Change to The Program 18th October

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The Program for the afternoon of the 18th of October is cancelled to facilitate the trial OSCE exam in the department.  If you are able to help with the exam, please contact Jon, Darren or Andy.

The scheduled ECG talk will now be in the morning program of teaching on Thursday the 1st of November.

Last Weeks Teaching Highlights

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The teaching highlight last week was our Journal Club session, where Glenn facilitated presentations by Paula and Lachlan on two big studies with potential implications for our practice (both articles sent around previously by Glenn, attached again above).  The PARAMEDIC2 study looked at whether Adrenaline use in out-of-hospital cardiac arrest cases was associated with any difference in survival and neurologic status.  Lots of interesting commentary around this study in the media since it was published, and the group was equally interested in the outcomes.  Whilst it is hard to extract meaning for patients arresting in the ED setting (given the mean time to therapy (adrenaline administration or control saline group) was 21 minutes), and the large proportion of patients where arrest was unwitnessed, it is hard to argue that adrenaline confers any meaningful patient-focussed benefit for the patients in this study.

What will this mean for us?  Will we see the removal of pre-hospital adrenaline from arrest management algorithms? I doubt it, but I suspect people will have less faith in the role of this drug than perhaps they did previously.

The Fluids in DKA trial also caught the interest of the group.  My anecdotal experience was that cerebral oedema, whilst a potentially devastating complication of severe DKA cases, was rarely encountered in our practice, and that kids who came in well stayed well.  This trial demonstrated that no matter whether the fluid replacement therapy used was hypotonic or isotonic, or whether it was replaced “fast” (half in the first 12 hours) or “slow” (over 48 hours), the incidence of cerebral oedema was unchanged, and remained low at around 1%.  For me, I found the use of a surrogate marker of cerebral oedema (a (transient in almost all cases) decline in GCS of 2 points) a weak primary end-point.  Whilst easy to understand from a study design perspective, the components of GCS are (in my opinion) not equivalent, and the decrease in GCS was not persistent, which whilst concerning for the treating team involved, the presence of persisting brain injury and decrease in IQ (secondary outcomes) would have been a much more compelling outcome (persisting brain injury was incredibly rare across the study population).  This study didn’t focus on the sickest children, and I suspect this is where the impact of iatrogenesis may be most felt.  However, I feel like this paper does tell us that variation between commonly used approaches to replacing fluid deficits in children with mild-mod DKA is not producing meaningful differences in cerebral oedema.

In the era of FEAST and concerns around fluid boluses and causing harm, the group was reminded that we should always be cautious when bolusing fluids in patients with diabetic (and other osmotically challenged) emergencies.

Weekly Teaching

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Hi team,

Last week saw another in our departmental audits, with Cris and Georgia H presenting on our use of COAG testing within the department.  It was very interesting to see how we order coagulation studies in the ED.

In summary we ordered 554 Coag tests in a single calendar month.

In a detailed anaylsis of a single week’s ordering, we ordered 133 coag tubes within ED.

(it was noted that some were requested by inpatient teams).

When compared to the ACEM Choosing Wisely indications for COAG testing, it was found that:

22/133 were clearly indicated in-line with the above recommendations

16 additional tests were performed in-line with local protocols (ie CODE STROKE), outside indications suggested by ‘Choosing Wisely’.

The remaining tests (85/133) were not clearly indicated based on either the above guideline or local protocol.

Interesting stuff, but not out of keeping with other studies presented by Georgia that looked at over testing of COAGs in the ED (in fact our numbers were around 40% of total tests sent when compared to a similar sized department studied previously in the ED literature.

A key take home for me was the cost of these tests.

A COAG profile costs approx. $19 to perform, and the tube itself costs $10.

Hence the practice (of which I have been guilty) of collecting a COAG tube and sending as a Pmisc in case of a need to later test coagulation is not cost effective, and should be discouraged.

Today’s teaching has continued parallel to the Accreditation visit, and saw Nivene Saad from radiology present some important radiologic lessons, Hector speak on ventilation in the ED patient (always gold) and Claire present some cases with valuable teaching points from her time as the QAS HARU registrar.

 

Next week will see the usual teaching program with:

8:00-9:00: Bedside teaching and Simulation

9:00-9:30: Module – ALS revision

9:30-10:30: Practical session – plastering

11:00-12:00: Clinical Case presentations

 

13:00-14:00: Airway Simulation

14:00-17:00: The program (Exam is the next day – this is a revision session only)