The St.Emlyn’s Podcast

Exciting Updates from St. Emlyn's: Highlights, Conferences, and Upcoming Events Welcome to the St. Emlyn's Podcast Recap Greetings, St. Emlyn's community! We are delighted to bring you the latest updates and highlights from our podcast and blogosphere. Let's dive into our recent achievements, exciting conferences, and what's on the horizon for our team. Highlights from the Past Few Months The past few months have been phenomenal for St. Emlyn's. Our blog has seen a surge in readership, and we’ve received fantastic feedback on various posts and podcast episodes. One standout topic has been the work on high-sensitive troponin, thanks to Rick's invaluable insights. Even those of us working with troponin in our department found new learnings through the podcast. Another high point was Natalie May's episode on button battery ingestion in children. This critical topic resonated with many of our listeners and highlighted the dangers and necessary precautions surrounding this issue. Additionally, having Alan Grayson critique NICE guidelines on heart failure provided us with fresh perspectives and sparked meaningful discussions within our virtual hospital. Conferences and Collaborations Our team has been active on the conference circuit, sharing knowledge and gaining new insights. The European Society of Emergency Medicine (EUSEM) conference in Amsterdam was a significant event, offering a plethora of information and networking opportunities. Natalie is even planning to produce a book and podcast to summarize the key takeaways from the conference. Down in Exeter, the Chem conference exceeded expectations. Adam Ruben’s podcast recap provided a comprehensive overview of the event, and we had the pleasure of paddleboarding with Cliff Reed, adding a bit of fun to the professional gathering. The Evolution of Emergency Medical Conferences Emergency medical conferences have evolved remarkably over the past decade. The variety and depth of content offered now are impressive. Our team is already gearing up for the Chem conference in Manchester next September, and the recently released program for SMACC Chicago has everyone buzzing with excitement. SMACC Chicago: A Preview The SMACC conferences are renowned for their exceptional quality and dynamic content, and SMACC Chicago is no exception. The program is packed with sessions from leading experts in emergency medicine, making it challenging to choose which talks to attend. Simon Carley will be presenting alongside luminaries like Scott Weingart, Pat Cross-Kerry, Ashley Shree, and Stephen Mayer, promising a wealth of knowledge and inspiration. The release of the SMACC Chicago program has us eagerly anticipating the event. With five streams of information, choosing which sessions to attend will be a delightful dilemma. Highlights include sessions with Karim Brohee, Paul Marik, Rick Body, and Louise Cullen. Simon is excited to be part of such an esteemed lineup, despite the stiff competition. Workshops and Debates Before the main conference kicks off, a series of workshops will provide hands-on learning experiences. Simon will join Scott from the Medical Evidence Blog, Ken Milne from SGEM, Rob McSweeney, Rick Body, and David Newman from Smart EM to discuss evidence-based emergency medicine. It’s an incredible opportunity to learn from and with the best in the field. One of the anticipated sessions is the SMACC Chicago forum on Thursday afternoon, featuring debates and discussions on topics that matter deeply to the emergency medicine community. The session titled “Seeking the Truth” promises to be a highlight, with speakers like Paul Young and Simon Finfer discussing randomized controlled trials (RCTs). Networking and Building Connections Conferences like SMACC are not just about attending sessions—they’re about building connections and forming lasting relationships with peers and mentors. Meeting the greats of emergency medicine, such as Dave Newman, and discussing both cutting-edge topics and the human side of medicine, makes these conferences invaluable. The Value of Investing in Education While attending conferences can be a significant financial investment, the benefits far outweigh the costs. The opportunity to learn from leading experts, network with peers, and stay updated on the latest advancements in emergency medicine makes these events a crucial part of professional development. For those considering attending SMACC Chicago, registration opens on the 5th of November. Early registration for trainees, nurses, and paramedics offers a more affordable way to join this transformative event. What's Next for St. Emlyn's? Looking ahead, we have a robust lineup of podcasts and blog posts planned. Our induction series continues to provide valuable insights for new doctors entering emergency medicine departments across the UK. We’re also exploring topics like Gestalt and clinical thinking to deepen our understanding and improve patient care. Join the Conversation: Get Involved with St. Emlyn's We want to hear from you! Your feedback helps us tailor our content to meet your needs. Connect with us on Facebook, rate us on iTunes, and share your thoughts and ideas. We’re always looking for guest writers to contribute to our blog. If you have a topic you’re passionate about, reach out to us and join the St. Emlyn's community. A Special Thanks A special thanks to Sarah Payne for her timely articles on Ebola, which have been incredibly well-received. Her contributions have enriched our blog, providing vital information and sparking meaningful discussions. Enjoy Your Emergency Medicine Journey At St. Emlyn's, our mission is to make your emergency medicine journey more enjoyable and fulfilling. We’re committed to enhancing your professional development and patient care through engaging content and insightful discussions. Stay tuned for more podcasts, blog posts, and exciting updates. Don’t forget to register for SMACC Chicago and join us for an unforgettable experience. Thank you for being part of the St. Emlyn's community. Enjoy your emergency medicine journey, have fun, and go forth and heal the sick. We’ll be back soon with more exciting content and updates.

