Category: Resources

Humeral Brace – Application

Inclusion Criteria – All closed neurovascular intact adult humeral shaft fractures

Exclusion Criteria – Intra-articular fractures of either the proximal or distal humerus, and surgical neck of humerus.

SizeTP-6401(normal)
Length (cm)
TP-6402(short)
Length (cm)
Humeral Circumference (cm)
127.522.522.5 – 26
229.524.526 – 29.5
3322729.5 – 33
4332833 – 36.5
5353036.5 – 40

Packet contains black humeral brace and blue sling. Size is based on mid humeral circumference and brace length, as per chart.

The hypoallergenic fabric casing holds two plastic shells – the inner shell should be removed and trimmed if concerns of pressure to inner elbow BEFORE applying the brace to the patient (either measure or try opposite arm).

Lengthen the chest strap as long as possible and unclip the clip that will be fastened behind the patient.

Crocodile Velcro fasteners are on the end of each strap. 

In order to stretch the brace to make it easier to apply, curl the crocodile fastener back on each adjustment strap and place your hands in the brace to stretch it out.

Place underneath clothing so that the patient does not attempt to remove it at home. Encourage the patient to drop the affected arm down by their side and glide the brace up the arm. If there’s a lot of resistance, a change in brace size may be required. Bring the brace up so that the outer shell is covering the shoulder and hold in place.

Holding the brace in position, clip the chest strap around the body. Ensuring it is over the chest and not beneath breast tissue. Tighten the chest strap by using the crocodile fastener. If the crocodile fastener ends up in the axillary area, it may cause friction. Remove the crocodile fastener completely and trim the chest strap so that the fastener ends up on the back.

Use the adjustment straps on the brace to tighten the brace, making sure that opposite straps and pulled at the same time to maintain tension. Both upper and lower adjustment straps must be tightened

Towelled side of the sling to skin, attach to the posterior aspect of the brace and bring over the opposite shoulder.

Bring the elbow of the braced arm to 90 degrees flexion and rest in the sling using the Velcro to attach the sling to itself. The wrist must be resting in the sling, not the forearm, to prevent wrist drop.

#RCEMasc 2019 – Day 3

AIRWAYS-2

ETT vs SGA (i.e. iGel) in out of hospital cardiac arrest (trauma and kids excluded)

  • Headline Results: 
    • Survival with good neurological out come (MRS 0-3) – No difference around 2.75% (for those that required either SGA or ETT)
    • Easiest – SGA easier achieving ventilation within 2 attempts (87.4% vs 79%)
    • Displacement – SGA suffer more displacement (10% vs 5%)
    • Aspiration – No difference around 15%
  • Interesting Results:
    • Survival – approx. 20%  in those that didn’t have an advanced airway attempted (indicating likely survival advantage of only needing a short resus)
    • Paramedic use of advance airways – Paramedics on average only need to use advanced airways 3-4 times a year!
    • PART study (USA) – ETT vs Larangeal Tube no difference
    • BMV vs ETT (France & Belgium) – no difference in out come, but BMV was more difficult

PARAMEDIC 2

Adrenaline vs Placebo in out of hospital cardiac arrest

  • Headline Results:
    • Survival to hospital admission: adrenaline 23.8% vs placebo 8% (Significant)
    • Survival @ 3 months: adrenaline 3% vs placebo 2.2% (Significant)
    • Survival @ 3 months with good neurological outcome (MRS 0-3): adrenaline 2.1% vs placebo 1.6% (Non-Significant)
  • Interesting Result:
    • What did the public thing was the important outcome? In the restudy survey 95% of public reported that survival with good neurological outcome was more important than surviving to hospital.
    • Extrapolation of Adrenaline use: to all UK adult cardiac arrests in a year, adrenaline would increase:
      • ROSC: 5602
      • Admissions: 3555
      • ICU Admissions: 1643
      • Discharged Alive: 203
      • Favourable Outcomes (MRS 0-3): 68
      • Unfavourable Outcomes (MRS 4-5): 135
    • What should happen? International resus (ILCOR) now strongly recommend adrenaline use, however, we probably need public consultation

