ECG shows regular narrow complex tachycardia with rate around 140
We suspected this was atrial flutter
Rather than subject a patient to the horror of iv adenosine (which only reveals flutter - it can’t convert it), we moved the ECG limb leads around to get a ‘Lewis lead’ which better shows atrial activity
This revealed quite clear evidence of atrial flutter
After some fentanyl, a checklist, some white medicine and 50 Joules of synchronised electricity, the patient was in sinus rhythm and discharged to follow up with his cardiologist after observation on the ED Short Stay Unit
2. A patient who had had a transcatheter aortic valve implantation (TAVI) a few days earlier came in feeling dizzy
He has complete heart block
Conduction problems are a well recognised complication of TAVI due to the close proximity of the aortic root and conduction tissue
He was normotensive and mentating normally with good skin perfusion and a normal lactate
He did not require intervention in the emergency department and was admitted for pacemaker insertion
3. A man walked in with a 30 minute history of severe chest pain
A diagnosis of anterolateral STEMI was made. Cath lab was activated and he was given fentanyl, aspirin, ticagrelor and heparin
The on call interventional cardiologist was still on his way in when other cath lab staff were ready
Normally the patient should stay in ED until the cardiologist is ready but we suggested bringing him up anyway to reduce delays and reassured the cath lab nurses we would stay with him until the cardiologist arrived
This enabled the patient to have wrist and groin prepped and draped and was ready for intervention as soon as the cardiologist arrived (ED registrar and cath lab nurse shown in image)
Summary from today’s cardiology patients in the ED:
1. Lewis lead unveils atrial activity that’s difficult to identify on standard ECG
2. Conduction problems can occur after TAVI
3. EM & Cardiology can work together to devise local solutions to minimise reperfusion delays
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How we describe a situation can have a psychological framing effect that can affect our performance
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Mindset, confidence, and therefore performance are likely to be worse if you expect the airway to be ‘difficult’ rather than prepare for it to be ‘potentially challenging’
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A previously well patient in her 60's presents with a first seizure & post-ictal coma
A nasopharyngeal airway has been placed for airway patency
She weighs 100kg
She receives 70mg propofol /100mg rocuronium after checklist completion, pre-ox & application of nasal cannula O2
This video shows what a nasopharygeal airway looks like, and how far it can go down
It was removed during laryngoscopy- not sure why. Consider leaving it in in case you need it to support facemask ventilation if laryngoscopy is unsuccessful
Stopping someone from bleeding to death requires many keys steps
Our team uses this cognitive aid
Page 1 covers general measures to guide vascular access, haemostatic resuscitation, reversal of anticoagulation, and optimising of clotting
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Page 2 gives specific guidance on managing the location of haemorrhage, eg. epistaxis, haematemesis, etc
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We use this to ensure things aren't forgotten, such as maintaining normocalcaemia and normothermia, and that doses are at our fingertips, eg. for prothrombin complex concentrate or terlipressin
Over the last couple of decades my colleagues and I have analysed HUNDREDS of resuscitation cases and here are the THREE things you need to master to save more lives
1. Airway management. You need checklists, videolaryngoscopy, waveform capnography, and an airway registry to enable you to review and share airway QI data
2. Shock and haemorrhage control: you need early POCUS in hypotensive patients, a massive transfusion protocol, viscoelastic testing, and systems for early humeral IO, US guided peripheral IV access, or wide bore CVC placement