The Danger of Button Batteries: Essential Information for Emergency Physicians Introduction Hello and welcome to the St Emlyn's blog. I'm Simon Carley, and alongside me is Natalie May. This post addresses a frequent and potentially serious issue in emergency departments: the ingestion of button batteries. With Halloween and Christmas approaching, these small but hazardous objects become more prevalent in households with small children. Here, we provide critical insights for emergency physicians on identifying, managing, and preventing complications related to button battery ingestion. Understanding Button Battery Ingestion Button batteries, or disc batteries, are small, round batteries found in devices like watches, musical badges, and holiday decorations. Their size and shiny appearance make them attractive to children, who may ingest them or insert them into their noses or ears. While they appear harmless, button batteries can cause significant harm if they become lodged in mucosal surfaces. The Risks of Button Battery Ingestion When a button battery becomes wedged against a mucosal surface, it generates a small electrical current. This current can cause chemical burns and tissue damage within as little as two hours. If not promptly removed, the battery can lead to severe complications, including death. Common Scenarios and Symptoms Children often ingest various objects, but button batteries pose a unique risk due to their electrical properties. Here are common scenarios and symptoms to watch for: Ingestion: Symptoms range from mild (drooling, difficulty swallowing) to severe (vomiting, abdominal pain, gastrointestinal bleeding). Nasal Insertion: Batteries in the nose can cause nasal discharge, pain, and significant tissue damage if unnoticed. Ear Insertion: Batteries in the ear can lead to pain, discharge, and hearing loss if not promptly addressed. Radiological Identification Button batteries are radiopaque, making them visible on X-rays. They can be distinguished from coins by their characteristic double shoulder appearance. This feature is crucial for accurate diagnosis and timely intervention. Management Strategies Immediate Steps for Suspected Ingestion High Index of Suspicion: Be vigilant for signs of button battery ingestion, especially if parents report missing batteries from devices. Radiological Examination: Perform an X-ray to locate the battery and determine its position. Removal from Ears and Noses ENT Referral: Button batteries in the nose or ears should be removed promptly by an ear, nose, and throat specialist. These areas are less moist than the esophagus but can still suffer chemical burns and tissue damage. Esophageal Ingestion Surgical Emergency: Batteries lodged in the esophagus must be removed immediately. This task is typically handled by general surgeons or gastroenterologists. Delaying removal can lead to severe complications, including perforation, erosion into blood vessels, and catastrophic bleeding. Post-Removal Care and Follow-Up Even after successful removal, children must be monitored for complications. Discharge instructions should include warning signs such as gastrointestinal bleeding, severe abdominal pain, vomiting, respiratory distress, and refusal to eat. Follow-up appointments and possibly additional X-rays are essential to ensure no further damage has occurred. Prevention Tips for Parents Educating parents about the dangers of button batteries is crucial. Here are some tips to share with them: Secure Storage: Keep button batteries out of reach of children. Device Safety: Ensure battery compartments in devices are secure and childproof. Immediate Action: If a battery is missing and a child shows symptoms of ingestion, seek medical attention immediately. Case Studies and Real-Life Examples Case 1: Nasal Insertion A child was brought to the emergency department with a suspected nasal insertion of a button battery. Despite a thorough examination, no battery was visible. However, an X-ray revealed a large button battery lodged in the posterior nose. Prompt referral to ENT and removal prevented further complications. Case 2: Esophageal Lodgment A child swallowed a button battery that became lodged in the esophagus. The battery was removed within two hours, but the child was monitored closely for weeks due to the risk of delayed complications. Despite initial removal, the child developed severe symptoms days later, highlighting the importance of vigilant post-removal care. Conclusion Button batteries pose a significant risk to children, particularly during festive seasons when they are more prevalent in households. Emergency physicians must maintain a high index of suspicion, utilize radiological tools effectively, and act swiftly to manage cases of ingestion or insertion. Educating parents about the dangers and prevention strategies is equally important. Stay vigilant, stay informed, and ensure the safety of our youngest patients. Additional Resources For more information on button battery ingestion and other pediatric emergencies, visit the St Emlyn's blog. Follow us on Facebook and join our community of emergency medicine professionals dedicated to providing the best care for our patients.

The Crucial Role of Accurate Coding in Emergency Medicine: Insights from St Emlyns Welcome to the St Emlyns blog! Today, we dive into a topic often overlooked but crucial to the functioning and financial health of emergency departments (ED): coding. This subject might not have the drama of resuscitations or surgical interventions, but it significantly impacts how we are perceived and funded. In this post, we explore how coding works in the context of emergency medicine in England, why it matters, and how we can improve our practices for better outcomes. Understanding Coding in Emergency Departments What is Coding? In the simplest terms, coding is the process of translating medical activities into standardized codes that determine how much a hospital gets paid for the services provided. This is done through systems like the HRG-4 (Health-Related Grouping) codes, which classify the treatments and investigations performed on patients. Why is Coding Important? Accurate coding is essential because it directly affects the revenue of an emergency department. The details recorded in discharge summaries play a significant role in determining the funds a hospital receives. For instance, different procedures and investigations, like CT scans or blood tests, have specific codes that contribute to the total amount of money paid to the hospital. The Financial Implications of Coding Top Earning Codes in Emergency Medicine The highest amount an ED can earn for a single patient episode is £237, applicable in cases involving resuscitation, thrombolysis, or laser eye surgery. However, if no tests or treatments are performed, the hospital only earns £58 for that patient. This stark difference underscores the importance of detailed and accurate coding. Common Investigations and Their Codes MRI/CT Scans: High-value procedures that significantly boost the hospital's revenue. Ultrasound Scans: Similarly valued to MRI/CT scans, contributing