RCEM Learning #FOAMed workshop

December 12th 2016

Octavia House | London

FOAMed has been around for a while now. I’ve been involved in producing online content since May 2011 (wow… that was a long time ago now…) and have learnt so much over the years about how to do things more efficiently and more effectively.

I’m always keen to get more people producing content as I have no doubt that there’s some real super heroes out there that we could all learn from.

So we at RCEM Learning have designed this one day workshop to help give you the knowledge and skills to produce your own content either for your own platform or through the RCEM Learning platform.

I don’t think any of us involved could be considered “experts” (apart from Nigel…) but we’re all super keen and have made learned loads through our many mistakes over the years.

So if you’ve always wanted to stop lurking and start producing then come along.

It’s low cost and we’ve got a great faculty (well we got Simon Carley and Nigel anyhow…) and we’d love to see you there

Booking link

Download the PDF file .

Declaration of interest:

I am part of the RCEM Learning team which is entirely voluntary. Though they did buy me a microphone once and cover my travel expenses.

 

Tasty Morsels of EM 135 – #FRCEM Pearls from the ERC Guidelines

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

The ERC guidelines are huge and summarised for ALS by the resus council in a much more abbreviated form.

They do contain a lot of guidance on critical illness and not just cardiac arrest but also lots of specific recommendations for cardiac arrest in special circumstances (which seems to be a favourite exam question.)

What is the recommended time for a pulse check

  • turns out this is 5 seconds (i had 10 in my head for some reason…)
  • except in hypothermia where you check for signs of life for at least 1 min

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What about hyperkalaemia

  • they borrow direct from the renal.org guidance covered here
  • key points
    • calcium only if ECG changes
    • 30 mls gluconate or 10mls chloride
    • HCO3 and dialysis have a role intraarrest
  • for hypokalaemia
    • 20mmol/hr max infusion rate but they make an allowance that you can give 2mmol/min if arrest imminent

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What are recommendations for heat stroke

  • temp>40 with mental state changes and usually organ dysfunction
  • split into
    • exertional in the young marathoners
    • classic in the elderly in a heat wave
  • risk factors
    • lack of accliatisiation
    • dehydration
    • obesity
    • alcohol
    • drugs
    • skin conditions
  • treatment is all cooling with spraying tepid water on a naked patient and fanning them being the most useful and practical along with ice packs
  • dantrolene not recommended
What are recommendations for exercise associated hyponatraemia
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  • exercise associated hyponatraemia has its own guidance
    • overall it’s down to excess hypotonic fluid intake (even the sports drinks are hypotonic)
    • most people with it have either gained or maintained weight with their exercise (when they should have lost at least some)
    • management
      • prevent by drinking to thirst
      • for asymptomatic low Na then restrict fluid until they’ve peed
      • for severe symptoms (vomiting, headache, AMS, seizure) they recommend liberal use of 3% saline – remember this is all very acute in onset so the concerns over rapid correction are quite different than in your standard hyponatraemia

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What are recommendations for traumatic cardiac arrest

  • good prognostic factors
    • pupil reaction
    • spont respiration
    • organised ECG rhythm
    • duration of arrest
  • steps in the ERC algorithm
    • stop massive external bleeding
    • airway
    • decompress chest (they recommend bilateral thoracostomies extended to a clamshell if needed)
    • relieve tamponade – thoracotomy (<10 mins from arrest for blunt and <15 for penetrating)
    • cross clamp
    • massive transfusion

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What about PE?

  • nothing solid on when to lyse but basically if you think a PE caused the arrest then give it
  • no recommendations on agent or dose but mine is 50mg alteplase stat (nice discussion on ALIEM)
  • they recommend continuing CPR for at least 60-90 mins post treatment

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What about Ventricular Assist Devices?

  • difficult to know if arrested, ERC allows if they are unresponsive and apnoeic consider them to be in arrest.
  • can also check the device read outs or look at invasive lines or a doppler of a big vessel
  • priority is to get a rhythm identified and shock it which may require turning off the pacing
  • they do allow for compressions if still no response at that stage.

