Paracetamol 12hr SNAP regime: 2014 & 2019

• What is it? 
  • Pre-NAC – 4mg Ondansetron IV
  • Bag 1 – 2hr 100mg/kg NAC in 200ml 5% Dex
  • Bag 2 – 10hr 200mg/kg NAC in 1000ml 5% Dex
• Advantages
  • Saves 9hrs
  • Significant reduction in anaphylactoid reactions 2% vs 11%
  • Significant reduction in gastric symptoms (if either ondasetron or 12hr regime used)
  • Significant reduction in treatment pauses
• What next?
  • 10 centres using (inc Edinburgh, Newcastle, Guys St Thomas’)
  • We can’t implement the 12hr regime just yet (however, discussions are going on with Acute Med and Hepatology)
  • Pre-NAC ondasetron does seem like a good idea

Frailty

• Comprehensive Frailty Assessments
  • NNT to prevent a death 17
  • NNT to prevent NH admission @ 6months 20
• Frailty Score @ Triage 
  • Initially 50% accuracy (esp. around 4/5)
  • Addition of props significantly improved triage accuracy
    • Do you find walking more difficult or do you need mobility aid? Yes > 4+
    • Do you do your own shopping & housework? No > 5
    • Do you need help washing & dressing? Yes > 6
    • Do you live in a care home or have carers?
      • If carers > 5+
      • If needs assistance with personal care > 6-7
    • Are they confused or have a diagnosis of dementia? Yes > 5
• Delerium
  • PINCHME  – for all frail patients they may not have delirium now but soon…
  • Parkinson’s Disease and can’t swallow
    • Find the right dispensable regime or patch – use pdmedcalc
  • Other ways of doing things
    •  TRAWL
      • South Tees frailty team call all discharged frail patients to ensure things are going well and arrange further input as needed
    • Falls Rapid Response Team
      • Newcastle and Gateshead, paramedic and OT in a car reduce, conveyance to ED from 75%(with Ambos) to 45%

Dying

We all do it and we all want the best death possible – But we often do it badly

• 1:3 patients admitted on acute adult take are in their last year of life
• 80% of NH patients are in the last year of life

But we don’t always know which patient or recognise how quickly this will happen – think about the following:

• Parallel planning: we can be both treating the patient, and making plans how we can allow them the best death if they are dying.
• Sedating For Scan: PAUSE – this might be the last time they are conscious, consider them and their family and do they need time
• Use the word Dying: find out what is important to them, and their family, what are their fears and what they want to know, allow silence.
• Society is unfamiliar with death: Narrating whats happening for the family can help, e.g “that rattley noise you can hear is only a small amount of fluid in their throat, it can sound horrid but its not bothering them at all” Remember we are used to these stages but to families they are scared and they often assume that the patient is suffering.

You may want to look at the talking about dying resources from the RCP

Top 10 papers

Go to St Emlyns’ see the whole thing and read the papers, subjects include:

• Should every ROSC go straight to the Cath Lab?
• AF: Mg & Early Shock
• Dose Criocoid press just make things more difficult?
• Can we bag during RSI?
• Vasopressors: septic shock & haemorrhagic shock?
• POCUS in cardiac arrest

For those back home its been an interesting 1st day at the conference  – and the top 5 are

1. Learning from Child Death

Great session, presented by both clinical staff and parents, around the death of a 3yo with Down’s syndrome, from sepsis. Highlighted some key points that we can all do better:

• Communication:
  • Listen to the Carers: the parents could see the patient wasn’t his normal self but staff didn’t head the warnings, and his parents felt ignored.
  • Let Carers know whats happening: The patient was moved to Resus, we might think the parents know what that means, but they thought it was just because everywhere else was busy.
• Unrecognised deterioration:
  • The child deteriorated through the ED stay of >8hrs, and the sepsis was only picked up and treated on paediatric ward, after a fresh set of eyes. Remember if you put a frog in boiling water it jumps, but if you turn the heat up slowly its dinner. Always be alert to the slow change!
• Responsibility:
  • The patient remained in Resus after being seen by PICU who had then referred to Paeds – Who was looking after him? We are ALL responsible for that patient – ED and the specialities!

2. Non-blanching rash & fever in children

There are many sets of guidance out there with 100% sensitivity, however, specificity varies. NICE has a specificity of approx 1%, while the best performing Newcastle, Birmingham, Liverpool (NBL) algorithm performs at about 44%. And Purpura (defined as being between 3 milimeters and 1 centimeter in size) is a BAD sign!!!

The NBL algorithm

3. STEMI – de Winter is coming!

The de Winter T wave is an important ECG sign of MI, that can develop quickly into the classic STEMI. Its present in 2% of cases so learn it.

• 

  Tall, prominent, symmetric T waves in the precordial leads

• Upsloping ST segment depression >1mm at the J-point in the precordial leads
• Absence of ST elevation in the precordial leads
• ST segment elevation (0.5mm-1mm) in aVR

4. Toxbase Pearls

• Severe Ca/β blocker overdose – move through the treatments relatively quickly in a step wise manner as Toxbase (i.e. dont wait for ages to see if it works it either does or doesn’t). To get to High Dose Insulin Euglycaemia Regime, this seems to be one of the best therapies
• Charcoal: Evidence coming out suggesting it is useful beyond the 1hr period, and higher doses seem better (watch this space)
• Whole Bowel Lavage: Really difficult but good in body-packers, Iron & Lithium as well as Sustained release compounds.

5. Malaria

• Rapid antigen test and thick and thin film – good but not 100% (esp with ovalae)
• 5-10/yr patients die in UK from malaria – Mainly as unrecognised (travel to malaria region and unsure why they are unwell test)
• Is it Ebola or Malaria? – if you can’t get malaria screen done (?ebola can slow the labs down) – Assume Ebola & treat as severe malaria concurrently