Parkinsons and Critical Appraisal - 24/5/17

1. Parkinsons Nurse on Parkinsons
 Linked to a journal article
 For further resources, we might like to look at RCEM Learning 

CAP12, CAP2, CAP30, CAP4, CAP8, CC1, CC2, CC3, CC4, CC5, CC6, HAP1, HAP13, HAP35, HAP36, HMP5 


2. Critical Appraisal 
Again, if you're needing updates on critical appraisal, look at RCEMLearning. 

We appraised an article looking at age adjusted d-dimers. 

- http://www.bmj.com/content/346/bmj.f2492

There’s a nice discussion http://rebelem.com/age-adjusted-d-dimer-testing/ 

CC20, CC21, HAP29, HAP6, HAP8

20/05/17

Major Incident Training: EL

Procedure, where equipment is, suits.

http://www.rcemlearning.co.uk/foamed/major-incidents-2-incident-plans/ 

10/05/17

Feeding Tube Problems
Presentation on google drive
No curriculum linking

3/5/17 - Obstetric

1. TO - talking ?peri-mortem c-section
  https://coreem.net/core/peri-mortem-c-section/

2. GB - obstetric problems
 Post partum bleeding
 Problems in delivery

Simulation: Trauma in Pregnancy and Conflicting Relatives, and OSCE Practice

26th April

- Domestic Violence case for a pregnant lady
 Remember need to treat the mum, but then consider the fetus (and rhesus)
 Look at the Kings guidance
 Look at RCEM Guidance - http://www.rcemlearning.co.uk/foamed/rcem-guideline-domestic-violence/
 https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0642

Pre Transfusion Bloods
http://www.rcem.ac.uk/code/document.asp?ID=6106

DV Guidelines - https://www.nice.org.uk/guidance/ph50



- "Conflicting Relative"
Remember we might have an unexpected patient
Calling security early can be helpful
Priority is patient care

19/04/2017

Last minute arrangements had to be made as the speaker cancelled at the last minute, but we managed well!

1. Propanolol Update
Talked about what to do if you had a patient with propanolol OD. Reminded everyone that these patients can often appear well, and deteriorate really really quickly.

Remember, propanolol has beta blocker effects and sodium channel blocking effects. This is why it is so dangerous - and can cause hypotension and seizures.
Treatment should be as per toxbase. There is a toxbase app.
ECMO may be a useful bridging tool.
**AVOID PHENYTOIN for seizures - Na blocking **

Article on LITFL.

2. Brief Human Factors Discussion 
It is easier to de-escalate than escalate.
Be careful with locums - not all are familiar with the department.

3. QUIP
RCEM has lots of QUIP resources.
There is always a balance between access, quality and finance.


HAP25

12/04/17

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