ObjectivesObjectives

Lots of topics requestedLots of topics requested– Acute cardiopulmonary diseaseAcute cardiopulmonary disease– AnaphylaxisAnaphylaxis– Cardiac arrest – ALS and BLSCardiac arrest – ALS and BLS– Septic shockSeptic shock– PaediatricsPaediatrics– Head injuryHead injury– TIA and StrokeTIA and Stroke

Acute respiratory distressAcute respiratory distress

24 year old with history of asthma arrives 24 year old with history of asthma arrives in some distress with a respiratory rate in some distress with a respiratory rate of 32 and SaO2 of 94%. Speaking in of 32 and SaO2 of 94%. Speaking in phrases. phrases.

– Moderate to severe exacerbationModerate to severe exacerbation– Initial treatmentInitial treatment

Salbutamol 5mg x 3 q20minSalbutamol 5mg x 3 q20min Ipratropium 500mcg x 1 Ipratropium 500mcg x 1 Oral or IV steroidsOral or IV steroidsReassessReassess

Asthma continuedAsthma continued No improvement after 2 nebs with No improvement after 2 nebs with

increasing resp distress, intercostal increasing resp distress, intercostal recession, speaking in wordsrecession, speaking in words

Urgent situationUrgent situation Continuous nebulised salbutamolContinuous nebulised salbutamol Intravenous salbutamolIntravenous salbutamol IV Magesium IV Magesium CPAP/ BiPAPCPAP/ BiPAP Intubation preparationIntubation preparation IV adrenaline in small doses eg 0.1mg IV adrenaline in small doses eg 0.1mg

diluted (1ml of 1:10,000)diluted (1ml of 1:10,000)

Take home messagesTake home messages

Severe asthmaticSevere asthmatic– Continuous oxygen driven nebulisersContinuous oxygen driven nebulisers– Get to hospitalGet to hospital– Small doses of IV adrenaline can buy Small doses of IV adrenaline can buy

timetime– Intubation last resortIntubation last resort

82 year old man presents by 82 year old man presents by ambulance with sudden shortness of ambulance with sudden shortness of breath, chest tightness. Chest breath, chest tightness. Chest sounds wheezy and rattly. Coughing sounds wheezy and rattly. Coughing frothy pink sputum.frothy pink sputum.

Obs: pulse 96, BP 200/130, RR 32, Obs: pulse 96, BP 200/130, RR 32, sats 96% on NRBsats 96% on NRB

Diagnosis?Diagnosis? Treatment?Treatment?

Hypertensive and LVF – need to Hypertensive and LVF – need to reduce afterload, increase preloadreduce afterload, increase preload

Fluid overload not usual problemFluid overload not usual problem ECG to rule out STEMI, ECG to rule out STEMI, Monitoring, O2, IV accessMonitoring, O2, IV access Nitrates +/- morphineNitrates +/- morphine BiPAP BiPAP

– Reduces work of breathingReduces work of breathing– Forces fluid out of alveolar spaceForces fluid out of alveolar space

LVF plus hypotensionLVF plus hypotension– Too much nitrate?Too much nitrate?– Tachyarrhythmia?Tachyarrhythmia?– Cardiogenic shockCardiogenic shock

Fluid gently if inferior AMIFluid gently if inferior AMI InotropicInotropicCath lab urgently if AMICath lab urgently if AMI

PneumothoraxPneumothorax

Types:Types:– Primary Primary

spontaneousspontaneous– Secondary – Secondary –

underlying lung underlying lung disease disease

– Traumatic +/- rib Traumatic +/- rib fracturesfractures

Primary PneumothoraxPrimary Pneumothorax

18yo presents with 18yo presents with sudden onset of sudden onset of left pleuritic chest left pleuritic chest pain. pain.

Some SOB when Some SOB when walkingwalking

No past med hxNo past med hx

Primary pneumothoraxPrimary pneumothorax Risk factors:Risk factors:

– Smoking Smoking 12% lifetime risk in men vs 0.1% non-smokers12% lifetime risk in men vs 0.1% non-smokers

– Pleural blebs and bullaePleural blebs and bullae– Tall, thin males Tall, thin males – Asthma history Asthma history – 50% recurrence rate in 4 years50% recurrence rate in 4 years

Evaluation of size:Evaluation of size:– British Thoracic Society Guideline 2003British Thoracic Society Guideline 2003– ExpiratoryExpiratory CXR not required CXR not required – Small vs Large ptx – 2cm rim of air = 50% ptxSmall vs Large ptx – 2cm rim of air = 50% ptx

Primary pneumothorax contPrimary pneumothorax cont Options for treatment:Options for treatment:

– Leave vs aspiration vs chest tubeLeave vs aspiration vs chest tube Leave < 2cm rim of air on CXR and not Leave < 2cm rim of air on CXR and not

breathlessbreathless Attempt aspiration Attempt aspiration > 2cm rim of air and/or > 2cm rim of air and/or

breathlessbreathless- 70-80% success- 70-80% success Unsuccessful aspirationUnsuccessful aspiration

– Try againTry again– Small bore intercostal catheter, remove at 24 Small bore intercostal catheter, remove at 24

hours if fully reexpandedhours if fully reexpanded– High flow oxygenHigh flow oxygen

Surgical pleurodesis at 5 days if persistent Surgical pleurodesis at 5 days if persistent leakleak

