Friday, 27 January 2017

25th January 2017: Simulation

Simulation Session
LA, AL, LG, CD, LH, SR

1. Hyperkalaemia and Arrest  
Guidelines on hyperkalaemia and reminder of what each treatment does from here, together with clear guidelines for hyperkalaemic arrest.
Look for our guidelines on the intranet - we now don't give insulin and dextrose mixed, but insulin in saline, and dextrose separately if BM low.

Hyperkalaemia 
http://www.aliem.com/2013/mythbuster-calcium-gluconate-raises-serum-calcium-as-calcium-chloride/
http://first10em.com/2016/01/21/hyperkalemia/
http://www.rcemfoamed.co.uk/portfolio/hyperkalaemia/ 
http://adultemergencymedicine.blogspot.co.uk/2016/03/hyperkalaemia.html?m=1 
http://learning.bmj.com/learning/module-intro/hyperkalaemia-diagnosis-management.html?moduleId=6055258&searchTerm=%E2%80%9Chyperkalaemia%E2%80%9D&page=1&locale=en_GB
http://learning.bmj.com/learning/module-intro/hyperkalaemia.html?moduleId=10047565&searchTerm=%E2%80%9Chyperkalaemia%E2%80%9D&page=1&locale=en_GB
http://lifeinthefastlane.com/hyperkalemia/

CPR and ROSC
There's links to loads of other CPR websites at the bottom of my blog post here (too many to copy and paste!).
There are Post ROSC guidelines - and a departmental / local policy
IResus app is available for android and iphone.
I wrote a summary for Foundation Docs a while ago - might be out of date.

Human Factors
There's always time to prescribe - and check medications. Look at this great blog here.
You can look up guidelines like you would in real life - cognitively unload 
Don't be afraid to be a leader. 

That’s Not My Job
 This is a story about four people named Everybody, Somebody, Anybody and Nobody.  There was an important job to be done and Everybody was sure that Somebody would do it.  Anybody could have done it, but Nobody did it.  Somebody got angry about that, because it was Everybody’s job.  Everybody thought Anybody could do it, but Nobody realized that Everybody wouldn’t do it.  It ended up that Everybody blamed Somebody when Nobody did what Anybody could have. 
Remember - if you don't direct your requests, nobody will do them, when anybody and everybody could have. 


2. Overdose and Serotonin Syndrome 
Toxbase app is available to everyone with an athens password - available from the library. 
Remember to do a proper neurological examination in overdose ?what - pyrexia and rigidity should make you think of serotonin syndrome. This needs treatment - you might need to speak to NPIS for cyproheptidine. 
For more information, if you go to googlefoam.com and search, you get loads of handy links. 
Serotonin syndrome vs neuroleptic malignant - I love these flashcards. 

Dantrolene can be given but might make the serotonin syndrome worse - so I'd stay away. Toxbase suggests it for serotonin - but not for serotonin syndrome. Cyproheptidine is recommended on toxbase. 

Wednesday, 18 January 2017

18.01.17 - Critical Appraisal of PESIT

Present: AL, CG, LH
Facilitating: CG

Paper Discussed:
http://www.nejm.org/doi/full/10.1056/NEJMoa1602172#t=articleDiscussion

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope
Paolo Prandoni et al.  N Engl J Med 2016; 375:1524-1531October 20, 2016

Appraisals Elsewhere
EM Nerd - the PE could be an incidental bystander
REBELEM - scanned only inpatients, 48hour after admission. This study is likely to be an overestimate.
PulmCCM - clot burden is not a useful marker of clot severity. Older patient group. (Also has a useful reminder of pathophysiology).
CoreEM
WikiEM - selection bias
EM:RAP
StEmlyns - is it clinically significant?
EMLit - remember to PERC first!
Spectrum Bias

Pulmonary Embolism
Scroll to the bottom of this link for lots more references and links

Critical Appraisal 
Free courses are run by the library.
RCEMLearning website has loads of free (at the moment) critical appraisal resources.
CASP Checklist

http://www.wessexics.com/The_Bottom_Line/appraisingpapers/
www.guideline.gov
www.tripdatabase.com
www.thecochranelibrary.com
www.cebm.net
http://stemlynsblog.org/tag/critical-appraisal/
https://rcpsg.ac.uk/media/pa/P3/Files/Examinations/Dentistry/ISFE/Introduction%20to%20the%20Critical%20Appraisal%20Section%20updated%20June%202012.pdf

Wednesday, 11 January 2017

11th Jan Teaching

Present: OG, BA, LH, CD, AL, HA, RP, EJ
Supervising: AH
Curriculum Codes: CC1, CC7, CC12, CC14, CC19, CC21, HAP2, HAP17

Management Case - 
A patient that staff didn't want to allow access to the hospital, ?opiate seeking, challenging behavior. Attending for the third time with the same problem.

- You can only refuse entrance if patient has an ASBO, and doesn't need immediate medical help - see frequent attender guidelines.
- Potential opiate seekers should be given analgesia, even opiates. Remember IVDUs have opiates at home, so there's a reason they're coming into hospital. Look at the college pain guidelines which specifically mention this.
- As they are a reattender, this patient must be seen by the most senior Doctor present according to Consultant sign off guidelines - RCEM standards. As they are a frequent attender, college guidelines also state that they should be seen by a senior doctor.

- If the patient is difficult, and refusing examination you must decide whether they have capacity to refuse. This can be difficult. RCEM Guidelines.
If they don't have capacity, sedate as appropriate, in the patient's best interests - to allow you to safely assess the patient.

Case Discussion
Patient with history of migraine, who attended with collapse and headache, ?SAH.
- Remember that transient loss of consciousness + headache could easily be a SAH.
- Migraine patients don't normally come to the ED with their headache.
- If you have an SAH, the aneurysm pops, you loose cerebral perfusion, get TLOC, and then blood flow returns. They may rebleed. The only way to exclude is CT (read the Stiell paper: within 6 hours, CT alone is normally sufficient) and LP.

- RCEM have a flowchart
- There are NICE guidelines

Other Headache Links
Hamid's CTR on LPs in SAH.
London network guidelines on headache: http://www.londonscn.nhs.uk/publication/adults-with-headache-edu-videos/
TLOC headache guidelines: http://www.londonscn.nhs.uk/publication/adults-with-transient-loss-of-consciousness-edu-videos/
http://adultemergencymedicine.blogspot.co.uk/search/label/headache
The Ottawa headache rules.

Thursday, 5 January 2017

4th January 2017 teaching

CD - CC6, CC21, HAP1,
Renal Colic and should we image?
                  https://www.aliem.com/2014/top-10-reasons-order-ct-scan-suspected-renal-colic/ 
                  https://cks.nice.org.uk/renal-or-ureteric-colic-acute
                  Charlotte's CTR: http://bit.ly/2iHv2vq 

BA - HMP5, HAP8
                ECG cases
                http://lifeinthefastlane.com/ecg-library/basics/right-axis-deviation/


Present: CD, BA, LH, AL, FA, SC