February 2009 Clinical Update CME Questions

Answer True or False:

1. The addition of a physician to a HEMS crew prolongs scene times due to the increased number and sophistication of interventions provided

2. Rural Australian HEMS services usually take less than 30 minutes from dispatch to arriving on scene.

3. Infants receiving alprostadil infusions for congenital cardiac lesions should be intubated prior to transport because of the risk of apnoea.

4. Like midazolam and propofol, dexmedetomidine is a GABA-agonist.

5. Benzodiazepine administration helps reduce the risk of delirium in ICU patients.

February 2009

London HEMS doctors describe their use of ketamine for pre-hospital analgesia and sedation in 1030 retrospectively reviewed cases, concluding its prehospital use is safe.

Emerg Med J. 2009 Jan;26(1):62-4
http://www.ncbi.nlm.nih.gov/pubmed/19104109?dopt=Abstract


171 rural Australian HEMS missions were retrospectively analysed. Some of the data contrast starkly with the more limelight-occupying urban services: average time from dispatch to scene was 48 minutes, average scene time was 50 mins, and average total distance flown was 160 nautical miles (297 km!) - the longest reported in the literature. There was no difference in injury severity between physician-staffed and paramedic-staffed missions, and no difference in mortality. When transport times for distances less than 50km from the hospital were compared, road responses were significantly faster than helicopter dispatch, whereas helicopter use created significant time savings at distances over 100km. The authors suggest that in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care. They also recommend caution in mandating physician staffing of HEMS, particularly in environments with a limited pool of critical care doctors.
Emerg Med Australas. 2008 Dec;20(6):494-9
http://www.ncbi.nlm.nih.gov/pubmed/19125828


Careflight Queensland report a 9 month series of intubations by their doctor-paramedic HEMS teams who performed 39 intubations (and assisted hospital doctors in an additonal 4), of which less than half were pre-hospital. There was one failed intubation, successfully ventilated with a laryngeal mask airway.
Emerg Med J. 2009 Jan;26(1):65-9
http://www.ncbi.nlm.nih.gov/pubmed/19104110

Two English HEMS services covering the same geographical area, one physican / paramedic crewed and one double paramedic crewed, were compared. There were no differences in scene times. As well as predictably providing more rapid sequence induction, nerve blocks, and ketamine use, the physician-paramedic team discharged more people at scene and were more likely to cease resuscitation attempts in GCS 3 patients.
Emerg Med J. 2009 Feb;26(2):128-34
http://www.ncbi.nlm.nih.gov/pubmed/19164630

The risk of apnoea in neonates requiring prostaglandin E1 infusions for duct-dependent congenital heart disease is well described and often results in the recommendation to intubate prior to transfer. An American study of 202 transported infants on PGE1 shows a higher rate of transport-related complications in those that had been intubated. None of the 73 (36%) unintubated patients required intubation for apneoa during transport. These data are in keeping with a previous Australian study of 300 infants receiving PGE1 in which only 2 of 78 unintubated patients experienced apnoea.
Pediatrics. 2009 Jan;123(1):e25-30
http://www.ncbi.nlm.nih.gov/pubmed/19064611?dopt=Abstract

An industry-sponsored double-blind randomised controlled trial comparing midazolam with the central alpha-2 agonist dexmedetomidine showed the newer drug to provide similar levels of sedation with less delirium and a shorter time to extubation. It was associated with more episodes of bradycardia not requiring intervention.
This new sedative drug, related to clonidine, provides some analgesia and anxiolysis, and is noted for its lack of respiratory depression. An accompanying editorial points out the known association between benzodiazepines and delirium, and asks whether a comparison with propofol would have shown the same improved outcomes.
JAMA. 2009 Feb 4;301(5):542-4
http://www.ncbi.nlm.nih.gov/pubmed/19188334?dopt=Abstract

Answers to February CME Questions:

1) F 2) F 3) F 4) F 5)F

January 2009 Clinical Update CME Questions

Answer true or false

1. Axillary temperature measurements are more accurate than tympanic measurements in adults

2. Oral temperature readings are approximately 0.5 degree lower than axillary

3. Length-based estimates of children’s weights are more accurate than age-based estimates

4. The administration of CPAP in the pre-hospital environment does not require a dedicated NIV ventilator

5. Central venous oxygen saturation of 70% is not a reliable goal in resuscitated septic shock patients in ICU

6. Passive leg raising as a predictor of fluid responsiveness is best done on a supine patient

7. Oral decontamination of ICU patients is almost as effective as selective decontamination of the digestive tract (SDD) with a number needed to treat (NNT) of approxmately 35

