Author: embeds

Hypomagnesaemia

Classification

  • Normal: 1.1-0.7
  • Mild: 0.69-0.5
  • Moderate: 0.49-0.4
  • Severe: <0.4

Signs/Symps (normally <0.5)

  • MSK: Muscle Twitch, Tremor, Tetany, Cramps
  • CNS: Apathy, Depression, Hallucination, Agitation, Confusion, Seizure
  • CVS: Tachycardia, Hypertension, Arrhythmia, Digoxin Toxicity
  • BioChem: Hypokalaemia, Hypocalcaemia, Hypophosphataemia, Hyponatraemia

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D&V in kids

Paediatric gastroenteritis can be a pain for everyone but as with most of EM – Keep It Simple

  • Not dehydrated – make sure they can tolerate fluids, and encourage hydration, think about ORT
  • Dehydrated – look for the red flags that indicate they are developing shock. Use ORT unless IV indicated
  • Shocked – you will need access and it will probably be difficult (IO on awake children really isn’t that bad)

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Hypothermia

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] – Low GCS, Bradycardia/pnoeic, Hypotensive, Arrhythmias, Cardiac Arrest

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Silver Trauma

The population is ageing and thus our ‘typical’ trauma patient is also changing. In 2017 the TARN report “Major injury in older people” highlighted the following issues:

  • The typical major trauma patient: has changed from a young and male to being an older patient.
  • Older Major Trauma Patients (ISS>15): A fall of <2m is the commonest mechanism of injury
  • Triage/Recognition of ‘Silver Trauma’ is POOR
    • Pre-hospital: Not identified hence taken to TU’s (Here) not MTC’s (Leeds).
    • The ED: Often seen by Junior Staff and endure significant treatment delays.
    • Hospital: Much less likely to be transferred to specialist care.
    • Outcomes: More likely to die, but those who survive have similar levels of disability to younger people.

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TXA – Tranexamic Acid

TXA a bleeding wonder drug!

Crash 2 Study (2010)

  • Multi-Centre RCT of the use of TXA in trauma
  • Inclusion – Adult trauma patients with ≥1 of
    • Suspicion of significant haemorrhage
    • HR ≥110bpm
    • sBP ≤90mmHg
  • Treatment – 1g TXA IV over 10min then a second 1g TXA IV over 8hrs
  • Outcome – Significant reduction in Death, bleeding with NO increase in clots(thrombotic disease)
    • Most benefit seen if given early (<3hr – NNT 53)

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Acidosis & VBG’s

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 (pH) it is the most important.

Acidosis: Unless you have a good reason (e.g. you know its due to DKA) you should be investigating and performing an Arterial Blood Gas (ABG)

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#RCEMasc 2019 – Day 3

AIRWAYS-2

ETT vs SGA (i.e. iGel) in out of hospital cardiac arrest (trauma and kids excluded)

  • Headline Results: 
    • Survival with good neurological out come (MRS 0-3) – No difference around 2.75% (for those that required either SGA or ETT)
    • Easiest – SGA easier achieving ventilation within 2 attempts (87.4% vs 79%)
    • Displacement – SGA suffer more displacement (10% vs 5%)
    • Aspiration – No difference around 15%
  • Interesting Results:
    • Survival – approx. 20%  in those that didn’t have an advanced airway attempted (indicating likely survival advantage of only needing a short resus)
    • Paramedic use of advance airways – Paramedics on average only need to use advanced airways 3-4 times a year!
    • PART study (USA) – ETT vs Larangeal Tube no difference
    • BMV vs ETT (France & Belgium) – no difference in out come, but BMV was more difficult

