This week I am (virtually) presenting in Riyadh, Saudi Arabia at the Saudi Arabian Society of Emergency Medicine 7th Scientific Assembly. It’s always a pleasure to join colleagues from Saudi Arabia and around the world to share ideas on how we practice and develop emergency medicine. I last joined them in person in Jeddah at a very interesting and incredibly professionally delivered conference back in 2019.
This time I have just 15 minutes to talk about myths in resuscitation which is quite a broad title that could go in many ways, but I thought it best to focus on some key messages that have changed my practice in recent years. The topic was suggested by the conference team as we’ve covered a lot of such issues in the past, and of course all these are related to the concept of #dogmalysis as described originally by Cliff Reid. So in many ways it’s a bit of a ‘top papers/lessons’ talk which, at 15 minutes will be quite focused. There’s also the opportunity to get a mention in for Dr John Hinds, and that’s always got to be a great thing to place in a presentation.
Airway management in cardiac arrest
Hopefully this is no great surprise, but I think it’s worth restating that we have pretty good evidence now that the first line approach for airway management in cardiac arrest should be an LMA and not tracheal intubation. The AIRWAYS-2 trial showed us that there was no difference in patient outcome if we adopt an LMA first approach and this is something that we have been following for some time now. However, there are some caveats that we need to remember. Some cardiac arrest patients in special circumstances (e.g. asthma, pregnancy, upper airway abnormality) will theoretically benefit from an ET tube. Personally I use the LMA as my go to airway but then will convert to an ET tube when ROSC achieved (unless the patient wakes up) and/or when the patient pathophysiology dictates.
Randomised Controlled Trial of LMA vs. Intubation in OOHCA
- Primary outcome: There was no statistical difference in the Modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred sooner
- In the SGA group, 311 of 4882 patients (6.4%) had a good outcome (modified Rankin Scale score range, 0-3) vs 300 of 4407 patients (6.8%) in the TI group (adjusted risk difference [RD], −0.6% [95% CI, −1.6% to 0.4%])*
What has been really interesting, and we may talk about this later is that there is significant resistance to this change. Clinicians ‘want’ to intubate and there is lots of resistance around to this change.
When I trained, which is some time ago, I put in a lot of chest drains. These were open chest drains since Seldinger drains did not exist, and they were pretty brutal as we put them in without sedation. Those days are long gone and now we have a much wider range of skills available to us in chest drainage. However, I still see a lot of custom and practice that has not adopted the evidence base. I could do a whole talk on chest drain myths, but let’s focus on some of the big ones that I suspect are happening in many departments right now, but certainly need consideration for change.
Conservative management of pneumothoraces in Australian EDs. 316 patients randomised. No real difference in medium term outcomes. 15% in conservative group needed further intervention.
No difference when large spontaneous pneumothoraces drained vs conservative management. Of the 602 traumatic pneumothoraces, 277 of 602 (46%) were initially treated conservatively. Two hundred fifty-two of 277 patients in this cohort (90%) did not require subsequent chest tube insertion, including the majority of patients (56 of 62 [90%]) who were receiving positive pressure ventilation (PPV) on admission. The hazard ratio (HR) for failure of conservative management showed no difference between the drained and non-drained patients (HR, 1.1; P = .84). Only the presence of a large hemothorax was associated with an increased likelihood of failure of conservative management.
- Smaller pig tail catheters 14F in stable traumatic haemothoraces work just as well as big ones (28F-32F) for stable trauma patients. Failure rates were 11% vs. 13% which was neither clinically or statistically significant.
Recent evidence shows that in stable patients with spontaneous pneumothoraces there really is no long term difference in medium term outcomes between drainage in the ED or not. So we should probably be adopting a much more conservative approach and making a judgement on the clinical status of the patient rather than the radiological size of the pneumothorax.
In trauma patients there is increasingly evidence that conservative management is also fine, even if the patient is on positive pressure ventilation.