AspirationAspiration Re Xray 4 hours after Re Xray 4 hours after

procedureprocedure Home if reexpandedHome if reexpanded• Warn if increasing Warn if increasing

pain, pain, breathlessness to breathlessness to seek help seek help immediatelyimmediately

Re X ray next day Re X ray next day then at 1-2 weeksthen at 1-2 weeks

Same if conservatively Same if conservatively treatedtreated

Follow upFollow up

Reabsorbs over weeksReabsorbs over weeks No flying till fully resolved (airline rules No flying till fully resolved (airline rules

6 weeks)6 weeks) No diving everNo diving ever Resumption of sporting activity ? 2-4 Resumption of sporting activity ? 2-4

weeksweeks

Secondary pneumothoraxSecondary pneumothorax

Age > 50, underlying pulmonary diseaseAge > 50, underlying pulmonary disease High rate of failure of conservative High rate of failure of conservative

treatmenttreatment– Only small apical asymptomatic, < 1cm ptxOnly small apical asymptomatic, < 1cm ptx

Usually need hospitalisation with a small Usually need hospitalisation with a small bore chest drain until reexpandedbore chest drain until reexpanded

BTS guideline:BTS guideline:– < 50yo, < 2cm rim of air, not breathless – try < 50yo, < 2cm rim of air, not breathless – try

aspiration and admit 24 hoursaspiration and admit 24 hours– > 50yo or > 2cm air or breathless - ICC> 50yo or > 2cm air or breathless - ICC– Early surgical referral (3 days)Early surgical referral (3 days)

Traumatic ptxTraumatic ptx

Ptx on CXR usually requires ICC and Ptx on CXR usually requires ICC and admissionadmission

Especially if requiring GAEspecially if requiring GA Traumatic ptx on CT scan less Traumatic ptx on CT scan less

importantimportant

Take home messagesTake home messages

Asymptomatic ptx < 2cm can be Asymptomatic ptx < 2cm can be treated conservativelytreated conservatively– in under 50, in under 50, – no underlying lung diseaseno underlying lung disease

Many primary pneumothoraces can Many primary pneumothoraces can be aspirated – 70-80% successbe aspirated – 70-80% success

60 year old with no known history of 60 year old with no known history of allergy eating an asian meal at a allergy eating an asian meal at a local restaurant.local restaurant.

Within 2 minutes develops Within 2 minutes develops generalised erythema and itch, generalised erythema and itch, vomits, dizzy and collapses. vomits, dizzy and collapses.

Develops increasing of face and Develops increasing of face and tongue and a hoarse voice, difficulty tongue and a hoarse voice, difficulty breathingbreathing

AnaphylaxisAnaphylaxis

Classified:Classified:– mild: skin and subcutaneous tissues mild: skin and subcutaneous tissues

only only non-sedating antihistamines (cetirizine, non-sedating antihistamines (cetirizine,

loratidine) for symptomsloratidine) for symptoms

– moderate: features suggesting moderate: features suggesting respiratory, cardiovascular, or respiratory, cardiovascular, or gastrointestinal involvementgastrointestinal involvement

– severe: hypoxia, hypotension or severe: hypoxia, hypotension or neurological compromiseneurological compromise

Treatment of mod/severe Treatment of mod/severe anaphylaxisanaphylaxis

Emergency management of anaphylaxis:Emergency management of anaphylaxis:– AdrenalineAdrenaline– AdrenalineAdrenaline– AdrenalineAdrenaline

0.5ml of 1:1000 amp IM in the lateral 0.5ml of 1:1000 amp IM in the lateral thigh (0.1 ml/kg to maximum 0.5ml)thigh (0.1 ml/kg to maximum 0.5ml)

ie half a 1ml amp for an adultie half a 1ml amp for an adultMay be repeated every 3-5 minutes May be repeated every 3-5 minutes

depending on responsedepending on responseBeware of using IV adrenalineBeware of using IV adrenaline

Adjunctive treatmentAdjunctive treatment Lie patient flatLie patient flat OxygenOxygen IV access/ NS 20mg/kgIV access/ NS 20mg/kg Salbutamol neb for bronchospasmSalbutamol neb for bronchospasm Neb adrenaline for upper airway Neb adrenaline for upper airway

obstructionobstruction Atropine for bradycardiaAtropine for bradycardia Glucagon for beta blocked patientsGlucagon for beta blocked patients

Steroids, antihistamines - H1 and H2 Steroids, antihistamines - H1 and H2 blockers (eg ranitidine)blockers (eg ranitidine)

Keep for 4 hours minimum post Keep for 4 hours minimum post Adrenaline – should be observed in Adrenaline – should be observed in ED ED

Follow up with allergy specialist if Follow up with allergy specialist if severe – RNSH OPDsevere – RNSH OPD

If severe provide EpiPen (0.3mg) and If severe provide EpiPen (0.3mg) and instructionsinstructions

CardiologyCardiology

Acute coronary syndromesAcute coronary syndromes– ETAMIETAMI– High sensitivity troponinsHigh sensitivity troponins

ETAMIETAMI - - EEmergency mergency TTreatment of reatment of AMIAMI

Ambulance paramedics do an ECG on Ambulance paramedics do an ECG on patients with chest painpatients with chest pain

Across Northern Sydney transmitted Across Northern Sydney transmitted to RNSH ED 24 hoursto RNSH ED 24 hours