8. Risk of death increases sharply when pre-hospital systolic blood pressure is less than 90 mmHg when compared with less than 100 mmHg

9. Standard Operating Procedures for trauma care are useful in the field, but there is no evidence to support their use in the emergency department

10. A large difference in pCO2 between central venous and arterial blood may indicate global tissue hypoperfusion

January 2009

A review of 1954 out-of-hospital tracheal intubation (ETI) attempts by EMS crews revealed 444 (22.7%) patients experienced one or more ETI errors, including tube misplacement or dislodgement in 61 (3%), multiple ETI attempts in 62 (3%) and failed ETI in 359 (15%). Pneumonitis was associated with failed ETI (n=20, 19%; univariable OR 2.54; 95% CI 1.24-5.25). The authors conclude that out-of-hospital ETI errors are not associated with mortality, but failed out-of-hospital ETI increases the odds of pneumonitis.
http://www.ncbi.nlm.nih.gov/pubmed/18952357?ordinalpos=20&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


A prospective observational study of paediatric patients requiring pre-hospital intubation attended by a helicopter medical team (HMT) included 95 children with a GCS of 3-4. Fifty-four received bag-mask support by EMS paramedics until the HMT arrived and intubated them (survival 63%), and 41 were intubated by EMS paramedics. Of these, ‘correction of tube/ventilation’ was required in 37% and the survival was 5%. The authors conclude that bag-mask support should be the technique of choice by EMS paramedics, as the rate of complications of tracheal intubation in this patient group is unacceptably high. Hard to comment as I only have access to the abstract but one wonders if the EMS-intubation group were sicker patients requiring more aggressive early control of airway and breathing.

http://www.ncbi.nlm.nih.gov/pubmed/18684547?ordinalpos=31&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

A nurse-based pre-hospital care system in Holland describes its experience with pre-hospital CPAP for acute cardiogenic pulmonary oedema. It appears that the simple Boussignac apparatus is straightforward to apply in the ambulance environment. Arguments about lack of outcome studies aside, if it’s necessary to undertake an interhospital transfer of a patient established on CPAP then this might be a relatively straightforward means of doing so.

http://www.ncbi.nlm.nih.gov/pubmed/19164632?dopt=Abstract

http://www.vitaid.com/canada/boussignac/index.html

The introduction of Standard Operating Procedures for trauma management into a German emergency department resulted in quicker resuscitation, shorter time in the ED, and shortened time to definitive diagnosis in polytrauma patients. Nice to see some evidence to support SOP use in critical medical settings, not least because there are still clinicians out there who fail to see their value.
http://www.ncbi.nlm.nih.gov/pubmed/19078832


In septic shock, a central venous oxygen saturation of 70% has been proposed as a target for early (ED-phase) goal-directed haemodynamic resuscitation, indicating adequate oxygen delivery to tissues. However later in the disease course (ICU-phase) disturbances in microcirculation or mitochondrial function may inhibit peripheral oxygen uptake, resulting in a healthy looking ScvO2 value in spite of evidence of inadequate tissue oxygenation (eg. rising lactate). ScvO2 targets are therefore of limited use in the ICU phase. French investigators hypothesised that an increased arterial-central venous CO2 difference [P(cv-a)CO2] may serve as a global index of tissue hypoperfusion when the ScvO2 goal of 70% has been reached in resuscitated septic shock patients. Using a P(cv-a)CO2 cut off of 6 mmHg, there was a significant difference between low and high ‘gap’ patients for cardiac index, lactate clearance, and improvement in SOFA score, but not for ScvO2. The authors conclude that in ICU-resuscitated septic shock patients, ScvO2 may be insufficient to guide therapy, and that when a target of 70% is reached, the presence of P(cv-a)CO2 > 6 mmHg may be a useful tool to identify patients who remain inadequately resuscitated.
http://www.ncbi.nlm.nih.gov/pubmed/18607565


A controlled crossover study cluster randomised among 13 Dutch ICUs examined both selective decontanimation of the digestive tract (SDD) and of the oral cavity (SOD) on 28 day mortality. The mortality rate associated with standard care
was 27.5% at day 28; the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. Concerns over the selection of multi-drug resistant organisms contribute to a lack of uptake of SDD; this study showing similar benefit of SOD which does not require the administration of systemic antibiotics, an so is more likely to be practice-changing.
http://www.ncbi.nlm.nih.gov/pubmed/19118302

