26 May 2021 - Cabrini Regional Education
Teaching will be on Zoom: https://cabrini.zoom.us/j/99488266172?pwd=TUoydW5kZnp4dDVvU05ITzJvcCtEZz09
Meeting ID: 994 8826 6172
Passcode: 480590
Program
1030-1045: Welcome — Ian Turner & Dane Horsfall
1045-1115: “So you’re telling me coffee is good for AF…but not alcohol?!” – Peter Kistler
1115-1145: How to pass the Fellowship Exams — Dane Horsfall
1145-1230: Lunch
1230-1300: Epistaxis, quinsy and other ENT secrets
1300-1330: Stroke Management Update — Jorge Zavala
NOTE:
1300-1400: Fellowship Break-out Group — Alex Handrinos
Join Zoom Meeting: https://us02web.zoom.us/j/89545481615
Meeting ID: 895 4548 1615
Summary
Many thanks to Ezra Limm for this week’s summary.
Atrial Fibrillation
Doubles mortality (35% in 5 years)
5% annual incidence of stroke, ACS, heart failure and death
Rate vs Rhythm control? Early rhythm control has a mortality benefit, but only if clear onset within 24 hours (not 48 hours)
Assume AF drives heart failure for presentations of new AF with heart failure
Obesity
Obesity causes AF through impaired diastolic function, inflammation scarring the atria and pericardial fat.
Paddles vs Pads for DCR in obese patients? 90% vs 60% success! Use 360J if possible.
You can reduce the incidence of AF in obese patients by reducing weight, lipids and sleep apnoea. Subcut semaglutide 2.4mg weekly led to sustained weight loss of >10% in a recent RCT
Alcohol
Increases risk of AF by 8% per standard drink consumed
Caffeine
Not pro-arrhythmogenic!
Reduces risk of AF by 2% per cup of coffee consumed daily
However it is an adenosine receptor antagonist, so you may have to give more adenosine to a patient in SVT who drinks a lot of coffee
Fellowship Exam Prep
Recommend 1 year of study and sitting the Written & OSCE back-to-back
Know ACEM’s Glossary of Terms
Recommend reading Chan’s ECG book front-to-back
OSCE Station Approach
4 min prep and 7min of OSCE
1st minute: Read all the info
2nd minute: Focus to task and cross reference with domains, e.g. management task with health advocacy domain
3rd minute: “What are my deficiencies in this type of OSCEs?”, e.g. I always forget disposition / follow-up
4th minute: Re-read all the info, “Have I missed anything?”, rehearse opening & closing statement, 15 seconds controlled slow breathing
7min of OSCE: Go at a sprint! Don’t waste time. Use every word to get marks. Don’t use the 1min warning bell to summarise; you won’t get more marks for saying the same thing. Use the last minute to ensure the examiner can mark off as much as possible on their marking sheet.
Explain your rationale at a FACEM level — ideally without needing to be prompted by the examiner. For example, regarding management of a patient with cardiogenic shock from massive AMI:
Registrar-level response: “The patient needs to go to cath lab”
FACEM-level response: “This patient has cardiogenic shock from an inferior STEMI. In order to support their circulation to enable them to receive definitive management with PCI in the cath lab, I would administer a peripheral adrenaline infusion. I understand that this would increase myocardial oxygen consumption and worsen acute myocardial ischaemia, but I feel this would be necessary in order to transport them to catch lab.”
OSCE Type — History-taking
Plan so that first 4min is history-taking, 4-5.5min is explaining diagnosis, and 5.5-7min is management plan
OSCE Type — Communication
Use the 7 Steps of Shared Decision-Making:
Ask — about the patient’s understanding, “What have you been told so far?”
Explain — the situation, “Your mother has a chest infection.”
Explore — functional status and values, “What was your mother like before she became unwell? Have you discussed with her what her wishes would be if she had a life-threatening illness? If she was sitting here, what would she want us to do?”
