Thursday, 23 May 2019

Vascular Ischaemia

Physical Exam
Cardiac - murmur, AD
Extremity - look for signs of chronic peripheral vascular disease
Neurological - sensory and motor loss
Vascular - grade peripheral pulses
ABPI

Amputations are more common with thrombotic occlusions.
Emboli are different - and most often from the heart and comprised of platelets. They can also come from aneurysms - and will be made of atheroma.
Vasculitis, iatrogenic, compartment syndrome, aortic dissection are also risk factors.

Upper arm emboli are less common. Thoracic outlset syndrome may masquerade - pressure on the subclavian artery from a cervical rib or abnormal soft tissue band may lead to a dilatation lined with thrombus, predisposing to occlusion or embolisatoin.  Popliteal aneurysms are very likely to be dislodged.

PAIN - worse on movement, and relieved by hanging your legs over the edge. Tenderness on examination is often due to muscle death.
PALLOR - limbs are often white. Chronically ischaemic limbs may turn sunset pink due to compensatory response. Dry gangrene is black, and a sign of chronic ischaemia for more than two weeks.
PARAESTHESIA-
PERISHINGLY COLD - compare
PULSELESSNESS - use dopplers

Check bloods including a creatinine kinase.

Treatment: Analgesia, Oxygen, 5000 units IV heparin, heparin infusion, IV fluids
   Unless bleeding, pregnant, CVA/TIA, tumour, previous GI bleed, trauma

References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117769/
https://www.rcemlearning.co.uk/references/acute-limb-ischaemia/
https://learning.bmj.com/learning/module-intro/aae-arterial-disease.html?moduleId=10057018&searchTerm=%E2%80%9Cvascular%E2%80%9D&page=1&locale=en_GB

Wednesday, 22 May 2019

Sexual Assault and STIs


As a presentation to ED, I don't think sexual assault is that common, and the brief mention in the curriculum probably supports that. Sexual assault is maybe underrepresented and more common than we think.
Sexual Assault
- Examine carefully including in the mouth and treat any injuries - consider liasing with SARC for forensic samples to be taken before irrigating wounds if appropriate.
- Advise patient not to wash or bathe, eat or drink - as it will affect samples
- Refer to SARC if patient wishes to attend. The investigations may take three hours. DNA can be gathered for up to seven days after vaginal penetration, up to two days in oral penetration and for up to three days in anal/penile penetration irrespective of washing or bathing
- Offer emergency contraception
- Safeguarding referrals
-Accelerated Hep B - one now, one month, two month
  If high risk Hep B immunoglobulin
- Bloods 3 months after exposure
- Consider PEPSE
- STI prophylaxis -  Cefixime 400mg + Azithromycin 1g + Metronidazole 2g as single oral stat
 (pregnant or breastfeeding women Cefixime 400mg + Azithromycin 1g).


Domestic Violence
SAFE Questions
S tress/Safety Do you feel safe in your relationship?
A fraid/Abused Have you ever been in a relationship where you were threatened, hurt, or afraid?
F riend/Family Are your friends aware you have been hurt?
E mergency Plan Do you have a safe place to go and the resources you need in an emergency?

Sexually Transmitted Infections
Reactive Arthritis aka Wegener's aka Reiter Syndrome 
2-6 weeks following infection (Chlamydia, salmonella, shigella, yersinia, campylobcater)
Symmetrical arthritis, knees, ankles, feet and heels
Triad - can't see, can't pee, can't climb a tree.
 Conjunctivitis or uveitis
 Dactylitis
 NSAIDs

Gonococcal Arthritis often causes septic arthritis

Other STIs
Our curriculum says we need to know the main types. I think that seems sensible...although actually, all we really need to know I think is test test test.

And secondary syphilis is making a come back.   


Herpes Zoster
Significant exposure
- infected people with exposed or disseminated lesions, or those with compromised immunity are more likely to shed the virus. Low risk of contracting the virus from the zozster rash under clothing.
- Infectious 48hrs before until crusts.
- Closeness and duration of the contact - face to face or contact in the same room for >15minutes.



Gonorrhoea
The clap. Causes urethritis and cervicitis. Can get extragenital infection in the rectum, pharynx, and conjunctiva. It can disseminate to cause polyarthritis, tenosynovitis and detrmatitis or septic arthritis. Disseminated gonococcal meningitis and endocarditis can occur but are rare. Treat!

