Learnings from EMCORE Sydney 2025

EMCORE Sydney 2025 was a great conference full of learning. Here are just a few of points I took away….. so many more.

See you at the Next EMCORE in London or Fiji. Or in 2026 Melbourne, Japan, London and Queenstown.

1.POCUS in CARDIAC ARREST

POCUS in Cardiac Arrest is a critical tool. “The Focused Echocardiographic Evaluation in Life support (FEEL) study showed that 38% of patients with asystole on ECG, and 58% of patients in PEA, had coordinated cardiac motion associated with increased survival.”

Ask 3 questions in cardiac POCUS, to simplify everything. These may be the only things we can act on. What are they?:

1. Is there cardiac activity?
2. Is there a pericardial effusion?
3. Is RV > LV?

Use the COACHRED approach in resuscitation:

C – CONTINUE COMPRESSIONS
O – OXYGEN AWAY
A – ALL OTHERS STAND CLEAR
C – CHARGING
H – HANDS OFF
E – EVALUATE RHYTHM
D – DEFIB OR DUMP CHARGE

2. THE COMATOSE PATIENT POST ROSC

Post ROSC patient care is a continuation of resuscitation. We must concentrate our efforts as intensely in the post ROSC period as we do, during the initial resuscitation, perhaps moreso.

During the initial resuscitation our goal is to detect output. Post ROSC, our goal is to monitor, measure and control heamodynamic, oxygenation, temperature and other parameters as much as possible, to ensure the best survival rates.

Monitoring in this post ROSC period is critical. Accurate BP measurement must be done. In some cases we are resource poor, however an arterial line is critical here.

Ischaemic injury occurs early in resuscitation, ie in the first few minutes of anoxia. It also occurs during reperfusion. In the post ROSC, comatose patient, prognostication for good neurological survival is difficult. This is done > 48 hours post ROSC. Our goal is to continue to monitor and control and stabilise, as we just don’t know which patients will have a good survival.

In the post ROSC comatose patient, we should aim for the following:

Blood Pressure:

• SBP > 90 mm Hg as patients with SBP < 90 mm Hg are more likely to arrest.
• MAP > 65 mm Hg: No great evidence for this. Based on sepsis literature.
• There may be some patients that we need to aim for a higher blood pressure in.
• The BOX Trial found no benefit from targeting a higher BP, but there was also no harm.

Oxygenation and Ventilation

• sPO2 94-98%
• pCO2 35-45 mm Hg
• The BOX trial found no significant difference between restrictive and liberal oxygen therapy in terms of death or poor neurological outcome.

Temperature Control

• Aim to avoid fever ie > 37.5 Celcius.

Seizures

• Beware the patient with seizures as 30-50% of patients have them. They usually indicate anoxic brain injury, although some of these patients will have a good outcome…. We just don’t know which patients.
• We discussed post anoxic myoclonus and how to recognise it.

3. RESUSCITATION

Detecting Output, Adrenaline, Stacked Shocks, Precordial Thump and more
There are a large number of false positives and negatives associated with checking a pulse.
The sensitivity of femoral doppler in finding a pulse, is so superior to trying to palpate for a pulse ie., 95% vs 54%.
If using the ETCO2 to detect output, look at the whole waveform not just the number. The ETCO2 reading, in most cases is measured at 1 second before the end of exhalation. This may be low, but the actual ETCO2 waveform may show much higher readings ie., where we thought we had no output, because of a single number reading, we do infact have ROSC, according to the total waveform. Why is this important? Mostly because continuing chest compressions and giving large doses of adrtenaline and increasing after-load, may be deleterious to that patient.

Adrenaline should not be given early in shockable rhythms

Stacked shocks still have a place if a defibrillator is nearby and it doesn’t delay chest compressions.

The precordial thump is for monitored pulseless VT, when there is no defibrillator readily available. It is not for VF and can cause rhythms to deteriorate into asystole.

Do not use bicarbonate in resuscitation, unless for specific overdoses. It usually allows adrenaline to work and give us ROSC, but not neurologically intact patients.

4. ANAPHYLAXIS

The simple pharmacokinetics of adrenaline, and the rapid progress of the disease make it important to act quickly. 2 doses of IM adrenaline and then start an adrenaline infusion, if the patient doesn’t improve.

Anaphylaxis is a relatively short-lived disease and it’s all usually over in 4 hours.

5. TOXIC SHOCK SYNDROME

Think of it in shock out of proportion to the infectious process.

Staphylococcal toxic shock syndrome(TSS) can be menstrual or non-menstrual.

