All posts by Mick Killeen

Teaching APRIL 2015 onwards

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SCHEDULE

16 APRIL PROCEDURAL SEDATION / AIRWAY ( Mick , Sol, Saffras ) 

23TH APRIL PAEDIATRIC CASES QUINS SISTERS ET ALL 

30 APRIL M and M – middlegrade doctors ( and anyother doctors they enlist ) 

7 MAY Respiratory emergencies . NIV / management of type two respiratory failure / CAP / chest drain / severe asthma / anaphylaxis / VBG v ABG . 

14th MAY -SHO presentations pick one : procedures plastering / ABG interpretation / ultrasound guided procedures / ECG interpretation / csf interpretation / xray interpretation / CT interpretation / novel joint reduction . Presentation must be contemporary and from emergency medicine literature or FOAMEM 

21 May OSCE ( based on all teaching ) All registrars to be tested on procedural sedation and ultrasound 

28TH MAY : M and M ( middlegrade doctors ) 

5th June Journal club : all nchds best articles in critical care /EM in last 12 months ( or favourite other journal for non ED trainees) 

12 june : Ultrasound day 

19th june : 

LOWER LIMB INJURY

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THE FOLLOWING IS A SUMMARY OF THIS THURSDAYS TALK ON LOWER LIMB INIJURY 

It is surprisingly short considering Orthopoedics is a bottomless pitt of detail . This  brief runthrough injury to the lower limb highlights the big issues from ourside of story . It is not important to know the difference between the treatment of an intracapsular Neck of Femur fracture and an intertrochanteric fracture .It is however crucial to understand that delay to operation of either ( past 48 hours ) impacts heavily on mortality and how to avoid this by making sure all the anaesthetic “tick box’s” are ticked. It is also important to make sure the patient is not in pain (hence the emphasis on regional anaesthesia 

PELVIC FRACTURE IS THE FIRST 
here is a link to a great EMRAP TALK ( 2014) on contemporary approach to exanginating pelvic trauma 
https://d140vvwqovffrf.cloudfront.net/media/segment/original/972c3fcf990eca3d477367e6d9b572897e0e1aa9.mp3
(if the link above doesnt work just select it and past into your browser ) 
scot wingart ( http://emcrit.org/podcasts/severe-pelvic-trauma/ ) gives a good up to date summary on the emergency managment of pelvic injury and covers most of the topics in the talk 
In the patient who is stable enought to go to CT , usually the CT angiogram will reveal the need for either embolisation via the angiosuite or OR for solid organ injury or ruptured hollow viscous . 
low pressure venous bleeding often stabilises by good intensive care but may need packing
In the patient who is unstable ( ie BP <<100) these patients are devided into those who likely have intraabdominal injury as a cause ( ie FAST POSITIVE ) and those that dont 

the next important orthopoedic injury is the hip fracture ( obviously less likely high speed trauma and more likely old person 
CRITICAL POINTS FOR ED 
These guys need their operation in 48 hours less ( or else they do worse ) and they also need pain relief 
to faciliate their speed to OR we need to make sure all the pre op boxes are checked and hence the need for a NOF pathway 
the following slide shows you what is important to anaesthetic doctors taking a patient to theatre 

so make sure these tests are done 
the next most important thing is to perform a femoral nerve block 
if you havent a lot of exeperience use lignocaine 1% and use about 20-30 mls ( avoid LATS) 
and look at this link for an indepth demonstration on how to do a fascia iliaca block 
http://3lliottjody.wistia.com/medias/0g25pucqw5  ( copy and paste this into your browser ) 
moving down the leg : femoral shaft fractures can loose buckets of blood so you should predict and correct this  . A Thomas splint ( or equivalent ) is necessary for pain relief and to stop bleeding. Make sure you give a femoral nerve block 
knee fractures are the domain of the orthopoeidic service . Our job is not to miss any injury that might need earlier follow up or suggest sigficicant ligamentous or even vascular injury 
the following xrays are ones that we should all be able to diagnose and get prompt orthopeodic consultation on 
1) knee dislocation should be suspected on history and any significant intraarticular fracture . Have a low threshold for getting an angiogram ( to avoid amputation and  litigation ) . ANKLE /BRACHIAL ABIs > 90 % have a good negative predictive value and maybe a useful adjunct 

