An observational cohort study of 7937 ED visits by patients presenting with chest pain or ‘ischemic equivalent’ (shortness of breath for which ACS was considered a possible cause) was done to examine the relationship between left bundle branch block (LBBB) on the ECG and the incidence of acute myocardial infarction (AMI). No difference was observed in the rates of AMI in patients with new or presumed new LBBB, old LBBB, and no LBBB. The authors suggest that this large cohort of undifferentiated ED patients may be more reflective of the true prevalence of AMI in LBBB (7.3% in this study) and question the appropriateness of a liberal fibrinolytic strategy for such patients. Another argument for primary PCI?
Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients
Am J Emerg Med. 2009 Oct;27(8):916-21
Category Archives: Resus
Life-saving medicine
How to spot paediatric myocarditis
The most common aetiology of heart failure in previously well children is myocarditis. A review of 62 cases whose final diagnosis was viral myocarditis showed that common features included:
- multiple visits / evaluations before the diagnosis was made
- initial misdiagnosis as respiratory disease (eg. pneumonia, asthma)
- presenting symptoms of shortness of breath, vomiting, poor feeding, lethargy, fever
- signs included hepatomegaly (50%), tachypnoea, respiratory distress
- although a normal heart rate for age was found in 41(66%) patients, ALL patients had an abnormal ECG
- Most had abnormal chest x-rays
The take home messages regarding this rare disease are that initial misdiagnosis is common, do not expect a resting tachycardia, look for hepatomegaly, CXR signs, and particularly ECG abnormalities.
Pediatric myocarditis: presenting clinical characteristics
Am J Emerg Med. 2009 Oct;27(8):942-7
12 Lead ECG Features of Proximal LAD Occlusion
An ECG pattern is described in chest pain patients which signifies proximal LAD artery occlusion found at angiography: precordial ST-segment depression at the J-point followed by peaked, positive T-waves. Lead aVR displays also displayed slight ST-segment elevation in the majority of cases.
A letter in response points out that this finding was first reported in 1947.
Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion
Heart 2009;95;1701-1706
Deciding who doesn't need abdominal CT in trauma
A derivation then validation study on adults with blunt torso trauma found the absence of the following factors to be associated with a very low risk of significant (intervention-requiring) abdominal pathology and such patients were unlikely to benefit from abdominal CT scanning:
- GCS score less than 14
- costal margin tenderness
- abdominal tenderness
- femur fracture
- hematuria level greater than or equal to 25 red blood cells/high powered field
- hematocrit level less than 30%
- abnormal chest radiograph result (pneumothorax or rib fracture)
Clinical Prediction Rules for Identifying Adults at Very Low Risk for Intra-abdominal Injuries After Blunt Trauma
Ann Emerg Med. 2009 Oct;54(4):575-8
Effects of bed height on the performance of chest compressions
In a manikin study of CPR, there was a decrease in mean depth of chest compressions when the height of the bed was over 20cm above the knee height of the nurse doing the compressions.
The study has several limitations, but serves as a helpful reminder that adjusting the height of the bed to suit the rescuer is an option not to be forgotten. At least for those areas where manual CPR is still performed.
Effects of bed height on the performance of chest compressions
Emerg Med J. 2009 Nov;26(11):807-10
Tying the tracheal tube
After intubation it is critical to securely fasten the tracheal tube so it does not dislodge during transfer. Dedicated devices are available for this although mostly cloth tape is used.
Different knots have been compared although not found be significantly different in terms of security1. One favoured knot, which is easy to learn and to teach, is the lark’s head (also called cow’s hitch)2.
The tape is folded in half so there is a loop at one end and two free ends at the other. The loop is wrapped around the tube and the two free ends are fed through the loop, and then taped around the patient’s head. It has been suggested that this results in the tape gripping the tube over the widest possible area, thereby reducing the potential for slippage and displacement.
Easy!
1.The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes
BMC Emerg Med. 2006 May 24;6:7 Open Access
2. A knotty problem resolved
Anaesthesia. 2007 Jun;62(6):637
Educational resources
Airway
Basic airway management in adults
Basic airway management in children
Tracheal intubation in adults
Tracheal intubation in children
Rapid sequence induction in adults
Rapid sequence induction in children
Surgical airway
Securing tracheal tubes in adults
Securing tracheal tubes in children
Breathing
Non-invasive ventilation in adults
Using a portable ventilator
Basics of mechanical ventilation
Breathing systems in the emergency department
Asthma case
Pneumothorax case
Pneumonia case
ARDS case
Circulation
Post cardiac arrest case
Basic echo
The hypotensive patient
Vasoactive drugs in the ED
Disability
Seizures in adults
Seizures in kids
VP shunt case
Neuroprotection in the ED
Sepsis
Sepsis: definitions and basics
Interhospital transport
Bivalirudin in STEMI
Bivalirudin is a direct thrombin inhibitor, and Continue reading Bivalirudin in STEMI
Decision instrument for head CT in children
A derivation then validation study was done on over 40000 children with head injuries to identify factors associated with clinically important brain injury. Prediction rules based on history and examination findings were developed for children younger than two years and for children two years and older. Both rules had high negative predictive values and may be useful tools in supporting the decision not perform a head CT.
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
Lancet. 2009 Oct 3;374(9696):1160-70
Burns formulas and fluid resuscitation
In most cases either the modified Brook formula or the Parkland formula was used for burned military casualties in Iraq and Afghanistan over the three years covered in this study.
The modified Brooke formula is 2mls x body surface areas burned (BSAB) x weight.
The Parkland formula is 4mls x body surface areas burned (BSAB) x weight.
Both formulas estimate the first 24 hour fluid requirements from the time of the burn, with half the amount given in the first 8 hours.
In this study which compared outcomes between the Brooks and Parkland groups, there were no differences in clinical outcomes. In both groups many patients were overresuscitated in terms of urine output goals. The authors’ main conclusion is that burns resuscitation can be successfully accomplished with lower initial fluid volumes. Take home message: individualise fluid resuscitation to patient’s clinical response, and avoid the ‘fluid creep’ of unphysiologic resuscitation management.
Resuscitation of severely burned military casualties: fluid begets more fluid
J Trauma. 2009 Aug;67(2):231-7