SEMS 2014: Prof Karim Brohi – Major Haemorrhage and Trauma Induced Coagulopathy

We have come to the end our run of selected videos from the SEMS Annual Scientific Meeting 2014 and it has been our pleasure to bring you this series. Hopefully this ushers in a new era of FOAM video and audiocasts of South East Asian Conferences.

We leave you with a detailed analysis on bleeding and coagulopathy in major trauma from the trauma guru himself. Prof Karim Brohi gave a series of talks in Singapore (not just the conference) and this one is essential for any level of medical personnel who deals with major trauma.

Slides are here:

SEMS 2014: Chong Shu Ling – Paediatric head injury

Our last paediatric video from SMS ASM 2014 is a must listen for all branches and levels of the ED.
Dr Chong Shu Ling is a senior clinician and articulate educator who delivered a tour de force on paedatric head injury. This will not just give you the "what-to-do" but also the "why-we-do-it".

Slides are here:

Don’t discount clinical gestalt just yet

Whether to ‘rule out’ or ‘rule in’ AMI in the emergency department, we have many tools at our disposal. In brief, though not exhaustive, we have in recent years the following:
1. The HEART score
2. The 2 hour AMI rule out
3. Even the 1 hour rule out AMI

Now, in the latest issue of EMJ, researchers asked if emergency physicians can possibly ‘rule in’ and ‘rule out’ AMI with clinical judgement i.e. clinical gestalt?
This single centre observational study recruited 458 patients with suspected cardiac chest pain. ‘Gestalt’ or clinical judgement about the probability of an ACS was assessed using a five-point Likert scale as follows: ‘definitely not’, ‘probably not’, ‘not sure’, ‘probably’ and ‘definitely’.
So, clinical gestalt alone wouldn’t cut it, with a ROC of 0.76, but with ECG and a hs-cTnT, the sensitivity was 100% in cases in which ACS was determined as ‘definitely not’ and ‘probably not’. Specificity, as with other studies, was low (<50%).
Bottom line
Yep, you don’t really need a score per se. Good clinical judgement, good read of the ECG and with the help of troponin (high sensitive if you have it) will help you make a good clinical decision at the bedside in the emergency department.
Limitations and caveats
  • Still a single centre, observational study. Not an RCT, and probably needs validation
  • Good sample representation – sample has significant number of AMIs and MACE – 21.8%
  • Well defined outcomes and good follow-up – e.g. AMI definitions and 30 day MACE
  • Doctors in study of varying skill level (SHOs all to way to consultants)
  • Still require the use of a custom-designed case report form when assessing patients – i.e. some kind of “score” already in my mind.
  • Single troponin only used when >12 h had already elapsed since peak symptoms, as opposed to latest ACC/AHA guidelines

SEMS 2014: Mok Yee Hui – Transport of the sick child

Dr Mok Yee Hui is a paediatric intensivist and transport guru who runs the KK children's hospital retrieval service. She justifies the case for a specialised paeds service as well as demonstrates the trials and tribulations of tranporting sick kids. This one is for all of the retrievalists out there!

Slides are here: