Tuesday, 27 September 2016

Soldier or scout?

Great talk which is very applicable to medicine. What we embrace and how we change our views could be more intrinsic than you think. Do you have a soldier or scout mentality?

Friday, 9 September 2016

ACLS come to life!

Another post from our senior residents in EM - Dr Koh Shao Hui.


It is a quiet Monday morning in the resus room. Suddenly the VHF radio crackles to life: “48, yr old, Indian male. Standby for AMI. ETA 10 mins”


A 12 lead ECG is faxed over by the paramedics


What does the pre-hospital ECG show? The team prepares for the arrival of the patient.


Patient arrives with rhythm strip on board ambulance. (Together with strip done at OPS)

2 3
Additional history: Chest pain radiating to left arm since last night. Worse this morning occurring even at rest. A/w diaphoresis. Went to OPS, conveyed here by SCDF. PO aspirin 300mg loaded en route.
O/e: Alert, Diaphoretic, cold and clammy peripheries. L: clear. H: dual heart sounds, no murmurs. Pulses equal. Calves supple. No pedal oedema
Vitals: BP 160/74 HR 70 spo2 98% on RA
Defib pads put on stat with continuous cardiac monitoring.


Standard and right-sided ECG leads

What do the above ECGs show?

Diagnosis: Inferior-right sided STEMI


Consent taken. Cath Lab activated. Patient loaded with PO ticagrelor. IV cannulation performed and bloods sent off.  Given IV morphine and maxolon.


Cath lab calls for patient. Ready to move out.


Change in cardiac rhythm noted on monitoring and patient becomes unresponsive.

1 x DC shock 150J delivered stat. Rhythm changes to NSR transiently and patient transiently regains consciousness. Goes back into VF shortly after. 2nd shock delivered. Goes back into NSR transiently but goes back into VF shortly after. Still spontaneously (agonally) breathing. Decision made to secure away via RSI. (Etomidate and Sux) Intubation performed. CPR commenced with manual bagging. Patient remains in VF. Further shock given. Given IV adrenaline 1mg. CPR continued. Further 4 shocks given. Further bolus doses of adrenaline given. IV boluses of amiodarone, lignocaine and MgSo4 given (As patient noted to have runs of polymorphic VT in between).


First semblance of a perfusing rhythm seen

Pulse present! BP 150/80. Total downtime (Time from collapse to first sustained ROSC) - 19 mins.
Patient connected to ventilator and started on IV fentanyl infusion 50mg/H. Maintained on amiodarone infusion.


Leaves ED for cath lab. Reaches cath lab. (Door to balloon time approx 1Hr)
Cardiac catheterisation performed with angioplasty done.

100% stenosis noted in p-mRCA (accounting for ST elevation in Right sided leads)

85% stenosis noted in dRCA extending into RPAV (accounting for ST elevation in inferior leads)
Thrombectomy performed and Drug eluting stents put into RCA and RPAV.

Patient is subsequently transferred to MICU (under cardiology) for further monitoring
He is extubated the next day with neurology fully intact.

2 days after:


Learning points:
1) Time is myocardium in STEMIs. The pre-hospital Emergency Medical System is an integral part of the chain of ensuring that the patient gets to the Cath lab ASAP (goal of 90mins door to balloon time). Do not disregard Pre-hospital ECGs and vitals as they provide important information.
2) Put on the defib pads onto the patient ASAP on STEMI cases. You may have to shock earlier than you think!
3) Take consent and active the CATH lab stat after (during office hours only).
4) Load the patient with PO ticagrelor 180mg and PO aspirin 300mg (if not given earlier) ASAP
5) Routine oxygen is out for normoxic patients. http://lifeinthefastlane.com/oxygen-in-acute-myocardial-infarction/
6) Do Right sided +/- posterior leads in patients with ST elevation in inferior leads
7) Avoid nitrates in patients with Right sided infarcts.
8) If patient collapses, to resuscitate as per ACLS, with early intubation (RSI needed if patient is still spontaneously breathing) ensuring high quality chest compressions with minimal interruptions in between (Switch rescuers doing CPR frequently)
9) Consider therapeutic hypothermia. http://lifeinthefastlane.com/postcardiac-arrest-therapeutic-hypothermia/
10) If no ROSC, ECMO CPR may be beneficial if available. http://www.scancrit.com/2012/01/11/ecmo-cpr-2/

Friday, 2 September 2016

Vader needs no satisfaction

Here's zDogg doing his best Force user impression. Pity our colleagues in the States.

