August 2017 – RCEMLearning India

Author: Andy Neill / Codes: / Published: 01/08/2017

Warning

The content you’re about to read or listen to is at least two years old, which means evidence and guidelines may have changed since it was originally published. This content item won’t be edited but there will be a newer version published if warranted. Check the new publications and curriculum map for updates

Intro

Improving performance and deliberate practice

Authors:

Robert Lloyd, CT2, England
Andy Neill, EM Trainee, Ireland

Codes: CC23

Robert Lloyd is currently a CT2 EM trainee in England. We talked about some of the learning points from the recent book Peak by Anders Ericsson and Robert Pool

Pondering EM – Robs Blog
Simon Carley on deliberate practice
St Emlyns interview with Rob about his experience in South Africa.
The recently published RAGE podcast covers a lot of similar ideas without reference specifically to deliberate practice. It is 2 hrs 45 mins of 3 blokes talking about how they think about excellence, training, weakness and improving. Well worth a listen

BTS Oxygen Guideline

Authors:

Becky Maxwell, EM Consultant, Bristol.
Chris Connolly, EM Consultant, Sheffield

Codes: CAP6, HAP6,

Right now we have given you enough time to digest all the clever definitions, lets drill down into the benefits and risks of oxygenation.

Firstly, we must prescribe oxygen. Would you expect the nursing staff in the department to administer any other drug without you prescribing it of course not! Oxygen has its side effects just like any other drug and we need to be more rigid about prescription and administration. This cant happen without a basic understanding..

But hold on second, oxygen is good right?? I need it to live, how could there be any bad effects to such a vital thing?? What are the risks of over oxygenating a patient?

The most significant effect that we talk about with oxygen administration is hypercapnic respiratory failure in those patients who are deemed at risk COPD patients, NMDs we know this and it doesnt come as any surprise, we are pretty good at this. The pathophysiology of this is complex from loss of respiratory drive through to V/Q mismatch and absorption atelectasis and none of this lends itself easily to discussing in this podcast.

What we dont talk about so often is those other effects:

Rebound Hypoxaemia in those who have developed T2RF if you suddenly withdraw the oxygen therapy you can get a rebound hypoxia which is often worse that the position you started in before you administered the oxygen!
Coronary and cerebral vasoconstriction there have been studies showing hyperoxia is bad for strokes and MIs secondary to this phenomenon. Potentially worse outcome have been demonstrated in those patients who have had a mild to moderate stroke in studies.
Damage from free oxygen radicals leading to alveolar damage and reperfusion injury post MI to name a few.

There are times when it is good to administer oxygen to patients who arent hypoxic in the ED.

Spontaneous pneumothorax probably the most common one well come across in the ED. high-concentration inhaled oxygen can also increase the rate of reabsorption of air from a pneumothorax up to fourfold.
Carbon monoxide and cyanide poisoning
Cluster headache immensely painful, oxygen is a wonder drug in these patients and should be administered at 12L per minute. One study comparing oxygen delivery via reservoir bag at 12L /min found that headache reduced by 78% in 15 minutes compare to 20% in those breathing air.

Ok so weve talked about definitions and those who arent hypoxic who benefit from oxygen. Lets talk about the more common reason to want to give oxygen hypoxic hypoxaemia.

The first thing to say is that recognition is key. The guideline calls SpO2 the 5th vital sign, poor sats. Only 5th! A timely reminder to use a validated track and trick tool such as NEWS score when assessing unwell adults.
Rapid assessment including history and examination should happen in conjunction with vital sign monitoring.
Dont take the oxygen off to get an air reading on those who are clearly requiring oxygen therapy.
Use an ABG in all critically unwell patients, in those who you are concerned are hypoxemic and those at risk of hypercapnic respiratory failure.

So when are we giving oxygen?

When we suspect or prove the patient is hypoxic.
Of unknown cause give 15l NRB is SpO2 <85%, if higher than this a NC 2-6L or Hudson 5-10L this is good advice IMHO starting with ALL the oxygen if its clearly all bad, if not then start medium and crank it up as needed.
If you know the cause is either Asthma, pneumonia, acute change in lung Ca or fibrosis, then the advice is the same.
If theres a pneumothorax causing the hypoxemia give high flow oxygen whilst prepping to get it drained, likewise pleural effusion.
All of these patients should be treated with a target of 94-98% saturation.
If your patient has risk factors for T2RF then start low and target 88-92% prior to blood gases. The guidance recommends venture 24 or 28% or nasal cannulae at 1-2L.
These folks are as youd expect
- IECOPD, CF, those with neuromuscular disorders, chest wall deformity and morbid obesity. This last category is one we seem to be seeing more and more of up here. They ventilate terribly, have a multitude of difficulties with obtaining a safe gas balance being just one! In terms of reversible disease theyre really tricky too Id be interested to know about long term ICU outcomes in those who are obese but have no underlying lung disorder.

