The St.Emlyn’s Podcast

Managing Early Pregnancy Problems in the Emergency Department Welcome to the St. Emelene's induction podcast. I'm Iain Beardsell, and I'm Natalie May. Today, we're discussing the management of early pregnancy problems in female patients presenting to the emergency department (ED). Some of you may rarely encounter these cases, while others may see them frequently. This podcast aims to provide a detailed guide on how to manage these patients effectively, optimizing our approach for better patient outcomes. Understanding Early Pregnancy Problems Early pregnancy problems can range from minor concerns to life-threatening emergencies. As emergency physicians, our primary goal is to identify and manage the worst-case scenarios promptly. In this post, we'll cover the following topics: Worst-case scenarios and initial steps History and physical examination Risk factors for ectopic pregnancy Diagnostic testing: urine vs. serum HCG Per vaginal (PV) examination: when to perform Management of threatened miscarriage Patient communication and support Worst-case Scenarios and Initial Steps In emergency medicine, we often think about the worst-case scenarios first. For early pregnancy problems, the most critical concern is an ectopic pregnancy. Ectopic pregnancies occur in about 1 in 100 pregnancies in the UK and can be life-threatening if not identified and treated promptly. Initial Steps When a young female patient presents with lower abdominal pain or spotting and is potentially pregnant, our first steps should include: Confirming pregnancy status: Use a urine pregnancy test initially. Assessing vital signs: Look for signs of hemodynamic instability, such as hypotension or tachycardia, which could indicate a ruptured ectopic pregnancy. Taking a detailed history: Understand the patient's symptoms, last menstrual period, and any previous gynecological issues. History and Physical Examination A thorough history and physical examination are crucial in managing early pregnancy problems. Here's what you need to focus on: History Last Menstrual Period (LMP): Helps estimate the gestational age. Symptoms: Type and location of pain, nature of bleeding, and presence of other symptoms like dizziness or shoulder pain. Previous Pregnancies: Gravida (number of pregnancies) and Para (number of completed pregnancies). Risk Factors: Previous ectopic pregnancy, pelvic inflammatory disease, and any surgeries or procedures involving the reproductive organs. Physical Examination Abdominal Examination: Look for tenderness, guarding, or rebound tenderness. Vital Signs: Monitor for signs of shock or hemodynamic instability. Pelvic Examination: In specific cases, to assess for cervical motion tenderness, adnexal tenderness, or masses. Risk Factors for Ectopic Pregnancy Understanding the risk factors for ectopic pregnancy can help identify patients who need urgent evaluation. Risk factors include: History of pelvic inflammatory disease (PID) Previous pelvic or abdominal surgery Use of intrauterine devices (IUDs) Previous ectopic pregnancy Assisted reproductive techniques like IVF Anatomical abnormalities of the fallopian tubes or uterus Endometriosis Use of the progesterone-only pill Diagnostic Testing: Urine vs. Serum HCG Determining the pregnancy status and ruling out ectopic pregnancy requires accurate diagnostic testing. Here's a comparison between urine and serum HCG tests: Urine HCG Test Sensitivity: About 96%, particularly when HCG levels are above 100. Specificity: High, meaning a positive result is reliable. Limitations: May give false negatives if HCG levels are very low, as seen in some ectopic pregnancies. Serum HCG Test Sensitivity and Specificity: Both close to 100%, making it the preferred test for confirming pregnancy and assessing HCG levels. Usage: Particularly useful when urine tests are negative but clinical suspicion remains high. When to Perform a Per Vaginal (PV) Examination The necessity of PV examinations in the ED can be debated. However, they are essential in specific situations: Retained Foreign Bodies: Such as condoms or tampons. Significant Vaginal Bleeding: Particularly in cases of suspected cervical shock due to retained products of conception. For other scenarios, PV examinations are best left to gynecology specialists who have the expertise and appropriate setting to perform these exams with the required sensitivity and specificity. Management of Threatened Miscarriage A threatened miscarriage involves vaginal bleeding in a pregnancy less than 24 weeks, with a closed cervical os. It is a common issue that can cause significant anxiety for patients. Here's how to manage these cases: Terminology Threatened Miscarriage: Vaginal bleeding with a closed cervical os. Inevitable Miscarriage: Open cervical os, indicating that miscarriage is likely to proceed. Complete Miscarriage: All products of conception have passed. Incomplete Miscarriage: Some products remain, requiring further management. Approach Assess Bleeding: Light bleeding can often be managed on an outpatient basis. Heavy bleeding requires immediate gynecological consultation. Provide Reassurance: Explain that early pregnancy bleeding is common and not necessarily indicative of a miscarriage. Pain Management: Offer analgesia, such as paracetamol or cocodamol, to manage discomfort. Follow-up: Arrange for follow-up with an early pregnancy assessment unit (EPAU) within 48 hours. Patient Communication and Support Dealing with early pregnancy problems can be distressing for patients. Effective communication and support are crucial. Tips for Communication Be Empathetic: Understand that this might be a significant and emotionally charged situation for the patient. Explain Clearly: Provide information about what is happening and what the next steps are. Avoid Definitive Statements: Unless certain, avoid saying that the patient has definitely miscarried. Offer Reassurance: Reiterate that early pregnancy complications are common and often not due to anything the patient did wrong. Psychological Support Acknowledge Emotions: Recognize the patient's feelings and provide support. Encourage Support Systems: Suggest involving family or friends for emotional support. Professional Help: Refer to counseling services if needed. Conclusion Managing early pregnancy problems in the ED requires a systematic approach, starting with identifying worst-case scenarios and performing appropriate diagnostic tests. Understanding the risk factors for ectopic pregnancy and knowing when to perform a PV examination are crucial. Providing compassionate care and clear communication can help support patients through what can be a distressing time. By optimizing our approach, we can ensure better outcomes for our patients and provide the best possible care in these challenging situations. Always consult senior colleagues when in doubt and follow local guidelines to ensure consistency and quality of care.

