Authors: Charlotte Davies, Liz Herrieven, Nikki Abela / Editor: Nikki Abela, Liz Herrieven, Charlotte Davies / Codes: / Published: 16/04/2021
The RCEM CPD Spring Conference this year made many of us think back to this time last year, when RCEM was the first of the royal colleges to cancel their face to face conference because of COVID, the new and emerging pandemic. A lot has happened since then, and the CPD conference platform just emphasises how far we’ve come. The interface was slick, the chat was fully integrated. Missed sessions could be caught up quickly and easily, and there was good social interaction. We’d thoroughly recommend buying a catch up pass – there’s much more to be learnt than we could ever encapsulate in a blog, and we might have misinterpreted the message the speakers wanted to give – who knows! The core themes of health inequalities, patient safety and emergency culture were key and emphasised. All three of the blogs editors have contributed their thoughts, and we’ve all got slightly different styles – we’ve kept it like that as variety is the spice of life, and therefore the spice of EM 🙂 .
As a welcome, the opening ceremony wasn’t quite SMACC standard, but it was a good attempt. The ACPs stole the show, and they’re all looking forward to different bits of the conference – and now I am too.
Dermatology in the ED
So, nothing like starting the day with an itch, talked through by Dr Mary Sommerlad. Thinking about how itchy atopic eczema is makes me itch itch itch – thankfully moisturiser normally makes it better. A kerion is more common than we consider – patients must have some skin scrapings for fungals, and then some oral anti-fungals for a long long time. They don’t need incision and drainage, or antibiotics (unless there’s superimposed bacterial infection).
Itchy rashes are very common and there are many differentials.
Skin conditions that need admitting are:
- Erythroderma – where erythema is associated with >90% of the body surface area. It’s often associated with systemic features. It’s harder to see in skin of colour – compare with their nose to see if the skin is redder than normal.
- Eczema herpeticum is a different pathology to standard eczema, and needs admission and treating with intravenous antivirals – this was a practice changer for me as I’m sure I’ve sent them home on POs most of the time.
- Staphylococal scalded skin syndrome created by an exotoxin that forms easily broken blisters that look like a burn or scald. A nose or throat swab should find the staph.
Dr Sarah Walsh then moved on to talk through drug reactions in the emergency department. If you haven’t attended the RCEMCPD conference, this session alone makes the catch up cost well worth it! She started well by acknowledging that dermatologists are unlikely to be lured to the ED easily!! SJS and TENS is rare, but the patient is normally unwell, with sore lips, sore throat and skin pain. Skin pain is a concept I’d never heard of – and there are only a few conditions that cause it, so eliciting it is essential. Any drug can cause any reaction – but consider the three As: Allopurinol, Antibiotics & Anticonvulsants. These patients can deteriorate rapidly, so should be in HDU/ ITU/ Burns unit. The scorten score can be useful. Remember there might be airway involvement, indicated by tachypnoea, low sats, and increased bronchial secretions. Lots of analgesia is likely to be needed – morphine and consider ketamine.
SJS/TEN has a high mortality rate (up to 90%) Recognise early – one of the rare conditions that causes skin pain. Initially red macules. Latency up to 28 days, so diagnosis can be delayed. Calculate SCORTEN – Dr Sarah Walsh @KingsCollegeNHS #RCEMCPD
— Matt (@themattmak) April 13, 2021
Moving on to a “drug rash +” or DRESS, another reaction that has a significant mortality reduced by early intervention with systemic involvement. The patient will have head and neck oedema, maybe with associated pustules together with their rash, fever and feeling unwell. The culprit drug might have started up to eight weeks ago, and again I’m questioning how many of these I’ve referred as facial cellulitis.
My three key take homes of #RCEMcpd session 1: Dermatology..
1. SCORTEN will help you communicate with team derm in SJS
2. Remember the 3 A’s for SJS and DRESS
3. Revise derm presentations on many skin tones to reduce missed diagnoses https://t.co/Jqn0TikeMY
— Lucie Cocker (@Lucie_Cocker) April 13, 2021
Further Derm Resources are derm net, pcds, calgary guide, brown skin matters, skin deep, ibuprofen vs chicken pox, paediatric rashes, RCEMLearning derm exam, RCEMLearning PEM rashes, RCEMLearning childhood rash.