A randomised prospective comparison study of 345 adult ED attenders with and without fever showed no difference in the reliability of temperature measurement by tympanic, oral, and axillary readings. Tympanic temperatures were not affected by otitis or by cerumen impaction. Although not statistically significant, tympanic readings were 0.15 degrees higher than oral, which the authors suggest may be advantageous in the elderly, in whom a single temperature reading of 37.8 degrees is a predictor of infection. Axillary temperatures were 0.27 degrees lower than oral.
http://www.ncbi.nlm.nih.gov/pubmed/19078836

The response of pulse-contour derived cardiac index to passive leg raising by 45 degrees predicts fluid responsiveness in patients with circulatory failure. French investigators demonstrated that performing this manoeuvre starting from a semi-recumbent, as opposed to a supine, position detected a greater number of patients with fluid responsiveness, thought to be due to recruitment of the splanchnic venous reservoir. In their study performing the manoeuvre from the supine position missed 15 of 35 fluid responsive patients. The recommend commencing with the patient in the semi-recumbent position, and simultaneous elevating the legs to 45 degrees while transferring the trunk from a semi-recumbent to a horizontal position.
http://www.ncbi.nlm.nih.gov/pubmed/18795254

A retrospective analysis of 16 365 patients from a Level I trauma center registry examined patient outcomes for several levels of pre-hospital systolic blood pressure. PSBP strongly correlated with systolic blood pressure obtained in the emergency department. The risk of death increased sharply when PSBP dropped less than 110 mmHg, which the authors suggest should become the cut-off for triage to a trauma centre.

http://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed&cmd=retrieve&dopt=Abstract&list_uids=19077604

Further evidence that the APLS formula (2 x (age +4)) underestimates a child’s weight is provided by a prospective study of 544 kids in Britain, in which the formula was compared with length-based and age-based estimates from growth chart reference data. While length-based estimates of weight were the most accurate, the authors concede that the practical difficulties of measuring a child during a resuscitation mean that the ready availability of age-based reference tables or charts in critical care areas is the best option, and more accurate than the APLS formula.
http://www.ncbi.nlm.nih.gov/pubmed/19104098?dopt=Abstract

December 2008 Clinical Update CME Questions

1. What is the effect on survival of administering pre-hospital thrombolytics to patients in cardiac arrest?
2. What percentage of patients who receive thrombolytics from massive PE will suffer fatal or intracranial haemorrhage?
3. What is the role of hypertonic saline in the management of severe hyperkalaemia?
4. What effect does sodium bicarbonate have on serum potassium levels in patients with renal failure?
5. What dose of salbutamol should be nebulised in severe life-threatening hyperkalaemia?

December 2008

Seasons Greetings! Some delicacies from this month’s literature to add to your Christmas fayre:

Some have theorised that giving thrombolytics during cardiac arrest might result in survivors in those with a thrombotic aetiology, such as MI or PE. An RCT from 10 European countries on 1050 patients may have put that idea to rest: tenecteplase and placebo had the same survival outcomes when given to out-of-hospital arrest patients prior to transport to hospital, although a seven times greater incidence (2.7% vs 0.4%) of intracranial haemorrhage in the tenecteplase group.
http://www.ncbi.nlm.nih.gov/pubmed/19092151

Speaking of pulmonary embolism, a review of the disease reminds us that a meta-analysis of 5 RCTs of thrombolysis in patients with PE and arterial hypotension or shock reduces death or recurrent PE from 19% to 9.4% compared with heparin alone (NNT = 10). The benefit is less clear in those with evidence of RV dysfunction but who are normotensive; the need for further therapeutic interventions is reduced but mortality rates are unaffected. The risk of intracranial or fatal haemorrhage from thrombolysis in PE is 1.8%.
http://www.ncbi.nlm.nih.gov/pubmed/19109575?ordinalpos=1&itool=Entrez...

