https://stjamesed.com/contact-us daily 0.75 2022-12-05 https://stjamesed.com/home daily 1.0 2023-05-22 https://stjamesed.com/about-us daily 0.75 2022-12-05 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067194382-MVS58QKGG8MJW3F97ERX/IAEM.jpg About Us IAEM https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067329634-IAQFDWHV6SE1II6XEXHJ/IEMTA.jpg About Us Irish Emergency Medicine Trainees Association https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067508381-KJO1OL3BSZS3G4QS5A2A/rcem+learning.png About Us RCEM Learning blog https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067631218-W4QS4AAPGIA5B7VNED1S/POCUS+ireland.jpeg About Us POCUS ireland https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067748611-6QWT3S1AQYBXFDYXMMDT/LITFL.png About Us Life in The Fast Lane blog https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594069998999-THBJ7H8LMK618SASW13P/the+case+report.jpg About Us The Case.Report podcast https://stjamesed.com/education daily 0.75 2022-12-05 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1596192431819-SHE01KO6111XL2R94WL3/IMG_5093.jpg Educational Cases Resuscitation & Shock https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1596198868590-QXSUG5JCY90T9IYB88C1/Attachment-1%5B1%5D.jpeg Educational Cases Sepsis & Infection https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606836090150-7EMHS2ZCF2XW50DAZ6XM/empty+packets.jpg Educational Cases Toxicology https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1596201577438-2G358CB1YXTFKEB14J4F/image-asset.jpeg Educational Cases Cardiology Presentations https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1596192961824-TP4EQKGKETYX475970IL/IMG_1786.jpg Educational Cases Respiratory Presentations https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594995800651-6PVJ6BP7UB0MXJ9FTBIY/image-asset.jpeg Educational Cases Abdominal Pain https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1596203084419-QH5YU0XPMVI2OOKLW7AD/image-asset.jpeg Educational Cases Neurological Presentations https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600781846128-Y6QKL0H9V1SJL3RGBNU9/IMG_5361.jpg Educational Cases Trauma presentations https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1597933684334-8I3JKEJAT0O3SD1NITZM/blood+gas.jpg Educational Cases Metabolic emergencies https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600782362642-BXC18HC8X0FP9UX7V5P6/psi.jpg Educational Cases Mental Health Crises https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1597934301906-G2YD0KIRKYE6AYP1HPHO/VTE.png Educational Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1596200683361-OOPG60LRU3NMLGDXJF7I/image-asset.jpeg Educational Cases Limb Injury & Swelling https://stjamesed.com/teaching daily 0.75 2021-03-23 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603133349196-U2Z3WJILW3YE1UPXDEV9/Registrar+teaching.jpeg NCHD Teaching - Registrar teaching Registrar teaching takes place on Monday mornings immediately after handover. This program is organised and delivered by the registrar group with consultant presence and support. This way registrars can identify and target their individual learning needs and ongoing professional development requirements. We try to take a blended approach encouraging a mix of theoretical, practical, management and leadership topics. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1596103463292-WSMYHIQ3R60D0YZE211B/teaching.jpg NCHD Teaching - SHO Teaching The formal education program for the SHO’s and interns takes place on Thursday mornings immediately after handover and is consultant delivered. The program is linked to the RCEM curriculum and through each six month period covers the range of presentations SHO’s would expect to see in the ED. Attendance is strongly encouraged. https://stjamesed.com/exams daily 0.75 2021-04-20 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067508381-KJO1OL3BSZS3G4QS5A2A/rcem+learning.png Emergency Medicine Exams RCEM learning platform https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067748611-6QWT3S1AQYBXFDYXMMDT/LITFL.png Emergency Medicine Exams Life in the Fast Lane blog https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598001790295-KPGLI8GT0U30MIYPSUMN/st+emlyns.jpeg Emergency Medicine Exams St Emlyns Blog https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598002325958-8B1U4JETDV8SPGFCK3FD/rebelem.png Emergency Medicine Exams Rebel EM blog https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594069998999-THBJ7H8LMK618SASW13P/the+case+report.jpg Emergency Medicine Exams The Case.Report Podcast https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598019197869-C4ARNH8YX92RL9QPADT2/first+101.jpg Emergency Medicine Exams First 10 in EM https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598019301946-VXJ8RIG7LFI9S0OJX8RQ/ecgw.png Emergency Medicine Exams ECG Weekly by Amal Mattu https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598019433359-3TFI0X1FL84KKE66R1G2/sgem2.png Emergency Medicine Exams Skeptics Guide to Emergency Medicine https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1618914892453-4CJSQVCFCWIZF9DMAJ28/unsplash-image-HahseXFw1M0.jpg Emergency Medicine Exams - Memberships MRCEM Primary 3 hour exam 180 single best answer questions mapped to RCEM basic sciences curriculum (June 2020) MRCEM Intermediate SBA Two 2 hour examinations 90 single best answer questions in each exam Mapped onto the RCEM 2021 Emergency Medicine Curriculum MRCEM OSCE 18 stations 7 minutes per station + 1 minute to read instructions Mapped onto the RCEM 2021 Emergency Medicine Curriculum All three of the above components must be passed to be awarded membership by examination. For candidates who started on the pre-August 2021 examination structure see RCEM website for details of which exams will count towards membership by examination. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1618915537327-YG0DNN11LUKSGF7E60QV/unsplash-image-1VqHRwxcCCw.jpg Emergency Medicine Exams - Fellowship Single Best Answer Exam 2 papers 2 hours each 90 questions per paper Clinical paper Single best answer format FRCEM OSCE 16 stations 8 minutes each 1 minute reading time Must pass at least one resuscitation station in addition to achieving the pass mark to pass the OSCE The critical appraisal, management and QIP examinations have been removed from the RCEM examination structure in favour of in-training assessment of these components. Irish Advanced Specialty Trainees will still have to sit a management exam administered by ICEMT, while the other components will be assessed during training. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594071823081-CVRDZ1JOI2W61G38S2SB/1.png Emergency Medicine Exams https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594071844372-YNUI6PD5BYDJDV58BRN8/2.png Emergency Medicine Exams https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594071901595-X5AI2F43S0KMBNR8B4V1/3.png Emergency Medicine Exams https://stjamesed.com/skills daily 0.75 2021-01-26 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611586002689-D99JCUIEX6RES7MWAAJX/teaching.jpg Skills Airway https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611585968317-FZAVNBA0ERYLHA54RBTZ/examinations.jpg Skills Examinations https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611586214286-FJZ5HUMC3S3W5X7D9FK9/LP%252Bprocedure.jpg Skills Procedures https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611586268369-ABK3LYXY6OGM1IRPK39E/IMG_6140.jpg Skills Equipment https://stjamesed.com/medical-students daily 0.75 2020-10-01 https://stjamesed.com/audit-resources daily 0.75 2021-08-03 https://stjamesed.com/cardiac-presentations daily 0.75 2021-02-15 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604582048376-1WW0OA78UZ22T8F0NFN9/Attachment-1%255B1%255D.jpg Cardiac Presentations Level A Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604582492740-XDHL24CJ5QW0H52BPNON/Attachment-1%255B2%255D.jpg Cardiac Presentations Level B Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604581754112-5ST4SP0LHKBB2B98Q8OB/Attachment-1.jpg Cardiac Presentations Level C Cases https://stjamesed.com/sepsis-infection daily 0.75 2022-04-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603104272359-1PZ0R9C1BAKKNYIT0YE9/Coamox.jpg Sepsis & Infection Level A Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603104416086-7QKLRWMA74RZAT10PMIQ/Tazocin.jpg Sepsis & Infection Level B Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603104796824-12D28WL5C3MGF4V1YLJD/Mero%2B%252B%2BVanc.jpg Sepsis & Infection Level C Cases https://stjamesed.com/resuscitation-shock daily 0.75 2021-05-21 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604074273220-91VH1UHRY6STRJ6BJRRC/IMG_5553.jpg Resuscitation & Shock Level A Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604074229940-UAZIMWLOSCZSPO9M96ZM/IMG_5559.jpg Resuscitation & Shock Level B Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604074189511-SG7RWE48XG8ZTYLPOUE2/IMG_5567.jpg Resuscitation & Shock Level C Cases https://stjamesed.com/mental-health-crises daily 0.75 2021-07-30 https://stjamesed.com/trauma daily 0.75 2020-12-22 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1596206927084-N720CVOBJGOXQ5A6ROWA/Resusbay.jpeg Trauma - Major trauma & approach to the multiply injured patient. How you approach to the multiply injured patient from their arrival in the emergency department will have a huge impact on their outcome, whether they live or die and what level of functionality they will have into the future. All multiply injured patients should be cared for by a trauma team with a trauma team leader who is experienced in the management of major trauma. Experience from other countries has shown that multiply injured patients who are cared for in an integrated trauma system have much better outcomes that those who are not. In Ireland we are currently in the middle of implementing an integrated trauma system that will consist of 2 trauma networks. These networks will consist of one major trauma centre each supported by a number of trauma units. Most importantly there will be a whole system approach to trauma driving improvements in patient care from their initial contact with first responders right through to discharge from rehabilitation services. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600781846128-Y6QKL0H9V1SJL3RGBNU9/IMG_5361.jpg Trauma - Team course The team course gives learners an excellent grounding in the principles of trauma care and the approach to the early care of the multiply injured patient. We would recommend that all medical students attend a team course. https://stjamesed.com/neurological-presentations daily 0.75 2022-06-22 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606321977862-B5R03XY64J8LERPNXOQ6/IMG_1788.jpg Neurological Presentations Level A Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606322707529-F2LEPR79L9CRRUO61KBO/IMG_5749%2B2.jpg Neurological Presentations Level B Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606322764508-IUXNJUEBRNI79ICGQQDU/IMG_5747.jpg Neurological Presentations Level C Cases https://stjamesed.com/limb-injuries-swelling daily 0.75 2020-07-31 https://stjamesed.com/abdominal-pain daily 0.75 2021-08-24 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598003243035-4CXRFEPCXW0S3I4JMT8Y/abdo%2B1.jpg Abdominal Pain Level A Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598007697298-CSEDOW2HD83OXYWX3N8Z/bladder.jpg Abdominal Pain Level B Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598007756466-HYSILINYB8K3WT4R89CL/abnormal+RUQ.jpg Abdominal Pain Level C Cases https://stjamesed.com/toxicology daily 0.75 2022-04-13 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607337540175-QWX0X8TWRN14K8ICC146/Paracetamol%2Bbox1.jpg Toxicology Level A Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607337515744-5MCWUR2I5IUY284DWJC2/SSRI%2527s.jpg Toxicology Level B Cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607337564043-PH867I8AHHU7OBL4SQ2N/Ca%2Bchannel%2Bblocker.jpg Toxicology Level C Cases https://stjamesed.com/metabolic daily 0.75 2021-05-18 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607423395351-1E2UT21WX5571PLFGD89/IMG_5845.jpg Metabolic & Endocrine Home Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607422866035-H1VXGPNCADQV4TFTCIV3/IMG_5840.jpg Metabolic & Endocrine Home Level B https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607423354771-6UQOH79X7NNAIMOIZAQO/IMG_5843.jpg Metabolic & Endocrine Home Level C https://stjamesed.com/appendicitis-level-a daily 0.75 2020-10-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600854185662-YI3RTHUIFMIQWWOGSXZG/Dipstick%252BUrine%252Bjpg.jpg Appendicitis Level A - Bedside Urinalysis Dipstick can aid in excluding UTI (nitrates) Leucocytes may be detected in some cases of appendicitis Urinary bhCG is mandatory in all women of child bearing age https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601647586572-JDSGCSQ04JG5NEWR4W7R/bloods%2B%252B%2Bpod.jpg Appendicitis Level A - Laboratory FBC – neutrophilia is suggestive but normal WCC doesn’t out rule the dx CRP – elevated level is suggestive but normal doesn’t out rule the dx U&E, BM, LFT, Amylase – help out rule other diagnoses https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601848217946-TBK3C5J4TYILGQC9NHZC/pus%2Bin%2Bpelvis.jpg Appendicitis Level A - Radiology Ultrasound – can be useful but appendix only visualised in <50% of cases Useful to out rule gynaecologic pathology in women CT Abdomen – sensitivity and specificity of ~ 98% Disadvantages = cost, availability, radiation exposure MRI abdomen – used to make the diagnosis in pregnant patients https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601849083417-2LHM8AHAQFHWTPS1JP1C/Alvarado.png Appendicitis Level A - Clinical Decision Rule Alvarado score (MANTRELS criteria) uses a combination of symptoms, signs and laboratory findings to calculate the likelihood of appendicitis https://stjamesed.com/abdo-lac1 daily 0.75 2020-10-01 https://stjamesed.com/venous-thromboembolism daily 0.75 2021-10-15 https://stjamesed.com/sjhedinduction daily 0.75 2023-05-22 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594069998999-THBJ7H8LMK618SASW13P/the+case+report.jpg SJH ED Induction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067194382-MVS58QKGG8MJW3F97ERX/IAEM.jpg SJH ED