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)
- Should ED manage the Trauma airway?
For: Dr Simon Laing @simon_laing
Against : Dr Felicity Clark @felicityjeclark
A debate with an ED consultant for and an Anaethestist against.
The eventual conclusion was that it doesn’tmatter who manages the airway as long as they are trained, competant and current with good governance in place.
- Chest tubes in Trauma – Mr Richard Steyn
Bigger drains aren’t always better however they need to be able to drain without blocking or clotting, not kink, secured appropriately.
Prime drains with sterile saline and thoracic surgeons can cell save blood.
Flutter bags for chest drains rather underwater seals are likely to be easier to manage until a ptoent gets to definitive thoracic care.
Chest drains should only be clamped to change bottle.
- Non-compressible torso harmhorrhage NCTH- Surgeon Commander ED Barnard @edbarn
Is REBOA effective in a TCA?
Haemorrhage is the leading cause of survivable trauma death, external haemorrhage has been reduced by the use of tourniquets.
We dont know if REBOA works but the key is placing REBOA during the low output state rather than during arrest.
The REBOA trial is ongoing.
Haemostatic agents for catastrophic haemorrhage – squadron leader Robert james
Major harmhorrhage is the major cause of preventable death in Trauma
A system approach improves survival.
Trauma chain of survival…
Early first aid, advanced Prehospital care, damage control resucitation and excellent rehabilitation.
- Simulation in Major trauma – Simon Mercer
Simulation allows people to rehearse skills in a risk free environment.
Functional fidelity (does it work like real), physical fidelity(does it look real), psychological fidelity (does it make people feel real).
- Moral Injury – Esther Murray @Em_Healthpsych
Moral injuries – Witnessing incidents which contravene your moral code
Most of those affected by incidents will not have a diagnosable mental disorder.
If you are stuck processing/reliving something you are less available to your team, it reduces your bandwith therefore you can’t offer support and empathy to colleagues.
It is often the little things that stick with you after a job, talking about it needs acknowledgement that it has affected you. Forced intervention is really bad for people, not everyone will be ready to talk at the same time, some will never want to talk. Providing spaces to talk is more important.
- Head Injury Prognostication – Professor Mark Wilson @markhwilson
SDH and EDH are not brain Injuries, the secondary brain injury occurs if these are not treated.
What time point are we prognosticating at? At times etc of injury or 6 hours later when bleeding has occurred due to antiplatelets?
Prognostication needs to occur over a few hours, resucitation needs to have occurred, the duration of observation is a clinical judgement.
Mix of PHEM and Major incident sessions today
- Mental Resilience – Professor Richard Williams
Resilience – a process linking a set of adaptive capabilities to a positive trajectory of functioning and adaption after a disturbance.
Compared to the reference population ED and Pre-hospital staff have higher levels of fatigue, poor sleep, depression and anxiety.
Stress levels tend to be higher when the care involves children, collegues, older people or disabled people. Psychological impact tend to be worse if patients die, we feel we should have done more, there is little percieved support from colleagues, family or friends or the incident follows other stressful events.
Improving patient care can only be done by increasing the care of staff as they deliver the care.
Caring for the personal needs of staff reduces clinical errors.
Things that affect staff experience are Organisational culture, workload intensity, relationships with peers, emotional intelligence, length of experience, injury, abuse, Role at work, and social support,
Secondary stressor can be worse than the primary incident and can be these things that prevent people from coping.
The primary mental disorder in relation to stress is substance misuse not ptsd.
It is OK to be upset it does not mean you are not resilient.
Social support and social integration are the most important factors in life expectancy…we need to turn groups of collegues into
- Field Amputation – Professor Sir Keith Porter @TCUK_KeithP
Like many things we do in Emergency Medicine the technique is not difficult and uses basic kit; it is the decision making that is the difficult part. Phone a friend and get someone else there with you for those difficult decisions.
- Mechanism of injury and new car design– Dr. Gareth Davies
Understanding Mechanism of Injury can help predict injury patterns.