A review of hyperkalaemia and its treatment contains some useful pearls: calcium gluconate is preferred to calcium chloride because of the latter's tendency to cause tissue necrosis if extravasation occurs; hypertonic saline may reverse the ECG changes of hyperkalaemia, particularly in the presence of hyponatraemia; 10mg nebulised salbutamol lowers serum potassium by about 0.6 mmol/l, whereas 20mg lowers it by about 1.0 mmol/l - however up to 40% of patients are resistant to the hypokalaemic effects of salbutamol, for unknown reasons; the effects of insulin/dextrose are additive to those of salbutamol; sodium bicarbonate does not reduce potassium in dialysis-dependent kidney failure. Read the full article for more detailed discussion
http://www.ncbi.nlm.nih.gov/pubmed/18936701

Cardiologists have described a new ECG sign of acute proximal left anterior descending coronary artery occlusion: instead of the signature ST segment elevation, the ST segment showed a 1-3 mm upsloping ST segment depression at the J-point in V1-V6 that continued into tall, positive, symmetrical T waves. In most patients there was also a 1-2 mm St elevation in AVR. These changes were seen in 30 of 1532 (2.0%) of anterior AMI patients. A recognition of this pattern is essential for ensuring these patients receive early reperfusion therapy.
http://www.ncbi.nlm.nih.gov/pubmed/18987380

November 2008 Clinical Update CME Questions

1. What effect does obesity have on outcome from critical illness?
2. List one or more ventilator measurements that might predict post-extubation laryngeal oedema
3. If you put the Zoll NIBP cuff on a patient's ankle at a primary due to limited access, how would you expect the reading to correlate with a brachial BP (if at all)?
4. List three reasons why outcome in severe burns has improved over the last few decades
5. What is the VITRIS trial, and where is it being conducted?
6. What is the evidence in the civilian population to support or refute the military 1:1:1 transfusion strategy in massive traumatic haemorrhage?
7. Which part of the body is most likely to be injured by the deployment of a steering wheel airbag

November 2008

Here’s the latest update of literature relevant to what we do. Don’t get stressed if you don’t get round to reading all the original articles -  reading the regular summaries should soothe your conscience and remove any nagging worries that you might be missing something big out there.

Let me know if these updates could be done in a more helpful way - feedback much appreciated


Critical care and retrieval
We all assume obese patients do badly on intensive care, but body fat may confer a survival advantage in critical illness. A study and editorial in Intensive Care Medicine add to the ‘large body’ of literature showing the optimal BMI for surviving critical illness is probably much higher than normally assumed, as adipocytes perform a number of protective functions including an immunomodulatory role.
http://www.ncbi.nlm.nih.gov/pubmed/18670754

A meta-analysis of six RCTs tells us that prophylactic administration of steroids in multidose regimens before planned extubation reduces the incidence of laryngeal oedema after extubation and the consequent reintubation rate in adults, with few adverse events. The accompanying editorial suggests a prudent approach might be to limit use to those patients at greatest risk of post-extubation stridor. Risk factors include female sex, short stature, trauma, and prolonged intubation. Laryngeal oedema may be predicted by deflating the cuff and demonstrating a leak of <18% ahref="http://www.bmj.com/cgi/content/abstract/337/oct20_1/a1841">

http://www.bmj.com/cgi/content/abstract/337/oct20_1/a1841

Pre-hospital Care and Trauma

For those of you following the etomidate story, a small nonblinded RCT in trauma patients comparing etomidate with fentanyl/midazalom is the first study to couple adverse clinical endpoints with depressed adrenocortical function. Not an issue in Australia of course, but there are enough Americans and Brits for this to give the willies to. http://www.ncbi.nlm.nih.gov/pubmed/18784570

So you're at a primary where a patient is trapped under a bus and just the legs are sticking out. Tempted to attach the Zoll to the lower limbs for Sats and BP? In normal subjects the mean NIBP at the calf or ankle is very similar to that at the arm, whereas the systolic will be a bit off. Now your obs chart needn't look incomplete even if your patient does. http://www3.interscience.wiley.com/journal/121509623/abstract

Ever been taught a simple way of predicting mortality from burns based on age and total body surface area burned (BSAB)? Examples include if age + BSAB > 75, there is a >50% probability of death. Well now there's a complicated one but it has a catchy acronym: The FLAMES score (Fatality by Longevity, APACHE II score, Measured Extent of burn, and Sex) was derived and (retrospectively) validated. The authors argue that a new more accurate predictive tool is needed because burns mortality has improved over the last few decades as a result of better management of burn shock, use of more effective topical antimicrobials, better systemic antibiotics, organization of regional burn units, earlier excision, and alternative measures for wound closure. Clearly this is tool for hospital use, catches on remember you heard it here first.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=...

