The St.Emlyn’s virtual hospital podcast

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May 22, 2015  

Barbra Backus on Risk scores in Acute Coronary syndromes

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Barbra Backus joins Rick Body to discuss the origin, development and future of risk scores for ED patients with possible acute coronary syndromes. Two researchers at the top of their game, and  authors of the HEART and MACS scores.

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February 2, 2015  

Karim Brohi at LTC with St.Emlyn’s

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Karim Brohi joins the St.Emlyn's team at the London Trauma Conference to talk on vascular injury and arterial dissection. A whole range of diagnoses that you should not miss, but which is easy to miss.

Tricky!

Check out the blog post that accompanies this podcast here.

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Understanding Troponin Part 3: The NICE guidance.

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Rick and Iain explore how the latest guidance about the use of high sensitivity troponin was developed and how far we can be assured that it is evidence based.

The NICE guidance is available here. http://www.nice.org.uk/guidance/dg15

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August 7, 2014  

Understanding Troponin Part 2. St.Emlyn’s

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Recently we published part one of our series on cardiac troponins.  If you haven't checked it out yet, you can find it here.    In the second part, we're going to take a look at high sensitivity troponins and some of the more advanced areas around understanding cardiac troponin and its use in practice.  We'll give you a quick run down on the troponin lingo - the language you need to be able to speak in order to fully understand how to use high sensitivity troponin in your practice, including terms like the limit of blank, limit of detection, co-efficient of variation and 99th percentile.

We'll also ask whether Joe Lex had a point when he stirred up controversy around these assays with this legendary tweet:

So, check out the associated BLOG POST here and listen to the podcast. There is more on diagnostics and troponin to come very soon.


Hope you enjoy! Please keep the feedback, questions and comments coming. As always, we'd love to hear from you.

Rick

DOI: Much of my research work involves HsT. To help with this I have received reagents from companies who make HsT assays, but I not received any other financial benefit or gifts in kind as part of my work and have no financial ties to any companies.

August 3, 2014  

Induction to EM. Shortness of Breath. St.Emlyn’s

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Breathless patients are a challenge in the ED. Shortness of breath can be a frightening presenting complaint for both patients and doctors. As always, think about the possible life threatening causes and actively rule them out. For breathless patients think especially about:

  • Pneumonia
  • Asthma/COPD
  • Pulmonary Embolism
  • Acute left ventricular failure
  • Pneumothorax

 

Breathless Patients Podcast

In this podcast Iain and Simon discuss their approach to breathless patients in the ED which we hope will provide you with a good starting point.

 For those of you who are more visual learners here is the video recorded a few years ago for SEMEP featuring our very own Iain Beardsell.

http://vimeo.com/35310564

 

Take Home Points

  • Oxygen should be used in the patient with shortness of breath and the patient monitored closely. Hypoxia kills
  • Always rule out life threatening causes first
  • These patients are sick - do not be afraid to ask advice from a senior colleague early
  • Look for clues - you don't have to wait until the penultimate page of the story to solve the mystery.


What have you learned about breathless patients?

 Oxygen - or no oxygen??
Oxygen administration is rarely a problem in the immediate and acute setting - and can save lives. So yes, when you first approach a patient who is short of breath, get that oxygen on while you make your assessment then think about the finer points of respiratory failure afterwards. 

Where do I begin?
A focused history, including asking the patient about previous conditions and whether they know what's going on!
And then - initial assessment and examination including vital signs (especially respiratory rate), looking for clues as to the underlying cause of their breathlessness, remembering the five common causes. 

What treatments might be useful?
A small fluid bolus might help and carries relatively little risk; think about the need for nebulised bronchodilators for patients with asthma or COPD, and remember that antibiotics given early to patients with sepsis save lives.
If the patient has pain we should definitely treat that too.

Which investigations might help me find out more?

  • A chest x-ray is often useful in patients who are short of breath; your ED seniors might be able to use bedside ultrasound to further ascertain the underlying pathology, so get help early!
  • ECGs are often useful in these patients
  • Blood gases can also provide lots of useful information - think carefully about whether you need arterial gases and if so, please use local anaesthetic.
  • If nothing makes sense - get a blood sugar, remembering that metabolic disease may cause an acidosis, presenting with an increased respiratory rate (although not often true dyspnoea).
  • And GET SENIOR HELP (including getting your seniors to assess you for those all-important workplace-based assessments; definitely start those early)


Other resources

Chest Radiographs

One of the key investigations in patients with shortness of breath is the humble chest radiograph. There are some phenomenal FOAM resources for interpretation of CXRs (along with other XRs) at Radiology Masterclass. Well worth bookmarking for your ED shifts (but do ask a senior if you're unsure).

Chest X-Ray Anatomy  -  Chest X-Ray Abnormalities  -  Chest X-Ray Systematic Approach

Blood Gases

Think! Do you really need an ABG? If the answer is yes, please use local anaesthetic! Your patients will thank you...

Further Reading on Shortness of Breath

The Flipped EM Classroom - Shortness of Breath (with further links).