2) the segond fracture suggests a medial injury : collateral ligament / AC and meniscal injury (the unhappy triad ) 

3) the reverse segond suggests similar pathology on the medial side 

4) tibial plateau fractures can be subtle 

5) the FBI sign is give away for significant fracture ( fat blood interface ) 

6) dont foreget the massoneuvre fracture 

7) ankle fractures are common in ED . Its important to know that a weber B or C are the ones that need surgery 

8) bimaleolar and trimaleolar fractures need reduction in ED 

9) consider a sciatic / POP fossa block if you cant adminster procedural sedation follow this link for the how to video , remember that it takes half an hour to work 
( copy and paste this link   http://3lliottjody.wistia.com/medias/vkw4qsewbx ) 
1) the ankle is best put back in dorsiflexion / traction and pressure backward along the direction of dislocation 
11)  this is a lisfranc fracture and often needs surgery ( subtle lisfrancs can be missed ) the whole point of the the oblique food xrays to is expsoe the alignement of the lisfranc articulation 

12) Jones fracture bad . Psuedo Jones good . growth plate lines run parallel to axis of bone and would be embarrasing to mistake as a fracture 

Summary of heart failure talks

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summary heart failure talks 

thanks to  Safras and Mohamed for the talks on heart failure 
Below is a summary of take home points 
1) new guidelines are out on Heart failure ( nice guidelines ) as of OCTOBER 2014- click on image above for link to FREEDOWNLOAD
. These guidelines are 100s of  pages long and reflect the opinion of 100s of clinicians , researchers and patients 
There is a de-emphasis on NIV and GTN which doesnt reflect our real world. This is not the fault of the guidelines because neither treatments have much effect on long term survival . I dont  believe we can prove their efficacy in terms of short term survival because it would be unethical to do RCTs that involve withholding these treatments on patients in distress in ED 
The take home points ( their best interpretation of evidence and expert advice ) 
Heart failure is the the commonest cause for hospital admissions to hosptial in the over sixty fives 
Acute Pulmonary Oedema – is the commonest True ED emergency related to heart failure . The blood pressure is preserved or even high ( I find the pathophysiology behind this hard to fully understand as the usual causes such as mi or Ischemia are not culprits . It  is said that there is often a diastolic component , so these patients often have the risk factors for diastolic dysfunction such as diabetes and hypertension )  
Assessment 
1) acutely the main things are a preserved or high blood pressure and wet lungs ( creps) . When this clinical finding is not obvious ( eg in an obese patient with a history of COPD or risk factors for PE ) , bedside ultrasound has a new and crucial role 
Treatment 
2)  traditional approach is oxygen , frusemide , morphine , nitrates and consider NIV
3) a more rational priority ( and reflective of current ED Practice ) is 
Oxygen – best given via NIV ( whatever you have BIPAP or cpap ) 
Frusemide – standard iv dose ( doesn’t really matter what that is but usually the patients oral dose is given iv) 
Gtn ( given first under the tongue 2 sprays = 400mcg) and then as an infusion starting high and lowering if patient becomes hypOtensive eg start at 100mcg per minute or even more ( double this ) 
congestive heart failure with preserved blood pressure 
Assessment. 
The crucial points about diagnosis are BNP and a good clinical exam with good basic tests ( ecg/cxr/labs) . The patient should then get an echo (best as in patient ) and this should be a formal one as valvular heart disease needs to be ruled out and this is not yet in the domain of a basic ed bedside echo. Of course it would not be unreasonable to assess EF on bedside echo eg by eye ball estimation or EPSS 
Important Inpatient recommendations and guidelines 
1) The need for heart failure patients to be linked in to Specialist Clinics 
This is an evidence based recommendation and may be because all the things that comes with specialist clinics eg attention to detail / community outreach etc and addressing risk factors :  
– dietary and life style measures 
– blood pressure / cholesterol / weight  / obviously smoking sessation 
medication 
See table attached below of appendix in guidlienes about drug doses 
take home points 
– give an ace inhibitor ( or equivalent … if possible ) -eg start enalapril 2.5 mg daily and get GP to oversee increments up to ……..
– add a betablocker if patient is stable .that means out of ED , off iv diuretics etc .  cardivolol  / metoproplol succinate / bispoprolol being evidence based . Better to add a betablocker than increase dose of ace inhibitor according to the guidelines . eg bisoprolol 1.25 mg daily increasing over weeks to 
– if giving a betablocker add a thiazide as ankle swellling is a problem