substantial amounts to the hospital's income. Vital Signs Recording: Even basic procedures like recording vital signs can elevate the payment from the lowest tariff. Challenges in Implementing Accurate Coding Perception vs. Reality Many healthcare professionals, including doctors and nurses, often view coding as an administrative burden rather than a critical part of patient care. This perception needs to change, as the quality of coding affects not only financial outcomes but also how the department's efficiency and effectiveness are perceived by external bodies like the CCG (Clinical Commissioning Groups). The Role of IT Systems Modern IT systems have made the coding process more streamlined, though they are not without their challenges. Integrating coding tasks into daily routines, such as through discharge summaries and GP letters, can help ensure that all activities are recorded accurately. Improving Coding Practices Education and Awareness Educating staff about the importance of coding and its impact on both departmental funding and patient care is crucial. Junior doctors and new consultants should be made aware of how their input affects the overall picture. Dedicated Coding Staff Some hospitals have experimented with employing dedicated coding staff who review and correct coding entries, leading to significant increases in revenue. This approach can alleviate the burden on clinicians and ensure more consistent and accurate coding. Streamlining Processes Integrating coding into clinical workflows can make it less of a chore. For example, requesting an X-ray through the hospital's system should automatically record it in the patient's coding data. Such improvements can simplify the process and reduce the likelihood of missed entries. The Impact of Coding on Departmental Perception Meeting Standards and Avoiding Fines In England, EDs are required to meet specific standards, such as the four-hour wait time target. Failing to meet these standards can result in fines, which further strain departmental resources. Accurate coding helps present a true picture of the department's workload and efficiency, potentially mitigating some of these financial penalties. Communicating with Commissioners Accurate coding ensures that commissioners have a clear understanding of the services provided by the ED. Misrepresentations can lead to misconceptions about the department's performance and the appropriateness of patient attendances, affecting future funding and policy decisions. Case Study: VB11Z Code The VB11Z code, which indicates that no investigations or treatments were performed, often misrepresents the actual work done in the ED. For example, patients admitted under the care of other specialists but using ED resources might be incorrectly coded, leading to a loss of revenue. By addressing such coding inaccuracies, departments can better reflect their true workload and resource needs. Practical Tips for Better Coding Record Everything Ensure that all procedures, tests, and treatments are recorded, no matter how minor they might seem. This includes vital signs, which can elevate the payment bracket significantly. Integrate Coding with Patient Care Make coding part of the routine patient care process. For example, use discharge summaries to not only inform GPs but also to ensure all activities are coded. Leverage Technology Utilize the full capabilities of IT systems to automate and streamline coding tasks. This can reduce the manual burden and improve accuracy. Continuous Training Regularly update staff on coding practices and the importance of accurate data entry. This helps maintain awareness and reduces the risk of complacency. Conclusion While coding might not be the most glamorous aspect of emergency medicine, it is undeniably one of the most crucial. Accurate coding not only ensures that departments are properly funded but also that they are accurately represented in terms of workload and efficiency. By integrating better coding practices into daily routines and educating staff on its importance, emergency departments can significantly improve their financial health and operational effectiveness. For more detailed information, including specific codes and their values, visit our blog or contact us directly. Keep coding and keep improving patient care!

Rick and Iain explore how the latest guidance about the use of high sensitivity troponin was developed and how far we can be assured that it is evidence based. The NICE guidance is available here. http://www.nice.org.uk/guidance/dg15 vb S

In Situ Simulation in Emergency Medicine: Insights from St. Emlyn's Welcome to the St. Emlyn's blog. I'm Ian Beardsell, and I'm Simon Carley. Today, we're exploring in situ simulation, a vital method for improving patient care and team efficiency in emergency medicine. I'll be discussing this at UCEM, and we want to share our insights on implementing it effectively in your department. What is In Situ Simulation? In situ simulation takes place in your clinical environment, such as the resuscitation room or patient cubicles. Unlike traditional simulation centers that require significant resources, in situ simulation happens where you work every day. This method allows teams to practice and refine their skills in the actual setting, making training more relevant and practical. Gorilla Simulation vs. In Situ Simulation Gorilla simulation, a subset of in situ simulation, involves an element of surprise. It means conducting unplanned simulations during odd hours to test spontaneous team responses. For instance, pressing the resus buzzer at 3 AM with no prior warning and having the team manage a mock patient. While gorilla simulation is riskier and more challenging, it provides valuable insights into team dynamics and readiness. The Importance of Simulation in Emergency Medicine Initially, many clinicians, including myself, were skeptical about the impact of simulation training. However, extensive research and our experiences at St. Emlyn's show that simulation significantly improves clinical skills, team coordination, and patient outcomes. Studies have demonstrated its effectiveness across various departments, and we've observed marked improvements in team behavior, organization, and efficiency since implementing regular simulation sessions. Overcoming Challenges in Simulation Training Not everyone is comfortable with simulation, especially those who are more introverted or less familiar with the process. It's essential to acknowledge this and create a supportive environment. Normalizing simulation as part of routine training helps, as does ensuring that initial sessions are positive and constructive. We learned through trial and error to gauge participants' comfort levels and adjust the training accordingly. Practical Tips for Conducting In Situ Simulation Integration into Daily Routine: Conduct simulations around handover times, usually at 8 AM. This timing ensures double staffing, and if handover finishes early, the simulation can proceed without disrupting the department's workflow. Multi-professional Participation: Involving nurses, healthcare support