risk of accidents.
Sunnah way of sleeping and Science
Sunnah (Islamic Hadith) posture of sleeping and science of reducing alzheimers and parkinsons disease risk.
Obstructive Sleep Apnoea: Diagnosis, Criteria, Management
Obstructive sleep apnea (OSA) is a common sleep disorder where the airway collapses or becomes blocked during sleep, disrupting breathing. Polysomnography is the gold standard test used to diagnose OSA by measuring breathing, oxygen levels, and brain waves during sleep. The main treatment is continuous positive airway pressure (CPAP) therapy, which uses mild air pressure to keep the airway open during sleep. Weight loss, avoiding alcohol, and sleeping on one's side can also help reduce OSA symptoms.
Unexpected Nasopharyngeal Foreign Body
Foreign bodies in aerodigestive tract are common entity but in nasopharynx it’s very rare to find an impacted foreign body.The anatomical structure of nasopharynx prevents any lodgement of foreign body. It is capacious and having nasopharyngeal sphincter preventing regurgitation of foreign body from oropharynx. Through nasal cavity foreign body cannot travel to nasopharynx as the former is narrower.
Airway Mini-residency: Intro to Airway Orthodontics
Dr. Barry Raphael gives an overview of a new subspecialty in orthodontics call Airway Orthodontics. This segment provides the rationale for this paradigm shift. (Animations and movies not included).
Studies evidence asof oct 2013
1) Multiple studies have found anatomical factors such as a narrow maxilla, retrognathic mandible, enlarged tonsils, and increased neck circumference are risk factors for obstructive sleep apnea.
2) Craniofacial morphology plays an important role in determining airway size, with a constricted maxilla placing the upper pharynx at greater risk of collapse during sleep. Maxillary deficiency is a key predictor of sleep apnea severity.
3) Chronic mouth breathing in children is associated with narrower pharyngeal airway space and forward head posture, which can negatively impact craniofacial growth patterns and increase risk of sleep disordered breathing.
Snoring and sleep apnoea
Rhinitis and mouth breathing are significant contributors to snoring and sleep apnea. Based on the book Sleep with Buteyko by Patrick McKeown
OSA JC
The document summarizes guidelines from the American Association of Orthodontists on the role of orthodontists in screening for and managing obstructive sleep apnea. It discusses how orthodontists can screen patients for risk factors and signs of sleep apnea. It also outlines how orthodontic treatments like oral appliances and orthognathic surgery can be used to treat sleep apnea in collaboration with physicians. The document separates discussions on adult and pediatric sleep apnea, covering etiology, risk factors, symptoms, diagnosis, and treatment approaches for each.
The difficult extubation
The document discusses the top five post-extubation emergencies: laryngospasm, laryngeal stridor, acute hypoxemia, acute respiratory failure, and neurologic pathology. It provides definitions and discusses how to potentially predict and treat each emergency. Key points include that extubations should not be treated as routine, extensive assessment is important, and having difficult intubation supplies available is critical in case re-intubation is needed. The document emphasizes being prepared for potential post-extubation complications.
Child with OSA Anesthetic considerations
This document discusses considerations for anesthesia in children with obstructive sleep apnea (OSA). It provides background on OSA, including definitions and classifications. It notes that children with OSA are at risk of postoperative complications like hypertension and pulmonary edema. The document recommends careful preoperative evaluation in high risk children. It suggests avoiding sedative premedication and using techniques like jaw thrust and CPAP at induction to relieve airway obstruction. Maintenance should use low doses of opioids and extubation when fully awake. Postoperative monitoring on a high dependency unit is important due to risk of reobstruction.
Osa Case Study
The article discusses how obstructive sleep apnea (OSA) presents differently in women compared to men, as women often experience less severe but more frequent breathing disturbances during sleep. Additionally, OSA symptoms in women are more likely to be overlooked due to being non-specific, such as insomnia, fatigue, and depression. The article emphasizes the need for healthcare providers to have a higher index of suspicion for OSA in women and consider gender-specific risk factors, presentations, and treatments.
Secrets Of The Heart
This document discusses recent scientific findings about the heart's role in human psychology and cognition. It summarizes research showing that the heart contains neurons, stores information, and influences brain function through electromagnetic signals. Studies of heart transplant patients found changes in personality, feelings, and beliefs. While the mechanism is not fully understood, evidence suggests the heart plays a greater role in the human experience than previously believed. The document examines ongoing research seeking to understand the relationship between the heart and brain.
Obstructive Sleep Apnea a type of sleep disorder
OSA, or Obstructive Sleep Apnea, is a sleep disorder characterized by repeated interruptions in breathing during sleep due to blocked or narrowed airways. This obstruction can lead to fragmented sleep, daytime fatigue, and other health complications if left untreated. Treatment options include lifestyle changes, CPAP therapy, and in some cases, surgery.
Anencephaly
This document discusses anencephaly, a neural tube defect characterized by the absence of the cranial vault, cerebral hemispheres, and diencephalic structures. These structures are replaced by a flattened, amorphous vascular-neural mass called the area cerebrovasculosa. Early detection of anencephaly can be attempted via ultrasound as early as 14 weeks gestation by assessing the frontal bones, but diagnosis should not be made before 10 weeks. The outcome of anencephaly is always fatal and termination is offered.
