Smacc

Gareth Grier discusses who should be intubated following severe trauma pre-hospital.

This talk will look at current and previous pre oxygenation practices and some of the current research. It will also discuss the notion of commitment to evolution of practice, the breakdown of cognitive biases and how to move forward with adequate self reflected practice.

Peter Brindley explains why teamwork is 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’. Peter describes communication and its critical role in the effectiveness of any team. He compares the voice of a team leader to a drug. Like a drug, it can be a placebo or a nocebo, depending on its use. As such you must use the right drug at the right dose for the right patient and the right time! Moreover, other forms of communication play an integral part of any team environment. Peter discusses verbal, paraverbal, non-verbal and other forms of communication which all need attention. Rudeness, and its damaging potential is highlighted. Peter contends that rudeness alone wi

Richard will cover the rationale and evidence for prehospital blood product transfusion in trauma, look at the available current and future options, suggest best clinical practice and highlight areas of future research.

William Knight presents the considerations in the management of extra-cranial injuries in patients with traumatic brain injuries (TBI). Patients with TBI often have concomitant systemic injuries that complicate the management of the TBI. In this talk William presents his five top areas to think about – prognostication, suitability for the operating room, use of ventilators, pressure considerations and monitoring. Prognostication becomes difficult when a brain injury is added to other injuries due to the long-term nature of neurological damage. This means that other clinicians can be unsure when managing extra-cranial injuries in such patients. Adding a brain injury on top of other injuries tends to make people unsure, and enhances nihilism. Intensivists in the neurological ICU tend to be very protective of their TBI patients. However, some simple measures and tests can go a long way to reassuring the treating team of a patient’s suitability for the operating room. William describes the ‘lay flat test’, which

Kieran Henry gives his insights into hospital handovers of major trauma. He makes the comparison between prehospital care and the life lived in a Western movie. Kieran stresses that he does not want you to behave like a cowboy, jumping off your horse (ambulance) as it is still moving into town, without much dialogue and with no one really knowing what is happening. Instead, be the preacher man! Be cool, concise, and clear in your messaging. Prepare, practice and be professional. Much like the preacher man, you will be listened to if this is how you carry yourself. You will then be able to convert the non-believers. Delivering the handover message effectively and efficiently is crucial. Tune in to Kieran to learn how to convert the non-believers into believers and do good patient handovers. Hospital Handover of Major Trauma: Kieran Henry For more like this, head to our podcast page. #CodaPodcast

Jo Anna Leuck discusses how to learn from error in paediatric sepsis. Rory was a healthy 12-year-old boy, known for his smile and for standing up for others. A simple fall during basketball practice caused an abrasion on his arm. This is the suspected beginning of a cascade of events that led to his death from sepsis. Rory was seen by both his paediatrician and a local Emergency Department and was sent home with a diagnosis of a viral illness. He returned the next day in septic shock and died shortly thereafter. A review of the medical records revealed that there were errors that occurred during his emergency department visit. This talk will attempt to move away from the controversy of the actual article and instead focus on how these common errors could have occurred during any busy shift and what we can do to prevent them in the future. Jo Anna’s intention in giving this talk is to continue to use this case to raise awareness of both paediatric sepsis and common medical error. When considering paediatric se

Simon Finfer explains the future of sepsis treatment focusing on life after surviving sepsis. Sepsis is the life-threatening condition that arises when the body’s response to an infection damages its own tissues and organs. It can lead to shock, failure of multiple organs, and death. Organ failure and death are more likely if sepsis is not recognised early and not treated promptly. Sepsis is the leading cause of death from infection around the world and contributes to or causes half of all deaths occurring in hospitals in the USA. Many people who survive severe sepsis recover completely and their lives return to normal. But some people, especially those who had pre-existing chronic diseases, may experience permanent organ damage, the common problems that afflict those who have recovered from sepsis have been termed the post-sepsis syndrome. Longer term effects of sepsis are extensive. They include sleep disturbance including insomnia and nightmares. People experiences hallucinations, flashbacks and panic atta

Alistair Nichol explains the use of hypothermia in the treatment of traumatic brain injury (TBI). TBI is a major cause of mortality and long-term morbidity. It leads to terrible outcomes and is a major cause of health burden across the globe. Prophylactic hypothermia presents a promising treatment to address this hidden epidemic. The pathophysiology of TBI is exceedingly complex. Evidently, one drug will likely not be the answer. This leads Alistair to discuss hypothermia as a treatment for TBI, which has huge potential benefit. As Alistair explains, it acts in many different places, in many ways, across many time periods. Could this be the ‘drug’ to give? The questions then become, when should you give it, how should you give it and how low should you aim? Alistair recommends inducing hypothermia as early as humanly possible. In the case of TBI, this means at the roadside if practical. How low should you go? Given the effect of hypothermia on coagulation, and the propensity for trauma patients to bleed, this

Ryan Radecki urges you to rethink the acute management of stroke. The current way of thinking about stroke and the acute treatment has been around for decades. In this time, a lot has changed, new technologies have been developed and we have learnt a lot about the underlying physiology of stroke. Endovascular therapy, CT perfusion, and patient-level predictive modelling are now all at the disposal of clinicians. Moreover, Ryan wonders if we are using the current treatments – namely tPA – more safely or effectively. In acute stroke management there are two key factors to consider. Successful reperfusion and salvageable tissue. To restore and save brain tissue one must successfully re-perfuse the tissue. The classic method for achieving this is by using tPA. However, Ryan contends that this is akin to using a sledgehammer to fix a teacup. It is a dangerous drug, with many risks, and it is not appropriate for all patients. Salvageable tissue is the second key factor. If brain tissue is dead, it stays dead. It do

