REALISTIC EMERGENCY MEDICINE
Why is this patient dying in my resus room? Dr Calvin Lightbody
4/10 patients in hospital are >75, 3\10 are in the last year of life
1/2 of those over 85 in hospital will dit within 1 year
11.5% of nhs budget spent on people who died in hospital
£777million spent on emergency admissions in over 80s
Questions to ask when patient may be at end of life:
What is your understanding of your current condition? How are things now compared to 6/12 ago?
What are the important things to you in life?
What are your fears and anxieties?
When caring for someone who is at the end of life:
Set appropriate goals
Avoid over treatment or investigation
Avoid under treatment of Palliative care needs
Minimise harm at the end of life, 1/3 of patients experience harm at the end of their life die to over treatment or investigation.
Supportive care is not the second best/giving up
Maintain dignity
Treatment escalation/limitation plans go beyond the scope of DNACPR.
Diabetes and Endocrinology; acute presentations and management Dr Una Graham
Acute pituitary bleed/adrenal insufficiency. .. need steroids asap, test electrolytes and glucose.
Adrenal insufficiency causes low na+ high k+, fatigue, weakness, myalgia, gi symproms, postural dizziness, pigmentation
Primary hyperthyroidism …ask about recent pregnancy, recent illness, new medication (?thyroiditis), eye changes /goitre (more likely autoimmune thyroid disease).
Thyroiditis will settle, autoimmune disease may need carbimazole.
Admission decided by how biochemistry affects patient – use the Wartofski score.
Severe hypertension…is it primary or secondary? Is there end organ damage?
Management depends on how the BP is affecting the patient.
If there is no end organ damage reduce BP over a few days with close monitoring. End organ damage requires rapid reduction in HDU setting.
Severe hypocalcaemia associated with hypomagnesiumia give calcium gluconate until asymptomatic, replace magnesium 6g over 24hours.
Top 5 trauma papers Dr Matt Davies #traumadocmatt
CT head in patients who present after 24 hours of injury Marincowitz et Al 2015
8.4% pre 24 hours and 9.9% post 24 hours had CT abnormalities. NICE Guidance is only 70% specific when it is more than 24hours since injury.
Beware of late presenting head injury
REBOA 2019
REBOA group had higher 24 hr mortality 26% vs 12% and time to definitive treatment was significantly longer. Howere the Data analysed 2015/16 so REBOA has improved since then…need to await more evidence.
Prehospital administration of plasma produced a decrease in bleeding and improved survival
Disparities in the management of paediatric splenic injury Warwick et Al 2018
More children under go splenectomy when treated in adult centres compared to paeds MTC.
Vast majority of isolated splenic trauma can be managed conservatively.
Changing the system, major trauma patients and their outcomes in the NHS 2008-2017.
Observational study using TARN database.
Case mix has changed- more elderly falls.
More TXA (0% to 90%) and more consultant led care.
Process measures improved eg CT times
19% increased risk adjusted odds of survival.
Reorganisation has significantly improved patient outcomes and process issues.
Establishing a Geriatric Emergency Medicine Service Dr Rachael Morris-Smith @two_docs
Rachael.morris6@nhs.net
Recommend Paper boat blog from the British Geriatric society
Geriatrircs have complex multifactorial needs and presentations are not what they seem. Prolonged stay deconditions and causes delirium.
Comprehensive Geriatric Assessment- a multidisciplinary assessment, gold standard of assessment resulting in a care plan.
GEMS team up skill whole ED, more likely to return home vs admission. GEMS teams have time for detective work, CGA, talking to Patients/carers/family.
Clinical Fraility sore to identify frail patients used by ambulance service and department for referral to GEMS.
Not an admission avoidance service.
PAEDIATRICS
Top 5 PEM papers Dr Tessa Davis …..co-founder of “don’t forget the bubbles”
JAMA paediatrics
Fever in children under 60 days old.
1821 febrile infants only 9% had serious bacterial infection
Low risk if negative urine, neutrophils less than 4 and procalcitonin less than 0.5.
There may be a group of well febrile infants that don’t need an lumber puncture but not yet a use able exclusion scoring system.
Franklyn et Al NEJM
Under 12 months with bronchiolitis and oxygen requirement.
2l/min via nasal Cannuale or 2l/kg/min
12% high flow vs 23% low flow needed escalation of care but no change in length of stay. High flow doesn’t increase rate of adverse incidents, consider high flow oxygen for children with bronchiolitis and an oxygen requirement.
Foster et al. Lancet respiratory
Preschool children with Viral wheeze receive Prednisolone1mg/kg or placebo for 3 days.
Some preschoolers are responsive to steroids but we aren’t sure which ones..likely because different pathologies are presenting with the same symptoms.
Journal of paediatrics and child health
Do not need to search child’s stool, once FB in stomach it will pass.
Borland et Al annals of Emergency Medicine
Outcomes for children with head injury presenting after more than 24 hours
Scan more in the late presenters, 3.8% have tbi vs 1.2% in the immediate presenters.
Increased tbi when present late.
Copperman et Al nejm
1389 episodes of DKA fast rehydration vs slow rehydration 0.9% and 0.45% for both groups.
No change in rate of cerebral oedema and brain injury.
Sudden a Unexpected Death in Infancy Dr Julie-Ann Maney
Co sleeping implicated in 72% of all sudics
Breastfeeding feeding is protective
Poor children are 5 times more likely to die
Paediatric Neurosurgical Emergencies Dr Nandini Kandamany
Doing the basics well will protect a child’s brain…
Aim for sats of 98%
Maintain CPP and assume ICP is 20mmHg to guide MAP
Maintain etCO2 4.5 -5.0
Allow a permissive tachycardia to maintain CPP.
