Here is the second of Dan Weston’s ED bytes. Some of his pics from the world of EMFOAM!

Enjoy and we look forward to more from him in due course!

 

Twitter links!

Don’t miss that dissection!!

So one not to miss! The basics of Type A Aortic Dissection from Dr Stamp, American surgeon. She also advocates siting two arterial lines (L&R) and treating the higher of the BP readings.

Here’s a reminder video of types and pathophysiology!

 

How 2 ED!

Drains, drains and more drains!

Here is a simple, American guide, to the insertion of an open chest drain including a quick video. Some of the drugs/procedural elements may not apply to all EDs, but a useful revision of the technique.

Do check out the blog below as well as our guide to chest drain insertion

 

 

Blogtastic!

Its autumn, the leaves are falling and kids are too!

With the presence of autumn and the approach of winter, paediatric respiratory disease is an increasing burden on the emergency department. This blog from Dr Roland includes some videos (some enclosed here), and looks at why we may find paeds respiratory diseases challenging!! The videos depict children the anaesthetists are often called down to look at. Remember, if they don’t respond to initial medical therapy, get their opinions in early!

 

Amiodarone…RIP in the ED?!

Amiodarone, does it have a place in the ED. The guys at Core EM are thinking not.

Here’s a reminder video on the Vaughan Williams drug classification system!

…and the cardiac action potential…

 

Lactate! How many times have you heard this one?!

These articles are extremely eloquent! We get quite excited by lactates in resus and often the response to a high lactate is to pour fluids into a patient, not really thinking about it too much! Survive:ED has written a couple of interesting articles on lactate that prompt some further thought.

See our piece on lactate here

 

Score my pain doc!

Prognosticating outcomes for patients presenting with chest pain is a daily challenge for ED physicians. There are a variety of scores available, with scores like TIMI (still used in Northampton), falling out of favour. Other scores like the HEART score are increasingly being used. A recent Italian paper has shown that patients with a HEART score of ≤3 are low risk for adverse cardiac events and may be candidates for outpatient follow up. There are lots of papers currently floating about looking at HEART and previous studies have shown that it performs better than both TIMI and GRACE scores.

 

Sprout some…and stop unnecessary tests in PE!

PE is a common differential in the ED and rates of testing for PE are increasing without a fall in PE related death. One tool to help is the Pulmonary Embolism Rule-out Criteria (PERC), which aims to identify pateints who do not need even a d-dimer to rule out PE, let alone a CTPA or a V/Q scan. This paper by Buchanan et al found that a significant proportion of PERC-negative patients were still undergoing testing for PE. Maybe we need to be thinking more of pre-test probability and implementing the PERC criteria. As we have mentioned over the last few weeks on the Crit care blog, there are many other ways to assess the probability of a significant PE, particularly by utilising sensible history, scores and POCUS.

See what we said here too

Also, along the lines of ruling out or in PE, there are other strategies involving d-dimer. One is the age adjusted d-dimer cut off which suggests age adjusting the d-dimer cut off for every year above the age of 50.

While Dr Radecki from ACEP Now advocates doubling the cut off to 1,000 ng/ml in patients who PE is unlikely, (Wells ≤4 or Revised Geneva Score ≤6), to reduce the overtesting for PE.

Are we being guided in the wrong direction…right from the CURB?

When dealing with community acquired pneumonia we use CURB-65 scoring in the ED to guide admission and treatment. We tend not to treat with macrolide antibiotics if the score is low. This paper from the European respiratory journal finds that severity scores do not accurately predict response to macrolides and may indicate a need to think again about our antibiotic choices.

 

It’s all about length! Or is it!?

A rate limiting step – the extension set. Often the IV cannula in the ED is connected to an extension set by the staff prior to using the cannula for resuscitation or administration of medications. This blog from canadiem reviews the science of flow and highlights why, in some circumstances, you may want to remove the needleless extension set. Another is a mention of some of the stuff the anaesthetists will wax lyrical about….flow rates, physics and some Hagen-Poiseouille equations!!

I’m going to flash the random number ‘special probe’ over the patient now!!

How often have you heard the thermometer described as a random number generator? This RCEM learning article goes through temperature taking the in ED and the implications for practice.

 

POCUS in CPR please!

We have talked about this at length on podcasts and in the crit care blog, but how good are we at POCUS during CPR? Part of the eFAST is ECHO in life support, it is valued by practitioners and may provide extra clinical information. A review from the resuscitation journal found that it is useful for identification of reversible causes and prediction of short-term outcome.

Have a look in our POCUS section all about how to perform eFAST.

 

 

Belter Cases!

Minutes are myocardium…but you do not want a bleed!

Interesting case from emrounds where a STEMI gives pause for thought and consideration of another cause.

Selected by Dr Dan Weston

Senior Editor Jonny Wilkinson