Tasty Morsels of EM 054 – Paeds Cardiology: Long QT

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Today we have some notes from a lecture by a paeds cardiologist at a recent national EM training day.

The first is on long QT

  • the Schwartz score can be useful for diagnosis of long QT syndrome. Now a bit old and superseded by genetics but important to know that it is not all about the QT on the ECG – it’s a syndrome with various factors.
  • T wave alternans is a marker of ventricular instability
  • 3 main provocations of arrhythmia
    • swimming
    • arguing
    • alarm clocks
  • long QT in the first 2 weeks of life will usually be normal
  • like many folk he emphasised the importance of manual measurement of QT
  • beta blockers really good for this disease. Only if you have an event on a beta blocker do you get an ICD implanted
  • there are the Bethseda guidelines on exercise which tend to be very conservative. There are some recent moves to relax this
  • if you find someone with syncope and a long QT then they probably don’t need admitted but this totally depends on the paeds cardiology service you have – they need to have a planned follow up and in my opinion if you’re in a system where you can’t get that then maybe admitting them is the way to go


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Tasty Morsels of EM 053 – Use of Naloxone

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Today it comes from a paper I found via the Poison Review from two well known names in Toxicology, Hong Kim [here him speak on MarylandCC Project] and Lewis Nelson.

For those that work with me naloxone is a bit of a personal hobby horse of mine. I think it gets overused and poorly used and we seem to take perverse pleasure and moral superiority in acutely and totally reversing someone’s “high”.

Below are some of the pearls and learning points I got from it..

  • despite popular opinion, if you can’t reverse a clearly opioid toxicity then it may well be buprenorphine you’re dealing with. (due to the complex chemical bit that I don’t really follow…)
  • 0.04mg (a tenth of the dose found in most amps in the UK/Ireland) is probably the starting dose of choice (probably, not great science behind this but it’s what all the smart people say) in the opioid dependant person and titrate up. You can titrate up to 10mg or maybe even more.
  • However if they have respiratory depression from opiates you have given the patient then feel free to give the whole  amp (in our case 0.4mg)
  • naloxone is short acting as it is very lipophilic and redistributes very quickly (possibly quicker than the opiate you were reversing) therefore patients can rebound into opiate toxicity (possibly after absconding from your ED…)
  • if the patient is profoundly bradypneoic or apnoeic then it might be better to bag them first prior to reversal. The theory is that if they have a high pCO2 when you reverse them it may cause an increased catecholamine response with the reversal (this is animal data but it’s a nice pearl)
  • therefore they suggest against use of o2 for patients with respiratory depression without CO2 monitoring. This is probably the right thing to do despite the routine practice of people slumped in wheelchairs with a face mask on and sats of 100% and a CO2 of dear knows what…
  • they recommend the widely known infusion of 2/3 of the reversal dose over an hour
  • they warn of the dangers of acute reversal (something many people seem quite satisfied with)

Check out the paper [if you can get access] and remember to watch my favourite scene of naloxone in popular culture.

Kim HK, Nelson LS. Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. Expert Opinion on Drug Safety. Informa UK, Ltd; 2015;14 (07 ):000–0.


Featured image via “M” on flickr CC license

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A note on the passing of John Hinds

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John Died on July 4th 2015 following a crash doing what he loved at the Skerries road race in North County Dublin.

John was year above me in medical school. He was an intern in the same hospital the year before I was 11 years ago. My first ICU job was in the ICU he ended up a consultant in. We bumped into each other occasionally in resus rooms. I moved to New Zealand and lost contact with him. Before he reappeared in my life on twitter a few years  ago we were more acquaintances than friends.

Like so many people I’ve got involved with through #FOAMed you develop a relationship that’s much more than just sharing pub med links and dark medical humour. I feel like I’ve become good friends with lots of people around the world through #FOAMed, John just happened to be one I’d already known in a former life, never mind the fact he also lived on the same small island.

I finally got to catch up with him again in person at SMACC Gold. Rob MacSweeney, John Hinds and me tagging along as the wannabe. Northern Ireland punching a tad above its weight as always.

Since then we met up a few times at the Irish meetings we were speaking at and I even got to record a podcast on airway management with him. I (like many others in Ireland) shared his love of trauma and the desire for a modern, organised trauma system. If we ever were to manage a physician HEMS across Ireland then that was a job I wanted. I looked forward to getting to work with him one day on it.

So his death needs marked, not so much for any sycophantic idolatry or hero worship that John would despise as much as anyone. Here’s some proof:

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But a website with this title can’t ignore the impact that John’s passion and enthusiasm had on how we thought about and practised pre-hospital and critical care across Ireland not just the North. This blog was created in part to do just that yet John managed to pull it off much better with just a twitter account and a sense of humour. John was important for inspiring enthusiasm for emergency critical care in Ireland (something that has historically been somewhat “outsourced” to our anaesthetic colleagues) and it was even more important for people like me because he wasn’t from our “tribe” of emergency medicine.

John was quite the personality no doubt, a daft pony tailed auld eejit too, but he was loved all the more for that. #FOAMed is full of wonderful mad eejits.

We all could have done with this daft auld eejit a while longer. You’ll be sorely missed mate.

John’s Family will miss him more than any of us and one wishing to send condolences please feel free to tweet/contact Rob Mac Sweeney  (@CritCareReviews)



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VTE Dublin 2015

VTE Dublin Header

This is a brief heads up about a new conference coming in Dublin, Friday 18th – Saturday 19th September 2015.

My current hospital as a venous thromboembolism working group (which I am nominally a part of) consisting of the whole gamut of specialties involved in the diagnosis and management of VTE. From the ED to the long term haematology follow up we have it all and everything in between.

We have some really smart and passionate people involved, so much so they’re planning the VTE Dublin 2015 conference.

The speakers come from a wide variety of backgrounds including the vascular medicine specialists who seem to “own” the disease in Europe. If you read the literature you’ll recognise a lot of the names on the programme, it’s a bit of a who’s who in VTE. Perhaps the most familiar name to an EM audience is that of Prof Wells, of the Wells score fame.

It’s looking like a great conference so check it out and the programme and book your place. We’re also on twitter so follow for all the updates


VTE Dublin Programme

[DOI: I am a tiny part on the planning committee and will receive some remunerating from developing the website (slowly…)]

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Anatomy for Emergency Medicine 032: CFN Eye Anatomy Part 3

This is the third of a series of podcasts I’m doing on basic eye anatomy for the CEM FOAMed Network. This is a developing resource which aims to provide a fully mapped college curriculum with FOAMed resources. Be sure and check it out and get the podcast. This podcast went out a while ago on the CFN and I’m just providing it for everyone else who hasn’t got it already.

The single most important resource you need is Ophthobook.com

Part 1

Part 2

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Tasty Morsels of EM 052 – Rheumatic Fever and the Jones Criteria

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

This is something you’re very unlikely to diagnose in Ireland. The real reason for including this is it seems to be a favourite exam question and I put it here in the hope that I’ll remember it. I did look after a couple of kids with ARF when I was in NZ in 2007 but that’s it.

As an acute illness you’re hoping to see

  • kid aged 5-15
  • Migratory Arthritis
    • usually the earliest manifestation
    • usually large joints
    • one joint just settling while another one flares up. Usually over a 2 week period or so
  • Carditis (a poker overuse syndrome?)
    • usually called a pancarditis cause it can affect everything from valves to myocardium
  • Sydenham chorea (nothing to do with the Sydenham bypass apparently…)
    • sometimes called St Vitus’s dance. See this video.
  • Rash
    • Erythema marginatum
    • serpinginous (what a word!) bright pink macules
    • apparently hot water (bath or shower) could make the rash worse
  • Subcutaneous nodules
    • small round and painless over the joints

These are summarised in the Jones criteria:

  • Major
    • Arthritis
    • Carditis
    • Chorea
    • Rash
    • Nodules
  • Minor
    • Fever >38
    • Arthralgia
    • ESR/CRP rise
    • Prolonged PR interval (without other carditis)

Two major criteria nails it or one major and two minor.

More FOAMed Resources:

Featured Image:

  • Painting by Pieter Brueghel the Younger on Wikipedia CC License. Of note it comes from a wonderful article called ‘dancing mania’.

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