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MODULE 8: resuscitation
Well, here we are - a heavy theory week. There is a LOT of reading!
ILCOR released the 2015 guidelines on resuscitation on October 15, and we think having a read of these is essential knowledge for exam candidates sitting this year. The guidelines are produced below. (We have referenced the European release over the Australian version. The ARC versions aren't as easy to read.)
We also delve into shock resuscitation, particularly septic shock. Several major studies have been published in the last year dealing with the issue of early goal directed therapy and sepsis. They are referenced below also.
We also have some videos from EMCORE 2015 on various resus topics - below - but really this week is in the reading.
ILCOR released the 2015 guidelines on resuscitation on October 15, and we think having a read of these is essential knowledge for exam candidates sitting this year. The guidelines are produced below. (We have referenced the European release over the Australian version. The ARC versions aren't as easy to read.)
We also delve into shock resuscitation, particularly septic shock. Several major studies have been published in the last year dealing with the issue of early goal directed therapy and sepsis. They are referenced below also.
We also have some videos from EMCORE 2015 on various resus topics - below - but really this week is in the reading.
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READ: RESUSCITATION IN 2015
As always, the resuscitation guidelines are HUGE. And, as always, only some of the guidelines need to be read by emergency clinicians. The full guidelines are available on the ILCOR website, but select portions with some reading notes are below. The Australian and New Zealand resuscitation council released updated guidelines in January 2016 based on these - you can find them here. We actually prefer the European documents in terms of accessing the major theory and points of interest. Our reading notes are below. Click on each document to be taken to the URL version with video summaries (pdfs also available at the site) of each document.
THE EXECUTIVE SUMMARY
You have to remember that the guidelines cover every aspect of resuscitation and post resuscitation care, so they are HUGE. The executive summary is a really good place to start, because it distills the guidelines down into "must know" segments. (Although at 62 pages PLUS references it's not the most concise "summary" in the world.
We would suggest paying particular attention to the following:
If you get through all of that you should have a pretty good overview of the major resuscitation changes and challenges in 2015.
You have to remember that the guidelines cover every aspect of resuscitation and post resuscitation care, so they are HUGE. The executive summary is a really good place to start, because it distills the guidelines down into "must know" segments. (Although at 62 pages PLUS references it's not the most concise "summary" in the world.
We would suggest paying particular attention to the following:
- The first 5 pages (up to the section on EMDs and BLS) provide a good overview of resuscitation in 2015.
- The advanced life support section from page 17 - 22 provides a good review and overview of ALS (including figure 1.7 on page 18)
- Figures 1.8 (page 23 and 1.9 page 24) on the management of tachy and brady arrhythmias are worth a look
- There is an executive summary of resuscitation in special circumstances following the ALS section,but save your powder for the special circumstance document below
- Have a read of the post resuscitation care segment (including ROSC) up until the prognostication segment on page 33.
If you get through all of that you should have a pretty good overview of the major resuscitation changes and challenges in 2015.
CARDIAC ARREST IN SPECIAL CIRCUMSTANCES
This is a long document, with a lot of nitty-gritty in the back half. The first half is an excellent overview of some major ED topics including electrolyte abnormalities, temperature abnormalities and traumatic cardiac arrest. We would recommend reading from page 150 onwards to about page 165. Page 166 - 167 cover toxicology, so it might be worth coming back here later in the course too. Page 167 onwards covers really special circumstances (like cardiac arrests in the dialysis unit!), so don't spend too much time on it.
This is a long document, with a lot of nitty-gritty in the back half. The first half is an excellent overview of some major ED topics including electrolyte abnormalities, temperature abnormalities and traumatic cardiac arrest. We would recommend reading from page 150 onwards to about page 165. Page 166 - 167 cover toxicology, so it might be worth coming back here later in the course too. Page 167 onwards covers really special circumstances (like cardiac arrests in the dialysis unit!), so don't spend too much time on it.
ADVANCED LIFE SUPPORT
The ALS document from the guidelines is below. To be honest, it doesn't add much over the discussion in the executive summary, but if you really are interested we would recommend starting from page 107 at the title "ALS treatment algorithm"
The ALS document from the guidelines is below. To be honest, it doesn't add much over the discussion in the executive summary, but if you really are interested we would recommend starting from page 107 at the title "ALS treatment algorithm"
BASIC LIFE SUPPORT
Although arguably this is first in the chain of survival, it's probably the least useful for examination purposes. It's worth a read of the CPR protocol section from pages 84 - 90 for an overview of where we are with CPR, but don't get bogged down. (And relax - several of the pages between 84 & 90 are actually full page pictures, not dense text!)
Although arguably this is first in the chain of survival, it's probably the least useful for examination purposes. It's worth a read of the CPR protocol section from pages 84 - 90 for an overview of where we are with CPR, but don't get bogged down. (And relax - several of the pages between 84 & 90 are actually full page pictures, not dense text!)
READ: SEPTIC SHOCK
Sepsis management is a cornerstone of good ED practice, and having something sensible to say about it is crucial to passing the exam. Three big trials: ARISE, ProCESS and PRoMISe have been released this year, re-evaluating the utility of early goal directed therapy, and it would behoove you to have something intelligent to say about them. The trials are all available via the NEJM website via the following links (unfortunately they can't be embedded for copyright reasons):
1. If you are only going to read one trial, read ARISE (conducted by ANZICS - i.e. the Australian trial)
2. ProCESS can be found here.
3. PRoMISe can be found here.
4. A nice commentary on the NEJM blog regarding the three trials can also be found here.
1. If you are only going to read one trial, read ARISE (conducted by ANZICS - i.e. the Australian trial)
2. ProCESS can be found here.
3. PRoMISe can be found here.
4. A nice commentary on the NEJM blog regarding the three trials can also be found here.
Based on all of this the Surviving Sepsis Campaign has changed the contents of its 3 and 6 hour bundles. The new guidelines can be found below. (File underneath for iPad users.)
| ssc_bundle.pdf |
The optimal timing of antibiotic administration is still a question not clearly answered by the literature. LITFL has a very good summary of the papers involved in examining the issue. Access it here. Alternatively, just be comfortable with the mantra that "earlier is better".
solve.
A bit of a different "solve" this week. Have a look at the question below. It's from the real exam.
You'll notice a couple of things:
With this in mind we want you to think very carefully about the new ILCOR guidelines, above. Rather than give you a summary, we think it's more useful from a learning perspective to make your own.
So, as a group via the week 8 discussion on the VSG, we would like you please to:
- The first is that there are more than 10 marks allocated - in fact there are 16. This means there are 16 facts you are expected to fill in on this page. (That's quite a lot!)
- The second is that this question is lifted almost directly from the 2010 ILCOR guidelines. It's a straight out test of knowledge - either you know it or you don't....
With this in mind we want you to think very carefully about the new ILCOR guidelines, above. Rather than give you a summary, we think it's more useful from a learning perspective to make your own.
So, as a group via the week 8 discussion on the VSG, we would like you please to:
- Post your "must know" changes between the 2010 and 2015 guidelines. Focus on the ED aspects, and remember that historically "list x changes between document A from 2010 and document B from 2015" have been favourite questions of the court of examiners, especially 6-12 months after document B has beeb published....
- Pick the flow diagram (as above) from the new guidelines that you think is most likely to be examined, reference it to the guidelines and provide a summary of important points to your colleagues.
write.
Homework this week is predictable!
Additional to the above discussion write 3 MCQs based on the new resuscitation guidelines and 3 MCQs concerning the management of septic shock.
Additional to the above discussion write 3 MCQs based on the new resuscitation guidelines and 3 MCQs concerning the management of septic shock.