1. Echo in the ED - EF
Lots of good tips and reminders on how to do echo.
Give your links here - http://adultemergencymedicine.blogspot.co.uk/search/label/echo
2. Critical Appraisal of the AHEAD study
The AHEAD study was written before the new NICE head injury guidelines, looking at when they all needed scanning or not.
It has also been appraised here: http://theresusroom.co.uk/the-ahead-study
Our points
- Why was it in BMJ Open
- Who was on the NICE guideline committee?
- This is only one study.
- Do we feel comfortable discussing risk with patients? Should or could they self discharge. If we give patients the information, do we trust their decisions?
- Does this mean we just need to observe people for longer so that we are happy? Bed doesn't do that.
- Their follow up was not sufficient.
- There are a lot of coufounders. including advice to attend hospital is given to warfarin patients, and it is more older patients on warfarin.
- The whole GCS being low thing wasn't very clinically useful as we know we are going to scan a low GCS irregardless of whether they are on warfarin.
- There was quite a lot of missing data which does mean we need to err on the side of caution, but makes the results difficult to interpret. 1/3 of the data was made up.
- Discussion about what is appropriate risk?
Take Homes
- INR is not important or relevant
- Warfarin does increase the risk of head injuries - asymptomatic had 2.7% risk of adverse outcome.
- Some of the symptoms are user dependent - what is amnesia, or LOC?
- We can use this information to prioritise our scans
Curriculum:
CAP 18, HMP 4
HAP 22, HAP 35
Monday, 24 April 2017
Friday, 24 March 2017
15.3.17 - Abdominal Diagnoses
Rectus Sheath Haematoma - http://reference.medscape.com/article/776871-overview
22.3.17 - Data and Derm
Data Discussion
Facilitated by OG - ECGs
https://lifeinthefastlane.com/ecg-library/
https://acadoodle.com/ - recommended by RP
Dermatology
Facilitated by DS
A vasculitis screen comprises:
• Bloods: FBC, U&E, LFTs, Bone, TFTs, CRP, ESR,
ASOT, Hep B, Hep C, HIV, syphilis
ANA, ENA, dsDNA, ANCA, C3/4, Rh F/CCP
Igs & SEP
Cryoproteins & anticardiolipin antibodies
• Throat swab
• BP
• Urine dip & microscopy
• CXR
http://www.pcds.org.uk/p/general-dermatology-table
http://www.rcemlearning.co.uk/references/common-childhood-exanthems/
PAP18, HAP28
Facilitated by OG - ECGs
https://lifeinthefastlane.com/ecg-library/
https://acadoodle.com/ - recommended by RP
Dermatology
Facilitated by DS
A vasculitis screen comprises:
• Bloods: FBC, U&E, LFTs, Bone, TFTs, CRP, ESR,
ASOT, Hep B, Hep C, HIV, syphilis
ANA, ENA, dsDNA, ANCA, C3/4, Rh F/CCP
Igs & SEP
Cryoproteins & anticardiolipin antibodies
• Throat swab
• BP
• Urine dip & microscopy
• CXR
http://www.pcds.org.uk/p/general-dermatology-table
http://www.rcemlearning.co.uk/references/common-childhood-exanthems/
PAP18, HAP28
Thursday, 9 March 2017
22/2/17 - Simulation - Peri Arrest Neonates
Sessions on Peri-Arrest Neonates
RCEM Congenital Heart Disease: http://www.rcemlearning.co.uk/references/congenital-heart-disease/
Metabolic Babies: http://www.rcemfoamed.co.uk/portfolio/metabolic-babies-in-the-ed-easy-as-1-2-3/
NLS Algorithm: https://www.resus.org.uk/EasySiteWeb/GatewayLink.aspx?alId=811
RCEM Congenital Heart Disease: http://www.rcemlearning.co.uk/references/congenital-heart-disease/
Metabolic Babies: http://www.rcemfoamed.co.uk/portfolio/metabolic-babies-in-the-ed-easy-as-1-2-3/
NLS Algorithm: https://www.resus.org.uk/EasySiteWeb/GatewayLink.aspx?alId=811
ELS USS and Management Discussion
1. Echo in Life Support - PS
This was a useful overview of all the different types of ultrasound level one equips us to do, and encouraged us all to start doing RUSH exams in our assessment of unwell and peri-arrest patients.
Echo in Life Support
Charlotte's Notes
Advanced Life Support
PEA Algorithm
Shock and Ultrasound
Had a discussion on how to drain a pericardial effusion. If the patient is arrested - ultrasound guided pericardiocentesis with an abbocath (long cannula) that should be in all of the resus trollies, and the "shock box". If the patient is peri-arrest, transfer to cardiothoracics at Kings, being ready to do a pericardiocentesis en route.
PS suggested Touch Surgery was a useful application to practice pericardiocentesis.
Useful tips for echo in life support
- put the probe on video mode. When you stop CPR, it'll keep "videoing". Then record and interpret.
