1 July 2020

Program

First session is on zoom.

Register here: https://zoom.us/meeting/register/tJwvcuGoqjsrEtD2Azl1DQRbn8QOdPHVusMQ (Password is 361695)

10-12noon LGBTIQ+ Workshop – Amelia Arnold, Suicide Prevention Training Project Officer, Thorne Harbour Health

Rest of teaching is on Microsoft Teams

12-1215hr, lunch, teams log in

1215-1245hr – ECG/image/gas of the week

1245-1315hr – Sarah B – Tropical Medicine with a Top End Focus

1315-1345hr – Maria – Managing vulnerable patients in the ED

Please note that Webex is no longer being used as we have moved to Microsoft Teams

Join Microsoft Teams Meeting

+61 2 8320 9200 Australia, Sydney (Toll) 

Conference ID: 714 090 561# 

Key Learning Points

LGBTIQ+ Workshop

Within the LGBTIQ+ communities, we as health care providers generally have more difficulty with the transgender and intersex communities. Why? Largely because this is something that we have been taught/learn.

Amelia from Thorne Harbour Health showed this video as part of her workshop. There are a number of other videos from the Trans 101 group.

There are some excellent resources out there to help us in the ED

Have you signed up to EMRAP yet? If not, do it. I have no conflict of interest, only to suggest my experience is that it is an excellent educational resource. There is a great episode from August 2019 describing some of the ED specific issues when carding for the LGBTIQ+ communities.

https://www.emrap.org/episode/emrap2019august/equalaccessfor

If you want to read a bit more about caring for patients in the ED click on the below images.

 ECG of the Week

A 42 year old male presents with sudden onset of palpitations. HR 150, BP 125/80, GCS 15, RR 12, SpO2 99% RA.

This ECG shows a narrow complex regular tachycardia at 150bpm. There is a right axis deviation and possibly retrograde p-waves best seen in V1.

My approach to all arrhythmias is to ask myself three questions.

• Is it fast or slow?

• Is it narrow or wide?

• Is it regular or irregular?

By doing this there are only a handful of differential diagnoses.

So for this case the rhythm is fast, narrow and regular and therefore is one of: sinus tachycardia, Atrial Flutter, SVT (AVNRT or AVRT), junctional tachycardia or atrial tachycardia

Let’s say the rhythm was fast, narrow and irregular. The differentials are now atrial fibrillation, multifocal tachycardia or atrial flutter with a variable block.

You can do the same for all variations based on those three questions.

So back to this ECG. To help differentiate between the above possibilities

• Look for P waves. These are best seen in V1. Are the P waves hidden in the previous T wave?

• Look for flutter waves

• Are there other signs of digoxin toxicity? (Commonest cause of junctional tachycardia)

• What is the rate doing on the monitor? Atrial flutter is usually very fixed with minimal variation. Sinus tachycardia still goes up and down with pain and exertion.

It can be hard to tell and often you end up with “It is most likely x but could also be y or z”. Remember that valsalva or adenosine can slow down the rhythm enough to make the diagnosis. I.e. the p waves or flutter waves become apparent.

 Image of the Week

You are the ED reg at 2am in ‘The Bush’ (rural emergency department)

28y/o male p/w a hand injury, unclear mechanism. Patient reported a screwdriver “fell” from a shelf causing the injury.

Image interpretation

1. Amputation

• Ring & little fingers

• Ulnar portion of the hand, from the webspace of 3rd/4th digits, to the mid-hypothenar eminence

2.     Open fracture

• Active haemorrhage

• Intact 4th & 5th fingers

These injuries are not consistent with the stated mechanism 

Xray Interpretation:

1. Amputation

   • Fracture through the 4th metacarpal head

   • Comminuted fracture of 5th metacarpal shaft, displaced fragment

2. No appreciable injuries to 4th & 5th digit phalanges

3. No other appreciable fractures

A common theme discussed is terminology. We need to use appropriate language when describing injuries and xrays. Perhaps we can discuss this another day but the difference between a partial and a complete amputation. What is a laceration? What is an incision?

Tropical Medicine

Melioidosis (Burholderia pseudomallei) is endemic in the wet season of northern Australia (November - April)

It can cause pneumonia, deep abdominal abscesses and visceral (liver and spleen) abscesses, skin effects, bacteraemia and cerebral infection (rare)

During these months empiric treatment for severe sepsis includes meropenem and vancomycin. Think about the returned traveller from Darwin to Melbourne also during these months.

Strongyloides is a parasitic infection that can occur in northern Australia. You can ingest the eggs by drinking contaminated water - yuck. Symptoms include itch, cough or abdominal pain depending on the location of the parasite.

It is usually diagnosed on stool culture.

Severe infections can occur in the immunocompromised.

Treatment is with albendazole