Understanding Impact Brain Apnea: A Revolutionary Insight into Trauma Care Today, we delve into a fascinating and crucial topic in trauma care: impact brain apnoea. We recently had the privilege of attending the London Trauma Conference and caught up with Dr. Gareth Davis, a leading figure in trauma care and pre-hospital emergency medicine in the UK. Dr. Davis shared his insights into impact brain apnoea, a phenomenon that, while not widely recognized, has significant implications for patient outcomes. The Unseen Danger: What is Impact Brain Apnoea? Impact brain apnoea refers to a sudden cessation of breathing due to a blow to the head. This phenomenon, although not commonly discussed, has been a subject of intrigue for trauma professionals for many years. Dr. Davis explained that this condition occurs when an impact to the brain stem interrupts normal breathing, potentially leading to severe consequences if not promptly addressed. This condition's significance lies in its subtlety and the challenges it poses in pre-hospital care. Many trauma incidents involve high-impact forces, such as car accidents, where a patient may suffer head injuries. Understanding the mechanics behind impact brain apnea can be the key to differentiating between minor and severe trauma cases, potentially saving lives. The Historical Context and Research Challenges The concept of impact brain apnoea isn't new, but it has been challenging to prove and widely accept due to a lack of concrete evidence. Gareth emphasized that the inconsistency in patient outcomes—where one individual might suffer severe consequences while another escapes with minor injuries—sparked curiosity among trauma specialists. Over time, through a combination of clinical observations and literature reviews, the medical community has started to piece together a more comprehensive understanding of this condition. A significant barrier in researching impact brain apnoea is the timing of medical intervention. Most pre-hospital care teams arrive at the scene minutes after an incident, often too late to observe the initial apnea phase. This delay makes it challenging to gather real-time data, leaving a gap in understanding the immediate physiological responses post-trauma. Physiological Mechanisms: The Dual Threat Dr. Davis highlighted two critical physiological responses following a head injury that contributes to the complexity of treating impact brain apnea: the immediate cessation of breathing and a subsequent catecholamine surge. Apnea and Hypoxia: The primary response is an apnea caused by the impact on the medulla oblongata, the brain's breathing control centre. This apnea leads to hypoxia (low oxygen levels) and hypercarbia (increased carbon dioxide levels), which can quickly deteriorate the patient's condition. Catecholamine Surge: Following the initial apnea, the body releases a significant amount of catecholamines—hormones like adrenaline—that flood the system. This response, while a natural reaction to stress, can be detrimental, especially when the heart is already struggling due to hypoxia. The combination of these factors can lead to traumatic cardiac arrest, a situation where the heart fails due to trauma-induced physiological stress rather than direct injury. Understanding these mechanisms is crucial for emergency responders. Recognizing the signs of impact brain apnea and addressing them promptly can be the difference between life and death. The Clinical Conundrum: Diagnosing and Treating Impact Brain Apnea One of the most challenging aspects of dealing with impact brain apnea is the clinical presentation. Patients may not exhibit obvious signs of severe trauma, such as external bleeding or visible injuries, making it difficult to diagnose based solely on physical examination. Gareth discussed the importance of thorough history-taking and observing indirect signs—akin to observing the "echo" of a particle, like in the Higgs boson analogy. The lack of direct evidence means clinicians often rely on a combination of observational data, patient history, and situational awareness. For example, if a patient presents with persistent hypotension without a clear source of bleeding, clinicians might consider central shock—a term used to describe shock due to central nervous system dysfunction rather than volume loss. The Role of Public Education and Pre-Hospital Care Gareth emphasized the crucial role of public education and pre-hospital care in managing impact brain apnoea. The public's ability to provide immediate aid, such as opening an airway and administering ventilatory support, can significantly affect outcomes. He pointed out that while there is a global trend to focus on chest compressions in cases of cardiac arrest, for patients with traumatic injuries, addressing airway and breathing is paramount. In London, initiatives like the GoodSAM app are helping bridge the gap by connecting trained responders with emergencies in real-time. This app allows people with medical training to provide critical first aid before professional services arrive, potentially mitigating the effects of impact brain apnea by ensuring the patient's airway is open and they are breathing adequately. Navigating the Future: Research and Education The conversation with Dr. Davis also highlighted the future directions for research and education. The medical community needs to invest more in understanding and validating the concept of impact brain apnea. This investment includes funding for clinical studies and fostering an environment where healthcare professionals can share their observations and experiences. Podcasts, blogs, and medical conferences are valuable platforms for disseminating information about new medical phenomena like impact brain apnea. Dr. Davis encouraged medical professionals to remain curious, continue their education, and be open to emerging concepts that may not yet have robust evidence but have practical significance in clinical settings. Key Takeaways and Clinical Pearls Recognition and Belief: Clinicians need to recognize and believe in the concept of impact brain apnea. Even if direct evidence is scarce, understanding the physiological mechanisms and potential clinical presentations can guide effective treatment. Focus on Airway and Breathing: In cases of traumatic injury, especially with suspected head trauma, the immediate focus should be on ensuring the airway is clear and the patient is breathing. This intervention can prevent the cascade of negative physiological responses that lead to traumatic cardiac arrest. Role of Bystanders and First Responders: Public education and the involvement of trained responders are critical. Tools like the GoodSAM app can play a significant role in ensuring timely intervention. Continuous Learning and Adaptation: The medical field must remain adaptive, incorporating new research findings and adjusting treatment protocols as more is understood about conditions like impact brain apnea. Conclusion Impact brain apnoea is a critical yet under-recognized phenomenon in trauma care. Through continued research, education, and public awareness, we can improve patient outcomes and provide better care in pre-hospital and clinical settings.   

