tc's whats hot in emergency medicine 5

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