London Cardiac Arrest Symposium #LTC2015 St.Emlyn’s

London Cardiac ArrestSymposium 2015

Well, the last day of a great four days came and went, and focused on core topics in trauma, and the Cardiac Arrest Symposium. I spent all day in the symposium, but saw a lot of good things on Twitter (other web-based microblogging applications are available) from the other room, including a talk from a cardiac arrest survivor on her experience, and Conrad Witek on suspended animation in cardiac arrest.

To catch up on the rest of the conference, you can check out Day 1, Day 2, and Day 3 here at St. Emlyn’s.

Here’s what happened in the cardiac arrest lectures.

To kick off, Prof Charles Deakin spoke about adrenaline in cardiac arrest. Mainly that there is no evidence that it improves survival to discharge, but does improve return of spontaneous circulation (ROSC), mostly in patients with a non-shockable rhythm. The PARAMEDIC2 trial has recruited 1,000 patients so far to look at its use, with results due in late 2018, so make sure it’s in your diaries!

Ken Spearpoint gave a very thought-provoking talk on his research into the experiences of patients who survived a cardiac arrest. There were some interesting conclusions, with the main one being that we don’t explain enough to them about what actually happened to them, leaving them left in the dark, confused, and sometimes frightened.

After ROSC, we have to work hard to get the heart stabilised again, and Simon Finney detailed how hard it was to make an accurate assessment of myocardial dysfunction at this time based on the clinical picture, blood pressure and biomarkers. He advised the use of cardiac output monitoring with careful echocardiography, which gives a more objective measurement to aid management. There is a role for ECMO in cardiogenic shock, but the optimal timing is unclear, and it is difficult to predict recovery.

PCA/PCI after cardiac arrest is challenging. Prof Philip MacCarthy spoke about who should go to the cath lab, noting that at present many cardiac centres will take those who have ST elevation on a post-ROSC ECG. Those without STEMI go to the emergency department for work up, but from one study by Bro-Jeppesen et al., 25% of patients in this group still had a culprit lesion, therefore in the absence of an obvious non-cardiac cause, he proposed that they should still have angiography.

Prof James Manning has been working on endovascular resuscitation techniques (such as SAAP, which you can hear more about from his lecture last year) since 1992, and discussed the use of these, and extracorporeal therapies to aid management of the cardiac arrest patient.

Conor Deasy, who gave a total of seven talks throughout the week (some sort of Irish super hero!), told us how he has been trying to improve outcomes in rural cardiac arrest, as patients who ambulances take longer to get to tend to do worse. Prof Deakin then returned to the stage, to present the 2015 European Resuscitation Council ALS guidelines, which were largely unchanged from the 2010 version, the main additions being mandatory end-tidal CO2 use with intubation, and consideration of E-CPR and cath lab activation written into the pathway.

Mechanical compression devices have been shown to be no better or worse than manual compressions, and can indeed help in some tricky situations. Prof Simon Redwood showed some great videos of coronary angiography and intervention in patients on MCDs, and some with ECMO underway.

How do we find fluid serenity in the Emergency Department? Prof Tim Harris gave his advice, which was to first decide whether your patient actually needs fluids, why they need fluids, and whether it will actually make them better. His addiction in life, and way to find the answers to these questions, involved ultrasound, and its use to measure stroke volume. Of course, it’s all about that Goldilocks amount of fluid…

For patients in VF, the main treatment is defibrillation and high-quality CPR. But what if that doesn’t work? It’s rare (incidence of 0.5-0.6/100,000), so Mark Whitbread gave some top tips on how to get patients out of resistant ventricular fibrillation, with the advice that recurrent (where the patient goes in and out of VF) and refractory (where the patient remains in) VF are two different states, and working out which the patient is in may aid us. For those in refractory VF, using AP placement of pads, and using double sequential defibrillation (which you can read more about at R.E.B.E.L. EM) may aid reversion, but ultimately your patient may just need a good dose of cath lab.

Rob Morrison reminded us all that it is a legal requirement to discuss DNACPR decisions with patients, and that we don’t pre-emptively talk to our patients about these decisions enough. For more information on this, the Resuscitation Council (UK), in conjunction with the BMA and RCN, has produced a document on decisions relating to CPR.

Marius Rehn concluded with probably the most unusual “last talk of a conference” I’ve seen so far, and spoke on cardiac arrest through hanging. Be it accidental or not, non-judicial hanging is more common that you think, and can cause a variety of injuries from spinal to vascular. It can lead to cardiac arrest through a multiple of factors, including asphyxia, cerebral vascular occlusion and spinal cord injury.

Well, that was the London Trauma Conference 2015, an insightful four days into the mind of a wealth of experts in the field, held at the Royal Geographical Society. Thank you to the organisers, and thank you for joining us for another year. Please have a listen to Nat, Iain and Simon’s podcasts for the first two days, read the blog posts and watch out for more podcasts on the way from some of the key speakers. We look forward to seeing you next year!

Chris

Chris Gray St.Emlyn's

Thanks so much for following. Viva la #FOAMed

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