Mental Health in the ED
It’s great to see so much covered on mental health in the ED, and we’re aware this is a blog area we’re a bit light on. We’ve been trying -having spoken to so many psychiatrists so many times we’re on first name terms with them! We have a few people who have agreed to write things on eating disorders – if you’d like to contribute anything on anything, but particularly patients with mental health presentations, get in touch- the blog guide is here. We do have lots of wellbeing resources, and induction module on mental health in the ED.
Dr Anne Hicks, EM Cons, Mental Health Impact of COVID-19 on Healthcare Workers
The public image of healthcare workers early in the pandemic was one of “heroes”, guardians of healthcare, battling on, which may have had an impact on how we saw ourselves, too. We hear a lot about how it’s ok not to be ok, but that doesn’t make it easy to admit we’re finding things tough. Not only were we facing the stress of new ways of working and wearing PPE, but also a constant barrage of new information on news channels and social media. There were very few places to hide! You can also add in the fear of bringing home the virus to our loved ones, answering questions from anxious friends and family members, homeschooling, not seeing those close to us and losing our usual routes of relaxation. Many struggled to balance professional and personal lives.
For some there will also have been a feeling of guilt – we still had jobs and were able to talk to people at work to break the isolation – or concerns around the validity of our role if working in green areas, or even shielding. It’s no wonder that the third wave has seen many of us feeling burned out or exhausted.
As we move forward we need to remember that we all have an important role to play, whatever our job title. We need to acknowledge the impact COVID-19 has had on our sense of worth and wellbeing and look for ways to recharge. At the same time, we need to remember that everyone recharges differently – there is no better way than the one that suits you. We mustn’t undervalue the things that others choose to do: not everyone likes running marathons!
We also need to consider the impact we have on others. As Dr Greene once said “You set the tone” – groupthink can quickly lead worsen the morale of the team.
Dr Sunil Dasan, Structural Wellbeing in Emergency Care
Structural wellbeing is the way in which a system can care for its workers. Lack of it is one of the biggest reasons for healthcare workers leaving their jobs, alongside musculoskeletal problems and psychological stress. Structural wellbeing in healthcare means having the right staff numbers, the right environment, enough time to care for our patients and the right culture.
Emergency Medicine has a reputation of being a “sink or swim” specialty, with its clinicians either being resilient and able to hack it, or not. But that’s neither helpful nor true. Some great work has been done which is starting to show improvements in structural wellbeing in EM but more can be done: self-rostering, sufficient rest periods and facilities, opportunities for growth and development, an inclusive culture, the RCEM Wellbeing Compendium and app and access to occupational health and talking therapies. Particular support needs to be provided for women, older staff and international medical graduates.
Dr Amrit Sachar, Consultant Psychiatrist, Personality Disorder in the ED
People with a personality disorder have difficulties with relationships with others, and with themselves. These difficulties are pervasive across all aspects of life, are lifelong and often worse in times of stress. People with a personality disorder often have high levels of physical and mental ill health. Alongside this, they may face challenges accessing healthcare and face a great deal of stigma. This results in a life expectancy 15-20 years shorter than that of the general population.
People with a personality disorder have difficulties in managing stress and distress, due to a mix of nature and nurture, so will use things such as self-harm, drugs, alcohol, anger, acting out or somatisation.
As clinicians we can find these patients difficult to deal with. They may trigger unpleasant or uncomfortable emotions within us. We need to recognise this and the effect it may have on our clinical decision making and communication. We must be consistent (with ourselves and our team), avoid conflict and get support from liaison psychiatry services when managing patients with personality disorder.
