tc's whats hot in emergency medicine 5
TRANSCRIPT
15/10.15
TC’s Potpourri 5The Holiday edition
HEAT
✤ Nurse: “The patient’s temperature is 37.598°C!”
✤ Doctor: “Quick get the antibiotics”
✤ Nurse: “That’s a funny way to pronounce panadol”
HEAT
✤ Fever in infection serves a purpose
✤ pathogens grow best in normothermia
✤ ie to cure syphilis get malaria
✤ Fever = ≥38.3 (WHO)
✤ HEAT trial showed that paracetamol in ICU did
nothing to reduce LOS and mortality
That Paul Young is busy - SPLIT
✤ NS 0.9% vs Plasmalyte (a low-chloride, acetate rich,
buffered crystalloid)
✤ 2278 ICU patients
✤ No difference in AKI, RRT or mortality
✤ On average only received about 2L
THM
✤ NS is not the devil
✤ However don’t go nuts with the NS
NEXUS Chest CT Decision
Instruments in Blunt Trauma
✤ An effort to reduce the ‘pan-man scan’
✤ No real guidelines into chest CTs in blunt trauma
✤ Using 14 clinical criteria, the “Chest CT-Major” and
“Chest CT-All” decision instruments were developed to
screen for (major only) vs (major + minor) injuries
NEXUS Chest Decision Instrument (Chest CT-Major):
To help rule out clinically MAJOR injuries
1. Abnormal CXR
1. Any thoracic injury (including clavicle fracture) or a
widened mediastinum
Inclusion: Age>14, Presenting
to ED for blunt chest trauma
within 6hrs of arrival, having
chest imaging in the ED
NEXUS Chest Decision Instrument (Chest CT-Major):
To help rule out clinically MAJOR injuries
2. Distracting injury (same as NEXUS c-spine)
3. Chest wall tenderness (isolated clavicular tenderness does not
qualify)
4. Sternal tenderness
5. Thoracic spine tenderness
6. Scapular tenderness
NEXUS Chest Decision Instrument (Chest CT-All):
To help rule out clinically MAJOR and MINOR injuries
✤ All 6 criteria from Chest CT-Major above plus…
✤ Rapid deceleration
✤ Mechanism of blunt trauma that exerts rapid deceleration force on the patient:
✤ Fall from a height > 20 feet, or
✤ Motor vehicle accident at speeds > 40 mph with sudden deceleration
✤ Note: Not all > 40 mph accidents qualify—there must be sudden deceleration.
For example a 45 mph collision with a wall or pole would qualify but a 50 mph
sideswipe or rollover MVA may not exert sudden deceleration and therefore
may not qualify)
TLDR
✤ The decision instruments:
✤ Chest CT-Major: Abnormal chest -ray + distracting
injury + thoracic tenderness
✤ Chest CT-All: Above + deceleration mechanism
Nontraumatic Thoracic Aortic
Dissection - Evaluation and Mx
Useful Not Useful
Clinical decision rules √
D-dimer √
CTA is as good as
TOE and MRA√
TOE√ (but mandates need
for urgent further Ix)
BP and Pulse targets√ (but no-one knows
exactly)
REVERT Trial 17 vs 43%
I just shat
myself
Do not ask for whom the bell tolls…
✤ Let’s do a public shaming/OSCE
✤ You are a new FACEM in a mixed ED
✤ Jeremiah is 12yo who hit his head playing football
✤ Task
✤ Take a focused history and examination
✤ Discuss management with Jeremiah and his mother
✤ Who is also a nurse
✤ and has fibromyalgia
✤ that is often flared up by her Lyme disease
Morituri te salutant
✤ There is no escape
✤ You are a new FACEM at a regional ED
✤ One of the residents has come asking advice about a
patient who has fallen over and they now have a sore
neck
✤ Task
✤ Teach the RMO how to determine if there is a need for
spinal immobilisation
✤ Teach the RMO how to apply the hard collar
I can’t breathe!
75yo intubated post single GTC seizure, ABG taken 10 mins post
✤ Uncompensated metabolic acidosis (or metabolic +
respiratory acidosis) with raised anion gap not solely
due to elevated lactate
✤ Raised A-a gradient
✤ Sodium adjusted to normoglycaemia is about 153
✤ Marked hyperglycaemia
✤ Hyperosmolar hyperglycaemic syndrome with
component of ketoacidosis and post-ictal lactic
acidosis.
✤ A question to the floor
✤ What does base excess tell yo that the bicarb doesn’t?
✤ Finally