SMACC

An eight minute summary of the evidence and clinical considerations regarding decompressive craniectomy, discussion of some controversies, and presentation of a decision matrix to use when considering surgery in your patient with malignant middle cerebral artery infarction.

Direct download: SMACC_Andrew_Chow.mp3
Category:general -- posted at: 7:00am AEST

In 2010, 400 children died from lead encephalopathy in the largest lead poisoning outbreak ever recorded, affecting more than 5000 children in Zamfara state, Northern Nigeria. The outbreak is ongoing. The source is dust from artisanal gold mining, a major economic boon to a remote and rural population much in need.

The response to the Zamfara outbreak is unprecedented and requires a nuanced interpretation of 'critical care'. Key life-saving activities include multi-level advocacy to address source control, management of inter-current outbreaks of cholera, measles and meningitis, addressing the logistical challenges of large-scale environmental remediation and navigation of an increasingly difficult security context. The situation is so dynamic and dense that knowing which way is up, or which way might cause inadvertent harm, is an ever present challenge.

This is the story of the Zamfara outbreak and response, but more importantly it is the story of the people affected, whose lives have been changed by a forgotten outbreak and whose deaths’ engender no outrage.

Direct download: Lead_Poisoning_In_Nigeria.mp3
Category:general -- posted at: 7:00am AEST

The medical non-governmental organisation ALIMA (Alliance for International Medical Action) in collaboration with the Guinean Ministry of Health opened and ran the Ebola treatment centre (ETC), in Nzerekore, Guinea during the recent outbreak of Ebola virus disease in West Africa. This paper will describe the issues faced in treatment of the evolving phases of the illness and the aero-medical evacuation of health workers with suspected Ebola virus disease. The difficulties of participating in a trial of experimental therapy during an epidemic of a highly contagious disease, with a terrified local population will be explored. An approach to working with the local community to optimise engagement and minimise stigma, to allow an appropriate public health response will be illustrated. Issues arising from ensuring safe handling and burial of corpses while maintaining respect and dignity for the dead person and their loved ones will be outlined. The stresses and strains of day to day life for the Ebola treatment team will also be shared. Sadly, the ETC has recently been re-opened due to a new cluster of cases.

Direct download: Fighting_Ebola_in_Guinea.mp3
Category:general -- posted at: 7:00am AEST

There is a rich literature showing excess stress - psychological, pharmacological or physiological - results in similar physical and cognitive manifestations. Critical illness is the perfect example of this manifestation of decompensated stress ("allostatic overload"). Failed organs frequently look normal histologically yet are functionally inactive, despite many varied insults/stressors triggering the failure. These organs regain their functionality prior to patient recovery suggesting, in most cases, reversibility. If this hypothesis were true, de-stressing manoeuvres should improve outcomes ... and they do, at least in specific human conditions and animal models. Grasping this concept offers a much more holistic approach than we use at present and may lead to improved outcomes.

Direct download: Should_we_De-stress_the_Distressed.mp3
Category:general -- posted at: 7:00am AEST

Recently published national guidelines and case series evidence supports a standardised management protocol for pre-hospital traumatic cardiac arrest (TCA) in adults due to penetrating trauma. However, the pathophysiology of pre-hospital TCA in children is different, as the mechanism is typically blunt trauma with concealed haemorrhage, and as such caution must be applied to direct extrapolation of adult guidelines in this situation. This talk will describe some recent paediatric TCA cases, review of the relevant evidence, and suggest a decision framework to support the pre-hospital team.

Direct download: SMACC_Jon_McCormack.mp3
Category:general -- posted at: 7:00am AEST

Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge. Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury. Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen.

Direct download: First_do_no_oxygen.mp3
Category:general -- posted at: 7:00am AEST

For the 30 years, clinical understanding of haemodynamic resuscitation has been based on physiological paradigms that focus on convective oxygen delivery. Most of these emphasise the role of cardiac output, haemoglobin and recommend interventions using synthetic agents such as dobutamine, synthetic colloids and blood transfusions. Markedly influenced by industry, these interventions and strategies hijacked critical thinking creating a belief in the utiliity of attaining short-term physiological surrogates for resuscitation that have little relevance in improving patient-centred outcomes. This 'physiological fallacy' has been demonstrated in high-quality RCTs of fluids, goal-directed therapy and catecholamines, that paradoxically inform the interpretation of new insights in the physiological basis of health and disease.

Direct download: Does_oxygen_delivery_matter.mp3
Category:general -- posted at: 7:00am AEST

Scott Weingart's opening talk at SMACCdub was on meditation: vipassana and stoic negative contemplation. Visit Scott's personal Blog EMCrit http://emcrit.org/wee/vipassana-meditation/

Direct download: 02_Scott_Weingart_.mp3
Category:general -- posted at: 11:00am AEST

2016 is the 30th anniversary of ischaemic preconditioning. Remote ischaemic preconditioning is the magical offspring of ischaemic preconditioning and refers to the phenomenon whereby brief periods of ischaemia in one organ can protect other organs from subsequent prolonged ischaemic insults. In theory, remote ischaemic preconditioning can be induced by temporarily interrupting the blood supply to an extremity using a blood pressure cuff.

In experimental models this technique is effective in reducing ischaemia / reperfusion injury when applied after ischaemia but before reperfusion. As a result the technique has a wide range of potential clinical implications including:
1. Heart surgery with cardiopulmonary bypass
2. Planned percutaneous coronary interventions
3. Acute myocardial infarction
4. CBA being treated with lysis or clot retrieval
5. Carotid endarterectomy surgery
6. Hypoxic ischaemic encephalopathy
7. Organ transplantation
8. abdominal aortic aneurysm surgery

While this technique is not yet ready for clinical application, it remains an exciting potential therapeutic modality for the future.

Direct download: The_magic_of_remote_ischaemic_preconditioning.mp3
Category:general -- posted at: 7:00am AEST

Combining academic activity with pre- and in-hospital clinical practice is hard work. So why should you do it? Are you a strong believer that care should be evidence-based and that this principle also pertains to pre-hospital practice? Do you believe that the nature of the pre-hospital environment does not allow automatic extrapolation of in-hospital evidence to the field? Do you believe in the relevance of critically appraisal of practice to identify areas of improvement, areas of harm, and to optimise a resource-effective practice? If so, lets discuss how to do pre-hospital research

Direct download: SMACC_Marius_Rehn.mp3
Category:general -- posted at: 7:00am AEST