In this entertaining talk, Ronan O’Leary discusses conflict in critical care. Ronan explains how to make a team decision about whether or not to perform a decompressive craniectomy. Undertaking a decompressive craniectomy is perhaps one of the most challenging decisions we face within critical care. Ronan contends that we do not know if we should do the operation. As he explains, even if we think we should do it, we don’t know when, or even how. Perhaps more importantly, intensivists do not perform the operation, the neurosurgeons do. However, we frequently put them in the position of doing the operation when we are at our wits end. Alternatively, they do the operation without asking us when we still feel we have space to play. Ronan poses the question - how can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches? Evidence based medicine is not going to provide an answer soon and it is unlikely that a superficial approach to improving t

Martin Smith persuades you that controversies in brain death should not, and do not, exist. Almost fifty years since the concept of brain death was first introduced, some individuals and whole nations still struggle with its concept and justification. Many controversies continue to surround brain death, although there is broad consensus that human death is ultimately death of the brain. Martin provides a history of the concept of brain death. He describes how advances in modern medicine have made the concept of death, and specifically brain death, muddled. This has broad implications on the diagnosis of brain death – and provides the basis to the controversies that exist. The concept of death as a process is explored. The idea, and in fact the truth, is that death does not happen at a discrete moment in time. Alive or dead may be the only two states an organism can be in. However, the transition from one to the other is not instantaneous. Martin contends that the process and the nomenclature has little practi

Hazel Talbot gives her insights from working in neonatal and paediatric retrieval. She delivers her talk with all the passion and dedication that she brings to her work as a neonatal and paediatric transport consultant. Equipment failure, rapidly deteriorating children and miscommunication are all common challenges that Hazel and her team encounter in their line of work. This is on top of the challenge of caring for neonates and children. How are children different? They differ in physiology, in disease profiles and even the way they make clinicians feel! In this talk, Hazel focuses on physiology and disease. The large majority of young deaths in the UK, where Hazel works, are neonates – under 28 days old. 50% of these deaths are due to perinatal diseases. These include congenital malformations, prematurity, sepsis, and congenital heart conditions. Children are small adults. Small airways, small necks, small lungs. Babies however are not small children. They use the majority of their physiological ability to

Simon Finfer argues that the transfusion threshold should be 70 g/L. Simon first raises the Choosing Wisely Guidelines for Critical Care. These state that one should not transfuse red blood cells in haemodynamically stable patients with a haemoglobin concentration of greater than 70g/L. He continues to discuss the application of this specifically to patients with an acute brain injury. In doing so he will talk about evidence generally and how one must approach the use of evidence in specific patient subgroups. Simon continues by raising further research to justify his position. Oli Flower on the other hand will take the position that the transfusion trigger should be 90g/L. He makes the point that this is the easy position to take. Essentially, he is just explaining why the critical care community does what it does! As Oli explains, haemoglobin plays a pivotal role in providing oxygen to tissue. In the case of a brain injury, to prevent further injury, one must ensure continued supply of oxygen to said tissue

Myths persist because they are essential to the human experience and our development as a society. They fill the gap between what we know and what we think we know. Where does this gap hurt us the most? In our vulnerable populations, for example, in our care of children. The “myth incarnate” in medicine: defective dogma. Not all dogma is bad – after all, dogma means “that which is believed universally to be true”. The problem with medical dogma is that our critical thought processes are curtailed by wholesale acceptance. Medical dogma is a special kind of myth, because it’s difficult to define. We repeat defective dogma for three reasons: “It is known”. Sometimes the dogma is all that is known on the subject, or it is simply the majority consensus. Be careful with this one – because there may be a reason for this specific teaching – not all dogma is bad. Dogma is sentimental. We learned from our teachers who learned from their teachers. We want to honor those who taught us, and we get attached to some

Ffion Davies gives her take on how to spot the sick child in the Emergency Department. 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. In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well. Ffion breaks her thinking into two main areas: physiology and psychology. Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid the feared crime of discharging a sick child. Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one’s suspicion of serious disease. Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true. Ta

Alex Psirides discusses the problem with major hospitals and the systems that they use. Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system. As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches. The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world. Many staff lack acute medical skills. Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs. Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows

Anthony Baca provides a focused talk on prehospital critical care response to the active shooter. Coming from the United States of America setting this is unfortunately not a rare occurrence. Anthony will discuss the real-world violence that exists, and what are the most important considerations for first responders in such situations. Anthony speaks about prehospital critical care team responses to mass shootings. He explores how emotional and physiological barriers run amok making the simplest logistical and clinical decisions extremely difficult. Moreover, Anthony provides real world advice should you ever find yourself called to a scene with an active shooter. This includes the importance of staying “left of bang”, incident recognition, initial confusion, and the critical nature of incident acceptance. Further, he reviews staff and patient safety priorities and basic concepts of tactical combat casualty care (TCCC). Finally, Anthony concludes with thoughts about your role as care provider when on duty as

Scott Weingart discusses post-intubation sedation – a topic that tends to aggrieve him on a regular basis. Scott explains in simple terms why he is bemused at the lack of understanding surrounding intubated patients who become agitated or aggressive. How would you like a piece of plastic placed down your throat? The problem, as Scott explains, is that sedation does not blunt pain. Sedation without analgesia leads to delirium. In simple terms delirium leads to poor outcomes and death. Moreover, concerningly, the early sedation strategy of intubated patients has long term and far-reaching outcomes during their course of critical illness. So, what can be done? Scott explains that we need patients properly sedated, however not too deeply sedated. The goal needs to be a patient who is oriented, safe and with a normal sleep-wake cycle. Paralysis is not the answer. What is the answer? Scott walks you through A1 sedation – meaning analgesia first. Once pain is controlled, then sedation comes in to play. Scott stresse