Anogenital warts- condylomata acuminata
90% caused by HPV6 and 11. Most are asymptomatic, and warts are mostly painless. Can confirm with biopsies.

Syphilis
10- 90 days incubation.
Primary infection - chancre
Secondary - 4 - 10 weeks later with a symmetric, non-pruritic, reddish pink rash. Condylomata latum may appear. Resolve over 3-6 weeks and disease becomes latent.
Tertiary Syphilis - 3 - 15 years later. Neuro, cardiovascular, or gummas - growths in skin, liver or bone. May get argyl robertson pupil. May cause anerysms. May get snuffles. Test for it - and treat with ben pen.

Chlamydia
Often silent. Can infect the eye causing trachoma.

Herpes Simpex
Incubation 2- 12days. Lifelong infection. Acyclovir can help. Can get skin to skin or skin to mat transmittion. Causing whitlow, eye problems and mouth and gums.

Trichomoniasis
Women more than men. Give metronidazole. Get frothy green smelly discharge.

References
https://www.rcemlearning.co.uk/modules/sexual-assault-victims-in-the-ed/
https://www.rcemlearning.co.uk/foamed/emergency-contraception/
https://www.rcem.ac.uk/docs/College%20Guidelines/5s.%20Management%20of%20Adult%20Patients%20who%20attend%20Emergency%20Departments%20after%20Sexual%20Assault%20and%20or%20Rape%20(revised%20Oct%202015).pdf

https://www.rcem.ac.uk/docs/College%20Guidelines/5t.%20Management%20of%20Domestic%20Abuse%20(March%202015).pdf

http://southlondonem.blogspot.com/2014/07/sexual-assault.html
https://learning.bmj.com/learning/search.html?locale=en_GB&collection=The+BMJ&collection=BMJ+Learning&searchTerms=sexual
https://www.rcemlearning.co.uk/foamed/rcem-guideline-domestic-violence/
https://learning.bmj.com/learning/module-intro/-women-domestic-abuse.html?moduleId=5003147&searchTerm=%E2%80%9Cdomestic%20violance%E2%80%9D&page=1&locale=en_GB
https://www.nice.org.uk/guidance/PH50
https://emj.bmj.com/content/21/1/9
https://www.aliem.com/2013/07/pv-intimate-partner-violence/
https://emergencymedicinecases.com/intimate-partner-violence/
https://learning.bmj.com/learning/module-intro/-women-domestic-abuse.html?moduleId=5003147&searchTerm=%E2%80%9Cdomestic%20violance%E2%80%9D&page=1&locale=en_GB
https://www.bmj.com/content/334/7585/143 

Saturday, 23 February 2019

Common Competencies

I wrote a summary of what each common competency involved to make sure I linked properly. Here's my summary:

CC1 - History Taking - Risk Factors, Communication Barriers, Time Management, Questionnaire,  conflicting family, assimilate, non-verbal queues, mechanism of injury, no bias in re-attenders, children, interpretor, third parties, notes review

CC2 - Clinical Examination - constraints to overcome them, limitations, targeted, DSH, interpet, mental state, clinical, psychologial, religious, social and cultural factors, adjunctive examinations, ECG, spirometry, ABPI, joints, FAST, echo

CC3  - Therapeutics and safe prescribing
Indications, contraindications, SEs, drug interaction, dose of commonly used drugs, adverse drug reactions, complementary meds, tools for patient safety and prescribing including ID, effects of age, body size, organ dysfunction, concurrent illness on drug distribution and metabolism, regulatory agencies, review long term meds, anticipate and avoid interactions, appropriate drug dose, adjustments, monitoring, concordane, explainations, minimise risk, non-medical prescribers, formulary, info sharing, therapeutic alert
Methadone
Meds from overseas, and translate into UK equivalent,
Children, rapid chemical tranq.
Empathetic for pain. PGD. Drug prescribing audits. Reviews stock. Introduces new drugs.

