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#EUSEM2020 (virtual conference)

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September 28, 2020

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)

KIDS

Paediatric status epilepticus (Dr Messahel –  Alderhey)

Until last year – No evidence for phenytoin use then 3 trials come along al at once

    • Eclipse – UK 
    • Concept – Aus/NZ
    • ESETT – USA 
      • Phenatoin 20mg/kg (max 2g)(no real evidence for its use prior to 2019)- hypotension, purple glove, arrythmia
      • Keppra 40mg/kg (max 2.5g)
      • No sig difference between keppra/phenytoin (terminating fit and side effects)

Thoughts: Guidelines will likely change to include keppra (as easier to give)

Paediatric sedation (Dr Shavit – Israel)

Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children

5yr study across Canada – serious adverse events –  1.1%

  • Apnea – 0.9%
  • Laryngospasm 0.1%
  • Hypotension 0.1%
  • Bradycardia 0.1%
  • No deaths/ long term inj
  • Only sig action required – positive airway pressure vent

JCI – should still regard sedation as a high risk procedure

 

RESUS

Thoracotomy Tips (Gareth Davies – London HEMS)

London HEMS approx. 10% survival (many done by first timers)

  1. Getting in
    • Thoracostomies – Are you too far forward? -go for posterior axillary line (will often stay open without spreaders)
  2. When you’re in
    • Getting through the pericardium
      • Pickup pericardium with forceps
      • Cut with scissors- (Vertical midline)
        • Scalples – often cause more damage (esp. with high adrenalin)
    • Finger on hole to stop bleeding
      • Suture without plegets – keep loose, avoid arteries
      • Can Staple
      • Foleys catheter – remember small volumes
    • Cardiac massage – bimanual
      • Often stunned – intracardiac adrenaline may help dose 1mg
      • VF- HEMS close chest and shock through adhesive pads usual places
    • Bleeding lung (options)
      • Lung squash (easiest)
      • Lung Twist- remember ligerment
      • Hilar Tie
    • Aortic compression
      • Manual better than clamps
        • Easier to do (finding right bit can be difficult)
        • Less likely to cause damage
        • Can allow partial occlusion of aorta
          • Help distal perfusion in transfer
          • Prevent ventricular overload – when pushing blood/fluids
  3. On the way Out
      • Internal mammories – May not bleed!!
        • If you haven’t tied them off – tell the surgeon

 

CRP vs ECMO – Could ECMO be coming to an ED near you?

CPR ROSC within 15min 80%, 30min 95%

North American – cohort study of out-of-hospital arrests

  • 11,368 patients
  • OVER 47min CPR – no patient survive with good neurological out come (Modified Rankin Scale 0-3)
  • OVER 55min CPR – no survivors to discharge

ECMO – will normalise circulation as soon as turned on thus should improve neurological outcome.

Metanalysis of ECMO – Showed ECMO increases neurologically intact survival –(but all of the studies are cohort/case series)

Minnesota Method (regional ECMO)

  • Ambulance Trigger Criteria:
    • Out-of-Hospital Cardiac Arrest – presumed cardiac cause
    • VF/VT as initial rhythm
    • 18-75years old
    • Body morphology – suitable for mechanical chest compression (transport issue)
    • Est. Transfer Time <30min
  • Ambulance transports local ED
  • ECMO team mobilised – from the centre to meet at local ED
  • ECMO started in Local ED – if suitable
  • Transfer back to centre – Survival rate 39.5%

Cardiogenic Shock 6 steps (Diercks – USA)

Often misdiagnosed as sepsis etc.

  1. Treat lungs BiPAP
    • Reduces intubation and cardiac preload + afterload
    • Titrate up expiratory pressure (i.e. CPAP)
  2. Optimise MAP (65mmHg)
    • Hypertention – Nitrates
    • Hypotension – Fluid unlikely to work (norad, vasopressin less pulmonary vasoconstriction)
  3. Volume status – Dilated IVC, Lung oedema, passive leg raise (does BP go up with leg raise?)
    • Too much (or no raise BP with leg raise) – remove fluid
    • Too little – add fluid
  4. ? Inotropes
    • hypoperfusion with low-normal BP OR refractory Pulmonary Oedema
    • dobutamine or digoxin
  5. Treat cause – arrhythmia, thyroid, MI etc.
  6. Nothing working ? call a friend – ballon pumps, impellers, ECMO (not currently an option in ED)

Sepsis

Antibiotics is faster better? (Nanayakkora – Netherlands)

Working out whether the patient is septic or has another cause for being unwell in ED can be difficult. However, we are pushed towards treating sepsis

Sterling 2015– Meta-analysis found – “no significant mortality benefit of administering antibiotics within 3 hours of ED triage or within 1 hour of shock recognition in severe sepsis and septic shock.”

Lui 2017– Delaying Antibiotics conferred a 0.3% increase in mortality/hr – however this was much bigger in SEPTIC SHOCK 1.8%/hr

Phantasi – Antibiotics given prehospital made no difference to survival. In treatment group patients received antibiotics 23min prior to reaching the ED on average. However, the usual care group received antibiotics 70min after arrival at ED (a mean difference of 93min)

Barbash 2020– Caution, giving antibiotics early may stop us looking for other causes (and may increase mortality) – Low risk of infection groups (10-20%, had 1 % increase mortality with early antibiotics, those with high risk 60% showed a 0.8% reduction in mortality.

