Welcome to the St Emlyn’s Monthly Medical Podcast, your go-to source for the latest insights, developments, and discussions in emergency medicine and critical care. Each month, Simon and Iain will bring you in-depth analysis, evidence-based practices, and practical advice to enhance your clinical practice and professional development. Whether you are a seasoned practitioner or just starting your journey in the field, our podcast aims to provide valuable knowledge and foster a community of learning and support.
In this round-up of February and March 2024, we talk about a wide range of issues relating to emergency medicine, including decompensated liver disease, mechanical CPR, frailty, global health and more
Listening Time – 24:42
Mechanical vs manual CPR for inhospital cardiac arrest
A recent study published in Resuscitation examined the outcomes of mechanical CPR (MCPR) versus manual CPR in in-hospital cardiac arrest cases. Despite the logistical advantages of MCPR, such as freeing up personnel and consistent compressions, the study revealed a lower survival rate to discharge compared to manual CPR (11.8% vs. 16.9%).
While mechanical CPR offers certain operational benefits, the lack of evidence supporting improved outcomes suggests that high-quality manual CPR remains preferable in most in-hospital settings. This finding aligns with practices in regions like Victoria, Australia, where manual CPR is prioritized.
Conference – Top Resus papers for The Big Sick 2024
We review the top resuscitation papers discussed at The Big Sick Conference 2024. Key topics include airway management, with evidence showing increased mortality from ED intubation versus OR intubation and improved first-pass success with video laryngoscopy. Haemorrhage control is debated, with studies questioning the efficacy of REBOA and cryoprecipitate. In cardiac resuscitation, alternative defibrillation strategies show promise for refractory VF. The post highlights the importance of continued research and careful application of findings in clinical practice.
Conference – CPD Update for UoT CPD conference Whistler 2024
The blog post on St. Emlyn’s provides a CPD update for the UoT CPD conference in Whistler 2024. Key topics include:
- Airway Management:
- Freund study: “Watch and wait” approach for comatose poisoning patients reduces intubation rates.
- Video vs. direct laryngoscopy improves first-pass success rates.
- Mac 3 laryngoscope blades show better first-pass success and view quality compared to Mac 4.
- Resuscitation Techniques:
- Smaller ventilation bags may reduce return of spontaneous circulation.
- REBOA’s effectiveness in trauma is questioned.
- CRYOSTAT-2 trial: Cryoprecipitate showed no significant benefit in major hemorrhage protocol.
Decompensated liver disease in the ED
Decompensated liver disease, often seen in emergency departments, is becoming increasingly prevalent. This condition involves chronic liver disease patients experiencing acute failure, characterized by jaundice, ascites, and hepatic encephalopathy. Notably, identifying the most specific sign, asterixis (the hepatic flap), is crucial.
The key to managing these patients lies in aggressively searching for underlying causes such as infections, GI bleeds, and alcohol withdrawal. Spontaneous bacterial peritonitis (SBP) is a common and severe infection in these patients, often presenting with minimal symptoms. Performing ascitic taps and administering appropriate antibiotics are essential steps.
There’s a need to shift our mindset from seeing these patients as futile cases to recognizing opportunities for intervention. Effective management includes addressing AKI, hyponatremia, and ensuring prophylactic anticoagulation to prevent venous thromboembolism. By focusing on comprehensive care, we can significantly impact patient outcomes.
Are long waits in the ED lethal for elderly patients?
A study from France investigated the effects of long waits in emergency departments on patients over 75. The findings were stark: those who stayed overnight had a significantly higher mortality rate (15.7%) compared to those admitted to wards before midnight (11.1%). This highlights the critical need to reduce prolonged stays for elderly patients.
The study underscores the importance of minimizing wait times in EDs to improve outcomes for elderly patients. This involves not only managing patient flow more efficiently but also addressing systemic issues that contribute to delays, such as resource allocation and staffing.
The Global Health Map
There’s an initiative to create an interactive map for connecting UK emergency care practitioners involved in global health. This map, hosted on the RCEM website, displays the global health engagements of UK colleagues to promote collaboration, mentorship, and sustainable global health efforts. Users can share their projects, filter results by type of work, and connect via a central email. The project encourages participation to enhance the network and improve global health work efficiency.
