REALISTIC EMERGENCY MEDICINE Read more
Advances in Acute Stroke Intervention
Dr Ian Rennie
Acute Stroke Thrombolysis only recannulates approximately 10% of large vessels.
MR CLEAN trial reduced disablED survivors following stroke from 53% to 29%. NNT <2 (New England Journal of Medicine 2015)
Dawn trial showed treatment up to 24 hours from “last well” can produce significant benefits. (New England Journal of Medicine 2018)
Included almost all patients for thrombectomy with large vessel occlusion who don’t have too much established infarct. No absolute cut off time, image vessels early.
Don’t treat those with a poor baseline function, extensive pmh, in hospital infarcts, established infarct on scan.
Pitfalls and Perils of Acute Neurology
Dr Thomas Peukert
Non orthopaedic cause of myelopathy (it’s not always cauda equina). ..
Think about onset…acute vs gradual
Think about time course…relapsing and remiting, deteriorating, stable, intermittent
If MRI spine is normal..have you imaged the right part of the spine? Is it too early? Have you imaged the right part or the right scan? Is the lesion not visible on MRI?
Is it a lesion in brain?
Is it a problem of neuromucular junction?
Is this a lower motor neuron lesion?
Spontaneous low pressure headache – sudden onset severe headache on standing can be associated with thoracic back pain due to spontaneous leak of csf often in the thoracic spine. Can pull brain downwards that looks like chiari malformation on MRI. Often associated with connective tissue disorders.
The Manchester Arena Major Incident
Mrs. Stella Smith
Patient id was a problem, the patients were carrying fake ID, particularly with transfusion, helped by ED based transfusion team.
Staff response needs to be tiered organisation by a distant member of staff helped.
Handovers needs to include everyone…managers, allied healthcare professionals, etc.
Ballistics and evidence collection training is needed by everyone as clothes, possessions, foreign bodies that are removed are all evidence.
Everyone needs Blast training….look in eyes, ears etc.
Managing a CBRN Incident
Dr Paul Russell
- Detect the incident…
- See. . ..self presenting toxidrome..123+ approach
- Hear ..take a history
- Smell..if it smells bad it is likely to be toxic
- Feel …unusual sensations
Many CBRN agents may have a delayed presentation or delayed detection so events may move on to other departments.
Protect yourself, collegues and environment
Decontamination should happen at scene however it often doesn’t happen.
Decontamination. ..remove clothes, blot dont rub with paper, wet decontaminate if needed.
Critical Care Research Update
Dr Rob MacSweeney
Polar trial – prehospital cooling for tbi and maintained for 7 days…no difference between 2 groups. Increased adverse events in cooled patients.
Eurotherm 3235 cooling raised icp patients caused harm, trial stopped early.
Rescueicp a decompressive craniectomy for icp>25mmhg, better icp control and more adverse events and no improvement in outcome
Paramedic2 adrenaline in shock refractory out of hospital cardiac arrest – adrenaline restarts heart and marginally improves survival but survivors had severe neurological impairment.
ALPS trial – Amiodarone, lidocaine, placebo in out of hospital cardiac arrest more likely to survive with drugs than placebo.
Eolia trial – ecmo for ARDS significantly improves survival at 60 days.
Florali – high flow nasal cannula oxygen vs face mask oxygen and niv for preoxygenation in patients with hypoxic respiratory failure needing RSI. Nasal Cannuale is best.
Beam trial boogie vs stylet for intubation with McGrath. ..boogie more likely to get 1st attempt intubation without complications.
IRIS trial – cricoid pressure vs sham pressure, no benefit from cricoid pressure.
Ideal-icu – when to start renal replacement therapy in severe sepsis induced renal failure at 12 hrs vs 48 hrs. ..no difference but very high mortality anyway.
Bicar-icu – bicarbonate for severe acidosis…some benefit of giving bicarbonate in severe acidosis.
Smart trial -Saline vs balanced crystolloid (Hartmans) for fluid resucitation in ICU, more adverse kidney events with saline.
Salt-ED Saline vs Hartmans in ED…no difference in hospital free days.
Adrenal trial -hydrocortisone vs placebo in Septic shock, reduced 90 mortality and reduced icu days with steroids.
Andromeda trial – shock treatment guided by peripheral perfusion vs Lactate guided resucitation …outcome better with perheral perfusion guided resucitation.
Censer trial – early noradrenaline in Septic shock reduces mortality
Tracheostomy Emergency Care – Dr Brendan McGarth
Needs to distinguish Tracheostomy from laryngectomy as a laryngectomy has no connection to the upper airway however a tracheostomy may have a connection so gives you 2 options for an airway.
