Category: Learning

RCEM CPD 2019 Day 2

NEUROLOGY

#RCEMcpd  @RCEMevents

Advances in Acute Stroke Intervention 

Dr Ian Rennie

Acute Stroke Thrombolysis only recannulates approximately 10% of large vessels.

MR CLEAN trial reduced disablED survivors following stroke from 53% to 29%. NNT <2 (New England Journal of Medicine 2015)

Dawn trial showed treatment up to 24 hours from “last well” can produce significant benefits. (New England Journal of Medicine 2018)

Included almost all patients for thrombectomy with large vessel occlusion who don’t have too much established infarct. No absolute cut off time, image vessels early.

Don’t treat those with a poor baseline function, extensive pmh, in hospital infarcts, established infarct on scan.

 

Pitfalls and Perils of Acute Neurology 

Dr Thomas Peukert 

Non orthopaedic cause of myelopathy (it’s not always cauda equina). ..
Think about onset…acute vs gradual
Think about time course…relapsing and remiting, deteriorating, stable, intermittent

If MRI spine is normal..have you imaged the right part of the spine? Is it too early? Have you imaged the right part or the right scan? Is the lesion not visible on MRI?

Is it a lesion in brain?
Is it a problem of neuromucular junction?
Is this a lower motor neuron lesion?

Spontaneous low pressure headache – sudden onset severe headache on standing can be associated with thoracic back pain due to spontaneous leak of csf often in the thoracic spine. Can pull brain downwards that looks like chiari malformation on MRI. Often associated with connective tissue disorders.

ENVIRONMENTAL INCIDENTS

The Manchester Arena Major Incident 

Mrs. Stella Smith

Patient id was a problem, the patients were carrying fake ID, particularly with transfusion, helped by ED based transfusion team.

Staff response needs to be tiered organisation by a distant member of staff helped.

Handovers needs to include everyone…managers, allied healthcare professionals, etc.

Ballistics and evidence collection training is needed by everyone as clothes, possessions,  foreign bodies that are removed are all evidence.
Everyone needs Blast training….look in eyes, ears etc.

Managing a CBRN Incident 

Dr Paul Russell

  • Detect the incident…
  • See. . ..self presenting toxidrome..123+ approach
  • Hear ..take a history
  • Smell..if it smells bad it is likely to be toxic
  • Feel …unusual sensations

Many CBRN agents may have a delayed presentation or delayed detection so events may move on to other departments.
Protect yourself, collegues and environment
Decontamination should happen at scene however it often doesn’t happen.
Decontamination. ..remove clothes, blot dont rub with paper, wet decontaminate if needed.

Critical Care Research Update 

Dr Rob MacSweeney

Http://bit.do/ccr-rcem2019

Polar trial – prehospital cooling for tbi and maintained for 7 days…no difference between 2 groups. Increased adverse events in cooled patients.

Eurotherm 3235 cooling raised icp patients caused harm, trial stopped early.

Rescueicp a decompressive craniectomy for icp>25mmhg, better icp control and more adverse events and no improvement in outcome

Paramedic2 adrenaline in shock refractory out of hospital cardiac arrest – adrenaline restarts heart and marginally improves survival but survivors had severe neurological impairment.

ALPS trial – Amiodarone, lidocaine, placebo in out of hospital cardiac arrest more likely to survive with drugs than placebo.

Eolia trial – ecmo for ARDS significantly improves survival at 60 days.

Florali – high flow nasal cannula oxygen vs face mask oxygen and niv for preoxygenation in patients with hypoxic respiratory  failure needing RSI. Nasal Cannuale is best.

Beam trial boogie vs stylet for intubation with McGrath. ..boogie more likely to get 1st attempt intubation without complications.

IRIS trial – cricoid pressure vs sham pressure, no benefit from cricoid pressure.

Ideal-icu – when to start renal replacement therapy in severe sepsis induced renal failure at 12 hrs vs 48 hrs. ..no difference but very high mortality anyway.

Bicar-icu – bicarbonate for severe acidosis…some benefit of giving bicarbonate in severe acidosis.

Smart trial -Saline vs balanced crystolloid (Hartmans) for fluid resucitation in ICU,  more adverse kidney events with saline.

Salt-ED Saline vs Hartmans in ED…no difference in hospital free days.

Adrenal trial -hydrocortisone vs placebo in Septic shock, reduced 90 mortality and reduced icu days with steroids.

Andromeda trial – shock treatment guided by peripheral perfusion vs Lactate guided resucitation …outcome better with perheral perfusion guided resucitation.

Censer trial – early noradrenaline in Septic shock reduces mortality

RCEM CPD 2019 Day 1

 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 upper airway however a tracheostomy may have a connection so gives you 2 options for an airway.

Trachostomy problems commonly seen in the ED:-
Tube obstructions
Tube displacement
Stoma problems
Skin problems

Tracheostomy Emergency Pathway

Laryngectomy Emergency Algorithm

Online learning  modules available at the link

www.e-lfh.org.uk/programmes/tracheostomy-safety/

 

The Impact of Dental Presentations to the ED  — Chetan Trivedi 

Facial imaging his a high dose of radiation to senative tissues in often young people therefore careful examination is required prior tor Xrays.

