We have had a longstanding and controversial discussion about thrombolysis and definitive management of stroke, however, there is a unified front in trying to find a neuroprotective agent, that somehow shields the cells from damage. Over 70 different such agents have been tried in the past, with no success. One of the main criticisms relating to previous studies has been that the median time that they were given, was over 7 hours. Studies in rodent and primate models , found benefit, when the delivery of these agents occurs within 2 hours of the insult.(J Stroke Cerebrovas Dis 2004;17:109-112.) This means prehospital delivery.
A new paper by the Resuscitation Outcomes Consortium (ROC) was published in the NEJM(November 9th 2015). Nichol et al looked at Trial of Continuous or Interrupted Chest Compressions during CPR and their effect on survival. This was a prospective randomised crossover trial of 26148 patients in the pre-hospital environment.In the test group, CPR was performed at 100 compressions per minute for 3 cycles or 2 minutes each. By the beginning of the second cycle asynchronous ventilation at a rate of 10 breaths per minute was commenced. At the end of the 3rd cycle either a supra-glottic device or an endotracheal tube was inserted.
I was talking to a group of my junior registrars the other day about cardiac physiology, and I was struck by how much trouble they seemed to have relating electrolytes to the QRS complex. We sat down and nutted it all out which left everyone happy. The key to understanding the effects of electrolytes is to understand the cardiac action potential, and how it relates to the QRST complex seen on an ECG. Below is a brief summary of our conversation.
The call came: a case of Box Jellyfish(Chironex fleckeri) envenomation in a young girl and her father. The father was stable and pain was under control, however the daughter had such significant pain that, anti-venom had to be used. The wound had been washed with vinegar. Both patients were stable and comfortable in terms of pain levels. Good job by the ambos. I thought it would be a good time to review. How do we treat these types of stings and are there any controversies?
Have you ever had to reduce a dislocated jaw? I’ve done about 3 and it is always tough. Either get in front or behind the patient and above the patient and with gauze over the gloved thumb of each hand, use intra-oral manipulation, which involves pushing down hard on the bottom molars and perhaps adding a slight anterior tilt, to get it in. It is painful and in many cases the patient needs sedation.
This year at EMCORE 30-31st May, we are proud to have Dr Ken Winkel, Toxicologist and Director of the Australian Venom Research Unit at the University of Melbourne, talking about cold blooded bites. Here is a recent article by Dr Winkel in The Conversation. The comments following the article are very worthy of a read.
Here is a 3 minute video on the Whistler technique for putting in hips. Its quick and easy and really doesn’t allow you to hurt yourself. You use your legs to give you the traction. Just watch and see. Try it for yourself. I call it the under-over technique: I put my arm UNDER the knee of the affected side and rest my hand OVER the good knee. I will use this a fulcrum. Both ankles are stabilised and all I do is straighten MY legs and lift up, putting traction on the dislocated hip.
I’ve been speaking and writing about Supra Ventricular Tachycardia(SVT) a lot recently. Perhaps because of the number of cases coming in. Someone mentioned a new way to give adenosine for SVT. A recent post on Academic Life in Emergency Medicine, also mentioned this approach.
If you’ve worked in the emergency department for a few years, you will have seen a pseudo-seizure and hopefully have picked it. I know I was terrified of these in the early days, as I had trouble making the diagnosis and I had seen neurologists get it wrong. Now, they are a little easier to pick.
I’m not one to do prolactin levels and blood gases in this group, although I do look at pulse oximetry, which should show a decreased oxygen saturation, during a real seizure.
Here are some other tips that might help you. Be careful as there are always exceptions and always err on the side of giving your patient the benefit of the doubt.