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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Thursday, January 29, 2015

Anaphylaxis - Now on the podcast !



Hi there!

Last week we dealt with anaphylaxis, now it is available on the podcast (15minutes).
This was a session which I took sometime back for the residents (The Flipped Classroom).


I still see shocked patients getting a trial of steroids/antihistaminics before epinephrine. Steroids/Antihistaminics work (if at all!) to prevent the biphasic reaction and relieve the skin symptoms.

Epinephrine is the DRUG of choice for anaphylaxis and it should be administered ASAP.




This podcast will give you an understanding about when and how to use epinephrine.

Listen to the podcast.
There is also a handout available.






Thursday, January 22, 2015

Anaphylaxis - how are we doing?

Anaphylaxis is often one of the first emergencies which is taught to the residents. But how good are we in treating anaphylaxis - as emergency health care providers? Well, the literature says that the DOC for anaphylaxis (Epinephrine) is under-utilised, under prescribed for future use! 

Let us familiarise ourselves once again with the management of anaphylaxis, no groundbreaking information here, just a review of what we are supposed to do. 

Diagnostic criteria: Likely if any one of these criteria are met:
  1. Acute onset illness with involvement of skin and/or mucosa accompanied by either respiratory compromise, falling blood pressure or end organ dysfunction. 
  2. Two or more of the following symptoms occurring rapidly after exposure to the likely allergen: involvement of skin and/or mucosa, signs of respiratory compromise, falling blood pressure or end organ dysfunction and persistent GI symptoms. 
  3. Falling blood pressure within minutes to several hours following exposure to a known allergen.
(Note: Do not equate anaphylaxis with hypotension/shock. Hypotension is not mandatory to administer epinephrine)

Signs and symptoms: It is primarily a clinical diagnosis. Labs are rarely helpful. 
Skin is almost always involved in about 80% of the cases. Other major systems which can be involved are: 

Skin: flushing, urticaria, angioedema, warmth, swelling, conjunctival injection
RS: Nasal congestion, Coryza, rhinorhea, sneezing, throat tightness, wheezing, SOB, cough, hoarseness of voice
CVS: dizziness, weakness, syncope, chest pain, palpitations
GI: Dysphagia, nausea and vomiting, diarrhoea, bloating, cramps
CNS: headache, dizziness, blurred vision, seizure (rare)

Management 
ABCs (Anticipate challenging airway, keep plan B ready)
O2, fluids and epinephrine
IM Epi 0.5mg 1:1000 anterolateral thigh, repeat q5-10min x 3

Adjuncts
Steroids, H1/H2 blockers, bronchodilators
For those on beta blockers : glucagon
Other vasopressors : epi, vasopressin, nor epi infusion 

Decide on admission discharge based on doses of epi required, age, comorbidities. 


Bottomline:
Know the diagnostic criteria for anaphylaxis
Don't delay epinephrine 
Hypotension is not mandatory to diagnose anaphylaxis 
Fluids, O2 and Epinephrine - treatment for anaphylaxis (not steroids and antihistaminics)
Give epi pen and educate them at discharge 

Check out the recent guidelines for more info:








Tuesday, January 13, 2015

The 3 minute EM presentation

Let us start with the first post on this blog.

In my opinion this is probably one of the most important one for the first year residents/medical students rotating through the EDs who are learning how to work up a patient and get a good history. Also senior faculty and registrars can use this information to streamline and organise the process of history taking/presentation by junior physicians.

Well, We all have seen, patients frequently changing their answers to the same questions when asked by different doctors (especially consultants/attendings). I think this depends a lot on the way a question is framed. Remember, patients are not trained to give history, but we are trained to take a good history, So it is our responsibility to get a short history pertinent to their current visit.

Those of us who have worked for a good amount of time, also know that all the emergency physicians suffer from attention deficit to some extent and we have really really short attention spans and we always work under time constraints. So listening to a complete medical school history kind of is not possible in emergency room. So what is the solution? "A short and succint history" !
These articles are great resources for learning and teaching how to do short EM presentations focussing on pertinent history and physical examination. They are written from an emergency medicine perspective, cutting the history short without missing the crucial questions.

http://onlinelibrary.wiley.com/store/10.1111/j.1553-2712.2008.00145.x/asset/supinfo/ACEM_145_sm_DataSupplementS1.pdf?v=1&s=4ea7171f6805460892e2b5ce9b7b84f17721d6cc

http://www.saem.org/docs/2012-annual-meeting/the-3-minute-emergency-medicine-medical-student-presentation-a-variation-on-a-theme-pdf-.pdf?sfvrsn=2

Have a good read!