SMACC

Where does the abdominal assessment occur when you manage a paediatric trauma patient? Warwick Teague challenges us to stop just leaving it to the paediatric surgeon as he talks us through his approach to the abdomen in a paediatric trauma, including the key aspects of assessment and treatment - so simple, he says, even a surgeon can do it.

Direct download: Warwick_Teague.mp3
Category:general -- posted at: 5:30am AEDT

Neonates are a nightmare.. until you appreciate the physiological transitioning required in the journey from fetal to neonatal state in the big outside world. Learn to understand the challenges faced by not-quite-ready-yet premature babies to those with critical physiology gone wrong and unlock the key to providing quality neonatal intensive care. Take the fear out of caring for newborns and in performing emergency care procedures. Don’t fly blind, use your tuned in clinical awareness and tools such as point of care lung and cardiac ultrasound. Apply your revised empathy and understanding of a journey you once made and learn how to think again like a baby!

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

Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human. When they run riot or the fine balance between pro- and anti-inflammatory states is shifted however there can be significant morbidity and mortality. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients.
Disseminated Intravascular Coagulation (DIC) is a clinical and laboratory diagnosis that affects about 1% of hospitalised patients. At the most severe end it is associated with bleeding and/or thrombotic complications.
Disorders such as thrombotic thrombocytopenia purpura (TTP) and other forms of micro-angiopathic hemolytic anemia (MAHA) will also be described including the role of ADAMST13.
HIT is an uncommon but important conditions which is difficult to diagnose in a critically ill patient. An approach to HIT is discussed.
Have you always wondered about NETs (neutrophil extracellular traps) and their importance?
If so this whistle-stop tour of non-malignant hematology in the ICU is for you!

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

Multiple biomarkers - physiological, biochemical, biological - can prognosticate early in critical illness, even in the ED. This implies the die is already cast (literally as well as figuratively) so we are simply prolonging death is those predetermined to die. We thus need to adopt a completely different strategy for such patients. This also applies to trial design, especially where survival is the endpoint.

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

The use of adrenaline in cardiac arrest resuscitation has been advocated since the 1960s. Laboratory studies and anecdotal experience showed improved rates of return of spontaneous circulation (ROSC) with the use of adrenaline at a dosage of approximately 0.01 mg/kg. This led to the widespread adoption of adrenaline administration during cardiac arrest into every resuscitation guideline for decades to come. Extensive laboratory studies characterized the beneficial physiological effects of adrenaline during cardiac arrest and closed-chest cardiopulmonary resuscitation (CC-CPR). Adrenaline administered during CC-CPR results in peripheral arterial vasoconstriction that raises the aortic pressure, particularly during the relaxation phase of CC-CPR. This increase in aortic pressure results in an increased aortic to right atrial pressure gradient that drives blood flow to the myocardium during CC-CPR. This pressure gradient is known as the coronary perfusion pressure (CPP) and has been shown to correlate with ROSC in both laboratory investigations and clinical studies. During the 1990s, the use of “high-dose” adrenaline showed increased rates of ROSC compared to “standard-dose” adrenaline. However, it was subsequently recognized that larger doses of adrenaline did not result in improved survival. Furthermore, questions have been raised as to whether or not “standard-dose” adrenaline improves survival from cardiac arrest. Recent meta-analyses have raised serious questions about the value of adrenaline, showing a benefit for achieving ROSC but no clear evidence of improved long-term survival. Controlled clinical trials to address this question are now underway. However, there is another important issue that needs to be addressed: the “route” of administration. With the growing interest in endovascular resuscitation, the use of intra-aortic adrenaline titration offers a means of rapidly and effectively delivering adrenaline to peripheral arterial effector sites while providing arterial pressure and CPP monitoring to guide titration of adrenaline doses to achieve an optimal hemodynamic effects while avoiding excessive adrenaline doses.

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

Congenital heart disease isn't just diagnosed in the antenatal period and during post-natal examination. Nick Pigott takes us through the three main presentations of congenital heart disease (shock, cyanosis and heart failure) and reassures us that treating these patients is simpler than we think, urging us to consider cardiac disease in the sick newborn. He covers duct-dependent lesions, structural obstructive lesions, immediate resuscitation, the usefulness of physical examination, a deeper dive into hyperplastic left heart syndrome, the known cardiac patients (and what to do with them) and the paediatric cardiology wonder-drug: Prostaglandin infusion.

Direct download: Nick_Pigott_.mp3
Category:general -- posted at: 12:00pm AEDT

Working in a Paediatric Emergency Department that has 52,000 attendances per year, means that at this point I have fallen into almost every possible pitfall associated with communicating with children and their parents, whether it be the seriously ill or the efficient disposition of the worried well and everything in between. The art of appearing to take all the time in the world whilst managing large volumes of patients can be challenging at times. It can be difficult to separate your emotional response to a patient and their parents from your professional assessment. I hope that by hightlighting mistakes I have encountered along the way that others will learn from them.

