When is the ACS pathway used? The ACS pathway is for patients where coronary ischemia is in your differential. It is not a blanket pathway for chest pain of unknown cause. Patients presenting >8hrs post chest pain *NEW* If an initial trop is taken >8 hours post chest pain, and… Read more
AHF Triggers there are many triggers for AHF, which if recognized and treated with help improve outcomes Cardiac: ACS, Arrhythmia, Aortic Dissection, Acute Valve Incompetence, VSD, Malignant Hypertension Respiratory: PE, COPD Infection: Pneumonia, Sepsis, Infective endocarditis Toxins/Drugs: Alcohol, Recreational drugs, NSAIDs, Steroids, Cardiotoxic meds Increased Sympathetic Drive: Stress Metabolic:… Read more
This guideline is a brief summary of the RCEM 2012 Safe sedation in the ED and RCEM – Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department – March 2019. Please read these documents in full or participate in RCEM learning elearning for further information. Who can… Read more
Aortic Dissection (AD), is uncommon (1 AD:200 ACS) but is…Rapidly FATAL! Unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%. Read more
For ALL conditions leading to bradycardia treating the underlying condition is the most appropriate treatment and for some the only thing that will work (i.e. severe hypothermia) Read more
Due to the limited capacity when referring patients to the “New Arrhythmia Clinic” we MUST Send a BNP We don’t need to wait for the result in ED prior to referral and discharge BNP Result (clinic will review) >400, we will arrange an urgent echo and face-to-face clinic. <400, we will book a remote… Read more
Symptoms suggestive of Acute Myocardial Infarction
Chest Pain within 12 hours
ECG showing acute myocardial infarction
ST elevation >1mm in limb leads
ST elevation >2mm in precordial leads
New LBBB with appropriate clinical history
Digital ECG has now gone live on both sites. We now have no excuse for loosing ECGs and not sending them to the wards with patients! Please ensure you put an operator ID in as well as all the patient information to ensure the ECG transmits to EPR – if… Read more
For many conditions the patient should be informed to stop driving and inform the DVLA of their condition. It is the patients responsibility to inform the DVLA, and we should encourage them to do so.
[There is a £1000 fine AND the risk of prosecution] Read more
V1: 4th intercostal space (ICS), RIGHT margin of the sternum
V2: 4th ICS along the LEFT margin of the sternum
V4: 5th ICS, mid-clavicular line
V3: midway between V2 and V4
V5: 5th ICS, anterior axillary line (same level as V4)
V7: Left posterior axillary line, in the same horizontal plane as V6.
V8: Tip of the left scapula, in the same horizontal plane as V6.
V9: Left paraspinal region, in the same horizontal plane as V6.
Signs/Symps (normally <0.5)
MSK: Muscle Twitch, Tremor, Tetany, Cramps
CNS: Apathy, Depression, Hallucination, Agitation, Confusion, Seizure
CVS: Tachycardia, Hypertension, Arrhythmia, Digoxin Toxicity
BioChem: Hypokalaemia, Hypocalcaemia, Hypophosphataemia, Hyponatraemia
PPCI (Leeds PPCI Pathway)
Target: Door to balloon 90min
Time: Chest pain within 12hrs (or worsened within 12hrs)
ECG: ST elevation MI (1mm Limb or 2mm Chest leads) OR New LBBB. (Posterior MI do posterior leads and discuss with LGI)
Contact PPCI team @ LGI (Mobile No. up in Resus)
Arrange blue light (P1) ambulance to LGI
Prasagrel 60mg if no previous CVA or Ticagrelor 180mg if previous CVA and Aspirin 300mg (if anti-coagulated Discuss with PCI team)
Intubated patient: Often LGI would accept but need to arrange Cardiac ICU. If no bed patient could go for PCI to return locally immediately after PCI to our ICU’S?
LGI Full: Occasionally the cath lab is full and can’t accept your patient
Calling Manchester and Sheffield: It’s worth a go but they don’t have agreements with us so having your patient accepted can be difficult
Don’t Forget Thrombolyisis: We need to open up the patients artery, if there is no quick decision to go for PPCI – Consider Thrombolysis
Before you start
Whats the cause? – treating the precipitant often sorts the AF (adding B-Blockers to Sepsis can make things worse)
Stable or Unstable? – Electricity vs. Drugs
less than 48hrs? – Rhythm vs. Rate control
CHADS-VASC vs. HASBLED – Anticoagulation
Arrhythmia Clinic – referral form attached tho the PDF
PE is somehow both the most over and under diagnosed condition. with severity ranging from the questionable sub-segmental PE to the Massive PE (an indication for thrombolysis). So think:
Does this presentation sound like a PE? – If not STOP here
Pregnant? – Click Here
Do you think this is likely a PE? (if so you can’t use PERC)
Does D-Dimer answer your question? (whats the Wells)
Massive PE – think Thrombolysis
Sub-Massive PE – there is lots of debate (involve seniors), locally needs 2 consultant sign off and not considered time critical.
Unfortunately the the normal pathway for investigation of PE performs poorly in pregnancy RCOG have the following pathway
1. Investigation – of suspected PE
Clinical assessment – its all on the history and exam scoring doesn’t work
Perform the following tests:
CXR – sheilding can protect the baby and may avoid further radiation
Bloods: FBC, U&E, LFTs
Commence Dalteparin (unless treatment is contraindicated) – Trust Guide
Arrange admission to AAU/AMU (>20/40 AMU @CRH and inform Obstetrics) – if admission not agreed refer to advice below
Defintion:Transient Loss of Consciousness (TLOC) due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery.
Common ED Complaint: 1.7% of all attendances
Difficult Diagnosis: less than 50% get a diagnosis in ED
Mortality & Serious Outcome: 0.8% mortality & 10.3% serious outcome @ 30 days
Ask 3 Questions!
Is this Syncope?
What is the underlying cause?
What is the best Follow-Up for this patient?
Cardiac arrhythmias are relatively common presentations to ED.
There are many causes, some more sinister than others.
If your patient is not acutely unwell then expert advice may be required.
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