— Rob Greig (@drrobgreig) April 13, 2021
Dr Vicky Vella, Associate Specialist in EM, Eating Disorders
Anorexia Nervosa has the highest mortality rate of any psychiatric illness. 20% of those who die from suicide, 80% from malnutrition. The illness is not rare and we can very easily cause harm by saying the wrong thing. If we suspect a new diagnosis, we must not assume someone else will deal with it. We need to take responsibility and refer for help. The MARSIPAN checklist can help with decisions about admission, and the MARSIPAN guidelines with clinical management of those most unwell. This includes correction of hypoglycaemia and hypokalaemia. Patients may be bradycardic, but atropine should not be used.
Patients with AN are likely to be very anxious about being examined and their body being seen, but a thorough examination, sensitively performed, must be done. When weighing patients, make sure they don’t have their shoes on and that their pockets are empty, and offer to weigh them “blind”, so they don’t have to think about the resultant number. Patients will be scared of being in hospital as this represents weight gain, and may give healthcare workers false reassurances. Compulsory treatment can be carried out under the mental health act if they are at risk of physical harm – a capacity assessment is less helpful than an assessment under the MHA.
We must recognise the person as separate from their disease, listen to the concerns of family, show compassion and be careful not to dismiss thoughts about body image.
— Indrani (@Indrani_S) April 13, 2021
If you haven’t already, make sure you share the RCEM Safety Flash, and distribute the marzipan checklist around your ED.
Dr Rachel Jenner, EM Consultant and member of the Violence Reduction Unit, Manchester, Violence Reduction
Behind each gang member is a vulnerable child.
Adverse Childhood Events (ACEs) are common. Up to half of us have had at least one to contend with. Exposure to multiple ACEs significantly impacts on life. Four or more ACEs means you are far more likely to be an ED frequent attender and suffer ill health and have a greater likelihood of committing a violent offence. Youth violence is 5 times more common in deprived areas compared to more affluent areas. A public health approach is needed, with multidisciplinary input – police, healthcare, community projects and social services all have a role.
In the ED, we may want to get involved in violence reduction projects or perhaps even consider joining our nearest Violence Reduction Unit, but we can also make a difference by remembering to safeguard those who present to ED after violent crime, and to use the “teachable moment” afterwards, when these young people are separated from their peers, feeling scared and aware of their own vulnerability, to intervene.
If you haven’t already read it, have a quick look at our adolescent blog which covers lots of tips on the forgotten tribe.
Toxicology and EM
This session started well, titled toxicology and Suicide and Getting away with Murder. What an excellent title! A good reminder that actually all those pesky insect bites are envenomation and therefore do count as a toxin, and that legacy toxins from munitions may appear Dr Russell has answered one of my life long questions (well, since Novichuk)- knowing who the victim is probably helps raise your suspicions, as much as the toxidrome. If you need specialist toxicology via DSTL, it will be through the police so get them involved early. My screen set up meant the small slides weren’t a problem, and I could focus on the audio.
Dr David Wood talked about toxicology related metabolic acidosis, and reminds us that the toxic alcohols aren’t toxic… … their metabolites are. The toxic alcohol blood screen will take a while to return, so have a look at other predictors. The osmolar gap needs the measured osmolality to calculate, and the measured osmolality might be “measured” by calculation or by other techniques – so may or may not be useful. After a brief moment of panic, we were reassured that contrast agents do not affect the osmolar gap. So once you’ve realised toxic alcohol poisoning may be a culprit, don’t relax- fomepizole is the treatment of choice, not alcohol, and haemofiltration may also be useful.
Dr Laura Hunter started her talk not how I’d expected, but with a reminder of the COVID induced health inequalities leading to reduced drug law offences but more importantly reduced availability and access to drug services. Many people expanded their knowledge during lockdown – we missed how to grow cannabis off of our holiday tips blog! We didn’t miss Cannabis Hyperemesis syndrome off (visit August 2019 EMJ podcast), and valued the reminder that it a) exists, b) gets better with hot showers and cessation c) opiates should be avoided as they reduce gastric mobility, d) an antiemetic helps. Moving on to opiates, titrated naloxone, titrated naloxone and more titrated naloxone. It’s difficult to say how much cannabis might cause CHS, but probably more than weekly use. Symptoms should resolve over weeks to months after cessation, and a useful patient information leaflet is here.