Follow him on twitter and his excellent Youtube channel.

Saturday, 20 August 2016

Sensitive about the test?

Troponins have been with us from the 90's and the more refined they are, the more wide your "catch" will be from the high sensitivity "net" we cast. But you may wonder what the outcome is from all the high sensitivity. Here's a short viewpoint from an Aus study.

Original article from Medscape:

High-Sensitivity Troponin Test Yields Only Modest Benefit in Assessing Chest Pain in ER

Larry Hand
August 12, 2016

BEDFORD PARK, AUSTRALIA — Use of high-sensitivity troponin T (hs-TnT) assays, compared with standard TnT assays, may result in only modest improvement in evaluating emergency-department patients with chest pain, according to a new study[1].
For the high-sensitivity assays to be clinically effective, it may require closely joining them with protocols that can help guide interpretation and care, researchers conclude.
"The adoption of new technologies such as high-sensitivity TnT assays requires commensurate adaptions in the health service. Just releasing the assays provides very modest improvements in care and outcome since practice, appropriately, needs to remain conservative," Dr Derek P Chew (Flinders Medical Center, South Australia), told heartwire from Medscape by email.
Chew and colleagues conducted a prospective trial involving 1937 emergency-department patients without ST-segment elevation presenting at five hospitals in Adelaide, Australia, between July 2011 and March 2013.
The results were published online August 9, 2016 in Circulation: Cardiovascular Quality and Outcomes.
The patients were randomized to troponin testing reported to standard TnT levels (>30 ng/L n=964) or high-sensitivity TnT levels (>3 ng/L, n=973) to assess for the cumulative composite end point of all-cause mortality and new or recurrent acute coronary syndrome (ACS) within 12 months. Median patient age was 61, and just over half were men.
The researchers found no significant between-group differences for the primary end point. At 12 months, deaths or new or recurrent ACS occurred in 57 (9.7%) of patients in the high-sensitivity group and in 69 (7.2%) of patients in the standard group (hazard ratio 0.83, P=0.362).
Although the researchers found no between-group differences overall in discharge to home directly from the emergency department, they did observe a higher rate of discharge from the emergency department among low- or no-risk patients in the high-sensitivity group compared with the standard group (168 vs 148, P=0.010).
Researchers observed a significant interaction between use of hs-TnT and the prescription of aspirin among patients with peak troponin of 14 to 29 mg/L within 24 hours (55.4% vs 34.0%, P=0.006).
During the index hospitalization, 1466 patients (75.7%) reached maximal troponin of <30 ng/L within 24 hours.
The researchers found no between-group difference in performance of angiography, and high-sensitivity reporting did not lead to a reduction in 12-month death or new or recurrent ACS overall. But they did observe a modest reduction in death or new or recurrent ACS among patients with troponin levels <30 ng/L (2.6% vs 4.4%, HR 0.58, P=0.050).
The authors say that this study is the first to evaluate unguided troponin T reporting at levels that are possible with a high-sensitivity troponin T assay "on clinical care and outcome within a randomized clinical trial embedded within routine emergency-department care.
"Reporting of the troponin T level without integration with clinical protocols had relatively little impact on admission and cardiac investigations, with modest differences in discharge rates among patients at low and intermediate risk based on other clinical criteria," they conclude.
"To that end, I am a little surprised that the difference is very small, given the numerous voices demanding access to new tests," Chew said. "Clearly, better access will require validated protocols. The further research that is needed is validation of some of the emerging protocols that have been promoted without randomized evidence of safety and efficacy. We have commenced a randomized study with a 1-hour protocol."
The National Health & Medical Research Council of Australia and the South Australian Department of Health supported this research. The authors reported no relevant financial relationships.

Tuesday, 26 July 2016

Webucation 24/7/16

This edition of webucation was slightly delayed due to holidays but we're back with pearls from surgical trauma, cardiology updates and even a funny xray of sorts... As always visit and support the content creators.

That last list is a solid reminder that although sedation is COMMON in EDs, it is far from safe. Buyer beware and make sure you got one of these before you start!