workers, radiographers, and other relevant staff enhances the realism and effectiveness of the simulation. For example, if a scenario involves a CT scan, we physically take the mannequin to the CT scanner. Patient and Staff Engagement: Inform patients and staff beforehand to gain their support. Most patients are understanding and even find it interesting when they know a training exercise is happening. Handling Distractions: Real-world distractions are an integral part of emergency medicine. Incorporating these into simulations teaches teams how to manage interruptions effectively. Securing Buy-in from Your Department Gaining support from senior clinicians and nursing leaders is vital. At St. Emlyn's, our clinical director and senior nurses championed the initiative. Presenting simulation as a solution to improve patient care and team coordination, backed by incident reports and data, helps persuade colleagues of its value. Frequency and Topics for Simulation We aim to conduct simulations three to four times a week. The focus is often on resuscitation and emergency scenarios, but we also cover other essential skills and processes, such as handover communication and teamwork. Keeping scenarios simple and relevant to daily practice ensures that training remains practical and impactful. The Role of Debriefing Debriefing is a critical component of simulation training. We conduct hot debriefs immediately after the simulation to capture fresh insights and feedback. This process is conversational, focusing on participants' experiences and learning points rather than a rigid critique. We also document key learning outcomes to track progress and identify areas for improvement. Involving Other Departments For scenarios involving multiple specialties, such as major trauma, we include relevant teams like anesthetists, surgeons, and radiologists. With high-level consent and coordination, these simulations provide comprehensive training and improve inter-departmental collaboration. Implementing Guerrilla Simulation While we haven't extensively practiced guerrilla simulation due to its high-risk nature, it offers significant learning opportunities. Conducting simulations in unexpected settings or times, such as a cardiac arrest in the minors area, tests the team's adaptability and response under pressure. However, it's crucial to balance this with the department's workload and stress levels to avoid overwhelming staff. Conclusion: The Value of Simulation in Emergency Medicine Simulation training, particularly in situ simulation, is a powerful tool for enhancing clinical skills, team dynamics, and patient care. It requires careful planning, support from leadership, and a commitment to continuous improvement. At St. Emlyn's, we've seen firsthand the positive impact of regular, practical simulation training, and we encourage other departments to adopt and adapt these practices to suit their needs. By integrating simulation into your routine, involving multi-professional teams, and maintaining a focus on practical, relevant scenarios, you can significantly improve your department's readiness and performance. As we continue to refine our approach and share our experiences, we hope to inspire others to embrace simulation as a cornerstone of emergency medicine training. Thank you for joining us on the St. Emlyn's blog. We look forward to sharing more insights and updates from UCEM and beyond. If you have any questions or would like to share your own experiences with simulation, please leave a comment or get in touch with us.

Mastering the Art of Presentation: Insights from St. Emlyns and Victoria Brasile Welcome to the St. Emlyns blog! I'm Iain Beardsell, and today, we're diving into a recent enlightening session with the rest of the St. Emlyns team—Simon, Nat, and Rick—alongside the exceptional educator, Victoria Brasile. Victoria recently visited the UK and shared invaluable tips on delivering excellent presentations to the emergency medical community in Manchester. For those familiar with Victoria’s engaging talks at SMACC, either in person or online, you're in for a treat as we explore the key points from this memorable evening. The Power of a Great Presentation Victoria Brasile's visit was a golden opportunity for the emergency medicine community. Her session focused on how to deliver impactful presentations—an essential skill for any healthcare professional. Here are the core messages she shared: Connect with Your Audience: Establishing a strong connection with your audience is fundamental. Look and Sound Great: Presentation is not just about content but also about delivery. Keep It Simple: Simplicity ensures clarity and retention. These principles form the bedrock of an excellent presentation, whether addressing a large lecture hall, a small group, or even a single patient. Connecting with the Audience Victoria emphasized the importance of making a genuine connection with your audience. She believes that regardless of the audience size, the ability to connect on a personal level is crucial. Here’s how you can achieve this: Engage Interactively: Encourage audience participation by asking questions or incorporating interactive elements. Use Relatable Stories: Share anecdotes that resonate with the audience’s experiences. Maintain Eye Contact: Establishing eye contact can make your audience feel involved and valued. During the Manchester session, Victoria practiced what she preached by fostering interaction and creating an inclusive environment. Her approach demonstrated how effective communication can transform a presentation into an engaging dialogue. The Importance of Presentation Victoria highlighted that looking and sounding great goes beyond mere aesthetics; it’s about being confident and authentic. Here are her top tips: Dress Appropriately: Your attire should be professional but comfortable, ensuring you feel confident. Voice Modulation: Vary your tone to maintain interest and emphasize key points. Body Language: Use purposeful gestures to reinforce your message and avoid distracting habits. In Manchester, Victoria’s presentation was a masterclass in these techniques. Her confident demeanor, combined with dynamic voice modulation and engaging body language, kept the audience captivated. Simplicity is Key The third cornerstone of a great presentation is simplicity. Victoria advised that a clear and straightforward message is more likely to be remembered and appreciated. Here’s how to keep it simple: Focus on Key Points: Identify and emphasize the main takeaways. Avoid Jargon: Use language that is easily understandable, avoiding technical terms unless necessary. Visual Aids: Use slides and visuals that are clear and directly related to your points. Victoria’s own presentations are a testament to this principle. She distilled complex information into easily digestible parts, ensuring her audience could follow along and retain the key messages. Lessons from the St. Emlyns Team Our team also shared their reflections and learnings from Victoria’s session: Rick Boddie: Managing Nerves Rick found the session particularly insightful for managing presentation nerves. He