We aim to run simulations every Friday at 11am, see the gmail calendar for the up-to-date schedule. The sim homepage is derriforded.com/sim where you can see our monthly theme and you can submit suggestions for what we should cover! In September we have covered (click to see the blog summary):
The DKA simulation below was carried out twice and the learning here is a summary of both sessions. The simulated case: Tara is a 10 year old child brought in by a parent. They have been feeling unwell for a few weeks and today they have developed vomiting and pain in their abdomen. Do you already have key diagnoses in mind? What examinations and selective testing will help you rule options in or out?
What did we think? In debrief we discussed:
We discussed in debrief the latest shift in DKA management, from a previous intention to restrict fluid input due to concern of causing cerebral oedema, to a stance of greater fluid administration. The weight of evidence indicates that cerebral oedema develops out of the disease process itself rather than related to fluid-giving. The local guideline (see below) gives clear instruction of the fluid required in this case. We talked through the balance required in keeping the parent informed about what is happening whilst ensuring no delay with immediate care needs. We briefly touched upon the PACE model of assertiveness. This blog describes the challenges of speaking up and how PACE can be used to gradually but assertively escalate your concern to a colleague - you can scroll down to where the example of this is given. Here is a case study of it being used by a “junior” colleague to make suggestions to a “senior” during the resuscitation of a child. Feedback from the sim participants noted the difficulty for adult-trained nurses to be familiar with the paediatric area and equipment - we can aim to pair a paediatric and adult nurse during scenarios. It was suggested we should have more speech directly from the mannequin - we can aim to do this if a facilitator remains outside of the room in future. The guidelines: On the ED browser page you can find two paeds DKA links - the documentation and an appendix for further information. The documentation link is a complete booklet that allows you to write in your results as it guides you through the process and the calculations. You can take a look at the same document on the British Society for Endocrinology and Diabetes page here. It is a good idea to print this off early in the process so it can guide you. I am going to look into whether we can have a few full-colour versions available. This guideline was brought out in March 2020 and represents some significant changes on previous versions that are worth being aware of. As mentioned above, the fluid strategy is now more permissive rather than restrictive, with all patients receiving a fluid bolus of 10mL/kg 0.9% saline, with an extra 10mL/kg (i.e. 20mL/kg total) for those in shock (Tasker 2020). Inadequate fluid resuscitation is noted as one of the key contributors to death in DKA resulting from inadequate cerebral perfusion (BDPED). Have a look at page 5 (and a little at the top of page 7) of the appendix document, also to be found here. This gives a (virtually) single-page overview of what we need to achieve for these patients in the ED. However when you are looking after a patient with DKA you should use the full guideline above. Some more detail on this change in guidance, by Dr Tom Siese: The latest thinking is that rather than the cerebral injury in DKA being simply related to osmotic shifts due to over-rapid fluid treatment, there is increasing evidence which points towards a state of metabolic acidosis and dehydration which then paves the way for a “hyperinflammatory state”. The results from the recent randomised controlled PECARN DKA Fluid Trial (Kuppermann et al 2018) supports the return of permissive fluid boluses in paediatric DKA. At time of writing, the latest editorial in the Archives of Disease in Childhood (Tasker 2020) notes caution in treating cases with altered consciousness, as only 2% of study participants in the above trial had a GCS<14. Therefore the bottom line is don’t be afraid to rehydrate children with DKA, but all cases will still need discussing with a senior member of the paediatric team from an early stage. To do: If it’s been a while since you worked in the paeds area, ask someone who is regularly there to show you where key items are, and if you have supernumerary time you could spend some of it in paediatrics [ ] Have a look at the main guideline document either on our ED browser or via the link above, plus page 5-7 of the appendix document [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] James Keitley - ED sim fellow On behalf of the faculty behind this sim Hana Bashir, Andy Robinson, Thomas Siese, Rachel Garlick References:
- British Society for Paediatric Endocrinology and Diabetes [BSPED]. 2020. Integrated care pathway for the management of children and young people with diabetic ketoacidosis. Available from: https://www.bsped.org.uk/media/1742/dka-icp-2020-v1_1.pdf. - British Society for Paediatric Endocrinology and Diabetes. 2020. BSPED Interim Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis. Available from: https://www.sort.nhs.uk/Media/Guidelines/BSPED-DKA-guideline-2020-update.pdf. - Kuppermann et al. 2018. Clinical Trial of fluid infusion rates for paediatric DKA. NEJM; 378:2275-2287. www.nejm.org/doi/full/10.1056/nejmoa1716816 - Nickson C. 2019. Speaking Up. LifeInTheFastLane blog. Available from: https://litfl.com/speaking-up/. - Tasker R C. 2020. Fluid Management during DKA in children: guidelines, consensus, recommendations and clinical judgement. ADC; 105: 917-918. pubmed.ncbi.nlm.nih.gov/32847796/ - Yianni L, Rodd IG236(P) Pace – ‘Probe, Alert, Challenge, Escalate’ Model of Graded Assertiveness Used in Paediatric ResuscitationArchives of Disease in Childhood 2017;102:A93. --------------- For clinical decisions please refer directly to the guidance. This blog will not be updated.
