Author: Andy Neill / Code: / Published: 08/03/2016
Welcome to the RCEM CPD event in Leeds.
We’re here to give you updates and some pearls that we’ve gleaned from the conference.
One week after JAMA released their #sepsisredefined article, #RCEMCPD16 opened with a talk on sepsis.
Sepsis
Stuart Nutall started the session by reminding us that sepsis screening is important for diagnosis and risk stratification, and the ED plays a critical role in this.
The problem we face, as diagnosticians, is identifying when an infection is just an infection, and when it is sepsis, he pointed out, as the patients in severe sepsis, are easy to identify.
Different patients react in a range of ways to infection, John Butler continued, and we face the dilemma of figuring out which of them have a deregulated response by the host to infection.
The entirety of evidence is based around the severe end of the spectrum, John Butler reminded us, making the dilemma more confusing.
And what is the evidence anyway? Well, my confused colleagues, if you thought you had it all figured out, think again.
There is no magic bullet for sepsis, he said, as some hospitals around the country are just rolling out their sepsis nurses.
The key is to give the right antibiotic, he continued. Within the first hour, I hear you echo (no not the ultrasound). Well, actually, in 2015 Sterling et al performed a meta analysis which found there was no statistical evidence in patient outcomes when antibiotics were given at 1 hour Vs antibiotics given at 3 hours. It is good to point out however, that their meta-analysis also included some sub-optimal papers. (Yes, I know this conflicts with the Kumars 2006 paper which shows a decrease in survival by 7.6% for the delay of 1 hour of antibiotic therapy over the ensuing 6 hours).
If youre still debating the crystalloids Vs colloids issue, it is time to put that one to bed as John Butler ran us through the evidence, and well, it backs up crystalloids.
If you sweat the small stuff (sorry @neel_bhanderi), there is no proven difference between buffered solutions (like Hartmanns) and normal saline. (although I do really like buffered solutions)
Blood? No real evidence unless Hb less than 7. (TRISS Trial)
And just in case you are still using CVPs to guide fluid resuscitation, John Butler said this was a thing of the past, and now bedside ECHO and stroke volume variation analysers are being used to guide treatment.
Professor Mark Bellamy continued with a sobering talk about what ICU can add to the septic patient, reminding us that a number of patients who are on the unit do not return to their baseline fitness level and fewer than half of patients are back at work at 1 year after ARDS.
Do simple things, do them early and do them well, he said, as ICU only acts as a bridge of multi-organ support while initial therapy kicks in.
Resuscitation
Tim Harris followed with an excellent talk after the coffee break on PEs, reminding us that 95% of deaths secondary to PE are in the undiagnosed group.
For those of you up to a bit of revision, Indy Karpha wrote an excellent blog for our network.
It is safe to say that many of us are now up to date with the indications to thrombolyse for those patients with PE and shock (if you are unlucky enough to not have access to a CTPA to confirm your suspected diagnosis, use ultrasound to for RV overload). However, what about in submassive PE?
Thrombolysis will improve short-term hemodynamics, but not long term mortality. Plus there is the risk of bleed (no one wants to risk a haemorrhagic stroke unless there is a clear benefit.
But what about low-dose thrombolysis? Bleeding risk same as LMWH, and improves hemodynamics, he said. Dont want to take his word for it? Read the LITFL blog.
Louisa Chan followed with her excellent talk on improving cardiac arrest outcomes.
If you want to improve cardiac arrest outcomes: primary prevention, public education and pre-hospital intervention is the way forward, she said boldly to the adrenaline-driven EM crowd.
In the ED, we are at the end of the chain of survival in CPR, she pointed out.
Early recognition, early access to CPR and a defibrillator are important therefore we need to spend time educating/training the public on this.
(If you still do not know where your nearest defibrillator is, you really really need to download the GoodSAM app).
Still not convinced? Lets look at the stats: in Norway you have a 70% chance (25% more than in the UK) of getting bystander CPR, with a 25% of survival in Norway, compared to 8% in the UK, Louisa Chan explained.
If you want to make a difference to your patient at the end of the chain, this is what she suggested:
- Do the basics well (e.g. ETCO2, minimize off the chest time, focused ECHO)
- Invest in your team (e.g. feedback on performance, team leadership skills, debrief)
- Develop critical care expertise (do the RSI and protect the airway, start vasopressors, minimize hypocapnoea)
- Make friends with your cardiologists (1/3 of NSTEMIs will have a lesion identified if they have a coronary angio)
- Dare to dream (e.g ECMO)
Bob Jarman opened the following talk very adequately by wishing a happy 200th birthday to the stethoscope.
The US is now stepping in to help us optimize our clinical skills when using something so old still.
Here are his Golden Rules:
Trauma
After lunch, Caroline Leech convinced us that the way forward is to increase primary transfers to MTCs and re-think our secondary transfers. (Although is transferring from remote areas like Bangor this may be a problem, Rob Perry enlightened us).
Jon Jones continued with a very entertaining talk on lessons learnt from an MTC. A take home for me is that faint + trauma = probable bleed.
The closing session was a good debate on ATLS (advanced or archaic?) between Stephen Bush (Chair, ATLS UK) and Matt Wiles (writer of the editorial in Anaesthesia entitled Archaic Trauma Life Support).
Now, I will let you come to your own conclusions on this one, as there were good points on each side, but ATLS is not to blame for it being mandatory for some clinicians in the UK, although it is far from perfect.
And in an ever-changing evidence-based trauma situation, can we really rely on a 40-year-old course which is updated every four years?
Well leave you with that thought. Hope this was useful. Visit this site tomorrow for more updates from #RCEMCPD16
References:
- Kumar, A., et al. (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006 Jun;34(6):1589-96
- Sterling, S.A., et al. (2015) The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis. Crit Care Med. 2015 Sep;43(9):1907-15.
- LITFL Thrombolysis for submassive pulmonary embolus
- ATLS: Archaic Trauma Life Support? (2015) Anaesthesia. 2 015 Aug;70(8):893-7. doi: 10.1111/anae.13166.
- RCEMFOAMed: VTE in the ED