More info this month on detection of intracranial hypertension by sonographic optic nerve sheath diameter measurement, this time in patients undergoing ICP monitoring. The take home messages: optic nerve sheath diameter correlates better than optic nerve diameter with ICP, and a small ONSD probably means ICP isn't raised. I'm not selling this very well am I?
http://icmjournal.esicm.org/journals/abstract.html?v=34&j=134&i=11&a=...

A nice example of an international collaborative pre-hospital research trial is VITRIS (Vasopressin In refractory TRaumatic HemorrhagIc Shock), being studied by a network of 40 EMS helicopters in Austria, Germany, Switzerland, The Netherlands. The rationale? To maintain coronary and cerebral perfusion pressures and minimise subdiaphragmatic bleeding in patients who would otherwise bleed out and arrest before getting to a hospital trauma team. This thinking is supported by successful animal studies, all further explained in the uploaded article.

Trial homepage: http://www.vitris.at/frameset.htm

Further data to support a liberal FFP and Platelet transfusion strategy in trauma is supplied by Vanderbilt University Medical Centre where they retrospectively evaluated their 'Trauma Exsanguination Protocol' (only in America... ). 30 day mortality was significantly better with FFP:RBC ratios > 2:3 and Plt:RBC ratios > 1:5. Nice to have civilian data to compare with the controversial and scarely achievable military 1:1:1 recommendations.

http://www.ncbi.nlm.nih.gov/pubmed/18469638


There’s another couple of papers to add to the pre-hospital intubation pile (thanks to Mark Newcombe for these). The first paper shows that air medical teams find it harder to effect advanced airway interventions inside the aircraft compared with on scene, and the second takes an interesting look at the effect of out of hospital intubation (OOH-ETI) on outcome when related to distance from hospital . At all distances OOH-ETI was associated with worse outcomes unless patients were transported by helicopter. Take home message? Intubation bad, helicopters good - or perhaps the RSI delivered by experienced helicopter teams provides a survival benefit in salvageable patients (as opposed to patients dead enough to be intubated without drugs). Take a look for yourself and see if you can make sense of it!
First paper: http://www.ncbi.nlm.nih.gov/pubmed/18924006

Second paper: http://www.ncbi.nlm.nih.gov/pubmed/18924009

You attend a motor vehicle collision and the driver’s airbag has deployed. Which part of the body is most likely to be injured by the airbag and its housing? The answer is the upper limbs , particularly forearm fractures. The risk is maximised when the forearm crosses the middle of the steering wheel, for example the left forearm when turning right. As pre-hospital specialists, you can sleep soundly at night smugly reassured that no-one else knows this sort of thing.

http://www.ncbi.nlm.nih.gov/pubmed/18784588

And on the horizon....
A supplement to November’s Critical Care Medicine contains a glimpse of what might be to come in the field of cardiopulmonary resuscitation: animal studies demonstrate the possible benefit of head cooling during CPR, infusion of bone marrow stem cells to facilitate neurological repair post-resuscitation, and replacing conventional chest compressions with electrical stimulation of thoracic cage musculature. Perhaps the most likely of the proposed interventions to reach clinical practice in the shorter term is the impedence threshold device, which appears to contribute to improved outcomes in both piglets and humans, although it has been around for a few years now without catching on.
http://www.ccmjournal.com/pt/re/ccm/toc.00003246-200811001-00000.htm;...

October 2008

Recent gems from the literature that we could use or should know about:

Pre-hospital Care and Trauma
There have been recent concerns expressed about the possibility of FAST scanning by our retrieval team prolonging scene times, but what about on board the helicopter in flight? Can it be done? Would the results be accurate? Looks like our counterparts in South Australia have answered the question
http://www.ncbi.nlm.nih.gov/pubmed/18339389
If anyone has full text online access to the journal Injury, please let me in!