2. Management - "Make the Doctors go faster"
We had a discussion on how you make the Doctors go faster! Our main points were
- your initial role is normally to calm the requester down, as often it's not as bad as they seem
- check the wellness of the Doctor. They might be struggling with ill health, or they might feel that you are unapproachable.
- perception is often not linked to reality
- let their supervisor know if you are really concerned.
Strategies that were discussed were...
- Not letting the potential psychiatric trainees see the psych patients as they will spend the rest of their career doing that, and end up doing a full psych assessment in ED which takes longer.
- Make Drs aware of the time - so you clicked on 30min ago...what have you done in 30min (in a non accusatory way!).
- Pre-empting. Giving people cards and saying it looks like xyz and you need to do this but take a history and see. Most felt this reduced the training of the junior (as RAT can) and made bias more likely. This is why there is no box for ?diagnosis in the RAT assessment notes.
- Balancing departmental needs (long waits) with service and training needs (Doc never sutured, needs to practice).
We talked about whether it was good to know what potential career path people were doing. Some felt it made it more likely you would pre-judge. Others thought it was useful.
This was based on, and supplemented by, a useful article from St Emlyns.
3.
PS suggested Touch Surgery was a useful application to practice pericardiocentesis.
If you want more podcasts than are freely available (see our resources page), after exhausting RCEMLearning etc. you might like to consider downloading the EM:RAP podcasts. A selection of these are available free but the full podcasts come at a cost. This cost is significantly reduced if you join EMRA.
This was a useful overview of all the different types of ultrasound level one equips us to do, and encouraged us all to start doing RUSH exams in our assessment of unwell and peri-arrest patients.
Echo in Life Support
Charlotte's Notes
Advanced Life Support
PEA Algorithm
US Journal Club: The RUSH Exam. The Pump, the tank and the pipes. https://t.co/Rl96E2LLla #FOAMed #FOAMus @TempleEM pic.twitter.com/g1goJCgJkH— Temple EM Ultrasound (@TempleEMUS) June 17, 2015
Mallemat: in shock, use ultrasound to look at HIMAP (RUSH). Weingart's #FOAMed version: http://t.co/9TAivf9M1S #CCEM13 #EMConf— Lauren Westafer (@LWestafer) September 18, 2013
Shock and Ultrasound
A Better way to Evaluate PEA— Salim R. Rezaie (@srrezaie) June 15, 2016
Great talk by @CriticalCareNow https://t.co/bMB8msjjTt#smaccDUB #FOAMed pic.twitter.com/dy3cOLNNgh
Had a discussion on how to drain a pericardial effusion. If the patient is arrested - ultrasound guided pericardiocentesis with an abbocath (long cannula) that should be in all of the resus trollies, and the "shock box". If the patient is peri-arrest, transfer to cardiothoracics at Kings, being ready to do a pericardiocentesis en route.
PS suggested Touch Surgery was a useful application to practice pericardiocentesis.
Useful tips for echo in life support
- put the probe on video mode. When you stop CPR, it'll keep "videoing". Then record and interpret.
2. Management - "Make the Doctors go faster"
We had a discussion on how you make the Doctors go faster! Our main points were
- your initial role is normally to calm the requester down, as often it's not as bad as they seem
- check the wellness of the Doctor. They might be struggling with ill health, or they might feel that you are unapproachable.
- perception is often not linked to reality
- let their supervisor know if you are really concerned.
Strategies that were discussed were...
- Not letting the potential psychiatric trainees see the psych patients as they will spend the rest of their career doing that, and end up doing a full psych assessment in ED which takes longer.
- Make Drs aware of the time - so you clicked on 30min ago...what have you done in 30min (in a non accusatory way!).
- Pre-empting. Giving people cards and saying it looks like xyz and you need to do this but take a history and see. Most felt this reduced the training of the junior (as RAT can) and made bias more likely. This is why there is no box for ?diagnosis in the RAT assessment notes.
- Balancing departmental needs (long waits) with service and training needs (Doc never sutured, needs to practice).
We talked about whether it was good to know what potential career path people were doing. Some felt it made it more likely you would pre-judge. Others thought it was useful.
This was based on, and supplemented by, a useful article from St Emlyns.
3.
PS suggested Touch Surgery was a useful application to practice pericardiocentesis.
If you want more podcasts than are freely available (see our resources page), after exhausting RCEMLearning etc. you might like to consider downloading the EM:RAP podcasts. A selection of these are available free but the full podcasts come at a cost. This cost is significantly reduced if you join EMRA.
8/2/17 - USS and Anticoagulants
Anticoagulant Use in ACS
Thoracic Ultrasound - PS
http://adultemergencymedicine.blogspot.co.uk/2015/06/e-fast-pneumothorax.html
http://www.foamem.com/2013/06/11/ultrasound-for-pneumothorax-detection/
Thoracic Ultrasound - PS
http://adultemergencymedicine.blogspot.co.uk/2015/06/e-fast-pneumothorax.html
http://www.foamem.com/2013/06/11/ultrasound-for-pneumothorax-detection/
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