11th Kongress der Arbeitsgemeinschaft fur Notfallmedizin

This month I was in Graz, Austria at the 11th Kongress der Arbeitsgemeinschaft fur Notfallmedizin. Although EM is not a primary speciality in Austria it is very clear that there are many clinicians who are interested in emergency care. There is always an English only track and so I would defo recommend a trip out here if you want to learn about EM in a wider Europe and without a focus on the Anglo/American/Australasian model that many of our readers are familiar with. I visited the conference in 2018 when I was really impressed at the enthusiasm for EM and the extremely talented clinicians I met there. It was absolutely wonderful to meet some of those clinicians again in 2024. Some were medical students when I was last there, and now they are driving EM forward across Styria and Austria. It reminded me of the early days of EM in the UK, and that was really inspirational.

I spoke on two topics. Firstly on the experience of moving from hospital to prehospital practice. Basically stating that it was quite tough, but certainly worth it. It’s really great to try a new speciality later in life. It’s sometimes tricky being a trainee once again, but it’s also fantastic. My second talk was on the impact of making a terrible error in clinical practice. That’s a talk I’ve developed over many years and it usually has good feedback as mistakes are something that happen to all of us, and so it’s a shared experience that is often difficult, but which can be managed.

I took a few notes as I went along which I will happily share below. I’ve taken many things away from the conference, but in particular the reinforcement in my mind that there is still a lot of work to be done in the understanding of the critically ill/injured patient. My apologies to those speakers that I missed making notes on, and to any factual errors below.

I’d also like to give a big shout out to Simon Orlob who has done amazing work in developing emergency medicine in Austria. He is a great friend of St Emlyn’s and it was absolutely wonderful to see him, his family and friends once again. It was also fantastic to see the Medical Corps of Graz at the conference once again. This is a really interesting approach to prehospital care with volunteer ambulances staffed by current and past medical students at Graz university. They respond as a team of four persons to all sorts of incidents and deliver advanced care. I don’t think we have anything like this in the UK, and I think some people will raise an eyebrow at medical students in ambulances. However, there are systems in place to support it, and it has acted as development tool for EM in Austria. You can read more about the corps here and also here. They have been active since 1890, which gives some idea about the incredible history of the region. Not many other organisations have been around for 130+ years!

Simon has asked me to pay due respect to all those who have developed this conference, and EM in general in Austria. Gerhard Prause shaped EM in Graz and Austria. I have met Gerhard several times and I can agree that he is truly an inspirational emergency physician who has led and shaped services that really make a difference to clinicians and patients. The conference and the interest in emergency medicine is his lifetime achievement and legacy. Without the oeuvre of Gerhard Prause there would neither be a community nor a conference. This years conference was the achievement of a team. Namely: Doris Dinbauer, Michael Eichinger, Michael Furtmüller, Raphael Haunold, Georg Kurtz, Simon Orlob, Gerhard Prause, David Purkarthofer, Mirjam Ribitsch, Gudrun Sommer, Johannes Wittig. I had the honour of meeting this team and they have indeed done a fantastic job.

The next conference will be in 2 years time and if you feel like making the trip, then please do. You’ll have a great time.

So……, in no particular order these are my notes from the conference from the sessions that I attended (between workshops, meetings and lunch!)

Theme 1. Cardiac arrest.

Robert Berg on individualised cardiac arrest management in kids.

Robert Berg talked on personalised cardiac arrest management with a focus on paediatric resuscitation, though nearly all is relevant to adult practice too. In fact I’d go as far to say that I think this is one of those areas where the research in kids is going to drive adult resuscitation practice (when we see more data of course). Bob presented a lot of data which was primarily from PICUs and therefore in patients who already had invasive monitoring. That makes it less directly relevant to EM/PHEM, but we are increasingly putting art lines in adult arrests too and so this is a really interesting area, and one which I am definitely shifting towards in practice.

