May 2026; papers of the month

due to uncontrolled hemorrhage. So basically how things have changed over the past 30 years with all the newer evidence-based strategies that we have. And then finally we're gonna be covering some emergency airway management.

Okay, well we're gonna start off thinking about blood pressure management in patients with spontaneous intracerebral bleeds. And this is a topic that's had a fair bit of research over the last decade, but probably still holds a bit of debate and is a bit complicated when it comes to instituting this blood pressure management.

in these intracerebral bleeds. It's something that we don't do that often and it might be with agents that we aren't totally familiar with. So we're using this paper as an opportunity to do a bit of a recap on it.

Now, thinking about the previous literature that's out there, the attached two trial that looked at patients with spontaneous intracerebral hemorrhage and showed the intensive Cystolic blood pressure reduction to 110 to 139 millimeters of mercury didn't give functional benefit over 140 to 179 millimeters of mercury and caused more renal adverse events.

Then we've had an Interact two, which showed intensive blood pressure lowering to below one hundred and forty millimeters of mercury within one hour in acute intracerebral hemorrhage was safe. And associated with slightly better functional outcomes compared to a higher target of one hundred and eighty, but didn't significantly reduce death or major disability compared to the higher target.

And then there was Interact three and that tested a care bundle including blood pressure control with that systolic, trying to get that down less than a hundred and forty again. But with the addition of glucose management, pyrexia treatment and anticoagulation reversal. And that showed improved functional outcomes when that bundle of care was instituted.

or if they're going for neurosurgery to evacuate the clot or have an underlying structural cause. When rapidly lowering blood pressure in people with acute intercerebral hemorrhage, they say that we should aim to reach a systolic blood pressure of one hundred and forty or lower, whilst ensuring that the magnitude of the drop does not exceed.

sixty millimeters of mercury within one hour of starting treatment. And they also say that we should be considering lowering the blood pressure of those who present after six hours of onset. Or have a systolic blood pressure of greater than 220, taking into account the risk of harm. And that is what this paper's about. hopefully going to give you a good idea of the risk of harm so that you can make a more informed and nuanced treatment plan for your patient, hopefully getting better outcomes.

So this is a retrospective cohort study looking at over four hundred adult patients presenting with spontaneous intracerebral hemorrhage I am finding that difficult to say every single time in two large academic centres. In the United States. And that's between 2017 and 2023. Now there were nearly 2,500 patients.

them with intracerebral bleeds in this time frame at these centers. But after the exclusions with things like interhospital transfers, when they were last seen, not having any outcome status on discharge, this whittled it down to that much smaller set of patients at just over four hundred. Now the title gave it away really. They looked at whether achieving a systolic blood pressure of one hundred and fifty millimeters of mercury or below within two hours of E D arrival.

was associated with better outcomes in a real world setting. And they also looked at whether dropping the blood pressure a bit too low, so below a hundred and twenty millimeters of mercury, and they called that overshooting, was harmful. Now this is retrospective so they're going back through the notes of these patients.

So those patients with no or only one recorded blood pressure measurement after admission were excluded, as clearly they couldn't assess any blood pressure trend there. And in terms of looking at the outcomes, they used the modified ranking scale score at discharge. to assess those using zero to three as good and four to six as poor.

Now of all of those patients, three hundred and twenty three arrived with a systolic blood pressure reading of over a hundred and fifty. And this is what they found with them. So just over sixty percent received anti hypertensive medications within one hour of E D arrival. And that's not of scam, that is of E D arrival, so that's pretty impressive. and seventy one percent achieved blood pressure goals within two hours of that E D arrival.

Now, achieving the gold blood pressure within two hours of coming into the ED was associated with worse outcomes with an odds ratio that was statistically significant of two point three two. And if you look at the slightly longer time frame of six hours, overshooting the blood pressure, dropping it too low, was again associated with worse outcomes, with an odds ratio of two point five five.

Now they noted that the anti hypertensive medication, either bolus or infusion, did not influence the overshooting risk. And they also found that a blood pressure that was high on arrival was associated, I guess as you might expect, with poor functional outcomes. So, Rob, we're nearly there. The author's conclusion Although successful early blood pressure reduction is common in intracranial hemorrhage care, excessive lowering is also common and associated with worse functional outcomes.

Caution is warranted to avoid overshooting during acute blood pressure management. So come on, you've been silenced for long enough. What did you make of this paper?

