Author: embeds

Hyperkalaemia

Remember: is it a haemolysed blood sample? (you can do an iSTAT)

Severity

  • Mild: 5.5-5.9mmol/l – No urgent action required (Dietary & Medication modification & GP F/U)
  • Moderate: 6.0-6.4mmol/l – Follow treatment guide (maybe suitable for discharge)
  • Severe: ≥6.5mmol/l OR ECG changes – Follow treatment guide, must admit

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Dislocated Shoulder (Teaching Video)

Great review of shoulder reduction, techniques and sedation. 

Learning points:

  • Most techniques will work 80% of the time (Best results tailor the technique to the patient)
  • Kocker’s shouldn’t be used in # greater tuberosity
  • Cunningham technique looks interesting (I’m going to give this a go)
  • Traction is the what causes the most pain. Reduce the traction & Reduce the sedation required

Necrotising Fasciitis

Necrotising fasciitis (NF) is a rare but serious bacterial infection that affects the soft tissue and fascia (Fournier gangrene, is NF affecting the perineum). In many cases NF progresses rapidly and early recognition and treatment is vital to halt progress. The mainstay of treatment is IV antibiotics and aggressive surgical debridement. Any delay increased the amount of tissue loss as well as the mortality. Read more

SAH – NICE 2022

Headache is a common presentation to ED and Subarachnoid Haemorrhage (SAH) is the diagnosis we never want to miss. However, working out who needs a scan can be difficult as 50% of patients presenting with a subarachnoid have no neurological deficit.

  • ‘Thunder Clap’ headache peak of pain within 5min is a RED-FLAG
    • Although, most patients with ‘Thunder Clap’ don’t have SAH, this should not deter emergent investigation
  • Patients may present more subtlety the following should make you consider the diagnosis:
    • neck pain or stiffness (limited or painful neck flexion on examination)
    • photophobia
    • nausea and vomiting
    • new symptoms or signs of altered brain function (such as reduced consciousness, seizure or focal neurological deficit)
  • Always be suspicious if the patient has communication difficulties.

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Paediatric ECG

Use the following chart as a quick checklist to review what’s normal and what’s not in a paediatric ECG. 

Remember:

  • Lead V4R in under5’s
  • Manually calculate QTc
  • WPW needs referral for ablation – increase risk of sudden death

If in any doubt discuss with paediatric registrar/senior. If in need of urgent interven:on then contact the paediatric cardiology team in LGI.

1. Placement of Leads: Precordial Leads

In young children, the right ventricle normally extends to the right side of the sternum. To appropriately display right ventricular potentials, ECGs for children in the under five-year age group must include an alternate lead (‘V4R’) on the right side of the chest at a point analogous to the left sided V4.

2. P Waves:

3. Axis:

In utero- high pulmonary pressures and a relatively thick Right Ventricle (RV) -> Initial Right Axis on ECG is normal and resolves after the first 6 months of life

QRS Axis Deviation

  • Chest leads in wrong position

     

RAD:

  • Newborns
  • RVH secondary to Right ventricular outflow tract obstruction eg: Pulmonary
    Stenosis ,Tetralogy Of Fallot, Noonans (characterized by mildly unusual facial features, short stature, heart defects, bleeding problems, skeletal malformations, and many others)
  • RBBB

 

LAD:

  • LBBB
  • LVH secondary to LVOTO (Left Ventricular Outflow Tract Obstruction) e.g. Aortic Stenosis, HOCM

 

Superior Axis

  • AVSD (Atrio ventricular septal defect – Trisomy 21)
4. QTc:

Manually calculate QTc – HERE

Normal QTc:

  • Infants less than 6 months = < 0.49 seconds.
  • Older than 6 months = < 0.44 seconds.

QTc is prolonged in:

  • Hypocalcaemia
  • Myocarditis
  • Long QT syndromes such as Romano-Ward Drugs

QTc is short in:

  • Hypercalcaemia
  • Congenital short QT syndrome
5. Ventricular Hypertrophy

6. T waves:
  • The precordial T-wave configuration changes over time
  • For the first week of life, T waves are upright throughout the precordial leads.
  • After the first week, the T waves become inverted in V1-3 (= the “juvenile T-wave pattern”)
  • This T-wave inversion usually remains until ~ age 8; thereafter the T waves become upright in V1-3.
  • However, the juvenile T-wave pattern can persist into adolescence and early adulthood (= “persistent juvenile T waves”).

Tall, peaked T waves are seen in:

Hyperkalaemia, Dilated LV (volume overload), Benign early repolarisation

 

Flat T waves are seen in:

Normal newborns, Hypothyroidism, Hypokalaemia, Pericarditis, Myocarditis

7. ST Segment:

Some ST changes may be normal:

  • Limb lead ST depression or elevation of up to 1mm (up to 2mm in the left precordial leads).

  • J-point depression: the J point is depressed without sustained ST depression, i.e. upsloping ST depression

  • Benign early repolarisation in adolescents: the ST segment is elevated and concave in leads with an upright T wave.

 

 

Others are pathological:

  • A downward slope of the ST followed by a inverted T.

  • A sustained horizontal ST segment depression

     

 

Pathological ST segment changes are commonly associated with T wave changes and occur in:

  • Pericarditis.

  • Myocardial ischaemia or infarction.

  • Severe ventricular hypertrophy (ventricular strain pattern)

Thanks to the paediatric dept for supplying the guidance –  trust PDF here

Swallowed Foriegn Body

The ingestion of a foreign body or multiple foreign bodies (FB) is a common presenting complaint in paediatric surgery, with a peak incidence from 12-24 months however, can occur at any age. Ingested foreign bodies rarely cause problems; almost 80% of patients pass the foreign body without intervention – in seven days2 (only 1% require surgical removal). However, occasionally foreign bodies can cause significant morbidity (for example, oesophageal rupture) and 1% require surgical removal.

The presenting symptoms and outcomes of an ingested foreign body is highly dependent on the swallowed object, and for this reason, the guidance for hazardous and non-hazardous foreign body ingestion has been divided accordingly.

Using the Metal Detector

Non-Hazardous Objects

Button Battery

Magnets

 

Sharp Objects

PDF copy – HERE

Silver Trauma

The population is ageing and thus our ‘typical’ trauma patient is also changing. In 2017 the TARN report “Major injury in older people” highlighted the following issues:

  • The typical major trauma patient: has changed from a young and male to being an older patient.
  • Older Major Trauma Patients (ISS>15): A fall of <2m is the commonest mechanism of injury
  • Triage/Recognition of ‘Silver Trauma’ is POOR
    • Pre-hospital: Not identified hence taken to TU’s (Here) not MTC’s (Leeds).
    • The ED: Often seen by Junior Staff and endure significant treatment delays.
    • Hospital: Much less likely to be transferred to specialist care.
    • Outcomes: More likely to die, but those who survive have similar levels of disability to younger people.

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