Persistent uncontrolled nyhc grades 2-4 : 

– add in spironolactone ( or equiv anti aldosterone equivalent ) —eg  
– add in digoxin — 
FINALLY 
tNOT INCLUDED IN THE NICE GUIDELINES THE COOL STUFF 
1) ULTRASOUND 
Bedside ultrasound really has such a useful and now evidence based role to play in acute assessment not the least of which includes 
IVC assessment when fluid loading 
left heart gestalt EF estimation and EPSS 
lung assessment – lung rockets or B lines and response to therapy 
rule out right heart strain 
2) 
The high end stuff -REBOA / AORTIC BALLOON COUNTER PULSATION 
when are these things to be considered

           

NOVEMBER DECEMBER TEACHING BLOG FOR SLIGO ED

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WELCOME TO SLIGO ED TEACHING BLOG (EMSLIGO.BLOGSPOT.IE) NOV / DEC 2014
The purpose of this blog is to store teaching talks and other information
The idea is that each talk has a 1 page  summary. posted here and links to references/websites used
The links on this page are a great start to finding information for your talks
There will be a (very flexible ) five week cycle

Week1  : NCHD / medical student talks – 4 10 minute talks ( strickly 10 mintues as we have short attention span ) .summary posted here(email me your summary with links mickilleen@gmail.com)
Week 2 : NCHD / medical studtent talks
Week 3 : simulaiton training
Week 4: NCHD / medstudent talks
Week 5: M/M ( review of interesting patients in Resus – keep a patient sticker so you can look up what happened to your patient and present it ) A middlegrade doc or consultant will oversee this .
There will be an OSCE type quiz on topics from these talks ( we will ask each presenter to create an OSCE type question ) this will happen once a term ( so pay attention to the blogsite !)
TOPICS WILL INCLUDE : (red denotes what we have partially covered so far )

1) Management of Acute cardiac emergencies including ACLS review
2) Management of acute respiratory emergencies including Airway management and  RSI )
3) Management of acute Neurological Emergencies including CVA (SAH/thrombolysis debate / stroke and TIA guidelines / syncope ) 
4) Vascular Catastrophes . AAA/ dissection  / cardiac Tamponade
5) Trauma management – Recent updates eg ICEM , Damage control resuscitation / crash 2 trial / TTM trial
6) Orthopaedic injuries ( pelvis / longbone / hand and foot / soft tissue injuries to shoulder , knee , wrist and ankle
7) The focussed clinical exam in 2014 – Different Joints / formal Cardiac exam / neurological examination .
8) ULTRASOUND TRAINING – (THREE LECTURES , LOGGING SCANS , SUPERVISION AND TESTING  )
9) Paediatric Emergencies ( Assessment of the unwell child / PALS / APLS / APLS review / NAI
10)Interpretation and management of Acute Electrolyte disturbances (hyperkaleamia / acid base / hyponatremia / Hypernatremia / DKA / Honk / Acute renal failure )
11) The critically ill patient – Sepsis bundles / BOIC / Post cardiac arrest management / post intubation check list / inotropes / antibiotics in serious sepsis 
12) Toxicology – general approach / Specific and common life-threatening overdoses. Seratonin and anticoholinergic syndrome 