Jan 07 handout
The document provides information on respiratory emergencies for different levels of medical training. It covers topics like anatomy of the upper and lower airways, respiratory physiology and pathophysiology, patient assessment of the respiratory system, management of airway obstructions and other respiratory conditions, and mechanical airway techniques. Key points include the definitions of terms like hypoxia and atelectasis, factors that can affect respiration, signs to assess the respiratory system, abnormalities in ventilation and perfusion, management of conditions like asthma and pneumonia, and indicators for endotracheal intubation. The document aims to equip medical responders with knowledge to recognize and treat a variety of respiratory distress presentations.
FAST
This document describes the use of ultrasound in trauma patients. It provides the history of ultrasound in trauma, describes the FAST (Focused Assessment with Sonography in Trauma) exam protocol, and reviews how to identify hemoperitoneum, hemopericardium, hemothorax, and fractures using ultrasound. Key applications of ultrasound in trauma include rapidly detecting free fluid to guide surgical management and identifying pneumothoraces not seen on chest x-rays. The document outlines the anatomy visualized in each view of the FAST exam and provides examples of normal ultrasound findings and signs of injury.
Introduction to Sleep apnea for Orthodontists
This document summarizes a presentation on obstructive sleep apnea (OSA) given by Dr. Jean-Marc Retrouvey. The presentation defines OSA, discusses its manifestations, describes common patient types, recognizes the difference between OSA and snoring, and suggests treatment approaches. It provides details on quantifying OSA severity using the apnea-hypopnea index and discusses common contributing factors like obesity, allergies, and genetics. The role of orthodontics in treating OSA and potential craniofacial impacts of untreated OSA are also summarized.
Pediatric airway management shapiro
This document summarizes pediatric airway management and respiratory arrest. It outlines the pediatric chain of survival, causes of cardiac and respiratory arrest in children, and basic life support techniques. It then describes airway assessment, various airway devices, bag-mask ventilation, intubation, and complications that can occur with acute airway management in children.
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Systematic review of 26 studies with 55,792 patients found that dedicated neurocritical care (NCC) was associated with decreased risk of mortality (17% relative risk reduction) and decreased risk of poor functional outcomes (17% relative risk reduction) in critically ill brain-injured adults. A survey of Australian ICUs found limited availability of NCC, with only 4 centers specializing in it and 9 employing an intensivist subspecializing in NCC. Continuous EEG monitoring was found to have higher sensitivity for detecting nonconvulsive seizures than routine EEG monitoring, and was associated with reduced in-hospital mortality, though barriers to its universal use include infrastructure and personnel requirements.
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.
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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?
This document discusses the concept of maintaining higher blood pressure levels, known as hypertension, after a spinal cord injury to improve spinal cord perfusion pressure and reduce secondary injury. It notes that while animal studies and some human trials have shown improved neurological outcomes, the evidence is still limited. It calls for larger randomized controlled trials in humans that also incorporate multi-modal monitoring and standardized outcome measures to further evaluate if inducing hypertension after spinal cord injury should be considered the gold standard of care.
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
Undertreatment of sepsis can lead to mortality, while overdiagnosis and overtreatment can increase future risk of antimicrobial resistance. Antimicrobial stewardship aims to balance these risks by prioritizing patient safety and appropriate antimicrobial use. Data shows variability in appropriateness of antimicrobial prescribing between different types of hospitals. Embedding antimicrobial stewardship principles throughout sepsis diagnosis and treatment, from initial microbiology testing to post-treatment review, can help standardize care and optimize outcomes.
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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Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
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- 14. JUST BREATHE… PEEP OR NO PEEP ?
- 15. JUST BREATHE… PEEP OR NO PEEP ?
- 16. No PEEP Phase contrast x-ray imaging of the lung S.J.HOOPER et al SPring-8/SACLA 2012;17(3):232-237
- 17. No PEEP Phase contrast x-ray imaging of the lung S.J.HOOPER et al SPring-8/SACLA 2012;17(3):232-237
- 18. With PEEP
- 19. With PEEP
- 21. Don’t Be PEEP SHY
- 24. Going to intubate Does Depth Matter?
- 25. PULMONARY FLOW Ventilated Lung Non- Ventilated Lung Increase in pulmonary blood flow at birth: role of oxygen and lung aeration J.A.LANG et al J Physiol. 2016 594(5):1389-1398
- 26. PULMONARY FLOW Ventilated Lung Non- Ventilated Lung Increase in pulmonary blood flow at birth: role of oxygen and lung aeration J.A.LANG et al J Physiol. 2016 594(5):1389-1398
- 27. Clamp the cord ?
- 28. Clamp the cord ? early or delayed?
- 29. PULMONARY Blood FLOW Rise Cardiovascular transition at birth: a physiological sequence S.B.HOOPER et al Pediatric Research 2015;77(5): 608 - 614
- 34. SICK Filling & Pulmonary resistance SICK CARDIAC Filling
- 35. SICK Filling & Pulmonary resistance SICK CARDIAC Filling
- 39. TURN THE PDA WORM
- 40. TURN THE PDA WORM
- 41. lung Recruitment
- 42. lung Recruitment
- 45. Mirror image.. Screen the lungs for Air Leak Ribs pleural line More Ribs ??!
- 46. Mirror image.. Screen the lungs for Air Leak Ribs pleural line More Ribs ??!
- 47. Lack Pleural sliding A Line profile Absent B Lines sliding coarse pleural line Coalescent B Lines LUNG POINT
- 48. Lack Pleural sliding A Line profile Absent B Lines sliding coarse pleural line Coalescent B Lines LUNG POINT
- 51. The Essentials