Staphylococcal TSS patients present with:

• Fever
• Rash
• Desquamation
• Hypotension
• Multi-system involvement
• They usually have Negative cultures (except S.aureus)

Streptococcal TSS patients present with:

• Hypotension and 2 or more of the following
  • Renal
  • Coagulopathy
  • Liver
  • ARDS
  • Rash +/- desquamation
  • Soft tissues necrosis
• On cultures they usually have Group A Streptococcus.

6. MEDICAL CLEARANCE OF MENTAL HEALTH PATIENTS

Routine testing is not required in patients with a normal physical examination, unremarkable medical history and normal vital signs.

Urine drug screens do not alter disposition and should not delay patient transfer

CT is not indicated for first presentation psychosis if

• no focal neurology
• normal LOC
• no significant head trauma, immunodeficiency
• seizures
• headache

7. PAIN MANAGEMENT IN CHILDREN

• Poorly measured and under-treated
• Pain is multifactorial
• Pain is difficult to differentiate from anxiety and distress
• Consider the child’s age, cognitive capacity, developmental stage, behaviour of caregivers, the environment
• Longer it takes to manage pain properly = more distress
• Poorly managed pain is remembered in subsequent hospital visits
• Remember to use distraction techniques in children.

Different Pain Scales for different ages:

• 2 months – 7 Years: FLACC ( Faces, Legs, Arms, Cry, Consolability) Scale
• 3-8 years – Wong-Baker Faces Pain rating scale.
• 8-16 years – Linear Visual Scale ie pain 1 to 10

When using medications use the ‘Pain Ladder’ approach:

• Mild Pain: Acetaminophen, NSAIDS
• Moderate Pain: Opioids, Non-opioid analgesics
• Severe Pain: Non-opioid analgesics , Opioids + adjuncts

Beware codeine in children as it is metabolised by a cytochrome P450 enzyme to the active compound, morphine. Poor metabolisers  may metabolise only up to 15% of the morphine concentration, receiving little or no analgesia from codeine. Ultra rapid metabolisers may metabolise up to 50% more morphine than normal metabolisers – which is potentially life threatening.

8. INTUSSUSCEPTION
Abdominal pain in children that resolves can still be intussusception.

Intussusception can occur in 3 locations:

• Ileo-colic (the bad one)
  • 80% of cases
• Ileo-ileal
  • Transient, usually resolve spontaneously
• Colo-Colic

We looked at what is involved In an air enema, and the pressures involved…. something I hadn’t appreciated:

• Foley inserted in the anus, and buttocks taped together.
• Air is insufflated at 60-80 and up to 120 mm Hg, for up to 3 minutes.
• Beware the air enema perforation. It’s uncommon, however it causes a tension pneumoperitoneum that requires immediate decompression.

9. VENTILATING THE CRITICALLY ILL PATIENT

4 cases: worked our way through ventilator settings.

Setting Volume Modes: The Basics

1. Ideal body weight: (M/F + patient height)
2.  FiO2: Set 100% then decrease to min to maintain O2 Sats
3.  Tidal Volume (Vt):  6-8ml/kg based on IDEAL BODY WEIGHT (or PIP).
4.  Rate:  what was the patient doing prior to intubation?
5.  PEEP: min 5 (improves oxygenation)
6.  Pressure Support:  only if spont breathing (makes spont breath effective
7.   I:E ratio:  increase if need to remove CO2 e.g. 1:3
8.  Pressure limit (Hamilton) : cuts out 10cmH20 below set pressure alarm
9.  Alarms incl PMax (set 10 above where you want it to cut out)

Setting Pressure Modes: The Basics   

1. Ideal body weight: (M/F + patient height)
2.  FiO2: Set 100% then decrease to min to maintain O2 Sats
3.  Peak inspiratory pressure (PIP):  Set this e.g. 15 cmH20 in children (NB. This is pressure above PEEP)
4.  Rate:  what was the patient doing prior to intubation?
5.  PEEP: min 5 (improves oxygenation)
6.  Pressure Support:  only if spont breathing (makes spont breath effective
7.   I:E ratio:  increase if need to remove CO2 e.g. 1:3
8.  Remember pressure limitation (Hamilton) : cuts out flow 10cmH20 below set pressure alarm
9.  Alarms incl PMax (set 10 above where you want it to cut out)

10.BIG BLEEDS IN LITTLE KIDS

A case discussion of intracerebral bleeds in children, due to cerebral AVM’s

• 0.1% of the population
• Can cause strokes: 3% in young adults
• They have 2 peaks; childhood and 30-50yo
• 40-60 ICH
• 10-30% have seizure
• < 1% – headache; 1-3% – focal neurological deficit, 10-20% incidental finding

11.PERSONALITY DISORDERS

We looked at patients with personality disorders and covered:

1. The concept of personality
2. Classification of personality disorders (PDs) and the difficulty in defining
3. Causes of PD
4. Comorbidities associated with PDs
5. Countertransference
6. Treatment of PD
   1. There is no treatment but patients are often on;
      1. Mood stabilisers
      2. Antipsychotics
      3. Benzodiazepines
      4. Antidepressants
7. Can you recover from PD?