Podcast transcription
Welcome to the St Emlyn’s podcast. I’m Iain Beardsell, and I’m Simon Carley, and this will be our monthly update for both February and March. We’re going to cover two months, not least because hopefully regular listeners to the podcast will have heard our bumper evidence-based issue where we covered 20 papers, and that did really make up the bulk of our February output. But we’ve a few other things to talk about. And not least, Simon, you’re on your travels again. You’re at another conference today.
I’m at the Tri Service Emergency Medicine Conference, which is the military arm of emergency medicine in the UK. Fantastically interesting with a wonderful group of trainees and trainers, really enthusiastic. One thing that’s special about this one is because it’s the military conference, they can get everybody together in the same place at the same time. It’s a real buzz. It’s orders, isn’t it? You will be there. Yes, that’s how it works. Good times and lovely to be a part of all of that. Let’s crack on. We’ve got lots to talk about.
Simon let’s talk about a subject that you did a talk on when you were at a conference across in Canada about decompensated liver disease. Perhaps a topic we may not give quite enough attention to. I’m not sure. I think when you were writing this, I remember you saying how much you picked up from doing it. There’s a lot to learn here, isn’t there?
The topic that was given to me in conjunction with David Carr, a great friend of the podcast, runs the Toronto Emergency Medicine updates conference in Whistler. Absolutely superb conference. I know it’s in a ski resort, and people say everybody might be there for the skiing. Absolutely not. Really enthusiastic educators, really enthusiastic learners. A timetable allowed a couple of hours on the slopes, but then right into the evenings and early starts, really worthy effort if you can get over there and a wonderful place to go.
We picked decompensated liver disease because my feeling was that it’s a condition that we see in the emergency department and we’re going to see a lot more of because if you look at the data, the number of people with decompensated liver disease is really going up for a number of factors. It’s one of those things where I always looked at it and thought, well, okay, just refer medics, we don’t really do that much, and you think, well, it’s a bit of an end stage and we’re not doing very much about it. But I think this kind of changed my view.
This is about decompensated liver disease, patients who’ve got chronic liver disease who then decompensate in acute failure. It’s not acute failure of disease on its own from something like hepatitis or drug ingestion. This is the group who’ve already got chronic liver disease. That’s very much on the up. We know about it from things like alcohol use, which will be dependent on where you are in the world. Non-alcoholic fatty liver disease, often related to obesity, is definitely on the up in high-income nations. In other parts of the world, less so in high-income nations, you’ve got the viral hepatitis, the chronic viral hepatitis that can cause problems. Whichever way you look at it, we’re going to see more of it, and that’s a problem.
If you present with decompensated liver disease, characterized by jaundice, ascites, and hepatic encephalopathy, you need to remember the most specific sign for hepatic encephalopathy: asterixis, the hepatic flap. If you spot that in your patients, there’s really high mortality, and we need to aggressively treat this group of patients. In terms of assessment, you’ve got the clinical assessment, ultrasound is good for looking for things like ascites, and then a whole range of blood tests that you probably know.
The key thing is the change in mindset. We don’t just see these patients as decompensated liver disease; we see these patients as something what has caused this. Aggressively looking for what has made this person with CLD go into this decompensated state. A couple of things you really need to look for: infection. It could be infection of any cause. Most patients with chronic liver disease do have a degree of immunosuppression, so they’re likely to have all the problems of that. They’ll have infections, but they’ll be difficult to find. Good screening: bloods, chest X-ray, urine, all those kinds of things.
In particular, the risk of this patient getting spontaneous bacterial peritonitis, because by definition, they’ve got ascites in this group. The classic for SBP is abdominal pain, high fevers, and signs such as that. But a lot of them don’t have it. About 30% of patients with SBP don’t have a fever and don’t have abdominal pain. The lesson from that is if you’ve got a patient with decompensated liver disease, do an ascitic tap. You need to get the fluid off, and you need to send it to the lab, and you need to find out what’s going on. If you can’t find any source, then you still have to be thinking this patient’s probably got spontaneous bacterial peritonitis anyway, and treat it. It’s really important.
Other things you need to look for: GI bleed is a common precipitant with or without varices. Look hard for GI bleed evidence. You need to do a PR, you need to look at what’s the vomited if they’ve been vomiting, look at what the urea is on the blood. Specifics around that are giving them platelets if they’ve got less than 50, reversal of the anticoagulation if they’re on that, and the general management of the bleeding patient. But not tranexamic acid, because if you remember the HALT-IT trial, which we’ve covered on the blog before, showed no benefit and perhaps potential harm if you give tranexamic acid to this group.