1. A lot of resuscitation is not patient centric but is rather rescuer centric. What that means is that we often assess performance against whether we are achieveing the protocol, measuring things like CPR rates, depth etc. If we take a step back then we realise that these are not the best measures. Surely a more physiological assessment of our patients during arrest is the way forward.
2. Coronary perfusion pressure really matters if we want to achieve ROSC, and we almost certainly need >30mmHg
3. Haemodynamic directed CPR is an alternative approach to just looking at the nechanics. In Swine the outcomes of resus guided by invasive monitoring (art lines) rather than mechanical guided resus is much better from cardiac arrest. This is both in terms of ROSC, and neuro outcome (not sure how we measure neuro outcomes in pigs but I guess we can). Possibly due to the fact that CPP is linked to MAP (obviously), and good cerebral perfusion is very likely a good thing.
4. Data for kids suggestst that target DBP > 25mmHg in infants and >30mmHg in kids >1 year is where we should be aiming for
5. The data presented here is another strong argument for the use of intra-arterial monitoring in cardiac arrest.
6. There is significant variability in the response of individuals to adrenaline in cardiac arrest, and this makes a big difference to outcome. Those that respond have much better outcomes. So can we identify non-responders and do something different? Might they be the ones who do better with Vasopressin???
7. PicqCPR study showed showed survival much better if able to get DBP above target in kids with Optimal DBP of 34mmHg
8. More work needed, but pulse oximetry traces may be linked to DBP and could be a non-invasive marker of this.
9. Summary
   a. Physiology directed CPR better than mechanically directed CPR
   b. Aiming for DBP targets works in kids
   c. It could work in adults
   d. Maybe ETCO2 or SaO2 plethysmography may be used in the future as markers of coronary perfusion without the need for invasive monitoring.

Sheldon Cheskes on the DOSE-VF study. @DrCheskes

Sheldon was the chief investigator for the DOSE VF trial which is arguably the most important paper in cardiac arrest management from the last few years. It was great to learn more about what it really means. He was accompanied by his fabulous with Shelley McLeod who is also part of the research team and a fellow Professor

1. We have covered the trial here and please have a read. IN addition Sheldon added a few pearls of wisdom that clarified a few elements.
2. Refractory VF is defined as a patient who remains in VF after three shocks, that’s because survival drops off a cliff after three shocks
3. Lots of patients who get shocked out of VF go back into VF. A main part of the DSD strategy is about stopping people go back into VF (not just getting them out of it). It’s likely that those patients who go back into VF have some area of the heart that has residual VF in it and that then recaptures the rest of the heart and the revert back to VF.
4. In DOSE VF the patients had to be in continuous VF/VT. So if they went into other rhythms along the way they were excluded, so this was really those in continuous VF.
5. The trial was stopped early because of COVID. A sensitivity analysis showed same result pre and post pandemic, so the result was unlikely to be affected by those patients who also had COVID at the time. Sheldon is open about the issues of stopping early and recognises that any trial stopped early may overestimate the impact.
6. There is a 30% drop in impedance between AP and AL pad positions. One of the reasons why changing positions/DSD may work.
7. Some really interesting secondary analyses
   a. In terms of timing for DSD the outcomes were better the closer the shocks were given (ideally less than 75mSecs. This is secondary analysis though so hypothesis generating for now. Paper imminent on this in the journals.
   b. They have looked at the waveforms from the study and it seems clear that in refractory group there are two types of patients. Those that go back into VF, and those that never really come out of it. The data shows that if you don’t fully come out of it with a shock then you have zero survival in AL paddle position. DSD and vector change have a much higher likelihood of achieving full defibrillation. In other words a lot of the time when we think we have defibrillated the patient we have not!
8. As I said at the beginning a game changer of a trial for me. My remaining question is whether we should start with AP pads as the data suggests it might be better. However, we don’t really have the data for that (yet) so only hypothesis generating.

Reflections on double sequential defibrillation – Sheldon Cheskes from live on Vimeo.

Ewald Kolesnik on drone delivered AEDs

Ewald is a cardiologist who is working on the use of drones to get AEDs to patients as soon as possible. This was very relevant after Sheldon’s presentation as there is n o doubt that early defibrillation makes a massive difference to outcome.

1. Drones can get AEDs to patients
2. Interestingly the use of drones in warfare has arguably accelerated the technology and understanding of how they can be used in clinical practice.
3. The concept has been proven in Scandinavia, they are faster than other methods of transport, they can fly at night, can fly beyond line of sight, and can even fly autonomously. So there is clearly potential here.
4. In Austria the TREATED study demonstrates feasibility.
5. In Sweden it’s been tested for real and Schierbeck et al EHJ. Results not that impressive as drones not always faster than EMS and just one successful defib prior to EMS arrival.
6. The paradox is that the best area for drones is in remote sites, which is where you have the fewest arrests. There are alos more difficulties (legal, obstructions, wires etc.) in more populated areas.
7. For now, the legal difficulties of flying drones in densely populated areas are a real barrier to innovation, but watch this space.

Gabriel Putzer on head up CPR

Gabriel talked on the use of head up CPR in cardiac arrest. We covered some of the trials on this on the blog here, and we wer eprety unconvinced at that time. However, interest continues in this technique in some centres.

