Past teaching sessions and blog posts

This week we talked about GI bleeding.

Dr Lev Veniamanov gave a talk on proton pump inhibitors in acute upper GI bleeding (the gist is you can expect a decrease in rebleed rates but not in mortality, the risk from the drugs is low so even the modest benefit probably justifies their use however they are not a high priority when resuscitating a sick upper GI bleed patient).

Dr Hatem Elkady gave a talk on beta-blocker use in chronic liver disease (gist is they give a significant reduction in rates of variceal bleed with a number needed to treat of only around 10 however they have no role in acute bleeds).

Dr Saif Abdulrahman gave a talk on Vasopressin and related drugs. Vasopressin or Terlipressin have a role in acute variceal bleeding when octreotide (which has a better safety profile) and urgent endoscopy are not available. Vasopressin, Terlipressin and Desmopressin also have uses in salt/water management (Vasopressin is ADH) and in haemophillia and vWBD (by uncertain mechanism).

My clinical presentation is here. See if you can work out where the three cases are bleeding from.

A great session today - thanks Lev and thanks to Simon Smith for special comments

Some of the original articles:

NEXUS criteria article                 Canadian C-Spine article                  Nexus Vs Canadian CSpine article

Lev's Spinal Presentation  Part 1  Part 2

No risk

No test.

Even an exercise ECG is dangerous in these people because a false positive will lead to an Angiogram which may lead to a stroke, dissection, renal failure, cancer. Whilst these complications are unlikely if they just don't have the disease clinically then no test is indicated.

Low risk

Male with exercise ability

Exercise ECG generally the appropriate test.

Recurrent presentations depsite negative EST or unable to exercise

Cardiac CT gives lower rates of people coming back with undifferentiated chest pain.. Once you have seen the arteries are normal you can feel more confident. Here this is only available as an outpatient (medicare) test. Radiology will provide same day or next business day test. Order must include consultant provider number and signature.

Remember, while it has a high sensitivity for significant stenoses ot has a much lower specificity so false positives are a problem in this group. Really it is better as an intermediate risk patient test but it might help with the repeat visitors.

Low risk female

Stress ECHO test of choice.

Too many false positives with exercise ECG and too much breast radiation with cardiac CT .

Intermediate risk

Young patient

Stress ECHO.

Older patient

Cardiac CT and/or thallium. The combination of CTCA, followed by thallium if positive, helps to sort out who has lesions that are meaningful although there is some uncertainty about whether you should just get on to the definitive procedure if you get a positive on either test rather than mucking around more.

Save the stress ECHO spots for those at more risk from radiation.

High Risk

You shouldn't even be here! If the patient has a positive Troponin or ECG changes or the whole thing just screams crescendo angina then they should be getting admitted for an angiogram.

After the jump is a quick and easy summary of what I have always found a bafflingly complex condition. Not anymore!

Here is the powerpoint presentation for the talk on SAH from 29/10/2011.

And here is a link to the BMJ article about CT in the first 6 hours.