Alcohol gels do contain a bitter agent to try and prevent ingestion – we all know it doesn’t stop everyone!
For further toxicological goodness, we’d recommend looking at our RCEMLearning health inequalities blog, MH induction module, nebulised naloxone blog, toxicology induction blog and our podcast on cannabis hyperemesis and the podcast on organophosphate poisoning. Dr Hunter recommends keeping an eye on EMCDDA for all drug related updates, and patient leaflets on cannabinoid hyperemesis were also highlighted.
The President’s Address
Dr Katherine Henderson focused on Health inequalities. Many of them had already been mentioned at today’s session, and others in the past, and we’ve written a summary blog on this already – available here. The Marmot review, 10 years on, highlights that there is a huge gap in the least and most deprived’s life expectancy. The King’s Fund has issued a challenge to the NHS to take a more proactive role in both public health and reducing poverty, and the RCEM Public Health SIG has created a description of what the departmental lead for public health would look like. This was a real wake up session reminding us to own the public health problems of our area – look at the demographics, work out what is needed, speak to people, create reasonable adjustments, and make a difference. This seems a very short paragraph for something that covered so much, with a guest Royal visit. Lots to think about – very thought provoking.
We started the day with Tai Chi. For me, this was a huge advantage of a virtual conference – I’d never have done Tai Chi if I knew more people could see me! Apart from revealing my innate bias against the Birmingham accent I really enjoyed it and am looking forward to some more regular tapping, and some actions to go with my simulated tension pneumothorax decompression hisssssssssss (you’ll have to sign up and watch it now to understand what I mean!).
Moving on to the medicine…
VITT was a much needed last minute addition, and highlights how our college acts quickly (even over the weekend), and notices new trends first. I think this fits in nicely with the health inequality theme as it reminds us of our unique data collecting advantage. The college guideline is on their website here, and there’s some exploration of post vaccine headaches here. It’s worth also mentioning that there is no specific headache pattern, as explored on a RCEMLearning podcast here.
Trauma in the ED started off with Dr Anne Weaver talking about thoracotomy. A useful reminder that this is really a UK procedure with success greater in stabbings than gun shots wounds, but that theatre thoracotomy is better than ED thoracotomy if possible (ie patient has not arrested). I really liked the reminder that you can pause for 10 seconds and ask “are we doing the right thing”, because it’s always your patient and your decision. In blunt thoracic trauma, thoracotomy may still be useful, despite the ERC guidelines.
BASTE – blood products (1:1:1), acid-base status, surgical status, temp & time, electrolytes. Consider hyperkalaemia – bolus it rapidly rather than give an infusion.
Terminate VF – the chest can remain open and metal implements do not need to be removed.
Prepare for disaster in the lift on the way to the OR.
If you’re not confident, think about a PERT course as well as having a recap of some of the physiology and process found on RCEMLearning. Thoracotomy in a DGH might be useful, with some anecdotal case reports of successful outcome, but more evidence is needed, as DGH’s don’t tend to have the systems set up. The RCEM guidelines exist, but are a bit old, and luckily we’ve got a podcast and a vodcast on thoracotomies to help you get your eye in.
Dr Caroline Leech then talked us through a case, with so many integrated pearls. TXA for head injury? RSI pre or post CT – most said pre to protect laryngeal reflexes. How would you reverse rivaroxaban indirectly. I liked this as it acknowledged that very few departments have the direct antidote, so we need to indirectly reverse the rivaroxaban with PCC and TXA. I didn’t think a trauma talk would include frailty scale calculations, but luckily the April 2021 podcast had updated me fully, and I whipped out the app to know the patient’s score. What I didn’t know was how strongly the CFS relates to mortality – the higher the score, the worst the prognosis. The final question, is one that we all have to answer. If prognosis is poor do we admit to ITU incase, or for organ donation, or do we extubate in ED? Neither Caroline nor I believe there’s a right answer – and I’m going to have a read of the consensus statement for care after a perceived devastating brain injury.