Natalie May

 

August 1, 2014  

Induction to EM. An approach to headache in the ED. St.Emlyn’s

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HORIZONS.jpgWe've all had headaches, but not often severe enough to prompt us to seek help in an Emergency Department.

In our practice 10% of patients who do present to the ED  with a primary presentation of headache will have serious pathology and our job as Emergency Physicians is to work out who these are. Key to this is actively ruling out the life-threatening and life-changing diagnoses:

  • Subarachnoid Haemorrhage
  • Meningitis
  • Tumours and Space Occupying Lesions
  • Temporal Arteritis

Listen to Simon and Iain discuss how to approach these patients here

Further Resources

Headaches at Life in the Fast Lane - a great summary from the LiTFL crew

NICE Guidelines (NCG150) - diagnosis and management of headaches; there's a flowchart and some red flags although you could read the St Emlyn's summary here!

Headache from the Flipped EM Classroom

July 27, 2014  

Understanding Troponin Part 1. St.Emlyn’s

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Do you remember when it took three days to 'rule in' or 'rule out' an acute myocardial infarction (AMI)?  When I was a medical student doing my first clinical attachments, I remember doing ward rounds on the CCU seeing patients with suspected AMI.  The way they were managed is a million miles from what we do now.  Back then, patients would have serial ECGs and then be admitted for cardiac enzyme evaluation over the course of the next 3 days.  We'd measure CK, AST and LDH.  'CK' was the so-called 'early marker', which would rise early after the start of an AMI.  Today we use CK as a marker of skeletal muscle damage (e.g. rhabdomyolysis).  AST and LDH (today we think of these as liver function tests, I know) were the 'late markers' - and by late I really mean late - we might see a rise on days 2 and 3.

Could you imagine for a second, in today's world, ruling out AMI because their CK and LFTs were normal?  It's completely unthinkable.  That's how much cardiac troponin has changed our practice.  We rely on it so completely to diagnose AMI.  And yet, it's one of the most misunderstood tests in medicine.  Given how much we use it, I guess we feel that we all should know lots about this test.  But doctors still have so many questions.  Here are just a few:

  • What is cardiac troponin?
  • Why is it a marker of AMI?
  • What else causes a raised troponin and how?
  • Should we be doing troponins at 3 hours, 6 hours, 12 hours?  What's the difference and what's the evidence?
  • What is a 'delta troponin'?
  • What do you need to 'rule in' AMI?
  • How do you use cardiac troponin in patients with renal failure?

This is just a brief list.  With the research I do in this area and my experience developing protocols/guidelines, people get in touch to ask questions like this quite a lot.  There are loads of questions that people ask - but there are lots of themes in common.  We thought it was about time we produced a handy run down in the true spirit of #FOAMed.

Take a listen to Part 1 of our troponin podcast.  While Simon and Iain have been prolifically churning out spectacular stuff for some time now, this is my debut on the St. Emlyn's podcast.  I really enjoyed talking about troponin with Iain - and I hope we covered some useful stuff.

We'll cover more in part 2, when we'll move on to discussing high sensitivity troponins, what they are, how to use them and how to speak the troponin lingo.  Please get in touch if there's anything we haven't covered that you'd like us to, or if there's anything you'd like us to elaborate on some more!

Rick

June 22, 2014  

Understanding diagnostics 3. Why prevalence helps us stay in practice. St.Emlyn’s

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Iain and Simon tackle the effect of prevalence on diagnostic performance. Mrs Trellis of North Wales makes a return appearance to discuss the delicate issues of sensitivity and Rick Body joins us by mail to raise concerns about the difficulties of missing patients with myocardial disease.

Listen and enjoy, visit the blog site and keep in touch.

Don't forget to subscribe to the podcast via iTunes, to subscribe to the blog site and to like us on facebook.

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Diagnostics 2. Beyond simple yes vs no diagnostics. St.Emlyn’s

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Dear all,

It would appear that the organ member was correct and we cannot be certain about the organ pipes. Apparently there are doubts about whether they are safe or need replacing. 
We will once again turn to Dr Beardsell and Prof. Carley to see if there is anything more that we can do. As I am due to allocate funds for repairs to musical instruments this year then we must ensure that these are spent wisely. 
If there is a less than 2% chance of failure we will wait. If there is a greater than 50% chance of failure then we should spend the money. 
The situation is uncertain and we need help.
I have the honour to be et. etc. etc.
The Choirmaster at St.Emlyn's
June 10, 2014  

Understanding diagnostics 1. SNout SpIn and Probability. St.Emlyn’s

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Dear all, 

Mr S. Pecifity the Verger has asked for clarification on whether or not the pipes in the organ need replacing. He was most dissapointed at the report from OrgansRUs which stated that the answer depended on how sure Mr Pecificity was that they needed replacing before they were asked. 
I agree that this answer clearly makes no sense at all and so I have decided to investigate the matter further. 
As I understand it, the best analogies to explain the answer lie in the realm of medicine and so it is to Dr Beardsell and Prof Carley that we must turn.
Gentlemen,
I have the honour to be your most worshipful servant etc.
The Choirmaster of St.Emlyn's