Past teaching sessions and blog posts

Phillip Visser presents Atrial Fibrillation and evidenced based management of this condition in the ED.  The push to rationalise management of this condition is through another ECIICN inititive.

Download The talk

Some accompanying articles for the talk

ECIICN AF Management Evidence Summary

American Heart Association 2013 Guidelines (Circulation Article)

Canadian Cardiovascular Society Guidelines 2010

CHADS (JAMA article)

Cost Benefit of AF Reversion (Western Journal Emergency Medicine)

Australian Resuscitation Council Guidelines

And here (for registered users) is the new Bendigo ED rapid AF pathway.

Thanks to Dr Lev Veniaminov for putting together this quick-start guide to the mystifying world of anaesthetics and anaesthetists for Emergency Medicine trainees on rotation. Click on read more for the guide.

Big thanks to Lev Veniaminov who offered the following comments on this concept when I sent him a copy of George Douros' (Austin Health FACEM) airway checklist card. This post is packed with links for the airway obsessed reader.


The first thing that struck me when I started the anaesthetic rotation was how anaesthetists approach airway, regardless of gender, experience, amount of intestinal fortitude and size of ego.

There always is heightened sense and awareness of disaster lurking around the corner when it comes to airway. EVERY intubation comes with consideration of possible ways, presence of airway adjuncts ready to go. Even in elective cases.
If there is a slightest hint of possible difficult ETT a plan is always discussed should things go out of quilter. Even if it is just "not able to pass the ETT on the first go"... in an uncomplicated AW...

There is interesting podcast on EMCrit.org (EMCrit 49, "amateurs discuss strategy; experts discuss logistics") where Scott talks about approaching various situations... This can be easily applied to AW management.

There also is a very interesting article in BJA in a way echoing this podcast:

Complications and failure of airway management T. M. Cook* and S. R. MacDougall-Davis
Br. J. Anaesth. (2012) 109 (suppl 1): i68-i85.

It can be accessed through your www.clinicians.vic.gov.au access via OpenAthens

This guy, Tim Cook is like Elvis Presley on the anaesthesia circuit and is heavily involved in NAP works (NAP 4 talks about AW disasters in EM too)...


The Difficult Airway Society (DAS) also offer airway mangagment algorithms that should be a part of the paintwork design of every resus cubicle in ED...

Also of interest is the podcast of Scott with Cliff Reid (he is a retrieval specialist in NSW and with HEMS in UK) on retrievals where Cliff mentions how they approach EVERY intubation. Meticulously planned ETT, stereotypically planned and set up as a result, he mentioned - in the five years of running the protocol they had ZERO failure rate.

Just to add to the importance of having a card like that...

We had a big day of fever in the returned traveller today.

Harpreet presented on Malaria and his presentation is attached here. Make sure you watch these fantastic youtube vids on the lifecycle of the parasite in the mosquito and in the human. There is no excuse for people not to know EVERYTHING these days, there is such amazing educational stuff out there.

Tom Brough followed up with Typhoid. His presentation is here.

Finally Alex Archer gave us Dengue, Japanese B encephalitis and Yellow Fever but she hasn't given me the slides to post- Bad Doctor!

There are a few important things to consider when managing a suspected (i.e. clinical suspicion but no Xray evidence) scaphoid fracture.

  1. Scaphoid fractures can be X-ray negative
  2. Scaphoid fractures can lead to avascular necrosis and chronic wrist immobility and pain
  3. X-ray negative scaphoid fractures might be amongst those that have a bad outcome
  4. Immobilising these in plaster of some sort might make a difference to the rates of those bad outcomes
  5. Wearing plaster for 10 days is a real pain in the neck, especially if you work with you hands, have both of them in plaster or have others to care for.

For these reasons please:

  • Make a proper clinical assessment of the chance of an occult scaphoid fracture

 

This means the patient having a meaningful mechanism of injury (true FOOSH with wrist extended), tenderness in the snuff box and on the tubercle of the scaphoid at the proximal end of the thenar eminence, pain on axial loading of the scaphoid along the 1st metacarpal, and reduction in grip strength or increased pain when gripping. Also the patient should have some hand function to save.

  • Always use a removable thumb spica slab rather than a full cast for the X-ray negative possible scaphoid fracture

 

They didn't manage to displace the fracture with the injury, why would the displace it now? The slab provides a reminder to be sensible and some comfort. Remember that good advice about avoiding further injury is more important than the slab (stay off the skateboard until fracture is ruled out).

  • Consider whether early diagnosis today or tomorrow with CT or MRI is worth the money and resource use.

 

In a publicly funded health care system the question is always, can we justify the cost of advanced imaging for all these patients. This is compounded by the problem of different departments all trying to shift costs to one another. "Why sould ED pay for that test? Let them go to fracture clinic and they can pay for it" and so on and so on. From a community perspective you might like to consider the cost of the clinic appointment, the cost of having a manual labourer or personal carer in plaster for 10 days unable to do their job, the overloading of your fracture clinic and so on. It may help to put together a guideline for advanced imaging that lays out clinical and other indicators for CT/MRI that prevent every sore wrist being sent for an expensive test. In a private setting the you can ask the patient. A self employed builder will much rather pay for a CT/MR today or tomorrow than be off tools for 10 days.

  • If you are opting for traditional management with immobilisation and fracture clinic ensure that follow up X-rays are taken out of plaster.

 

As to which advanced imaging test to employ, bone scan is pretty hopeless and doesn't differentiate between bone oedema, fracture and ligamenous injury. It just tells you something is going on which you could have told by poking the patient. CT and MR are pretty close. MR shows more detail of the non-fracture injuries which may be useful for the high level sportsperson who is going to have some specially tailored physiotherapy intervention for every ligament sprain. CT is often quicker to get (although an MRI wrist is a pretty quick easy scan). They are close enough together in sensitivity and specificity to justify choosing a test based on availability, time of day and patient factors (MRI for kids and pregnant women for example and CT for the others).