1. Head up CPR is thought to promote venous return by increasing the vacuum effect during recoil in the chest compressions.
2. In theory that should increase cerebral blood flow by increasing MAP and decreasing ICP
3. It has been trialled in combination with an impedance threshold device, but only in observational trials.
4. Porcine models suggest that it might work in terms of CPP, but no change in Pbt02 or rSO2. So maybe the physiological impact is questionable. In other words head up CPR may improve pressure, but not influence flow. And it’s flow that’s important. In some porcine models Pb02 and rSO2 is worse in head up position.
5. CABARET survey worth a look in the UK which showed that no-one is using it here.
6. Bottom line for me appears to be that the evidence for head up CPR is pretty weak at the moment and there are a number of COI issues around the development. Does not seem to be ready for prime time and we need more data.

Simon Orlob on the use of AI/Machine learning in cardiac arrest research. @simonorlob

Simon is a driving force of the conference and one of the main reasons why I made the trip to Graz. He’s done amazing work on improving emergency care in Graz and in Austria. In this session he was exploring how big data might give us more insights into resuscitation science.

Also noting that this presentation had the best slides of the conference. The apples and pears sequence (you’ll have to invite him to speak to find out) was awesome.

1. We have loads of data, especially from things like defibs and monitors, but we are not using it well at the moment. The information we use is just the tip of the iceberg of what is out there, recorded and stored.
2. Computers are really good at handling large amounts of data, but they need guidance in determining what is important and what is not.
3. There is actually a lot of data recorded by the machines we use, but that is often then subjected to algorithms that interpret the data for us. Quite a few of those algorithms ‘dumb down’ the data to make it more palatable, but we may be losing some really important stuff.
4. Taking data from something like a defib in cardiac arrest can give us insights into the quality of CPR, but the process to get to data that is meaningful is really tough. A lot of the data still requires processes (often previously involving laborious human tasks) to clean and interpret the data before it can make sense in clinical research. That process can be automated to some extent which brings us closer to getting important data back.
5. Simon introduced te concept of chest compression fraction which is basically a measure of how much time is spent with high quality chest compressions. `This data can be available but is not associated with outcome. However, long pauses are potentially associated with poor outcomes. We can identify these facts through examining regularly recorded data in very large databases.
6. I think the key point here was that when dealing with the vast amount of data that we can get in emergency care from devices such as defib/monitors then we need a collaborative approach with clinicians, engineers and mathematicians to make that data work well, and subsequently influence patient care. That’s certainly happening in Europe and it’s going to be really interesting to see how that develops in the next few years.

Theme 2. Trauma

Zane Perkins on traumatic cardiac arrest. @ZBPerkins

Zane spoke on the real world experience of traumatic cardiac arrest. A really interesting data on the role of thoracotomy in prehospital care. I’ve seen some of this before, and have followed the evolution of the management of traumatic cardiac arrest, but this was a more in depth insight into those areas where we as clinicians can really make a difference. The spoiler alert is – time really matters.

1. The right time to do a thoracotomy is not when the patient has bled out. You need to do it before then if you want your patients to live.
2. Lots of experience in London with regard to traumatic cardiac arrest, but still uncertainties of what to do.
3. Overall survival of penetrating cardiac injury is about 10%. So not high, but not insignificant and comparable to medical arrest.
   a. In London the experience is that it takes on average 11 minutes from injury to cardiac arrest from penetrating cardiac arrest.
   b. In London those bleeding to death by exsanguination, then 50% arrest within 15 mins.
4. Bottom line is that if you want to intervene in traumatic cardiac arrest, then it has to be done prehospital
5. Four steps for thoracotomy as taught to HEMS team in London (we agree). Also do bilateral thoracostomies first.
   a. Clamshell
   b. Open pericardium
   c. Repair wound(s)
   d. Restart the heart
6. Every minute counts in tamponade
   a. No survivors after 15 mins
   b. 25% survivors in London.
   c. 50% survival if done within a minute of arrest
   d. Aim for thoracotomy within 10mins of cardiac arrest (ROSC rate 70% and survival of 40%)
   e. Many survivors with asystole as presenting rhythm with a tamponade (so asystole is not a single reason to not do a thoracotomy)
7. Different story for exsanguination
   a. Stop the bleeding is so important. Aggressive approach to haemorrhage control. Every ml counts.
   b. Give blood if you have it. If you don’t have blood give fluid. If you run out of blood and need more fluid give the fluid.
   c. Outcomes for arrest from exsanguination are much much worse.
   i. Overall 1.9%
   ii. None after 5 mins of arrest
   iii. No blunt trauma survivors
   iv. All survivors had PEA with an organised rhythm on ECG when initially in arrest (different to tamponade)
   d. So you have to avoid the patient getting to arrest, and this means intervening earlier. Don’t wait for your patient to arrest.
8. The two factors that predict outcome in TCA from logistic regression analysis of London HEMS data.
   a. Time from arrest
   b. Tamponade present

You can watch the presentation here.