So were going to start oxygen in lots of patient and then were going to do some blood gases.

The guidance recommends the first sample is done arterially and then subsequent gases can be an arteriloised lobe sample, warning that these can under-estimate the pO2 by 0.5-1kpa

We should try and remember to use LA unless its a dire emergency Ill be honest I only started doing this about a year or so ago after seeing some talk about it on twitter. Unlike with cannula which I find the LA makes it more difficult the ABG is sooooo much easier with a cooperative patient that has a numb wrist!

So lets talk COPD

The first point the guidance raises which is welcome is that you dont have to have a formal diagnosis of COPD to treat a patint as though they have COPD this is great advice.
If someone is over 50, smokes properly and has a hsitroy of exertional SOB, and there isnt another cause idenitifable then assume COPD.

Giving oxygen:

remember we said to start low and slo with these guys. 24 or 28% venture. But if this isnt working then increase to 5L via face mask or a 2-6L NC.
Remebeer that if the RR is >30 then you need to increase the flow rate on a venturi mask to higher than on the packaging this is something I remember some of the time Ill be honest!!
If the pH and PCO2 were normal on your COPD patients first gas then aim at saturation 94-98 and repeat the gas in 30-60 minutes. If you know their usual resting sats are <94 then aim at 88-92%.
If the pCO2 is raised but the pH is normal aim sats at 88-92% and recheck at 30-60 minutes.
If the pH <7.35 and PCO2 > 6 then start NIV if no improvement at 30 mins from starting medical therpay.

This is great advice. Although Im never that optimistic Ill get the repeat gas done at minute 30. I often start NIV early doors, as they usually had salbutamol and Atrovent a couple of times in the ambulance. Means the medics can do the repeat ga at 60mins post BIPAP.

Another useful bit of advice sneaked away at the bottom consider NIV for all patients with hypercapnoeic respiratory failure due to CF/obesity/ NMDs. Wooohoooo. Gone are the days of the chest doctors rolling their eyes and only wanting it started on those with COPD. Obvs weve been ignoring them for years, but now I can send them away to read this 100 page epic!!

So that all sounds pretty important right? Yep well it is. Patients can get harmed by too much or too little oxygen. So it needs prescribing. Its a bloody drug!!

The guidance says we should have a standardised prescription chart for this. This prescription should be for/to a target saturation rather than a specific flow rate of oxygen. If the situation is emergent then just giving the 15L O2 via NRB is fine, and shouldnt be delayed for a formal prescription similar to anaphylaxis adrenaline really. Last thing to say on prescribing is oxygen alert cards. If your patient has one then use it, flow the targets on it until you have a blood gas back. I saw on twitter a while back (I think in Stoke) livestrong style bracelets for people in hospital for target saturations I liked this although obvs is open to abuse/failure. We just have a acahrt above the drugs bit on our ED card with 88-92, 94-98 and other with space for a signature. Im a pedant when it comes to oxygen prescription. One day Ill audit our practice. Not sure Ill like the results..

Paper Number 1

Authors:

Casey Parker, Rural GP and ED Doc, Broome, Western Australia

This month our new in EM section is a bit different. I (Andy) had the pleasure in taking part in a podcast at SMACC in Berlin. This is from Casey and Justins regular journal review podcast. They cover some great stuff and its really worth subscribing.

The Paper

Spinner RJ, Poliakoff MB, Tiel RL. The origin of Saturday night palsy? Neurosurgery. 2002; 51(3):737-41.

BroomeDocs (Casey)
First 10 EM (Justin)

RCEM Reference

Authors:

Simon Laing, EM Consultant, Bristol

Codes: CAP 29

This month we have a look at a n area that may not be everyones strength, eyes! The reference section on Atraumatic Red Eyes covers a whole host of presentations and deserves a full read.