ECG Read by EM specialist/registrar -ECG Read by EM specialist/registrar -call back to ambulance via mobilecall back to ambulance via mobile– STEMI: transport to RNSH/ Cath lab STEMI: transport to RNSH/ Cath lab

alertedalerted– others: to local hospitalothers: to local hospital

ETAMIETAMI

Pioneered at RNSH from 2004 Pioneered at RNSH from 2004 Front door to needle time of 18 Front door to needle time of 18

minutesminutes Sydney wide system from August to Sydney wide system from August to

cath labs at major hospitalscath labs at major hospitals

High sensitivity troponinsHigh sensitivity troponins 6-7% patients present to ED with chest pain – 6-7% patients present to ED with chest pain –

about 3,500 pa. Half have ACS.about 3,500 pa. Half have ACS. Over 10,000 troponins a yearOver 10,000 troponins a year Until end 2009 using 3Until end 2009 using 3rdrd gen trop test: gen trop test:

– NR < 0.03 mg/L, 0.03 – 0.2 equivocalNR < 0.03 mg/L, 0.03 – 0.2 equivocal Now 4Now 4thth generation troponin assay generation troponin assay

– < 14ng/ml negative, 13-100ng/mL equivocal< 14ng/ml negative, 13-100ng/mL equivocal

What does this mean?What does this mean?– Many more false positivesMany more false positives– How do you interpret a low positive test?How do you interpret a low positive test?

High sensitivity troponins cont.High sensitivity troponins cont.

Patients need to be clinically risk stratifiedPatients need to be clinically risk stratified– Good ACS story plus N trop = admission for IxGood ACS story plus N trop = admission for Ix– Poor ACS story plus low N trop may be able to Poor ACS story plus low N trop may be able to

go homego home

Change in serial troponin importantChange in serial troponin important– We are using 30% change in 6 hoursWe are using 30% change in 6 hours– 3 hour trop for high risk patients 3 hour trop for high risk patients

Be aware of other diagnoses causing rise in Be aware of other diagnoses causing rise in troponintroponin

Non ACS causes of raised troponinNon ACS causes of raised troponin

Pulmonary embolismPulmonary embolism Acute cardiac failureAcute cardiac failure MyocarditisMyocarditis Aortic dissectionAortic dissection Acute decompensated AV diseaseAcute decompensated AV disease Renal insufficiencyRenal insufficiency

BLS and ALS changesBLS and ALS changes

BLSBLS– New literature New literature

emphasising minimal interruptions to ECMemphasising minimal interruptions to ECM questioning role of early breathing interventions – questioning role of early breathing interventions –

compression only CPR?compression only CPR?

– ARC: "ANY ATTEMPT AT RESUSCITATION ARC: "ANY ATTEMPT AT RESUSCITATION IS BETTER THAN NO ATTEMPT" and if a IS BETTER THAN NO ATTEMPT" and if a rescuer is unwilling to do rescue breaths rescuer is unwilling to do rescue breaths then chest compressions are better than then chest compressions are better than nothing.”nothing.”

– Revised ARC guidelines due Dec 2010Revised ARC guidelines due Dec 2010– www.resus.org.au/www.resus.org.au/

BLSBLS

– Rate of compression to breath 30:2Rate of compression to breath 30:2– 2 initial rescue breaths2 initial rescue breaths– ECM 100/min (5 cycles in 2 minutes)ECM 100/min (5 cycles in 2 minutes)– Frequent rotation of rescuers – every 2 Frequent rotation of rescuers – every 2

minutesminutes– Don’t interrupt CPR to check for signs of Don’t interrupt CPR to check for signs of

lifelife– Use AED as soon as availableUse AED as soon as available

ALS for VF /pulseless VTALS for VF /pulseless VT

Early defibrillation for VFEarly defibrillation for VF Look for alternative reversible causesLook for alternative reversible causes Witnessed arrestWitnessed arrest

– Precordial thumpPrecordial thump– Stacked shocks x 3 - 200J biphasic defibStacked shocks x 3 - 200J biphasic defib– AEDs will only deliver a single shockAEDs will only deliver a single shock– Commence CPR ASAPCommence CPR ASAP

ALS for VF/pulseless VTALS for VF/pulseless VT

Further DC shocks for VF/VT:Further DC shocks for VF/VT:– Given every 2 minutesGiven every 2 minutes

Adrenaline – 10mls of 1:10000 (1mg) Adrenaline – 10mls of 1:10000 (1mg) IVIV– Given every 3 minutesGiven every 3 minutes

Securing airway – no more than 20 Securing airway – no more than 20 seconds break in CPRseconds break in CPR

ALS - other drugsALS - other drugs

AntiarrhythmicsAntiarrhythmics– Amiodarone drug of choice for Amiodarone drug of choice for

prolonged VF/pulseless VTprolonged VF/pulseless VT– 300mg (5mg/kg) 300mg (5mg/kg)

Atropine, Calcium, Bicarbonate, Atropine, Calcium, Bicarbonate, MagnesiumMagnesium– No evidence of benefit except in specific No evidence of benefit except in specific

circumstancescircumstances

Patient in non-shockable rhythm Patient in non-shockable rhythm

Asystole/Pulseless Electrical ActivityAsystole/Pulseless Electrical Activity– CPR / Rescue breathing 30:2CPR / Rescue breathing 30:2– Adrenaline every 3 minutesAdrenaline every 3 minutes– Search for a reversible cause:Search for a reversible cause:

4 H’s and 4T’s:4 H’s and 4T’s: HypoxiaHypoxia TamponadeTamponade HypovolaemiaHypovolaemia Tension ptxTension ptx Hypo/hyperkalaemiaHypo/hyperkalaemia Toxins / drugsToxins / drugs Hypo/hyperthermiaHypo/hyperthermia Thrombosis – pulm or Thrombosis – pulm or

cardiaccardiac

Paediatric resusPaediatric resus

Rare!Rare! Shocks: first 2J/kg then subsequent Shocks: first 2J/kg then subsequent

4J/kg 4J/kg Importance of CPR/rescue breathingImportance of CPR/rescue breathing Ratio for advanced providers 15:2Ratio for advanced providers 15:2 Using IO accessUsing IO access

Take home messagesTake home messages

Don’t interrupt chest compressionsDon’t interrupt chest compressions– 100/min100/min– change regularlychange regularly

Place of rescue breathing being Place of rescue breathing being questioned but still in guidelinesquestioned but still in guidelines– Ratio 30:2Ratio 30:2

DC shocks 2 minutely for VT/VFDC shocks 2 minutely for VT/VF Adrenaline 1mg IV q3minAdrenaline 1mg IV q3min

70 year old man presents with a 70 year old man presents with a week of left loin pain, difficulty week of left loin pain, difficulty passing urine, poor oral intake. Now passing urine, poor oral intake. Now confused and febrile. confused and febrile.

At triage vital signs: At triage vital signs: – P 120, BP 90/60, P 120, BP 90/60, – RR 28/min, sats 98% room air, RR 28/min, sats 98% room air, – T39.2T39.2

EGDT in septic shockEGDT in septic shock

Early 2000’s US study (Rivers) Early 2000’s US study (Rivers) – aggressive early resuscitation, aggressive early resuscitation, – Early ICU care, Early ICU care, – maintenance of blood pressure with maintenance of blood pressure with

inotropes, inotropes, – Hb/haematocrit optimisation, Hb/haematocrit optimisation, – Careful monitoring of oxygenation via CVCCareful monitoring of oxygenation via CVC

– improved mortality 50% to 35%improved mortality 50% to 35%

Clinical Excellence Commission Clinical Excellence Commission Sepsis ReviewSepsis Review

Recent NSW study showed septic shock Recent NSW study showed septic shock markedly over represented in major reported markedly over represented in major reported incidents incidents – Across all types of hosp.Across all types of hosp.– Non-recognition of sepsisNon-recognition of sepsis– Delays in starting treatmentDelays in starting treatment

ABxABx Treatment of poor organ perfusionTreatment of poor organ perfusion

– Poor monitoring of vital signsPoor monitoring of vital signs– Over 65 yo and after hours over representedOver 65 yo and after hours over represented– Oliguria, hypotension, tachycardia +/- fever = Oliguria, hypotension, tachycardia +/- fever =

septic shock until proven otherwiseseptic shock until proven otherwise

ARISE trialARISE trial

attempting to study role of EGDT in Australian attempting to study role of EGDT in Australian population - RNSH lead hospitalpopulation - RNSH lead hospital

Patients who present with:Patients who present with:– sepsis (T >38 or < 34 with evidence of an infection) sepsis (T >38 or < 34 with evidence of an infection) – BP < 90 systolic not responding to 1000mls IV fluid orBP < 90 systolic not responding to 1000mls IV fluid or– Lactate > 4 Lactate > 4

All get early antibioticsAll get early antibiotics Randomised into trial for EGDT vs normal Randomised into trial for EGDT vs normal

treatmenttreatment

YES

ADULT Sepsis / SIRS Guideline*

NO

Does the Patient meet the SEPSIS CRITERIA?

SEPSIS CRITERIA Known or Suspected Infection PLUS: ≥ 2 SIRS criteria Temp ≤ 36.0 or ≥38.0°C Heart Rate > 90 Resp Rate >20 or PaCO2 <32

mmHg WCC >12 or <4

+

EVIDENCE OF ORGAN DYSFUNCTION or SEPTIC SHOCK

ORGAN DYSFUNCTION Pale / Clammy skin Tachycardia / Tachypnoea Systolic < 90 or > 40mmHg

drop from baseline in hypertensive pt

Acute change in mental status Oliguria (<0.5 ml/kg/hr) Lactic Acidosis – Lactate 4

Initiate Initial management Insert IV line Bloods / ABG & lactate Blood Cultures / Urine

MC&S / Swabs & CXR Consider LP IV fluids IV Antibiotics Reassess in 1 Hr For Surgical causes contact the Surgical Team (For Elderly/ Frail patients, more frequent reassessment may be required)

Triage to Resuscitation Room or acute area

Category 2

Inform Registrar in charge Transfer to Resus room Insert second IV line Second set of Blood Cultures Coags/DIC screen Bolus 500mls Crystalloid over 10

mins / Reassess & repeat up to 2litres Crystalloid as required +

Broad Spectrum IV Antibiotics Insertion of IDC & hourly U/O

monitoring

Contact ED Consultant for: ICU referral and Admission Ongoing Fluid Resuscitation

500mls Crystalloid over 10 mins / Reassess & Repeat

Consideration of CVP Line Placement Arterial line Vasopressors

SEPTIC SHOCK CRITERIA Acute Circulatory failure

and Persistent hypotension despite

fluid resuscitation & not explained by other causes

Is the Patient achieving the Early

Treatment goals within 2 hrs?