Year in Review: Highlights in Emergency Medicine and Critical Care As we close out the year, St Emlyn's takes a moment to reflect on the significant events and advancements in the field of emergency medicine, critical care, and FOAMed (Free Open Access Medical Education). The past year has seen remarkable progress in research, education, and community engagement, with key studies reshaping our understanding and practices. Here's a look back at the highlights and what we can look forward to in the coming year. Key Research and Trials This year has been notable for the publication of several high-impact studies in emergency medicine and critical care. While some findings may have appeared negative at first glance, they have ultimately underscored the strengths of current practices. For example, trials on mechanical CPR devices, such as the Lucas device, showed no significant improvement in outcomes for out-of-hospital cardiac arrest patients. Similarly, research on starch solutions in sepsis concluded that these substances could be harmful, advocating for their discontinuation despite continued use in some clinical settings. The ARISE and ProCESS trials were particularly influential, examining the effectiveness of early goal-directed therapy in sepsis management. Although these studies did not demonstrate a significant advantage over standard care, they highlighted the high quality of usual treatment protocols, which have improved considerably over the past decade. The ANZICS trial also reported a significant decrease in sepsis mortality, further emphasizing the advancements in patient care. Additionally, the Targeted Temperature Management trial found no difference in outcomes between maintaining post-cardiac arrest patients at 33°C versus 36°C. This finding suggests that more aggressive temperature control may not be necessary, streamlining care protocols. The Role of FOAMed The FOAMed movement has revolutionized access to medical education, allowing healthcare professionals to stay updated with the latest research and discussions. Within hours of publication, new studies are analyzed and debated on various platforms, enhancing knowledge dissemination and critical appraisal. St Emlyn's, along with other prominent FOAMed resources like Life in the Fast Lane, has played a crucial role in this educational revolution. The emergence of new platforms, such as The Bottom Line, has provided additional avenues for high-quality content. The Bottom Line, in particular, offers concise, critical appraisals of literature from a British perspective, catering to a broad audience interested in emergency medicine and critical care. Noteworthy Blogs and Podcasts The past year has seen an increase in the quality and quantity of blogs and podcasts in the FOAMed community. Established sites like Resus.Me, EM Lyceum, and the SGM continue to provide valuable insights, while newer entries such as Broom Docs have brought fresh perspectives. Broom Docs, led by Casey Parker, is particularly noted for its thoughtful discussions on diagnostic tests and clinical judgment. Podcasts have also become an essential part of the FOAMed landscape. St Emlyn's own podcast has grown significantly, offering interviews with experts and discussions on a wide range of topics. Other notable podcasts include Foamcast, which presents a polished and well-structured approach to emergency medicine education, and the Rage podcast, known for its informal yet informative style. Conferences and the Evolution of Medical Education Conferences remain a cornerstone of professional development in emergency medicine and critical care. This year, St Emlyn's team members attended several notable conferences, including the EMS Gathering in Ireland, which featured innovative learning approaches like the "Puss Bus" for sepsis education and Pecha Kucha-style presentations. These events provided valuable opportunities for networking, knowledge exchange, and exploring new educational formats. A significant trend in conferences is the shift towards "Medutainment," which blends medical education with entertainment. This approach, inspired by platforms like TED Talks, emphasizes engaging and visually appealing presentations over traditional lecture formats. The move towards more dynamic and interactive sessions reflects the growing demand for high-quality, engaging content in medical education. Looking Forward to 2015 The upcoming year promises to be equally exciting for emergency medicine and critical care. The SMACC Chicago conference in June is highly anticipated, featuring a lineup of world-class speakers and sessions. Additionally, the College of Emergency Medicine's conference in Manchester is expected to be a major event, with an impressive list of speakers and topics. At St Emlyn's, we plan to continue expanding our content offerings. Our goal is to provide comprehensive coverage of key presenting complaints in the College of Emergency Medicine curriculum through our blog and podcast. We aim to deliver high-quality educational resources that not only inform but also inspire and engage our audience. Acknowledgements We would like to extend our heartfelt thanks to everyone who has supported St Emlyn's and the broader FOAMed community. Special thanks go to Mike Cadogan, whose behind-the-scenes work has been instrumental in maintaining many FOAMed platforms. We also appreciate the contributions of our guest writers and the entire Life in the Fast Lane team for their invaluable support. Conclusion The past year has been marked by significant advancements and enriching experiences in emergency medicine and critical care. The growth of FOAMed has democratized access to knowledge, allowing healthcare professionals to stay current with the latest research and best practices. As we look forward to 2015, we are excited about the opportunities for further growth and learning. We remain committed to providing high-quality, accessible education and fostering a supportive, informed community. We wish all our readers and listeners a happy and healthy holiday season. Whether you're spending time with family or working through the festive period, we hope you find joy and fulfillment in your work and life. Thank you for being part of our journey, and we look forward to another year of learning and growth together.