I mean maybe conflicting might be a better way of putting it and it's certainly not of definite benefit to patients in terms of outcomes. And this paper just I think makes it a bit more complicated actually rather than simplifies it. I mean

They also had a higher NIHSS score. And the time to imaging was actually different between the groups as well. So I basically what I'm trying to say here is I think this means that those bigger and more obvious bleeds were being more aggressively treated and more expensive.

expediently treated. So it might not actually have been that that treatment necessarily was causing the harm, as in the blood pressure coming down. It might be that they were just within this study, because it was retrospective, they're identifying a group who are inherently at greater risk of a worse outcome anyway. But I think what's super interesting for me is the way actually, as you described, the nice guidelines tie in

Quite nicely with the findings here. They recommend, you know, for a subset of patients to aim for that blood pressure of around one hundred forty millimetres of mercury. But they specifically say, don't they, to do that carefully and not to drop that blood pressure by more than sixty millimetres of mercury in that first hour. So again, alluding to the fact that the magnitude of that drop matters just as much, I think.

And this paper I think it reinforces those principles for me in what is a very, very complicated set of patients here. So you want to avoid massive swings in blood pressure and you definitely want to avoid overshooting and taking that blood pressure too low would be my take home from this paper. So a smoother rather than super aggressive strategy.

would be the way that I was doing it. But this is super complicated and we talked about this off air, didn't we? So I mean what what were your thoughts and what was your take on this?

I know one of the markers of success is to get the blood pressure down and to be fixated on bringing it down and that being success. And I think this is a really great paper for highlighting Actually in quite a similar way to how we might think about rapid sequence induction of anesthesia.

That although you may not want the patient to be very hypertensive, you also need to be aware that going too low and going hypotensive is a real risk and that you can afford to take a bit of time to be really confident in the way that you're prescribing these, in the way that you're delivering them, and it is not a failure not to have that blood pressure sorted within the first few minutes.

This is about understanding where that sweet spot is and then really aiming in an informed manner to get there. I certainly don't think this paper means that we should suddenly abandon trying to correct their blood pressure, but we just need to be really precise. Uh and clearly there are some other bits in the paper, aren't there? That's the way that they've used the modified ranking score, which is a bit different to other papers.

This is looking at their functional outcome at discharge rather than ninety days. But that doesn't downgrade how useful the paper is. That's just the work that they're publishing. But no, I think this is Really informative and this is about precision medicine, isn't it? And I think this is well worth a read and well worth a delve around the topic in general.

Now there is some good news though. There was a seminal report back in twenty sixteen, so ten years ago, that estimated that around twenty percent of trauma related civilian deaths were preventable or potentially preventable at least. But since then, in the US at least

things have got actually a little bit worse. So what on earth's going on? You know, care has moved forwards obviously, hasn't it? Considerably in many ways, and we've got blood components which are more frequently used. We've got damage control, surgery. Early tranxamic acid, all now commonplace, but what effect have all these interventions had? Well, my paper this month looked at this in some detail and I think this is super important. Okay. So the group hypothesized that

that access to this modern hemostatic care should have changed the timing and the proportion of those bleeding related deaths. So let's take a look at what they found. Well the paper title is Timing of trauma deaths due to uncontrolled bleeding have not changed in three decades, a multicentre study of patients in hemorrhagic shock. So basically they've given it all away within the very first line of the paper. So anyway, what I would say is Bear with me, bear with me.

study. So that stood for the Shock, Whole Blood and Assessment of TBI study. Now this was a multicentre prospective cohort study of patients at high risk of life threatening traumatic hemorrhage and it recruited from seven level one trauma centers between twenty eighteen and two thousand and twenty one. Now, as we've said, these weren't just any trauma patients, though. This was a pretty specific and high risk group. So they were adults.

adults who had to meet at least two of the ABC criteria. Now the ABC criteria were a systolic blood pressure of less than ninety, or a penetrating mechanism, or a positive FAST scan. a heart rate of more than 120 beats per minute. So they needed at least two of those to get entered into the study in the first place. And then they needed to require blood products.

And needed operative or interventional radiology hemorrhage control, so IR hemorrhage control within one hour of arrival. So these are a super sick cohort of patients, which clearly the clinicians thought these people are in serious trouble from hemorrhage. They then took those cases where the patient did die and then established the cause of death, the timing of that death and the survival probability.

Now one of the s issues with studies like this is that you often look retrospectively at the data, but here importantly and I think this is why it's a really nice paper is that the cause of death was basically prospectively adjudicated by a group of trauma surgeons and then discussed across the SWOT investigators to reach a consensus, which I think is a massive strength of this work and a really nice way to do it when you're trying to work out complicated questions like this.

So, what did they actually find? Well, of the one thousand and fifty-one patients in the SWAT cohort, a hundred and seventy-six of them died in hospital. So an in-hospital mortality of sixteen point seven percent. And the timing, well, this is the bit that's really important. So seventy four percent of deaths occurred within twenty four hours of admission. Fifty-six percent of them occurred within six hours of admission, and thirty-five percent occurred within three hours of hospital admission.