Other stuff like alcohol: do the CIWA score, manage their decompensated alcohol withdrawal if they’re a boozer. Other management: they’ve often got an AKI and often hyponatremia, so you need to manage that. You can get fooled on the assessment of AKI because a lot of these patients, particularly alcoholics, will run low creatinines, so you may not trigger that this is an AKI in your patient if you just look at the machine learning type stuff that you get off your computer monitor. Stop all the diuretics, stop the nephrotoxic drugs, and use albumin. Albumin’s been shown in a number of RCTs to improve prognosis in this group of patients, so that’s a good thing to do.
Management of the encephalopathy: make them poo. Lots and lots of laxatives. It probably removes the amount of ammonia in the blood, which is a cause of the encephalopathy. Have a really low threshold for CT in this group. You don’t want to miss the fact that the reason why this person’s gone off is because they’ve got a subdural, and they are much more likely to have a subdural.
Finally, in terms of treatment, one which is often missed for good reason: these patients are often thought to have liver disease, decompensated, low platelets, omit the low-molecular-weight heparin as prophylaxis, and that’s absolutely the wrong thing to do. They are extremely prone to venous thromboembolism. Even if the platelets are low, even if you think they’ve got a bit of a coagulopathy, you should make sure that these patients are appropriately anticoagulated when you admit them to the hospital.
I thought it was quite a lot to learn, particularly around the SBP, always doing the paracentesis tap if it’s there, and particularly about the VTE stuff, which is a bit counterintuitive, and particularly about the use of albumin early in these very decompensated patients, which has a big impact on mortality. It’s not a disaster. If you can get the patients through this, there are things that you can do to make them better: liver transplantation as an option, a range of new drugs on the market or in research that may be helpful for them, and of course, you can manage the alcohol. Lots of what we can do in the emergency department, we should be driving.
I think that’s probably the biggest message for me: sometimes we can judge patients from why they have their disease. Our hepatologists have a big push for us to stop calling it alcoholic liver disease. How many other diseases get defined by what causes it? We don’t just call it smoking cancer, do we? We do label people, and we should be more open to the fact that whatever the cause of your chronic liver disease, if you’re having an acute decompensation, we need to do something about it. We need to put aside the prejudices of who’s responsible and why that might happen. It’s that triad of jaundice, ascites, and hepatic encephalopathy. Lots of things can precipitate these acute decompensations, and it’s about aggressively looking for the cause. Remember that spontaneous bacterial peritonitis can exist with very few signs, and that may well be the most likely thing you’re looking to get.
Simon, do you do ascitic taps in the emergency department? I do. Do you think it’s something we should be doing? Yeah, absolutely. If you put an ultrasound probe on, you can see where there’s fluid. An ascitic tap is not a complex thing to do. On our system now, you can go to a button and say, print off the stuff which I need to send for an ascitic tap, and you can get it off the patient and get it away. I can’t see any reason why we shouldn’t be doing that in the emergency department. I would encourage my colleagues to do so. It is one of those skills that I think we learn when we’re doing medicine and then we sort of put to someone else. This idea that if we refer a patient, everything will happen. My experience currently is you refer a patient, and some things might happen, but they may be waiting a long, long time. Referral is not the end of the process for a patient who’s got something like this. Referral is just part of the process, and we need to keep the treatment going. We don’t want these patients just diagnosed as acute decompensated liver failure and think it’s a medical problem for the medical team to sort out. We need to be aggressive, think about what’s causing it, and there is a high mortality. Everyone deserves a second chance, regardless of how they’ve ended up where they’ve ended up. It’s not up to us to judge and make decisions based on our own prejudices about why that patient has ended up with us in the emergency department. We need to give them the chance to have decisions made further down the line, and it’s clearly something where we can make a difference.
Some simple messages there, I think. I do always enjoy the idea of lactulose for a confused patient. I quite like the biochemistry, the bit about ammonia binding and all that stuff. All you need is a few key facts, and you can look after these patients well. Did it go down well? The talk in Canada, did people think that there was something they knew about, or was this old information? I think you’ve encapsulated it well. There are tips about what you actually do, but much more important is the attitudinal stuff. It’s about taking this as a group of patients where we can make a difference from a group of patients who we feel that we’re a little bit futile. That, to me, is the game changer with this group. Open mind. Go and look after every patient with an open mind, and you’ll make a difference.
