SMACC

In Critical Care we deal with death on a regular basis and although it seems an ‘on or off’ issue where you are either dead or you are not, nothing is more true. Not only physicians but scientists, philosophers, writers and theologians have been debating about the subject for as long as we have become aware of the concept of death.
To try to create order from chaos I divide the deceased in 5 categories:
The soon to be dead,
The reversibly dead,
The irreversibly dead
The walking dead (although this group I will leave to Hollywood to educate us about)
and the most curious group
The reversibly, irreversibly dead.
They are the patients of whom we think they are irreversibly dead, we stop our resuscitation efforts, and then they have return of spontaneous circulation. This is known as the Lazarus phenomenon and although many case reports have been published about this phenomenon over the years, presumably it’s only the tip of the iceberg.
In providing Critical Care we sometimes need to make immediate decisions on who’s dead and who’s not. Yet decisions about whether further treatment of patients is futile or not can only be made when one is aware of the limits of extremes in physiology that are survivable. Although not every patient should be treated up to these physiological limits, knowing these extremes can help in making an informed decision of whether to continue treatment.

Direct download: 02_Patricia_Gerritsen.mp3
Category:general -- posted at: 7:00am AEST

Since it was first described in 1763 Bayes' theorem has been applied, rejected and rediscovered in many fields. It's use in medical diagnostics is a relatively recent phenomenon. This talk will review the history of Bayes in medicine. We will then explore how Emergency doctors can practically apply these ideas in daily practice. How can we estimate pretest probability? How does Gestalt work? How can we use likelihood ratios to understand our diagnostic testing and the results? We will explore the threshold model of diagnostic reasoning and its application to patient-centred, shared decision making. Bayesian reasoning will be illustrated with common diagnostic dilemmas: subarachnoid haemorrhage, chest pain, cervical trauma, appendicitis, pulmonary emboli and tonsillitis.

Direct download: 01_Casey_Parker.mp3
Category:general -- posted at: 7:00am AEST

"Unexpected survivors" are those patients who, according to their injury severity score, should die of their injuries but they survive against the odds.. The years of conflict in Afghanistan saw increasing numbers of these grievously injured patients surviving to live a fulfilling life. How was this achieved? This talk will cover rewriting the ABCDE of ATLS, the delivery of self and buddy first aid, the use of novel haemostatics and tourniquets, rapid delivery of specialist pre-hospital emergency care by physician-led teams, AKA the Medical Emergency Response Team or MERT, with high quality pre-hospital interventions such as io access, blood transfusion, RSI, analgesia and how these lessons learned from the battlefield can be translated in to civilian practice. However, sometimes the very best we can do isn’t enough, because of the catastrophic nature of the patient’s injuries and a vital lesson learned is to how to cope when your best just isn't good enough.

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

Peer review is central to science and yet was not scientifically examined until the 1980s. Studies of peer review show that it is slow, expensive, something of a lottery, anti-innovatory, ineffective at detecting errors or fraud, prone to bias, and easily abused. So we have lots of evidence of its failings but no convincing evidence of its effectiveness. "If it was a drug it would never get onto the market." Attempts have been made to improve peer review, but these have not proved successful. The time has come for journals to abandon prepublication peer review and "let the market if ideas decide," which is what happens anyway.

Direct download: 04_Richard_Smith.mp3
Category:general -- posted at: 7:00am AEST

The exposure of fabricated numbers in published papers by eagle-eyed readers has been due to sporadic serendipity. I am going to describe a semi-automated method that you can take away with you to do some sleuthing. I am going to describe what I found when I analysed over 4500 papers.

Direct download: 03_John_Carlisle.mp3
Category:general -- posted at: 7:00am AEST

Medicine is powered by knowledge, but how do we know what is true and what is not? How do we deal with uncertainty in a setting where outcomes are not closely related to known variables? For example, although there are a few people who have survived jumping or falling from an airplane at high altitude (http://zidbits.com/2010/12/can-you-survive-a-freefall-without-a-parachute/), it is a rare event. Thus, a test to determine how to prevent death from such a disaster would only take a small number of participants to see if a particular method works. In contrast, when considering a medical condition where a large fraction of people might seemingly "recover" without treatment, such as tuberculosis (http://www.who.int/mediacentre/factsheets/who104/en/print.html), how does one determine if a treatment is effective? In this talk, I will examine how we gained knowledge about tuberculosis as an example of a disease where a combination of observational scientific findings and clinical trial data are linked to advance knowledge. I will also discuss other examples of clinical trials challenges and the solutions to these challenges.