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What about pregnancy?

  • above 20/40 should consider section
  • start at 4 mins, be done by 5 mins (but they allow that intact foetal survival reported at 20 mins post arrest delivery)
  • remember to displace the uterus

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Tasty Morsels of EM 134 – #FRCEM An RCEM Potpourri & the Guidelines

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

This one covers a variety of RCEM produced position statements, guidance and guideline summaries from the main college repository. Many of them weren’t big enough to deserve their own post so I’ve collected them here. I’ve also included links to many of the external guidelines I’ve covered for the FRCEM.

RCEM clinical responsibilty

  • if a specialty sees them they have responsibility (including onward referral)
  • poor referrals to be directed to ED consultant
  • if patient changes while awaiting specialty then it is our problem (inc blood results)

RCEM Frequent attenders

  • have a means of identifying them
  • bespoke management plans are good

RCEM 50 guidance some highlights (or things that didn’t seem immediately obvious)

  • messages on the ceiling tiles for those lying flat (you are in xxx ED)
  • joint nursing medical hand over
  • statutory duty of candor
  • comfort rounding
  • delirious offered distraction therapy

RCEM Female genital mutilation

  • always document it
  • for over 18s offer support and consider other younger household children
  • report of FGM by under 18 or clinical findings of same then involve police and safeguarding protocols

RCEM Domestic violence

  • no need to screen routinely but access simple direct questions if suspicion

RCEM Chaperones

  • offer to all patients with sensitive area examinations
  • “sensitive area examinations” = below clavicles and above mid thigh

RCEM Concealed Drugs

  • police or UK border authority deal with these
  • remember our role in confidentiality and drug smuggling itself is not a reason to break confidentiality
  • imaging only undertaken with patients consent and request by rank of inspector or equivalent
  • intimate examination – presumably PR or PV requires a similar standard and should be done by forensic doctor but in a hospital able to deal with consequences rather than a police station
  • we should not handle the packages
  • don’t use urine tox screens – what a surprise
  • stuffers should be admitted for 6-8 hours obs
  • AXR is reasonable as a screening tool in packers. If negative or inconclusive then a CT would be next
  • Indications for urgent removal
    • obstruction
    • cocain/amhetamine toxicity
    • suggests opiates can be managed with naloxone infusion and consideration of surgery
  • proven packers that are asymptomatic can be discharged to UK boarder authority force who have specialised suites and systems for observation (basic but more than a cell)

RCEM/Vasc society AAA

  • those previously decided not for surgery should still be discussed consultant to consultant if they present with rupture (though they note if consultant is off site then senior to senior trainee is OK)
  • alert with systolic 70 is the aim
  • only contraindications to transfer here are cardiac arrest as part of this episode
  • no essential investigations prior to transfer
  • CT etc should not delay transfer
  • transfer within 30 mins of diagnosis

RCEM 2010 C spine

  • all roads point to CT….
  • you can get an xray if you can’t get the collar off with nexus/canadian and there’s no indication for immediate CT
  • they include 7/10 pain as an indication for CT by most routes in the algorithm
  • they also include MRI if normal CT but unable to do 45 degrees or in severe pain

RCEM Summary of NICE CG88 (LBP)

  • don’t X-ray
  • consider MRI in red flags
  • movement and exercise is good
  • offer exercise, consider manual therapy or acupuncture
  • paracetamol then NSAID and/or weak opioid (strong opioids for short term also an option)

The Guidelines

These are loosely organised by topic. The links should take you direct to PDF in most cases

Anaphylaxis
Sepsis

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Stroke

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Atrial fibrillation

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Delirium

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Violence Aggression

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Procedural Sedation
Endocrine
Sexual Assault

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Urology
Sepsis

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Local Anaesthetic Toxicity

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Asthma

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COPD
Pneumonia

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GI Bleed

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Psych