Key Insights from the London Trauma Conference: Training, Innovation, and Clinical Governance in Emergency Medicine Welcome to the St. Emlyn’s podcast summary of the London Trauma Conference. Over the past few days, experts in emergency medicine and pre-hospital care have shared valuable insights into the latest developments in our field. This blog post covers the highlights, focusing on effective training strategies, innovative practices, and crucial discussions on clinical governance. Quality Education in Pre-Hospital Care by Cliff Reid Cliff Reid’s session on delivering quality education in pre-hospital care was a standout. He emphasized that training for performance goes beyond knowledge acquisition. While understanding SOPs and the flip classroom approach are important, practical application is crucial. Key Training Techniques: Stress Exposure Training: Regularly exposing doctors to high-pressure situations to build resilience. Perturbation: Introducing distractions during simulations to test team stability, such as simulating patient vomiting or monitor failures during an RSI procedure. Cross-Training: Ensuring paramedics and doctors train together and are evaluated as a team. Cliff's insights highlight the necessity of training cohesive units to prepare effectively for real-world scenarios. Learning from Failures in Modern Forensic Pathology Professor Guy Ratti discussed modern forensic pathology, focusing on how clinical techniques are applied post-mortem to determine causes of death. The use of CT scans, angiography, and point-of-care toxicology testing has revolutionized post-mortem investigations, providing quicker and more detailed insights. Learning Points: Application of Clinical Techniques Post-Mortem: Using CT scans and angiography to identify trauma causes. Point-of-Care Toxicology Testing: Rapid results within 45 minutes that can guide future clinical decisions. For pre-hospital providers, understanding these techniques helps in learning from patients who couldn’t be saved, improving future care strategies. Clinical Governance: Striking the Right Balance Clinical governance was a key theme, with discussions on its importance and implementation. Effective governance structures are essential for ensuring consistent, high-quality care. Governance Highlights: Structured and Regular Feedback: Creating environments where teams feel comfortable receiving and acting on feedback. Balancing SOP Adherence and Flexibility: Recognizing situations where deviation from SOPs is necessary for patient care. The consensus was that governance must be tight enough to maintain standards but flexible enough to accommodate individual patient care nuances. Transporting and Transferring Difficult Patients A session dedicated to transporting and transferring difficult patients in the HEMS context provided practical advice and highlighted innovative approaches from international contingents. Patient Categories: Psychiatric Patients: Safe sedation with ketamine for acutely psychotic patients. Bariatric Patients: Innovative positioning techniques, such as using a vac mat for intubation. Infectious Disease Patients: Protocols for safely managing and transporting patients with infectious diseases. These insights are valuable for those working in diverse and challenging environments, ensuring patient safety and effective care during transfers. Afternoon Sessions: EMS Disasters and Quick Hits The afternoon sessions covered a range of topics, from emotional accounts of EMS disasters to rapid-fire discussions on current practices. EMS Disasters: Case Studies from Norway and Glasgow: Brave speakers shared their experiences, offering lessons on safety and crisis management. Quick Hits: Cervical Collars Debate: Discussing the efficacy and necessity of cervical collars, with evidence suggesting limited benefit but continued standard use. Pre-Hospital Blood Testing: Advocating for the feasibility and benefits of conducting blood tests in the pre-hospital environment. These sessions underscored the importance of staying updated with current debates and practices, continuously evaluating and improving methods. Innovation in Medical Technology: The GoodSAM App Mark Wilson’s presentation on the GoodSAM app showcased how technology can revolutionize emergency response. The app alerts trained responders to nearby cardiac arrests, potentially saving lives by reducing response times. Key Features: Free to Download: Available on both the App Store and Google Play. Community-Based: Encourages both medical and non-medical individuals to participate. This app exemplifies how digital innovation can enhance traditional emergency response mechanisms, making it a must-have tool for responders and a valuable resource for the community. Apnoeic Oxygenation During RSI Cliff Reid returned to discuss apnoeic oxygenation during RSI, a technique that can extend the safe apnea period and reduce the risk of desaturation during intubation. Practical Tips: Use of Nasal Oxygenation: Attach nasal specs to the patient in addition to mask ventilation. Simulation and Practice: Regular training to integrate this practice seamlessly into procedures. This straightforward yet effective technique can significantly improve patient outcomes during RSI, both in pre-hospital and hospital settings. Reflections and Future Directions The London Trauma Conference provided a wealth of knowledge, practical advice, and innovative ideas for improving emergency medicine and pre-hospital care. From advanced training techniques to embracing new technologies and refining clinical governance, the insights shared by experts like Cliff Reid, Guy Ratti, and Mark Wilson are invaluable. Key Takeaways: Emphasize team-based training and resilience-building techniques. Leverage modern forensic methods to learn from patient outcomes. Maintain structured yet flexible clinical governance. Implement innovative practices for transporting difficult patients. Stay updated with current debates and emerging technologies. We hope these insights inspire you to reflect on your practices and consider how you can integrate these ideas into your work. Keep pushing the boundaries of emergency medicine, and stay tuned for more updates and interviews from the St. Emlyn’s team. Keywords: London Trauma Conference, emergency medicine, pre-hospital care, clinical governance, forensic pathology, Cliff Reid, GoodSAM app, apnoeic oxygenation, cervical collars, blood testing, trauma training, EMS disasters, St. Emlyn’s.

