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 AEDT

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 AEDT

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 AEDT

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 AEDT

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 AEDT

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 AEDT

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 AEDT

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 AEDT

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 AEDT

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 AEDT

All diseases exist on a spectrum. Although the pathophysiology and relative illness of patients on the spectrum are different, we often apply the concepts of management of one of the spectrum to the other end. This can be extremely deleterious to our patients. For example, we cannot treat CHF exacerbations, acute pulmonary edema and cardiogenic shock with the same approach (i.e. no role for loop diuretics early in APE). Thin-slicing disease into a spectrum allows us to tailor our management to our patients and maximize good outcomes.

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

This talk will outline the current state of play in terms of the 'silver tsunami' of elderly patients attending our EDs. What the evidence is for managing them effectively within the ED, and how we could manage them better. It will focus on the effective and efficient delivery of services for the elderly within the ED, the need for training and specialist skills and research to deliver improved care.

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

The key to dystopian literature is the backstory. These brutal, terrifying worlds are grim forecasts of the future, spawned from the choices and actions of the present. In critical care medicine we make rafts of decisions everyday - not all of them ideal. This talk looks at a projection into the future, both fictional and real, based on those small decisions, actions, and processes.

Direct download: 1984_Dystopian_Literature_and_Emergency_Medicine.mp3
Category:general -- posted at: 7:00am AEDT

The farm is a dangerous workplace. Accidents have an unusually high morbidity and mortality not only for the worker but also his/her family members. The reasons are multi-factorial but are the result of a complex interaction of environment, equipment, and human factors. Tractors are involved in the vast majority of agricultural deaths. No other industry uses 70-year-old machinery operated by workers whose age ranges from 10 to 90. How can we prevent such incidents?


Today’s presentation is from my viewpoint as a prehospital physician (who is a wannabe farmer & tractor mechanic) and longtime resident of an agricultural community. We will examine the details of a life threatening accident involving one of my neighbors which perfectly illustrates the multifaceted nature of agricultural trauma

Direct download: 04_Mike_Abernethy.mp3
Category:general -- posted at: 3:00pm AEDT

In the busy world of emergency medicine it's easy to focus on the here and now, there is always something that demands immediate attention. What of the future? How will demographics, workforce, technology, finance and politics affect the practice of emergency medicine? This talk explores these issues and charts a future that will be very different to today.

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

John Hinds' tragic death has affected many people all over the world. In the inaugural John Hinds Plenary session at SMACCDUB, John's partner Janet and his mentor Fred MacSorley celebrate John's life in a fitting tribute to the man that has become a legend.

Direct download: FIRST_AMONG_EQUALS_A_TRIBUTE_TO_DR_JOHN_HINDS.mp3
Category:general -- posted at: 1:30pm AEDT

Lets explore dogma and myths about the knowledge and skills of 'resuscitationists', and the way we think we maintain and improve our skills.
BLS and trauma team leadership will come under the spotlight - we often don't do what we think we do.
Resuscitationists are exceptional people - but not necessarily in the way we think we are.
And finally - some thoughts on what we'll leave behind as resuscitationists... with a tribute to John Hinds

Direct download: So_You_think_youre_a_Resuscitationist.mp3
Category:general -- posted at: 9:00pm AEDT

Agitation poses a direct threat to the safety of both patient and staff, as well as being an important manifestation of dangerous conditions that require rapid identification and treatment. Management of agitation consists primarily of physical and chemical restraint, and the details of how restraint is carried out–usually based more on tradition than considered plans or thoughtful protocols–directly determine case outcome. In this talk, we’ll discuss the initial approach to agitation, focusing on the appropriate role of physical restraint, as well as best practice technique for physical restraint. We will then deliberate the options for chemical sedation and propose a menu of the safest and most effective agents for a variety of common agitation scenarios. Some of the questions we will address include: What are the most important dangerous conditions that cause–or are caused by–agitation? What are dangerous restraint holds, and how can physical restraint be accomplished in the safest manner? In the initial management of an agitated patient, should chemical restraint be administered by the intravenous or intramuscular route? How do haloperidol and droperidol compare speed in efficacy when used for calming the agitated patient? How should providers manage concerns around prolonging the QT interval when using butyrophenones for sedation? Which benzodiazepine is preferred, as a treatment for agitation? How should neuroleptics and benzodiazepines be used as monotherapy or in combination? In which type of patient should ketamine be used as a sedation agent? How should ketamine be dosed for tranquilization, and what adverse effects should providers be mindful of when using ketamine for this indication? Can ketamine be used in patients with hyperdynamic vital signs? What is the role of crystalloids in managing the agitated patient? Once the agitated patient has been calmed, what are the primary, secondary and tertiary resuscitative maneuvers (diagnostics and therapeutic)?

Direct download: disruption_danger_and_droperidol.mp3
Category:general -- posted at: 9:00pm AEDT

As our population ages, the complexity of patients seeking care in the emergency department will increase dramatically. Chronic and terminal diseases will be ever-present but increasingly in patients also negotiating challenges like functional and cognitive decline. While their needs are different, in many hospitals, it is business as usual. A highly skilled and well-intentioned staff stands ready to deploy a limitless supply of diagnostic and therapeutic options designed to help patients live longer, not necessarily better.

Relying on default pathways that prioritize life-prolongation at the mercy of comfort and dignity has already left many patients and doctors feeling unsatisfied, while wasting precious healthcare resources. The future should not be more of the same.

If a new and better clinical road is to be paved in the future, it will be with the aid of palliative care, a specialty, philosophy and movement in medicine. Getting patients better access to palliative care should be a priority for our specialty. For some, this will mean partnering with existing palliative care specialists and hospices. Unfortunately, for most of us, the palliative care workforce will never be able to match the increasing demand created by our patients. This means that we must all do the hard, but incredibly rewarding work of learning a basic palliative care skillset. No pressure but the future of healthcare depends on it!

Direct download: Why_we_need_palliative_care_everywhere.mp3
Category:general -- posted at: 9:00pm AEDT

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