A dilemma we sometimes face: big trauma mechanism, but the patient seems fine. Do we immobilise? Do we give oxygen? Do we take to a
trauma centre? Well here’s some Australian evidence that supports what we’ve known inside all along: mechanism alone does not usefully
predict major injury in patients whose physiology and physical exam are normal
http://www.ncbi.nlm.nih.gov/pubmed/18674759

Identifying raised ICP using ultrasound of the eyes: This technique has been known about for a while but the evidence base hasn’t been strong. A recent Indian study adds further weight to the conclusions of this year’s BestBet on the topic: that there is a correlation between raised ICP and an optic nerve sheath diameter greater than 5mm. Likely to change our practice in pre-hospital and retrieval work? You decide!
Optic nerve ultrasound http://www.ncbi.nlm.nih.gov/pubmed/18325519
BestBet http://www.bestbets.org/bets/bet.php?id=1641

Cardiovascuar Critical Care
AHA/ACC guidelines for STEMI - implications for emergency medicine practice. This helpful summary provides a useful update as well as guidance for when particular procedures and drugs are indicated. Could be useful for retrieval practice, for example in assessing the appropriateness of a request to transfer a patient for rescue PCI.

http://www.ncbi.nlm.nih.gov/pubmed/18519158


Heart failure therapy - out with the old, in with the new: Morphine’s role in acute heart failure has been questioned for a while now. This article from New Zealand summarises what’s known. Take home message: don’t use it as a heart failure treatment - it doesn’t work and could be harmful.

http://www.ncbi.nlm.nih.gov/pubmed/18973635

What about CPAP/BiPAP? We know that works right? The most solid evidence to date - a multicentre RCT - says nope! Outcomes are the same as ‘medical’ therapy, other than a small difference in patient-reported dyspnoea. Nice to know we don’t need to transport heart failure patients on NIV now - fix ‘em medically or intubate them.
http://www.ncbi.nlm.nih.gov/pubmed/18614781

So gimme something that works for heart failure!! Okay, but you’re not going to like it......Ultrafiltration seems to work better than diuretics, with a lasting benificial effect on the hormonal components of heart failure. A bit fiddly at the moment because it requires a similar set up to haemofiltration (central access, ICU nurses, a haemofilter). From a retrieval point of view let’s hope it doesn’t catch on Australia until the newer peripheral access devices become available.
http://www.ncbi.nlm.nih.gov/pubmed/18787444?dopt=Abstract


On the subject of central venous access, there are some things that will improve your chances of hitting the femoral vein : reverse Trendenlberg position, Valsalva maneouvre, or pushing on the abdomen in the RUQ. Combining them improves things further.
http://www.ncbi.nlm.nih.gov/pubmed/18632187

And finally...

Want a useful update on evidence-based management of GI bleeding? This one is brand new and fits in your pocket - from the Scottish Intercollegiate Guidelines Network (SIGN)
http://www.sign.ac.uk/pdf/qrg105.pdf

That’s it for now....enjoy!!

September 2008

Hearts and Minds
Some interesting stuff in the literature in the last few months, from high quality RCTs that may change your practice to review articles that can bring you up to date on the latest management of common emergencies:

HEARTS
Are you happy with the diagnostic criteria for MI? What about relative benefits of thrombolysis vs PCI? Have you heard of the newer alternatives to heparin: the DTIs and Factor Xa inhibitors? Check out the Lancet review of Myocardial Infarction

http://www.ncbi.nlm.nih.gov/pubmed/18707987

Extracorporeal Life Support (ECLS) vs convential CPR? Wouldn't that be nice!
http://www.ncbi.nlm.nih.gov/pubmed/18603291

Hard to imagine how this evidence could be applied locally, but for interest here’s an article on the pre-hospital administration of GP 2b-3a antagonists for STEMI:
http://www.ncbi.nlm.nih.gov/pubmed/18707985?ordinalpos=1&itool=Entrez...

This has to be the best paper of the season: the CAT study by Sydney’s own John Myburgh comparing noradrenaline vs adrenaline in 280 critically ill patients requiring vasopressors. What do you think the difference in outcome was?
http://www.ncbi.nlm.nih.gov/pubmed/18654759

MINDS
Review of therapeutic hypothermia for neuroprotection - what it works for, and the dos and don'ts. Recommended reading for FACEM and FJFICM candidates - this is a favourite topic for exams at moment
http://www.ncbi.nlm.nih.gov/pubmed/18539227

Thrombolysis for stroke - up to 4.5 hours now, although that’s not an excuse to dawdle (if you’re a believer).
http://content.nejm.org/cgi/content/short/359/13/1317

Want to waste money and time? Then give rFVIIa for intracerebral haemorrhage! Hemostatic therapy with rFVIIa reduced growth of the hematoma but did not improve survival or functional outcome after intracerebral hemorrhage.
http://content.nejm.org/cgi/content/short/358/20/2127

More soon!