Friday, 8 July 2016

Time to pace, no time to waste

Here is another post from one of our senior residents - Dr Gayathri Nadarajan.
It is 5am in the resuscitation room. And just when everyone was starting to space out, the nurse brings in a 18-year-old girl on a wheelchair, following a near-syncopal episode. She looked pale, diaphoretic and something didn’t seem quite right.
Presenting Complaint
Diarrhoea, vomiting  and dizziness for 2 days. No actual syncope or seizure like episodes. No fever. No HI and no headache. Has mild abdominal cramping sensation.
Past Medical History
NIL. Certain she is not pregnant
BP 100/60     HR-45/min     Temperature- 36.7
Unremarkable. Abdomen was soft without any guarding or rebound.
ECG shows
Complete heart block

During the consult….
While talking to the patient, her eyes rolled upwards, her body went stiff and she appeared to have a tonic clonic seizure. I couldn’t feel a pulse and the cardiac monitor showed asystole. We immediately started chest compressions. Within a few seconds, she regained consciousness and was shocked to find all of us fussing over her.
Her heart rate was about 40-45. Hence we gave her atropine and prepared for transcutaneous pacing. While preparing for transcutaneous pacing, she had 2 more episodes of brief tonic clonic seizure following a sinus pause. Dopamine was prepared concurrently as the pacing wires were attached to the monitor.
We finally started pacing her and called for a cardiology consult.
That was not the only problem….
In view of the abdominal discomfort in a young girl with syncope, bedside FAST was done, which showed free fluid in the abdomen.
Rapid urine HCG was done, which was negative. Hence a GS consult was called for.

Findings and progress
CT scan showed:
  • Moderate ascites
  • Mild diffuse thickening of the large bowel, which is nonspecific and could be associated with non-specific colitis.
  • Gallbladder is distended.
  • Bilateral pleural effusion with associated atelectasis/ consolidation
Her troponin T was 870 ng/L and CK-MB was 39.99.
WCC was 15.4
Rest of her bloods were unremarkable and CXR was clear.

In ED, we concluded that she had symptomatic heart block and the most likely diagnosis was myocarditis. (after ruling out things like drug overdose, pregnancy)
The free fluid in the abdomen could have possibly been due to an inflammatory process such as colitis
In view of the complete heart block with syncope, she needed tranvenous pacing. Hence the cardiology team reviewed her in the ED.
Patient had the transvenous pacing wire inserted and she was admitted under the CGH cardiology team. Inpatient echo was normal. During her stay, family requested for transfer of care to NHC. She is currently recuperating there. She is currently off the transvenous wire and awaiting a pacemaker.

Learning points
  • It is important to check the pulse in patients with a seizure as the seizure could have been the result of hypoxia to the brain from a loss of cardiac output (such as VF/VT/ ventricular pause). This was probably the mechanism of her tonic clonic seizure.
  • Don’t hesitate to pace. When there is significant bradycardia / sinus pauses, indications to pace are:
    • hemodynamic instability (hypotension/ cold, clammy peripheries),
    • altered conscious level
    • syncope
  • Myocarditis can have various cardiac manifestations. Do not forget to include it in our list of differentials.
  • Free fluid in abdomen doesn’t always mean a surgical abdomen / cause. Clinical correlation is important.

Myocarditis in a nutshell (from Life in the Fast Lane)
Possible ECG changes:
  • Sinus tachycardia.
  • QRS / QT prolongation.
  • Diffuse T wave inversion.
  • Ventricular arrhythmias.
  • AV conduction defects.
  • With inflammation of the adjacent pericardium, ECG features of pericarditis can also been seen
  • Viral – including coxsackie B virus, HIV, influenza A, HSV, adenovirus.
  • Bacteria – including mycoplasma, rickettsia, leptospira.
  • Immune mediated – including sarcoidosis, scleroderma, SLE, Kawasaki’s disease.
  • Drugs / toxins – including clozapine, amphetamines.

Wednesday, 8 June 2016

Cliff Reid - Advice to a young resuscitationist

Dr Cliff Reid of Greater Sydney HEMS is probably one of the finest exponents of not only resuscitative science but also in transmitting ideas via talks/presentations. This plenary from SMACC Chicago last year gives us important insights into:

  • overconfidence
  • following up
  • changing oneself and systems when thigns go wrong
  • other specialists and using their skill and experience
  • risks and rewards of being in this field

He has his own channel here for other inspiring talks on resuscitation.