London Trauma Conference Day 2: Comprehensive Summary Welcome back to the St. Emlyn’s blog. I'm Iain Beardsell, joined by Natalie May, here to recap the second day of the London Trauma Conference at the Royal Geographical Society in Kensington. The day was filled with insightful talks and valuable teaching points, which we’re eager to share with you. Elderly Trauma: Addressing Under-Triage The day began with Marius Reigns focusing on the challenges of elderly trauma. Reigns highlighted the growing number of elderly patients in emergency departments and the critical issue of under-triage. Studies indicate that almost 50% of elderly trauma cases are under-triaged, compared to about 20% in younger patients. This leads to missed opportunities to reduce morbidity and mortality. Reigns emphasized the need to recognize the unique factors in elderly trauma, including multiple medical conditions, medication use, and systemic disadvantages in trauma management. Pediatric Trauma: A Unique Approach Ross Fischer, a favorite at St. Emlyn’s, delivered an outstanding presentation on pediatric trauma. He stressed the importance of not managing pediatric trauma with the same principles as adult trauma. Children have different injury mechanisms and often require different management strategies. For example, splenic injuries in children are less likely to need surgical intervention compared to adults. Fischer called for more research in pediatric trauma, emphasizing the rarity of these cases and the need for collaborative efforts to determine best practices. He also highlighted the importance of simulation in maintaining skills, noting that emergency physicians might only see one or two cases of pediatric trauma annually. Obstetric Trauma: Critical Four-Minute Window Tim Draikot followed with a humorous yet insightful talk on obstetric trauma. He reiterated the critical four-minute window for resuscitation in traumatic maternal cardiac arrest, after which a paramortum C-section should be performed. Draikot emphasized that this procedure is vital for the survival of both mother and child. He stressed the importance of this cognitive protocol—looking at the clock and acting decisively. Draikot’s engaging style made this crucial message resonate, reminding us that swift action can save lives. Coaching Principles in Emergency Medicine Tom Evans, a pre-hospital physician and rowing coach, shared fascinating insights on applying coaching principles to emergency medicine. He discussed the importance of clear mental models, focused teamwork, and having a defined endpoint. Evans drew parallels between coaching an elite athlete and managing a trauma team, emphasizing the need to strive for excellence. He posed the thought-provoking question: "What is our Olympics?" Evans’ talk encouraged us to find our own goals and work towards giving 100% in our practice. The Future of ATLS: Evolving Beyond the Basics Matt Walsh challenged the current status of Advanced Trauma Life Support (ATLS) in his talk. He argued that ATLS should now be considered a basic rather than an advanced course. Walsh proposed the idea of creating local trauma courses tailored to specific systems and teams, incorporating the latest evidence from conferences and social media. This approach aims to improve patient care by adapting training to local needs and continuously updating it with current best practices. Afternoon Highlights: Forensic Pathology and Quick Hits The afternoon session featured the Peter Baskett Memorial Lecture by forensic pathologist Stephen Lead-Beater. Lead-Beater provided a unique perspective on trauma through post-mortem examinations, offering insights that can inform and improve clinical practice. His lecture was both enjoyable and enlightening, adding a valuable dimension to the conference. In the quick hits session, several key points were discussed: Cooling in Isolated Head Injuries: Currently, there's insufficient evidence to support this practice, but further research is anticipated. Calcium in Shocked Trauma Patients: It's advisable to consider calcium administration in hypovolemic patients, particularly those with calcium levels below 0.9 mmol/L. For massive transfusion protocols, administering 10 ml of 10% calcium chloride for every four units of blood is recommended. IO Access: While intraosseous (IO) access remains a vital option, especially for rapid sequence intubation (RSI), it's not the ultimate solution. The debate continues on whether IO can effectively deliver blood due to potential hemolysis issues. FAST Scanning: The role of FAST (Focused Assessment with Sonography for Trauma) scanning in stable patients is diminishing. Operator dependence and declining performance outside research centers are concerns. However, ultrasound's evolving role in assessing general shock remains significant. Social Media in Trauma Care: Connor Deasy highlighted the importance of social media in trauma care, with St. Emlyn’s receiving notable mentions for its contributions. Conclusion and Looking Ahead The second day of the London Trauma Conference has been immensely rewarding, offering a wealth of knowledge and practical insights. From the challenges of elderly and pediatric trauma to the critical timelines in obstetric emergencies, the talks have reinforced the need for continuous learning and adaptation in emergency medicine. As we look forward to day three, focusing on air ambulance work and pre-hospital care, we hope you’ve found these recaps useful. Follow the discussions on Twitter for real-time updates and join us again tomorrow for more highlights. Thank you for reading, and stay tuned for our next update from the London Trauma Conference. Take care and keep striving for excellence in your practice.

London Trauma Conference 2024: Day One Highlights Welcome to the St Emlyn's blog! I'm Iain Beardsell, and I'm Natalie May. We’re excited to share insights from the London Trauma Conference 2024, held in the glamorous heart of Kensington, London. This year’s conference has brought together national and international experts, offering a wealth of knowledge on trauma care. Here, we’ll take you through some of the key highlights from day one, hoping to give you a feel for the event and perhaps persuade you to join us for the remaining days. Karen Bray’s Dynamic Talk on Trauma Dissection One of the standout sessions was Karen Bray's talk on trauma dissection. Her dynamic presentation, complemented by stunning slides, provided numerous take-home messages. For those following us on Twitter, you might have seen some key points and visuals already. Karen’s discussion was particularly poignant given the recent tragic events in Australia involving Phil Hughes. Her ability to weave current events into her presentation added a layer of immediacy and relevance. We’ll delve deeper into her insights in a separate podcast, but suffice it to say, her talk was both enlightening and thought-provoking. Pediatric Trauma and Research Challenges Ian McConaughey addressed the perennial issue of pediatric trauma, emphasizing the inconsistencies in pre-hospital assessments. He pointed out the challenges due to the lower incidence of pediatric trauma compared to adults, which hampers research efforts. Ross Fisher from Sheffield built on this, discussing potential pathways to overcome these barriers in pediatric trauma research. In line with these discussions, Ian Bailey from Southampton raised critical points about the evolution of trauma surgery in the UK. He highlighted the need to attract young doctors to general and trauma surgery, questioning why this isn’t currently a structured career path. His candid approach to addressing these “elephants in the room” was refreshing and necessary for future improvements in trauma care. The Helmet Debate: To Mandate or Not? One of the liveliest sessions featured a debate between Mark Wilson and Karim Brohi on the use of cycling helmets. This debate sparked significant discussion on Twitter. The crux of the debate was whether making helmets mandatory would reduce cycling participation and thereby negate the overall health benefits. Ultimately, Karim won with the argument that helmets should remain a choice rather than a mandate, but the conversation is far from over. Impact Brain Apnea: A New Mechanism We also had a compelling discussion with Gareth Davies on impact brain apnea—a newly recognized mechanism where a head injury can temporarily stop breathing. This simple yet critical understanding could reshape how we manage head trauma in the