RCEM Belfast Day 3

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Day 3 at the First Annual CPD Event Since the College Went Royal

As the #RCEMBelfast conference comes to a close, RCEM FOAMed Network’s, Nikki Abela, Dave McCreary, Simon Laing, Rebecca Maxwell and Andy Neill discuss the final day.


Day 3 at #RCEMBelfast continued on yesterday’s medical thread, with an excellent talk on Heart Failure by consultant Cardiologist Mark Petrie.

Here are some of his top tips:

  • NICE recommend that you can use BNP to rule out heart failure in patients with SOB. – This has already sparked some twitter debate – join in here
  • If the ECG is normal, HF is unlikely.
  • β -blockers are good for CHRONIC HF

These, on the other hand, are things he advises you do not do:

  • Use β-blockers for ACUTE heart failure
  • Give fluids
  • Forget that 25% of patients are young and may present differently with orthopnoea and abdominal pain


Continuing on a cardiology theme, Francis Morris gave another hugely entertaining talk on ECG Tips from the Shop Floor (or Pitstop- which is where you will find him).

(why isn’t this man on twitter again? #getfrancismorrisontotwitter)


Here are some of his take-home messages:

  • P waves in lead I should not be inverted (causes are rare, so its usually a misplaced lead)
  • Always read what is written on the automated strip
  • Use the calculations of PR, QRS and QTc
  • RBBB is rarely pathological, but RV dysplasia is the exception to prove the rule
  • Low voltage criteria + tachycardia – think pericardial effusion
  • LVH + “Dagger-like” Qs = HCM
  • In WPW, RBBB pattern gives appearance of acute MI
  • T wave inversion across chest leads – suggestive of PE
  • If Ts also inverted inferiorly = highly suggestive of PE.
  • Rule of thumb for QTc: If T wave ends beyond half of RR interval – QTc is likely prolonged


Vince McGovern spoke then to us about COPD,  advocating the GOLD guidance for this condition.

“Frequent fliers” are spiraling downwards with their condition, he pointed out, and in the ED we need to continue advocating smoking cessation. Think about antibiotic prophylaxis, take sputum samples (as pseudomonas is bad news and needs long courses of ciprofloxacin), he said.

When treating these patients, he continued, eosinophilia may have a role in predicting which patients do well on oral steroids.

“ALWAYS ask about blood in sputum. CXR is only 90% re-assuring that they don’t have serious pathology so refer for further investigation,” he also highlighted.


Another interesting talk at the conference was given by nephrologist Niall Leonard on AKI, where he described the kidney like a smoke alarm- when it goes off it’s rarely because of a problem in the kidney itself – it is usually due to a problem in the body.

According to NCEPOD, management of AKI is suboptimal in 50% of cases, and in response to this Dr. Leonard has come up with an ABCDE approach for the management of kidney injury, which went down a treat with us emergency physicians (don’t we all just love ABCDE algorithms?):





Next up was Gavin Lloyd who talked about improving ED care. This was a great talk about what matters to patients visiting our department, and how we can help improve their experience.

The senior “meet and greet” (RAT/Pitstop) was again praised as improving care. Interestingly the hospital in Exeter where he works is looking to recruit (paid) medical students to help with tasks like taking bloods and making teas for patients in the ED. He has recorded a separate podcast with Simon Laing which should be available on the website soon.


One of our favourite talks of the day came next (not that we’re biased of course), when our very own Simon Laing stood up and made us proud when he talked about #FOAMed. Now, we appreciate that if you are reading this blog, it is likely that we are writing to the converted, but we can assure you that as progressive as Emergency Medicine and the Royal College has been on #FOAMed, there were still many participants who felt enlightened after his talk. Of course, if you want to get involved with RCEM’s FOAMed Network’s work, please do not hesitate to get in touch.

Simon also announced that Richard Body will be delivering regular#FOAMed‪from the College’s R&P committee, so watch this space.


After lunch came another of our favourite talks, not only because Rebecca Maxwell is one of our own, but also because she has done a fair bit of research on toxicology, and while we can be a bit blaze about Paracetamol Overdose, she did have some important messages for us, namely:

  • Time and type of OD are crucial to management, where we should be aiming to treat single acute ODs within 8 hrs for maximum benefit and staggered ODs within 1 hr of arrival in ED
  • Interestingly, the new guidance on paracetamol ODs cost £17.4 million per life saved
  • Pregnant women have different weight calculations, where we should calculate the paracetamol dose taken on pre-pregnancy weight, and the NAC therapy dose on actual weight
  • The future in this field is finding a way to predict who is going to get paracetamol toxicity and a lot of work is being done in Edinburgh on biomarkers


And as all good things come in threes, the #FOAMed crowd had a third avid supporter speaking at the conference- the excellent John Hinds. Speaking about airway management in the ED, John gave practical advice on his approach to RSI, and how it doesn’t change regardless of location (and he’s tubed people in a few locations!).

