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.
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
Vertigo – Guide to the big 3
& today has been all about the Heart (New MI definition, Think Aorta, Failure) + some disaster med for my own interest
4th universal Definition of MI
Very Geri’s heavy day today @ #EuSEM2018 but lots to think about, and even squeezed in a bit of USS
Gait is an observation
- Timed Up and Go test – get up from chair walk 6m turn and come back, over 10s is a marker of frailty
- Also mortality – same predictive value as RR>25 or sBP of 90mmHg
For those of you working hard on the shop-floor a quick summary of whats going on in Glasgow @ #Eusem2018
3 interesting talks from dual Emergency Med and Infectious disease specialists, from Denmark and Germany, which highlighted that we are all in the same boat, and again doing the basics right is what maters.
Antibiotic Stewardship (What we do in ED, dictates inpatient care)
- Viral v.s. Septic – clinical differentiation is not reliable, and POCT for flu may be useful in the high prevalence of an outbreak but performs poorly the rest of the time.
- Choosing well – we can reduce the use of broad-spectrum antibiotic usage dramatically by using our site specific antibiotics [68-85% of the time we can correctly establish site clinically i.e. without tests – if it sounds like a chest infection it is]
- Blood cultures – really important for guiding the care of our inpatient colleges, esp. to help deescalation, [2 sets are better than 1]
Antibiotics within an hour
- 33% mortality reduction – more and more studies demonstrate the benefits of early antibiotic treatment
- Delay of 2nd dose kills – with longer boarding times in ED waiting for wards we need to remember that second dose it matters.
Is TCI (Target-Controlled Infusion) the way forward? Basically using an anaesthetic pump to smooth sedation instead of bolusing. Its already be used by non-anaesthetics in several areas and demonstrates lower complication rate than the RCEM sedation audit 0.05% vs approx 4%, when you look across studies.
PROTEDs group are currently doing a feasibility study into its application into the ED, early results show set up is quick, but the sedation time is slow. However, they admit that so far they have been very cautious with their dosing and are looking for optimal dosing regime.
Doing the basics well
There were a few pearls to take away.
- ECG moment artefact – if you get the patient to hold their arms out forward until they are too tired to move the artefact goes away!!
- Radiology in pregnancy
- Doses under 50mSV are not harmful to baby
- CXR is 0.1mSV (10 days background radiation)
- CT abdo pelvis 20mSV
- Once again doing the best for Mum is best for the baby
- Use Ultrasound/MRI where we can but if X-Ray/CT is warranted use it
- However, when multiple test are required (i.e. trauma) we need to actively monitor how that dose is increasing.