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

Every Pre Hospital and Retrieval Medicine (PHARM) mission involves a series of complex decisions, which must be rapidly made in a fluid and often pressured environment. Excellent PHARM clinicians are invariably expert decision makers, and the ability to identify, accept and manage trade offs is a key skill in prehospital and retrieval medicine.

Some of these trade offs are obvious, and the best options are clear – for example aircraft and crew safety cannot be compromised regardless of the clinical situation on scene. Other choices are far more complex, and require rapid and accurate cognitive appraisal of a dynamic and often incomplete information set.

Interventions performed on scene, and the order in which they are performed involves a balance of the patient’s immediate requirements against how much it will cost in time and risk. During a mission, each decision to do something leads to another layer of decisions on how and where it should be done. This often results in a trade off between principle and preference. Decisions on which team member should perform a particular procedure must balance competence, training opportunity and the concurrent performance of other tasks.

Every mission is a continuous efficiency-thoroughness trade off, and each individual decision must be made to positively affect overall patient care. There is often no single ideal solution to these trade offs, and each decision must be tailored to the circumstances at a given point in time.

The way in which the clinician manages these trade-offs is vital both for effective patient care the overall performance of the mission. Excellence in PHARM is a function of training and experience, with expert clinicians operating within a robust system that allows for flexibility - protocols are powerful but individual insight is indispensible.

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

A demonstration in the ECMO-CPR process and then going back to basics, to understand the need for such a process and how to design and develop it from scratch using simulation to cut lead time and highlight and remove issues prior to rolling out on the patients. Making E-CPR both possible and safer.

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

This session will review the latest evidence for resuscitative hysterotomy (aka perimortem cesearean section), in light of the latest ACLS guidelines. Is there really evidence for the 4 minute rule? How fast do we need to do this? Terrified of this risky procedure? Come learn some practical tips for getting through this as effectively as possible. No time for the whole podcast? Check out these quick links and references:
• http://emupdates.com/2013/10/22/perimortem-cesarean-section-in-the-emergency-department/ This one has many details of the procedure itself.
• http://stemlynsblog.org/peri-mortem-c-section-at-st-emlyns/ Great review of the procedure, nice FOAM resources at the end
• http://emcrit.org/wee/peri-mortem-c-section/ Includes links to the videos below.
• Prefer a review article? This is a great review of the science on maternal cardiac arrest and PMCD (PMID 24797653)
• An excellent review of published cases is here (PMID 22613275), describing the details of timing of PMCD as it relates to maternal and neonatal survival

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

This talk uses a case study approach to discuss why resuscitation practitioners should focus upon technical accuracy when resuscitating, focussing on all of the facets of a resuscitation, compression, decompression, trans-thoracic impedance. It suggests that many of the smallest of subtleties can have a dramatic effect on patient survival.
We focus on the physiological effects of Manual Chest Compression and use historical reference to underpin modern techniques.

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

The child with the reduced conscious level presents a unique challenge to the Emergency provider - how can we recognise normal sleepiness versus pathology? Natalie May reminds us that, even if it's after bedtime, we have to take the time to wake children up fully as part of our routine assessment. She then explores the common pathologies - 5MF! - we need to consider in children with a reduced conscious level and how we can figure out which one is in front of us.

Direct download: Natalie_May.mp3
Category:general -- posted at: 12:00pm AEDT

For retrieval medicine specialists and pre hospital care providers, terrorist attack is one the new threat! Terrorist attack is not an accident: It is a human activity whose purpose is to kill, injure, the maximum casualties to disrupt society, to spread the feeling of fear of panic and insecurity in the population. Terrorism is not blind, it is an organized strategy, much more complex than any natural or technological disaster. To oppose an aggressive strategy a static plan is not enough, you must develop a counter strategy comprehensive and adaptable to multiple scenarios. Effective leadership, combining the expertise of the Police, Rescue and Emergency Care allows a customized solution using the elements prepared in advance. One of the worst threats is the multiple sites multi-modal attack, like in Mumbai or in Paris. To face such a complex situation you may need:
- Improvement of pre hospital and in hospital organization for massive casualties. Alert shared by all services, close coordination between Rescue Police and Emergency care, backup on a regional basis, strategic allocation of resources and keeping reserve for the next attack are some of the options that may be extremely helpful.
- Improvement of care for injuries related to military weapons: Major penetrating trauma caused by powerful (kamikaze) bombings and assaults riffles. Management of these victims is very different of the care of a multiple trauma patient after a traffic accident. Adaptation of the principles of the military “damage control” to civilian practice is mandatory. From the scene to the operating room and the critical care unit all actions must be coordinated to prevent the death triad: Hypothermia, coagulopathy and acidosis.
The action of Health Care Services is not limited to medical care, it is also a first step of resilience: By maintaining the quality and the organization of care despite surprise, violence and aggression you oppose directly the objectives of terrorism.