initial stages. Stay tuned for an upcoming podcast where we’ll explore this topic further. Chris Moran on the Future of Trauma Care Professor Chris Moran, a leading figure in trauma care in England, provided an insightful talk on the progress of major trauma centers over recent years. He also addressed the contentious issue of whether the focus should shift from in-hospital care to pre-hospital phases or rehabilitation. Surprisingly, he advocated for greater emphasis on rehabilitation, sparking a gut reaction among many attendees. However, upon reflection, the audience began to see the merit in his argument. Rehabilitation, though less glamorous than pre-hospital interventions, plays a crucial role in patient recovery and long-term outcomes. Practical Insights on Chest Trauma and Rib Fractures Doug West, a cardiothoracic surgeon from Bristol, delivered a practical talk on chest trauma, particularly the management of rib fractures. He highlighted the disparity in practices across centers, with some performing rib fixation regularly and others not at all. This variation underscores the need for standardized protocols and further research. Tim Moll on Trauma in Motorsport Tim Moll gave an entertaining and informative presentation on trauma in motorsport, a field with a historically high injury rate. He focused on the unique challenges of managing injuries in this sport, emphasizing the importance of understanding the specialized gear and protocols involved. This talk was enhanced by the presence of John Hinds, a veteran motorsport doctor, who added his invaluable perspective. The Complex Relationship Between Shock and Blood Pressure Tim Harris’s session on shock was another highlight. He challenged the traditional view that blood pressure is a direct surrogate for shock, emphasizing instead that shock is defined by inadequate oxygen delivery to tissues. This nuanced understanding is critical for trauma team leaders in managing hypotensive patients more effectively. Looking Ahead: Day Two at the London Trauma Conference As we wrap up day one, we’re looking forward to another full day of insightful sessions. Tomorrow’s program includes talks focused on patients requiring special consideration—such as the elderly, pediatric trauma cases, and trauma during pregnancy. These sessions promise to provide valuable knowledge for tailoring trauma care to these vulnerable populations. Additionally, there will be master classes and breakaway sessions on remote critical care and core topics in trauma, as well as a full day dedicated to motorsport medicine. If you’re in the area, it’s not too late to join us. Turn up at the door, and you might find a space available. Engage with Us We’re the slightly tired but enthusiastic team running around Kensington, usually attached to our mobile phones or computers. If you see us, please say hello! We’d love to meet our listeners and readers. If you have any questions for the speakers, reach out to us, and we’ll try to include them in a special follow-up podcast. From the beautiful, Christmassy setting of Kensington, the St Emlyn’s team at the London Trauma Conference wishes you a good evening. We’ll be back with more updates tomorrow. Thank you for listening and following along.

Exciting Collaboration Between St Emlyns and the London Trauma Conference Welcome to the latest St Emlyns podcast! I'm Iain Beardsell, and alongside Natalie Mace, we are thrilled to announce an exciting new collaboration between the St Emlyns team and the London Trauma Conference. This esteemed conference will take place in London next week, and we've been honored with the opportunity to attend as members of the press. We will be interviewing some of the prominent speakers participating in the event, marking a significant first for our team at St Emlyns. The London Trauma Conference: Dates and Highlights The London Trauma Conference is scheduled from Tuesday, December 9th to Thursday, December 11th. This three-day event promises a stellar lineup of speakers from the Trauma World, including sessions on Trauma Surgery, Trauma Nursing, and a dedicated day for trainees. There’s even a special Thoracotomy day planned. This comprehensive program ensures there’s something for everyone in the field of trauma care. Why Attend the London Trauma Conference? We are not just attending to listen; our goal is to bring you the inside stories and insights from the speakers after their sessions. We aim to ask the questions you want answers to, making this conference more interactive and engaging for all of us. Whether you are a seasoned professional or a trainee, this conference offers invaluable knowledge and networking opportunities. If you’re considering attending, we highly encourage it. You can find all the details and register at www.londontraumaconference.com. There are still places available, so don’t miss out on this exceptional event. Engaging with the Conference Online For those who can't make it to London, there are still plenty of ways to stay involved. Follow along on Twitter using the hashtag #ltc2014. We will be tweeting live updates from the sessions, and you can tweet your questions to us. We’ll do our best to catch up with the speakers and get your questions answered. Getting Ready for Trauma Week To get in the mood for the upcoming trauma week, we recommend listening to "The Fight for Life," a program by Kevin Fong on BBC Radio 4. This enlightening show traces the origins of trauma care and brings it up to the modern day. Kevin speaks with James K. Steiner, the American orthopedic surgeon who designed the ATLS course after his family was involved in a tragic air accident. The program is both moving and inspiring, highlighting the importance of coordinated trauma care. Meet the Speakers: Friends of St Emlyns We are excited to reconnect with many friends of St Emlyns at the conference. Among the notable speakers are Mark Wilson, a renowned neurosurgeon from London, and Karen Brodie, a respected vascular and trauma surgeon. Ross Fisher, a pediatric surgeon from Sheffield, will be discussing pediatric trauma. Additionally, our colleagues from Sydney Hems, including Cliff Reed and Brian Burns, will also be presenting. The lineup reads like a who's who of UK and international trauma medicine, ensuring a wealth of knowledge and experience will be shared. Our Mission at St Emlyns At St Emlyns, we are dedicated to spreading trauma care education as widely as possible. None of our team members have any financial interest in the conference; our goal is purely educational. We hope to learn and share valuable insights with you, our community, to enhance our collective understanding and capabilities in trauma care. Welcoming New Doctors to Emergency Medicine This week is particularly special as it marks the arrival of new doctors in our emergency departments across the UK. This transition happens four or five times a year, bringing fresh faces, enthusiasm, and, understandably, a bit of nervousness. We urge everyone to extend kindness and support to these junior doctors. Our emergency departments thrive on a culture of learning and collaboration, and it’s essential to make our new colleagues feel welcome and valued. If you are one of these new doctors, make sure to check out our induction blog posts and podcasts. They are available on the St Emlyns blog at stemlynsblog.org and on our iTunes podcast feed. These resources are designed to help you navigate the initial challenges and embrace the exciting journey ahead in emergency medicine. The Importance of Continued Learning in Emergency Medicine As we see from the current news, it’s a challenging time for UK emergency medicine. However, at St Emlyns, we are committed to bringing you the best resources, insights, and inspiration to help you continue delivering exceptional care to your patients. Our collaboration with the London Trauma Conference is just one example of our efforts to enhance the education and support available to all healthcare professionals in our community. Conclusion We are incredibly excited about this new venture and look forward to sharing our experiences and learnings from the London Trauma Conference with you. Whether you join us in person or follow along online, we hope this event will be as enlightening and inspiring for you as it promises to be for us. Thank you for being a part of the St Emlyns community. Please continue enjoying your work in emergency medicine, and we’ll be back with more updates and insights very soon. Take care and thanks for listening!

