Author: embeds

TXA – Tranexamic Acid

TXA a bleeding wonder drug!

Crash 2 Study (2010)

  • Multi-Centre RCT of the use of TXA in trauma
  • Inclusion – Adult trauma patients with ≥1 of
    • Suspicion of significant haemorrhage
    • HR ≥110bpm
    • sBP ≤90mmHg
  • Treatment – 1g TXA IV over 10min then a second 1g TXA IV over 8hrs
  • Outcome – Significant reduction in Death, bleeding with NO increase in clots(thrombotic disease)
    • Most benefit seen if given early (<3hr – NNT 53)

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Acidosis & VBG’s

We are frequently asked to check the lactate on Venous Blood Gases (VBG’s), by the nursing staff. However, remember to look at the first result (pH) it is the most important.

Acidosis: Unless you have a good reason (e.g. you know its due to DKA) you should be investigating and performing an Arterial Blood Gas (ABG)

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#RCEMasc 2019 – Day 3

AIRWAYS-2

ETT vs SGA (i.e. iGel) in out of hospital cardiac arrest (trauma and kids excluded)

  • Headline Results: 
    • Survival with good neurological out come (MRS 0-3) – No difference around 2.75% (for those that required either SGA or ETT)
    • Easiest – SGA easier achieving ventilation within 2 attempts (87.4% vs 79%)
    • Displacement – SGA suffer more displacement (10% vs 5%)
    • Aspiration – No difference around 15%
  • Interesting Results:
    • Survival – approx. 20%  in those that didn’t have an advanced airway attempted (indicating likely survival advantage of only needing a short resus)
    • Paramedic use of advance airways – Paramedics on average only need to use advanced airways 3-4 times a year!
    • PART study (USA) – ETT vs Larangeal Tube no difference
    • BMV vs ETT (France & Belgium) – no difference in out come, but BMV was more difficult

PARAMEDIC 2

Adrenaline vs Placebo in out of hospital cardiac arrest

  • Headline Results:
    • Survival to hospital admission: adrenaline 23.8% vs placebo 8% (Significant)
    • Survival @ 3 months: adrenaline 3% vs placebo 2.2% (Significant)
    • Survival @ 3 months with good neurological outcome (MRS 0-3): adrenaline 2.1% vs placebo 1.6% (Non-Significant)
  • Interesting Result:
    • What did the public thing was the important outcome? In the restudy survey 95% of public reported that survival with good neurological outcome was more important than surviving to hospital.
    • Extrapolation of Adrenaline use: to all UK adult cardiac arrests in a year, adrenaline would increase:
      • ROSC: 5602
      • Admissions: 3555
      • ICU Admissions: 1643
      • Discharged Alive: 203
      • Favourable Outcomes (MRS 0-3): 68
      • Unfavourable Outcomes (MRS 4-5): 135
    • What should happen? International resus (ILCOR) now strongly recommend adrenaline use, however, we probably need public consultation

TXA for bleeding

Dr Ian Roberts

  • Inhibits fibrinolysis – i.e. stops plasmin breaking down clots
  • Treats bleeding – NOT coagulopathy
  • Given TXA Early – as tPA activates early and PIA-1 is later, we need to stop the tPA
    • 15min treatment delay > 10% reduction in effect
  • Give on the suspicion of bleeding? – you get the same risk reduction  what ever your base line risk (i.e. 30% risk of death > 20%, 3% risk > 2%)
  • Safety – in Japan TXA bought over the counter for headaches
  • RCT’s
    • Surgery – TXA reduces blood loss by 1/3 & death, NO increase in clot events
    • Post-Partum Haemorrhage – PPH reduced by 1/3
    • Trauma – Sig. reduction in DEATH (<1hr reduced by 1/3, 1-3hr by 1/5)
    • Vascular occlusive events – data seems to show TXA reduces them
      • Bad bleeding  increases vascular-occlusive events
    • Brain  – results apparently don’t contradict other studies but full results in 2weeks
    • GIT – results due next yea, recruitment stopped in uk as TXA was being give anyway
  • Why have the infusion? – added to regime to (theoretically) replace the loses from ongoing bleed, its utility is unknown.