Early Treatment goals (2hrs) Capillary Refill < 2secs U/O > 0.5 ml/kg/hr MAP >65

Continue to monitor and reassess patient. Aim to maintain vital signs.

Admit to appropriate Inpatient team / ICU as necessary

NO

NOO

YES

YES

0 Hrs

2 Hrs *This is a general guideline only – it is always important to consider the individual requirements of the patient and to give consideration to other clinical causes Adapted from Manly Hospital Sepsis guideline, Drs Phipps, Rochford, Franks & LKirkwood

Exit Guideline Refer to admitting team

70 yo patient with urosepsis:70 yo patient with urosepsis:– Recognition at triage – resus bedRecognition at triage – resus bed– Aggressive fluid resuscitation to restore Aggressive fluid resuscitation to restore

BP > 90 systolic – may need 2-4 litresBP > 90 systolic – may need 2-4 litres– After 1000mls NS if BP< 90 or lactate > After 1000mls NS if BP< 90 or lactate >

4 entered into ARISE trial4 entered into ARISE trial– Early antibiotics essential – broad Early antibiotics essential – broad

spectrum ABx should be given within spectrum ABx should be given within one hourone hour

– Early inotropic support eg noradrenalineEarly inotropic support eg noradrenaline– Look for a source – urine, abdominal, Look for a source – urine, abdominal,

chest, cannulas, cellulitis, otherschest, cannulas, cellulitis, others

Take home messagesTake home messages

Think about sepsis as a diagnosis – Think about sepsis as a diagnosis – subtle early signssubtle early signs

Urosepsis, hypotension dangerous Urosepsis, hypotension dangerous combinationcombination

Early antibiotics and resuscitationEarly antibiotics and resuscitation

Paediatrics - dehydrationPaediatrics - dehydration

DOH CPG: Management of Children with DOH CPG: Management of Children with GastroenteritisGastroenteritishttp://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_009.pdf

Major themes:Major themes:– Rehydration:Rehydration:

Less use of IV fluidsLess use of IV fluids More emphasis on oral rehydrationMore emphasis on oral rehydration

– If child requires IV:If child requires IV: Use of NS + 2.5% glucoseUse of NS + 2.5% glucose rather than hypotonic rather than hypotonic

solutionssolutions

Oral rehydrationOral rehydration

Oral rehydration solutions Oral rehydration solutions – Hydralyte, Gastrolyte (no sports drinks, fruit Hydralyte, Gastrolyte (no sports drinks, fruit

juice, soft drinks)juice, soft drinks) Parent should offer 0.5mls/kg every 5 Parent should offer 0.5mls/kg every 5

minutes eg with a syringeminutes eg with a syringe– Charted by parent including vomits, U/OCharted by parent including vomits, U/O

Parental attention, persistence Parental attention, persistence encouraged by staffencouraged by staff

Rapid rehydration via NGT an optionRapid rehydration via NGT an option– ORS via Kangaroo pump @ 10mls/kg/hr x ORS via Kangaroo pump @ 10mls/kg/hr x

4hrs4hrs

Medications in gastroenteritisMedications in gastroenteritis

Antiemetics: Antiemetics: – Ondansetron: some evidence of benefitOndansetron: some evidence of benefit– No evidence for prochlorperazine or No evidence for prochlorperazine or

metoclopramidemetoclopramide Antidiarrhoeals / antimotility agentsAntidiarrhoeals / antimotility agents

– No evidenceNo evidence Antibiotics:Antibiotics:

– Rarely requiredRarely required

IV therapyIV therapy

Who for? Who for? – Mild (3%) - Reduced UO, Thirst, Dry Mild (3%) - Reduced UO, Thirst, Dry

mucous membranes, mild tachycardia mucous membranes, mild tachycardia – Oral only requiredOral only required

– Moderate (5%) - Dry mucous membranes, Moderate (5%) - Dry mucous membranes, tachycardia, abnormal respiratory pattern, tachycardia, abnormal respiratory pattern, lethargy, reduced skin turgor, sunken eyes lethargy, reduced skin turgor, sunken eyes – try oral first if fails go to IV– try oral first if fails go to IV

IV therapyIV therapy

– Severe (10%) Severe (10%)

– all of above, poor perfusion: mottled, cool all of above, poor perfusion: mottled, cool limbs/Slow capillary refill/Altered limbs/Slow capillary refill/Altered consciousnessconsciousness

Shock: thready peripheral pulses with marked Shock: thready peripheral pulses with marked tachycardia and other signs of poor perfusion tachycardia and other signs of poor perfusion

– – IV or IO therapy, 20mls/kg bolus NSIV or IO therapy, 20mls/kg bolus NS

Which IV solution?Which IV solution?

NS plus 2.5% or 5% glucoseNS plus 2.5% or 5% glucose Reduced risk of hyponatraemiaReduced risk of hyponatraemia All get an EUC, BGLAll get an EUC, BGL Low BGL < 3.5 or formal BSL < 2.6 Low BGL < 3.5 or formal BSL < 2.6

– extra glucose bolus IV extra glucose bolus IV

Rehydration: rapid over 4 hours or Rehydration: rapid over 4 hours or standard over 24 hoursstandard over 24 hours

Who gets admitted?Who gets admitted?

