ACS (HS-Trop) Pathway

April 16, 2019

  Patients on Warfarin/DOAC : Use Asprin and Clopidogrel PDF: Full Guidance FAQ’s highSTEACS pathway developed in scotland.  When do we take the blood samples? – The initial troponin must be taken at least 2hrs after chest pain, a second trop may be required 6hrs after the 1st  (AAU/CDU) Do we… Read more

Acute Heart Failure (AHF) – ESC 2016

October 9, 2018

  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

Aortic Dissection

June 16, 2018

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

Arrhythmia Clinic (COVID-19 escalation)

March 26, 2020

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


August 12, 2018

ALS Bradycardia Algorithm – Adult


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

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

January 2, 2019

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

DVLA – Driving & Medical Conditions

May 8, 2018

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


December 11, 2019


Normal: 1.1-0.7
Mild: 0.69-0.5
Moderate: 4.9-4.0
Severe: <0.4

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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Myocardial Infarction (MI) – PPCI/Thrombolysis

June 22, 2018

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
Ticagrelor 180mg 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

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Primary Atrial Fibrillation (AF)

December 23, 2017

Before you start treating make sure you ask a few question

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

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Pulmonary Embolism – PE

December 20, 2017

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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Pulmonary Embolism in Pregnancy

July 19, 2019

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) – BNF
Arrange admission to AAU/AMU (>20/40  AMU @CRH and inform Obstetrics)

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Syncope – ESC 2018

September 25, 2018

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?

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February 28, 2018


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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