Lots of good stuff again from the virtual #RCEMasc21 – here are a few of the topics that got me thinking Read more
My first virtual conference – has been great to dip in and out of all the streams at my leisure. Just a shame they didn’t send some Danish liquorice.
So here is my Summary…..(Kids, Resus, Heads, Others)
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
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:
- 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
- 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.
- 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.
- 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
- Agitation, Environment, Intent, Objects
- VISA: Violent,Irrational thought, Suicidal, Alone
- Capacity – Are they really weighing it up? if in doubt NO
- 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
- 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
- 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
- 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
- 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
- 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%
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
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:
- 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!
- 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.
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.
- 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
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.