realized that controlling nerves is essential not only for the speaker but also for the audience’s comfort. Rick’s takeaway included: Preparation and Practice: Regular practice to build confidence. Breathing Techniques: Simple breathing exercises to calm nerves. Audience Empathy: Recognizing that the audience might be just as nervous. Natalie May: Planning for Interaction Natalie focused on incorporating audience interaction into her presentations. She plans to use: Social Media and Technology: Integrating modern tools to engage the audience. Structured Interactivity: Planning specific moments for audience participation. Pacing: Slowing down her speech to ensure clarity and engagement. Simon Carly: First Impressions Simon highlighted the importance of making a strong first impression. His key points included: Immediate Engagement: Captivating the audience right from the start. Preparation: Ensuring thorough preparation before stepping onto the stage. Action-Packed Opening: Starting with a memorable and impactful opening, akin to a Bond movie. Enhancing Audience Interactivity Victoria’s innovative approach to audience interaction was a standout feature of her session. She shared how dedicating a few minutes for the audience to interact amongst themselves can enhance the overall experience. This strategy not only breaks the ice but also makes the audience feel more connected and engaged. During her SMACC Gold talk, Victoria’s use of theatre—changing the stage setup and creating a visually intriguing environment—demonstrated how a bit of drama can capture and hold the audience’s attention. Conclusion: The Three Pillars of a Great Presentation Victoria Brasile’s session at Manchester reinforced the three pillars of a great presentation: connecting with the audience, looking and sounding great, and keeping it simple. These principles are not just theoretical; they are actionable strategies that any speaker can implement to enhance their presentations. The St. Emlyns team’s reflections further underscore the importance of preparation, interaction, and first impressions. As we continue to learn and grow in our professional journeys, let’s keep these valuable lessons in mind. Whether you’re presenting at a conference, teaching a class, or communicating with patients, these insights will help you deliver your message more effectively and confidently. Stay tuned for more insights and tips from the St. Emlyns team. We hope you enjoyed this deep dive into the art of presentation. Until next time, embrace your emergency medicine practice with enthusiasm and excellence! For more resources and links to Victoria Brasile’s talks, visit our blog site. If you have any questions or thoughts to share, please leave a comment below. We’d love to hear from you!

Understanding and Managing Diffuse Axonal Injury in Neurointensive Care Welcome to the St Emlyn’s blog. I’m Iain Beardsell, and today we delve into the complex and crucial topic of diffuse axonal injury (DAI) with insights from John Hell, a consultant in Neurointensive Care at the University Hospital of Southampton and former director of the Wessex Neuroscience’s Intensive Care Unit. With his extensive experience and co-authorship of the Neurointensive Care guidelines, John provides a comprehensive overview of DAI, its pathophysiology, management, and prognosis. What is Diffuse Axonal Injury? Diffuse axonal injury is a type of traumatic brain injury where the brain’s axons are sheared due to rapid acceleration or deceleration forces. This can occur in various scenarios, from minor to severe head injuries. The axons, which connect the grey matter (cell bodies) on the brain's surface to the white matter (nerve fibers) inside, are particularly susceptible to damage when subjected to such forces. Pathophysiology of Diffuse Axonal Injury The pathophysiology of DAI involves axonal shearing due to differing densities and connections between grey and white matter. When the brain moves at different rates within the skull during an injury, this shearing occurs. Initially, this stretching does not necessarily rupture the axons but causes them to swell and release mediators. These mediators lead to further axonal breakdown and secondary brain injury characterized by cerebral edema, increased intracranial pressure (ICP), and restricted diffusion of glucose and oxygen. Clinical Presentation and Diagnosis DAI can be challenging to diagnose initially, as early imaging might show minimal changes. However, small petechial hemorrhages at the grey-white matter interface can be indicative. These are more evident on MRI scans or repeat CT scans after 6 to 24 hours. Clinicians should be vigilant about mechanisms of injury, Glasgow Coma Scale (GCS) scores, and clinical presentation to suspect DAI. Management Strategies in Neurointensive Care The management of patients with DAI involves a multi-faceted approach focused on stabilizing and maintaining normal physiological parameters. Key steps include: Initial Stabilization: Ensure normal blood pressure, oxygenation (PACO2 and PIO2), and venous drainage from the head by positioning the patient appropriately and avoiding obstructions like tight cervical collars. Monitoring and Imaging: Initial imaging may show little, but repeat CT or MRI scans can reveal the extent of the injury. Placing an ICP monitor helps in maintaining adequate cerebral perfusion pressure (CPP) as ICP rises over 72 to 96 hours. Intravenous Fluids: Use of normal saline is recommended due to its osmolality. Other fluids like Hartmann's, which are hypo-osmolar, can exacerbate cerebral edema by diluting plasma. Anticoagulation Management: Reversal of anticoagulation and ensuring normal platelet function is crucial. Patients on anticoagulants should have these reversed immediately, and those on antiplatelet agents should receive platelet transfusions if still bleeding. Prognosis and Outcomes Prognosis in DAI is variable and often unpredictable based on initial presentation. While patients with poor GCS scores tend to do worse on average, individual outcomes can vary widely. Aggressive monitoring and management in neurointensive care units have shown that many patients can recover to independence and good quality of life, challenging the previous perception of uniformly poor outcomes. Practical Insights for Emergency and Pre-Hospital Care In emergency and pre-hospital settings, early interventions can significantly impact outcomes. Prioritizing normal physiological parameters, using appropriate induction agents, and ensuring timely referral to neurointensive care are essential steps. For instance, thiopental is recommended for induction in hemodynamically stable patients with isolated head injuries due to its efficacy in minimizing cerebral metabolic rate for oxygen (CMRO2). For unstable patients, ketamine remains a safe alternative despite old concerns about its use in head injuries. Case Study and Practical Application Consider a hypothetical case of a 45-year-old cyclist involved in a high-speed accident, resulting in severe head injury without intracranial bleed but with suspected DAI. The patient is intubated and ventilated