Dr Zaf Quasim spoke to us about reboa. Coming from a TU that struggles to get a trauma team to ED, I find it hard to get excited about reboa, despite being able to see its benefit and utility. I wouldn’t say I hate it, but the speaker said “there’s probably been more tweets about reboa than actual cases”, and I suspect he’s hit the nail on the head. RCEMLearning had its first podcast on it back in 2014 (yes, that’s 7 years ago!), and several more since.
He suggested it might be useful for post-partum haemorrhage, and even complicated general surgical cases – an area to keep an eye on I guess. RCEMLearning has four gems on reboa if you’d like to learn more – a podcast, another podcast, a third podcast and a fourth podcast.
COVID updates have been added to the RCEMLearning COVID blog, which can be found here. It’s been live for a long time and has had a gazillion updates as new and involving information has appeared. If we’ve missed any updates do let us know. We’ve updated sections on PIMS-TS, and breaking bad news over the telephone.
Regional Anaesthesia in the ED
The regional anaesthesia afternoon session served to make me envious of physicians who knew these tricks and used them on a regular basis. I think many of us are happy with fascia iliaca blocks, and many do them on a regular basis in the ED, but how well do we know our anatomy?
Some really good resources here. Serratus Anterior blocks certainly seem like the future FIB for chest trauma and I am putting it in my PDP to learn how to do these, or set up a system for them to be done for chest trauma, especially when we all know how painful open drains and multiple fractures are, we probably need to do this sooner to improve the patient journey.
There is some reading on them here.
Another regional block I always wished I was more comfortable with is facial/dental blocks. We all can probably think of a time when a patient came at night with dental pain, and couldn’t get to a dentist within a few hours. Or when we wanted to suture some face lac but didn’t want to distort the tissues with local to do this. There is some good reading on facial blocks here and some on dental blocks here. Remember to always use an appropriate needle (a small one) and preferably one which self-aspirates (yes, it’s a thing apparently).
Paediatrics in the ED
Dr Hesham Ibrahim, Paediatric ECGs
The heart starts off with a dominant right ventricle at birth, which means the paediatric ECG looks very different to the adult ECG. A slight change in age can result in big changes in the ECG. Some features which would look abnormal in an adult ECG may be completely normal for a young child.
A baby will have an ECG with a right axis, right bundle branch block and tall R wave in V1 and V2. The heart rate is faster than in adults, with shorter intervals, except for the QTc, which is longer.
T waves are inverted in small children. In fact, upright T waves in V1-3 in children under 7 years of age is due to right ventricular hypertrophy. Inverted T waves may persist into adulthood, especially in people of Afrocaribbean ethnicity.
For more on paediatric ECGs, take a look at Do away with the Heartache – ECGs in Children – RCEMLearning
Dr Ed Abrahamson, Severe Acute Asthma (in Children)
Children still die from asthma. Chronic disease management has a lot to do with this, including the use of spacers. The fundamental treatment of acute severe asthma has not really changed, although there is some variation in practice.
First line: inhaled beta-agonists and anticholinergics
Second line: consensus rather than evidence-based – magnesium sulphate IV
Third line: IV salbutamol or aminophylline. If there have been several salbutamol nebs, then it may be sensible to go with aminophylline, as beta-receptors are likely to already be saturated.
Consider alternative diagnoses, including anaphylaxis, inhaled foreign body and mediastinal mass (this one might respond to steroids, making it difficult to diagnose initially).
Don’t use wheeze as a guide for treatment. It’s very easy to overdose on salbutamol. Instead look for respiratory distress.
Dr Shelley Riphagen, Cons Paed Intensivist, Paediatric Cardiology
Congenital structural defects: is the child blue, shocked or blue AND shocked?
Blue: Right-sided obstructive lesions such as tricuspid stenosis or atresia, pulmonary tricuspid or atresia, or tetralogy of Fallot. Treat with alprostadil to re-establish the foetal circulation to the lungs via the ductus arteriosus.
Shocked: Left-sided obstructive lesions such as mitral stenosis or atresia, aortic stenosis or atresia, hypoplastic left heart or coarctation of the aorta. Treat with alprostadil to re-establish the foetal circulation to the body via the ductus arteriosus.
Blue and shocked: Transposition of the Great Arteries or Total Anomalous Pulmonary Venous Drainage. Needs emergency surgery.
Ffion Davies The final day opened with an inspiring lecture by Ffion Davies. Set at just the right note, Ffion reminded us that our careers are a journey – plan the route and think about your legacy.
Ffion described how she CCT’d in 1999, and it was a low point in her personal life as she was initially refused a job but now after a winding road is president elect of IFEM.
“Define your core values, be true to them. They will become your gut instinct.” Ffion said. A career isn’t plain sailing, however, and she spoke openly about challenges like being a female in EM, how to deal with (and seek) feedback and how to reflect on mistakes and failures.
She finished off with a quote from one of RCEM’s favourite presidents, Cliff Mann:
“Make the most of any opportunity you have.”
Management in the ED
We moved on to the next session which was more managerial, talking about tariffs and examples of how to reduce costs in emergency care such as:
Care in the right setting
Reduce LOS/supporting discharge
Measuring Value is something most emergency physicians want to do, especially those who’ve had a recent bad comment or similar on an MSF who are questioning their life choices. One method of measuring value is financial, and Virginia Massaro talked us through some financial measures. We have the national tariff which was introduced in 2003, and moves us away from block contracts. COVID funding was all a bit different, and more block funding was introduced to provide more stability, and emergency funding etc. We’re not sure how long this type of funding will last, but it is associated with a need to reduce pressure and costs of emergency care by using SDEC, reducing length of stay etc. Clinical coding is really important to make sure we get paid properly, and alongside this session the chat bar was buzzing with concerns about the appropriateness and usability of ECDS. My go to resource for financial information is the Kings fund.
Ms Neena Vivash talked about value in healthcare, and started by mentioning Professor Michael Porter and Sir Muir Gray CBE, two people I look forward to hearing more about.
Value = health outcomes that matter to patients
Costs of delivering the outcomes
There are three contributory factors to value:
The population value, determined by the treasury looking at investments to support the population need.
Personal value achieved from healthcare, and a focus on things that matter to patients – personal time, and personal money.
Technical value is how well the resources are used, and includes efficient work, with reduced “stress” in the system..
Things that matter to patients are most interested – patient reported outcome measures and patient reported experience measures. Really interestingly, what we’re accountable for doesn’t always match with what matters to patients.
ED is a VUCA environment, and flexibility to develop dynamic solutions is needed. This is an essential but huge paradigm shift, as the structure is altered and changes.
Dr Tom Hughes talked to us about data, and starts by confirming what we already knew – no UK electronic health record systems have high usability. 85% of admissions come through ED, with >80% of all hospital bed days acute, and EM is 3% of the NHSE budget.
Importantly, there’s no funding or national tariff for SDEC (previously called ambulatory emergency care, which confused people), but funding will become pathway based.
Special Patient Populations in the ED
Katerina Iatropoulou spoke about the risk of Ovarian Hyperstimulation syndrome in IVF patients. RCEMLearning has covered this here. She reminding us strongly that IVF units can’t provide care for acutely unwell patients. The first step of IVF is stimulation, leading to that surprisingly common exam presentation, OHSS (covered in an RCEMLearning podcast here). A nice note at the end encouraging us to support colleagues undergoing IVF, especially during the stimulation time when they are receiving regular hormone injections.
Moving on to the trans population, we’ve had a blog in the pipeline for a while so this was a good starter for six. James Barret advised us to be more talk sensitive, refer to them as the gender they identify with. If you don’t know what that is, ask. Call genitals “genitals” and treat them with dignity. trans patients are not automatically psychiatrically unwell, and get the same physical illnesses as everyone else. If you want to read more about this, there is a recommended blog here and a book and we are in the process of writing a blog on the topic, so keep your eyes peeled.
