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Daniel Lichtenstein wants to make his past your future. Join him on a journey through the history of lung ultrasound in critical care and resuscitation. The scene is over 20 years ago in the desert of Mauritania. It is a noisy environment full of trucks and planes and motorbikes whipping up sand in a frenzy. You are attending a chest trauma and suspect a pneumothorax. However, in this chaotic environment, chest auscultation with a stethoscope is futile. Daniel describes a visual approach with a portable ultrasound in what was possibly the first extra-hospital ultrasound use. Daniel also has a passion for in-hospital point of care. This stems from a time he “borrowed” an ultrasound machine from the radiology department and reached a critical diagnosis. His journey with lung ultrasound in critical care and resuscitation was born. The usefulness of point of care ultrasound in critical care is far reaching. It is used for subclavian catheter insertion, searching for abdominal blood, and assessing the optic nerve

Emotion has a profound effect on decision-making. Chris Hicks demonstrates this as he discusses medical simulation and its ability to teach us skills to manage challenging emotions. As scientists and rational beings, we like to believe that we can control our emotions and make good decisions regardless of the context in which those decisions must be executed – The reality is, that is far from the truth. We rarely take the opportunity to deliberately examine how emotional valence can influence the choices we make, or how we sort and process information as clinicians. Simulation-based training often provokes strong emotions, both positive and negative, whether we intend it to or not. Simulation may be an ideal tool for eliciting challenging emotions – anger, fear, anxiety, joy, prejudice – and developing skills to manage them in real time. Chris highlights a number of strategies to make this process more effective. He recommends starting with developing a fiction contract. This creates by in and ensures psychol

What is New York City style resuscitation? Reuben Strayer and Scott Weingart honed their chops in public hospitals in America’s largest city, where patients come from every country, speak every language, and manifest every physiologic derangement on earth. Preferring to ask neither permission nor forgiveness, Reuben and Scott have long challenged emergency medicine and critical care orthodoxy and developed lateral (though sometimes divergent) strategies in their approach to problems that arise in the care of the sometimes unwashed masses who tend to avoid presenting to medical attention until they’ve fallen off the Frank-Starling curve. Topics that may be discussed (or argued) include the use of epinephrine, the use of noninvasive ventilation, the management of recently intubated patients, the use of ketamine as an induction agent with and without a paralytic, and decision-making in badly injured trauma patients. Ad hominem attacks will be defined and probably employed. Though Weingart has a physical and int

Doctors are usually the ones who rule the resuscitation. They are the ones in charge, the boss, the person giving all the instructions. By design, doctors rule the resus. But what if they didn’t? In order to optimise teams to be seamlessly effective at resuscitation, we need to change the way that resuscitation is done. We need to challenge healthcare to embrace a new model. Ashley Liebig proposes five key concepts for effective resuscitation: 1. Ergonomics should rule the resus. Where are all the people standing? Where is the clock in the room? Where is everything placed? 2. Nurse-led codes should rule the resus. Let nurses run the codes, this is what they are trained to do and it is what they are doing up until the time that the Doctor arrives in the room. For physicians this means cognitive offloading, allowing space to think about the important things and to consider the differential diagnosis. 3. Assigned roles should rule the resus. The importance of assigned roles means that everyone knows what their j

Haemostatic resuscitation of haemorrhagic shock by Wolfgang Voelckel Haemostatic resuscitation of haemorrhagic shock is an area great leaps forward can be made, as Wolfgang Voelckel discusses. Exsanguination and brain injury are the leading causes of death after major trauma. During the last decades, significant progress has been made in the fight against haemorrhage. Nevertheless, the window of opportunity is still small and the golden hour of shock more fiction than fact. Hence, the majority of trauma patients are still lost on the street and during the first hour after hospital admission. Moreover, trauma is an increasing epidemiologic burden worldwide. Pre-hospital emergency care plays an essential role when distances are long and immediate damage control is key. Since evidence of established interventions (such as fluid resuscitation and vasopressor use) is spare, Wolfgang presents his summary of currently available trauma care guidelines. Through this his team has collaborated best practice advice for m

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

Leanne Hartnett is a massive fan of bedside ultrasound. Here, she tells a story of using ultrasound for the diagnosis of acute pulmonary embolus and the decision-making process for management. This is the story of a 65-year-old man who was brought into the Emergency Department with acute shortness of breath and chest tightness. This was on a background of motor neuron disease, due to which he was confined to a wheelchair. Despite this he reported a good quality of life. He enjoyed getting out and about with his wife, spending time with his family and reading the newspaper. In saying this, he was aware of the seriousness of his disease, and did not want any invasive treatments or CPR. The history and examination were unremarkable, although Leanne’s clinical suspicion of a pulmonary embolism was still high. She wanted to order a CT pulmonary angiogram. However her patient was sure he would not tolerate laying flat for that length of time. So, Leanne wheeled over the ultrasound machine. Despite the technical dif

