21 Valuable lessons from a recent EMCORE Conference

As part of my learning and review process, I took time to just recount some of the most valuable lessons that stood out in my mind as take-aways from the recent EMCORE Fiji Conference. I wanted to share 21 of them with you.

I hope:

• They will benefit you
• They will inspire you to read more on the topics
• They will give you the clinical edge you need

Here they are

1. Get rid of pulse checks in resuscitation. Use the ultrasound. You don’t have to be great at ultrasound to do this.
   1. Use the subscostal view, if you can’t get a good view then,
   2. Use the parasternal view for the 4-5 seconds during the pulse check. If you can’t get a good view,
   3. Look at the femoral vessels and find the artery and see if there is pulsation when chest compressions are paused.
   4. If you can’t get a good view of the femoral vessels try the carotids.

2. Post cardiac arrest the following patients benefit from emergency coronary angiography:
   1. STEMI on ECG
   2. Electrically unstable patients (refractory VF/VT)
   3. Haemodynamically unstable patients (cardiogenic shock)

3. The 3 most common causes of electrical storm are:
   1. Increased sympathetic tone
   2. Ischaemia
   3. Electrolyte Imbalance

4. Rules for Vascular Access: Bigger is better, IN is even better
   1. 2 is better than 1
   2. Anything can be given by intraosseous in an emergency
   3. Never forget the neck

5. POCUS of the heart in patients in asystole or PEA changes the management in a significant number of patients as it can identify:
   1. Ventricular fibrillation: fine fibrillation mistaken as asystole
   2. Cardiac motion when asystole or PEA was the original diagnosis

6. 3 questions asked in the COACHRED ultrasound protocol:
   1. Is there cardiac activity?
   2. Is there a pericardial effusion?
   3. Is RV>LV?

7. Interventions that can help the left ventricle, can make right ventricular failure worse.

8. Resuscitative sequence intubation is about taking care of 4 elements of physiology to minimise peri/post intubation arrest:
   1. Hypotension
   2. Hypoxaemia
   3. Severe Metabolic Acidosis
   4. Right Ventricular Failure

9. The 4 T’s for management of Post Partum Haemorrhage are:
   1. Tone (70%)
   2. Trauma (20%)
   3. Tissue (10%)
   4. Thrombin (1%)

10. Corona Mortis is a vascular anastomosis between the inferior external iliac system and the obturator system (present in 84% of cadavers in one study), which may be damaged by a pubic ramus fracture in the elderly, leading to significant bleeding, especially in anticoagulated patients. Have a low level of suspicion and consider:
    1. Non-contrast CT
    2. Repeat Heamoglobin at 4 hours

11. In traumatic Cardiac arrest, giving blood alone is better than all of the below:
    1. Blood and chest compressions
    2. Fluid
    3. Fluid and chest compressions
    4. Chest compressions

12. Imaging in the pregnant trauma patient should be focused on optimal assessment of the mother.

13. FAST Scans have not been validated in the obstetric trauma patient, but a positive scan is a guide for theatre.

14. Have a low threshold for scanning the elderly trauma patient:
    1. Elderly patients with falls from a standing height and blunt trauma can sustain significant head injuries
    2. Less than 20% of patients (in one recent study), who had sustained a significant head injury from a fall from standing height, had any historical or examination findings to make us suspicious of the injury.

15. There is very little evidence for how to assess outcomes in patients >75yo, with cardiogenic shock, however:
    1. Age alone should not be used to make decisions about survival
    2. Lactate rise and creatinine rise can assist in predicting outcomes
    3. Revascularisation with PCI may have a role in select patients
    4. Patients who require ventilation and renal replacemant have worse outcomes.

16. If we have to intubate the patient in status asthmaticus and they are paralysed, here are 3 things to remember for initial ventilation:
    1. Set RR slow
    2. IE Ratio long (1:6)
    3. PEEP and P_INSP to maximise minute volume with minimal P_LAT

17. Asthma is less likely in < 1 year old children with a wheeze.

18. Beware transverse myelitis as a red flag alternative to cauda equina:
    1. It results in rapid onset of weakness, sensory deficits and bladder and bowel dysfunction
    2. It occurs in the spinal cord at any level
    3. It most commonly affects the thoracic spine, so cauda equina MRI may miss it.

19. Cognitive errors are a type of diagnostic error, which can range from knowledge deficiencies to the way we respond to patients in predictable ways.

20. BRASH Syndrome is something to consider in elderly patients who present in a bradycardic decompensated state and are on an AV nodal blocker. It is usually precipitated by dehydration or sepsis and stands for:
    1. Bradycardia
    2. Renal Impairment
    3. AVN blockade
    4. Shock
    5. Hyperkalaemia

21. In patients who present with recent (<48 hour) onset of atrial fibrillation:
    1. A significant number of patients (around 60%) spontaneously cardiovert
       1. Duration of AF, prior cardioversion, heart rate on admission may give an indication of who will cardiovert spontaneously (ReSinus Score)
    2. Superiority of one Pad position over another, for defibrillation is questionable (EPIC vs RAFF-2 Trial)
    3. AF is a resistant arrhythmia, high non-escalating energy (200J), may be the best approach to cardioversion
    4. Stroke risk is about 0.3% if cardioversion occurs < 12 hours after AF onset. It increases to 1.2% from 12 -48 hours.
    5. Elderly patients with <48 hour AF, with co-morbidities of heart failure and diabetes have a significant increase in the risk of stroke (approaches 10%) if cardioverted
    6. There is a temporal relationship between cardioversion and stroke:
       1. Majority of strokes and TIAs occur with a median time from cardioversion of 2 days
       2. Over 80% of events occur within the first week after cardioversion
    7. Which patients do you anticoagulate? Only the ones with a CHA₂DS₂VASc score > 0, or all patients and for how long?
    8. In patients with a HAS-BLED score higher than their raised CHA₂DS₂VASc Score- the Garfied AF Risk Tool may help us make a decision on anticoagulation.

I hope you found these useful. See you at EMCORE.