Go homeGo home Most Mild DehydMost Mild Dehyd

– Must have passed Must have passed urine, able to take urine, able to take some fluidsome fluid

– occasional social occasional social admissionadmission

– GP review in 24-48 GP review in 24-48 hours hours

Moderate who pass Moderate who pass TOF go homeTOF go home

AdmittedAdmitted Mild < 6mthsMild < 6mths Moderate who fail TOF Moderate who fail TOF any severe get any severe get

admitted for IV therapyadmitted for IV therapy Any question about Any question about

diagnosisdiagnosis RNS doesn’t do RNS doesn’t do

acute paed abdo acute paed abdo surgery < 14yo eg surgery < 14yo eg appendicitis, torsion appendicitis, torsion testistestis

Red flagsRed flags Gastroenteritis = V + D + fever Gastroenteritis = V + D + fever

– Beware vomiting in the absence of diarrhoeaBeware vomiting in the absence of diarrhoea

Differential diagnosis large:Differential diagnosis large:– AppendicitisAppendicitis– Intussusception < 2yoIntussusception < 2yo

Beware:Beware:

n n Abdominal distensionAbdominal distension

n n Bile-stained vomitingBile-stained vomiting

n n Fever >39ºCFever >39ºC

n n Blood in vomitus or stoolBlood in vomitus or stool

n n Severe abdominal painSevere abdominal pain nn

n n HeadacheHeadache

Reintroduction of dietReintroduction of diet

BF should continue with ORS BF should continue with ORS supplement if neededsupplement if needed

Resume N diet as soon as vomiting Resume N diet as soon as vomiting stopsstops

Fact sheet on CHW websiteFact sheet on CHW website Some evidence probiotics helpfulSome evidence probiotics helpful

2yo, presents in the late evening, 2 2yo, presents in the late evening, 2 days of upper respiratory symptoms, days of upper respiratory symptoms, barking coughbarking cough

Tonight increasing, cough, agitation, Tonight increasing, cough, agitation, stridorstridor

ImmunisedImmunised On exam sitting forward, alert but On exam sitting forward, alert but

not interacting much, insp. stridor at not interacting much, insp. stridor at rest, intercostal recession, accessory rest, intercostal recession, accessory muscle usemuscle use

Not toxic lookingNot toxic looking Hopefully hear the cough!Hopefully hear the cough!

Moderate/severe croupModerate/severe croup Straight into resus areaStraight into resus area Monitor pulse and saturations - P140, Monitor pulse and saturations - P140,

RR 36, sats 99%RR 36, sats 99% Nebulised adrenaline - 5mg of 1:1000Nebulised adrenaline - 5mg of 1:1000

– Rapid action, lasts 2 hoursRapid action, lasts 2 hours Dexamethasone – IM (or po) 0.3 mg/kgDexamethasone – IM (or po) 0.3 mg/kg

Paeds - croupPaeds - croup

New DOH clinical practice guideline New DOH clinical practice guideline in Aug 2010: in Aug 2010: http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_053.pdf

Mostly 6-36 monthsMostly 6-36 months Mostly viral - RSV, parainfluenzaMostly viral - RSV, parainfluenza Spasmodic croup – atopic group, Spasmodic croup – atopic group,

sudden onset, improve quicker, sudden onset, improve quicker, recurrentrecurrent

Worry if:Worry if:

Rising pulse, RRRising pulse, RRLess interactive, more Less interactive, more

agitated/anxious, sleepyagitated/anxious, sleepyMore respiratory distressMore respiratory distressCyanosis/pallor or low O2 sats a Cyanosis/pallor or low O2 sats a

late signlate sign

DispositionDisposition If settle after neb AdrenalineIf settle after neb Adrenaline

– 4 hours obs and home4 hours obs and home– Expect illness last 4-5 daysExpect illness last 4-5 days– GP reviewGP review– Mostly only need one dose steroids - Mostly only need one dose steroids - Use of Use of

steroids has dramatically decreased admission steroids has dramatically decreased admission and intubation ratesand intubation rates

• AdmitAdmit– If further neb Ad neededIf further neb Ad needed– Age < 6 mthsAge < 6 mths– Any uncertainty about dxAny uncertainty about dx

Differential diagnosis:Differential diagnosis:– Less than 3 months think ? Structural Less than 3 months think ? Structural

/congenital problem/congenital problem– Foreign bodyForeign body– EpiglottitisEpiglottitis– Bacterial tracheitis Bacterial tracheitis

Croup – take home messagesCroup – take home messages

Nebulised adrenaline 0.5mls/kg to Nebulised adrenaline 0.5mls/kg to 5mls of 1:1000 (5mg) for mod or 5mls of 1:1000 (5mg) for mod or severe. At least 4 hours obs needed.severe. At least 4 hours obs needed.

Steroids – one (or two) doses only Steroids – one (or two) doses only has reduced admission/complication has reduced admission/complication ratesrates

A 4 month old child presents snuffly for A 4 month old child presents snuffly for the last couple of days, occasional the last couple of days, occasional coughing, low grade fevers. Breast coughing, low grade fevers. Breast feeding poorly, decreased wet nappies. feeding poorly, decreased wet nappies. Today mum has noticed breathing Today mum has noticed breathing rapidly, seems to be working hard.rapidly, seems to be working hard.