The arrested heart surgery patient is a unique beast in surgery and critical care. Dr Nikki Stamp gives a whirlwind tour of post cardiac surgery resuscitation. She will discuss how to spot the potential arrest, how to manage it and some special situations to be aware of in this special group of patients Post cardiac surgery resuscitation is complex. Nikki describes them as “brown trouser moments”. She highlights this with three cases. A15-year-old girl who exsanguinated on Day 12 after dissection repair in the community. A 40-year-old female arrested within an hour of a re-do aortic root procedure. A 72-year-old lady who arrested after a bradycardic arrest following an aortic valve replacement. Only one survived – this is serious business. Cardiac arrest post cardiac surgery is relatively uncommon. The survival rate is also quite high. This is due to it being recognised and treated early with a high proportion of reversible causes. The key is to think of these causes and treat them as a team. Nikki breaks the

Management of Status Epilepticus in Neuro Critical care Brandon Foreman talk about the management of status epilepticus in neuro critical care. What are seizures? Why is this important? There are 1 million ED visits due to seizures every year with a quarter getting admitted to the hospital. 1 in 10 people will have a seizure in their lifetime. It is common. Status epilepticus is defined as seizures lasting greater than 5 minutes or recurrent seizures without interval recovery back to baseline. Practically speaking, if the person is seizing when you walk into the room or they remain comatose after they just seized, assume they are in status epilepticus. A key point - the longer the seizure, the greater the mortality. So early and effective management is critical. The first line of defence is benzodiazepines. Give it however you want, give it fast and give it in the correct dose. Brendon stresses dosage is really important. This treatment is effective, with one study showing by following a status epilepticus pr

Maaret Castren passionately delivers her take on how to improve outcomes from out-of-hospital cardiac arrests. Maaret brings resuscitation back to the basics. Using science, education and local organisation factored together, we can drastically improve the chance of survival in out-of-hospital cardiac arrest. Currently, the best systems in the world only garner 20% survival rates in these situations. Mareet explains that quite simply, education is lacking. She believes the first step is to know your patient. 50% of cardiac arrest patients have signs and symptoms in the preceding weeks before their arrests. However, there is no current sudden cardiac arrest risk prediction tool available! Maaret explains the concept of precision medicine – the idea that medicine practised in a one size fits all manner provides successful treatments to some patients but not all. One must consider individual differences in people’s genes, environments and lifestyles. In resuscitation medicine this can simply mean altering hand p

Resuscitation is complicated, but the solutions don't have to be. Chris Hicks brings you four psychological strategies that will help you manage complex resuscitations. It is a fascinating time to be a resuscitationist with ROBOA, ECMO and EPR. Chris explains that as we learn more about critical illness, we learn more about the complexities of resuscitation. Therefore, we need ways to manage and constrain complexity and to simplify and organise problems that will see us through. Chris’s lessons are founded on a case. A 22-year-old female is brought into the Emergency Department. She was an unrestrained driver in a motor vehicle accident. She is agitated, has multiple facial smash injuries, burns to her torso and neck, a right sided flail segment, and a mechanically unstable pelvis. Also, when you ultrasound her abdomen, you realise she is well into the third trimester of a pregnancy. Chris discusses four strategies to cope in a complex situation. The first is grounded in habits. Habits have a lot to do with w

Neurologic airway manipulation is unforgiving; errors lead to hypoxia and secondary injury. Managing the airway with an eye towards success, the first time, every time, without allowing sats to drop below 90% is the holy grail of neuro airways. Selection of RSI techniques, DSI techniques, and pharmacologic management is critical for success. The TBI airway with ICP issues and the post tPA airway present unique problems and the failed extubation in the neurologic patient is as common as the day is long. We will explore the latest theories and data (if there are any) and debunk some common myths together during this session.