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For our first month of SimFridays we’re looking at paediatrics, and if you couldn’t join us for 18th September this blog covers some of the learning points. We will be aiming to run simulations every Friday at 11am - go to derriforded.com/sim, particularly if you have suggestions of what we should cover! Some of the sessions will be moved to Thursdays (!) but the gmail calendar is up-to-date. What happened? The nurse assessed James and noted he’d been out drinking with older teenagers and had an injury to his head. They noted normal observations, GCS14 (E4V4M6), and no serious concerns at this point. The doctor’s assessment was interrupted by the arrival of James’ mother. She was unhappy and keen to remove James from the ED. The team attempted to engage with her on the importance of staying with James while he is assessed and treated. It was noted that James met the criteria for a CT of his head. What did we think? In debrief we discussed:
Feedback from the participants noted that greater staffing might make the care of patients like this easier. It was noted that this sim being in the Stewart room rather than in situ meant a reduction in realism. For the next sim we will ensure the room is better kitted out with the equipment necessary. The guidelines: Consent in children: The mental capacity act doesn’t apply to children under 16. Children under 16 can give affirmative consent if they are deemed “Gillick competent” - see link. If the parents disagree with treatment like they did in this sim: “Where such a disagreement arises, further discussion should take place and a second opinion offered, but it may be necessary to seek legal advice. In the interim, only emergency treatment that is essential to preserve life or prevent serious deterioration should be provided.” from this link. The NICE guidance on deciding whether to use CT for head/neck injuries gives advice both for adults and children. See here.
To do: If it’s been a while since you worked in the paeds area, ask someone who is regularly there to show you where key items are [ ] Find where the head injury guidelines and advice leaflets are on EDIS [ ] Consider a past situation where you have looked after a child and the parents have been involved in the decision making process about their care. What do you do if there is disagreement between child/parent/medical team? [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] James Keitley - ED Sim Fellow --------------- For clinical decisions please refer directly to the guidance. This blog will not be updated. For our first month of SimFridays we’re looking at paediatrics, and if you couldn’t join us for the second session (11 September) this blog covers some of the learning points. We will be aiming to run simulations every Friday at 11am - go to derriforded.com/sim, particularly if you have suggestions of what we should cover! What happened?
In this simulation, the nurse started with triage and a set of obs. They noted a prolonged capillary refill, tachycardia and a high temperature.They filled out sepsis bundle paperwork. The nurse escalated early to doctors and conveyed their concerns. The patient was discussed with the paediatrics registrar. What did we think? We talked through the scenario in debrief. Key points were:
We discussed the importance of recognizing the possibility of sepsis and the need to communicate this clearly in handovers. We discussed the importance of adopting an SBAR format in order to give a clear idea on worries and concerns. We discussed that the paediatric team may be far away, both in time and in space! So it’s important to highlight sick people to seniors within ED too, and start management pending arrival of the paediatric team. We discussed what a septic screen in an infant would include, i.e inflammatory markers, blood cultures, urine analysis, lumbar puncture. We discussed how it is sometimes difficult to find a balance between the urgency of giving antibiotics within the ‘golden hour’ or waiting until a full septic screen can be done prior to starting antibiotics. We acknowledged the difficulty given the sometimes long times for transfer and wondered whether a faster pathway could be developed to allow smoother transfers for paeds ED to CAU. The guideline: On the ED browser under paediatric guidelines scroll down to “assessing febrile children” and there are resources and proformas for each age group. The guideline for giving empirical antibiotics in children is also in this list near the top. It’s useful to read the NICE guidance on sepsis - there are sections for each age group. Here is the risk stratification tool for children under 5 in hospital. To do:
Blog post by Dr Hana Bashir, paediatric sim fellow Ed: Dr James Keitley, ED sim fellow Photos of this sim can be found on the ED Simulation Facebook page. --------------- For clinical decisions please refer directly to appropriate guidance. This blog will not be updated. For our first month of SimFridays we’re looking at paediatrics, and if you couldn’t join us for the first session (4th September) this blog covers some of the learning points. We will be aiming to run simulations every Friday at 11am - go to derriforded.com/sim particularly if you have suggestions of what we should cover! The simulated case: Dylan is a 6 year old child brought in by his mother. He was short of breath and wheezy at school, and his inhaler didn’t seem to resolve it. What would you do? How would you feel approaching Dylan?