CC4 - Time management and decision making
Organisation, prioritisation, delegation, techniques for time management, prompt investigation, diagnosis + treatment. Estimate time.  Workload. Work to deadline. Calm in stress.
Manages multiple patients. Quick disposal decisions, CTR... Staff allocation. Team management. Teaching during low demand.
Rota vs patient attendances

CC5 - Decision making + clinical reasoning
Interpret hx + signs. Hypothesis. Expert advice, clinical guidelines + algorithms. Best value + effectivness. Risk assessments. Statistical methodology. Relative + AR, predictive value, sensitivity, specificity.
Recognise critical illness.
Communicate and construct management plan. Risk calculators
Avoid pre-assessment bias


CC6 - Patient central focus of case
Recall health needs to deal with diverse patient groups  - learning disabled, elderly, refugees and non-English speaking. Gives time. Answers questions honestly. Self-management plan. Voice preferences. Acts as advocate.
Time off work. GP letters.
Gillick-competent adolescent. Assess capacity.
Alternative management options. Worried well.
DNAR + end of life decisions
Complaints
Patient survey + local patient groups

CC7 - Patient safety
Safe working environment. Hazards of medical equipment. Med side effects. Risk assessment + management. Safe working practice. Local procedures for optimal practice. NHS and regulatory procedures where concern about performance of team.
Recognise failure to response. Use medical equipment carefully, report faults. Improve understanding of SEs and CIs. Sensitively cousel a collegue following SE or near miss.
Root cause analysis.
High risk patients - nonEnglish speaking, agressive, un-cooperative, clinically brittle
Supports trainees + nursing staff after SUIs
Handover


CC8- Team working _ patient safety
Effective collaboration. Roles + responsibilities. Factors adversely affecting a Drs performance.
Note keeping. Patient lists. Handover. Leadership and management in education & training, deteriorating performance of collegues (stress fatigue), high quality care, effective handover.
Interdisciplinary team meetings. Supervision.
Encourage open environment. Second opinion. Induction. Information sharing. Debrief.

CC9 - Quality and Safety Improvement
Clinical governance, local and national significant event reporting, EBP, local health + safety protocols (fire and manual handling), risk - biohazards, patient early warning systems, national patient safety initiatives - NPSA, NCEPOD, NICE
Surgical checklits. Quality improvement process eg. audit, errors/ discrepancy meetings, critical incident reporting, unit mortality and morbidity, local and national databases.
Reflect regulalrly
No-blame culture.
Audit

CC10 - Infection Control
Prevent infection in high risk groups. Notification in UK. HPA / CCDC / LA in infection control. Potential for infecition. Counsel patients on risk. Local infection control procedures. Antibiotics according to local guidelines. Cross - infection. Aseptic technique.
Atypical common infections.
Not eating on shop floor
Blood cultures, sepsis 6

CC11 - Long term conditions + patient self care
Natural history of diseases that run a chronic course, rehab and MDT, QoL, medical and social models of disability, social services, carers, information, patient advocate. Feedback on referrals. Patient notes. Self-help groups,

CC12 - Patients + Communication
Structure an interview, understand importance of patient's background, rapport, sensitive, manage communication barriers, deliver information compassionately, use and refer to other sources, check understanding, notes, follow up.
Language line, anxious patients.
Acutely disturbed psych patient. Safe and lawful restraint.

CC13 -Breaking Bad news
Stressful. Honest, factual, realistic, empathetic.
Organ donation. Lead resuscitation with relatives present.

CC14: Complaints and Medical error
Local complaints procedure. Factors likely to lead to complaints. Deal with disasatisfied patients. Honest. Apologise. Review. Support junior ED staff in responding.

CC15: Communication with collegues + cooperation
MDT + team dynamics. Inter-professional collaboration. Communicate accurately, clearly, promptly. Use whole MDT. Hospital at night. Behavioural management skills with collegues.
Healthy work / life balance for whole team. Confidentiality. Accept additional duties. Handover. Manages shift to ensure breaks. Respect for nursing staff.

CC16: Health promotion and public health
Incidence and prevalence of communication conditions - biological, social, cultural and economic. Lifestyle on health. Screening. Smoking, obseity. Globalisation. Substance misuse, gambling. Ill health and disease. Lifestyle changes.
Registered with Dr. Encourages alcohol, drug, smoking. Discourages high risk.
Display local information.


CC17: Medical ethics + confidentiality
GMC on confidentiality. Data Protection Act + FOI Act. Caldicott Guardian. Caldicott approval. Patient consent - desirable but not required eg. communicable diseases. Consent. Confidentiality following death. Problems by disclosure in public interest. Factors influencing ethical decision making. DNR. MCA.
Confidential waste, no password sharing, doesn't take notes home, anonymisation, DNAR


CC18: Valid Consent
Consent is a process that may culminate in a consent form. Consider understanding and mental state. Balanced view. Autonoy. Scope of authority. Don't withold information. Seek advance directives. 2nd opinion.
STEMI/ stroke thrombolysis
Patient advocacy


CC19: Legal framework
Best interest of the patient. Legislative framework - death certification and role of coroner/ procurator fiscal. Safeguarding children. Mental health legislation. Advanced directives. Living Wills. Withdrawaing and witholding treatment. Resus decisions. Surrogate decision making - organi donation + retention. Communicable disease notification. Medical risk + driving. Data protection + FOI Act, continuing care.
Differences in legislation in 4 countries of UK. Disciplinatry processes. Role of medical practitioner in relation to personal health + substance misue including what to do ?abuse.
Report to Coroner.