Induction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067329634-IAQFDWHV6SE1II6XEXHJ/IEMTA.jpg SJH ED Induction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1597997369861-EP5N8XBW23U71CPAL0Q3/wellness+compendium.jpg SJH ED Induction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1594067508381-KJO1OL3BSZS3G4QS5A2A/rcem+learning.png SJH ED Induction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598001790295-KPGLI8GT0U30MIYPSUMN/st+emlyns.jpeg SJH ED Induction St Emlyns Blog https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598002045458-EDNB3LZ1JFF3OVR299OA/sgem.jpeg SJH ED Induction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598002158956-A4LN7SFCEB5V096TN9EZ/ecg+weekly.png SJH ED Induction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598002253780-5MNH4MLFNB9ZZS68NYJP/first+10.jpg SJH ED Induction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598002325958-8B1U4JETDV8SPGFCK3FD/rebelem.png SJH ED Induction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1608544392341-0NFAB8I44TL77OXG7ZJJ/mdcalc.png SJH ED Induction MdCalc https://stjamesed.com/emergency-nursing daily 0.75 2021-02-01 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612194841583-5EANIT7QH0XD12YK4UI7/Yvonne%2B3%2B%2B14442.jpg Emergency Nursing - “Emergency Nurses work independently and interdependently with the multidisciplinary team to provide the optimal level of emergency nursing care that is patient focused, family centred, maximises health and social gain, promotes excellence in nursing practice and advocates for all patients who suffer sudden injury or illness. Emergency nursing practice is underpinned by expert knowledge gained through specialist education and clinical experience. It is informed by best evidence and research” — Mission of Emergency Nursing https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612195517517-ECE2BGKL9TFIPKW807H4/Ollie+3++14439.jpg Emergency Nursing - The involvement of nursing in the Emergency Medicine Programme has provided an opportunity to develop a definition of Emergency Nursing across the National Emergency Care System. Emergency Nursing is defined as the provision of immediate nursing care and intervention to adults and children who have undiagnosed, undifferentiated healthcare needs arising from social, psychological, physical and cultural factors. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612195609796-8WQHHHZ548GA49UGDDTQ/Dee+2++14430.jpg Emergency Nursing - The key components of Emergency Nursing include: Rapid patient assessment and assimilation of information, often beyond the presenting problem Allocation of priority for care Intervention, based on the assessment On-going evaluation Discharge or referral to other sources of care undertaken independently by the nurse within guidelines https://stjamesed.com/diverticulitis-level-a daily 0.75 2020-10-16 https://stjamesed.com/abdo-lac2 daily 0.75 2020-10-04 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1599511432687-7OB3Q18JV6XFTZEVZE2J/Case+2+CT.png Abdo L.A.C.2. https://stjamesed.com/abdo-lac3 daily 0.75 2020-10-01 https://stjamesed.com/ectopic-pregnancy daily 0.75 2020-10-16 https://stjamesed.com/abdo-lac4 daily 0.75 2020-10-04 https://stjamesed.com/ruptured-aaa daily 0.75 2020-10-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598006661189-7AMTXDQC47ZDUPU5J077/AAA.jpg Ruptured AAA Level A - Clinical Investigations Bedside Immediate bedside point of care ultrasound looking for a AAA (sens + spec >95%) in trained hands ECG - looking for other causes Venous blood gas - low pH and high lactate - shocked patient Finger prick blood glucose https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600701494853-PT5FHD5BBRP01OW09E14/blood+bottles.jpg Ruptured AAA Level A - Laboratory Group and crossmatch at least 6 units FBC U&E Co-ag Looking for alternative diagnoses Amylase LFT’s CRP https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1599839110642-USB80WAFGP9Z095EF88T/AAA%2BCT.jpg Ruptured AAA Level A - Radiology Unstable patients Convincing clinical scenario and bedside ultrasound is sufficient to take patient to theatre directly Stable patient CT angiogram aorta is the gold standard and shows size location any leak any other complications https://stjamesed.com/mesenteric-ischaemia daily 0.75 2020-10-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601561677187-5ZKGFKD1BVMA32VFP153/a+fib.jpg Mesenteric ischaemia Level A - Bedside Venous Blood Gas – lactic acidosis is often present but it’s absence doesn’t out rule the dx ECG – mesenteric ischaemia is more common in atrial fibrillation POCUS – Out rule AAA, Look for free fluid indicating another diagnosis e.g. perforated viscus https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600701494853-PT5FHD5BBRP01OW09E14/blood+bottles.jpg Mesenteric ischaemia Level A - Laboratory FBC – elevated WCC CRP – often elevated U&E – May be evidence of AKI or CKD. LFT and amylase – help out rule other conditions CoAg and Group + Hold – if suspicious and think pt may be going to theatre https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601629579802-D4QLEHW1KDFYN13LY048/Mesenteric+ischaemia+2.png Mesenteric ischaemia Level A - Radiology Erect CXR – helps exclude perforation AXR – may have nonspecific signs such as dilated loops in ileus, thumb printing, portal vein gas CT angiogram – 96% sensitive, 94% specific – mesenteric or bowel oedema, air in bowel wall or in the portal system, abn gas pattern, signs of perforation CT angiogram not 100% sensitive or specific. Sometimes condition is only diagnosed at lapraoscopy https://stjamesed.com/abdo-lac5 daily 0.75 2020-10-02 https://stjamesed.com/abdo-lac6 daily 0.75 2020-10-01 https://stjamesed.com/renal-colic daily 0.75 2020-10-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600854185662-YI3RTHUIFMIQWWOGSXZG/Dipstick%252BUrine%252Bjpg.jpg Renal Colic Level A - Bedside Urinary BHCG is mandatory in all women of child bearing age Urinalysis microscopic haematuria is common 10-30% pts with nephrolithiasis do NOT have haematuria look for evidence of infection VBG – abnormal VBG concerning for sinister pathology not renal colic. POCUS out rule AAA https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600701494853-PT5FHD5BBRP01OW09E14/blood+bottles.jpg Renal Colic Level A - Laboratory FBC – WCC often mildly elevated. Marked leucocystosis ? infection U&E - ? evidence of renal impairment CRP – if elevated concerning for infection or other DDx LFT + Amylase – looking for other diagnoses https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600813733857-PLZ9ZYL7RWVWEMD0P6U6/ureteric+stone.png Renal Colic Level A - Radiology Non Contrast CT KUB = investigation of choice Highly sensitive and specific Shows presence of complications Xray KUB – ONLY if CT positive for stone Approx 60% sensitive. If stone visible can be used to monitor position when followed up by urology https://stjamesed.com/biliary-colic daily 0.75 2020-10-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601648235308-P0WR41AT83T0P9CKUK23/Dipstick%2BUrine%2Bjpg.jpg Biliary Colic Level A - Bedside Urinalysis, Urine BHCG, ECG – Primarily to out rule other pathology VBG – high lactate + low pH concerning in sepsis POCUS if concerned