Frank Chege talked on ‘The Fluffy Stuff’

This was about working with patients and families to improve care. Frank is the patient liaison nurse with London HEMS and has 11 years experience in the role. It’s clear that he is an amazing resource for the service. This was a wonderful presentation and fantastically delivered. A really great speaker and a recommendation from me to get him to speak at your conference. You can watch the presentation here.

1. When clinical care finishes it’s not the end. For families and patients it’s often just the start of a long and difficult process.
2. Recovery is not linear. Supporting families and patients may be needed for a long time and the amount of support will change over time.
3. We are getting much better at improving survival, but there is always a human at the centre of this. We must remember that and ensure that we treat the person and not just the disease. Patients should not be defined by their disease.
4. If we work in PHEM/EM it is possible to consider the abnormal to be normal. We see a lot of very abnormal events, that are once in a lifetime events for our patients and families. Keep that in mind when speaking to patients.
5. Maintain hope for our patients. It’s a balance as we need to be realistic when things are not going well, but also offer hope if it’s possible. A strong theme from Frank is how language matters. It’s clear that he has spent a lot of time talking to patients and families, and that in those conversations what we say really matters. Words that we commonly use, even something like ‘END’ tidal can have connotations that may be unintended.
6. It’s important to be honest with patients. In things like spinal cord injury, they probably know what’s wrong and you can be honest with them. Their initial reaction will obviously be difficult, but that’s where maintaining hope and following the patients up matters.
7. The key message across Frank’s talk is that language really matters. We should train for this and sadly just training with mannikins does not help this. One of the many reasons why we use live actors on ATACC courses.

https://vimeo.com/user126885195

Theme 3. Sepsis

Judith Martini (from Innsbruck) on the management of the microcirculation in sepsis.

The main point in this talk is that we really need to talk about flow and not pressure in the management of septic shock. Of course it’s tricky to measure the microcirculation which is why we measure the macro-circulation (usually by looking at blood pressure), but that really does not tell us what we need to know.

1. Capillary collapse: In low flow states we get capillary collapse and depressurisation of the capillaries. The impact of this is damage to the glycocalyx that changes vascular permeability and a loss of fluid into tissues. At the moment there are no specific therapies but lots of research ongoing.
2. O2 exchange in the microcirculation: We are probably familiar with the simplistic models of this from med school, but the reality is it’s quite different and complex. The vessel walls are significant consumers of oxygen. Really interesting to see the adverse impact of vasopressin on peri-capillary oxygen concentrations.
3. Fluids choice and shear stress: The viscosity of fluids can impact the capillary wall through inducing a greater shear stress. Higher viscosity fluids may increase capillary perfusion through the release of nitric oxide into the smooth muscle as a result of that shear force!
4. Surviving sepsis recommends adequate fluid resus I(30ml/Kg/Hr) and pressure (MAP of 65mmHg).
5. The future may be in measuring microcirculation and titrating fluid and vasopressors accordingly. We are not there yet though and a recent trial demonstrated that it can be done, but no survival benefit seen.
   a. Direct assessment of microcirculation in shock: a randomized-controlled multicenter study. 2023 Jun;49(6):645-655. doi: 10.1007/s00134-023-07098-5. Epub 2023 Jun 6.
6. Mottling scores may help in assessing microcirculation.
   a. Merdji, H., Bataille, V., Curtiaud, A. et al. Mottling as a prognosis marker in cardiogenic shock. Ann. Intensive Care 13, 80 (2023). https://doi.org/10.1186/s13613-023-01175-0

Marie Jessen (from Aarhus) on Early Fluid Management in Sepsis.

A great intro that stated that this is hard, and there are no easy answers, but we should understand the complexity. You can watch the presentation here.

1. Key points
   a. IV fluids are drugs
   b. Fluid responsiveness is tricky to do
   c. Can the patient drink?
2. No real difference between normal saline and crystalloids
3. Gelatins and starches increase mortality
4. Albumin still up for debate, but likely that there are subgroups who will benefit.
   a. Note recent post on decompensated liver failure where albumin does show a benefit
   b. Maybe after large amounts of crystalloid or in conjunction with vasopressors but more work needed to define this
5. Restricted fluid approaches have been tested and we can certainly run patients with less fluid.
6. Monitoring the impact of fluid resuscitation requires a combination of
   a. Clinical exam (including passive leg raise test)
   b. USS assessment
   c. Regular test boluses and look for response
7. Don’t underestimate the potential benefits of using oral fluid resuscitation. Orally or via NG tube.
8. The key to fluid management is repeated clinical review and assessment.

