I received the following interesting email from *******. Comments, please!
In regard to the almost blind adherence of many (including myself) for reaching for the BVM to provide oxygenation for hypoxic critically ill patients in an emergency here is some food for thought!
Thanks Naing for a well-researched review of PE diagnosis.
For an interesting perspective on the issue, see Newman and Schriger’s editorial on Annals of Emergency Medicine. The gist of this article: The PEs we stress about missing (in stable, haemodynamically normal patients) are not the same disease as the deadly PEs of the past (easily clinically diagnosed, devastating ones). Therefore, over-zealous investigation may cause more harm (contrast, radiation, anticoagulated haemorrhage) than the minor disease we are trying to detect.
Are you testing for PE rationally?
When it’s a neonate, of course!
Confused? The Australian Resuscitation Council may be to blame.
The following is a fictitious case:
Local identifiers removed
Thanks to Trudi Disney from the Acute Pain Service for her interesting talk on OIVI – Opioid-Induced Ventilatory Impairment. The following (edited) summary from Trudi comprises the essentials from her talk – thanks Trudi.
That, and other dental trauma tidbits, courtesy of Andrew Climie. Many thanks.
For those keen to revisit his presentation, see here.
And for an excellent, concise handbook for ED dental repairs, see here.
Case details censored
To see the case in context, hop on over to here
Thanks Domhnall, for introducing us to The Vortex, a cognitive aid for managing a Can’t Intubate, Can’t Ventilate (CICV) scenario.
For some background on why this is necessary, see the previous post on human factors – which shows how loss of situational awareness in CICV can have tragic results.
“All patients are considered to have a spinal injury until proven otherwise – if lack of significant injury cannot be ruled out at presentation, the immediate institution of spinal precautions is necessary“
This is how to put on a super-duper fully enclosing plaster forearm cast. Put on one of these for your distal radius fractures which you have reduced. Then split it with the saw.
First, assemble two rolls of plaster. How do you select the right width? Put the roll in the palm of the patient’s hand – it should be the same width as his/her palm. That’s 7.5cm for most people, 10cm for the, er, big-handed punters. Also ready your undercast padding, crepe bandage, and importantly, your stockinette. Here, we have two lengths of 5cm stockinette, one for the arm and one for the thumb.
Thanks to Erica Trandafilovic of Smith&Nephew for a fantastic plastering workshop peppered with handy plaster handling tricks.
Here’s how to finesse your distal forearm volar slabs:
Case removed from post, factual management retained
Differential = PE vs Neutropaenic sepsis
Thrombolysis criteria have been discussed in a previous post (Lysis for high-risk PE).
Your next patient is a 50 year old man, a pedal cyclist run over by a truck. He clearly has severe blunt injuries to chest, abdomen and pelvis. He is in hypovolaemic shock. eFAST is positive for right PTX, negative for intraperitoneal or intapericardial blood. Right ICC evacuates air but no blood. Pelvic XR shows a complex, unstable, lateral compression type injury with multiple fractures. What now? The NSW Health Institute of Trauma and Injury Management has published these guidelines, outlining a possible approach to this kind of patient.
Thanks David Brook for a comprehensive review of low back pain.
For additional reading, click here
Thanks Mel Venn for a great review of an important topic.
Australian Prescriber have a fantastic Anaphylaxis Wall Chart which summarises the available treatment options. Print it for your toilet door!
REMEMBER: the dose of adrenaline for anaphylaxis (given IM, into the anterolateral thigh) is:
10mcg/kg, up to 500mcgAgain from Australian Prescriber is a great review of adrenaline auto injectors (eg. Epipen). Useful information to give your patients.
A more in-depth recent review of anaphylaxis is found here.
And a post on the controversy of biphasic anaphylaxis is here.
Thanks Josh Power for the comprehensive review of blood gases. For those who felt they failed to grasp all the concepts presented in 45 minutes, don’t worry, you aren’t expected to be fluent after just one lecture…
… because you are expected to spend a lot more time than 45 minutes studying this stuff!
Josh did a nice job of demonstrating the calibre expected of a FACEM Fellowship candidate. For those aiming to sit the exam in the next year or two – you may now realise how much work there is to be done.
Here are the slides from Josh’s Blood Gases lecture, which will be a great resource for those looking to sit the exam:
My favourite text for the subject is Brandis, found at http://www.anaesthesiamcq.com/AcidBaseBook/ABindex.php
Josh also recommends http://emcrit.org/wp-content/uploads/acid_base_sheet_2-2011.pdf & http://lifeinthefastlane.com/education/ccc/
Julia Haire presented the Statewide Grand Round on Dec 4 “New and Future Strategies in Chest Pain, STEMI and ACLS”.
Included were a recent Australasian observational study of an “accelerated diagnostic protocol” for ACS. In short, patients presenting with chest pain due to suspected ACS were risk stratified on the basis of TIMI score, ECG and serial troponin at 0 and 2 hours. Only one patient out of 392 (0.25%) had a “major adverse cardiac event”.
ADAPT trial 2012
A followup validation study of sorts was performed at Nambour ED, and identified zero major adverse cardiac events in the cohort risk stratified according to the ADAPT ADP:
EMA Nambour ADP 2013
Great results, but have these studies simply identified a subset of possible-ACS patients whose risk is so low that in fact no troponins and no further testing are needed?
Summary of Ray’s case presentation on 4 Dec:
Obese 55 year man presents after a sudden collapse at home, with new-onset rapid AF and profound, hypotensive shock. His illness seemed to have a very short time-course.
Thanks John Dewing for a snappy talk on cellulitis.
Here’s an up to date review for those interested:
BMJ Cellulitis Review 2012