1. Why we get things wrong – “A tale of two systems”

November 3, 2018

Very few of us come to work intent on doing harm. However, despite that we all keep making mistakes. Most of them pass unnoticed and… Read more

A-a gradient

March 25, 2018

A-a gradient = Alveolar Oxygen – arterial Oxygen This is “relatively” simple way of working out if the paO2 on a ABG is normal, and demonstrates… Read more

Acidosis & VBG’s

October 4, 2019

We are frequently asked to check the lactate on Venous Blood Gases (VBG’s), by the nursing staff. However, remember to look at the first result… Read more

ACS (HS-Trop) Pathway

April 16, 2019

When is the ACS pathway used?  The ACS pathway is for patients where coronary ischemia is in your differential. It is not a blanket pathway… Read more

Acute Behavioural Disturbance / Excited Delirium

December 24, 2017

Most of us will have seen patients like this – agitated, aggressive and often with police or security pinning them down. High risk of Cardiovascular… Read more

Acute Heart Failure (AHF) – ESC 2016

October 9, 2018

  AHF Triggers there are many triggers for AHF, which if recognized and treated with help improve outcomes Cardiac: ACS, Arrhythmia, Aortic Dissection, Acute Valve… Read more

Adrenal Crisis

February 11, 2018

Adrenal crisis or insufficiency is a life threatening emergency due to the lack of glucocorticoid. Adrenal crisis can be primary due to destruction of the… Read more

AKI – Acute Kidney Injury

June 13, 2020

AKI is a common issue for patients presenting to the ED and  not only has a significant mortality associated with it but also a massive… Read more

Alcohol Withdrawl

June 20, 2018

Generally we DON’T admit patients acutely solely for “Detox” However the following groups should be admitted [taken from trust guide] Patients requiring admission for another… Read more

Anion Gap & Metabolic Acidosis

March 26, 2018

The anion gap (AG) represents the amount of unmeasured anions in the plasma. AG =([Na]+[K]) – ([HCO3]+[Cl]) The main contributor to the AG is albumin… Read more

Aortic Dissection

June 16, 2018

Aortic Dissection (AD), is uncommon (1 AD:200 ACS) but is…Rapidly FATAL!  Unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%. Read more

Are You CO Aware?

October 24, 2018

With the onset of colder weather, many households in the UK are turning on their heating for the first time in months. Heating appliances need… Read more

Asthma – Adult

December 24, 2017

Asthma is common and potentially fatal. Severity – Severe or Life threatening – think RESUS Treatment within 30 min – bronchodilators and steroids should bee… Read more

Be #urosceptical

July 1, 2019

Ditch the Dipstick – for patients >65Yrs or Catheterised! Approx. 50% of over 65’s and most of those with catheters have asymptomatic bacteriuria. The patient… Read more

Bell’s Palsy

May 2, 2018

Bell’s Plays is a lower motor neurone (LMN) lesion of the facial nerve (CN VII), which causes one side of the face to “droop” [1%… Read more


August 12, 2018

Causes Cardiac: Heart Block, Myocardial infarction, Myocarditis Metabolic: Hypothermia, Hyperkalaemia, Hypokalaemia, Hypothyroid, Hypoxia Toxin: digoxin, B-blocker Treatment For ALL conditions leading to bradycardia treating the… Read more

Button Battery Ingestion

July 9, 2018

A button battery lodged in the Oesophagus is a medical emergency as it can cause necrosis and significant GI bleed – Refer immediately If anybody… Read more

Cervical (Carotid OR Vertebral) Artery Dissection

November 24, 2018

Cervical artery dissection is a rare but significant cause of stroke and headache/neckache, which is easy to overlook. Leading to a typically delay in diagnosis… Read more

COPD – exacerbations

December 22, 2017

COPD patients vary widely, due to their comorbidities, social circumstances, and wishes. So choosing the best treatment pathway for the patient can be complex. Involve… Read more

COPD think VBG

February 18, 2018

We have recently introduced the use of VBG in COPD. Why Change? Pain – we all know and warn our patients ABG’s are painful. Patients… Read more


April 15, 2020

Experience is showing that those with diabetic patients with COVID-19 are more likely to develop DKA/HSS. However, treating them with the traditional large amount of… Read more

COVID-19 (X-Ray learning resource)

March 15, 2020

British Society of Thoracic Imaging (BSTI) have released a free learning resource containing CXR and CT of confirmed Covid-19 cases, will short history including time… Read more

Covid-19 [Hyperglycaemia]

July 17, 2020

Both COVID-19 infection and treatment with dexamethasone impair glycemic control. So its important to monitor blood sugars and consider DKA & HHS in COVID-19 patients.… Read more

Dabigatran Reversal

September 16, 2019

Bleeding on Dabigatran? <C>ABCD – as usual trying to stop bleedBloods: FBC, Clotting, U&E, G&SDiscuss with Haematologist (esp. if taken within 12-24hr)Idarucizumab (PRAXBIND) 5g IVFound… Read more

Deep Vein Thrombosis (DVT)

December 22, 2017

It is worth remembering that HRI and CRH have different processes for the management of DVT see Management section. Signs and Symps No single feature… Read more

Delirium in the ED

March 11, 2019

Delirium is one of a number of geriatric syndromes and has significant associated morbidity and mortality. 3 subtypes of delirium Hyperactive – easies to spot,… Read more

DKA – Adult

February 6, 2018

Things to remember Give 0.9%NaCl Actrapid “Fixed Rate” 0.1unit/kg/hr Basal Insulin (lantus/levemir) give this too – usual time and dose Potassium – if below 5.5 will… Read more

DVLA – Driving & Medical Conditions

May 8, 2018

For many conditions the patient should be informed to stop driving and inform the DVLA of their condition. It is the patients responsibility to inform the… Read more

Giant Cell Arteritis – GCA

March 13, 2018

GCA is a is a vasculitis generally seen in the over 50’s and associated with polymyalgia rheumatic (PMR). However, unlike a lot of rheumatology, GCA… Read more


February 27, 2018

There are numerous causes of headache, however, the pressing question in the ED is, Is this a primary or SECONDARY headache? Primary headaches [e.g. tension… Read more

High INR

March 17, 2018

Patients sometimes present to ED or are send to ED due to over anticoagulation with warfarin 1. Is there Major/Significant bleeding? Yes Resuscitate (ABCD) Give… Read more


February 11, 2018

90% of hypercalcaemia is due to either malignancy or hyperparathyroid. Severity: Adjusted Calcium (Ca) Severe: >3.5mmol/l – URGENT treatment (risk of dysrhythmia) Moderate: 3.0-3.5mmol/l  – PROMPT treatment (maybe well tolerated if… Read more


February 11, 2018

Remember: is it a haemolysed blood sample? (you can do an iSTAT) Severity Mild: 5.5-5.9mmol/l – No urgent action required (Dietary & Medication modification &… Read more

Hyperosmolar Hyperglycaemic State (HHS)

May 23, 2018

HHS (A.K.A. HONK) is a diabetic emergency, but unlike DKA we don’t always think about it. Patients with HHS are often elderly with multiple co-morbidities,… Read more


February 11, 2018

Hypocalcaemia can life threatening, due to arrhythmias and seizures. Severity – Adjusted Calcium (Ca) Mild: >1.9mmol/l Severe: ≤1.9mmol/l OR Symptomatic Read more

Hypoglycaemia – Adult

July 8, 2018

Hypoglycaemia (Blood glucose under 4.0 mmol/l) is potentially fatal and should be treated. it may be defined as “mild” self-treated, or “severe” treated by a… Read more


June 2, 2018

Hypokalaemia (low potassium), is a common problem. It is found in 14% of outpatients and 20% of inpatients, however only 4-5% of those are of… Read more


December 11, 2019

Classification Normal: 1.1-0.7 Mild: 0.69-0.5 Moderate: 4.9-4.0 Severe: <0.4 Signs/Symps (normally <0.5) MSK: Muscle Twitch, Tremor, Tetany, Cramps CNS: Apathy, Depression, Hallucination, Agitation, Confusion, Seizure… Read more