And when you look, there's a really interesting graph on page five, so there is a big early peak which is really striking, and the deaths cluster right at the front end, particularly from bleeding. Now, in terms of the cause of death, so there were three ones that they broke it down into. So firstly, well bleeding was the major cause which contributed to sixty one percent of all deaths and was the single cause of death in over half and it occurred mostly in the first three hours.

Now they also report something called the TRIS survival probability, and this is a probability that is based on anatomical and physiological factors, and for those bleeding deaths. A third of them had a TRIS survival probability of over fifty percent. So their survival of probability was over fifty percent in a third of those that died. So that certainly implies that these were not all patients who were unsalvageable from the outset.

Now, we mentioned about bleeding. So after that, well traumatic brain injury was second most common cause of death, so contributing to eleven point four percent. That was usually later though, so typically those patients were dying twelve to forty-eight hours afterwards, and they had a much lower TRIS score. So only around eight percent of them were potentially salvageable or preventive.

And then well the last one, well that was organ failure. So that was third contributing to around ten percent and as you'd expect that obviously occurred further down the line. Now there are a couple of bits which I think are worth noting before I bring you the author's conclusions. So about one third of these patients receive pre hospital blood products.

and just two point three percent of them received prehospital tranxamic acid and just forty percent received it within three hours of their overall injury. Now, the author's conclusion before I let you in, Simon. So in conclusion, major causes of death and timing in a contemporary multicentre cohort of patients in traumatic hemorrhage shock admitted to advanced trauma centres remain remarkably similar to

to those described for the past three decades. And uncontrolled bleeding with a high probability of survival remains a challenge and a priority to reduce preventable trauma death.

uh mode of trauma that we're seeing here, isn't it? So firearms is pretty significant when we're looking at the cause of trauma and hopefully that won't reflect quite what we see here in the UK, but sadly that is what we're seeing in the US. I guess the other thing, other than just feeling a bit down about it all. Could this be accounted for by more pre hospital survivors making it to hospital and therefore moving the point of death into hospital? Could could that be

you know, a micro success. That's one more step along the pathway to there being survival for these patients. Yeah, I d I don't think there's an awful lot that I can critically appraise in this paper. This just really highlights the fact that really good essential care, you know, preventing those secondary traumatic brain injuries as well as we can, really good airway positioning, supporting ventilation, and really good expedient care.

to definitive care, I think is really important. And and that's what I took away from this. And we cannot, just because we think that we've got more bits in our toolkit, we cannot just assume, as I may have done, that actually outcomes are going to improve as a result.

the main group that you'd hope to see improvements in. But like you say, you might be, if you like, kicking the ball further down the line, you know, within terms of if you're getting more pre hospital survivors, but

I think in terms of the patient cohort that you've got here, I mean they were obviously really sick and fairly clearly had life threatening hemorrhage from the outset. So this doesn't apply to all the cases of major trauma we see out there that you know the prevalence of hemorrhage is definitely going to be

overinflated as the cause of death within here. But you know, I think that these are potentially those patients that we might have an opportunity to intervene on. And like you say, it's about making sure that we're doing the very best. within those time periods that we have those patients for. So whether that be pre hospital, as in are we making decisions that enable us to give the best evidence based treatment

and get them to a place of definitive care. Likewise in the ED, are we doing the right investigations to expediently get these patients to theatre or to IR? It's about just saying, right, we really need to consider now

that we've got these things in place. What is the priority for these patients? You know, what are the interventions that are gonna make a difference?'Cause there are still potential survivors within this group. So that means that if we can bring that care either further forward, so potentially earlier care out of hospital, either by bystanders or by clinical staff, whatever it might be.

Or when they arrive in the E D, let's just make sure that what we're doing is we're giving them the best care and we're making their transit through that system to that definitive point of care as quick as possible and as evidence based as possible for me. So yeah, I think it's an interesting paper. Really strange to see tranlexamic acid use so low, but I guess this was twenty eighteen.

two thousand and twenty one. So a little while ago now, hopefully that would improve if we're talking about evidence based care. That is for hemorrhagic death clearly one of the most evidence based strategies we have out there. So it would be Great to see that increase. But I think this is fascinating. It'd be great to have another look in five or ten years' time to see if we've narrowed that any more or made any further improvements. But yeah, interesting paper.

Because we've talked here a lot about the importance of high quality advanced airway management in the emergency department, we very often focus on it in the pre hospital setting, where potentially there's more time and resource allocation to improve it. But this paper gives a fantastic insight into how to make sure that practices of a high level in an emergency department and can give you some ideas about ways to improve it.

So the title of the paper is the rather catchily named The Infusion After the Bolus, a quality improvement programme to support emergency department airway governance in Ireland. The lead author is Lee and it's published in the EMJ this year. Okay, so this paper from Galway in Ireland looks at what happened when one Irish emergency department built a structured airway governance programme from not having one beforehand.

