#RCEMasc 2019 - Day 3
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October 3, 2019
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:
- 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
- Triage: