Ep 147 - August 2019 Round Up

A Comprehensive Review of St Emlyn’s Blog: August 2019 Highlights

Welcome to St Emlyn’s blog and podcast, where we reflect on the key topics and research from August 2019. In this review, we’ll explore the most impactful discussions and studies, providing valuable insights for emergency medicine professionals. From managing lower GI bleeding and addressing climate change in anaesthesia to examining PTSD in emergency services and the future of diagnostics, this post summarizes essential takeaways that are shaping our field.

Managing Lower GI Bleeding in the Emergency Department

One of the significant topics covered was the management of acute lower gastrointestinal (GI) bleeding, a common but challenging condition in the emergency department (ED). The complexity of managing these cases often lies in determining the correct priority of care, appropriate management strategies, and even the correct speciality for handling these patients.

We reviewed a consensus guideline from the British Society of Gastroenterology and Hepatology, published in Gut, which offers practical recommendations for the diagnosis and management of acute lower GI bleeds. The guideline emphasizes the importance of using stratification tools to distinguish between stable and unstable patients, which can help streamline management in the ED.

For stable patients, the Oakland score is recommended. This scoring system helps identify which patients can be safely managed on an outpatient basis, reducing unnecessary hospital admissions. Conversely, patients with a major bleed should be admitted and scheduled for a colonoscopy at the earliest opportunity. The guideline also highlights the value of CT angiography for hemodynamically unstable patients, a practice increasingly integrated into emergency care.

Transfusion thresholds, set at 70 grams per litre, align with standard practices in other clinical settings, with adjustments for patients with cardiovascular disease. The guideline also recommends having dedicated GI bleed leads within trusts to ensure seamless coordination with emergency services.

Sustainability and Climate Change in Anesthesia

Another crucial discussion from August focused on the environmental impact of healthcare, particularly in anaesthesia. In the UK, healthcare is a significant contributor to climate change, driven by factors like travel, disposable materials, and the use of anaesthetic gases such as nitrous oxide and desflurane.

A key paper by Cliff Shelton and colleagues underscores the need to adopt more sustainable practices in anaesthesia. For example, desflurane is approximately 3,000 times more potent as a greenhouse gas than carbon dioxide. The paper advocates for reducing the use of high-polluting gases and considering greener alternatives where possible.

This shift towards sustainability in healthcare is essential, although challenging, given the nature of medical practice. However, small changes, such as reducing nitrous oxide use in departments where alternatives exist, can collectively make a significant difference. The paper serves as a call to action for healthcare professionals to be more mindful of their environmental impact and to seek sustainable solutions in their practices.

Pre-Hospital Care: Comparing Macintosh and McGrath Laryngoscopes

The debate over the best laryngoscope for pre-hospital rapid sequence intubation (RSI) is ongoing, and in August, we reviewed a study that contributed valuable data to this discussion. Published in Critical Care Medicine, the study compared the Macintosh and McGrath laryngoscopes in pre-hospital settings, involving 514 adult emergency patients.

The study found that both devices were equally effective for pre-hospital RSI. Notably, it also revealed that switching to a different device after a failed intubation attempt was more successful than repeating the attempt with the same device. This finding aligns with the 30-second RSI drills many practitioners use, which advocate for changing the approach after a failed attempt.

These findings have practical implications for both pre-hospital and in-hospital care. In the ED, switching to a video laryngoscope, such as the McGrath, after a failed intubation attempt could improve patient outcomes. As video laryngoscopes become more accessible in emergency departments, integrating them into RSI protocols could be a beneficial strategy.

PTSD in Emergency Services: Rusty Carroll’s Series

Rusty Carroll’s ongoing series on PTSD within the ambulance service continues to be one of the most impactful contributions to the St Emlyn’s blog. The August instalment focused on the aftermath of PTSD, exploring the journey towards understanding what “normal” looks like after such an experience.

Rusty’s candid reflections resonate with many in the emergency services community, highlighting the mental health challenges prevalent in our field. The series has received positive feedback, with many readers finding comfort and validation in Rusty’s experiences.

However, the widespread relatability of this series also underscores a concerning reality: many emergency service professionals are struggling with similar issues. As a community, we need to support one another, promote mental health awareness, and advocate for resources to address the psychological toll of our work. Revisiting Rusty’s previous installments in this series is highly recommended for a deeper understanding of the complex emotions associated with PTSD in emergency services.

The Realities of Packed Red Cell Transfusions

Another fascinating topic from August was the metabolic and biochemical characteristics of packed red cell transfusions, which have significant implications for trauma care in the ED. This discussion was sparked by a conversation on Twitter, leading to critical reflections on the assumptions we hold about blood transfusions.

In trauma care, blood is often regarded as a superior alternative to crystalloids. However, the reality of what we’re transfusing—packed red cells—is quite different from whole blood. A study we reviewed highlighted some surprising statistics about the contents of packed red cells, including a pH of 6.79, a potassium level of 20, and a lactate level of 9.4. These figures reveal that packed red cells are far from the idealized image of whole blood.

The metabolic implications of these characteristics are significant, particularly in the context of massive transfusions. For instance, packed red cells have low levels of 2,3-DPG, which affects their ability to release oxygen to tissues. This raises important questions about how we use blood in trauma resuscitation and whether our current practices are truly optimal.

There’s also an ongoing pre-hospital trial in the UK, known as the RePHILL trial, which is examining the outcomes of patients randomized to receive either blood or no blood in pre-hospital settings. The results of this trial are eagerly anticipated and could challenge the assumption that blood is always better. This could lead to more nuanced transfusion practices in the future.

The Future of Diagnostics: Insights from Rick Body

Finally, we explored the future of diagnostics with insights from Rick Body. His presentation, originally given at the St Emlyn’s Live conference, offers a compelling vision of where diagnostics in the ED is heading. With the rise of machine learning, artificial intelligence (AI), and personalized diagnostics, the landscape of emergency medicine is rapidly evolving.

These technologies are already being integrated into diagnostic processes, but they bring new challenges. The data generated by AI and machine learning can be complex, requiring a shift in how we interpret diagnostic results. We must move away from binary thinking and embrace a more nuanced understanding that includes probabilities, uncertainties, and complexities.

As emergency medicine professionals, we need to prepare for this shift by engaging with these new technologies and incorporating them into our clinical practice. The future of diagnostics is exciting, but it will require ongoing education and adaptation to fully harness its potential.

Conclusion

August 2019 was a month rich with insightful discussions and important research that continue to influence our practice in emergency medicine. From managing lower GI bleeding and the environmental impact of anaesthesia to the complexities of blood transfusions and the future of diagnostics, these topics highlight the diverse challenges and opportunities we face in the ED.

The St Emlyn’s blog and podcast aim to keep you informed and engaged with the latest developments in our field. This review has provided valuable insights that can be applied in your practice, helping you stay ahead in the ever-evolving landscape of emergency medicine. Stay tuned for more updates, and as always, feel free to share your thoughts and experiences with us. Until next time, take care and continue to push the boundaries of what’s possible in emergency medicine.