The bottom line appears to be that we should all be more thoughtful about placing chest drains. We probably don’t need them as much and when we do they should be smaller and if time permits placed using a seldinger technique. Of course this will (and is) a challenge for open chest drain skill acquisition and retention. The trainee’s of today simply will not get the exposure to this skill that we did 20+ years ago.
Bold is not Gold
This should not need to be said, but it’s really important. How teams behave and how we talk and support each other is truly important. This is especially important when dealing with the critically ill and injured. The populist view of resuscitations on TV and other media is a high stakes, high stress, loud, brash and challenging event where the normal interpersonal skills that would be appropriate in almost any other workplace are abandoned. Individuals do not always support each other, rudeness, shouting and bad behaviour are all too often seen and in many cases tolerated and perhaps even celebrated.
What do we know about bad behaviour in medicine? There is increasingly evidence that bad behaviours not only influence the interactions between colleagues, but also affect patient outcomes. Chris Turner, a UK emergency physician, has done fabulous work in this area through the Civility Saves program and there are others around the world. A recent systematic review shows that the adverse effect of bad behaviour is demonstrable across a range of specialities and localities, but the evidence is perhaps strongest in resuscitation settings. See examplar links below.
An RCT of behaviours in resuscitation. Rudeness had adverse consequences on the diagnostic and procedural performance of the NICU team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.
Systematic review in 2021 of disruptive behaviours shows consistent adverse effect on staff and patients.
Civility saves key themes on the impact of rudeness
- Quality of work reduces
- Clinicians are less likely to help others
- Patients suffer
- Clinicians become less likely to help each other
The bottom line is that idea of bold, aggressive behaviours in resuscitation is outdated and dangerous. We must all look to improve our own behaviours and to call out bad behaviours in others.
Calcium in cardiac arrest (and other stuff)
Perhaps not so much a myth as a long held belief amongst many resuscitationists that I’ve worked with. Calcium has been in and out of the guidelines for the management of cardiac arrest, notably in non-shockable rhythms. There is some pathophysiological arguments for this and as a result it has been used outwith the guidelines many times.
This year we were fortunate enough to see the results of a large RCT that demonstrated that it does not work and we should stop using it routinely, reserving it for arrest scenarios where it has specific indications e.g. hyperkalaemic cardiac arrest. In fact the data suggests that calcium may in fact be harmful.
- The administration of Calcium in OHCA does not improve ROSC or 30 day survival. The data may actually trend to the use to calcium causing harm. Our view is that calcium should only be used in cardiac arrest if the clinicians specifically suspect hypocalcaemia as a cause or for its use as an antidote/treatment. 383 patients. At 30 days, 10 patients (5.2%) in the calcium group and 18 patients (9.1%) in the saline group were alive
The other reason to mention calcium is that it is increasingly apparent that it’s use in trauma is that hypocalcemia is associated with poor outcomes when patients require transfusion. So keep your calcium in the resus room and give it liberally in your severe bleeding trauma patients, but keep it in reserve for your cardiac arrest patients.
- Systematic review. Hypocalcemia is a common finding in shocked trauma patients and associated with mortality. However, association is not causation.
Blood is Blood
I hope that you are all avoiding the use of excessive amounts of crystalloid in the treatment of your trauma patients. There is now pretty good evidence that crystalloid is associated with worsening coagulopathy and death in trauma patients and as a result most trauma systems have moved to using ‘blood’ as a resuscitation fluid wherever possible.
We also now know that in most health economies the ‘blood’ that we give is not really blood, but is in fact packed red blood cells (PRBCs) which lack the important clotting factors and platelets that are so important in trauma. The PROPPR trial showed that we really do need to give balanced resuscitation strategies using platelets and plasma as well as PRBCs to get better outcomes, and more recently trials such as PaMPER have indicated that early plasma use may well be the appropriate strategy in the more severely injured.
So now that we have major haemorrhage protocols providing 1:1:1 ratios of transfusion products it’s tempting to think that we are now giving a something close to what the patient is losing, but we must also think about the metabolic consequences of blood transfusion. As mentioned above we have already identified the need for calcium in blood transfusions for trauma, but have you ever stopped to think about the metabolic and biochemical characteristics of PRBCs?
