All posts by Michael Sweeney

Summary of heart failure talks

summary heart failure talks 

thanks to  Safras and Mohamed for the talks on heart failure 
Below is a summary of take home points 
1) new guidelines are out on Heart failure ( nice guidelines ) as of OCTOBER 2014- click on image above for link to FREEDOWNLOAD
. These guidelines are 100s of  pages long and reflect the opinion of 100s of clinicians , researchers and patients 
There is a de-emphasis on NIV and GTN which doesnt reflect our real world. This is not the fault of the guidelines because neither treatments have much effect on long term survival . I dont  believe we can prove their efficacy in terms of short term survival because it would be unethical to do RCTs that involve withholding these treatments on patients in distress in ED 
The take home points ( their best interpretation of evidence and expert advice ) 
Heart failure is the the commonest cause for hospital admissions to hosptial in the over sixty fives 
Acute Pulmonary Oedema – is the commonest True ED emergency related to heart failure . The blood pressure is preserved or even high ( I find the pathophysiology behind this hard to fully understand as the usual causes such as mi or Ischemia are not culprits . It  is said that there is often a diastolic component , so these patients often have the risk factors for diastolic dysfunction such as diabetes and hypertension )  
Assessment 
1) acutely the main things are a preserved or high blood pressure and wet lungs ( creps) . When this clinical finding is not obvious ( eg in an obese patient with a history of COPD or risk factors for PE ) , bedside ultrasound has a new and crucial role 
Treatment 
2)  traditional approach is oxygen , frusemide , morphine , nitrates and consider NIV
3) a more rational priority ( and reflective of current ED Practice ) is 
Oxygen – best given via NIV ( whatever you have BIPAP or cpap ) 
Frusemide – standard iv dose ( doesn’t really matter what that is but usually the patients oral dose is given iv) 
Gtn ( given first under the tongue 2 sprays = 400mcg) and then as an infusion starting high and lowering if patient becomes hypOtensive eg start at 100mcg per minute or even more ( double this ) 
congestive heart failure with preserved blood pressure 
Assessment. 
The crucial points about diagnosis are BNP and a good clinical exam with good basic tests ( ecg/cxr/labs) . The patient should then get an echo (best as in patient ) and this should be a formal one as valvular heart disease needs to be ruled out and this is not yet in the domain of a basic ed bedside echo. Of course it would not be unreasonable to assess EF on bedside echo eg by eye ball estimation or EPSS 
Important Inpatient recommendations and guidelines 
1) The need for heart failure patients to be linked in to Specialist Clinics 
This is an evidence based recommendation and may be because all the things that comes with specialist clinics eg attention to detail / community outreach etc and addressing risk factors :  
– dietary and life style measures 
– blood pressure / cholesterol / weight  / obviously smoking sessation 
medication 
See table attached below of appendix in guidlienes about drug doses 
take home points 
– give an ace inhibitor ( or equivalent … if possible ) -eg start enalapril 2.5 mg daily and get GP to oversee increments up to ……..
– add a betablocker if patient is stable .that means out of ED , off iv diuretics etc .  cardivolol  / metoproplol succinate / bispoprolol being evidence based . Better to add a betablocker than increase dose of ace inhibitor according to the guidelines . eg bisoprolol 1.25 mg daily increasing over weeks to 
– if giving a betablocker add a thiazide as ankle swellling is a problem

Persistent uncontrolled nyhc grades 2-4 : 

– add in spironolactone ( or equiv anti aldosterone equivalent ) —eg  
– add in digoxin — 
FINALLY 
tNOT INCLUDED IN THE NICE GUIDELINES THE COOL STUFF 
1) ULTRASOUND 
Bedside ultrasound really has such a useful and now evidence based role to play in acute assessment not the least of which includes 
IVC assessment when fluid loading 
left heart gestalt EF estimation and EPSS 
lung assessment – lung rockets or B lines and response to therapy 
rule out right heart strain 
2) 
The high end stuff -REBOA / AORTIC BALLOON COUNTER PULSATION 
when are these things to be considered

           

NOVEMBER DECEMBER TEACHING BLOG FOR SLIGO ED

WELCOME TO SLIGO ED TEACHING BLOG (EMSLIGO.BLOGSPOT.IE) NOV / DEC 2014
The purpose of this blog is to store teaching talks and other information
The idea is that each talk has a 1 page  summary. posted here and links to references/websites used
The links on this page are a great start to finding information for your talks
There will be a (very flexible ) five week cycle