Predictors of radiological abnormality in facial trauma-

Tenderness over maxillary
Step deformity in maxillary
Sensory loss over site of injury
Change in bite
Subconjunctival haemhorrhage
Broken teeth
Periorbital haematoma
Abnormal eye signs

Predictors of radiological abnormality in mandibular trauma-
Restricted or painful mouth opening
Tenderness over mandible
Sensory loss over site of injury
Change in bite/painful bite
Broken teeth
Step deformity

Try to assess carefully prior or to imaging

 

Acute Ophthalmology— Felipe Dhawahir-Scala

https://www.beecs.co.uk

Viral conjunctivitis all have preauricular or submandibular lymphadenopathy, highly contagious.

Do not give chloramphenicol to contact lens wearers use something with a broader spectrum.

Urgent conditions (reasons to get an ophthalmologist out of bed) —

Acute angle closure glaucoma -red painful eye, semi dilated pupil, – start iv acetazolamide immediately

Orbital cellulitis – eye doesn’t move, colour vision loss, fever, chemosis,  proptosis -start Ciprofloxacin and clarithromycin orally, image and call ophthalmology.

 

 

Vertigo – Peter Johns 

Concerning features- new or sustained headache or neck pain it’s a stroke or vertebral artery dissection until we prove it isn’t.

A central cause …Unable to walk or stand unaided, Weakness in limbs, the Deadly d’s… dysarthria,  diplopia, dysphagia, dysarthria,  dysphoria.

Short episodes of Vertigo  (spinning/dizziness) on getting up/rolling over in bed, no spontaneous or gaze provoked nystagmus.
(End gaze nystagmus so normal variant,  look to 30 degrees only.)
Need dix-hallpike testing likely BPPV – posterior canal BPPV.
Treat with Epley manoeuvre.

Horizontal Canal BPPV – Dix-hallpike manoeuvre is negative and they are less clear which side they turn to to get dizzy.

Spontaneous or gaze provoked nystagmus for days, nausea and vomiting and gait disturbance likely to be Vestibular neuronitis.

Test using HINTS plus Exam– nystagmus,  test of skew, head impulse test, hearing loss. All components have a central or peripheral result for each component. If all 4 are peripheral results then it is a acute Vestibular neuroitis

Vestibular migraine – 30% never get headache,  can last hours or days.
More common in women, perimenopausal, often get photophobia, phonophobia, nausea, vomiting and other typical migraine symptoms.

You tube – peter Johns (links here)

 

Thomas Spint – how to apply

Invented by a Welshman ‘Hugh Owen Thomas’, the introduction of this simple device in World War 1 went on to reduce the mortality of #femurs from 80% to 16%.

The Kit

  • Measuring Tape
  • Thomas splint – Adult or Paediatric (depending on size)
  • Hoop – Sizing guide can be found here
  • Slings
  • Hoop Pad
  • Skin Traction – Adult or Paediatric
  • Padding rolls x 2
  • Bandages (wide) x 2
  • Tape
  • Scissors
  • Tongue Depressors x 2

Printable application guide

Measuring

Measure the Inside Leg (unbroken leg) and add 30cm/12inch (to give room for the traction)

Adjusting Splint

Adjust length to the above measurement. ensuring the Hoop is at an angle with the lateral (outside leg) higher than the medial (inside leg).

Set up

  • Apply the hoop Pad (to reduce pressure and secure to tight)
  • Apply the 4 slings (lowest should be 40cm from base)
  • Apply padding along slings
  • Creat a small padding for behind the knee

Application

  • Ensure Adequate analgesia (this hurts) – typically Opiates and entonox
    • Femoral nerve block may be helpful (however, this is variable due to the innovation of the femur and reduces the more distal the fracture)
  • Check Genitals not trapped – by the hoop
  • Apply skin traction & and bandage from ankle to thigh
  • Secure the tight Clip – remembering to put the padding under the clip and velcro round

The Knot

1. take the strings and pass one over and one under the sides of the frame.

2. secure tightly with a Reef Knot

3. pass strings down (one over and one under) around the base, bringing them back over the Reef Knot and  back around the base. This makes a pulley system.

4. Tension the pulley system and tie-off using a bow

5. Pass the tongue depressors (2 tongue depressors tapped together), twist the tongue depressors to achieve the required tension, and lock off against the side.

 

Bandage & Elevate

  • Bandage the leg to the sling using the bandage – to keep secure
  • Place a pillow or blankets under the splint to elevate the heel – To prevent pressure sores

Dislocated Shoulder (Teaching Video)

Great review of shoulder reduction, techniques and sedation. 

Learning points:

  • Most techniques will work 80% of the time (Best results tailor the technique to the patient)
  • Kocker’s shouldn’t be used in # greater tuberosity
  • Cunningham technique looks interesting (I’m going to give this a go)
  • Traction is the what causes the most pain. Reduce the traction & Reduce the sedation required