The next post in February, Simon, was from Anisa. This was one of those posts pointing you in the direction to connect with other individuals. One of the great things about online learning and social media is that we’re able to connect with other people. If it hadn’t been for me and you connecting via the SMACC conference many years ago, which we got involved in via Twitter, this would not be happening. There are many ways we can connect, and there are undoubtedly global challenges going on. It’s great that we’ve got Anissa there to put that information out there, but this is worth a read. There are lots of clickable links, lots of ways in which you can get involved. This is about us looking a little bit beyond our own boundaries and seeing what we can do to help. It’s a nice little topic, and it links in with the work that Archim’s doing and the global emergency care collaborative around global health. It’s an area that a lot of people want to develop. You want to do it in the right way with the right people and the right organizations. The lone wolf going off and doing stuff on their own isn’t the way forward. To do this in a managed way with people who have got experiences is the right thing to do. If you’re thinking about this in the early part of your career, getting involved in the global health map and making those links is a fantastic way to find a mentor, coach, or sponsor who can develop that part of your career. Strongly encourage if you’re interested to give that blog a look. Anissa, who we know well, is absolutely fantastic, and I’m sure you can contact her for more details.
The next post is a journal club. This is into March, and this is a paper reviewed by you, Simon, and this is a hot topic in many ways. This is probably a reminder to challenge some of our accepted beliefs that mechanical CPR is brilliant. The evidence really isn’t there, and it’s worth working out whether this changes our mind. This is a paper from Resuscitation: Is Mechanical CPR Associated with Better Outcomes for In-Hospital Cardiac Arrest? It’s important that we’re talking about in-hospital here. We often talk about pre-hospital papers, but this is in-hospital. There have been previous posts and evidence that suggest there are some benefits that are obvious to us, such as you don’t get tired, and you can replace a battery, not a human, freeing other people up. But actually, outcomes from reviews and SGM and other people haven’t really proven that. Simon, does this change where we are with this idea?
A lot of the previous evidence has been in pre-hospital care. Studies like Paramedic 3, a big RCT of mechanical CPR, showed no benefit, but it has got into practice. We use it in our practice because it’s considered to be an extra person. If you have to dispatch four people to cardiac arrest, you can replace one of those people with a Lucas device or some other form of mechanical CPR. From a logistics point of view, there are clearly advantages because the trials showed no benefit but no potential harm. They’ve also been used in the hospital environment, which is interesting because we often have lots of people in the hospital, so do question whether or not it’s of value.
This is an interesting study. It is retrospective, from routinely collected data from 153 hospitals in the US, which is good because it gives you a lot of patients to look at. In fact, there’s over 111,000 patients in this study, of which 2,232 received mechanical CPR. Essentially, they looked at the survival to discharge, whether or not you had mechanical CPR or just normal CPR. Observational retrospective studies come with lots of caveats and cautions, and generally, when we talk on the blog, we say that kind of study is hypothesis-generating rather than definitive.
What they found is if you got mechanical CPR, your survival rate till discharge was 11.8%, compared to 16.9% in the manual CPR group. Quite a difference, which even when they did propensity score analysis to adjust for patient factors, was still clinically and statistically significant. They also did a sensitivity analysis and still found worse outcomes if you had mechanical CPR. You might say we should stop doing this in the hospital setting. But as always, there are caveats, and the big one is that to get the mechanical CPR onto the patient often takes time, whereas manual CPR is done straight away. If you had a very short arrest time, it might be that you only had manual CPR because the mechanical didn’t turn up on time. They tried to adjust for that and still found differences, but you must be cautious about such factors influencing the results.
For me, it says that I’ve not seen any evidence that using mechanical CPR improves outcomes. That’s pretty universally accepted. This tells me they didn’t find any benefit in the hospital either, and it might be a disadvantage. In terms of my practice, I can’t see a major benefit for using mechanical CPR on the wards outside of a clinical trial at the moment. If a trial comes forward and the results change my mind, I’ll be happy to see them. It’s really interesting. If you survey colleagues and ask which is better, mechanical CPR or human CPR, they would almost certainly go for mechanical, but the evidence doesn’t point in that direction. I spoke to colleagues from Australia in Victoria, where they have one of the best outcomes from cardiac arrest in the world. They don’t use mechanical CPR at all. They believe it’s better to have high-quality, well-trained manual CPR in the pre-hospital setting. Association isn’t causation, but it would appear to be not a disadvantage in Victoria.