Top Five Diagnoses to Rule Out in Patients with Chest Pain In emergency medicine, our primary objective is to rule out life-threatening conditions first. This principle guides our approach to patients with chest pain. Here are the top five diagnoses to consider: Acute Coronary Syndrome (ACS) Pulmonary Embolism (PE) Pneumothorax Pneumonia Aortic Dissection These conditions can have overlapping symptoms but differ significantly in their management and prognosis. Let’s explore these further. Acute Coronary Syndrome (ACS) When a patient presents with chest pain, ACS is often the first concern. Key symptoms include central crushing chest pain, which may radiate to the arm or neck. While classic presentations are familiar to most, not all patients exhibit textbook symptoms. Factors like age, gender, and comorbidities can alter the clinical picture. Initial Assessment and ECG Interpretation Every patient with chest pain should receive an ECG as part of the initial workup. Interpreting ECGs requires a high level of expertise, as subtle changes can indicate significant pathology. In our department, only senior emergency physicians are tasked with reading initial ECGs to minimize the risk of missing critical findings. It's important to assess each ECG independently, even if previous records are available, as baseline abnormalities can obscure new, acute changes. Troponin Testing For patients where myocardial ischemia is suspected, a troponin test, particularly high-sensitivity troponin, is essential. This biomarker helps identify myocardial injury, even in cases where the ECG does not show definitive changes. Given the serious implications of missing an ACS diagnosis, a low threshold for testing is prudent. Approximately 10% of patients with a normal ECG may still have significant disease, highlighting the importance of comprehensive evaluation. Pulmonary Embolism (PE) Pulmonary embolism is another critical condition to consider, especially in patients presenting with pleuritic chest pain, shortness of breath, or risk factors such as recent immobilization, malignancy, or surgery. The clinical presentation of PE can vary, complicating diagnosis. Clinical Decision Tools The Wells score and PERC (Pulmonary Embolism Rule-out Criteria) are valuable tools in assessing the likelihood of PE. For low-risk patients, D-dimer testing can be used to rule out the condition, reducing the need for further imaging. However, for patients deemed at higher risk, CT pulmonary angiography (CTPA) is the gold standard for diagnosis. The decision to pursue imaging should be guided by clinical judgment and, where necessary, discussed with senior colleagues to avoid unnecessary radiation exposure and follow-up testing. Pneumothorax Pneumothorax should be considered in both young, otherwise healthy individuals and older patients with underlying lung disease. The hallmark symptom is sudden onset pleuritic chest pain, often accompanied by shortness of breath. Diagnostic Approach A chest x-ray is typically sufficient to diagnose pneumothorax. Given the low radiation dose and high diagnostic yield, x-rays should be performed for most patients with suspected pneumothorax. The imaging will not only confirm the presence of air in the pleural space but also help assess the severity and guide management decisions. Pneumonia Pneumonia is a common cause of chest pain, often accompanied by fever, cough, and sputum production. It is more common in patients with a history of respiratory disease or immunosuppression. Identifying Pneumonia A chest x-ray remains the cornerstone of pneumonia diagnosis. Clinical symptoms, such as productive cough and fever, along with imaging findings of consolidation, help differentiate pneumonia from other causes of chest pain. While not immediately life-threatening in most cases, timely recognition and treatment are crucial to prevent complications. Aortic Dissection Aortic dissection is a less common but highly dangerous cause of chest pain. Classic symptoms include severe, tearing pain radiating to the back. It is critical to maintain a high index of suspicion for aortic dissection, especially in patients with risk factors such as hypertension, connective tissue disorders, or a family history of the condition. Confirmatory Testing The definitive diagnostic test for aortic dissection is a CTA aortogram. While a chest x-ray can sometimes reveal mediastinal widening, it is not sufficiently sensitive to rule out dissection. Early consultation with cardiothoracic surgery and rapid imaging are key to managing suspected cases. Communicating with Patients Once life-threatening causes have been ruled out, patients often seek answers about their symptoms. When the etiology remains unclear, it’s important to communicate transparently with the patient. Possible benign causes include musculoskeletal pain or gastroesophageal reflux disease (GERD). While it’s reassuring to exclude serious conditions, acknowledging the limitations of our diagnostic tools and advising patients to return if symptoms change is crucial. Patient Reassurance and Follow-up Patients should be advised to follow up with their primary care physician for further evaluation and management of non-urgent conditions. Clear communication, including documenting your diagnostic reasoning and plan, is vital for medico-legal protection and patient safety. Conclusion: Mastering Chest Pain in the ED Chest pain remains a complex and multifaceted challenge in the emergency department. The ability to swiftly differentiate between benign and life-threatening causes is a critical skill for emergency physicians. Our approach should be guided by a thorough history, physical examination, and appropriate use of diagnostic tools. Remember, the primary goal is to exclude serious conditions, ensuring patient safety while avoiding unnecessary investigations. As you continue your journey in emergency medicine, refine your skills in evaluating chest pain. Be diligent in your assessments, stay updated with the latest guidelines, and always communicate clearly with your patients and colleagues. This comprehensive approach will not only improve patient outcomes but also enhance your clinical practice. Read the blog post here  

