Category: Learning

NEW: Burns Referral Pathway

A new burns referral pathway has been developed with Mid Yorks to securely send images of the patients burn. Allowing the burns team to arrange the most appropriate follow-up for your patient.

This requires BOTH online referral & phone call

The Process

  1. GoTo –  Burns Homepage (NHS computers ONLY)
  2. Select – New Referral (NO login required)
  3. Complete – the following sections (* means required field)
    • Referrers Details – you will need an NHS email address
    • Patient Details
    • Injury Details – Answering “Yes” to airway burns or fluid resuscitation will open further boxes
    • Additional Details – Patient’s phone number and address (only appears if NO airway or resuscitation issues)
  4. Checklist – Ensure ALL completed and submit
  5. Sending an Image – After submission a QR code will appear to send an image you will need to us the SID App
    • Launch the SID App on mobile device – Yours or ED Co-Ordanator (apple/android)
    • Scan the QR code
    • Consent the patient – Patient Information Leaflet
    • Take Photo of Injury  – this will not be saved on the device
  6. Phone Burns team – They can review the details and images and better advise you on management.

Resources

Lateral Canthotomy

Retrobulbar Haematoma secondary to blunt eye injury is a a rare but potentially sight threatening injury.

  • Blood collects in the retrobulbar space
  • Pushing the eye forward to accommodate the extra volume.
  • The Orbital Septum (made up of the eyelids and ligaments that attach them to the orbital rim) restricts this forward movement, creating a compartment syndrome for the eye. Thus threatening the patients sight if not treated quickly.

Recognition

From Royal College Ophthalmologists
  • Severe pain
  • Red/Congested conjunctiva
  • Exophthalmos with proptosis – eye pushed forward
  • Internal ophthalmoplegia – impairment or loss of the pupillary reflex.
  • Visual flashes
  • Loss of vision – initially colour vision, progressing to local visual loss.

However, this may only be recognised on CT if there is significant facial injury and altered conscious level.

Treatment

Call Ophthalmology immediately to attend. If there is going to be any significant delay, it may be necessary for ED to preform a Lateral Canthotomy, to allow the eye to move forward, reduce the orbital pressure & preserve the patients sight.

Kit needed

  • Lidocaine with adrenaline (needle & syringe)
  • Clamp – ideally curved to crush the tissues
  • Forceps
  • Scissors

Resources

Coroners Referrals

The patients ED needs to report has changed…

The key change with the new guidance is that not all patients who die in the ED need to be reported to the coroner….

Provided that none of the other circumstances as detailed in the guidance note apply deaths within 24 hours of admission to Hospital or a Hospice do not need to be reported with respect to a death of a person over 18 years of age in the following circumstances:

  • A qualified medical practitioner certifies death is due to natural causes and
  • The family or other party do not raise any concerns

The full guidance is available – Guide to Reporting Deaths April19

If you need to report to coroner – Death in ED

RCEM CPD 2019 Day 2

NEUROLOGY

#RCEMcpd  @RCEMevents

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.

ENVIRONMENTAL INCIDENTS

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

Http://bit.do/ccr-rcem2019

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

RCEM CPD 2019 Day 1

 HEAD AND NECK

Tracheostomy Emergency Care – Dr Brendan McGarth

www.Tracheostomy.org.uk

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:-
Tube obstructions
Tube displacement
Stoma problems
Skin problems

Tracheostomy Emergency Pathway

Laryngectomy Emergency Algorithm

Online learning  modules available at the link

www.e-lfh.org.uk/programmes/tracheostomy-safety/

 

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
Subconjunctival haemhorrhage
Broken teeth
Periorbital haematoma
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
Broken teeth
Step deformity

Try to assess carefully prior or to imaging

 

Acute Ophthalmology— Felipe Dhawahir-Scala

https://www.beecs.co.uk

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)