Thought – 1 hour target probably important in Septic Shock. But DON’T stop looking for cause once you have decided to prescribe antibiotics

 

Head

Head Injury (Markus Wehler/Mark Wilson)

Remember a clear CT – just means there is no blood, not that they don’t  have a brain injury i.e. concussion. EXPLAIN to the patient

Biomarkers – GFAP (peak 20hr)/UCH-L1(peak 8hr)

However talking to Scandinavian EM doctors – who use S100B already in their guidance – they still seem to have to scan all the elderly and drunks just like us as the biomarkers always seem to be up in these groups.

 

Transient Global Amnesia (Hohenstein – Germany)

60% ED drs think stroke, 30% no idea, 10% confusion

  • History – Longterm memory OK, Short term memory poor- test short term 3 words: Repeat>Distract for 90s >Repeat (short-term memory dumps after 90s)
  • Hodges and Warlow criteria
    • The attack was witnessed and reported.
    • There was obvious anterograde amnesia during the attack.
    • There was an absence of clouding of consciousness.
    • There were no focal neurological signs or deficits during or after the attack.
    • There were no features of epilepsy.
    • The attack resolved within 24 h.
    • The patient did not have any recent head injury or active epilepsy
  • Acute MRI – shows hypodensen hippocampus (transient)
    • Similar to migrane
    • often complain headache nausea, dizzy
    • often linked to stress
  • Differential
    • ZEMANS criteria: Recurrent TGA or evidence epilepsy – think transient epileptic amnesia (fit in sleep and amnesia tends to occuer when wakes up)
    • Painless aortic dissection – one case report
    • Acute amnestic syndrome
      • Autoimmune encephalitis – psychosis uncoperatiev, neurology
      • Alcohol/cocaine
      • Post-traumatic
      • Psychogenic (always retrograde not anterograde)
      • Cardio embiloc strokes (likely longer)
  • Management – German Society Neurology
    • No prophylaxis
    • No work up required

Medical clearance of psych patient (Nickel – Switzerland)

  • Only 52% get a full set of obs
  • ACEP – don’t routinely do labs
    • systematic rv (only grade C evidence) 0.0-0.4% had clinically significant results
  • SMART medical clearance form – validation showed failure rate of <1%

 

Others…

PE ESC 2019 (Becker/Hemple – Germany)

  • D-dimer raised for up to 3weeks post event
  • YEARS + algorhythm  – used in Germany in pregnant patients (? how useful)
  • Echo – RV dilatation NPV 54 not a good rule out
    • (60/60 sign /mcconnels better but difficult)
  • Diagnostic utility of subsegmental PE – “uncertain value” should we treat ? the debate goes on.
  • Can we believe the CTPA?
    • NPV of CTPA: 89-96% in low/moderate risk patients BUT only 60% in high risk
    • PPV of CTPA: 92-96% in high probability, but only 58% in low risk
    • “In case of a negative CTPA in patients with high clinical probability, investigation by further imaging tests may be considered before withholding PE-specific treatment”

Pre-eclampsia/Eclampsia (Prosen – Slovenia)

  • 20/40 to 4/52 postpartum
    • hypertensive disorders of preg
      • chronic HTN
      • Gestational HTN
      • Chronic with pre-eclampsia
      • Pre-eclampsia
    • Spectrum from pre-eclampsia to HELLP
  • Definitions
    • Mild: HTN>140/90 +proteinuria
    • Severe: above + any ofSBP>160, proteinuria >+++, cerebral disturbance, pulmonary oedema /cyanosis, Thrombocytopenia, Foetal growth restriction, AKI, liver imparment
    • Eclampsia: above + fitting
  • Eclampsia – treat with Mg
    • 44% occur post-partum reports in literature up to 8 weeks
  • Always consult Ob/Gynae
    • Mild: may be oral antihypertensive and OP with close followup
    • Severe: reduce SBP by 20mmHg – labetalol
      • Starting Mg 4-6g 30min (reduced in renal dysfunction)
      • keep checking tendon reflexes (reduced early sign of hypermagnesaemia)
    • Eclampsia:
      • 4-6g MgSO4 15min
      • can use benzo as well
      • gravid > left lat

Mesenteric iscaemia (Spiteri – Malta)

  • 1:100 hospital admissions – generally old with clotting hx (but can be young)
  • Sign/Symp
    • Pain++
    • Little tenderness
    • Associated GI emptying (D+V)
    • Mesenteric claudication –post prandial
    • Blood PR – often occult and late
    • Sepsis late
  • Mortality >70%
  • Bloods not specific or sensitive
    • Lactate (gen high)/BG (met acidosis + surg abdo ischaemia until proven otherwise)
    • Amylase high in 50% of cases
  • AXR>25% normal, suggestive in 20-30% (SBO/Thumbprinting)
  • CT iv contrast much better test
  • Treatment
    • Analges
    • Fluid
    • Anticoag – unless bleed
    • Broad spec AB’s
    • Surgery
    • ? vasodilators

Deep Neck Space Infection

Uncommon can be discreet, Often post simple ENT infection

  • 10-20% mort in these infections
  • Sign/Symps depend on site/plane of the infection
    • general: fever, malase etc
    • neck pain 90%
      • torticollis
      • crepitation’s neck
    • swelling – not always obvious
      • pitting/doughy
      • check the teeth
    • CN impingements
    • Pain swallowing
    • Horse voice(duck quack)
    • Stridor
  • Contrast CT neck would diagnose
  • Treat: Early intubation (be ready for trach), IV abs, surgery