January 13, 2020

Hyponatraema is a common finding, especially within our elderly population. However, its significance is is not a simple numbers game, and needs senior input. Prior… Read more


December 22, 2017

Remove COLD, Add WARM, Don’t SHAKE 32-35ºC [Mild] – Shivering, Tachycardia, Tachypnoeic, Vasoconstriction 30-32ºC [Moderate] – Shivering stops, Pale/Cyanosed, Hypotensive, Confused, Lethargic <30ºC [Severe] –… Read more

Influenza POCT (Adult)

December 17, 2019

The 2019-20 Flu season has arrived, and we need to be thinking about who to test and who to treat. Full guide HERE But don’t forget… Read more

LA – Toxicity

December 22, 2017

We are regularly doing femoral blocks next to major vessels. So warn the patient of the symptoms, & keep them monitored(at least 15 min). Symptoms… Read more

Lower Back Pain: Red & Yellow Flags

December 14, 2019

Each year 1:15 of the adult population will seek medical help for Lower Back Pain, that is 2.6 million patients in the UK. Most Lower… Read more

Massive Transfusion Pathway

February 6, 2018

In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MTP Remember: Do the Basics… Read more

Meningitis – Adults

December 16, 2017

This advice is based on Becky’s CTR, as well as NICE and the joint consensus statement. Keep your suspicions high – early signs it may not be… Read more

Metastatic Spinal Cord Compression (MSCC)

October 3, 2018

This is guide to the investigation of Metastatic Spinal Cord Compression (MSCC) in Oncology/Haematology patients. You need to be a bit more suspicious and have a… Read more


September 18, 2018

Wear Gloves & Wash Your Hands!!! In September 2018 there have been 2 cases of Monkey pox in the UK (Hence the PHE advice) Monkeypox… Read more

Myocardial Infarction (MI) – PPCI/Thrombolysis

June 22, 2018

PPCI (Leeds PPCI Pathway) Target: Door to balloon 90min Criteria: Time: Chest pain within 12hrs (or worsened within 12hrs) ECG:  ST elevation MI (1mm Limb… Read more

New: MERS Standard Operating Procedure

August 22, 2019

Please see the updated SOP for Middle East respiratory syndrome coronavirus. Make sure you are familiar with this protocol and for anymore information please contact… Read more

NIV (Non Invasive Ventilation)

February 6, 2020

NIV should be considered for use in patients with a  persisting Acute Hypercapnic Respiratory Failures after a maximum of one hour of standard medical therapy. However, ICU… Read more

Notifiable Diseases

May 10, 2019

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… Read more

Octaplex – work fast its an EMERGENCY!

December 16, 2017

In recent incidents we have had significant delays in giving OCTAPLEX, So ….. Activate EARLY in head injury patients on warfarin. Order on EPR &… Read more


May 12, 2018

  Often patients with cellulitis, need more than oral antibiotic management. However, they are not so sick to require hospital admission. OPAT allows suitable patients… Read more

Ottawa SAH Rule

June 27, 2019

Headache is a common presentation to ED and Subarachnoid is the diagnosis we never want to miss. However, working out who needs a scan can… Read more

Parkinson’s Disease & can’t swallow

October 2, 2019

We all recognise the importance of ensuring patients with Parkinson’s disease (PD) get their medication, but.. What do you do if the patient can’t swallow?… Read more

Pneumonia (Community Acquired)

March 9, 2018

BTS Definition of CAP Signs of acute Lower Respiratory Tract illness (LRTI) [Cough] &:  ≥1 other LRTI Symptom [Pleuritic pain, Tachypnea, Dyspnea, etc] New Focal Chest… Read more

Pneumothorax – Medical ones

December 20, 2017

To drain or not to drain? – that is the question (Follow the BTS algorithm).This is not for Tension! Read more

Pre-Arrival Blood (O-ve)

March 13, 2019

On rare occasions you may receive a pre-alert, where you want blood available for the patient when they arrive (for example in major haemorrhage). This… Read more

Primary Atrial Fibrillation/Flutter (AF)