Lightning papers

  • Mobile phone use @ work(Derby)
    • 80% patients thought it ws fine – this increased to 95% if explained for medical reason
    • Patients didn’t want – you to be using it while talking to them (distraction/rude), dont wipe it on them (infection control)
  • Hair Ties with glue (HAT) vs Suture (not those that would only have been glued anyway)
    • Reduced pain
    • Reduced follow up
    • increased patient satisfaction (less pain and no need to see
    • Faster and increased staff satisfaction
  • No Room @ the Inn (Bristol children)
    • Used winter pressures money to open the clinic space next to ED 18:00-23:00 (if needed)
    • Opened it 50% of the time
    • Used it for 10% of patients
    • Minor Injury/Illness (they do have a UTC)
    • Staffed from the ED
    • Patients and Staff like it!
    • Plymouth also do – staff love it as almost a break from the chaos of majors
  • Who’s pain are we treating?
    • 50% Dr’s assume patients want a prescription, but <30% actually do
    • Patients expect more pain in the following days – than Dr’s expect
    • Patients want to know that codeine is potentially addictive within 3 days
    • They have reduced co-codamol scrpts from approx 10% to 3% of discharges – with no increase in complaints or patient satisfaction.

Mental Health

  • RESPOND  – multiagency mental health crisis simulation
    • Everyone has to make the decisions of each role (Police, Nurse, Dr, Paramedic)
    • Reduced demand on each agency
    • Strengthens partnerships
    • Streamlines process
  • Presentation in the ED –  RCEM mental health tool kit
    • Triage:
      • Agitation, Environment, Intent, Objects
      • VISA: Violent,Irrational thought, Suicidal, Alone
    • Capacity – Are they really weighing it up? if in doubt NO
    •  Observation
      • Mental Health Obs: Calm/Distresses/Agitated/Aggressive/Gone
    • No Scores predict risk – its a holistic assessment thats needed
    • Compassion & Communication – we shouldn’t make things worse for the patient
    • Restraint what to do and do we need it?
    • APEx course – ALSG

 

#RCEMasc 2019 – Day 2

Paracetamol 12hr SNAP regime: 2014 & 2019

  • What is it? 
    • Pre-NAC – 4mg Ondansetron IV
    • Bag 1 – 2hr 100mg/kg NAC in 200ml 5% Dex
    • Bag 2 – 10hr 200mg/kg NAC in 1000ml 5% Dex
  • Advantages
    • Saves 9hrs
    • Significant reduction in anaphylactoid reactions 2% vs 11%
    • Significant reduction in gastric symptoms (if either ondasetron or 12hr regime used)
    • Significant reduction in treatment pauses
  • What next?
    • 10 centres using (inc Edinburgh, Newcastle, Guys St Thomas’)
    • We can’t implement the 12hr regime just yet (however, discussions are going on with Acute Med and Hepatology)
    • Pre-NAC ondasetron does seem like a good idea

Frailty

  • Comprehensive Frailty Assessments
    • NNT to prevent a death 17
    • NNT to prevent NH admission @ 6months 20
  • Frailty Score @ Triage 
    • Initially 50% accuracy (esp. around 4/5)
    • Addition of props significantly improved triage accuracy
      • Do you find walking more difficult or do you need mobility aid? Yes > 4+
      • Do you do your own shopping & housework? No > 5
      • Do you need help washing & dressing? Yes > 6
      • Do you live in a care home or have carers?
        • If carers > 5+
        • If needs assistance with personal care > 6-7
      • Are they confused or have a diagnosis of dementia? Yes > 5
  • Delerium
    • PINCHME  – for all frail patients they may not have delirium now but soon…
    • Parkinson’s Disease and can’t swallow
      • Find the right dispensable regime or patch – use pdmedcalc
    • Other ways of doing things
      •  TRAWL
        • South Tees frailty team call all discharged frail patients to ensure things are going well and arrange further input as needed
      • Falls Rapid Response Team
        • Newcastle and Gateshead, paramedic and OT in a car reduce, conveyance to ED from 75%(with Ambos) to 45%