for AAA https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601647586572-JDSGCSQ04JG5NEWR4W7R/bloods%2B%252B%2Bpod.jpg Biliary Colic Level A - Laboratory FBC – WCC typically elevated if infective pathology CRP – elevated in cholecystitis, cholangitis, pancreatitis U&E – AKI concerning for infective pathology LFT – Cholestatic Pattern i.e. elevated bilirubin, ALP + GGT. Would be expected in choledocholithiasis and ascending cholangitis Amylase – elevated in Pancreatitis. (may be gallstone related or secondary to other cause) CoAg – elevated INR if acute liver injury Blood Cultures – if concerned for sepsis https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601648056249-P6C93GI04FJIQGGNM8XI/Actue+cholecystitis.png Biliary Colic Level A - Radiology Upper Abdominal US Presence of gallstones and location Signs of cholecystitis. Gallbladder wall thickness > 5mm, Pericholecystic fluid, Probe tenderness Dilated CBD indicating choledocholithiasis CT Abdomen US is generally more sensitive for gallstones but CT can have a role in complications e.g. cholecystitis, pancreatitis, GB perforation MRCP/ERCP MRCP is gold standard for diagnosing choledocholithiasis ERCP for treatment https://stjamesed.com/abdo-lac8 daily 0.75 2020-10-02 https://stjamesed.com/abdo-lac7 daily 0.75 2020-10-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601634289870-634A3RTOP6DQ202PAU1W/SBO.png Abdo L.A.C.7 - A 51 year old lady presents with 2 days of central abdominal pain with associated vomiting. She passed a bowel motion initially but nil in the last 24 hours. She is not passing flatus. She has past history of a laparotomy and incisional hernia repair. This is her abdominal x-ray. What is the diagnosis? How do you know? Reference: Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 66670 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1602856171746-N8833R6FIFWY7AA6NREX/LBO.jpg Abdo L.A.C.7 - An 85 year old gentleman is brought to hospital by ambulance from his nursing home. The staff there report he has been complaining of abdominal pain for a number of days, is off his food and today the staff noticed his abdomen is distended. This is his abdominal x-ray. What is the diagnosis? How do you know? https://stjamesed.com/respiratory-complaints daily 0.75 2021-02-23 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607337754799-76G437T8OXEQLBFM3NFT/Pneumo%2B27mmsmaller.jpg Respiratory Complaints Level A cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607337605438-PW05X985Z7A7VUGS1IWE/right%252Bupper%252Blobe%252Bmass.jpg Respiratory Complaints Level B cases https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607337623945-7NA3RLVK0GCA42KJ4WL8/Multifocal%2Bpneumonia.jpg Respiratory Complaints Level C cases https://stjamesed.com/pe-level-a daily 0.75 2020-10-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601826464327-W0M3F4O7070VFL273R9K/PERC.png PE Level A - PERC Rule Used when the diagnosis pf PE is being considered but the risk is considered low. If a patient is negative in all components of the PERC rule then they can be considered low risk and it may be reasonable to carry out no further work-up for PE If any component of the PERC rule is positive, the patient requires further investigation to assess for PE. The PERC rule is NOT for use in pregnancy https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601842373636-MSI9EFHOZW1YQR1BCG57/Wells+score.png PE Level A - Well’s Score A useful clinical decision rule to help assess the probability of a patient having a PE and guiding further investigation in patients where there is a suspicion of PE A low Well’s Score with a negative D Dimer result is considered safe in ruling out PE. Not validated in pregnancy or people who inject drugs Score 0-1 – Low Risk (1.3% prevalence of PE) Score 2-6 – Moderate Risk (16.2% prevalence of PE) Score >6 – High Risk (37.5% prevalence of PE) https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601586838104-VLHXBGY2XSY05ZMOO379/LITFL+ecg.png PE Level A - Bedside 12 Lead ECG Assess for myocardial ischaemia to rule out ACS Sinus tachycardia is the most common ecg finding in PE S1Q3T3 pattern is rarely seen but if present suggests massive PE as it is a sign of right heart strain Deep S wave in lead I, Q wave in lead III and T wave inversion in lead III RBBB (right bundle branch block) may also be present which also suggests the presence of right heart strain ABG may show Hypoxaemia Respiratory alkalosis May be normal https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600701494853-PT5FHD5BBRP01OW09E14/blood+bottles.jpg PE Level A - Laboratory FBC, U&E, CRP, Coag screen, Troponin Helpful in ruling out other causes D Dimer Degredation product of fibrin and is raised as a result of fibrinolysis when clotting is taking place Can be raised for a number of other reasons including inflammation, trauma, recent surgery, pregnancy (has not been validated in pregnant patients and therefore should not be used). Sensitive but not specific Sensitivity 96.4%, specificity 52% for PE in the emergency department (3) A negative result is reliable for ruling out VTE in low to intermediate risk patients, but a positive result is not reliable for ruling in VTE https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601911339030-44H3FBPIA6FBMINQLTIN/Saddle+embolus.png PE Level A - Radiology Chest x-ray Useful for ruling out other causes (pneumothorax, infection) but is neither sensitive nor specific for diagnosing PE Rarely wedge shaped infarcts may be seen CT Pulmonary Angiogram (CTPA) is the most common diagnostic radiologic test to diagnose PE (4) A V/Q scan is performed less commonly as an alternative to CTPA The safety of CTPA vs V/Q scan in pregnancy has been extensively debated however, 2015 RCOG Guidance preferentially recommends CTPA for diagnosis of PE (5) https://stjamesed.com/pageresplac1 daily 0.75 2020-10-04 https://stjamesed.com/bowel-obstructionlevela daily 0.75 2020-12-14 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601643840786-3MBUK8IRCT8LY85EGZT3/SBO%2B%252B%2BLBO.jpg Bowel obstruction Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601644062419-8ZJKB2GNSBWKTXQS14GD/Erect+CXR+radiopaedia.jpg Bowel obstruction Level A Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 17957 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601643565434-3G7JPDAYWP17MCEYJT63/Bowel+obstruction+CT.jpeg Bowel obstruction Level A Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 6135 https://stjamesed.com/abdo-lac9 daily 0.75 2020-10-16 https://stjamesed.com/acute-pancreatitis-level-a daily 0.75 2020-12-14 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1602854655366-NMCEPVW5V30IDFWECQ33/Normal+Aorta+US.png Acute Pancreatitis Level A - Bedside POCUS out rule AAA, assess for presence of free fluid +/- GB bladder pathology depending on operators experience Uranalysis, Urinary BHCG, ECG Primarily to out rule other pathology VBG high lactate and low pH concerning for severe disease. Elevated BM https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601647586572-JDSGCSQ04JG5NEWR4W7R/bloods%2B%252B%2Bpod.jpg Acute Pancreatitis Level A - Laboratory Amylase > 3 times normal is highly suggestive. Can be