Managing Shortness of Breath in Pediatric Patients: A Comprehensive Guide Welcome to the St. Emlins blog. I’m Iain Beardsell, and I’m joined by our resident pediatric expert, Natalie May. Today, we’re discussing a challenging but crucial topic for those in Emergency Medicine: managing pediatric patients with shortness of breath. Understanding Pediatric Shortness of Breath Shortness of breath in children is a frequent and often intimidating presentation in the emergency department, especially during winter. This guide aims to provide a systematic approach to assess and manage these young patients effectively. Initial Assessment: Stay Calm and Structured When managing a child with shortness of breath, it's essential to stay calm and use a structured approach: Level of Consciousness: Determine if the child is alert or needs immediate resuscitation. Breathing Effort: Look for signs of respiratory distress such as the use of accessory muscles, intercostal and subcostal recession, tracheal tug, or head bobbing in infants. Breathing Efficacy: Listen for extra sounds like wheezes or stridor to identify the underlying pathology. Oxygen Delivery: Check the child's oxygen saturation, level of consciousness, and heart rate to evaluate breathing effectiveness. Oxygen Administration: A Safe First Step Administering oxygen is a safe and effective initial treatment for children with shortness of breath. It is unlikely to cause harm and can be crucial for stabilizing the patient while further assessments are made. Detailed History and Physical Examination Gathering a detailed history from the parents is essential: Chronology of Events: Determine how long the child has been short of breath. Pre-existing Conditions: Ask about any previous lung problems. Additional Symptoms: Note any associated symptoms like fever or cough. Inhaled Foreign Body: Consider this, especially if the onset of symptoms was sudden. This information helps in deciding the appropriate therapy and whether the child needs hospital admission. Common Causes of Pediatric Shortness of Breath 1. Bronchiolitis and Viral Wheeze Bronchiolitis is a common winter illness in children under two, often caused by respiratory syncytial virus (RSV). Key signs include: Respiratory distress with significant use of accessory muscles. Wheezing and low oxygen saturation. History of recent cold symptoms in the family. Viral Wheeze often presents similarly but occurs in slightly older children. Differentiating between bronchiolitis and viral wheeze involves assessing the severity and duration of symptoms. Management: Oxygen: Provide supplemental oxygen if saturation levels are low. Bronchodilators: Trial with salbutamol through a spacer or nebulizer can be beneficial. Steroids: Generally avoided in children under five unless there is a formal asthma diagnosis or previous steroid-responsive episodes. Admission Criteria: Severe respiratory distress. Persistent low oxygen saturation. Poor feeding and hydration status. History of prematurity or chronic lung disease. 2. Croup Croup is another common viral illness presenting with a characteristic seal-like barky cough and inspiratory stridor. It often worsens at night, causing significant distress to both the child and the parents. Management: Dexamethasone: A single oral dose (0.15-0.6 mg/kg) is effective in reducing airway inflammation and improving symptoms. Observation: Monitor the child for 2 hours post-treatment to ensure improvement. Calm Environment: Minimize distress and avoid unnecessary interventions that might exacerbate symptoms. Safety Netting: Provide parents with clear instructions on when to return to the hospital, especially if symptoms worsen during the night. 3. Bacterial Infections: Pneumonia Though less common than viral infections, bacterial pneumonia should be considered, particularly if the child presents with: Fever. Persistent cough. Decreased oxygen saturation. Subtle respiratory distress. Management: Chest X-ray: Useful for diagnosis if bacterial infection is suspected. Antibiotics: Initiated based on clinical judgment and X-ray findings. Admission: Necessary for children with significant respiratory compromise or those unable to maintain adequate oxygen levels. Special Considerations Feeding and Hydration Children with respiratory distress often have poor oral intake, leading to dehydration. Assess feeding history and urine output: Supportive Feeding: Nasogastric or intravenous fluids may be required. Monitor Hydration: Ensure adequate fluid intake and monitor for signs of dehydration. Obligate Nasal Breathers Infants are obligate nasal breathers, and nasal congestion can severely impact their breathing. Simple measures such as nasal saline drops can alleviate congestion and improve breathing. Inhaled Foreign Bodies Always consider the possibility of an inhaled foreign body, especially if the presentation is sudden and there is no clear viral cause. A chest X-ray or bronchoscopy may be required for diagnosis and management. Conclusion: A Structured Approach for Success Managing pediatric shortness of breath requires a calm, structured approach, leveraging skills from adult practice and adapting them for pediatric patients. Key steps include: Initial Assessment: Stay calm and systematic. Oxygen Administration: A safe first step. Detailed History and Physical Examination: Crucial for diagnosis. Management of Common Conditions: Bronchiolitis, viral wheeze, croup, and bacterial pneumonia. Remember, there is always senior support available, whether from a senior emergency physician or a pediatric colleague. By staying cool and methodical, you can effectively manage these challenging cases and provide excellent care for your young patients. Stay tuned to the St. Emlins blog for more in-depth discussions on pediatric emergencies and other critical topics in emergency medicine. Stay calm, stay curious, and keep learning.

The Challenge and Value of Research in Emergency Medicine: at DGINA 2014 Rick Body's talk from DGINA on the need for research in EM. Check out the associated blog post at http://stemlynsblog.org