On exam: pulse 160, RR 40, nasal flaring, On exam: pulse 160, RR 40, nasal flaring, intercostal recession, sats 92% room airintercostal recession, sats 92% room air

Chest auscultation: fine crackles on Chest auscultation: fine crackles on inspiration, occasional exp wheeze.inspiration, occasional exp wheeze.

Most likely diagnosis?Most likely diagnosis?Management?Management?

Paeds - bronchiolitisPaeds - bronchiolitis

DOH CPG availableDOH CPG available Mostly children less than 12 monthsMostly children less than 12 months RSV causes > 90%RSV causes > 90% Clinical diagnosisClinical diagnosis

– No CXR unless another dx eg bacterial No CXR unless another dx eg bacterial pneumonia suspectedpneumonia suspected

Differential dx in this case?Differential dx in this case? Acute asthma – less than 12 months, Acute asthma – less than 12 months,

not recurrent episodesnot recurrent episodes Pneumonia – not toxic, URTI sxPneumonia – not toxic, URTI sx Bronchial foreign body – infective Bronchial foreign body – infective

history, not sudden onset in well childhistory, not sudden onset in well child Pertussis – cough not prominent, no Pertussis – cough not prominent, no

contactscontacts Cardiac failure – usually earlier, well Cardiac failure – usually earlier, well

child till now, normal growthchild till now, normal growth

Management of bronchiolitisManagement of bronchiolitis Self limiting viral illness – red flags:Self limiting viral illness – red flags:

– Less than 3 months, preterm/small – risk Less than 3 months, preterm/small – risk of apnoeasof apnoeas

– Underlying heart or lung diseaseUnderlying heart or lung disease– Feeding poorly/dehydratedFeeding poorly/dehydrated– ApnoeasApnoeas– Resp distress – tiring, marked chest wall Resp distress – tiring, marked chest wall

retractions, grunting, low O2 satsretractions, grunting, low O2 sats Treatment mainstays:Treatment mainstays:

– Oxygen, adequate hydrationOxygen, adequate hydration– No role for bronchodilators, steroids or No role for bronchodilators, steroids or

antibioticsantibiotics

How sick is this child?How sick is this child?

A 4 month old child presents snuffly for the A 4 month old child presents snuffly for the last couple of days, occasional coughing, last couple of days, occasional coughing, low grade fevers. Breast feeding poorly, low grade fevers. Breast feeding poorly, decreased wet nappies. Today mum has decreased wet nappies. Today mum has noticed breathing rapidly, seems to be noticed breathing rapidly, seems to be working hard.working hard.

On exam: pulse 160, RR 40, nasal flaring, On exam: pulse 160, RR 40, nasal flaring, intercostal recession, sats 92% room airintercostal recession, sats 92% room air

Chest auscultation: fine crackles on Chest auscultation: fine crackles on inspiration, occasional exp wheeze.inspiration, occasional exp wheeze.

How sick is this child?How sick is this child?

A 4 month old child presents snuffly for A 4 month old child presents snuffly for the the last couple of dayslast couple of days, occasional coughing, , occasional coughing, low grade fevers. low grade fevers. Breast feeding poorly, Breast feeding poorly, decreased wet nappiesdecreased wet nappies. Today mum has . Today mum has noticed breathing rapidly, seems to be noticed breathing rapidly, seems to be working hard.working hard.

On exam: On exam: pulse 160, RR 40, nasal flaring, pulse 160, RR 40, nasal flaring, intercostal recession, sats 92% room airintercostal recession, sats 92% room air

Chest auscultation: fine crackles on Chest auscultation: fine crackles on inspiration, occasional exp wheeze.inspiration, occasional exp wheeze.

Moderate bronchiolitisModerate bronchiolitis

Admit for:Admit for:– O2 to keep sats > 95%O2 to keep sats > 95%– Look at child feed: IV fluids vs oral Look at child feed: IV fluids vs oral

rehydrationrehydration– Close observation for apnoeasClose observation for apnoeas– NPA for RSV NPA for RSV – no CXRno CXR

Home when normal feeding, little or Home when normal feeding, little or no resp distress, not hypoxaemicno resp distress, not hypoxaemic

Head Injury – Case 1 Head Injury – Case 1

18yo who presents after a having a few 18yo who presents after a having a few drinks, falling with a short LOC less drinks, falling with a short LOC less than a minute. Now alert and than a minute. Now alert and orientated but complaining of orientated but complaining of dizziness and a headache, vomited dizziness and a headache, vomited once. Haematoma over forehead.once. Haematoma over forehead.

Does he need to come to hospital?Does he need to come to hospital? Does he need a CT scan?Does he need a CT scan? Follow up needed?Follow up needed? Time off sport?Time off sport?

Head Injury – Case 2 Head Injury – Case 2 72 year old on warfarin for chronic AF. 72 year old on warfarin for chronic AF.

INR 2.3 last week. Simple fall at home INR 2.3 last week. Simple fall at home with a scalp lac needs suturing. with a scalp lac needs suturing. Possible short loss of consciousness, Possible short loss of consciousness, amnesic for event.amnesic for event.

Does he need to come to hospital?Does he need to come to hospital? Does he need a CT scan?Does he need a CT scan? Follow up needed?Follow up needed?