normal in 10-20% cases. Amylase not specific to pancreatitis. Rises in first 10 hours. Stays elevated for ~ 5 days FBC + CRP Leucocytosis and elevated CRP are typical U&E Look for signs of acute kidney injury, HypoK or HypoNa from vomiting LFT often elevated especially ALP and GGT in gallstone pancreatitis. Albumin helps predict severity CoAg signs of coagulopathy indicating severe disease Urinary Amylase has a role in the late presenter as may remain elevated when serum amylase returns to normal. Again not 100% sensitive or specific https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1602851193870-DOPPFN8EIM0WPZFMJ5J9/interstitial-edematous-pancreatitis.jpg Acute Pancreatitis Level A - Radiology CXR especially if unwell. Presence of effusions or ARDS picture = severe pancreatitis AXR May have role in out ruling other pathology. Not a routine investigation Abdominal Ultrasound If concerned regarding biliary pathology CT Abdomen not usually indicated in mild pancreatitis. Important when diagnosis is uncertain and also in severe cases to identify any complications https://stjamesed.com/resplac2 daily 0.75 2020-10-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1602517804800-5HY1V515LO3M2LJUXFR7/ABG.jpg Resp L.A.C.2 - A 19 year old male is brought in by ambulance to the Emergency Department with a 90 minute history of worsening dyspnoea. He has a history of Asthma since childhood for which he has had 2 previous hospital admissions and takes Symbicort BD and Salbutamol prn. On arrival of Paramedics to his home, he was unable to complete sentences, his SpO2 was 94% on room air, he was tachypnoeic at 30 breaths/minute and tachycardic at 112 beats/minute. A diffuse expiratory wheeze could be heard. He was commenced on Salbutamol nebulisers continuously until his arrival in ED. An immediate ABG was performed and the result is shown opposite Question 1 What is the immediate management of this patient? Question 2 How is the severity of an Acute Asthma Exacerbation graded? Question 3 How is the severity of an Acute Asthma Exacerbation graded? Question 4 What is the ultimate disposition of this patient? https://stjamesed.com/under-construction daily 0.75 2020-10-09 https://stjamesed.com/cauda-equina-level-a daily 0.75 2020-10-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1602861326230-FDFBM4TRFLM6LVF85XKV/cauda-equina-compression.jpg Cauda Equina Level A Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 13942 https://stjamesed.com/neurolac1 daily 0.75 2020-12-22 https://stjamesed.com/asthma-level-a daily 0.75 2020-10-24 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1602509951309-FX9AX8LJU6RV6BLLENKR/PEFR.png Asthma Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1602512985177-BL0B5APGPZ7D9AM7UM7I/Asthma+Severity+2.png Asthma Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1602514097448-P0VC5RDV7GJKJWR4X35I/PEFR+device.jpg Asthma Level A - Bedside Investigations o PEFR Apart from classifying the severity of Asthma as shown above the PEFR is also useful to monitor response to emergency treatment in the ED o ABG In particular looking for Hypoxia (PaO2 <10kPa), Normocapnoea/Hypercapnoea (PaCO2 >4.6kPa) and Acidosis (pH <7.35). o ECG Most likely finding is Sinus Tachycardia. Remember that Tachycardia is also a side effect of Salbutamol. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601647586572-JDSGCSQ04JG5NEWR4W7R/bloods%2B%252B%2Bpod.jpg Asthma Level A - Laboratory Full Blood Count, Urea & Electrolytes, CRP, D-Dimer (if PE considered and if test indicated) Not useful for immediate management of acute severe asthma, however necessary for further investigation/ruling out other causes of dyspnoea. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601567331440-RVRT6PLTRSW83BJ0Z9ME/normal+cxr.jpg Asthma Level A - Radiology Chest X-Ray Useful to help rule out Pneumothorax or Pneumonia as a cause of the patient’s presentation. Up to 75% of x-rays are normal in an acute exacerbation of asthma.(4) May see hyperinflation Greater spacing between ribs Horizontal appearance of ribs >10 posterior ribs visible above diaphragm https://stjamesed.com/sepsis-lac3 daily 0.75 2020-10-30 https://stjamesed.com/septic-shock-level-a daily 0.75 2022-04-14 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603119235663-J2WFXJQ9DJU8YCZD9111/Sepsis+Continuum.png Septic Shock Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603122265522-TXCW59DRBI9JG1A3C2F9/IMG_5491.jpg Septic Shock Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603122032645-NLRCG12KPEHOREB33RFW/IMG_6847.jpg Septic Shock Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601566901919-JVB1XUX00DY7DLYTAK3Y/Multifocal+pneumonia.png Septic Shock Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603124165620-ZZL82WODVTJRPABANU44/Screenshot+2020-10-19+at+17.15.56.png Septic Shock Level A https://stjamesed.com/meningitis-level-a daily 0.75 2022-04-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603115024790-A5GN0DYNU5V3WGG9WG6S/Bedside.jpg Meningitis Level A - Bedside VBG ? high lactate, ? low pH in sepsis. ? Low BM accounting for GCS Urinalysis Seeking other causes for sepsis Urine Toxicology screen ECG https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603112616009-3V7CKQ5N6C9R5SRL7Y7N/LP%2Bequipment.jpg Meningitis Level A - Laboratory General Investigations FBC, U&E, CRP, LFT, CoAg Assist in building the overall clinical picture e.g. presence of end organ dysfxn Blood Cultures Take prior to Empiric antibiotics especially if LP is delayed Lumbar Puncture – Antibiotics should not be delayed for LP CT before LP if decreased GCS, focal neurological abnormality, seizure, concern for SOL If evidence of high ICP on CT there is a risk of brain herniation during LP so it should be delayed CSF in bacterial meningitis = High opening pressure, High protein, Low glucose, High WCC mostly polymorphs, +ve Gram Stain CSF or Blood for viral and meningococcus PCR CSF or urine for rapid antigen tests for Strep, Listeria MSU - ? other cause of sepsis https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603114812943-3W5F5XOMI46JWF0YDHNP/CTB%2Bwork%2Bstation.jpg Meningitis Level A - Radiology CT Brain occurs in most cases to out rule increased ICP/other causes of headache e.g. SOL, Haemorrhage etc CXR – as part of work up https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603116170662-6UB9K7O5H9ZMWAZMOLGT/IMG_7688.jpg Meningitis Level A - Infection Control Patient should be managed in an isolation room with contact and droplet precautions and staff in full PPE https://stjamesed.com/paracetamol-level-a daily 0.75 2020-12-22 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600854117766-E3GMAL011LWZUXZ13ZXB/Dipstick%2BUrine%2Bjpg.jpg Paracetamol Level A - Bedside Glucose bedside finger stick glucose in all patients with altered consciousness Urine dip may show bilirubin in late presentations ECG in case of polypharmacy overdose, patients may have co-ingested medications that affect the QT or QRSD VBG Check lactate and pH https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601647586572-JDSGCSQ04JG5NEWR4W7R/bloods%2B%252B%2Bpod.jpg Paracetamol Level A - Laboratory FBC, U/E, LFT, Coag screen - all taken on arrival Paracetamol level should only be taken 4 hours after ingestion, or on arrival in ED if >4 hours have elapsed since ingestion https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1598003199747-HHO4MRH53J4O9QGQ5SOG/abdo+1.jpg Paracetamol Level A - Radiology Radiology investigations are not usually required in paracetamol overdose however ultrasound gallbladder or liver may be useful in ruling out alternative diagnoses. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607352230883-W2FWKZSMGPWFQDCAW8OS/8hrs.png Paracetamol Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607352351967-ST39W7EM10IFJLNFDCO1/8-24hrs.png Paracetamol Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607352746273-GY475OY8VRKRIYEQ1WOK/24hrs.png Paracetamol Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607352940511-S3DR3JVD54DQC4U55ZVQ/normogram.png Paracetamol Level A Check units carefully as different assays may use different units https://stjamesed.com/tox-lac3 daily 0.75 2020-10-20 https://stjamesed.com/sepsis-lac-1 daily 0.75 2020-10-30 https://stjamesed.com/sepsis-lac-2 daily 0.75 2020-10-30 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603275621853-1VU0V3GZ643PCK12O4NQ/Lobar+pneumonia.jpg Sepsis L.A.C. 2 - An 80 year old man presents to the ED complaining of 4 days of chesty cough productive of green sputum, anorexia, malaise and fevers. He has a past history of Hypertension, hypercholesterolaemia and ischaemic heart disease with previous CABG. He was discharged from hospital 1 week ago following a 5 day admission with an NSTEMI which was medically managed. His observations are as follows; Temp 38.9, RR 24, Sats 90% RA, HR 102, 155/87 His Chest x-ray is opposite. https://stjamesed.com/pneumonia-level-a daily 0.75 2020-12-22 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603277983272-QOJU521XDT4S4LAYERGX/IMG_5479.jpg Pneumonia Level A - Bedside Arterial Blood Gas (if Hypoxic) Low pH = acidosis (resp or metabolic i.e. sepsis) PaO2 < 8kPA = Respiratory Failure. with normal or low PaCO2 = Type 1 resp failure with high PaCO2 (>6.7kPa) = Type 2 resp failure High PaCO2 = Resp Acidosis. Low PaCO2 = Resp Alkalosis (Tachypnoea) Electrolytes, Hb, Lactate, BM ECG ? Cardiac cause for symptoms POCUS Lung US more sensitive and specific for consolidation than CXR Bedside Echo - ? CCF, ? pericardial effusion https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603291151409-17YYMGGKB4VRW60F8FQF/bloods+%2B+pod.jpg Pneumonia Level A - Laboratory Bloods Tests Inflammatory markers - High neutrophils, Low lymphocytes (viral), High CRP U&E – AKI, Low Na often associated with chest sepsis LFT – often abnormal, especially with Mycoplasma Mycoplasma serology Blood cultures if ? sepsis Sputum for Culture Urine for Culture and Legionella/Pneumococcal Antigen Nasal/Throat Swab for Viral PCR https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603275621853-1VU0V3GZ643PCK12O4NQ/Lobar+pneumonia.jpg Pneumonia Level A - Radiology CXR Consolidation, air bronchograms, parapneumonic effusion, Cavitation Normal CXR doesn’t out rule pneumonia as CXR changes can lag behind clinical findings CT Chest Diagnosis may be made when looking for other pathology e.g. PE on CTPA. May have role in atypical pneumonia e.g. COVID 19 https://stjamesed.com/sepsis-lac4 daily 0.75 2020-10-30 https://stjamesed.com/sepsis-lac-2-1 daily 0.75 2020-10-21 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603275621853-1VU0V3GZ643PCK12O4NQ/Lobar+pneumonia.jpg Resp L.A.C. 4 - An 80 year old man presents to the ED complaining of 4 days of chesty cough productive of green sputum, anorexia, malaise and fevers. He has a past history of Hypertension, hypercholesterolaemia and ischaemic heart disease with previous CABG. He was discharged from hospital 1 week ago following a 5 day admission with an NSTEMI which was medically managed. His observations are as follows; Temp 38.9, RR 24, Sats 90% RA, HR 102, 155/87 His Chest x-ray is opposite. https://stjamesed.com/pneumonia-level-a-resp-copy daily 0.75 2020-10-21 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603277983272-QOJU521XDT4S4LAYERGX/IMG_5479.jpg Pneumonia Level A resp copy - Bedside Arterial Blood Gas (if Hypoxic) Low pH = acidosis (resp or metabolic i.e. sepsis) PaO2 < 8kPA = Respiratory Failure. with normal or low PaCO2 = Type 1 resp failure with high PaCO2 (>6.7kPa) = Type 2 resp failure High PaCO2 = Resp Acidosis. Low PaCO2 = Resp Alkalosis (Tachypnoea) Electrolytes, Hb, Lactate, BM ECG ? Cardiac cause for symptoms POCUS Lung US more sensitive and specific for consolidation than CXR Bedside Echo - ? CCF, ? pericardial effusion https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603291151409-17YYMGGKB4VRW60F8FQF/bloods+%2B+pod.jpg Pneumonia Level A resp copy - Laboratory Bloods Tests Inflammatory markers - High neutrophils, Low lymphocytes (viral), High CRP U&E – AKI, Low Na often associated with chest sepsis LFT – often abnormal, especially with Mycoplasma Mycoplasma serology Blood cultures if ? sepsis Sputum for Culture Urine for Culture and Legionella/Pneumococcal Antigen Nasal/Throat Swab for Viral PCR https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603275621853-1VU0V3GZ643PCK12O4NQ/Lobar+pneumonia.jpg Pneumonia Level A resp copy - Radiology CXR Consolidation, air bronchograms, parapneumonic effusion, Cavitation Normal CXR doesn’t out rule pneumonia as CXR changes can lag behind clinical findings CT Chest Diagnosis may be made when looking for other pathology e.g. PE on CTPA. May have role in atypical pneumonia e.g. COVID 19 https://stjamesed.com/sah-level-a daily 0.75 2020-12-17 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600854117766-E3GMAL011LWZUXZ13ZXB/Dipstick%2BUrine%2Bjpg.jpg SAH Level A - Bedside Bedside glucose ECG - usually normal but other possible ecg findings include; Sinus tachycardia ST elevation, may mimic myocardial ischaemia or pericarditis Raised ICP Widespread deep T wave inversion QT prolongation Bradycardia https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601647586572-JDSGCSQ04JG5NEWR4W7R/bloods%2B%252B%2Bpod.jpg SAH Level A - Laboratory FBC, U/E, CRP, Coag screen useful in ruling out other causes Lumbar puncture In cases with a normal CT scan a Lumbar puncture may show xanthochromia - >12 hours after onset of the headache Red cell count increasing across successive bottles May show alternative diagnoses such as meningitis Recent evidence suggests that a lumbar puncture may not be a useful test for diagnosing subarachnoid haemorrhage and if you are highly suspicious further imaging should be peformed. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607093814425-5MGGVQ0QBN2QXG55ZZWV/SAH.png SAH Level A - Radiology Non contrast CT brain (3rd generation CT) Remains the initial diagnostic test of choice Sensitivity and specificity depend on Time since onset Amount of blood One study quotes a sensitivity and specificity of 92% and 100% respectively in neurologically intact patients(4) Patients with a positive CT should undergo angiography to detect any underlying aneurysms Patients with a negative CT’s management depends on the degree of suspicion for SAH MRI has a high sensitivity and specificity within 12 hours of onset of headache however it is far less readily available https://stjamesed.com/neuro-lac3 daily 0.75 2020-12-07 https://stjamesed.com/copd-level-a daily 0.75 2020-11-04 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603747479493-74JIRG3U0WJ2Y4RN7G2Z/Bedside.jpg COPD Level A - Bedside ABG May show type 2 respiratory failure Acidosis Hypercapnia Hypoxia ECG Often tachycardic Help rule out other pathology https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603122032645-NLRCG12KPEHOREB33RFW/IMG_6847.jpg COPD Level A - Laboratory FBC, U&E, CRP Raised WCC suggestive of infection but may be raised in context of steroid use also Raised CRP may also be suggestive of an infectious process Blood Cultures If patient is pyrexic at presentation, blood cultures can help direct targeted antimicrobial treatment in the coming days https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601567331440-RVRT6PLTRSW83BJ0Z9ME/normal+cxr.jpg COPD Level A - Radiology Chest x-ray Order a portable x-ray for patients with a markedly increased work of breathing who need management in Resus Findings for COPD are non-specific but may include flattened hemidiaphragms due to hyperinflation and increased bronchovascular markings Acutely, a chest x-ray is useful for ruling in consolidation suggesting an infectious exacerbation and for ruling out pneumothorax, pulmonary oedema or other causes of shortness of breath. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603748619294-VDHCR7M5GAB3E7U5231S/AECOPD.png COPD Level A - All patients presenting with a markedly increased work of breathing or hypoxia should be managed in resus. Give supplemental O2 to target an SpO2 88-92%. Avoid over-oxygenation as it is thought to depress the respiratory drive in patients with COPD. Continuous cardiac and SpO2monitoring should be in place and IV access secured. It is useful to draw a venous blood gas when IV access is obtained to assess the pH and PaCO2 initially as these differ very little from an arterial sample. If the patient has a markedly increased work of breathing, is acidotic (pH <7.35) or hypercapnic (PaCO­2 >6.0kPa) on VBG, an ABG should be obtained. Give nebulised bronchodilators, corticosteroids (PO or IV if unable to take PO), antibiotics if indicated and anitpyretics if the patient is febrile. https://stjamesed.com/resp-lac3 daily 0.75 2020-10-30 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604065634997-K17ZLV93EBYI1UUHMTGM/type%2B2%2Bresp%2Bfailure%2B2.jpg Resp L.A.C.3 - A 76 year old man attends the Emergency Department with a 3 day history of worsening shortness of breath. He has also noticed a worsening, productive cough with green sputum and was having fevers and chills. His past medical history includes COPD, hypertension, dyslipidaemia and previous prostate cancer. He is a lifelong smoker and currently smokes 15 cigarettes per day. On examination, there is an audible wheeze from the bedside, he is tachypnoeic at 28 breaths/minute, tachycardic at 105 beats/minute, SpO2 is 84% on room air. His arterial blood gas is shown opposite. https://stjamesed.com/resp-lac5 daily 0.75 2020-11-04 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604068310126-6SOL0KJY6SNRH8Z5YBJB/pneumothorax+27mm+at+hilum.png Resp L.A.C.5 https://stjamesed.com/pyelonephritis-level-a daily 0.75 2020-11-03 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603122265522-TXCW59DRBI9JG1A3C2F9/IMG_5491.jpg Pyelonephritis Level A - Bedside Urinalysis Presence of leucocytes = PPV 50%, NPV 92%, Nitrites = +ve if Gram Negative infection. High PPV. Low NPV as nitrites not produced by Gram +ve bacteria, enterococcus + pseudomonas Urinary BHCG in all women of child bearing age VBG – if concerned re sepsis. POCUS – experienced operator. Looking for hydronephrosis or signs of pyelonephritis https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604393834168-PBU8ZW73HLVUFENJI3D4/IMG_5608%2B%25281%2529.jpg Pyelonephritis Level A - Laboratory MSU WCC > 10,000 = Pyuria Urine Culture Blood Culture if concerned for Sepsis FBC – High WCC, CRP – elevated U&E -? AKI if dehydrated, septic, obstructed LFT + Amylase – out rule other causes https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604067176909-16ZAF53VGYT6LGUMR5J5/pyelonephritis-2.jpg Pyelonephritis Level A - Radiology Imaging not indicated in mild cases Renal Ultrasound normal in 75% cases of pyelonephritis but useful in showing complications e.g. abscess, hydronephrosis, renal infarction CT more sensitive especially if concerned regarding stone or obstruction https://stjamesed.com/pneumothorax-level-a daily 0.75 2020-12-17 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601561677187-5ZKGFKD1BVMA32VFP153/a+fib.jpg Pneumothorax Level A - Bedside 12 lead ECG May be normal or show sinus tachycardia in pneumothorax Useful to rule out other differentials, ie pericarditis Arterial blood gas if O2 sats are low, otherwise venous gas is adequate Shows degree of hypoxia May show hypercapnia & acidosis if significantly compromised Point of care lung ultrasound – rule in investigation Inter-operator variability reduces usefulness Most commonly used in trauma patients who must remain supine and will show Absent lung sliding Absent B-lines Barcode sign on M mode Presence of transition point https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601647586572-JDSGCSQ04JG5NEWR4W7R/bloods%2B%252B%2Bpod.jpg Pneumothorax Level A - Laboratory Laboratory investigations are not that useful in the initial diagnosis and management of spontaneous pneumothorax however they are useful in ruling out other causes and in patients with concomitant problems such as infection. FBC May show elevated WCC – non-specific CRP, U/E, LFT’s, Coag screen, troponin Useful to rule out other differentials https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604070624425-2QHWX8WEID0RR5GGXHZB/Pneumo+27mmsmaller.png Pneumothorax Level A - Radiology Chest x-ray Initial investigation of choice due to ease of access Difficult to accurately quantify the size of pneumothorax on chest x-ray Large bullae may mimic pneumothoraces. If any doubt about the diagnosis CT thorax should be performed Small apical pneumothoraces sometimes may be missed on traditional chest x-rays CT Thorax Considered gold standard for diagnosis and size estimation Useful to rule in or out alternative diagnoses including bullae which can sometimes mimic pneumothorax https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604268235479-9KXKQ9X7YFPGKXHSX7KZ/PSP.png Pneumothorax Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604268657657-PR9UOJIHTIUD9QPTKUVV/SSP.png Pneumothorax Level A https://stjamesed.com/cardiology-lac1 daily 0.75 2020-11-05 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604403331538-MVA5SZXRKZCMM44X6VTP/IMG_5539.jpg Cardiology L.A.C.1 - A 69 year old man is brought to the ED by his wife. He developed sudden onset chest pain radiating to his left arm while watching television 30 minutes previously. The pain is associated with nausea, vomiting and diaphoresis. On arrival his HR is 90 bpm, RR is 24/min, BP 140/90 and SPO2 92% on RA. He is pale and clammy. An ECG is performed at triage and is opposite. https://stjamesed.com/stemi-level-a daily 