Interprofessional issues in critical care Meeting of the Tribes brings together clinicians from a broad range of health professions, including medicine, nursing, social work and physiotherapy, to explore interprofessional issues in critical care. In addition to their clinical work, panelists have unique perspectives on education, simulation and resilience in healthcare. In discussing issues related to tribalism and their implications for interprofessional practice, the panel explore what it will take to overcome a tribal mentality in the service of improved patient care. Tune in to this discussion as the panel strive to: (a) present a snapshot of the status quo (b) explore key issues and their implications for clinical practice (c) envision of future of enhanced interprofessional collaborative practice. For more head to https://codachange.org/podcasts/ 

Ronan O’Leary discusses reversing coagulopathy in traumatic brain injury. The PATCH trial was a trial look at the use of platelets to reverse the effects of aspirin and clopidogrel in patients with spontaneous cerebral haemorrhage. Ronan asserts that overall platelets are harming patients. Through his talk he highlights many studies that have been inconclusive about the benefits of giving platelets in traumatic intracerebral haemorrhage. As one study eloquently described, “It was not possible to determine if platelet transfusion was superior, inferior or not different from control interventions.” So why are platelets given at all? In haemorrhage, reduced platelet activity is associated with adverse outcomes. This is demonstrated with larger haematoma size in patients with lower platelet counts. So, it would make sense that replacing platelets should lead to better outcomes. However, this is not the case. Furthermore, as Ronan articulates, sometimes it just feels better to do something over nothing. The aetiol

Moderate panel discussion on FOAM Open Access Medical Publishing Data sharing

The door to needle time for acute stroke in Critical Care is a key variable when striving for good outcomes. Rhonda Cadena answers the question - Who should pull the trigger on tPA for acute ischemic stroke? Medical management of acute strokes has changed dramatically over the years. We used to rely on clinical exams for diagnosis, prescribe strange medications and undertake interventions that were scary! This has changed in recent times. We have now evolved to advanced imaging techniques, new medications and interventions including endovascular treatments. These advances have dramatically increased the likelihood of positive outcomes in stroke patients. The new problem coming to light is time. All the modern treatments that exist do wonderfully well in achieving what they are supposed to. However, the longer it takes for a stroke patient to be get the treatment equates to more deficits and less chance of having a complete recovery. The process as it currently exists can take time. A patient will notice sympt

Claire Park delivers a riveting talk, bringing military trauma lessons from MERT (Medical Emergency Response Team) back home. Claire tells two stories from her tours in Afghanistan. The first begins in the early hours of the morning when the MERT team is tasked on a job. They receive word of five casualties including two above knee amputations and one unconscious without a radial pulse. On arrival to the scene the paramedics leave the helicopter to triage and bring the casualties aboard to Claire and her team. They begin to take enemy fire. The second experience was delivering care to an Afghan national soldier with a gunshot wound to the neck. He was alert when he came onboard the helicopter but quickly deteriorated. Claire decided he need to be intubated. However, there was an expanding haematoma across his cricoid area with a deviated trachea. An extremely difficult airway in an extremely difficult environment. The lessons from her experiences as a part of the MERT? Do the basics well. This means prioritis

Join the debate between Bill Knight and Fernanda Bellolio as they go head-to-head, discussing diagnosing subarachnoid haemorrhage in neuro critical care headache. Should you rely on CT and lumbar puncture or, CT followed by CT angiogram. Why should you care? Acute headache accounts for 4% of all visits to the emergency departments. These patients will often describe the “Worst headache of life” – a phrase which can ring the alarm bells in the clincian’s mind. 88% of these will be from benign causes including migraine, tension and cluster. However 10% will have a subarachnoid haemorrhage, of which the vast majority are caused by an aneurysm. These are frequently missed - up to 51% of the time in all settings and 6% of the time in the emergency department. It is in face one of the largest sources of US litigation claims and settlements. So – what is the best way to diagnosis subarachnoid haemorrhage? Bill asserts that the lumbar puncture (LP) following the CT is the way to go. He stresses that the “miss rate” n

Prehospital high acuity transport by air rescue has the capability to deliver the sickest of patients to high quality, advanced care, and support. However, not all patients are transferred. Why? Per Bredmose tells the tale of Emma. Emma is a 12-year-old girl who developed a cough. She is admitted to local peripheral hospital, correctly diagnosed with pneumonia, and treated with IV antibiotics. Emma continues to deteriorate and is transferred to an ICU where she fails a trial of BiPAP and is intubated. She continues to deteriorate. She requires high pressure ventilation and vasopressor support – advanced, high end, specialist interventions. The truth… this never happened. This talk from Per is about all the future Emma’s. Someone in the hospital system (either the sending or receiving hospital) decided that Emma was too sick to be retrieved. Per challenges this notion of “Too sick to be retrieved”. He says it is rather a case of being in the wrong place at the wrong time. Or getting the wrong disease in the wr