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Difficult Decision Sim Scanario – Breakfast meeting 30/1/14

Hi

Some general feedback from today’s simulation.

Thanks to all who attended – we will email you with some more detailed feedback in the next few days – check your mail.

A few points we thought were relevant to all were as follows.

Handover:

Best done at the end of the bed or at least away from the bedside

Calling a timeout or asking for a little quiet will ensure that you receive all the relevant information.

Don’t forget that there are many cognitive aids in resus – today the paediatric formulae – NETS calculator wasn’t used. It sits on the shelf in a folder – find it and use it.

 

Please post any comments.

See you next month for our Neurotrauma scenario – February 27th 07:00

Pacing in ED – permanent and temporary

Pacing in ED is not technically difficult. Below is a presentation from today’s teaching.

The decision to commence pacing is challenging and can be a cause for hesitation.

Failure of chronotropic therapy and an inadequately perfusing rhythm e.g.bradycardia, complete heart block should prompt initiation of treatment.

Transvenous pacing is the gold-standard but requires a skill set not always available.

Follow the link to a power point presentation from today’s teaching with an overview of pacemakers and pacing in the ED. At the end are links which I have included below for convenience – or if you want more detail. Send in your comments as usual.

Pacing in ED

Links:

http://lifeinthefastlane.com/education/ccc/pacemakers/

http://lifeinthefastlane.com/education/ccc/temporary-pacemaker-troubleshooting/

http://radiopaedia.org/articles/cardiac-pacemakers

http://www.cardiacengineering.com/pacemakers-wallace.pdf

http://www.modernmedicine.com/modern-medicine/news/temporary-pacemakers

X-ray education link

Thanks to Ali Mahoney for this one.

www.radiologymasterclass.co.uk

A comprehensive look, learn and test yourself site for medical students and junior doctors.

ED Inotropes

Choosing when to start, add or stop inotropes can be challenging.

On Tuesday we talked a bit more about the difference in actions and the uses of some of the inotropes we have in ED to use on our patients using a case presentation.

Open the presentation which I’ve added a bit more content to so it’s easier to follow if you weren’t there.

Please post any comments or questions.

Dan

Inotropes

For someone else’s views try Chris Nickson’s summary in life in the fast lane. http://lifeinthefastlane.com/education/ccc/inotropes-vasopressors-and-other-vasoactive-agents/

 

Snake Bites – a practical approach

Hi – another article from the inimitable Geoff Isbister. Slowly we are seeing the use of Venom Detection Kits (VDK) devolve in importance. Treat the patient – don’t worry too much about the kit.

Antivenom should be administered as soon as there is evidence of envenoming. The VDK may assist in regions where the range of possible snakes is too broad to allow the use of monovalent antivenoms.

Also one vial of suitable anti venom is enough – recovery from the clinical and laboratory effects are likely to be delayed. Specific and supportive treatment for these should be aggressively pursued and implemented.

Have a look at:

Snake Bite MJA_fm

Asymptomatic hypertension – don’t do anything!

Hi – the news we’ve all been waiting for.

ACEP published a consensus statement in July 2013, Weingart blogged in October, you have it now.

Is there any evidence to further assess OR treat asymptomatic hypertension in ED – NO.

Send them back to their GP for further evaluation and treatment – they’ll be fine.

There are some provisos so please read the article attached.

Asympt-hypert2-Final-BOD-approved-2013

Here’s a link to Scott’s emcrit post: Weingarts’s podcast on asymptomatic hypertension

Comments welcome as usual

 

Dan

Targeted therapeutic hypothermia – is it effective?

Targeted therapeutic hypothermia – is it effective?

Hi

Just posting some commentary regarding the recently published trial in NEJM.

Central Line Insertion – practical tutorial 5th December pre-reading

Follow the link a pdf of the article published by BMJ in their CME clinical review section: Central Venous Catheters.

CVC BMJ 2013 CVC clinical review bmj

Here are the key findings:

  • Overall – route probably not important, less thrombotic complications from sub-clav. vs femoral  2% vs 22%
  • No difference in infection
  • Optimal location of CVC tip is at level of carina for short-term catheters.
  • USS guided is standard of care reduced rate of complications and more rapid insertion
  • Antiseptic dressings or lines are worthwhile in ICU and if in for longer than 5 days
  • Peripiherally inserted central lines have a higher rate of upper limb DVT and no difference in rates of infection.

Technique of inserting a central venous catheter into the internal jugular vein (see original article for pictures)

Explain the procedure to the patient and obtain written informed consent

Continuously monitor with pulse oximetry (for arterial blood oxygen saturation) and electrocardiography (for early identification of arrhythmias induced by the wire or catheter)

Using ultrasound, assess the anatomical location and patency of the internal jugular vein (fig 3A and B)

Place the patient in the Trendelenburg position, with the head slightly rotated to the contralateral side; excess rotation will compress the internal jugular vein, compromising the ability to cannulate the vessel

Use a strict aseptic technique. After thorough hand washing, put on a sterile gown, gloves, mask, and hat and place a sterile full body drape over the patient. Lay out all equipment on a trolley. Use a sterile ultrasound probe cover and sterile conductive jelly

Guided by real time ultrasound imaging (ideally, using both in-plane and out of plane views), insert a needle mounted on a syringe into the internal jugular vein (fig 3C)

Once blood is freely aspirated, set aside the ultrasound probe and remove the syringe from the needle. Blood flow from the needle should be non-pulsatile, but non-pulsatile blood flow does not exclude arterial penetration

Advance the guide wire through the needle into the vessel, remove the needle, and then confirm the guide wire position with ultrasound imaging (fig 3D). If the guide wire position remains uncertain, insert a short narrow cannula over the wire and into the vessel. Connect the cannula to a transducer system to confirm a venous pressure waveform. Reintroduce the wire through the cannula and then remove the cannula

If a narrow bore cannula is placed in an artery, remove it and apply pressure. Options for dealing with a large bore catheter introduced into an artery are covered in a recent review.8 Make a small incision with a scalpel to facilitate the passage of the dilator. Pass the dilator over the wire to a depth a little greater than the predicted vessel depth; this reduces the risk of vessel injury. Maintain control of both the guide wire and dilator at all times

Remove the dilator. Pass the central venous catheter on to the guide wire and withdraw the guide wire until it protrudes from the end of the catheter

Advance the catheter into the vessel and remove the guide wire
Using ultrasound, confirm correct placement of the catheter in the vein Secure the catheter and place a dressing over the insertion site Obtain a chest radiograph to confirm the location of the catheter tip.

Additional resources can be found at:

Ortega R, Song M, Hansen CJ, Barash P. Ultrasound-guided internal jugular vein cannulation. N Engl J Med 2010;362:e57. Video showing insertion of an internal jugular central venous catheter

University of West London. Epic 3 national evidence based guidelines for preventing healthcare associated infections. 2013. http://www.uwl.ac.uk/sites/default/files/Academic-schools/College-of-Nursing-Midwifery-and-Healthcare/Web/Epic3/epic3_Consultation_Draft.pdf

Early morning Resus team

Early morning Resus team

How to save a mannequin at 7am – the first Thursday morning session.

Thanks to Laura, Lucy, Kate, Kevin and Ferenz for taking part. Well done to everyone – great communication skills demonstrated.

The case was status epileptics in a 30yr old female who presented from the community by ambulance.

Next one in 4 weeks – December the 5th.

TMT – intracranial haemorrhage

ICH image.2ICH imageThis weeks handout to accompany the tutorial.

Retinal USS

BP control

Osmotherapy

Ventilation

Intracranial haemorrhage