What did we think? We talked through the scenario in debrief. Key points were:
We noted that in reality in our ED the tannoy system is used to request urgent reviews. This has the potential to be impersonal “can a doctor come to…” and there is some risk of bystander effect with it. Do we assume someone else will go? Very early on the question of whether to move to resus was raised. To arrange this, one would need to speak to the team in Majors - when is a good time to leave the patient if this is what is needed? We discussed the usefulness of having a capillary blood gas if possible when discussing with the paediatric team. We discussed that the paediatric team may be far away, both in time and in space! So it’s important to highlight sick people to seniors within ED too, and keep treatment/monitoring going to make sure they’re still improving. In the feedback for the session it was raised whether doctors should rotate through allocated paediatric ED days. It was also asked about how to access asthma action plans - see the “to do” section below for this. The guideline: I can’t post the asthma guideline here but you can find it on the ED browser under children’s guidelines. It’s split into pdfs for each age range, and it’s a really straightforward single-page sheet. You can see how to grade the child’s observations into the severity of asthma attack, and there are clear treatment options. There is also an advice sheet for parents under the patient information leaflets section. Here is the BTS/SIGN equivalent in how to grade moderate vs severe vs life-threatening attacks (BTS/SIGN 2019) - the full guideline is under the “to do” section below. Key steps in child >5 years old:
To do: If it’s been a while since you worked in the paeds area, ask someone who is regularly there to show you where key items are [ ] The SIGN asthma guideline here [ ] Check out the asthma plans that can be downloaded from Asthma UK here [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] See you at the next one! James Keitley - ED sim fellow -------------- References: British Thoracic Society and Scottish Intercollegiate Guidelines Network (2019). British guideline on the management of asthma: quick reference guide. Available from: https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-asthma-guideline-quick-reference-guide-2016. Viewed 09/09/20. Photos either taken by the author or copyright- and attribution-free in the public domain. --------------- For clinical decisions please refer directly to appropriate guidance. This blog will not be updated. I thought it prudent to give another academic update, given that there has been some big research news in terms of COVID-19 and other relevant emergency medicine studies in the last couple of weeks. If you want a general update on the state of play nationally with regards to emergency medicine research, some of the challenges we’ve faced and how the future might look, check out this recent podcast which is available via the RCEM Learning site:
http://iz4.me/VO8s6zO8eBb1 COVID-19 research I’ve mentioned the RECOVERY (Randomised Evaluation of COVid-19 thERapY) trial before. This is a large UK multicentre randomised controlled trial, led by researchers in Oxford, of possible treatments for patients admitted to hospital with COVID-19. Many of us have recruited patients to this study, which is still ongoing. As a reminder, the treatment arms are:
It has an unusual and novel adaptive design – so it changes as time goes on, and tests multiple interventions, with the ability to stop or start different treatments as the trial progresses. It makes traditional methodologists twitch. Outcome is all cause mortality at 28 days. The first result published was hydroxychloroquine – which showed no benefit – and so that arm was discontinued. The second result, which resulted in a press release last week, was the dexamethasone arm. The pre-print of the full results paper is now available at: https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1 They found that dexamethasone reduced deaths by one-third in patients receiving invasive mechanical ventilation (29.0% vs. 40.7%, RR 0.65 [95% CI 0.51 to 0.82]; p<0.001), and by one-fifth in patients receiving oxygen without invasive mechanical ventilation (21.5% vs. 25.0%, RR 0.80 [95% CI 0.70 to 0.92]; p=0.002). Impressive stuff from the UK medical research community, and a further illustration that academia is the new rock and roll. Non-COVID evidence More big news from an emergency medicine study that spanned half a decade in our emergency departments across the UK and indeed the world. Should we give TXA to patients with GI bleeds? The results of the HALT-IT study have now been published: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30848-5/fulltext The trial found that tranexamic acid does not reduce deaths from GI bleeding (mortality was 4% in both the intervention and control groups). Of note, it increased the risk of venous thromboembolic events (deep vein thrombosis or pulmonary embolism), although the absolute risk was low (0.8% versus 0.4%). Re-bleeding was similar in both groups. So, an intervention that had crept into routine practice in my hospital, certainly among the admitting physicians looking after these patients because it felt like the right thing to do, is torpedoed by robust clinical evidence from a randomised controlled trial. Stay safe and sane, Jason Smith on behalf of the academic team |
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The Derrifoam BlogWelcome to the Derrifoam blog - interesting pictures, numbers, pitfalls and learning points from the last few weeks. Qualityish CPD made quick and easy..... Archives
October 2022
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