Every mechanism gives a predictable pattern of injuries, what happens to the patient depends on speed of vehicle, shape of vehicle, rigidity of vehicle, presence of advanced protection,speed of pedestrian, size of pedestrian and age of pedestrian. Ask a 1st hand witness if possible to prevent Chinese whispers.
Injuries come from change in velocity and exchange of energy over time.
Low speed deceleration causes less injury than sudden stop.
- Organisational Leadership – Mrs Jane Gurney @janegurney5
Be passionate about what you do.
Engage with all members within your organisation.
Lead by example.
The right decisions are not always the easy decisions.
- Learning From Traumatic Deaths –Professor Guy Rutter
Post-mortum CT gives the cause of death for most patients, medical or traumatic. It can also tell us if our attempts at life saving interventions were done correctly.
Analysis of post-mortem images and injuries can help confirm the mechanisms of injury.
- Emergency Planning for Major Incidents @qehbham
Casualty regulation and capability chart determines how many pts (go to MTC) P2 go to TU. P3 go to other hospitals.
Recent major incidents have higher numbers of P1 casualties – previously assumed 10% in a major incident…recent incidents have all have been considerably more than this; trauma units will get some P1 patients. Trauma Units therefore need to declare what sort of patients they can take… P1 but with specific injuries.
When trying to clear the ED patients don’t necessarily leave ED even when told it is a Major incident they need to be individually redirected.
NHS England have produced clinical guidelines for major incidents and mass Casualty incidents in an easy to read format.
- Seizure type
- Treatment of Status (Generalised, Focal, Absence)
Invented by a Welshman ‘Hugh Owen Thomas’, the introduction of this simple device in World War 1 went on to reduce the mortality of #femurs from 80% to 16%.
- Measuring Tape
- Thomas splint – Adult or Paediatric (depending on size)
- Hoop – Sizing guide can be found here
- Hoop Pad
- Skin Traction – Adult or Paediatric
- Padding rolls x 2
- Bandages (wide) x 2
- Tongue Depressors x 2
Measure the Inside Leg (unbroken leg) and add 30cm/12inch (to give room for the traction)
Adjust length to the above measurement. ensuring the Hoop is at an angle with the lateral (outside leg) higher than the medial (inside leg).
- Apply the hoop Pad (to reduce pressure and secure to tight)
- Apply the 4 slings (lowest should be 40cm from base)
- Apply padding along slings
- Creat a small padding for behind the knee
- Ensure Adequate analgesia (this hurts) – typically Opiates and entonox
- Femoral nerve block may be helpful (however, this is variable due to the innovation of the femur and reduces the more distal the fracture)
- Check Genitals not trapped – by the hoop
- Apply skin traction & and bandage from ankle to thigh
- Secure the tight Clip – remembering to put the padding under the clip and velcro round
1. take the strings and pass one over and one under the sides of the frame.
2. secure tightly with a Reef Knot
3. pass strings down (one over and one under) around the base, bringing them back over the Reef Knot and back around the base. This makes a pulley system.
4. Tension the pulley system and tie-off using a bow
5. Pass the tongue depressors (2 tongue depressors tapped together), twist the tongue depressors to achieve the required tension, and lock off against the side.
Bandage & Elevate
- Bandage the leg to the sling using the bandage – to keep secure
- Place a pillow or blankets under the splint to elevate the heel – To prevent pressure sores
Great review of shoulder reduction, techniques and sedation.
- Most techniques will work 80% of the time (Best results tailor the technique to the patient)
- Kocker’s shouldn’t be used in # greater tuberosity
- Cunningham technique looks interesting (I’m going to give this a go)
- Traction is the what causes the most pain. Reduce the traction & Reduce the sedation required
Hej Hej Glasgow it was fun, now back to work. Day-4 was full of great Canadian thoughts on neurology (Vertigo, SAH, and TIA) all topped off with a sprinkle of Organophosphates