THIS MONTHS TOPICS
WEEK ONE ( 13th Nov) – SUMMARY OF ESSENTIALS OF  EM CONFERANCE (no NCHD TALKS)
WEEK TWO ( 20 November ) 4 talks in total :

evidence based management  of heart failure acutely and as an outpatient 
use up to date recognised guidelines ( ie 2012+ ) – UK / canadian / ESC / AHA and FOAM 
for talks 1 and 2 suggest you base it around 3 cases 
talk 1 )  – emergency dept ASSESSMENT of flash pulmonary Oedema / cardiogenic shock / undifferentiated decompensated heart failure 
talk 2 ) – emergency department MANAGEMENT of flash pulmonary Oedema / cardiogenic shock / undifferentiated decompensated heart failure ( including heroic things like REBOA or  IABC )
talk 3) – outpatient MANAGEMENT and  investigations of heart failure – drugs / lifestyle modification/ supportive care / prognosis 
talk 4 ) lung ultrasound in an emergency medicine setting focus on A and B lines etc – Registrar
—————————————————————————————————————–
Week THREE

1)  DDimer in pregnancy and the over 50s – new guidelines -http://rebelem.com/age-adjusted-d-dimer-testing/     and http://www.perinatology.com/Reference/Reference%20Ranges/D-Dimer.htm
2+3)2 talks aortic dissection – assessment and management in the emergency department ( two talks )  assessment = hx/exam/INVx  mangement= resus/defintive tx/ consultation / disposition and other issues (controversies and pit falls , prognosis ) 
4+5) 2 people : treatment of DVTs of the lower limb , below and above knee – the options and controversies for a start check : http://stemlynsblog.org/new-nice-guidance-on-investigation-of-dvt-in-the-ed/
debate for and against below knee dvt anticoagulation 
week 4
Simulation training
week 5
M/and M 

OCTOBER TEACHING – week 1 Sodium

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Moving on to medical emergencies , this weeks teaching is brought to you by the elelement Na !

Please pick a topic to present , email the group what you are going to present and email me a one page summary so that I can post it on the website , thanks 
Sodium 
1) There are some recent updated guidelines on the management of Hyponatremia 
http://www.eje-online.org/content/170/3/G1.full . This needs a volunteer to summarise and present . Please also give us a 1 paragraph summary of necessary take home information 
There is also a great summary on emcrit for the emergency treatment of life threatening hyponatremia ( http://emcrit.org/podcasts/hyponatremia/ ) 
2) Sort of related to Sodium . Pathogenesis of cerebral oedema in DKA in children.How to avoid it !
3) Correction of severe hypernatremia and dehydration in children and infants – APLS guidelines 
4) HONK – treatment , particularly fluid resuscitation 
5) NOT related to sodium 
FOAM :  review of a particular website 
If someone could pick a particular website and review it . The best way to do this is based around a particular clinical question and see if the website sensibly answers your question .  

Last week of september -Trauma round up

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This week we have the following / talks discussions

Last trauma week in September 
1) the rectal exam in trauma 
2) chest drain insertion -click on the following link for video on how to place a chest drain 
3) ultrasound guided pericardiocentesis –

click on image for link to how to perform

4) Ultrasound guided nerve blocks in the ankle and the femoral nerve block

LINK TO powerpoint on Nerve blocks to lower limb
( useful really only for references and diagrams of relevent nerves )
click on image below to be forwarded to icloud version of PPT

click on this link for access to power point ( icloud)

summary to this weeks talks

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ED THORACOTOMY 

thanks Karen for a great talk on ED thoracotomy 
Here are some of the take home messages and references 
1) Penetrating stab wounds to the chest ( particularly in the area of the left parasternal /precordial area) are the sort of patients that may come to ED and having suddenly lost an output and need consideration for ED thoracotomy .These patients DO survive , commonly ! 
2) the ED thoracotomy is performed in the periarrest situation where the patient cannot be taken to theatre in sufficient time .  If the patient can be taken to theatre ( because he has a perfusing circulation ) then an Emergency Thoracotomy should be performed there instead . 

