Thread by @Michael_T_Smith

This thread is going to be my #ERC19 tweet-torial with all the best pearls of resuscitation wisdom! @ERC_resus

We opened with a performance from the pop choir of Slovenia! A great way to start the conference and spread a bit of joy!

The first lecture was the Peter Safar lecture. We learnt about the origins of CPR and how effective public health interventions such as teaching CPR in schools can be! We also saw this delightful video from the Italian Resuscitation Council

Next we were asked ‘what’s basic about BLS?’ And ‘can lay rescuers master mouth to mouth’. If being taught in the moment over the phone, lay rescuers should do compression only CPR. If learning on a course the answer is unclear but hopefully TANGO-2 will give a clearer answer!

Does ALS save lives? The answer seems clear but the evidence from many recent trials seems to suggest that less is more! Each intervention has a signal of benefit but the effects are limited! It is likely to help some patients - we just have to learn to work out what helps who!

There are many reasons that kids are different - including some clear physiological and anatomical differences. The chances of ROSC are often higher owing to the lower levels of coronary disease! But one of the key differences is the impact on the rescuers and the family!

Neonatologists can teach adult physicians plenty - including the importance of monitoring oxygen therapy! Resuscitating in controller oxygen levels compared to 100% has a number needed to treat of just 20 to save another neonatal life!

We also learnt about some educational theory - ensure that you mix up your teaching sessions to keep them interesting! Increase the difficulty for those who are performing well and ensure they are training in their zone of proximal development!

Resuscitation and medical education are evolving in the social age! Doctors used to need to know all of the facts but now they are accessible in an instant! Now critical appraisal skills are the most important - know who to trust and beware mavens!

We also battled the ethical issues arising in resuscitation! Why do many ED staff struggle with palliative care? Because they have been trained to view death as a failure and do not feel prepared for such situations! We need to reframe the situation!

The first lecture of day 2 saw the conversation switch to dispatch! Is machine learning the future? A system which involved analysing the wording used and the sounds in the background of the call increased OHCA identification from 72% to 84% but also gave more false alarms!

Next the conversation came back to ventilations in BLS. Current guidelines suggest that the delay in compressions shouldn’t exceed 10 seconds. It has been shown lay responders can achieve this on mannequins, but will they achieve this in the stress of a real arrest?

Next we learnt about what is new in choking! This is often thought of as a problem in the young but is most commonly seen in elderly patients with many comorbidities. For lay rescuers the old combination of backslaps and abdominal thrusts is still the most effective way to help!

We also heard about the different phenotypes of brain injury seen after a cardiac arrest! The most severe are severe cerebral oedema which leads to neurological death, and EEG suppression with polyspike bursts where the patients have normal GWR but often progress to WLST.

Next we discussed airways in paediatric arrest! The results from an observational study appeared to be in line with AIRWAYS-2, suggesting no difference in pre-hospital ROSC or 1 month survival between SGA and endotracheal intubation!

Much has been said in recent years about text/app cardiac arrest responders. But how many responders and AEDs are required for an ideal system? In the Netherlands some recent work suggests at least 2 AEDs and 10 rescuers per square kilometre - and this still isn’t always enough!

Another researcher attempted to understand the variation in the use of first responders across Europe! The most common method is to use the fire service but practice varies widely. It is suggested that all countries should utilise a system - selected based on their unique system!

We also heard some analysis of the German mobile rescuer system. The presence of a mobile responders reduced time to first CPR from 4 to 7 minutes. This did not affect the rates of ROSC but improved the number of patients surviving with a good neurological outcome!

The next section discussed changes to resuscitation in abnormal situations. It was thought that the coldest survivor was 11.8c. That was until the rediscovery of some research from the 1960s where patients were resuscitated after being cooled as low as 4.2c.

So be careful not to stop resuscitation just based on temperature! K+ over 12 is an indication of poor outcomes, but there is hope that the new hypothermia (HOPE) score will allow more effective prognostication!

In drowning patients prevention is better than the cure! Recognising a drowning patient is vital - they are likely to be vertical in the water, facing the shore with their head leaning back and their mouth just at the level of the water!

Traumatic cardiac arrest has long been associated with poor outcomes but these have significantly improved in recent years! Remember the HOTT causes of traumatic arrest and aim to treat the underlying cause! If feasible to do so - CPR is still recommended!

One of the key resuscitation differences in a mass casualty incident is the change in ethical thinking. Your focus is no longer an individual patients outcome - but the outcomes of multiple patients. Sometimes it may not be suitable to utilise all of your resources on one resus.

The next section discussed some controversial topics within ALS. Starting with advanced airways! The advice was that if you can ventilate with basic techniques, then delay intubation until after ROSC. Especially in systems with lower first pass success rates!

Paramedic-2 showed that adrenaline improves ROSC rates and survival rates, but not survival with a good neurological outcome! Is it beneficial? Remember that the data shows that 120 patients need to receive adrenaline to produce 1 patient with severe neurological disability!

The ROC-ALPS study also suggested that lidocaine was more effective than a placebo in the return of ROSC. Many centres are therefore utilising lidocaine instead of amiodarone in cardiac arrests with a shockable rhythm (a position supported by ILCOR)

The same study was also used to discuss access. The study found that in patients receiving IV lidocaine/amiodarone there was a significant improvement in neuro outcome over placebo- but in the IO access group the drugs had no effect! Is this because IO access is less effective?

In the afternoon I attended a workshop on the use of virtual reality in teaching CPR. Although the development of a programme is time consuming and costly - once the equipment is in place could it provide the opportunity to bring distance learning to BLS?

The third day the discussion was centred on prognostication. Pupils have long been used for this but is quantitative pupillometry the future? The neurological pupil index outperformed the standard pupil light reflex in a number of ways as a prognosticator!

Biomarkers are also useful as they indicate the level of insult received. It has been shown that Classical thresholds of NSE are incorrect and the test is non-specific! Neurofilament light chain is showing great promise as a future prognostic indicator!

Seizure activity is also assessed in patients and status epilepticus present on an EEG is a poor indicator. However, patients with spike wave patterns may have survival rates as high as 50%. If treating with AEDs, be careful not to let sedative side effects could prognostication!

So can we begin to prognosticate earlier after cardiac arrest? The signs are promising with gray/white ratio, malignant EEG, neurofilament light chain and quantitative pupillometry all demonstrating false positive rates below 5% in the first 24 hours!

The final set of lectures teased the exciting upcoming EuReCa2. The results are sure to help guide resuscitation practices and policy over the next few years!

We also heard about the question of organ donation and how we can maximise benefit while optimising patient autonomy.

The final lecture was the negovski lecture - where we heard about the astonishing use of chest compressions, defibrillation and even ECPR long before the rest of the world was using it!

We also heard about the outstanding work being done in Ljubljana in increasing cardiac arrest survival - particularly in those with a cardiac cause!

The entire conference was an outstanding experience, and Ljubljana was a beautiful host city!

On a personal note it was a great experience to present some of my own research, meet some of the great minds working in resuscitation and get to join the young ERC as their new social media coordinator! #ERC19