PARAMEDIC 2

Adrenaline vs Placebo in out of hospital cardiac arrest

  • Headline Results:
    • Survival to hospital admission: adrenaline 23.8% vs placebo 8% (Significant)
    • Survival @ 3 months: adrenaline 3% vs placebo 2.2% (Significant)
    • Survival @ 3 months with good neurological outcome (MRS 0-3): adrenaline 2.1% vs placebo 1.6% (Non-Significant)
  • Interesting Result:
    • What did the public thing was the important outcome? In the restudy survey 95% of public reported that survival with good neurological outcome was more important than surviving to hospital.
    • Extrapolation of Adrenaline use: to all UK adult cardiac arrests in a year, adrenaline would increase:
      • ROSC: 5602
      • Admissions: 3555
      • ICU Admissions: 1643
      • Discharged Alive: 203
      • Favourable Outcomes (MRS 0-3): 68
      • Unfavourable Outcomes (MRS 4-5): 135
    • What should happen? International resus (ILCOR) now strongly recommend adrenaline use, however, we probably need public consultation

TXA for bleeding

Dr Ian Roberts

  • Inhibits fibrinolysis – i.e. stops plasmin breaking down clots
  • Treats bleeding – NOT coagulopathy
  • Given TXA Early – as tPA activates early and PIA-1 is later, we need to stop the tPA
    • 15min treatment delay > 10% reduction in effect
  • Give on the suspicion of bleeding? – you get the same risk reduction  what ever your base line risk (i.e. 30% risk of death > 20%, 3% risk > 2%)
  • Safety – in Japan TXA bought over the counter for headaches
  • RCT’s
    • Surgery – TXA reduces blood loss by 1/3 & death, NO increase in clot events
    • Post-Partum Haemorrhage – PPH reduced by 1/3
    • Trauma – Sig. reduction in DEATH (<1hr reduced by 1/3, 1-3hr by 1/5)
    • Vascular occlusive events – data seems to show TXA reduces them
      • Bad bleeding  increases vascular-occlusive events
    • Brain  – results apparently don’t contradict other studies but full results in 2weeks
    • GIT – results due next yea, recruitment stopped in uk as TXA was being give anyway
  • Why have the infusion? – added to regime to (theoretically) replace the loses from ongoing bleed, its utility is unknown.

Lightning papers

  • Mobile phone use @ work(Derby)
    • 80% patients thought it ws fine – this increased to 95% if explained for medical reason
    • Patients didn’t want – you to be using it while talking to them (distraction/rude), dont wipe it on them (infection control)
  • Hair Ties with glue (HAT) vs Suture (not those that would only have been glued anyway)
    • Reduced pain
    • Reduced follow up
    • increased patient satisfaction (less pain and no need to see
    • Faster and increased staff satisfaction
  • No Room @ the Inn (Bristol children)
    • Used winter pressures money to open the clinic space next to ED 18:00-23:00 (if needed)
    • Opened it 50% of the time
    • Used it for 10% of patients
    • Minor Injury/Illness (they do have a UTC)
    • Staffed from the ED
    • Patients and Staff like it!
    • Plymouth also do – staff love it as almost a break from the chaos of majors
  • Who’s pain are we treating?
    • 50% Dr’s assume patients want a prescription, but <30% actually do
    • Patients expect more pain in the following days – than Dr’s expect
    • Patients want to know that codeine is potentially addictive within 3 days
    • They have reduced co-codamol scrpts from approx 10% to 3% of discharges – with no increase in complaints or patient satisfaction.

Mental Health

  • RESPOND  – multiagency mental health crisis simulation
    • Everyone has to make the decisions of each role (Police, Nurse, Dr, Paramedic)
    • Reduced demand on each agency
    • Strengthens partnerships
    • Streamlines process
  • Presentation in the ED –  RCEM mental health tool kit
    • Triage:
      • Agitation, Environment, Intent, Objects
      • VISA: Violent,Irrational thought, Suicidal, Alone
    • Capacity – Are they really weighing it up? if in doubt NO
    •  Observation
      • Mental Health Obs: Calm/Distresses/Agitated/Aggressive/Gone
    • No Scores predict risk – its a holistic assessment thats needed
    • Compassion & Communication – we shouldn’t make things worse for the patient
    • Restraint what to do and do we need it?
    • APEx course – ALSG