So to give a bit of background, Core Specialty Training in Emergency Medicine in Ireland has six months foundational anesthesia training before going on to advance specialty training in emergency medicine, where those emergency physicians frequently intubate in recess in those larger teaching hospitals with minimal airway training on a regular basis moving forward, which is also reflected in many other systems.

Now the Emergency Medicine Airway Registry Island or MRE represents the only existing airway database for Irish EDs and is a national quality assurance and audit initiative. And the team in this hospital in Galway introduced a whole series of quality improvement interventions over an eighteen month period.

as part of a quality improvement programme. And that hospital saw approximately eighty thousand attendances per year. So we're going to come on to their performance in a bit, but it's just worth having a think about what those interventions were. So throughout this time period they appointed an emergency airway lead.

They use the Amari linked QR code to capture data, and what that essentially means is they're prospectively capturing that data of that advanced airway intervention and being cognizant of that. They standardize airway checklists and equipment. They introduce video laryngoscopy and the recording of those events. They ran regular teaching sessions with a structured teaching programme called again, very catchy, Airways Biscuits and Caffeine, and that's ABC Rob in case you weren't concentrated.

Now this sounds absolutely aspirational, but also can uh get a feel for how much work this may have involved. It really does sound like a fantastic quality improvement process. But how big is that department? Well, there were eight and a half. whole time equivalent consultants in emergency medicine.

And at the time the Quality Improvement Project implementation there were sixteen registrars on the rotor. And they've got a team implementing all these changes, which has got two consultants in emergency medicine and really importantly nursing clinical facilitators. with additional support from the clinical lead of the intensive care unit.

Now, using the model for improvement, they made sequential interventions which were implemented between may twenty twenty four and october twenty twenty five. And in the paper they report the performance during this time period. And this is the point, I guess, to reflect on where your performance is in your emergency department and what you would aspire that it would be.

So during that time there were one hundred and fifty six intubations in the emergency department, with emergency physicians being the primary intubator in over eighty percent of cases. Overall first pass success was ninety-two percent with a complication rate of twelve percent and both of those were within their predefined safety target.

Now it's worth having a look at the paper because there's a load of detail in there that we won't cover on the podcast, but the authors note that one of the biggest steps forward seemed to come once they moved beyond the equipment changes and started focusing on human factors.

So with those daily drills, sign off processes, supervision, and a culture of feedback, they all seem to make a real difference. And the conclusions from the authors a structured airway governance program combining leadership, Checklist standardisation, simulation and continuous feedback was associated with maintenance of a first pass success of greater than ninety percent and low complication rates over time.

This pragmatic, replicable framework supports the establishment of national emergency medicine airway governance standards to maintain procedural competency and patient safety and is replicable in international EDs. with similar pre existing airway management practices. So Rob, clearly an interest of mine, but what did you make of this paper?

written on the topic, but obviously that's not why I really like this paper. It's about that approach that they've taken that they've described, isn't it? All of those interventions that they've layered together, not just that one thing. So, you know, it's like

Th well it's all written within there. You can go and have a reading it, all the different steps. I think there's about eleven or twelve different things that they instituted over the four PDSA cycles and this is a really well thought out, really well described programme, been introduced across that whole system and that's clearly

clearly where the the real value is for me. I think it it really shows you how you can go from a sort of a a a reactive governance process, so, you know, through incident reporting, datics, whatever it is that you use, through proactive governance where you're just just continuously measuring, reviewing, improving performance, having educational opportunities, listening to feedback.

It just shows you that beautifully and essentially how you start to remove, as they mentioned within the paper, you know, the latent patient safety risk that sits with all of our departments when you have that reactive governance.

And this is about taking ownership of that system wide issue and using data to drive that rather than waiting for stuff to go wrong. So I mean I I just think it's a great paper for many different reasons. And if anyone is getting involved in any quip processes, go and have a look at this. It's a great starting place for anything to do with emergency care. Yeah, hats off to the authors. It's great read.

I found this really inspiring. There are a couple of little bits in the paper, you know, I think this is amalgamating card deck arrest and RSIs into one thing. So really understanding the complication rates is difficult. But that really doesn't take away from the fact that there are some great suggestions in here on how you can deliver safe and effective care. And anyone interested in delivering excellent resuscitation should really go and have a look at this. Great work.

A massive thanks once again to Zol Medical Corporation for collaborating with us on the podcast and making this all free open access available to you. And if you fancy a bit more, if this hasn't done you in so far, then why not go and take a look at our online courses? We've got the RSI, intubation, cardiac arrest. Critical appraisal, extrication, etc etc. All available on the recessroom.co.uk. So that's it from us. Take care of yourselves and we'll speak to you soon.