SMACC

It’s been two decades since NINDS and MAST and ECASS and the other clot-busting lore cluttering up your brain. Have we learned anything in the interim? Are we using tPA more safely, more appropriately – or just more? And, what now, of endovascular therapy, CT perfusion, and patient-level predictive modeling – are you ready for the next decade of evolution in stroke care?

In this talk, we’ll go into the most recent trial evidence relating to saving neurons, and whether we should be suspicious or celebratory of their outcomes. On one hand, we have clinicians putting the low-tech non-contrast CT in a mobile stroke unit to treat more patients, while other clinicians are using rapid MRI and CT perfusion to precisely target treatment. We’ve also seen endovascular treatment finally hit prime-time after years of false starts, and systems of stroke care re-organized around its delivery. The pace of practice change – and the reliability of the evidence – is enough to give you a stroke!

Finally, we’ll look at the clinical trials underway, which may produce zero, subtle, or huge changes in practice. At the minimum, we’ll at least get a handful of new acronyms to file away.

Direct download: Ryan_Radecki.mp3
Category:general -- posted at: 7:00am AEDT

Undertaking a decompressive crainectomy is perhaps one of the most challenging decisions we face within critical care, we don't know if we should do the operation, and even if we think we should we don't know when, or even how. Perhaps more importantly we don't do the operation, the neurosurgeons do, but we frequently put them in the position of doing the operation when we are at our wits end, or they do the operation without asking us when we still feel we have space to play. How can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches? Evidence based medicine isn't going to provide an answer soon and it is unlikely that a superficial approach to improving teamwork will either. An important component will be the future structure of clinical training, our current systems reflect the way hospitals worked decades ago and the specialties we now have exist almost independently of the training which leads to consultant posts. Training should involve exposure to collegiate decision making and consensus building but this will be difficult to achieve within our current nationally co-ordinated training schemes.

Direct download: Ronan_OLeary.mp3
Category:general -- posted at: 7:00am AEDT

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. This crucially involves the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe since, taken together, these elements represent the most basic manner in which a human being can interact with their environment.

Confusingly brain death is defined in two different ways based on ‘whole’ brain and ‘brainstem’ formulations, although the clinical determination of both is identical. It is not widely appreciated that death is a process, and this leads to misunderstanding by both the public and professionals; reports of brain dead patients ‘being kept alive’ on a ventilator are familiar. Pragmatically, once a threshold of irreversibility in the dying process has been reached, and brain death is such a point, it is not necessary to wait for the death of the whole organism for the inevitable consequence of its biological death to be certain.

The majority of countries specify that a clinical diagnosis of brain death is sufficient for the determination of death in adults, but there are major international differences in the criteria for the determination of brain death. There is unanimity that confirmation of absent brainstem reflexes is fundamental, but wide variations in requirements for the apnoea test. The diagnosis of brain death is robust when established diagnostic criteria are strictly applied but, somewhat worryingly, deviation from jurisdiction-specific diagnostic guidance is relatively common.

This lecture will discuss the history and development of the concepts and diagnosis of brain death internationally, examine current challenges and controversies, and make the case for an international consensus.

Direct download: Martin_Smith.mp3
Category:general -- posted at: 7:00am AEDT

Hazel Talbot provides an insightful look at neonatal and paediatric retrieval in her talk "Small Packages, Big Lessons"

Direct download: Hazel_Talbot.mp3
Category:general -- posted at: 7:00am AEDT

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?

Direct download: BRAIN_05.mp3
Category:general -- posted at: 7:00am AEDT

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 ideas. Sometimes – even subconsciously – we allow our attachment to an idea to give it more credence than it deserves.

The third driver of dogma is insecurity. “I know what I know”. In other words, “don’t make me reveal my limitations.”

Myth: “They’re all fine”
Remedy: Remember to look for the subtleties in children. Early warning signs are there, in the history or in the physical exam. If it doesn’t add up, investigate.

Myth: “Only pediatricians are experts”
Remedy: Don’t delegate decisions. You can do this. You sometimes are the only one that can.

Myth: “I will break them”
Remedy: Children are not another species. Use all of your skills for all of your patients”

Powered by #FOAMed – Tim Horeczko, MD, MSCR, FACEP, FAAP

Direct download: Tim_Horeczko.mp3
Category:general -- posted at: 7:00am AEDT

Reflecting on 26 years of frontline practice in paediatric emergency care: while there’s no substitute for knowledge and experience, I can see some common themes to failing to spot a sick child. By sick, I mean injuries and illness that need hospital attention or hospitalisation. This talk tries to draw from all those errors I’ve both made and seen, into a couple of easy-to-apply mantras.

Physiology matters. It really does. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid our feared crime: discharging a sick child. And how to deal with fever, as a confounding factor.