December 23, 2017

Before you start  Whats the cause? – treating the precipitant often sorts the AF (adding B-Blockers to Sepsis can make things worse) Stable or Unstable? … Read more

Proximal Myopathy/Muscle Weakness

May 1, 2018

The Case An elderly patient attends the ED with difficulty mobilising, Nursing staff tell you that the patient needs a CT head for STROKE? –… Read more

Pulmonary Embolism – PE

December 20, 2017

PE is somehow both the most over and under diagnosed condition. with severity ranging from the questionable sub-segmental PE to the Massive PE (an indication… Read more

Pulmonary Embolism in Pregnancy

July 19, 2019

Unfortunately the the normal pathway for investigation of PE performs poorly in pregnancy RCOG have the following pathway 1. Investigation – of suspected PE Clinical… Read more

Purple Glove Syndrome – Case

September 23, 2018

Is a rare complication of I.V. Phenytoin, which presents with a triad of: Pain, Oedema & Discolouration, typically in the hand. In our case a… Read more

Rabies [notifiable disease]

July 17, 2018

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… Read more

Rare Antidotes – how to get

August 30, 2018

Getting some of the rarer antidotes has recently been clarified across Yorkshire (Accessing rarely used antidotes-SOP) Read more

Rash/Derm Guide

August 26, 2020

Guide Taken from the Primary Care Dermatology Society(PCDS) other good sourse is DermnetNZ. A relatively easy way to find out what you’re looking at! Rash –… Read more

RCEM CPD 2019 Day 1

April 2, 2019

 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… Read more


January 15, 2019

We often worry about patients developing rhabdomyolysis and consequently developing AKI. However, there is much debate and little consistency in the published data, over how… Read more

Scombroid Poisoning- NOT another fishy allergy

April 19, 2018

Scombroid poisoning (AKA – Histamine fish poisoning) is apparently more common than we think and accounts for 40% of seafood related illness in the USA… Read more


March 13, 2018

Background 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… Read more


November 23, 2018

Our video maybe light hearted but… SEPSIS is a Killer (1:4 Die)  and time matters Recognise, Resuscitate, Review  Read more

Sex, Bites, and Needle Sticks

February 28, 2018

First Aid (ALL) Encourage bleeding Wash with copious amounts of water or saline Don’t Suck Don’t use Caustic agents   Read more

Sickle Cell Crisis

June 7, 2019

Painful Crisis Severe pain is the most common reason that patients with sickle cell, will attend the ED. The pain can be agonising (and often… Read more

Sore Throat

March 17, 2018

Background Acute sore throats are often caused by a virus, last about a week and get better without antibiotics. withholding antibiotics rarely causes complications. Antibiotic… Read more

Syncope – ESC 2018

September 25, 2018

Defintion:Transient Loss of Consciousness (TLOC) due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery. Common ED Complaint: 1.7% of all attendances Difficult… Read more


February 28, 2018

Background Cardiac arrhythmias are relatively common presentations to ED. There are many causes, some more sinister than others. If your patient is not acutely unwell… Read more

Tick-Bourne Diseases

August 6, 2020

The prevalence of diseases transmitted by tick bite have increased in recent years, within the UK. And it is now recognised that there are 3… Read more

Transfusion Care Pathway

July 13, 2018

PDF: Transfusion Care Pathway When giving blood products you need to use the transfusion care pathway. Octaplex Blood/Plt’s/FFP It can be found on intranet >… Read more

Trust Dalteparin dosing

July 12, 2020

Trust Guidance varies slightly from BNF for those patients over 100kg Non-Pregnant PE/DVT treatment CrCl Calculator – HERE CrCl <20ml/min contact haematologist Pregnant PE/DVT treatment… Read more

Upper GI Bleed (UGIB)

December 22, 2017

Not normally difficult to spot, but look for it in unexplained anaemia, or collapse. Questions Is it VARICEAL? Mortality 35%, so is an emergency whatever… Read more

Vertigo in ED

December 20, 2017

Vertigo is not always labyrinthitis!! There are some potentially serious conditions to think about. Your main question should be is it peripheral [good] or central… Read more