In this short section we concentrate on the easily missed acute angle glaucoma and when to prescribe antibiotics in conjunctivitis.

Further reading:

Assessing the older patient with confusion

Authors:

Rosa McNamara, EM Consultant
Andy Neill, EM Trainee, Ireland

Codes: HAP 13, CAP 13, CAP 32, HAP 5

Rosa Mcnamara is an emergency physician trained in Ireland and the UK with a special interest in care of the older person in the ED.

Further reading/listening:

Myths in COPD

Authors:

Kirsty Challen, EM Consultant, Preston
Andy Neill, EM Trainee, Ireland

References:

Hurst JR, Vestbo J, Anzueto A, Locantore N, Mllerova H, Tal-Singer R, Miller
B, Lomas DA, Agusti A, Macnee W, Calverley P, Rennard S, Wouters EF, Wedzicha JA;
Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints
(ECLIPSE) Investigators. Susceptibility to exacerbation in chronic obstructive
pulmonary disease. N Engl J Med. 2010 Sep 16;363(12):1128-38. doi:
10.1056/NEJMoa0909883. PubMed PMID: 20843247
Kitaguchi Y, Yasuo M, Hanaoka M. Comparison of pulmonary function in patients
with COPD, asthma-COPD overlap syndrome, and asthma with airflow limitation. Int
J Chron Obstruct Pulmon Dis. 2016 May 9;11:991-7. doi: 10.2147/COPD.S105988.
eCollection 2016. PubMed PMID: 27274220; PubMed Central PMCID: PMC4869610
Jennings JH, Thavarajah K, Mendez MP, Eichenhorn M, Kvale P, Yessayan L.
Predischarge bundle for patients with acute exacerbations of COPD to reduce
readmissions and ED visits: a randomized controlled trial. Chest. 2015
May;147(5):1227-1234. doi: 10.1378/chest.14-1123. PubMed PMID: 25940250.
Harrison SL, Janaudis-Ferreira T, Brooks D, Desveaux L, Goldstein RS.
Self-management following an acute exacerbation of COPD: a systematic review.
Chest. 2015 Mar;147(3):646-661. doi: 10.1378/chest.14-1658. Review. PubMed PMID:
25340578.
Hitchings AW, Baker EH. Avoiding unnecessary arterial blood sampling in COPD
exacerbations: a stab in the right direction. Thorax. 2016 Mar;71(3):208-9. doi:
10.1136/thoraxjnl-2015-208205. Epub 2016 Feb 9. PubMed PMID: 26860345.
McCanny P, Bennett K, Staunton P, McMahon G. Venous vs arterial blood gases in
the assessment of patients presenting with an exacerbation of chronic obstructive
pulmonary disease. Am J Emerg Med. 2012 Jul;30(6):896-900. doi:
10.1016/j.ajem.2011.06.011. Epub 2011 Sep 9. PubMed PMID: 21908141.
Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA.
Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane
Database Syst Rev. 2012 Dec 12;12:CD010257. doi: 10.1002/14651858.CD010257.
Review. PubMed PMID: 23235687.
Stefan MS, Nathanson BH, Higgins TL, Steingrub JS, Lagu T, Rothberg MB,
Lindenauer PK. Comparative Effectiveness of Noninvasive and Invasive Ventilation
in Critically Ill Patients With Acute Exacerbation of Chronic Obstructive
Pulmonary Disease. Crit Care Med. 2015 Jul;43(7):1386-94. doi:
10.1097/CCM.0000000000000945. PubMed PMID: 25768682; PubMed Central PMCID:
PMC4470719
Hajizadeh N, Goldfeld K, Crothers K. What happens to patients with COPD with
long-term oxygen treatment who receive mechanical ventilation for COPD
exacerbation? A 1-year retrospective follow-up study. Thorax. 2015
Mar;70(3):294-6. doi: 10.1136/thoraxjnl-2014-205248. Epub 2014 May 14. PubMed
PMID: 24826845; PubMed Central PMCID: PMC4345793
Bereza BG, Troelsgaard Nielsen A, Valgardsson S, Hemels ME, Einarson TR.
Patient preferences in severe COPD and asthma: a comprehensive literature review.
Int J Chron Obstruct Pulmon Dis. 2015 Apr 8;10:739-44. doi: 10.2147/COPD.S82179.
eCollection 2015. Review. PubMed PMID: 25914530; PubMed Central PMCID:
PMC4399696