If you want to read that paper yourself, it’s in Resuscitation from February this year, titled “The Association between Mechanical CPR and Outcomes from In-Hospital Cardiac Arrest: An Observational Cohort Study.” As we always say, don’t take our word for it just because you’re hearing it on a podcast. Go and have a look at the paper yourself, see what you think, and see if you agree with what’s been written on the site.
Simon, elderly patients, long waits, Greg Yates wrote this journal club for us. This is another paper review. This is something we all believe and see on a day-to-day basis. This is about whether long waits in the emergency department are lethal for elderly patients. This is a study from France where they looked prospectively at patients older than 75 who were in the emergency department in France at 97 emergency departments. They defined two groups: those who stayed in the ED from midnight until 8 am, the overnight stay, and those who were admitted to a ward before midnight. They were looking at whether it’s not just about how long they’re there, but what time of day. Things are different at night in hospitals.
The primary endpoint was in-hospital mortality up to 30 days, and they also looked at falls, infection, bleeding, stroke, etc. Among just under 1600 patients, they found that those who stayed in ED overnight had a mortality rate of 15.7%, versus those who managed to get onto the wards, which was 11.1%. That’s statistically and clinically significant and in keeping with what we’ve seen in the UK from studies that show if you wait more than eight hours in the emergency department, your mortality goes up dramatically.
Not only did they more likely die, they were more likely to have an adverse event on the wards, stay longer, and it’s just bad all around, particularly for those patients who required assistance with activities of daily living. The ones who had the most dependency did the worst, which again suggests this is probably a real effect. It’s an interesting study, probably as good evidence as we’re going to get around this particular question about overnight stays. It’s in keeping with everything else we know and is once again an appeal to reduce those long stays in the emergency department.
While some people are obsessed with the four-hour target and manipulating that by getting low-acuity patients out, my real concern is for these long waits of elderly patients. The number of 12-hour waits in the UK is rising, and these patients are suffering and causing irreparable harm. It’s not just about the target; it’s about patient care. Not a happy paper, but a useful one. Thanks to Greg for reviewing this and turning it into a blog.
In stark terms, taking those figures, the absolute risk increase was 4.6%. The inverse gives the number needed to kill: for every 21 patients who stay in the emergency department overnight, one extra patient will die. That’s stark. There are multiple reasons why patients stay in the emergency department overnight, and not all emergency departments are created equal. I have never visited a French emergency department, but this study might not translate directly to what happens with us. Our emergency department has a clinical decisions unit where elderly patients stay overnight, which might be different from what this paper talks about.
The bottom line is we all know being on a trolley for long periods is not good, and if you’re old and come into an emergency department, it’s likely you’re poorly and may die. What worries me is how targets drive practice. There’s a flurry of activity to get people out within four hours, and if they miss that, then the next marker is 12 hours. Nothing happens between four and 12 hours, and once they’re beyond 12 hours, it doesn’t count, leading to longer waits. In the UK, we had prospects of a different way of looking at emergency department performance, but it’s now back to the four-hour target set at 76%.
It’s interesting to think that when the target first came in, it was 98%, with 2% for clinical exceptions. The target was 100% to get people in or out within four hours but allowed some leeway. Then it became 95%, and now it’s 76%, based on the admission rate being 24%. What you need is a team passionate about looking after patients and doing the right thing. I’m pleased to say where I work, the target is thought of but doesn’t mean patients will jump the queue. We put patients first. That’s the policy in our department, but I know that’s not universal.
I don’t feel like we’ve ended on a particularly positive note talking about targets and elderly patients, but there are positive things. The sun is shining. I’ve moved on to a new phase in my career. I’ve done my last hem shift after 10 years, and it’s time to move on to something new. There are lots to be grateful for and lots to look forward to. If you’re thinking about study leave, there are a couple of courses and conferences we recommend. There’s the premier conference in Wessex for paediatric emergency medicine, the tactical trauma conference in October in Sweden, and the Royal College education days and major academic conference coming up.
Online learning is great, convenient, and easy, but try to get to a few face-to-face events locally and nationally. It’s really good to share learning experiences and positivity. The case mix in paediatric emergency medicine is changing, more minor injuries now and fewer coughs and colds. There’s potential for a respiratory syncytial virus vaccination, which could transform the winter experience for paediatric emergency medicine.
As ever, Simon, thanks very much. Please do like and subscribe, tell your friends, and explore our back catalogue of over 220 podcasts. There’s something in there you might not have heard and might find useful. We’ll talk to you again soon.
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