#RCEMasc 2019 – Day 3

AIRWAYS-2

ETT vs SGA (i.e. iGel) in out of hospital cardiac arrest (trauma and kids excluded)

  • Headline Results: 
    • Survival with good neurological out come (MRS 0-3) – No difference around 2.75% (for those that required either SGA or ETT)
    • Easiest – SGA easier achieving ventilation within 2 attempts (87.4% vs 79%)
    • Displacement – SGA suffer more displacement (10% vs 5%)
    • Aspiration – No difference around 15%
  • Interesting Results:
    • Survival – approx. 20%  in those that didn’t have an advanced airway attempted (indicating likely survival advantage of only needing a short resus)
    • Paramedic use of advance airways – Paramedics on average only need to use advanced airways 3-4 times a year!
    • PART study (USA) – ETT vs Larangeal Tube no difference
    • BMV vs ETT (France & Belgium) – no difference in out come, but BMV was more difficult

PARAMEDIC 2

Adrenaline vs Placebo in out of hospital cardiac arrest

  • Headline Results:
    • Survival to hospital admission: adrenaline 23.8% vs placebo 8% (Significant)
    • Survival @ 3 months: adrenaline 3% vs placebo 2.2% (Significant)
    • Survival @ 3 months with good neurological outcome (MRS 0-3): adrenaline 2.1% vs placebo 1.6% (Non-Significant)
  • Interesting Result:
    • What did the public thing was the important outcome? In the restudy survey 95% of public reported that survival with good neurological outcome was more important than surviving to hospital.
    • Extrapolation of Adrenaline use: to all UK adult cardiac arrests in a year, adrenaline would increase:
      • ROSC: 5602
      • Admissions: 3555
      • ICU Admissions: 1643
      • Discharged Alive: 203
      • Favourable Outcomes (MRS 0-3): 68
      • Unfavourable Outcomes (MRS 4-5): 135
    • What should happen? International resus (ILCOR) now strongly recommend adrenaline use, however, we probably need public consultation

TXA for bleeding

Dr Ian Roberts

  • Inhibits fibrinolysis – i.e. stops plasmin breaking down clots
  • Treats bleeding – NOT coagulopathy
  • Given TXA Early – as tPA activates early and PIA-1 is later, we need to stop the tPA
    • 15min treatment delay > 10% reduction in effect
  • Give on the suspicion of bleeding? – you get the same risk reduction  what ever your base line risk (i.e. 30% risk of death > 20%, 3% risk > 2%)
  • Safety – in Japan TXA bought over the counter for headaches
  • RCT’s
    • Surgery – TXA reduces blood loss by 1/3 & death, NO increase in clot events
    • Post-Partum Haemorrhage – PPH reduced by 1/3
    • Trauma – Sig. reduction in DEATH (<1hr reduced by 1/3, 1-3hr by 1/5)
    • Vascular occlusive events – data seems to show TXA reduces them
      • Bad bleeding  increases vascular-occlusive events
    • Brain  – results apparently don’t contradict other studies but full results in 2weeks
    • GIT – results due next yea, recruitment stopped in uk as TXA was being give anyway
  • Why have the infusion? – added to regime to (theoretically) replace the loses from ongoing bleed, its utility is unknown.

Lightning papers

  • Mobile phone use @ work(Derby)
    • 80% patients thought it ws fine – this increased to 95% if explained for medical reason
    • Patients didn’t want – you to be using it while talking to them (distraction/rude), dont wipe it on them (infection control)
  • Hair Ties with glue (HAT) vs Suture (not those that would only have been glued anyway)
    • Reduced pain
    • Reduced follow up
    • increased patient satisfaction (less pain and no need to see
    • Faster and increased staff satisfaction
  • No Room @ the Inn (Bristol children)
    • Used winter pressures money to open the clinic space next to ED 18:00-23:00 (if needed)
    • Opened it 50% of the time
    • Used it for 10% of patients
    • Minor Injury/Illness (they do have a UTC)
    • Staffed from the ED
    • Patients and Staff like it!
    • Plymouth also do – staff love it as almost a break from the chaos of majors
  • Who’s pain are we treating?
    • 50% Dr’s assume patients want a prescription, but <30% actually do
    • Patients expect more pain in the following days – than Dr’s expect
    • Patients want to know that codeine is potentially addictive within 3 days
    • They have reduced co-codamol scrpts from approx 10% to 3% of discharges – with no increase in complaints or patient satisfaction.

Mental Health

  • RESPOND  – multiagency mental health crisis simulation
    • Everyone has to make the decisions of each role (Police, Nurse, Dr, Paramedic)
    • Reduced demand on each agency
    • Strengthens partnerships
    • Streamlines process
  • Presentation in the ED –  RCEM mental health tool kit
    • Triage:
      • Agitation, Environment, Intent, Objects
      • VISA: Violent,Irrational thought, Suicidal, Alone
    • Capacity – Are they really weighing it up? if in doubt NO
    •  Observation
      • Mental Health Obs: Calm/Distresses/Agitated/Aggressive/Gone
    • No Scores predict risk – its a holistic assessment thats needed
    • Compassion & Communication – we shouldn’t make things worse for the patient
    • Restraint what to do and do we need it?
    • APEx course – ALSG

 

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