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"Episode 7"

"Show Notes"

"Refractory VF in ED"

 

 

40 years old female, collapsed & found to be in a VF cardiac arrest, terminated after the first shock.

She was admitted to ICU - later had another VF cardiac arrest that required 18 shocks in total.

​

"Refractory Ventricular Fibrillation"

 

It is a shockable presenting rhythm that is still observed after three shocks and associated with 2 minute CPR cycles (1)

 

What could be the cause of the refractory VF in this patient?

 

R on T phenomenon: PVC on the T wave - can provoke VT/VF.

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Management discussion:

 

- Antiarrhythmic drugs during VF/pVT cardiac arrest: amiodarone, lidocaine (4)

 

- Antiarrhythmic drugs post VF/pVT cardiac arrest: beta-blockers and lidocaine (4)

 

- During arrest resuscitation, if using too much adrenaline dose due to refractory nature of VF, consider reducing adrenaline dose or increasing adrenaline administration interval.

 

- Optimal pads position and contact to skin to maximise electrical energy.

 

- Consideration of Double sequential external defibrillation (DSED; rapid sequential shocks from two defibrillators) and Vector-change (VC) defibrillation (switching defibrillation pads to an anterior–posterior position) (3).

(5)

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"Subtle STEMIs"

 

  • Clinical Governance Case:

 

40 years old male presented with cardiac chest pain. Pain improved with simple analgesia. Looks well.

 

What can you see on this ECG?

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  • ECG: ST depression in inferior leads with subtle ST-elevation of about 1 mm in lead 1 and AVL.

 

  • The Cath Lab was activated.

 

  • Learning point:

 

If you see ST segment depression in anatomical distribution compared to widespread ST depression, actively look for ST elevation somewhere else.

In this case, the ST-elevation was subtle due to low voltage ECG and can easily be missed.

"Post thrombolysis complications (specifically rectus sheath haematoma)"

 

  • Clinical Governance Case:

 

An elderly female presented with acute abdominal discomfort with suspected acute urinary retention.

Bladder scan 800ml. Urinary catheter drained only 200ml. 

 

  • What can you see in the CT KUB performed?

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CTKUB showed rectus sheath haematoma and no urinary retention.

 

The revisited history revealed that the patient had recent abdominal trauma, had also thrombolysis for PE, and was on DOAC.

​

  • Management:

 

- A reversal agent for DOAC was given.

- Ongoing bleeding controlled with conservative management.

 

  • Learning point:

 

- Good history taking and focused examination are key.

- Always bear in mind the complications of post-thrombolysis.

"Basilar thrombus occlusion"

 

  • Clinical Governance Case:

 

The patient presented with low GCS, poor historian with a vague history of chest pain & involvement of alcohol intake.

 

The CT head initially looked unremarkable.

 

  • What are your differentials?

 

CT angiogram showed Basilar Artery Thrombus.

 

5-10% of medical comas have basilar artery stroke.

1/5th patients have reasonable outcomes.

 

  • Learning points:​

    • Patients with low GCS with unclear cause - have suspicion for posterior circulation stroke.

    • Non-contrast CT head may show some hyperdense localised area.

    • If the CT head (non-contrast) is unremarkable, then consider a CT head angiogram whilst the patient is still on the table to exclude other causes of stroke and manage accordingly.

    • If clinically suspected, exclude aortic dissection with a CT aortogram before thrombolysing the stroke in this case.

"Paediatric safeguarding discussion"

 

  • Clinical Governance Case:

 

An adolescent presented to ED with alcohol in possession overnight. Challenging behavior.

The patient was a looked-after child accompanied by a friend who was over 18 years of age.

 

The patient wanted to self-discharge.

 

  • How would you manage this case?

 

  • Learning points:

 

- Mental capacity assessment

- Patient needs to be safe before self-discharge

- Questions to ask before discharge:

           1) Who has parental responsibility?

           2) Will the patient be discharged to someone with parental responsibility?

- Consider issues around possible exploitation such as

           1) Who was the friend?

           2) Were they a potential exploiter of the patient?

"EDGovCast Team"

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Dr. Helen Bates

Pediatric Emergency Medicine Consultant in Hampshire Hospitals.

UK

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Dr. Gareth Davies

Emergency Medicine Consultant in Hampshire Hospitals.

Founder of ED GovCast.

UK

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Dr. Lee Barnicott

Pre-hospital & Emergency Medicine Consultant in Hampshire Hospitals.

UK

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