#RCEMasc 2021

Lots of good stuff again from the virtual #RCEMasc21 –  here are a few of the topics that got me thinking

Sepsis – Timing of antibiotics

  • This retrospective single site cohort paper – looked at factors affecting mortality in Sepsis patients
  • It found:
    • “Septic Shock patients” Giving antibiotics in <55min had a massive mortality benefit and a NNT=4
    • But NO mortality befit in the “All septic patients group” for IV antibiotics given <1hr vs >1hr
  • This fits to the findings of a recent meta-analysis by Rotherick et. al. 2020 
  • Bottomline:
    • Treat Septic Shock Fast <1hr – it saves lives!
    • Timing of antibiotics generally in sepsis? – Keep aiming for 1hr, we prob needs to have a trust discussion regarding: resource, stewardship & outcomes.

 

Pediatric MAJAX Triage (Pre-Print article)

  • This study examined 4 different paediatric MAJAX triage tools
    • 2 current tools , a proposed tool from Sheffield and the standard Adult tool
  • The Sheffield(SPTT) and Adult (MPTT-24) tools both out performed our currently tools [SPTT (right) MPTT-24 (left)]
  • However, the Adult (MPTT-24) is simpler and more familier
  • Bottomline: we will. need to await publication but one to think about for MAJAX committees

 

Children with Fever and Non-Blanching Rash – PiC study

  • If they look sick its easy(treat meningitis) but what about those well looking ones?
  • The study examined the sensitivity and specificity and cost for picking up serious illness, of Trust guidelines from around the UK + NICE
  • All 100% sensitive for Meningitis and serious infections
  • Specificity varied from 0% with NICE to 36% for the best performing (BART’s guideline)
  • However, for Doctors going off guide, sensitivity dropped to 89%

Risk of missing Orbital Cellulitis in children

  • So you think the kid may have peri-orbital cellulitis – should you go oral antibiotics and go home or should you give IV’s and keep in?
  • This study recruited 216 children with ? periodical cellulitis.
  • 5/216 had potentially missed orbital cellulitis
    • 5/5 had fever (31% of periodical cellulitis)
    • 4/5 had vomiting or headache (3% of periorbital cellulitis)
    • 1/5 was an infant who was difficult to examine and not chatty about any headaches
    • All got IV medication
  • 3% of those started on oral medication – returned requiring IV’s
  • Recommdation in paper : use the ASSET score (4+) to differentiate between oral and IV groups (below)
    • Reduced IV antibiotic use
    • Picked up all the orbital cellulitis children and those who represented
  • Bottomline:
    • Guess orbital cellulitis if the patient has fever or systemic features.
    • Discussion with Paeds team about adoption of ASSET genrally

Other Interesting Bits

  • What animal are you?
    • find your personality on icould buzz quiz (100% susses for my family)
    • should we all weara badge – to warn others??
    • Bottomline: Tawny Owls rule!
  • Huddles
    • Should seniors ask – “what are your learning objective for the day?”
    • Should we so a mental rehearsal/sim of a case? – found to identify service and knowledge gaps
  • Ultrasound Pulse check in CPR
    • feeling pulses can be difficult and slow during CPR – should we think about ultrasound?
    • POCUS pulse check (5.39s)  vs Manual pulse check (6.40s)
      • p value <0.001
  • Concussion
    • not as simple as it seems
    • 30-50% have persistent symptoms for >6months
    • Should we be using SCATs tool – ?
    • What follow up is there – ?
    • Do we need better patient advice – Yes
  • Injuries
    • Remember!: X-rays are just a test they can be wring (as usual Hx and Ex improtant
    • If X-ray -ve think what are you SCAReD OF?
      • Septic arthritis
      • Compartment synd
      • Abuse
      • Referred pain/Report wrong
      • Dislocation/subluxation
      • Operative soft tissue injury
      • Fracture (occult)

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