What is Countertransference?

“A jointly created reaction in the clinician that stems in part from contributions of the clinician’s past and in part from feelings induced by the patient’s behaviour” 

12. THE NEW AUSTRALIAN ACS GUIDELINES 

Prof Louise Cullen, one of the authors, took us through the ACS guidelines and new ECG classifications (video on EM Mastery):

• STEMI Equivalents
  • Regional STE with reciprocal STD
  • High Lateral MI
  • Posterior MI
  • RV MI
  • De-Winters T waves
  • Modified Sgarbossa criteria.
• High Risk ECG Findings
  • Wellens
  • STD in mulktiple leads and STE in aVR
  • Hyperacute T waves
  • STD
  • TWI

13. SEPTIC ARTHRITIS

Making the diagnosis of Septic arthritis

• Blood results don’t really help us, as there are no safe cut-off points to rule out a septic joint
  • WCC elevated +ve LR 1.4
  • ESR > 30 +ve LR 1.3
  • CRP > 100 +ve LR 1.6
• In prosthetic joints, the following should be considered positive for septic arthritis:
  • Synovial WCC > 1,100 cells/mm3 (LR 7.6) OR
  • Synovial PMNs > 64% (LR 17.9)
• Future testing(which is already here) may involve PCR of the joint aspirate looking at a gene signature. This has a 95% sensitivity.

14. HYPERTHERMIA

Exertional and ‘classic’ hyperthermia was discussed

Recommended rate of cooling is about 0.15 degrees Celcius per minute.
There is no place for Dantrolene.
Avoid paracetamol (may exacerbate liver damage in hyperthermia) and ibuprophen.
Seizures should be treated with benzodiazepines and Phenytoin, with early intubation if needed.

Cooling options:

• Controversy exists over the most effective in the treatment of heat stroke.
• We must rapidly lower the core temperature to about 39°C (to avoid overshooting and rebound hyperthermia) as a primary goal.
• Rehydration therapy alone is insufficient for heat stroke patients and should be combined with active cooling.
• Active cooling with evaporative strategies may be enough.

Modalities for cooling that should be used:

• Pure exertional hyperthermia benefits from ice water emersion.
• Classic probably does better with immersion, but many of the patients are frail and risk benefit may favor aggressive evaporative cooling or hybrid approach.

15. DEXMEDETOMIDINE IN PAEDIATRIC PROCEDURES

• Centrally acting alpha-2 agonist (like clonidine but more selective)
• Reduces sympathetic activity (decr HR BP)
• Anxiolysis
• Minimal respiratory depression
• Limited analgesia

Dosing:

• 1mcg/kg IV load over 10 mins (ICU/anaes)
• IM
• 2-4mcg/kg nasal (max 200mcg)

Why might we use it over Ketamine?

• Nausea/vomiting with ketamine
• Emergency Delerium with ketamine
• Laryngospasm with ketamine
• (HR, BP, salivation with ketamine)

16. SCAPE

SCAPE (Sympathetic Crashing Acute Pulmonary Oedema),is the flash pulmonary oedema that occurs in unison with hypertension. The best treatment strategies involve NIV with IV Nitroglycerin.

There is increasing evidence to start with higher GTN dosing. Small studies have supported using a bolus of 600-1000mcg, titrated to a BP of 160-200 mm Hg over 2 minutes, then followed by an infusion. There is some suggestion that this infusion needs to be at 100mcg/min. There are no large prospective trials.

17. OTHER TOPICS COVERED

There were multiple other topics covered, including:

• How we learn and the effects on Neurodivergent doctors
• 5 threats to Keeping ourselves and our patients safe.
• Virtual Resuscitation of patients- new trends that will increase
• FGM/C
• Ketamine for analgesia

18. LITERATURE REVIEW

We must have covered over 200 or so latest studies from the literature over the 3 days of the conference, however as is our way, at the end of the last day we do a special review.

The EM Mastery literature reviews included:

The acute treatment of hyperkalaemia.

7 Studies on when to treat hyperkalaemia and the role of the ecg

Ventilation with endotracheal tube when BVM fails.

The FLORALI Trial

VL vs DL in adults and children

The practice changing PREOXI Trial

11 of the biggest trial in 2024

The practice changing Maternal and Neonatal outcomes following resuscitative hysterostomy

… and more

See you at the next EMCORE.