CC20: Ethical Research
Good practice in research. Audit vs research. Understand how guidelines produced. Knowledge of research principles. Formulate research question. Comprehend principal qualitative, quantitative, bio-statistical and epidemiological research methods. Funding.
Critical appraisal skills
Write scientific paper. Ethical research, literature databases, good verbal + written presentation skills Popuation based assessment + unit-based studies and evaluate outcomes.
Complete a BestBET. CTR.


CC21: Evidence and Guidelines
Application of statistics in scientific medical practice. Different style methodologies. Critical appraisal. Level of evidence + quality. Advantages and disadvantages of guidelines. NICE and SIGN process. Search medical literature. Address clinical question. Limits of research.

CC22: Audit
Data for audit. Role + steps. Local + national. Local / national audit meetings.

CC23: Teaching and training
Adult learning principles, identification of learning methods. Educational objectives. Questinoning tecnhiques. Teaching format and stimulus. Literature. Appraisal interview. Bodies in med ed. Appraisal vs assessment. WBPA knowledge. Define learning objectives and outcomes.
Failing trainee.
Vary teaching format and stimulus. Feedback. Appraisal.
Demonstrate effective lecture, presentation, small group + bedside teaching sessions. Career advice. Improve patient education. Departmental teaching programmes, failing trainee. Has discussion. Formal tuition in medical education. Personal development as a role model.
PowerPoint. Small group teaching. Simple feedback. Supevision. WBPA.Teaces med students. Supervises things. Medical student programme.

CC24: Personal Behaviour
Inappropriate patient and family behaviour. Respect rights of children, elderly, physical, mental, learning or communication difficulties. Eliminate discrimination. Honesty and probity. Honesty and sensitivity. Ethical reasoning. Value-based practice. Royal Colleges, JRCPTB, GMC, Postgraduate Dean, BMA, specialist societies, medical defence organisations
Practice with integrity, compassion, altruism, continuous improvement, excellence, respect for cultural and ethnic diversity, equity
Rotas. Utilise resources. Specialist support. Press + media.
Clinical leadership + management
Mentor, educator and role model. Accept mentoring. 360 feedback.
Annual departmental stragetic vision.


CC25: Management and NHS Structure
GMC management guidelines. Understand local NHS structure. Structure and function of healthcare systems. Understand NHS debates and changes in the NHS. Local demographic data.
Clinical coding, EWTD, NSF, health regulatory agencies, NHS structure + relationships, NHS finance and budgeting, consultant contract + contracting process, resource allocation, independent sector. Managerial meetings. Technology.

Tuesday, 29 January 2019

Stroke and TIAs


TIAs 
Isolated vertigo is rare in posterior circulation TIAs. They may be hard to diagnose.

There is little benefit from further aspirin if patients are already on aspirin. If patients present late, they should be treated as lower risk of stroke.

For risk assessment, RCP guidelines say investigate all urgently without further risk stratification, and all patients need to be seen within 24hours. No imaging unless to exclude haemorrhage - in patients taking an anticoagulant.

TIAs need aspirin (for 2 weeks), clopidogrel, statins, and BP lowering therapy.

Confusion, memory problems, faintless or syncope, generalised weakness or numbness and incontinence are NOT TIA symptoms.


Always assess the carotid as part of your TIA assessment.

Stroke Anatomy
Anterior circulation is served by the internal carotids which branch into the MCA, ACA.
- weakness or sensory loss affecting the contra-lateral arm, leg or face - mostly leg. Dysphasia or dysarthria. Monocular visual loss.
- Middle cerebral - contra-lateral face and arm more than leg.
- Internal capsule often affects the face, arm, and leg equally.

Poster circulation: CN palsy + contralateral deficiency or bilateral. 20% dead, 20% dependent, 60% independent
Lacunar: pure motor or pure sensory. Dependent 30%, independent 60%
TACS: cortical dysfunction and field deficit and contralateral weakness in 2 areas. 60% dead.
PACS: 2/3 of TACS.