by the pre-hospital team and transferred to a major trauma center. Initial CT shows minimal injury, but due to the mechanism and presentation, DAI is suspected. In neurointensive care, management focuses on: Stabilization: Ensuring normal blood pressure, oxygenation, and venous drainage. Monitoring: Placing an ICP monitor and repeating imaging at 6, 12, or 24-hour intervals. Fluid Management: Using normal saline to maintain plasma osmolality. Anticoagulation Reversal: Reversing any anticoagulation and ensuring normal platelet function. Over the next 72 to 96 hours, the patient’s condition is closely monitored, with adjustments made based on ICP readings and repeat imaging. The interdisciplinary team works together to minimize secondary brain injury and support recovery. The Role of Education and Ongoing Research Continuous education and staying updated with the latest guidelines and research are crucial for healthcare professionals managing traumatic brain injuries. The Neurointensive Care guidelines co-authored by John Hell and his team are a valuable resource available online, providing evidence-based practices for managing these complex cases. Conclusion Diffuse axonal injury remains a significant challenge in neurointensive care, requiring a comprehensive and multidisciplinary approach for optimal outcomes. Early recognition, aggressive management, and ongoing research are key to improving the prognosis for patients with DAI. By maintaining normal physiological parameters, utilizing appropriate fluids, and implementing timely interventions, healthcare professionals can make a substantial difference in the recovery and quality of life for these patients. Thank you for joining us on the St Emlyn’s blog. We hope this detailed exploration of DAI provides valuable insights for your practice. Stay tuned for more discussions on critical topics in emergency and intensive care medicine.

Understanding Syncope: A Comprehensive Guide for Emergency Medicine Introduction Today, we are discussing syncope, a common yet complex condition involving a transient loss of consciousness due to a temporary reduction in blood flow to the brain. This comprehensive guide aims to provide insights into diagnosing and managing syncope in the emergency department. The Challenge of Syncope Diagnosis When patients present with collapse, it’s essential to differentiate between mechanical falls and syncope due to physiological reasons. The key to diagnosis lies in understanding whether the event was caused by a transient loss of consciousness or a mechanical fall. This distinction guides the diagnostic pathway and ensures the appropriate management of potential life-threatening conditions. Physiology of Syncope Syncope results from a temporary reduction in cerebral perfusion pressure, which can occur due to various physiological disruptions. Understanding the factors affecting cerebral perfusion, such as mean arterial pressure, cardiac output, and peripheral resistance, is crucial. Any significant deviation in these parameters can lead to syncope. Cardiac Causes of Syncope Rhythm Issues Cardiac syncope often involves rhythm disturbances like bradycardia (abnormally slow heart rate) or tachycardia (abnormally fast heart rate). Bradycardia can reduce cardiac output, while tachycardia can decrease stroke volume. Identifying these rhythm issues is vital as they can be life-threatening. Structural Issues Structural heart diseases, such as aortic stenosis or hypertrophic cardiomyopathy, restrict blood flow, leading to syncope. Pulmonary embolism, although less common, can also cause syncope by obstructing pulmonary circulation. Importance of ECG in Diagnosis The electrocardiogram (ECG) is a critical tool for diagnosing cardiac causes of syncope. It helps identify arrhythmias, conduction abnormalities, and other cardiac issues. Continuous ECG monitoring, or Holter monitoring, can capture transient arrhythmias not seen on a standard ECG. Neurological Causes of Syncope Neurological conditions, such as seizures and transient ischemic attacks (TIAs), can present as syncope. Differentiating between these and true syncope is essential. Seizures often have specific signs like tongue biting, loss of bladder control, and post-ictal confusion. TIAs can cause temporary disruptions in blood flow to the brain, leading to syncope-like episodes. Physiological Causes of Syncope Vasovagal Syncope Vasovagal syncope, triggered by stress, pain, or prolonged standing, involves a sudden drop in heart rate and blood pressure. It is a common and generally benign cause of syncope. Orthostatic Hypotension Orthostatic hypotension, a drop in blood pressure upon standing, can result from dehydration, medications, or autonomic dysfunction. It is a frequent cause of syncope, especially in elderly patients. Diagnostic Approach Patient History A thorough patient history is crucial for identifying the cause of syncope. Key elements include the circumstances of the episode, prodromal symptoms, witness accounts, and medical history. This information helps distinguish between different causes of syncope. Physical Examination A comprehensive physical examination includes checking vital signs, cardiovascular examination, and neurological assessment. Identifying abnormalities during the physical exam can provide clues to the underlying cause of syncope. Diagnostic Tests ECG: Identifies arrhythmias and conduction abnormalities. Holter Monitoring: Captures transient arrhythmias. Echocardiogram: Assesses structural heart diseases. Tilt-Table Test: Diagnoses vasovagal syncope or orthostatic hypotension. Blood Tests: Evaluate electrolyte levels, blood glucose, and cardiac biomarkers. Management Strategies Cardiac Syncope Management of cardiac syncope focuses on stabilizing heart rhythm and function. Treatments may include pacemaker implantation for bradycardia, medications for tachycardia, and surgical interventions for structural heart diseases. Arrhythmias may require implantable cardioverter-defibrillators (ICDs). Neurological Syncope Managing neurological causes involves addressing the underlying condition. Antiepileptic medications control seizures, while immediate interventions restore blood flow in strokes or control bleeding. TIAs require medications and lifestyle changes to reduce recurrence risk. Physiological Syncope Vasovagal Syncope: Management includes avoiding triggers, increasing fluid and salt intake, and using compression stockings. Severe cases may require medications. Orthostatic Hypotension: Gradual position changes, increased hydration, and reviewing medications. Medications like fludrocortisone may be necessary. Dehydration: Rehydration with oral or intravenous fluids. Medication Review: Adjusting or discontinuing medications contributing to syncope. Safety Netting and Follow-Up Safety netting ensures patients receive appropriate follow-up care and instructions. Key elements include providing clear discharge instructions, scheduling follow-up appointments, and educating patients about syncope causes and management. Special Considerations Reflex Anoxic Seizures Reflex anoxic seizures, seen especially