RCEM Belfast Day 1

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Authors: Nikki Abela, Dave McCreary, Becky Maxwell, Simon Laing, Andy Neill / Codes: CC6 / Published: 24/03/2015

Day 1 of the First CPD Conference since the College went Royal

RCEMFOAMeds Nikki Abela & Dave McCreary from FOAMedNW keep us up to date with what is happening at the #RCEMBelfast Annual CPD Conference 2015 with this summary blog and podcast with Andy Neil and Becky Maxwell.

Morning of Day 1- Care of the Elderly

Its been a great day at the first day of the RCEM annual CPD conference in Belfast today. Those who have been following us on Twitter on #RCEMBelfast will know many of our speakers have made interesting points for discussion.

First to get us talking was Kevin Maguire from Ulster hospital who spoke about physiology in the elderly and started off with some bad news, Physiology of ageing starts at 30, with a general deterioration after that.

The haematopoietic system changes and age on its own is a pro-coagulant state, which has us questioning: do we need to increase our d-dimer for diagnostic purposes in the elderly for diagnostic purposes?

Moreover, the elderly are more sensitive anti-coagulants like anti-Vitamin Ks, due to loss of 20-40% of liver mass with age, which decreases general function of the liver, even though LFTs do not change much!

This ties in very much with Richard Wilsons talk on sepsis in the elderly, where he questioned whether the SIRS criteria needed modification for older adults.

This is especially important as the condition, which kills 37,000 people per annum in the UK, has an increased mortality with age, where, even for those without co-morbidities compared to those who are younger with co-morbidities.

Immune senescence, co-morbidities, instrumentation, institutionalisation, immobility and malnutrition and in general a lower physiological reserve in older adults make the elderly more vulnerable to sepsis, Dr Wilson pointed out.

Youll be happy to find out that the mainstay of treatment does not really change with the elderly. It is still a time-critical condition with the general principals being:

  • Early senior involvement
  • Early antibiotics
  • Early fluid resus
  • Early BP management

(Im sure you can guess that early is the key word here, and it would be nice to resonate, at this point, Kumars 2006 paper which shows a 7.6% increase in mortality for every hour delay in antibiotics).

Richard Wilson also made an interesting point that although it is not appropriate to undertreat patients based on age, we do need to seriously consider the appropriateness of escalation of care for every patient.

This is where the 9-point mortality prediction score by Shapiro and RCEM End of Life Care guideline (great podcast on it here), will come in useful, especially in discussions with the family.

Sepsis is not the only condition that differs in the extremes of age, Bernardette Garrihy reminded us, in her lecture on Trauma in the Elderly. This age group are not only under triaged for major trauma, but under diagnosed and under treated. When you consider that 12% of major trauma patients are over 65 years and trauma is the 5th leading cause of death in elderly, Dr Garrihy had us questioning whether an ETLS (Elderly Trauma Life Support) would be an appropriate way forward with this?

If you would like to expand your knowledge on this topic, this podcast on the HECTOR project (@HECTORCares) with David Raven, EM Consultant at HEFT is a good place to start.

Now when it comes to geriatrics in the ED, unless you work in a paediatric trauma center, theres no shying away from it, Jay Banerjee, Consultant at the Leicester Royal Infirmary, pointed out.

With the elderly being nearly 2/3 of adult trolley patients, and the largest group conveyed by ambulance, you have to admit, You already work in a geriatric ED, he continued.

This is why we need appropriate outcome indicators for frail older people and EDs need to be more elderly friendly because if an ED is made for the most frail and vulnerable, it will work for the strongest.

And while the ED may not be the most appropriate place for a falls risk assessment, it is certainly appropriate for us to screen patients for it, Kevin Dynan pointed out.

Last but not least for the morning session, RCEMs very own Taj Hassan presented, Granny is not right- Neuro emergencies not to miss. Dr Hassan stirred up some talking on the controversial topic of LPs in normal CTs for SAH when only 1-2.5% of LP are positive, and in his own (as yet unpublished) research on these patients, in the 1200 patients studied, only 1 patient in 1500 needed intervention.

His take home considerations were:

  • Senior sign off for acute headache in the ED (where resources allow)
  • Consider strategies to have expert pharmacist in your CDUs and even EDs as a valuable risk/educational strategy
  • Think Thiamine deficiency, next time you see someone with recent onset memory loss and metabolic stress
  • It is important to have a high index of suspicion for NCSE (non-convulsive status epilepticus) in all elderly patients with confusion and altered conscious level, especially where there may not be a history of epilepsy.
  • It is vital to identify any patient with acute neurological deficit and pyrexia early and instigate therapy ASAP.

Afternoon of Day 1- MSK

After a super morning at the RCEM annual CPD conference in Belfast talking about care of the elderly, we moved on to musculoskeletal injuries. Myself and Dave McCreary have been tweeting away trying to keep everybody in the loop, and there have been a fair few discussions which can be followed on #RCEMBelfast.

Michael Earnes presentation on The Saturday Shoulder had a number of take home messages including:

  • Always test axillary nerve in shoulder injuries
  • Dont worry about special tests. It is more important to diagnose a rotator cuff teat and refer appropriately then sweat about the tests
  • A good history is essential in diagnosis of shoulder injuries
  • Ultrasound is a great imaging modality for these injuries as it can be used for assessment and intervention if needed

Later in the day Irelands own FOAMed guru, Andy Neill gave the most practical anatomy session that most of us have ever had. Popular topics were distinguishing extradural bleeds from subdurals on CT- Extradurals don’t cross suture lines, but subdurals do.

Moving on to spinal cord pathology, dont get jumbled up in the complex anatomy, what u need to remember is what youre examining. In the ED it’s largely touch, motor & pain, Andy continued.

Andy then went on to talk about hand injuries, but a short paragraph would not do the man any justice, so please, please visit his excellent website emergencymedicineireland.com to learn more from this excellent physician.

Later on, Christopher Moulton talked about the Not so minor… injuries we see in the ED, pulling the RCEM agenda into his talk that urgent care and ED services need to be co-located. While preaching to a largely converted audience, Dr Moulton dedicated his last 5-10 minutes on non-evidenced based but largely helpful tips on a range of minor injuries, including IV hyoscine hydrobromide for acute labyrinthitis and swimming nose clips for anterior nasal bleeds.

Last speaker of the day was Addenbrookes Adrian Boyle who brought us up to date on Soft Tissue Infections.

His talk on Necrotising Fasciitis, reminded us on the importance of this diagnosis which is missed in of cases, in spite of its 20% mortality rate and 15% amputation rate. This is an especially important diagnosis to consider in patients with disproportionate pain, he said.

High Risk factors for Necrotising Fascitis include:

  • Diabetes
  • Cirrhosis
  • Pressure sores- (look at perineal areas)
  • Recent surgey
  • Leukaemia

The LRINEC: lab risk factors for necrotising fascitis is a useful adjunct to clinical judgment (a medcalc version can be found here) and the Finger Test for Necrotising Fascitis, which has been tried and tested is something worth reading about.

A number of trainees had condensed 5 minute presentations which were very useful. Of particular mention is Andrew Smiths video on Valsalva manouvers in the ED, which he tried and tested himself.

It was a productive day for us all at the sessions, and if you want to be here but cant, you can, at least, follow us on twitter at #RCEMBelfast.

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