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Emergency Department Staff SUPping on Lough Gill June 2015
Unfortunately, Dr Mick Killeen is returning to New Zealand after a year at the ED in Sligo.
We had a great year with him on our team, and he’ll be sorely missed
In order to bid him farewell , the ED crew (that weren’t on duty) spent the afternoon on Lough Gill learning to Stand Up Paddle (SUP) with SUPForAll. In treacherous conditions, the ED staff braved the elements. 
Celebratory meal, and awards ceremony that evening.
For more photos see www.facebook.com/SUPforall
Teaching APRIL 2015 onwards
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
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
Opinion piece on Emergency Medicine in Ireland published in The Irish Times
Fergal Hickey’s piece regarding the future of Emergency Medicine in Ireland published in today’s Irish Times
ED teaching for the beginning of the new year
Summary of heart failure talks
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
. 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
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
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Week THREE
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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
Simulation training
week 5
M/and M
OCTOBER TEACHING – week 1 Sodium
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 .