Dying

We all do it and we all want the best death possible – But we often do it badly

  • 1:3 patients admitted on acute adult take are in their last year of life
  • 80% of NH patients are in the last year of life

But we don’t always know which patient or recognise how quickly this will happen – think about the following:

  • Parallel planning: we can be both treating the patient, and making plans how we can allow them the best death if they are dying.
  • Sedating For Scan: PAUSE – this might be the last time they are conscious, consider them and their family and do they need time
  • Use the word Dying: find out what is important to them, and their family, what are their fears and what they want to know, allow silence.
  • Society is unfamiliar with death: Narrating whats happening for the family can help, e.g “that rattley noise you can hear is only a small amount of fluid in their throat, it can sound horrid but its not bothering them at all” Remember we are used to these stages but to families they are scared and they often assume that the patient is suffering.

You may want to look at the talking about dying resources from the RCP

Top 10 papers

Go to St Emlyns’ see the whole thing and read the papers, subjects include:

  • Should every ROSC go straight to the Cath Lab?
  • AF: Mg & Early Shock
  • Dose Criocoid press just make things more difficult?
  • Can we bag during RSI?
  • Vasopressors: septic shock & haemorrhagic shock?
  • POCUS in cardiac arrest

 

Parkinson’s Disease & can’t swallow

We all recognise the importance of ensuring patients with Parkinson’s disease (PD) get their medication, but..

What do you do if the patient can’t swallow?

We will need to work out what alternative routes we could use, for example dispensable via NG or patches, and what dose. For an ED clinical it is most likely beyond us and we need help! However, that may be extremely difficult to get especially Out of Hours

pdmedcalc

Excellent website that can give you options – select the patients normal regime (initially just one line but you can add as many as needed) and press calculate.  It gives you a dispensable and patch dose, which can help the discussion with pharmacy about where we can get it

#RCEMasc 2019 – Day 1

For those back home its been an interesting 1st day at the conference  – and the top 5 are

1. Learning from Child Death

Great session, presented by both clinical staff and parents, around the death of a 3yo with Down’s syndrome, from sepsis. Highlighted some key points that we can all do better:

  • Communication:
    • Listen to the Carers: the parents could see the patient wasn’t his normal self but staff didn’t head the warnings, and his parents felt ignored.
    • Let Carers know whats happening: The patient was moved to Resus, we might think the parents know what that means, but they thought it was just because everywhere else was busy.
  • Unrecognised deterioration:
    • The child deteriorated through the ED stay of >8hrs, and the sepsis was only picked up and treated on paediatric ward, after a fresh set of eyes. Remember if you put a frog in boiling water it jumps, but if you turn the heat up slowly its dinner. Always be alert to the slow change!
  • Responsibility:
    • The patient remained in Resus after being seen by PICU who had then referred to Paeds – Who was looking after him? We are ALL responsible for that patient – ED and the specialities!

2. Non-blanching rash & fever in children

There are many sets of guidance out there with 100% sensitivity, however, specificity varies. NICE has a specificity of approx 1%, while the best performing Newcastle, Birmingham, Liverpool (NBL) algorithm performs at about 44%. And Purpura (defined as being between 3 milimeters and 1 centimeter in size) is a BAD sign!!!

The NBL algorithm

 

3. STEMI – de Winter is coming!

The de Winter T wave is an important ECG sign of MI, that can develop quickly into the classic STEMI. Its present in 2% of cases so learn it.

