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
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
Our video maybe light hearted but…
SEPSIS is a Killer (1:4 Die)
and time matters
Recognise, Resuscitate, Review
Recent Incident: Bat contact was not recognized (effectively touching a bat without gloves means treatment is recommended)
Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in “Rabies-Free” counties the bat population posse a risk.
In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.
Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.
To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]
Combined Country/Animal & Exposure Risk
Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.
If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)
You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]
Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400
Do NOT use this regime for:
- Pregnant women
- Children under 16 years
- Urology surgery prophylaxis patients
- ANY patient who has ascites, limb amputation, cystic fibrosis, endocarditis, major burns, Cisplatin Chemotherapy, renal transplant.
- Creatinine clearance <30ml/min seek advice from pharmacy.
Often patients with cellulitis, need more than oral antibiotic management. However, they are not so sick to require hospital admission. OPAT allows suitable patients to be managed through the ambulatory services rater than being admitted. Read more
Acute sore throats are often caused by a virus, last about a week and get better without antibiotics. withholding antibiotics rarely causes complications. Antibiotic stewardship is everyone’s responsibility to prevent resistance developing.
Assess all under 5s with a temperature as per the NICE fever guidelines
Assess the patient for signs of severe sepsis – if present use the severe sepsis guidelines
If no signs of sepsis assess patient and calculate the FeverPAIN score and Centor score
FeverPAIN = 1 point for each of –
- Purulent tonsillar exudate
- Attendance within 3 days of onset
- severely Inflamed tonsils
- No cough/coryza
Centor = 1 point for each of –
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenititis
- History of fever >38
- No cough
FeverPAIN = 0 or 1/ Centor = 0,1 or 2 – no antibiotics, self care advice
FeverPAIN = 2 or3 – no antibiotics or a script for 3-5 days time if no better, self care advice
FeverPAIN = 4 or 5 / Centor 3 or 4 = give Antibiotics immediately, self care advice
Patients to seek medical advice if become more unwell or not improving after 1 week
Self care advice – Paracetamol, Ibuporfen, Adequate fluids, Medicated lozenges
If the patient has signs of being significantly unwell or a high risk of complications do not withhold antibiotics
Phenoxymethylpenicillin 5-10 days
If Penicillin allergy – Clarithromycin or Erythromycin 5 days
Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs. Sepsis can lead to shock, multiple organ failure and death especially if not recognized early and treated promptly.’ (GSA, 2010) Read more