Adrian Wong on sonography in sepsis. @avkwong

Adrian was due to join us last night but had a most amazing train journey that went wrong. Not sure what time he got in, but he was his usual awesome self by the morning.

1. Everyone who deals with severely septic patients should be able to use USS to at least a limited degree (and they need the training to do so).
2. Evaluate and Diagnose
   a. Check out Jonny Wilkinson site for a review of how USS can assist the ABCDE assessment
   b. Learn the RUSH examination
   c. Learn the BLUE protocol for the assessment of lung pathology
3. USS so much better than CXR
   a. More sensitive
   b. More specific
   c. Most importantly – you can repeat it and re-evaluate easily. Several machines now allow you to record a protocolised examination that is then stored and can be used for serial comparisons. So USS, then do something, then another USS and compare and contrast.
4. IN CVS management
   a. Spectral tracking may pick up abnormalities early (but more research needed)
   b. Consider the https://www.pocus101.com/vexus-ultrasound-score-fluid-overload-and-venous-congestion-assessment/VEXUS score for assessing venous excess using USS. Looks at hepatic vein, portal vein and renal vein flow to assess venous congestion. This has real potential, but the clinical importance of the results and what we do about it needs more clarification and trials to evaluate.
5. Key message is that USS is a tool that we can use to support decision making in fluid management, but it is just one component of decision making. We should use it in conjunction with other findings. We should treat the patient, not the image, but good images and interpretation can help the patient

Theme 4. Research, teaching, patients and errors.

Sheldon Cheskes spoke on errors in research.

He clearly has a huge amount of experience in research and like anyone who works in academia that journey is a tricky one with many successes, but also challenges.

1. Mistakes are inevitable in research, and that’s OK. What we need to do is learn from them and share that learning with others such that we can all get better.
2. Sheldon started in EM as a clinical emergency physician with no research, coming to it late, probably after 20 years of practice. This is interesting to me as in the UK it often feels that academic careers need to start in the womb and that it’s not possible post qualification. I agree with Sheldon that there are still opportunities for clinicians to get involved in research later in their careers and there are many great examples of this in the UK. Bottom line – you can always get involved in research.
3. Sheldon advocates for developing a niche for research. I hear this a lot, and especially from North American researchers, and increasingly the UK and Europe too. Developing a niche may be tricky, but getting an awesome mentor to support and cultivate your career is really vital. This chimes with a lot of what I’ve talked about this conference, in that the culture of colleagues is so important to success. If you have a great culture that supports research then you’ll have great times, and patient care will no doubt improve.
4. You need a mentor who is engaged and willing to work with you, and even better than that build research networks for junior clinicians coming through. One of the most exciting and satisfying things to do as an academic is to develop the next generation.
5. Most trials involve building relationships and often bridges with other organisations. This takes time and effort and commonly cannot be delegated.
6. Funding is a tough gig. Especially for emergency care, but it can be done, and there is no reason why we cannot work with industry so long as all parties are clear on the ground rules around publication, oversight and design.
7. Sheldon mentioned his wife many times in his presentations. They are clearly an amazing team. Shelley Mcleod is a PhD professor and trials methodologist and is a key member of the DOSEVF team and other studies. It was wonderful to spend time with Shelley and Sheldon, and all the other delegates and speakers in Graz.

Kasper Lauridsen.

Kasper talked on learning from mistakes in teaching. A personal perspective on errors and educator development.

1. It’s important to try and teach in a safe space where learners can be try things out, reflect, make errors and share success and failure. This is more than just saying ‘this is safe’. It’s more about a culture that actually demonstrates this. A safe learning environment is one where everyone involved cares.
2. Ensure that your content is relevant to learners, which means that you have to get into their heads and understand what’s important to them. If it’s not obviously relevant, find a way to make it so. If leaners are not engaged in the topi, they just won’t be engaged at all, and that means it will be a waste of time for learners and tutors alike.
3. It’s really important to keep your klearning objectives in mind when designing and delivering teaching programs. Kasper talked about how they changed their mode of CPR training, and this was educationally sound and well received, but it made no difference to actual performance in practice. So always keep the end goal in mind and don’t just rely on educational theory in terms of delivery.
4. In terms of debriefing then the learning conversation model works well and is better than the Pendleton sandwich (which is somewhat unfairly maligned in my opinion)..

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