Stealthy Pulmonary embolism
Dr. Anthony M Trinidad presented an unusual case of a patient who presented with left upper quadrant abdominal pain, and turned out to have a Sub massive pulmonary embolism (PE) masquerading as a fake pneumonia (Hampton hump). He highlighted the risks of a universal medical error phenomenon called Premature diagnostic closure.
This interesting case presentation was an opportunity to revisit the details of assessment and management strategies in pulmonary embolism. The role of combining a pretest probability, Modified Wells score, PERC rule and tests were discussed. These scoring systems and a suggested pathway of testing for PE will be shortly added to the Clinical guidelines section. You can also access these here.
Treatment options for pulmonary embolism (including submassive and massive) and variations were discussed with references made to the relevant recent scientific trials such as PEITHO
Paediatric trauma themed combined simulation
Emergency registrars and nursing staff attended a combined simulation session. Dr. Riaz Khan FACEM designed a scenario based on a prior real ED case; a child who presented non-critical multi-trauma. The key goals of the sim session was to practice teamwork, exercise restraint and finesse.
Collective thinking, good communication and teamwork concepts were emphasized in the feedback. Both doctors and nurses are encouraged to feel bold and be assertive for the best care of the patient. We build the team we want. With practice let’s build a spectacular one at that.
Clinical nurse educator Stuart Davidson organised the simulation equipment and made the fidelity as high as possible within limits of our available sim equipment. Plans are under way to procure higher fidelity Simulation equipment for our department.
Stuart reiterated the importance of writing the calculations on the templated resus room white board in advance.
Alternatively the computer (available in every cubicle) can be used to display calculations on a pediatric resuscitation tool such as PEMSOFT, RCH Clinical Practice Resuscitation guidelines etc.
Not everything has to be committed to memory. However, it is important to know the dosing of some essential drugs and interventions. Prompt analgesia is always important. Please also refer to the Paediatric analgesia leaflet by Dr. Marcus Yong from last week.
Dr. Riaz Khan led a clinical discussion and discussed the changing management strategies from the trauma care world (increasing push towards conservative management) of abdominal injuries including Splenic trauma and traumatic pneumothorax.
Recent relevant papers published in high ranking journals are attached below for you reference. The adaptability of this approach to pediatric practice is not yet established.
The concept of Damage control resuscitation, Haemostatic principles and transfusion principles were discussed. Agreeably we do not see many major trauma cases at LGH. However, it could happen any time and trauma drills will keep our skills top notch. Mock trauma drills will be starting in the department shortly.
ED registrar Dr Elena Smolianinova presented an Australian review article on pediatric seizure management from the EMA. The variations in practice across the country in seizure management was noted. However, several common concepts stay solid all across the country. For easy reference, the RCH Melbourne seizure management guideline seemed to be the crowd favorite.
The Pediatric doses of important emergency anti-epileptic agents are listed below (Courtesy: RCH CPG)
|Midazolam|| IV /IO/IM |
|0.15 mg/kg |
0.3 mg/kg (max 10mg)
0.2-0.5 mg/kg (max 10mg)
|IV route preferable but alternate routes can be used if rapid IV access not achieved. |
If 2 appropriate doses fail to terminate the seizure, further doses are unlikely to be effective and increase the risk of respiratory depression.
Use plastic ampoules for buccal and intranasal dosing.
| 0.1-0.3 mg/kg |
0.3-0.5 mg/kg (max 10mg)
| IV route preferable but alternate routes can be used if rapid IV access not achieved. |
If 2 appropriate doses fail to terminate the seizure, further doses are unlikely to be effective and increase the risk of respiratory depression.Use the rectal kits for PR dosing.
|20 mg/kg |
|Both given as loading doses over 20 minutes in a monitored patient.|
|Midazolam Infusion||IV/IO||Titrate dose |
1 – 5 micrograms/kg/min
|Incremental increase until control. Only to be initiated in a high dependency setting with involvement of senior staff. May be considered for treatment of refractory seizures as an alternative to RSI and ventilation.|
|Propofol||IV/IO||2.5mg/kg stat followed by infusion at 1-3mg/kg/hr for no longer than 48 hours||Use only with involvement of senior staff confident with airway management. For refractory seizures requiring RSI and ventilation. Beware hypotension.|
|Thiopentone(may not be available at all hospitals) ||IV/IO||2-5 mg/kg slowly stat followed by IV infusion at 1-4 mg/kg/hr||Use only with involvement of senior staff confident with airway management. For refractory seizures requiring RSI and ventilation. Beware hypotension.|
Presenters and facilitators please take note: In future, for Journal Club sessions, it would be useful for the audience if the articles are circulated electronically at least a week prior to the session.
Tasmania Health employees can access high ranking medical journals through EPOCH. As you know, this can be accessed from home too after a one-time set up from work.
ACEM members can access the EMA journal, by clicking the following link:
The Mortality and morbidity Review portfolio will be formally handled by an Emergency consultant starting mid February. Monthly Mortality and morbidity meetings shall be head thereafter by compiling case of each month. The name shall be announced to staff soon. Please watch this space.
Again, attendance was remarkable this week. Nurses who attended have been noted to put into practice their newly learnt tips in subsequent shifts.
We also welcomed our Swedish Exchange Medical students who attended the sessions, and reminded us that many medical things are named differently in Sweden, e.g. ‘Pulmonary embolism (PE)’ is called ‘Lung embolism (LE)’ over there. They were probably left tortured by all our Aussie acronyms.
Success is getting what you want. Happiness is wanting what you get.