TXA for bleeding

Dr Ian Roberts

  • Inhibits fibrinolysis – i.e. stops plasmin breaking down clots
  • Treats bleeding – NOT coagulopathy
  • Given TXA Early – as tPA activates early and PIA-1 is later, we need to stop the tPA
    • 15min treatment delay > 10% reduction in effect
  • Give on the suspicion of bleeding? – you get the same risk reduction  what ever your base line risk (i.e. 30% risk of death > 20%, 3% risk > 2%)
  • Safety – in Japan TXA bought over the counter for headaches
  • RCT’s
    • Surgery – TXA reduces blood loss by 1/3 & death, NO increase in clot events
    • Post-Partum Haemorrhage – PPH reduced by 1/3
    • Trauma – Sig. reduction in DEATH (<1hr reduced by 1/3, 1-3hr by 1/5)
    • Vascular occlusive events – data seems to show TXA reduces them
      • Bad bleeding  increases vascular-occlusive events
    • Brain  – results apparently don’t contradict other studies but full results in 2weeks
    • GIT – results due next yea, recruitment stopped in uk as TXA was being give anyway
  • Why have the infusion? – added to regime to (theoretically) replace the loses from ongoing bleed, its utility is unknown.

Lightning papers

  • Mobile phone use @ work(Derby)
    • 80% patients thought it ws fine – this increased to 95% if explained for medical reason
    • Patients didn’t want – you to be using it while talking to them (distraction/rude), dont wipe it on them (infection control)
  • Hair Ties with glue (HAT) vs Suture (not those that would only have been glued anyway)
    • Reduced pain
    • Reduced follow up
    • increased patient satisfaction (less pain and no need to see
    • Faster and increased staff satisfaction
  • No Room @ the Inn (Bristol children)
    • Used winter pressures money to open the clinic space next to ED 18:00-23:00 (if needed)
    • Opened it 50% of the time
    • Used it for 10% of patients
    • Minor Injury/Illness (they do have a UTC)
    • Staffed from the ED
    • Patients and Staff like it!
    • Plymouth also do – staff love it as almost a break from the chaos of majors
  • Who’s pain are we treating?
    • 50% Dr’s assume patients want a prescription, but <30% actually do
    • Patients expect more pain in the following days – than Dr’s expect
    • Patients want to know that codeine is potentially addictive within 3 days
    • They have reduced co-codamol scrpts from approx 10% to 3% of discharges – with no increase in complaints or patient satisfaction.

Mental Health

  • RESPOND  – multiagency mental health crisis simulation
    • Everyone has to make the decisions of each role (Police, Nurse, Dr, Paramedic)
    • Reduced demand on each agency
    • Strengthens partnerships
    • Streamlines process
  • Presentation in the ED –  RCEM mental health tool kit
    • Triage:
      • Agitation, Environment, Intent, Objects
      • VISA: Violent,Irrational thought, Suicidal, Alone
    • Capacity – Are they really weighing it up? if in doubt NO
    •  Observation
      • Mental Health Obs: Calm/Distresses/Agitated/Aggressive/Gone
    • No Scores predict risk – its a holistic assessment thats needed
    • Compassion & Communication – we shouldn’t make things worse for the patient
    • Restraint what to do and do we need it?
    • APEx course – ALSG

 

#RCEMasc 2019 – Day 2

Paracetamol 12hr SNAP regime: 2014 & 2019

  • What is it? 
    • Pre-NAC – 4mg Ondansetron IV
    • Bag 1 – 2hr 100mg/kg NAC in 200ml 5% Dex
    • Bag 2 – 10hr 200mg/kg NAC in 1000ml 5% Dex
  • Advantages
    • Saves 9hrs
    • Significant reduction in anaphylactoid reactions 2% vs 11%
    • Significant reduction in gastric symptoms (if either ondasetron or 12hr regime used)
    • Significant reduction in treatment pauses
  • What next?
    • 10 centres using (inc Edinburgh, Newcastle, Guys St Thomas’)
    • We can’t implement the 12hr regime just yet (however, discussions are going on with Acute Med and Hepatology)
    • Pre-NAC ondasetron does seem like a good idea

Frailty

  • Comprehensive Frailty Assessments
    • NNT to prevent a death 17
    • NNT to prevent NH admission @ 6months 20
  • Frailty Score @ Triage 
    • Initially 50% accuracy (esp. around 4/5)
    • Addition of props significantly improved triage accuracy
      • Do you find walking more difficult or do you need mobility aid? Yes > 4+
      • Do you do your own shopping & housework? No > 5
      • Do you need help washing & dressing? Yes > 6
      • Do you live in a care home or have carers?
        • If carers > 5+
        • If needs assistance with personal care > 6-7
      • Are they confused or have a diagnosis of dementia? Yes > 5
  • Delerium
    • PINCHME  – for all frail patients they may not have delirium now but soon…
    • Parkinson’s Disease and can’t swallow
      • Find the right dispensable regime or patch – use pdmedcalc
    • Other ways of doing things
      •  TRAWL
        • South Tees frailty team call all discharged frail patients to ensure things are going well and arrange further input as needed
      • Falls Rapid Response Team
        • Newcastle and Gateshead, paramedic and OT in a car reduce, conveyance to ED from 75%(with Ambos) to 45%