3) penetrating stabs are the ones that may ( and often do ) survive. Blunt trauma is unlikely to survive ( < 1%) chance if they go into arrest in ED.  A patient with blunt trauma and cardiac tamponade who goes into arrest in ED could be considered for thoracotomy in ED . A patient with blunt trauma and massive Heamothorax who goes into arrest (and without a tamponade ) will not survive unless the person opening the chest can manage hemorrhaging mediastinal vessels ( and that just is not us in ED ) 
4) it would be considered worthwhile to attempt ED thoracotomy on a balllistics injury to the chest if there is evidence of tamponade in a patient who loses output on arrival . If there is no evidence of tamponade then ED thoracotomy should not be done unless there is a surgeon there who is willing to help ( stop catastrophic mediastinal vascular injury )    

summary 
1) make the decision that ED Thorocotomy (Be very clear of the indication and what you intend to do once you open the chest ) 
2) WHO DOES It? surgeon if he has experience and is there , if not the most senior ED doctor (hope its not me ) 
3) This is a periarrest scenario so no time for niceties – use poviodine if its there and protect yourself and your staff with appropriate surgical gowns and possibly eye gear  
4) during the periarrest situation there should be someone managing the Airway and intubation ( RSI with or without sedation and paralysis ) and there should also someone managing access ( IO / rapid transfuser / activating MTP etc ) .ALTHOUGH CONTROVERSIAL TAMPONADE IS STILL TREATED WITH FLUID LOADING AS PRELOAD WILL HELP OVERCOME FORCE OF TAMPONADE 
5) the third doctor who may be the team leader  : cut at or just below where the nipple line would be if the patient were a skinny male . Cut deep to fat and right down to intercostal ligament and either cut right down through pleura oruse a blunt dissector of this ( this is a life saving emergency so  speed is of the essence and cutting right down to lung would be considered acceptable ) . Be aware of two possible sources of iatrogenic bleeding , this would be the intercostal areteries running below the rib and the internal mammary arteries running parallell and close to the sternal margin. So if you are cutting so deep the Mantra ” above the rib below is of importance 
6) The pericardium should be immediately exposed by this and the lung automatically collapsed and out or the way .The ribs are held back by the rib spreader . IF the pericardium is not exposed then continue the cut across the sternum and to the otherside (clam shell ) 
7) Divide the pericardium using forceps ( Beware of cutting the phrenic nerve – this should be visible on the pericardium ) . Look for a ventricular hole and suture it , put a finger on it , put a Foley catheter baloon through it and inflate it DO ANYTHING ! 
8) the patients heart may need to be restarted and hand cardiac massage may need to be performed (two hands ) during much of this period ( use paddles only 20-30 joules necessary ) 
9) if you have managed to gain a perfusing blood pressure then the patient needs to go to theatre and this needs to be in sligo , regardless of the expertise of the surgeon on call . He can be stabilised more before definitive transfer 

TALKS FOR THIS WEEK SEPT 18

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hi
To complement TRAUMA talk last week the following talks need to be covered next thursday
please pick a talk and post a summary on this website (via www.emsligo.blogspot.ie) the summary should be a paragragh and contain at least one reference

1) Thoracotomy – Karen ( or mick )
2) Chest drain placement / include indications for hand thoracostostomy ( Eimhear)
3) Massive transfusion protocol
4) sort of goes with 3 but good to divide up between two : DAMAGE CONTROL RESUSCITATION
5) the rectal exam in trauma – Mohamed
6) pelvic fracture classification ( young ) and significance – MEDICAL STUDENT PRESENTATION
7) RSI practice and  Gidascope demonstration ( rep )
8) review the FAST scan if time ( for people who werent there the last time )

remember to check this link for review of FAST SCAN -http://www.sonoguide.com/FAST.html