Options — CPR vs NFR, medical ward vs ICU
Advice — “From what you’re telling me, your mother would have wanted xyz”
Agree — on a plan
Communicate — document plan, explain to relative
OSCE Type — Teaching
Plan so that first 1min is establishing level of understanding, 2-5.5min is teaching, 5.5-7min is checking understanding / follow-up
Front-load the teaching in the first minute (rather than the end) and lead with medical expertise: “This is trifascicular block”
Establish level of understanding: “Have you seen many Xs?”, “I will run you through my approach to X” (lesson plan), “Is there anything you saw me do that you wouldn’t have?”, “What worked well? What didn’t?”
Check understanding: “What’s one take-away that you’ve learnt?”, “Is there anything you’d like to discuss?”, “I will ask you to present this case at education next week, and I would like you to read more about it on this website.”
OSCE Type — Procedure
e.g. Bier’s Block, CVC insertion
Indications / Contraindications
Consent
Team prep
Procedure
Post-procedure care
Management of complications
OSCE Type — Simulation
Always introduce self, allocate roles, used closed loop communication, recap, and “think out loud” your rationale
ENT
Epistaxis
Bleeding is almost always from the septum (Little’s area):
First, remove the clot
Second, apply pressure to the bleeding site with a co-phenylcaine-soaked Q-tip
Third, apply silver nitrate for 20 seconds
Last, fill nostril with Kenocomb ointment
If the patient is elderly and anticogulated (and the above does not work):
Soak Rapid Rhino in water (not saline!) — will begin to expand immediately, so be ready to insert as soon as it’s wet
If you can’t fit a Rapid Rhino, then use Nasopore or ribbon gauze
If bleeding has not stopped after 5 minutes, put a Rapid Rhino in the other nostril
Leave in situ for at least 12 hours
After packing, administer PO cephalexin 500mg BD until removed
Tonsillitis
Lymphocytosis is more helpful in diagnosing EBV than Monospot (as it can take 2 weeks for Monospot to be positive)
Trismus and unilateral throat pain = Quinsy until proven otherwise
Uvular deviation and muffled voice are not reliable signs
Think retropharyngeal abscess if the patient has neck swelling, pain on head turning or difficulty breathing
Think epiglottitis if the patient has severe throat pain but the tonsils look ok
Otalgia
Consider CT to rule out subperiosteal mastoiditis (different to radiological mastoiditis, which is fluid in the mastoid and present in every patient with AOM)
Think cerebral sinus thrombosis if the patient has a headache
Think intracranial spread if the patient has a headache and fever
Give antibiotics for acute otitis media in kids if:
Severe otalgia
<2yo
Bilateral
Tympanic membrane perforation
This is because the above were exclusion criteria in studies that recommended the “watch and wait” approach to AOM.
Stroke
TL;DR
Be liberal with CT perfusion scanning in all presentations within 24 hours
CT Brain + Perfusion for anterior strokes within 24 hours (for salvageable penumbra)
CT Brain + Angiogram for posterior strokes
Reperfusion
Goal is to salvage penumbra. CT perfusion is useful for this, even in country settings.
Good for more peripheral lesions (occluded large vessels rarely re-perfuse)
More conservative than in STEMIs due to risk of haemorrhagic transformation and inflammation
NNT of 10 if under 3 hours (but can be beneficial up to 9 hours if salvageable penumbra)
Under what circumstances can reperfusion be considered even when contraindications exist?
When clot retrieval is not appropriate and disability is severe
Beyond timeframe (>4 hours) if salvageable penumbra
Clot retrieval
Central lesions of M1, carotid and basilar arteries are more appropriate for clot retrieval as occluded large vessels rarely re-perfuse
NNT 5 to prevent disability. Same risk of death.
Timeframe is up to 24 hours with salvageable penumbra
Contraindications:
Coagulopathy (not including thrombolysis!)
Refractory hypertension
> 1/3rd MCA established infarct
Poor premorbid function / short life expectancy
Severe contrast hypersensitivity