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

Discover how 3D scanning and printing can be used to develop low cost but high fidelity simulation training equipment. An introduction to free, open access Design software and affordable Compact 3D scanners. Cut out the middle men and save your department $$$ by making your own training manikins. Surgical airway trainer, central line insertion phantom, even an ultra-low cost video laryngoscope can easily be created without learning how to use complex 3D software packages.


It’s natural that as doctors we fear failure. In Health, never has so much been asked by so many of so few. Every day feels like a battle zone. Engage a Chief Medical Informatics Officer (CMIO) to introduce technology. That will save us. Established with structure, status and enough support to create and translate innovative models of change in the mindsets of clinicians and healthcare politicians alike, this role could work. However reality is so different. So lets understand failing early to succeed sooner, simplifing and standardising the clinical arena for clinician interoperability, and driving clinician inclusion in the business of health.

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

In the evaluation of an emergency and critical care patient, the provider accounts for the chief complaint, the relevant history and the physical examination. With the evolution of Point-of-Care Ultrasound protocols and algorithms, such as the RUSH protocol or the BLUE protocol, the provider now can organize differential diagnoses and treatment options by integrating point-of-care ultrasound interpretations. However, these are not absolutes. These are probabilities. Although we are following recipes, we must never forget to be creative.

And, we actually crave creativity.

Studies support that handwork such as gardening, wood working, knitting can decrease stress, anxiety, and improve your mood. Perhaps work which requires meaningful hand use may contribute to your creativity- to your following algorithms and delivering more optimal patient centered care. Emergency and critical care medicine can be formulaic- following an algorithm, a pathway, or a protocol. Point-of-care ultrasound may offer the ability to be creative and increase the accuracy of diagnoses and treatment plans.

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

'"Think of the danger while things are going smoothly." Chicago's own Lisa McQueen picks apart the challenges of identifying those children who genuinely need sepsis resucitation in the "pre-shock phase" and explores the pathophysiology and treatment of shock in children.

Direct download: Lisa_McQueen_-_Shock.mp3
Category:general -- posted at: 12:00pm AEDT

Two simulations for prehospital care - tactical and motorcycle pit crew with a panel discussion debrief following. Demonstration and discussion of the medical response to these incidents.

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

Technology (tech) makes our lives in many ways, yet that same technology is lacking from healthcare. Many of the things that are used in our daily lives can be applied to providing better healthcare to our patients and bring specialized care to any corner of the planet. This talk will discuss some of the ways such technology is being used and ideas for care in the future.

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

As many other emerging countries, Brazil has two completely different healthcare systems, a private system restricted to those who are insured and a public system free-of-charge available for everyone. As anywhere, there are lots of boring things in our daily routine. Some of them will piss you off regardless if you are working for a very nice private ICU or for an overcrowded public one. Deal with the assistant physicians, with our own colleagues and other healthcare professionals is not exactly easy and fun. Can you imagine something more repetitive than a checklist? However, some will be different. To decide who will get the last free bed? Put a patient in ECMO knowing how much it will cost? Having a fight after finally finding our ward colleagues to get a patient discharged? To discharge a patient knowing that he will come back because we don’t have step-down units? Yes, that is sometimes just too much! And this just all in a day’s work in a public ICU in Brazil.

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

Providing a service to the critically ill depends on a number of essential building blocks: Trained staff, diagnostics, equipment, drugs, guidelines and processes. Compromise one element and maintaining quality of care becomes precarious.
Jenga is a game of physical and mental skill. Using real cases see how removing one block at a time may see even the seasoned clinician struggle to perform well. Welcome to Fiji Critical Care Jenga.

Direct download: Fiji_Critical_Care_Jenga.mp3
Category:general -- posted at: 7:00pm AEDT

The paediatric airway terrifies many of us: at the smaccMINI paediatric critical care workshop, Fran Lockie explores some real-life examples of airway challenges and considerations. He takes us through the concept of the "airway bundle" and how teamworking and communication is key to improving paediatric airway care, emphasising the concepts we can borrow from adult practice to offload some of our cognitive burden and outlining the key components of first-class post-intubation care, with pitfalls and pearls of wisdom from his experiences as a prehospital clinician. Phil Hyde follows on with the nuance of assessing paediatric ventilation, starting with simple interventions and exploring the factors that make big differences for children in respiratory distress.

Direct download: Fran_Lockie__Phil_Hyde_.mp3
Category:general -- posted at: 12:00pm AEDT

1