Registered Medical Practitioners in England and Wales have a statutory duty to notify Public Health about the following diseases. To facilitate rapid treatment and control of outbreaks. (Links to Wikipedia for illustrative purposes) Read more
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
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)
On rare occasions you may receive a pre-alert, where you want blood available for the patient when they arrive (for example in major haemorrhage). This process has been agreed with transfusion so this can be done safely and responsibly. Read more
Delirium is one of a number of geriatric syndromes and has significant associated morbidity and mortality.
3 subtypes of delirium
- Hyperactive – easies to spot, one we are most familiar with. Characterised by agitation/aggression/hallucinations “the non cooperative patient”
- Hypoactive – harder to spot. Characterised by drowsiness, less responsive, vacant, sleeping more at home
Remember there is NO SUCH THING AS A “POOR HISTORIAN” !! – Just a poor clinician! If your patient is not cooperating and can’t tell you very much then you need to find out why!!! Read more
Cervical artery dissection is a rare but significant cause of stroke and headache/neckache, which is easy to overlook. Leading to a typically delay in diagnosis of 7 days. Unfortunately imaging the cervical arteries is not simple, with MRA being the method of choice. Hence these patients must be referred to the “Stroke Consultant”.
Our video maybe light hearted but…
SEPSIS is a Killer (1:4 Die)
and time matters
Recognise, Resuscitate, Review
Very few of us come to work intent on doing harm. However, despite that we all keep making mistakes. Most of them pass unnoticed and do little harm, although we are all aware the times they don’t, and it is not only the patient that suffers. Read more
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.
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: DKA, Thyroid dysfunction, Pregnancy, Adrenal Dysfunction
- Cerebrovascular Insult
Presentation & Clinical Classification
The presentation of AHF can vary but tends to fall in to the following 4 categories, which can be determined clinically and can help guide your approach to treatment; warm-dry, warm-wet, cold-dry, cold-wet.
It is worth noting that the vast majority of patients will be norm-hypertensive. However, 5-8% are Hypertensive this confers a very poor prognosis.
- ECG: Rarely normal (High NPV), and may identify underlying cause
- CXR: Pulmonary congestion, Effusion, Cardiomegaly (20% will have an almost “Normal” CXR)
- BNP: Can be helpful (we have it)
- >845 show increased mortality
- <100 AHF is unlikely
- BNP is not a specific test and will elevate for many reasons
- POCUS: This can be very useful in identifying cases but training is required [Bilat B lines in 2 zones each side]
- Condition specific tests: Try to identify the underlying trigger dependent on history and exam (e.g. ABG, Trop, U&E, TFT, LFT, CTPA)
- ECHO: this is important but not necessary in the ED phase (unless the patient has haemodynamic instability i.e. cardiogenic shock)
Treatment – Time Matters!!!
- Mortality increased by 1%/hour IV treatment not started
- Treatment after 12hrs from onset makes little difference
- Vasodilator: has 2 effects reducing vascular resistance and thus increasing stroke volume [NOT to be used if sBP<90mmHg]
- Diuretic: commonly we use frurosemide 20-40mg IV, however, depending on the patient higher doses can be used. [Doses over 160mg has been shown to increase mortality!]
- Oxygen: maintain SaO2 of 95% OR 88-92% if at risk of hypercapnic coma [Avoid hyperoxia]
- NIV: recommended in respiratory distress (RR >25bpm, SpO2 <90%) & start ASAP, this can reduce intubations and make the patient feel more comfortable. However, doesn’t increase survival
- SHOCK!!!: there is no agreement on the best treatment, ICU & Medical/Cardiology input is vital, as inotropes & vasporessors (Noradrenaline recommended) will need to be considered.