Week1  : NCHD / medical student talks – 4 10 minute talks ( strickly 10 mintues as we have short attention span ) .summary posted here(email me your summary with links mickilleen@gmail.com)
Week 2 : NCHD / medical studtent talks
Week 3 : simulaiton training
Week 4: NCHD / medstudent talks
Week 5: M/M ( review of interesting patients in Resus – keep a patient sticker so you can look up what happened to your patient and present it ) A middlegrade doc or consultant will oversee this .
There will be an OSCE type quiz on topics from these talks ( we will ask each presenter to create an OSCE type question ) this will happen once a term ( so pay attention to the blogsite !)
TOPICS WILL INCLUDE : (red denotes what we have partially covered so far )

1) Management of Acute cardiac emergencies including ACLS review
2) Management of acute respiratory emergencies including Airway management and  RSI )
3) Management of acute Neurological Emergencies including CVA (SAH/thrombolysis debate / stroke and TIA guidelines / syncope ) 
4) Vascular Catastrophes . AAA/ dissection  / cardiac Tamponade
5) Trauma management – Recent updates eg ICEM , Damage control resuscitation / crash 2 trial / TTM trial
6) Orthopaedic injuries ( pelvis / longbone / hand and foot / soft tissue injuries to shoulder , knee , wrist and ankle
7) The focussed clinical exam in 2014 – Different Joints / formal Cardiac exam / neurological examination .
8) ULTRASOUND TRAINING – (THREE LECTURES , LOGGING SCANS , SUPERVISION AND TESTING  )
9) Paediatric Emergencies ( Assessment of the unwell child / PALS / APLS / APLS review / NAI
10)Interpretation and management of Acute Electrolyte disturbances (hyperkaleamia / acid base / hyponatremia / Hypernatremia / DKA / Honk / Acute renal failure )
11) The critically ill patient – Sepsis bundles / BOIC / Post cardiac arrest management / post intubation check list / inotropes / antibiotics in serious sepsis 
12) Toxicology – general approach / Specific and common life-threatening overdoses. Seratonin and anticoholinergic syndrome 

THIS MONTHS TOPICS
WEEK ONE ( 13th Nov) – SUMMARY OF ESSENTIALS OF  EM CONFERANCE (no NCHD TALKS)
WEEK TWO ( 20 November ) 4 talks in total :

evidence based management  of heart failure acutely and as an outpatient 
use up to date recognised guidelines ( ie 2012+ ) – UK / canadian / ESC / AHA and FOAM 
for talks 1 and 2 suggest you base it around 3 cases 
talk 1 )  – emergency dept ASSESSMENT of flash pulmonary Oedema / cardiogenic shock / undifferentiated decompensated heart failure 
talk 2 ) – emergency department MANAGEMENT of flash pulmonary Oedema / cardiogenic shock / undifferentiated decompensated heart failure ( including heroic things like REBOA or  IABC )
talk 3) – outpatient MANAGEMENT and  investigations of heart failure – drugs / lifestyle modification/ supportive care / prognosis 
talk 4 ) lung ultrasound in an emergency medicine setting focus on A and B lines etc – Registrar
—————————————————————————————————————–
Week THREE

1)  DDimer in pregnancy and the over 50s – new guidelines -http://rebelem.com/age-adjusted-d-dimer-testing/     and http://www.perinatology.com/Reference/Reference%20Ranges/D-Dimer.htm
2+3)2 talks aortic dissection – assessment and management in the emergency department ( two talks )  assessment = hx/exam/INVx  mangement= resus/defintive tx/ consultation / disposition and other issues (controversies and pit falls , prognosis ) 
4+5) 2 people : treatment of DVTs of the lower limb , below and above knee – the options and controversies for a start check : http://stemlynsblog.org/new-nice-guidance-on-investigation-of-dvt-in-the-ed/
debate for and against below knee dvt anticoagulation 
week 4
Simulation training
week 5
M/and M 

OCTOBER TEACHING – week 1 Sodium

Moving on to medical emergencies , this weeks teaching is brought to you by the elelement Na !

Please pick a topic to present , email the group what you are going to present and email me a one page summary so that I can post it on the website , thanks 
Sodium 
1) There are some recent updated guidelines on the management of Hyponatremia 
http://www.eje-online.org/content/170/3/G1.full . This needs a volunteer to summarise and present . Please also give us a 1 paragraph summary of necessary take home information 
There is also a great summary on emcrit for the emergency treatment of life threatening hyponatremia ( http://emcrit.org/podcasts/hyponatremia/ ) 
2) Sort of related to Sodium . Pathogenesis of cerebral oedema in DKA in children.How to avoid it !
3) Correction of severe hypernatremia and dehydration in children and infants – APLS guidelines 
4) HONK – treatment , particularly fluid resuscitation 
5) NOT related to sodium 
FOAM :  review of a particular website 
If someone could pick a particular website and review it . The best way to do this is based around a particular clinical question and see if the website sensibly answers your question .  

