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On the 8th of May we are changing our current troponin test to a HS-Trop (high sensitivity troponin). This will allow us to exclude ACS earlier in the patient journey, however it does mean getting used to new numbers and a new protocol. 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

ALS Bradycardia Algorithm – Adult

Causes

Cardiac: Heart Block, Myocardial infarction, Myocarditis
Metabolic: Hypothermia, Hyperkalaemia, Hypokalaemia, Hypothyroid, Hypoxia
Toxin: digoxin, B-blocker

Treatment
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

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

Classification

Normal: 1.1-0.7
Mild: 0.69-0.5
Mod-Severe: <0.5

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

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PPCI (Leeds PPCI Pathway)

Target: Door to balloon 90min
Criteria:

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)

Actions:

Resuscitate
Contact PPCI team @ LGI (Mobile No. up in Resus)
Arrange blue light (P1) ambulance to LGI
Ticagrelor 180mg and Aspirin 300mg (if anti-coagulated Discuss with PCI team)

Problems: 

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

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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.

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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
ECG
Bloods: FBC, U&E, LFTs

Commence Dalteparin (unless treatment is contraindicated) – BNF
Arrange admission to AAU/AMU (>20/40  AMU @CRH and inform Obstetrics)

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Background

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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