We were reminded here of the importance of an RSI checklist (everytime) and that, while the standard answer for the choice of anaesthetic agent is “the one with which you are most familiar”, that this isn’t the case in resus patients if you’re most familiar with using propofol in well, elective patients, for example. His drugs of choice are ketamine and rocuronium, and he discussed this further with us in a podcast interview, along with his scalpel, finger, bougie, tube technique for a surgical airway…


The following topic was on difficult conversations in the ED, not only with patients but also with members of staff, where Sean McGovern advocated a SPIKES methodology approach to the two. For those who haven’t come across it or need some revising, here it is:

  • Setting up the interview
  • Perception assessment
  • Invitation for information
  • Knowledge sharing
  • Emotions/empathy
  • Strategy to go forward


Lastly, Charlie Martin spoke about how we judge success and promote safer practice in the ED. Key ingredients to safe ED services were based on a little TLC (no, not tender, loving care): Teamwork, Leadership and Culture. If you would like to read more on this topic, the RCEM published recommendations following a lot of (largely ongoing) work in this area.


And as all good things come to an end, sadly so did the conference. It was been thoroughly enjoyable for us to be there and to be able to share all this with you. The organizing team for #RCEMBelfast were absolutely brilliant and we, as a team have learnt a lot from each other through working together.


We hope our daily summaries have been beneficial for you and we hope many of you can make it to #RCEMManchester in September.

Vital Connect Unveils VitalCore Biosensor Processor for Managing Vital Signs Data


At the upcoming HIMSS conference in Chicago, Vital Connect (Campbell, CA), maker of the chest-worn HealthPatch MD vital signs monitor, will be showing off their tiny new chip for integrating data coming from a variety of biosensors. As seen in the photo, the device is less than a quarter of a penny in size and consumes a minimal amount of energy for easy integration into electronic devices.

The processor features both digital components and analog circuits for processing common vital sign data. The company will be making the device available to medical technology companies, as well as integrating it into future generations of its own health monitoring devices.

Link: Vital Connect…

The post Vital Connect Unveils VitalCore Biosensor Processor for Managing Vital Signs Data appeared first on Medgadget.

Acerca de serpientes, agujeros permeables y demás…

  JEM Link   Los trombos en la aurícula derecha, a menudo secundarios a tromboembolismo venoso, pueden clasificarse en tres tipos: Tipo A, es decir, grandes, móviles y con elevada morbimortalidad, Tipo B, fijos, pequeños y con mínima morbimortalidad, a menudo secundarios a catéteres que tocan la aurícula, Trombos atravesando el foramen oval, también denominado embolia paradojal inminente, “straddling thrombus … Seguir leyendo

Nanoparticles Deliver siRNA to Wound Sites to Speed Up Healing (VIDEO)


Researchers at the Albert Einstein College of Medicine, a part of Yeshiva University, are using novel nanoparticles to significantly speed up the healing of wounds. They discovered that the naturally produced fidgetin-like 2 (FL2) enzyme slows down the migration of cells as they travel toward a wound site. To counteract this process, the investigators developed a silencing RNA (siRNA) drug that inhibits the gene responsible for the production of FL2.

In order to actually deliver the siRNA into the interior of cells before degrading, the researchers encapsulated it in specially designed nanoparticles that keep their cargo fresh and intact before reaching the cell and letting it flow out.

Here’s a time lapse video of burned skin healing with and without the nanoparticle delivered gene inhibitor:


From the study abstract in Journal of Investigative Dermatology:

In this study, we identify the previously uncharacterized microtubule-severing enzyme, Fidgetin-like 2 (FL2), as a fundamental regulator of cell migration that can be targeted in vivo using nanoparticle-encapsulated siRNA to promote wound closure and regeneration. In vitro, depletion of FL2 from mammalian tissue culture cells results in a more than two-fold increase in the rate of cell movement, due in part to a significant increase in directional motility. Immunofluorescence analyses indicate that FL2 normally localizes to the cell edge, importantly to the leading edge of polarized cells, where it regulates the organization and dynamics of the microtubule cytoskeleton. To clinically translate these findings, we utilized a nanoparticle-based siRNA delivery platform to locally deplete FL2 in both murine full-thickness excisional and burn wounds. Topical application of FL2 siRNA nanoparticles to either wound type results in a significant enhancement in the rate and quality of wound closure both clinically and histologically relative to controls.

Study in Journal of Investigative Dermatology: Fidgetin-Like 2: A Microtubule-Based Regulator of Wound Healing…

Source: Albert Einstein College of Medicine…

The post Nanoparticles Deliver siRNA to Wound Sites to Speed Up Healing (VIDEO) appeared first on Medgadget.

Importance of Vital Signs during Handoff

Well, I just sent an article that how important is the role of vital signs during pre-hospital or in ED assessment. Annals of EM published an article: Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement. In a prospective observational study, authors  observed 1,163

patients sign out during 130 ED shifts. We did not communicate hypotension in 42%, and hypoxia in 74% at our sign out. Interestingly, ED overcrowding was not associated with this communication error. We need to do a better job on sign out and at least start on reminding ourselves about vital signs!

Link to article