The posterior circulation is served by the vertebrobasilar arteries - which supply to the posterior 2/5 of the cerebrum, and the basilar arteries.

Anterior and posterior circulations are linked by the posterior communicating arteries, forming the circle of Willis.

Malignant MCA infarcts cause a lot of brain oedema, which may lead to herniation and early death. Young patients are particularly at risk because they don't have any spare brain space. A decompressive hemicraniectomy may be considered if pre-stroke rankin <2, defects indicate MCA, NIHSS >15, not alert, signs on CT of at least 50% of the MCA. Refer to neurosurgery. Likely fatal, and early senior neurosurgical involvement is necessary.

Monocular vision loss = optic nerve lesion
Bitemporal hemianopia = optic chism lesion
Homonymous hemianopia = optic tract lesion
Upper quadranopia = temporal lobe lesion
Lower quadranopia = parietal lobe lesion

Stroke Assessment
Consider a ROSIER score - negative score for LOC/ syncope or seizures, with positive for weakness, speech and visual fields.
NIH score
Perfusion scan if diagnosis in doubt, or >4 hours including wake up stroke

Stroke Treatment 
- Very high BP is a contraindication to thrombolysis so stick on a GTN patch on the way

Hypertensive encephalopathy or nephropathy
Hypertensive cardiac failure/myocardial infarction
Aortic dissection
Pre-eclampsia/eclampsia
Intracerebral haemorrhage with systolic blood pressure over 200 mmHg.
In patients being considered for thrombolysis, a blood pressure target of less than 185/110 mmHg should be achieved

- ASPECT score to see if for thrombolysis - determined from CT findings >7 = thrombolyse. - Alteplase is the preferred option. 19/20 stay the same, 1/20 get worse.
- If on NOAC (not dabigatran) no thrombolysis. Consider if clotting normal.
- If need thrombectomy have thrombolysis first

Mortality 
- Increased on pyrexia

References
https://www.rcemlearning.co.uk/modules/transient-ischaemic-attacks/ 



Vertebral Artery Dissection

A tear in the vertebral artery, is a common cause of stroke in young people. The tear has a clot and causes a false blockage - causing an ischaemic stroke. It can happen spontaneously or after minor trauma to the neck, including yoga and chiropractice.

A recent respiratory tract infection may also predispose - making vertebral artery dissection seasonal.

There are two types:
Infarction - ischaemia of the vertebrobasillar circulation due to arterial narrowing and thromboembolism
Haemorrhagic type - presents as a SAH

They may not present with problems, because of the contralateral vessel. Acutely ruptured dissections have a high mortality, and may rebleed (mostly in the month immediately after).

Clinical Symptoms
Severe neck pain, followed later by neurological symptoms
May get a spinal cord infarction
Maybe with a headache and horners syndrome


Normally treated with anticoagulants

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2588305/
https://pmj.bmj.com/content/81/956/383
http://emergencymedicineireland.com/2011/12/21/anatomy-for-emergency-medicine-2-the-vertebral-artery/

Sunday, 27 January 2019

SCAD


We think of spondaneous coronary artery dissection as being a cause of peripartum myocardial infarction - but about 90% of cases are not pregnant. It can be precipitated by valsalva type manoeuvres. There is an association with exercise, especially in male users. There are case reports linking SCAD with drugs, and emotional stressors.

Thrombolysis is considered safe and apparently effective but generally avoided, because can cause rupture leading to tamponade. Dual antiplatelet therapy probably indicated  - but may cause menorrhagia as is used for women of child bearing age.


https://heart.bmj.com/content/103/13/1043


http://www.emdocs.net/spontaneous-coronary-artery-dissection/

VBI

Also called beauty parlor syndrome.

Transient ischaemia of the basilar circulation system. Dizziness, vertigo, headaches, vomit, diplopia, blindness, ataxia, imbalance and weakness are all possible symptoms.

Ear symptoms may also cause ischaemia of the inner ear. Posterior circulation imbalance rarely causes only one symptom. Isolated dizziness is rarely VBI.  Standard artherosclerotic risk factors. May be associated with facial pain - sharp single stabs or jolts of pain.

Wallenberg Syndrome - lateral medullary syndrome, caused by a vertebral artery stroke. May be facial pain with a contralateral hyperanalgesia.



https://www.sciencedirect.com/topics/medicine-and-dentistry/vertebrobasilar-insufficiency
https://bmjopen.bmj.com/content/7/8/e017001