in children, involve shaking movements due to a drop in oxygenation. These can be misinterpreted as epileptic seizures but require different management. Misdiagnosis Risks Misdiagnosis of syncope as epilepsy or vice versa is common. Always consider both possibilities, especially when symptoms overlap. Postural Hypotension and Specific Diagnoses Postural hypotension requires careful evaluation. Special considerations include ruling out abdominal aortic aneurysm in older men and ectopic pregnancy in younger women. Conclusion Syncope is a multifaceted condition that demands careful evaluation and management in the emergency department. By understanding the underlying causes, utilizing appropriate diagnostic tools, and implementing effective management strategies, healthcare professionals can optimize patient outcomes and reduce the risk of recurrent episodes. This guide aims to provide valuable insights into the diagnosis and management of syncope, helping healthcare providers deliver high-quality care. For further information, examples, and case studies, visit the St Emlyn's blog, where we continue to share knowledge and expertise in emergency medicine. Remember, accurate diagnosis and timely intervention are key to managing syncope effectively. Stay vigilant, consult with senior colleagues when needed, and always prioritize patient safety. Thank you for reading. If you have any questions or need further information, please get in touch. We look forward to continuing the conversation and improving patient care together.

Understanding High Sensitivity Troponins: A Guide for Emergency Physicians Welcome to the St. Emlyn's podcast. I'm Ian Beardsell and I'm Rick Bodden. This is part two of our troponin special where we delve deeper into high sensitivity troponins (hs-Tn) and their significance in emergency medicine. Today, we'll explore the nuances of hs-Tn assays and how they can enhance our work in the emergency department (ED). Introduction to High Sensitivity Troponins High sensitivity troponins (hs-Tn) have transformed how we detect and manage myocardial infarctions (MI) in emergency settings. Unlike traditional assays, hs-Tn tests detect much lower concentrations of troponin, a protein released during myocardial injury, allowing for earlier and more accurate detection of cardiac events. Analytical Sensitivity vs. Diagnostic Sensitivity Understanding the difference between analytical and diagnostic sensitivity is crucial. Analytical sensitivity refers to the assay's ability to detect low concentrations of troponin, whereas diagnostic sensitivity relates to the test's performance in diagnosing acute myocardial infarctions (AMI). Key Points on Analytical Sensitivity: Detection Threshold: High sensitivity troponin assays can detect troponin in over 50% of healthy individuals. Precision: These assays have a coefficient of variation (CV) of less than 10% at the diagnostic threshold, ensuring consistent results. Diagnostic Sensitivity: Improved Detection: Studies show hs-Tn assays have a higher diagnostic sensitivity (90-92%) compared to older assays (80-85%). Early Rule-Outs: This makes hs-Tn particularly valuable for ruling out AMI in patients presenting with chest pain in the ED. High Sensitivity Troponin Assays: A Closer Look To illustrate, let's focus on the Roche troponin T high sensitivity assay: 99th Percentile Cutoff: 14 nanograms per liter. Detection Range: Can detect levels as low as 3 nanograms per liter. Higher Readings: It's common for hs-Tn assays to give higher readings than older assays for the same sample, which affects the diagnostic threshold. The Balance Between Sensitivity and Specificity While hs-Tn assays improve sensitivity, they may reduce specificity: More Positives: Lowering the diagnostic threshold results in more positive results, increasing diagnostic sensitivity but reducing specificity. Predictive Value: For example, a positive hs-Tn T result at patient arrival has a specificity around 70% and a positive predictive value of 50%. Using High Sensitivity Troponins in the Emergency Department Early Rule-Out Protocols: The most significant advantage of hs-Tn assays is their potential to expedite the rule-out process: Zero and Three-Hour Protocols: Studies suggest that hs-Tn assays can effectively rule out AMI with samples taken at 0 and 3 hours after arrival, instead of the traditional 6-hour wait. Efficiency: This protocol can significantly speed up patient throughput in the ED, reducing congestion and wait times. Understanding Deltas: Delta refers to the change in troponin levels between tests: Absolute vs. Relative Deltas: Absolute changes (e.g., an increase of 10 nanograms per liter) are often more reliable than relative percentage changes. Clinical Context: It's crucial to interpret deltas in the context of the patient's overall clinical picture. Practical Considerations for Emergency Physicians Incidental Troponin Elevations: With increased testing at the front door, incidental findings are inevitable: Low Pre-Test Probability: In patients with a low pre-test probability of AMI (e.g., mechanical falls), a positive hs-Tn result often does not indicate AMI. Clinical Judgment: Consider repeating the test and evaluating the patient's history and clinical presentation before making a decision. Patients with Comorbidities: Troponin levels can be elevated in patients with various comorbidities: Age and Chronic Conditions: Older patients and those with conditions like LV dysfunction may have higher baseline troponin levels. Reference Ranges: Use broader reference ranges for patients with comorbidities, as suggested by studies from Paul Collins and colleagues. Future Directions and Guidelines Ongoing Research: Research and guidelines on hs-Tn usage are continually evolving: NICE Guidelines: Recommendations on using hs-Tn in clinical practice are expected to be published, providing clearer protocols for emergency physicians. Early Adoption: As new evidence emerges, early adopters must balance innovation with patient safety. Point-of-Care Testing: While hs-Tn assays currently require large analyzers, point-of-care testing remains a goal: Future Developments: Advances in technology may eventually make hs-Tn testing available at the bedside, further streamlining ED workflows. Conclusion High sensitivity troponins represent a significant advancement in the early detection and management of myocardial infarctions in the emergency department. By understanding the nuances of analytical and diagnostic sensitivity, utilizing early rule-out protocols, and interpreting results within the clinical context, emergency physicians can leverage these assays to improve patient care. As always, ongoing research and adherence to evolving guidelines will be essential in optimizing the use of hs-Tn in clinical practice. We hope this podcast helps you better understand the complexities and advantages of high sensitivity troponins. For more insights and updates, stay tuned to the St. Emlyn's blog and feel free to reach out with your questions and experiences. Together, we can continue to advance emergency medicine for the benefit of our patients.

