"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.
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"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.
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)
"Subtle STEMIs"
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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.
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The Cath Lab was activated.
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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)"
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Clinical Governance Case:
An elderly female presented with acute abdominal discomfort with suspected acute urinary retention.
Bladder scan 800ml. Urinary catheter drained only 200ml.
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What can you see in the CT KUB performed?
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.
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Management:
- A reversal agent for DOAC was given.
- Ongoing bleeding controlled with conservative management.
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Learning point:
- Good history taking and focused examination are key.
- Always bear in mind the complications of post-thrombolysis.
"Basilar thrombus occlusion"
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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.
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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.
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Learning points:​
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Patients with low GCS with unclear cause - have suspicion for posterior circulation stroke.
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Non-contrast CT head may show some hyperdense localised area.
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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.
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If clinically suspected, exclude aortic dissection with a CT aortogram before thrombolysing the stroke in this case.
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"Paediatric safeguarding discussion"
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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.
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How would you manage this case?
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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?