Dying

We all do it and we all want the best death possible – But we often do it badly

  • 1:3 patients admitted on acute adult take are in their last year of life
  • 80% of NH patients are in the last year of life

But we don’t always know which patient or recognise how quickly this will happen – think about the following:

  • Parallel planning: we can be both treating the patient, and making plans how we can allow them the best death if they are dying.
  • Sedating For Scan: PAUSE – this might be the last time they are conscious, consider them and their family and do they need time
  • Use the word Dying: find out what is important to them, and their family, what are their fears and what they want to know, allow silence.
  • Society is unfamiliar with death: Narrating whats happening for the family can help, e.g “that rattley noise you can hear is only a small amount of fluid in their throat, it can sound horrid but its not bothering them at all” Remember we are used to these stages but to families they are scared and they often assume that the patient is suffering.

You may want to look at the talking about dying resources from the RCP

Top 10 papers

Go to St Emlyns’ see the whole thing and read the papers, subjects include:

  • Should every ROSC go straight to the Cath Lab?
  • AF: Mg & Early Shock
  • Dose Criocoid press just make things more difficult?
  • Can we bag during RSI?
  • Vasopressors: septic shock & haemorrhagic shock?
  • POCUS in cardiac arrest

 

#RCEMasc 2019 – Day 1

For those back home its been an interesting 1st day at the conference  – and the top 5 are

1. Learning from Child Death

Great session, presented by both clinical staff and parents, around the death of a 3yo with Down’s syndrome, from sepsis. Highlighted some key points that we can all do better:

  • Communication:
    • Listen to the Carers: the parents could see the patient wasn’t his normal self but staff didn’t head the warnings, and his parents felt ignored.
    • Let Carers know whats happening: The patient was moved to Resus, we might think the parents know what that means, but they thought it was just because everywhere else was busy.
  • Unrecognised deterioration:
    • The child deteriorated through the ED stay of >8hrs, and the sepsis was only picked up and treated on paediatric ward, after a fresh set of eyes. Remember if you put a frog in boiling water it jumps, but if you turn the heat up slowly its dinner. Always be alert to the slow change!
  • Responsibility:
    • The patient remained in Resus after being seen by PICU who had then referred to Paeds – Who was looking after him? We are ALL responsible for that patient – ED and the specialities!

2. Non-blanching rash & fever in children

There are many sets of guidance out there with 100% sensitivity, however, specificity varies. NICE has a specificity of approx 1%, while the best performing Newcastle, Birmingham, Liverpool (NBL) algorithm performs at about 44%. And Purpura (defined as being between 3 milimeters and 1 centimeter in size) is a BAD sign!!!

The NBL algorithm

 

3. STEMI – de Winter is coming!

The de Winter T wave is an important ECG sign of MI, that can develop quickly into the classic STEMI. Its present in 2% of cases so learn it.

  • LITFL

    Tall, prominent, symmetric T waves in the precordial leads

  • Upsloping ST segment depression >1mm at the J-point in the precordial leads
  • Absence of ST elevation in the precordial leads
  • ST segment elevation (0.5mm-1mm) in aVR

 

4. Toxbase Pearls

  • Severe Ca/β blocker overdose – move through the treatments relatively quickly in a step wise manner as Toxbase (i.e. dont wait for ages to see if it works it either does or doesn’t). To get to High Dose Insulin Euglycaemia Regime, this seems to be one of the best therapies
  • Charcoal: Evidence coming out suggesting it is useful beyond the 1hr period, and higher doses seem better (watch this space)
  • Whole Bowel Lavage: Really difficult but good in body-packers, Iron & Lithium as well as Sustained release compounds.

5. Malaria

  • Rapid antigen test and thick and thin film – good but not 100% (esp with ovalae)
  • 5-10/yr patients die in UK from malaria – Mainly as unrecognised (travel to malaria region and unsure why they are unwell test)
  • Is it Ebola or Malaria? – if you can’t get malaria screen done (?ebola can slow the labs down) – Assume Ebola & treat as severe malaria concurrently

 

 

 

Junior Doctor Training Open to all Nursing Staff

Hello Everybody It has been agreed that all nursing staff (HCAs/RNs) can attend the Junior Doctor Training which happens every Thursday afternoon (1-4). This will be on a voluntary basis and there is no pressure to attend it is for your own learning and professional development (It can be used as evidence for revalidation)  Please find the rota below.

Junior Doctor Teaching Programme April – August 2019

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 OphthalmologyFelipe 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)