College of Emergency Medicine Conference 2024: Everything You Need to Know Welcome to the St. Emlyne's blog, where we provide the latest updates and insights into the world of emergency medicine. Today, we're diving into the much-anticipated College of Emergency Medicine (CEM) Conference, set to take place in Exeter from September 9th to 11th. This conference is not only a hub for academic learning but also a celebration of the progress and future of emergency medicine. Why Exeter? Exeter, nestled in the scenic Southwest of England, offers an exciting venue for this year’s CEM Conference. The University of Exeter provides a fresh and dynamic backdrop, allowing attendees to experience a new environment. The choice of Exeter also aims to highlight the region's significant contributions to medical research and practice. Plus, the location promises better weather compared to other parts of the UK, making it a pleasant destination. Key Highlights and Speakers The conference is packed with sessions designed to engage and educate emergency medicine professionals. Here are some highlights to look forward to: Inspirational Talks and Keynote Speakers Ann Marie Kelly from Australia will share her expertise on arterial and venous blood gases, offering critical insights for daily medical practice. James Robson, doctor to the Scottish rugby team and the British and Irish Lions, will discuss the pressures and challenges of pitchside medicine and his experiences over the past 15 to 20 years. Cliff Reed, a renowned figure in emergency medicine, will inspire attendees with his motivational presentations. Cliff Mann, the current college president, will discuss clinical topics, reflecting his deep involvement in frontline emergency medicine. Engaging Sessions The conference features a variety of sessions tailored to different interests within emergency medicine: Dragon's Den: Watch as grant applicants pitch their projects to a panel of emergency medicine experts, competing for a share of £1000 to fund their innovative ideas. Stroke Management: Jason Kendall will provide an in-depth look at stroke management and the latest research in this critical area. Social and Networking Events Balancing work with social activities is a key theme of the conference. Highlights include: Gala Dinner at Exeter Castle: An opportunity to unwind and network in a historic setting. Explore Devon Activities: From surfing at Bantham to paddleboarding on the River Exe, there are plenty of outdoor activities. Attendees can also enjoy kayaking, mountain biking, or exploring local museums. Academic Excellence The conference boasts a robust academic programme with four tracks running simultaneously on some days, ensuring there's something for everyone, whether you're a trainee, an established consultant, or involved in cutting-edge emergency medicine research. Core Emergency Medicine Topics Sessions focus on essential topics in emergency medicine, aiming to reconnect professionals with the fundamentals that make this field vital and rewarding. The goal is to address rising attendances and increasing pressures in emergency departments by reinforcing core knowledge and practices. Cutting-Edge Research Attendees will engage with the latest research and innovations in emergency medicine. The programme is designed to be both educational and academically stimulating, attracting participants with its high-quality content. Why Attend? The CEM Conference in Exeter offers numerous benefits: Professional Development: Enhance your knowledge and skills through sessions led by top experts in the field. Networking: Connect with colleagues from across the country and beyond, sharing experiences and best practices. Inspiration: Gain new perspectives and motivation from leading figures in emergency medicine. Fun and Relaxation: Enjoy the social events and explore the beautiful surroundings of Exeter and Devon. Practical Information Booking and Availability If you haven't booked your place yet, it’s not too late! There are still a few spots available, but they are filling up fast. Visit the college website to secure your place and register for the explore Devon activities, which are also in high demand. Staying Updated For those who can’t attend in person, the conference will share video excerpts of key sessions. Follow the #CEMEXETER2014 hashtag on Twitter and check out the college's YouTube channel for updates and highlights. Conclusion The CEM Conference in Exeter is shaping up to be an unmissable event for anyone in the field of emergency medicine. With its combination of high-quality academic content, inspirational speakers, and engaging social activities, it promises to be both educational and enjoyable. Whether you're attending for the learning opportunities, the chance to network, or simply to enjoy the vibrant atmosphere, this conference has something to offer everyone. Don't miss out on this fantastic opportunity to advance your career and connect with the emergency medicine community. Book your place today and join us in Exeter for an unforgettable experience!