Trachostomy problems commonly seen in the ED:-
Online learning modules available at the link
The Impact of Dental Presentations to the ED — Chetan Trivedi
Facial imaging his a high dose of radiation to senative tissues in often young people therefore careful examination is required prior tor Xrays.
Predictors of radiological abnormality in facial trauma-
Tenderness over maxillary
Step deformity in maxillary
Sensory loss over site of injury
Change in bite
Abnormal eye signs
Predictors of radiological abnormality in mandibular trauma-
Restricted or painful mouth opening
Tenderness over mandible
Sensory loss over site of injury
Change in bite/painful bite
Try to assess carefully prior or to imaging
Acute Ophthalmology— Felipe Dhawahir-Scala
Viral conjunctivitis all have preauricular or submandibular lymphadenopathy, highly contagious.
Do not give chloramphenicol to contact lens wearers use something with a broader spectrum.
Urgent conditions (reasons to get an ophthalmologist out of bed) —
Acute angle closure glaucoma -red painful eye, semi dilated pupil, – start iv acetazolamide immediately
Orbital cellulitis – eye doesn’t move, colour vision loss, fever, chemosis, proptosis -start Ciprofloxacin and clarithromycin orally, image and call ophthalmology.
Vertigo – Peter Johns
Concerning features- new or sustained headache or neck pain it’s a stroke or vertebral artery dissection until we prove it isn’t.
A central cause …Unable to walk or stand unaided, Weakness in limbs, the Deadly d’s… dysarthria, diplopia, dysphagia, dysarthria, dysphoria.
Short episodes of Vertigo (spinning/dizziness) on getting up/rolling over in bed, no spontaneous or gaze provoked nystagmus.
(End gaze nystagmus so normal variant, look to 30 degrees only.)
Need dix-hallpike testing likely BPPV – posterior canal BPPV.
Treat with Epley manoeuvre.
Horizontal Canal BPPV – Dix-hallpike manoeuvre is negative and they are less clear which side they turn to to get dizzy.
Spontaneous or gaze provoked nystagmus for days, nausea and vomiting and gait disturbance likely to be Vestibular neuronitis.
Test using HINTS plus Exam– nystagmus, test of skew, head impulse test, hearing loss. All components have a central or peripheral result for each component. If all 4 are peripheral results then it is a acute Vestibular neuroitis
Vestibular migraine – 30% never get headache, can last hours or days.
More common in women, perimenopausal, often get photophobia, phonophobia, nausea, vomiting and other typical migraine symptoms.
You tube – peter Johns (links here)
We often worry about patients developing rhabdomyolysis and consequently developing AKI. However, there is much debate and little consistency in the published data, over how to diagnose and who needs admission to treat. So its important to consider both clinical context along with laboratory values
With the onset of colder weather, many households in the UK are turning on their heating for the first time in months. Heating appliances need chimneys and flues to work safely – and these can block up over the summer months. So autumn is traditionally the period when people get poisoned by carbon monoxide (although it can happen any time of the year!)
Carbon monoxide (CO) is produced when anything containing carbon burns or smoulders. For practical purposes, this means the burning of any kind of fuel, commonly:
- Oil/Petrol/Diesel – (All UK cars have a ‘catalytic converter’ in the exhaust system, which converts carbon monoxide (CO) to carbon Dioxide (CO2), which is less poisonous. However, these converters need to warmed up – a cold car produces fatal amounts of CO in the exhaust)
CO is very poisonous. Exposure to as little as 300 parts per million (that’s just 0.03%) can prove fatal.
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
Scombroid poisoning (AKA – Histamine fish poisoning) is apparently more common than we think and accounts for 40% of seafood related illness in the USA according to the CDC. But Scombriod poisoning is missed as its put down to allergy. Read more
When we need to book an MRI e.g. for Cauda Equina, we need to print the MRI Questionnaire and complete it!
Although, most of this is built in to the EPR request that is not good enough, so avoid delays and do the form
Ending up in the ED as a result of alcohol and or substance use is NOT normal behaviour
- Children who use alcohol or other substances are hugely vulnerable to sexual exploitation and other forms of abuse.
- The use of alcohol or drugs can be encouraged as part of the grooming process, or as a means of coping with a difficult situation for the young person.
- It is also likely that friends and close acquaintances of the young person are equally vulnerable.
- Defined as any traumatic injury to the head other than superficial facial injuries.
- The commonest cause of death and disability in people age 1-40 in the UK.
- Account for 1.4 million ED attendances each year, 95% of these are minor head injuries that can be managed in the ED.