Mild head injury Mild head injury Low Risk Factors Low Risk Factors LOC < 5 minutesLOC < 5 minutes Amnesia < 30 minAmnesia < 30 min GCS 15 at 2 hoursGCS 15 at 2 hours No focal neuro deficitNo focal neuro deficit No evidence for skull fractureNo evidence for skull fracture No seizure post eventNo seizure post event Nausea or single vomitNausea or single vomit Mild headacheMild headache Age < 65Age < 65 No coagulopathyNo coagulopathy Isolated HIIsolated HI No drug or alcohol ingestionNo drug or alcohol ingestion

High Risk Factors High Risk Factors LOC > 5 minutesLOC > 5 minutes Amnesia > 30 minAmnesia > 30 min GCS < 15GCS < 15 Focal neuro deficitFocal neuro deficit Possible skull fracturePossible skull fracture Post event seizurePost event seizure 2 or more vomits2 or more vomits Severe headacheSevere headache Age > 65Age > 65 CoagulopathyCoagulopathy Multiple injury/ dangerous Multiple injury/ dangerous

mechanismmechanism Drugs or alcoholDrugs or alcohol RepresentationRepresentation

Indication for CT scanning Indication for CT scanning and prolonged observationand prolonged observation

Mild head injuryMild head injury

4 hours observation 4 hours observation and home if: and home if:

- normal cognition and - normal cognition and alertnessalertness

- N CT or no indication - N CT or no indication for a CTfor a CT

- should be a - should be a responsible person at responsible person at homehome

- given HI advice sheet- given HI advice sheet - be able to return - be able to return

Keep in hospital if:Keep in hospital if: - clinical symptoms - clinical symptoms

not improving at 4 not improving at 4 hourshours

- abnormal CT scan- abnormal CT scan - use judgement- use judgement

- elderly- elderly- coagulopathy- coagulopathy- intoxicated- intoxicated

- social issues- social issues

Case 1 - 18yo – 4 hours obs and Case 1 - 18yo – 4 hours obs and home if well to parents with HI home if well to parents with HI advice cardadvice card

Case 2 - CT scan head, check INR, Case 2 - CT scan head, check INR, observe. May need overnight stay. observe. May need overnight stay.

CT radiation effective doseCT radiation effective dose

Chart giving effective dose in Chart giving effective dose in mSv/CXRs/cigarettes/hours of plane travelmSv/CXRs/cigarettes/hours of plane travel

Eg CT head Eg CT head = 2.3 mSv= 2.3 mSv

= 115 CXR= 115 CXR

= 1 yr of background = 1 yr of background radiationradiation

= 920 cigs= 920 cigs

= 329 hours of plane = 329 hours of plane traveltravel

CT radiation effective doseCT radiation effective dose

Lumbar spine XR = 65 CXRLumbar spine XR = 65 CXR CT chest = 400 CXRCT chest = 400 CXR CT abdo/pelvis = 500 CXRCT abdo/pelvis = 500 CXR

Increase in cancer risk under 40yoIncrease in cancer risk under 40yo Head CT on a 1yo may give lifetime cancer Head CT on a 1yo may give lifetime cancer

risk of 1:1000risk of 1:1000 1 mSV = 500CXR = smoking 400 cigs = 1 mSV = 500CXR = smoking 400 cigs =

1:17,000 ca risk1:17,000 ca risk

74 year old presents with a episode 74 year old presents with a episode of left arm weakness lasting 30 of left arm weakness lasting 30 minutes which has now resolved.minutes which has now resolved.

P 72 regular, BP 145/95P 72 regular, BP 145/95 Not diabetic, no cardiac historyNot diabetic, no cardiac history You diagnose a TIA. What is his risk You diagnose a TIA. What is his risk

of having an early acute stroke? of having an early acute stroke?

ABCD2 Score for TIAABCD2 Score for TIA AgeAge ≥ 60? ≥ 60? Yes +1 Yes +1 BPBP ≥ 140/90 mmHg at initial evaluation? ≥ 140/90 mmHg at initial evaluation?

Yes +1 Yes +1

Clinical FeaturesClinical Features of the TIA: of the TIA: – Unilateral WeaknessUnilateral Weakness

+2+2– Speech Disturbance without Weakness Speech Disturbance without Weakness

+1+1

DurationDuration of Symptoms? 10-59 minutes of Symptoms? 10-59 minutes +1+1≥ ≥ 60 minutes60 minutes +2+2

DiabetesDiabetes in Patient's History? in Patient's History? Yes +1 Yes +1

High risk TIAsHigh risk TIAs

Score of 3 or above:Score of 3 or above:– Start aspirin (as with all TIA)Start aspirin (as with all TIA)– Early specialist investigation in next 24 Early specialist investigation in next 24

hours ie hospitalisationhours ie hospitalisation– TIA clinicTIA clinic

Why?Why?– New onset TIA - 10% risk of stroke in New onset TIA - 10% risk of stroke in

next 90 days however half will have next 90 days however half will have their stroke in the first weektheir stroke in the first week

Acute stroke management at Acute stroke management at RNSHRNSH

IV TPA is offered for acute IV TPA is offered for acute thrombotic/embolic stroke able to be thrombotic/embolic stroke able to be investigated and treated within 3 hoursinvestigated and treated within 3 hours

IA thrombolysis is offered up to 6 hours IA thrombolysis is offered up to 6 hours Time is from the time last seen normalTime is from the time last seen normal ED arranges CT, rings stroke team, ED arranges CT, rings stroke team,

neurologist makes decision and neurologist makes decision and administersadministers

Stroke unit/HDU bed after procedureStroke unit/HDU bed after procedure

That’s All Folks!That’s All Folks!