  • LITFL

    Tall, prominent, symmetric T waves in the precordial leads

  • Upsloping ST segment depression >1mm at the J-point in the precordial leads
  • Absence of ST elevation in the precordial leads
  • ST segment elevation (0.5mm-1mm) in aVR

 

4. Toxbase Pearls

  • Severe Ca/β blocker overdose – move through the treatments relatively quickly in a step wise manner as Toxbase (i.e. dont wait for ages to see if it works it either does or doesn’t). To get to High Dose Insulin Euglycaemia Regime, this seems to be one of the best therapies
  • Charcoal: Evidence coming out suggesting it is useful beyond the 1hr period, and higher doses seem better (watch this space)
  • Whole Bowel Lavage: Really difficult but good in body-packers, Iron & Lithium as well as Sustained release compounds.

5. Malaria

  • Rapid antigen test and thick and thin film – good but not 100% (esp with ovalae)
  • 5-10/yr patients die in UK from malaria – Mainly as unrecognised (travel to malaria region and unsure why they are unwell test)
  • Is it Ebola or Malaria? – if you can’t get malaria screen done (?ebola can slow the labs down) – Assume Ebola & treat as severe malaria concurrently

 

 

 

Haematoma Block – Colles’

Haematoma blocks can be a safe and effect method of pain relief to facilitate reducing Colles’ fractures.

What to give?

  • 1% Lidocaine
    • Onset 10-15min
    • Offset up to 2hr
  • 3mg/kg (maximum dose)
    • 70kg patient could have up to 210mg
  • Volume 1% Lidocaine = 10mg/ml 
    • 70kg = 210mg / 10 = 21ml
  • Signs of TOXICITY 
    • Sensory Disturbance: Facial tingling,  Numbness, Metallic taste, Tinnitus, Vertigo
    • Functional Disturbance: Slurred speech, Seizures, Reduced GCS
    • Cardiovascular: Hypotension, Palpitations
    • Treatment – ABCD, see LA-Toxicity [HERE]

Asepsis

Remember you are putting a needle into a sterile fracture and bone infection never ends well.

  • Chloro prep or Betadine – ensure it has time to dry
  • Sterile field
  • Sterile Gloves (particularly when learning)
  • No-Touch technique (Only if proficient)

Method

a. Insertion

  • Find fracture site – move approx. 1cm proximally
  • Insert needle – bevel down & at approx. 30°, towards the fracture
  • Hit bone & slide – forward into the fracture
  • Aspirate – you should be able to aspirate some blood, but not always (however, its should not flow too easily, if it does are you in a vessel?)
  • Inject –  this often needs a bit of pressure, infiltrate approx. 1/4 of the volume.

b. Fanning (this is not always necessary but seems to improve outcome)

  • Withdrawal needle a little – keeping it under the skin.
  • Change angle & advance – into the fracture
  • Aspirate and Infiltrate – more lidocaine
  • Repeat – do this several times so you have walked needle across the fracture (Use approx. 1/2 the lidocaine)

c. Ulna styloid (Only needed if fracture or tender)

  • Find Ulna styloid
  • Insert needle – straight onto the styloid
  • Aspirate
  • Inject – you are not normally going into the fracture but leaving a bolus approx.1/4

Give the patient 10-15min while you set up for reduction for it to achieve peak effect –  then check how its working. (getting the patine to move their wrist is a good test)

 

ENP’s – DOP’s forms can be found here

Diabetic Hyperglycaemia (Kids)

Diabetic children sometimes attend ED with hyperglycaemia, but not in DKA (what should we do?)

Paeds have produced some advice to follow:

  1. Ketones over 0.6?
    • <0.6: Encourage fluids & food, may need an insulin correction
    • >0.6: ask Question 2
  2. Are there clinical features of DKA?
    • NO: Encourage fluids & food, decide Insulin correction, will need to be monitored
    • YES: Will need Paeds admission