Topic this week: RESPIRATORY
Thursdays programme:
14.00-14.20 Pulmonary Embolism (Keta McDowall)
14.20-14.50 Pneumothorax (Jane Senior)
15.00-16.00 Practical session on Chest drain insertion (Jane Senior)
Pre-reading & references:
Pneumothorax guidelines BTS pneumothorax guideline
Pleural drain insertion ACI Video insertion of a pleural drain
Topic this week: Paediatrics
Pre-reading & references:
Paeds ALS Assessment & Management
Thursday’s program:
1400-1420: Buckle fracture management (Thea Bishop)
1420-1450: Neonatal Resus case presentation & discussion (Claire Allerton)
1500-1600: Paediatric SIM scenarios (Claire Allerton & Ben Taylor)
1400 Airway Mangement Checklist
1430 Case Presentation
1500 Airway Practical Skills
References / Further Reading:
Age adjusted D-dimer cut-off values (age×10 µg/L) improve specificity without losing sensitivity for venous thromboembolism. This could spare many elderly patients unnecessary imaging.
Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis
BMJ. 2013 May 3;346:f2492
http://www.ncbi.nlm.nih.gov/pubmed/23645857
Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial
Lancet. 2013 Feb 16;381(9866):546-56
http://www.ncbi.nlm.nih.gov/pubmed/23260167
Emergency Neurology Updates
1. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study.
Perry JJ, Stiell IG, Sivilotti ML, et al. BMJ. 2011 Jul 18;343:d4277Take home points: Non-contrast CTB performed within six hours of headache onset can be considered “rule out” test for subarachnoid haemorrhage, without performing an LP
2. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?TBI Study Group for the Pediatric Emergency Care Applied Research Network (PECARN). Ann Emerg Med. 2011 Oct;58(4):315Take home points: Kids with minor HI and a normal CTB are safe to discharge home
3. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and pre-injury warfarin or clopidogrel use.Clinical Research in Emergency Services and Treatment (CREST) Network. Ann Emerg Med. 2012 Jun;59(6):460-8Take home points: IC bleed is at common in patients taking clopidogrel alone. Delayed ICH is rare in patients taking warfarin or clopidogrel.
4. Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol.Menditto VG, Lucci M, Polonara S, Pomponio G, Gabrielli A. Ann Emerg Med. 2012 Jun;59(6):451-5Take home points: 6% incidence of delayed ICH in warfarinised patients 24 hrs after an initial normal CTB
5. An analysis of predictive markers for intracranial haemorrhage in warfarinised head injury patients
Authors: Rendell, S et al. Emerg Med J. 2013 Jan;30(1):28-31.
Take home points: Up to 15% of warfarinised patients have an abnormal CTB after head trauma. A subtherapeutic INR is not protective or predictive.
6. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke [IST-3]: a randomised controlled trialThe IST-3 collaborative group. Lancet. 2012 Jun 23;379(9834):2352
Take home points: You need to read this one and come to your own conclusions. The following editorials may help clarify your viewpoint:
• The Lancet, Volume 380, Issue 9847 p 1053, 22 September 2012
• Emergency Medicine Australasia (2012) 24, 473–476
• Emergency Medicine Australasia (2012) 24, 477–479
Central venous catheters, CVP, and fluid responsiveness
The five components of the ‘bundle’ that aim to reduce catheter-related blood stream infection are:
Further information is here.
Fluid responsiveness
The failure of CVP to predict fluid responsiveness is nicely demonstrated in this landmark study.
A recent summary of methods of predicting fluid responsiveness is here.
We’ve moved to using new sidestream end tidal carbon dioxide adaptors in resus.
A video on how to connect them is here:
Remember, end tidal CO2 detection, or capnography, is mandatory in ALL intubations, including cardiac arrest. It is the most reliable way of confirming that the tracheal tube is in the airway (as opposed to the oesophagus).
A summary of the audits presented in January 2013 is available on the Audit page.
Includes UTIs in kids, and 3 ENT audits (management of Tonsillits, Otitis Media and Epistaxis).
Ventilation in ARDS
The updated (Berlin) definition of ARDS can be found here
Here’s the original ventilation strategy used in the ARDSnet study:
ARDSnet mechanical ventilation protocol card
Severe life-threatening asthma
Check out Dr Weingart’s notes on asthma on crashingpatient.com and consider what aspects you might modify for local (Australian) practice.
Further reading – this article is thoroughly recommended to advance your understanding of advanced therapies and of the limitations of inhaled therapies in severe asthma management:
Sellers WF. Inhaled and intravenous treatment in acute severe and life-threatening asthma.
Br J Anaesth. 2013 Feb;110(2):183-90
Beaches Emergency Team 