Last week of september -Trauma round up

This week we have the following / talks discussions

Last trauma week in September 
1) the rectal exam in trauma 
2) chest drain insertion -click on the following link for video on how to place a chest drain 
3) ultrasound guided pericardiocentesis –

click on image for link to how to perform

4) Ultrasound guided nerve blocks in the ankle and the femoral nerve block

LINK TO powerpoint on Nerve blocks to lower limb
( useful really only for references and diagrams of relevent nerves )
click on image below to be forwarded to icloud version of PPT

click on this link for access to power point ( icloud)

summary to this weeks talks

ED THORACOTOMY 

thanks Karen for a great talk on ED thoracotomy 
Here are some of the take home messages and references 
1) Penetrating stab wounds to the chest ( particularly in the area of the left parasternal /precordial area) are the sort of patients that may come to ED and having suddenly lost an output and need consideration for ED thoracotomy .These patients DO survive , commonly ! 
2) the ED thoracotomy is performed in the periarrest situation where the patient cannot be taken to theatre in sufficient time .  If the patient can be taken to theatre ( because he has a perfusing circulation ) then an Emergency Thoracotomy should be performed there instead . 

3) penetrating stabs are the ones that may ( and often do ) survive. Blunt trauma is unlikely to survive ( < 1%) chance if they go into arrest in ED.  A patient with blunt trauma and cardiac tamponade who goes into arrest in ED could be considered for thoracotomy in ED . A patient with blunt trauma and massive Heamothorax who goes into arrest (and without a tamponade ) will not survive unless the person opening the chest can manage hemorrhaging mediastinal vessels ( and that just is not us in ED ) 
4) it would be considered worthwhile to attempt ED thoracotomy on a balllistics injury to the chest if there is evidence of tamponade in a patient who loses output on arrival . If there is no evidence of tamponade then ED thoracotomy should not be done unless there is a surgeon there who is willing to help ( stop catastrophic mediastinal vascular injury )    

summary 
1) make the decision that ED Thorocotomy (Be very clear of the indication and what you intend to do once you open the chest ) 
2) WHO DOES It? surgeon if he has experience and is there , if not the most senior ED doctor (hope its not me ) 
3) This is a periarrest scenario so no time for niceties – use poviodine if its there and protect yourself and your staff with appropriate surgical gowns and possibly eye gear  
4) during the periarrest situation there should be someone managing the Airway and intubation ( RSI with or without sedation and paralysis ) and there should also someone managing access ( IO / rapid transfuser / activating MTP etc ) .ALTHOUGH CONTROVERSIAL TAMPONADE IS STILL TREATED WITH FLUID LOADING AS PRELOAD WILL HELP OVERCOME FORCE OF TAMPONADE 
5) the third doctor who may be the team leader  : cut at or just below where the nipple line would be if the patient were a skinny male . Cut deep to fat and right down to intercostal ligament and either cut right down through pleura oruse a blunt dissector of this ( this is a life saving emergency so  speed is of the essence and cutting right down to lung would be considered acceptable ) . Be aware of two possible sources of iatrogenic bleeding , this would be the intercostal areteries running below the rib and the internal mammary arteries running parallell and close to the sternal margin. So if you are cutting so deep the Mantra ” above the rib below is of importance 
6) The pericardium should be immediately exposed by this and the lung automatically collapsed and out or the way .The ribs are held back by the rib spreader . IF the pericardium is not exposed then continue the cut across the sternum and to the otherside (clam shell ) 
7) Divide the pericardium using forceps ( Beware of cutting the phrenic nerve – this should be visible on the pericardium ) . Look for a ventricular hole and suture it , put a finger on it , put a Foley catheter baloon through it and inflate it DO ANYTHING ! 
8) the patients heart may need to be restarted and hand cardiac massage may need to be performed (two hands ) during much of this period ( use paddles only 20-30 joules necessary ) 
9) if you have managed to gain a perfusing blood pressure then the patient needs to go to theatre and this needs to be in sligo , regardless of the expertise of the surgeon on call . He can be stabilised more before definitive transfer