Direct download: 01_Jeff_Drazen.mp3
Category:general -- posted at: 7:00am AEST

Medicine is powered by knowledge, but how do we know what is true and what is not? How do we deal with uncertainty in a setting where outcomes are not closely related to known variables? For example, although there are a few people who have survived jumping or falling from an airplane at high altitude (http://zidbits.com/2010/12/can-you-survive-a-freefall-without-a-parachute/), it is a rare event. Thus, a test to determine how to prevent death from such a disaster would only take a small number of participants to see if a particular method works. In contrast, when considering a medical condition where a large fraction of people might seemingly "recover" without treatment, such as tuberculosis (http://www.who.int/mediacentre/factsheets/who104/en/print.html), how does one determine if a treatment is effective? In this talk, I will examine how we gained knowledge about tuberculosis as an example of a disease where a combination of observational scientific findings and clinical trial data are linked to advance knowledge. I will also discuss other examples of clinical trials challenges and the solutions to these challenges.

Direct download: 01_Jeff_Drazen.mp3.mobile_low.mp3
Category:general -- posted at: 7:00am AEST

Sepsis is a difficult diagnosis to make, even in the hospital, where a plethora of tests are available to assist the clinician. However, the diagnosis remains a challenging one, due to the very nature of sepsis: a shadowy shape-shifter notorious for its ability to hide in plain sight, eluding early diagnosis and treatment. For now, even in-hospital, there is no test with perfect sensitivity or specificity for sepsis. This is especially true in the prehospital environment, where we must rely on tools we can bring into the field: physical exam, point of care tests (lactate/venous gas), assessment of end-tidal CO2, and ultrasound.

The aim of prehospital sepsis care is twofold: First, early diagnosis of cases ranging from early sepsis to septic shock. Point of care testing is essential. Lactate can assist in identifying occult sepsis and may also be used to prognosticate. Measurement of EtCO2 serves two purposes: first, in systems where point of care lactate is not available, there is evidence suggesting that EtCO2 is a reasonable surrogate for lactate. Secondly, for spontaneously breathing patients, EtCO2 provides an accurate respiratory rate, a vital sign that is notoriously poorly assessed. Respiratory rate plays a key role in both SIRS and SOFA/qSOFA criteria for sepsis, making an accurate count essential. Ultrasound should also play a pivotal role in prehospital sepsis management. Much has been made of the prehospital FAST exam; however, the ability of POCUS to gauge fluid responsiveness and cardiac function is far more useful. Assessment of the IVC may aid in determining the value of volume resuscitation by helping to identify patients who are responsive to volume and those who would be better served by early initiation of vasopressors. Similarly, assessment of cardiac function may prove extremely useful in selecting a pressor. POCUS may also assist in differentiating sepsis from other etiologies by identifying a source, such as pneumonia.

The second fundamental aim is treatment equivalent to that available in-hospital, with judicious administration of balanced IV fluids guided by POCUS and clinical assessment of fluid responsiveness, early pressors (including push-dose pressors during RSI), and early antibiotics, particularly where transport times are significant. When sepsis is diagnosed by EMS, a “sepsis alert” should be communicated to the receiving hospital, in order to facilitate ongoing early, aggressive care upon arrival of the retrieval team. Advanced prehospital diagnosis and treatment can produce dramatic reductions in mortality from sepsis.

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

Normally the endothelium plays a key role in maintaining homeostasis. Systemic and pulmonary endothelial dysfunction in the setting of critical illness results in multiple organ dysfunction. In this presentation, the following will be reviewed;

1) Evidence for the role of endothelial dysfunction in the pathogenesis of critical illness. Systemic endothelial dysfunction is implicated in the pathophysiology of sepsis and trauma, pulmonary endothelial dysfunction is involved in the development of ARDS.
2) Methods used to assess endothelial function in critical illness will be reviewed.
3) Mechanisms by which interventions may modify endothelial function will be discussed. The future potential role for treatments to modulate endothelial function in the management of the critically ill will be speculated.

In summary the aim of this review will be to highlight an important role for endothelial dysfunction in the critically ill.

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Direct download: Danny_McAuley.mp3
Category:general -- posted at: 12:00pm AEST

Bill Knight gives a superb 20 minute talk with the North American perspective on Organ Donation, brain death and management of the brain dead donor prior to organ donation. Bill is an neuro intensivist, pre-hospital and emergency physician from Cincinnati so he has a great global perspective.

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