Next up was Oncology patients in the ED. At this point I’m sure we all know immunotherapy, radiotherapy and chemotherapy patients are special patients in the ED and the side effects can manifest in all organ systems. Immunotherapy toxicity is something which is quite novel and something we need to make sure we know well so be sure to be up to scratch with the guidelines, also a available on the UKONS app, but also via your local oncology team.
The final two days had sessions on ophthalmology and the first day gave more practical tips, the second day covered eye US, a skill I’m keen on learning more as it seems really good for:
- Retinal detachment
- Foreign body – especially because if the FB is within cavity of the eye then surgery is indicated
- Vitreous haemorrhage
This website has some good learning.
Miss Olivia Li had some lovely pictures of Traumatic Eye Injuries. Knowing the mechanism of injury is crucial – blunt, penetrating, speed, chemical (and has there been irrigation?), foreign body (intraocular, orbital or subtarsal?).
Eye history: ask about acuity, double vision (which direction?), floaters or flashes, shadows, pain, photophobia and discharge (directly from the eye, or rhinorrhoea).
Examination: asymmetry (look from the front, side and above), pupils (size, shape, reactivity – direct and consensual), vision, fields, colour (not something we often do in the ED formally, but worth asking about), eye movements, subconjunctival haemorrhage (is there any scleral injury underneath?), uveal tissue (darker tissue visible), fluorescein (remembering that in chemical injuries to the whole epithelium, no “uptake” may be seen) and cranial nerves (including facial, if any suspicion of bony injury).
Open globe: eye shield (not pad!), consider x-ray for ?foreign body, oral antibiotics (augmentin for fractures – “open” into sinuses, moxifloxacin for open globe), analgesia, antiemetic and don’t let the patient blow their nose!
Chemical injury: denaturation of proteins leads to inflammation, scarring and loss of vision. Irrigate with 0.9% saline – at least 1 litre, for at least 15 minues, the earlier the better. Use topical anaesthetic eye drops to help the patient tolerate it (proxymethacaine stings less than others and has a rapid onset of action). pH can be slow to come down – don’t re-test immediately after irrigation, leave it 15 minutes or so. If unsure, use a “control eye” (can even be your own eye!)
Dr Gordon Hay had strong opinions on “what to refer to ophthalmology in the night”:
- Open globe, lid laceration and retinal detachment – although they won’t be operated on until the morning.
- Acute angle closure glaucoma – difficult to diagnose. Agonising pain with or without vomiting, hazy cornea, unreactive pupil. Top tip – if they’ve had cataract surgery, they won’t have AACG. Treatment whilst waiting for the eye doctor: lie supine (the patient, I’m assuming, not the ED doc), IV access, analgesia, antiemetic, topical pressure agents.
- Orbital compartment syndrome – but needs a lateral canthotomy before the eye doctor gets there, usually. It’s worth learning how to do this (take a look at RCEMLearning or here Resus Drills: Lateral Canthotomy — #EM3: East Midlands Emergency Medicine Educational Media).
- Chemical burns – but irrigate, irrigate, irrigate whilst waiting.
If this has inspired you to learn more about eyes, have a look at RCEMLearning on lateral canthotomy here, but remind yourself of the anatomy by listening to Andy’s three podcasts. There’s a myriad of other learning opportunities on eye assessment, and various pathologies – have a search.
Ultrasound in the ED
The US session is something which does not lend itself well to a blog, but Anna Colclough had some excellent tips on how to improve US training and skills in the ED and we will be contacting her to try and publish something soon. Michael Trauer who chaired the session has shared links to his ultrasound youtube guide.
Paper for the Year
The last session was the battle for paper of the year. It saw some of our well known professors and researchers present their favourite paper for this year. Here were their offerings, let us know which one you prefer!
- Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised control trial
- ULTRA: Ultra-early tranexamic acid for subarachnoid haemorrhage
- Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase2, single centre, open label, randomised control trial
- Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions:A Double-Blind, Randomized Clinical Trial also covered here in RCEMLearning
- Combination therapy of vitamin C and thiamine for septic shock: a multi-centre, double-blinded randomized, controlled study also covered in The Bottom Line
- Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial also covered in the Bottom Line