Psychology matters. It really does. Talks on PEM are always popular because as EM physicians, we’re insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem. Less knowledge, less experience, less confidence? Yes? Then there's less Type 1 thinking.
We’ll talk about the risks in needing to rely more upon Type 2 thinking. How to deal with the time-poor resuscitation situation. How to avoid denial. What makes some staff be over-confident with children (hint - type 2 thinking is hard work!). What stops us applying our usual filters (eg risk stratification).

Finally, I can signpost more specific help with developing your PEM skills, which can be found at www.spottingthesickchild.com , an eLearning package containing hours of videos of real-life cases, endorsed by the NHS in the UK, and https://www.youtube.com/watch?v=N35J3NLJW_s , a 10-minute podcast also endorsed by the NHS.

Direct download: Ffion_Davies.mp3
Category:general -- posted at: 7:00am AEDT

In sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited. The TRansfusion and TReatment of severe Anaemia in African Children: (TRACT ISRCTN84086586) is a 3x2x2 factorial controlled trial involving 3954 children (aged 2m to 12y) with severe anaemia (haemoglobin <6g/dl). The trial has been designed to address the poor outcomes following SA in children in sub-Saharan Africa, which is associated with high rates of in-hospital mortality (9-10%), 6-month case fatality (12%) and relapse or re-hospitalisation (6%) indicating that the current recommendations and/or management strategies are not working in practice. Hospitalised children will be enrolled at 4 centres in 2 countries (Malawi, Uganda) and followed for 6 months. TRACT trial is designed to answer 4 simple questions. Q1 and 2: which children should receive a transfusion (since current guidelines recommend transfusions only in children with a Hb <4g/dl (or <6g/dl if accompanied by complications)); and how volume to transfuse in each transfusion event?. Q3 and 4: Since the major factors related to poor longer term outcome are micronutrient deficiencies and sepsis would post-discharge multi-vitamin multi-mineral supplementation versus routine care (folate and iron) for 3 months and/or cotrimoxazole prophylaxis for 3 months versus no prophylaxis improve outcome and prevent relapse. Primary outcome is cumulative mortality to 4 weeks for the transfusion strategy comparisons, and to 6 months for the nutritional support/antibiotic prophylaxis comparisons.
If confirmed by the trial, a cheap and widely available ‘bundle’ of effective interventions could lead to, if widely implemented, substantial reductions in mortality in African children hospitalised with severe anaemia every year. The trial started in Sept 2014 and currently 2700 children have been enrolled. We expect the trial results to be available in 2017.

Direct download: Kath_Maitland.mp3
Category:general -- posted at: 7:00am AEDT

As patients becomes more complex, the tribal systems we use to look after them remain stuck in the 18th Century when the treatment for everything was amputation and, if you survived, leeches. The large modern hospital is becoming a battleground of competing SODs* and SONs** practising their art in a multi-organ (failure) world. Many staff lack acute medical skills; those with such expertise are siloed far away from the ward in emergency departments, operating theatres and ICUs. Despite disease not knowing or caring what time it is, all hospitals remain solar powered with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence-summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission.

The two most dangerous words in healthcare may well be ‘_my_ patient’.
Come listen to a middle-aged intensivist rant about how things were so much better ‘back in the day’*** and bask in the utopian dream of a healthcare system that provides better, safer, patient-centred care.

*Single Organ Doctor
**Single Organ Nurse
***they weren’t

Direct download: Alex_Psirides.mp3
Category:general -- posted at: 7:00am AEDT

Cops and robbers, cowboy and Indians, and military movies have filled the minds of generations of healthcare providers with a vision of what gun fights and combat look like. Unfortunately, real violence looks nothing like any of these. As emergency and critical care providers, we forge additional perspectives as we care for the victims of violence. Yet, views of violence aftermath only scratch the surface of first-hand experience during the brutal, scary, gritty, and dirty realities of real world in-progress violence. It is horrible, and It is quick… really quick.

In this focused discussion, we will talk about prehospital critical care team response to the mass shooting. We will explore how emotional and physiological barriers run amok making the simplest logistical and clinical decisions extremely difficult. We will discuss the importance of staying” left of bang”, incident recognition, initial confusion, and the critical nature of incident acceptance. Next we will review staff and patient safety priorities and basic concepts of tactical combat casualty care (TCCC). Finally, we will conclude with thoughts about your role as care provider when on duty as part of a pre-formed team, and what to do if off duty facing an active shooter.

Today is the day to ponder actions you must take the moment an active shooter begins taking lives at an astonishing rate; THAT moment when the choices you make next will be the most important of your career. The choices you make today will affect the milliseconds and millimeters that determine survival… patient survival, your survival, and the survival of those waiting at home for you to walk back through the door.

Direct download: Anthony_Baca.mp3
Category:general -- posted at: 7:00am AEDT