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.
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.
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
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:
What if we called it "low specificity troponin" instead of "high sensitivity troponin?" Would that knock some sense into people?
— Joe Lex (@JoeLex5) October 9, 2012
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.
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.
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:
- Pulmonary Embolism
- Acute left ventricular failure
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.
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)
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).
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).
We'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
- Tumours and Space Occupying Lesions
- Temporal Arteritis
Listen to Simon and Iain discuss how to approach these patients here
Headaches at Life in the Fast Lane - a great summary from the LiTFL crew
Headache from the Flipped EM Classroom
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!
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.