I looked at this a few years back and was really surprised to see the typical characteristics of the fluids that we regularly transfuse into our patients who are already shocked, acidotic and metabolically deranged. These are from a 2001 study of stored blood.
When you see these figures it certainly makes you think and is a reminder that managing the biochemical and metabolic aspects of trauma resuscitation are vital. Indeed Karim Brohi has proposed that we need a new triad of death for trauma in the 21st Century with a strong emphasis on this, some of which may in fact be a consequence of resuscitation itself (together with cell death, anoxia etc.).
I’m also really looking forward to the results of the RePHILL trial in the next few weeks. That RCT of blood/plasma vs. Saline in the prehospital setting will add more information and debate on this important topic.
Two reasons to perform a procedure.
Reflecting on the topics above, and in particular the topics of intubation and chest drains it reminds me of the idea that there are universally two reasons for any procedure. Seriously, think about any procedure, in any speciality, at any time and I will try and convince you that there are 2 universal indications.
- The patient needs the procedure because it is indicated and they are likely to benefit from it.
- The clinician wants to perform it.
Clearly only one of these is right and honorable, but just stop and think about your practice and that which you see around you. Have you ever seen clinicians ‘disappointed’ when it is suggested that we won’t perform the procedure that is perceived as ‘cool’ or is required for the log-book. I do understand the pressures, but it is always important that we ensure that, in the immortal words of Dr John Hinds, that our intentions are honorable.
It’s great to join the SASEM team once again, but also a shame that it’s another virtual event as a result of COVID. I’m really looking forward to the future of events which I suspect will be a mix of virtual, face to face and blended events. With that in mind don’t forget the RCEM Spring CPD conference which will be RCEM’s first large face to face event. I’m really looking forward to that and if you’re there it will be great to see you.
- AIRWAYS-2 review on the Bottom Line https://www.thebottomline.org.uk/summaries/icm/airways-2/
- Ashley Liebig, “JC: OOHCA and Airway management. Do we need a tube? St Emlyn’s,” in St.Emlyn’s, September 2, 2018, https://www.stemlynsblog.org/jc-oohca-and-airway-management-do-we-need-a-tube-st-emlyns/.
- Simon Carley, “JC: Can we use smaller pigtail drains in traumatic haemothorax?,” in St.Emlyn’s, November 11, 2021, https://www.stemlynsblog.org/jc-can-we-use-smaller-pigtail-drains-in-traumatic-haemothorax/.
- Simon Carley, “JC: Conservative management of chest trauma. St Emlyn’s,” in St.Emlyn’s, December 7, 2018, https://www.stemlynsblog.org/jc-conservative-management-of-chest-trauma-st-emlyns/.
- Simon Carley, “JC: Conservative management of pneumothoraces.,” in St.Emlyn’s, February 10, 2020, https://www.stemlynsblog.org/jc-conservative-management-of-pneumothoraces/.
- Simon Carley, “Chest drains & aspiration: Do it better with St.Emlyn’s,” in St.Emlyn’s, November 19, 2016, https://www.stemlynsblog.org/chest-drain-excellence-microskills/.
- Laura Howard, “JC: Should we use calcium in out of hospital cardiac arrest? St Emlyn’s,” in St.Emlyn’s, January 7, 2022, https://www.stemlynsblog.org/jc-should-we-use-calcium-in-out-of-hospital-cardiac-arrest-st-emlyns/.
- Iain Beardsell, “Hypocalcaemia, Trauma and Major Transfusion. St Emlyn’s,” in St.Emlyn’s, May 22, 2021, https://www.stemlynsblog.org/hypocalcaemia-trauma-and-major-transfusion-st-emlyns/.
- Simon Carley, “JC: The metabolic and biochemical characteristics of packed red cell transfusions.,” in St.Emlyn’s, August 23, 2019, https://www.stemlynsblog.org/jc-the-metabolic-and-biochemical-characteristics-of-packed-red-cell-transfusions/.