0.75 2020-12-22 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604584202312-N376VGWVV5BNPF8K0XS9/Screenshot+2020-11-05+at+13.49.48.png STEMI Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604582048376-1WW0OA78UZ22T8F0NFN9/Attachment-1%255B1%255D.jpg STEMI Level A - Bedside ECG 12 lead ECG and interpretation within 10 mins of arrival to ED VBG ? lactic acidosis implying shock. Check BM POCUS Skilled operator may be able see regional wall motion abnormality Evidence of complications e.g. pericardial effusion, papillary muscle rupture Evidence of underlying heart disease e.g. LVF, LVH https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604589065205-OSVHXD39OCHVMUIEH7TA/bloods%2B%252B%2Bpod.jpg STEMI Level A - Laboratory Troponin Do not delay coronary reperfusion (Cardiology referral) to wait for troponin results. Levels usually begin to rise around 2 -3 hours after onset of myocardial ischaemia. Levels peak at approx 18 hours post pain and remain elevated for 14 days FBC elevated WCC not unusual. ? Low Hb as contributing factor to AMI Routine U&E, LFT, Coag Ca, Mg, K Decrease risk of cardiac arrhythmias by ensuring normal levels https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604589741189-BA8RVGF8F01XGODIDVYS/normal%2Bcxr.jpg STEMI Level A - Radiology CXR To exclude alternative causes and to aid indirect assessment of cardiac function. Do not delay definitive treatment for Chest x-ray https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604594405831-D1M3G17KP1EXFF17C7YF/Inferior%2525252BSTEMI.jpg STEMI Level A Inferior STEMI https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604594431775-IW8U0U5HZS2QA6I3F3JW/Screenshot%25252B2020-11-05%25252Bat%25252B16.25.21.jpg STEMI Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604594383139-879H5NG4AXTZ31TQ4DUY/Screenshot%2B2020-11-05%2Bat%2B16.37.56.jpg STEMI Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604656240437-87IWVW940EZ0GNY9RZIB/Screenshot+2020-11-06+at+09.48.08.png STEMI Level A Report of the National Clinical Programme for Acute Coronary Syndrome (ACS) on standardising treatment of patients with STEMI in 2016 https://stjamesed.com/cardiology-lac3 daily 0.75 2020-11-10 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605023134485-5YXFF5EL0ZMHLE81NSAP/FdK3g%2BslTSi9YzJ1D03gXQ_thumb_4.jpg Cardiology L.A.C.3 A 45 year old female presents to the ED with a 3 day hx of sharp retrosternal chest pain that radiates to the back of her shoulder. The pain is worse on lying down and is relieved somewhat on sitting forward. She has a medical history of HTN and rheumatoid arthritis for which she is on methotrexate. Her ECG is opposite. https://stjamesed.com/pericarditis-level-a daily 0.75 2020-12-22 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605023134485-5YXFF5EL0ZMHLE81NSAP/FdK3g%2BslTSi9YzJ1D03gXQ_thumb_4.jpg Pericarditis Level A - Bedside ECG (abnormal in 90% of patients) Diffuse concave ST elevation except aVR and V1. PR depression except at aVR and V1 where the PR segment is elevated VBG POCUS Echo - looking for complications e.g. effusion, tamponade, CCF https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605281271286-X1EQ8C7LDVNH0UKOJRN5/bloods%2B%252B%2Bpod.jpg Pericarditis Level A - Laboratory Troponin - elevated in 2 of the most common alternative diagnoses i.e. Myocarditis + Acute Coronary Syndrome FBC - elevated WCC are common CRP - will generally be elevated. Can be monitored along with symptoms to ensure resolution U&E - ? underlying renal failure as cause of pericarditis Depending on severity and possible aetiology may require blood cultures, viral screen, autoimmune screen etc. This tests should generally be arranged and followed up by in-patient teams Given the relatively benign course associated with most cases of pericarditis in the developed world it is not necessary to search for aetiology unless symptoms are severe or fail to respond to NSAID therapy. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605283631771-70OFCN092T9SR0WN3F1Y/Screenshot+2020-11-13+at+16.06.49.png Pericarditis Level A - Radiology CXR primarily looking for complications e.g. large pericardial effusion or alternative diagnosis e.g. pneumothroax, pneumonia Echo if concerned regarding effusion, heart failure, myocarditis. Not necessary if diagnosis of pericarditis is clear and troponin and physical exam non concerning https://stjamesed.com/nstemiua-level-a daily 0.75 2020-11-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605527894158-QA1KF5AQST13MB0YX32X/Ischaemic%2BECG.jpg NSTEMI/UA Level A - Bedside ECG 12 lead ECG and interpretation within 10 mins of arrival to ED to out rule STEMI which is a time critical, life threatening diagnosis. dynamic ST-segment deviation (>0.5mm), or new T wave inversion (>2mm) ECG may be normal or show minor changes in up to 50% cases. VBG acid-base status. ? high BM in poorly controlled DM https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605534265404-QKILKFPEOK4GFU00A5QD/bloods%252B%25252B%252Bpod.jpg NSTEMI/UA Level A - Laboratory Serial Troponins Used to distinguish NSTEMI (high troponin) from unstable angina (normal troponin). Levels usually begin to rise around 2 -3 hours after onset of myocardial ischaemia. Therefore serial troponins over at least 6 hours is necessary to out rule NSTEMI Levels peak at approx 18 hours post pain and remain elevated for 14 days FBC Hb measurements may help to evaluate a secondary cause of NSTEMI (i.e., acute blood loss, anaemia) ? thrombocytopenia to estimate risk of bleeding. U&E ? underlying CKD. Baseline renal function prior to commencing meds K/Mg/Ca Electrolyte derangements may predispose to cardiac arrhythmias. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604067552669-X51NSTUS50I2Z07JCBF0/1.8cm+pneumothorax.png NSTEMI/UA Level A - Radiology CXR Assess for other diagnoses. Assess for signs of heart failure Echo ? regional wall motion abnormality Evidence of underlying heart disease e.g. LVF, LVH https://stjamesed.com/cardiology-lac2 daily 0.75 2020-11-16 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605527894158-QA1KF5AQST13MB0YX32X/Ischaemic%2BECG.jpg Cardiology L.A.C.2 https://stjamesed.com/afib-level-a daily 0.75 2020-11-18 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605700801656-PU7N3T0UMXDQKY6PJRQ4/Screenshot%2B2020-11-17%2Bat%2B11.40.32.jpg AFib Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605701068150-QYXDUT04RWP1U8CJTWF9/Screenshot%2B2020-11-18%2Bat%2B12.02.53.jpg AFib Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600701494853-PT5FHD5BBRP01OW09E14/blood+bottles.jpg AFib Level A - Laboratory FBC - ?raised inflamm markers, ? anaemia U&E - ? evidence of dehydration/electrolyte derangement Mg, Ca, Troponin if concerned about myocardial ischaemia CRP if concerned about infection Other laboratory testing to be guided by most likely underlying aetiology e.g. blood culture, D-Dimer, TFTs https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605701580118-6ZSM5UW3X1TAVZQQFL22/education%2Bpage.jpg AFib Level A - Radiology CXR – cardiomegaly, pulmonary oedema, pneumonia ECHO POCUS in ED by experieced operator if patient is unstable and concerned about acute pathology e.g. Massive PE, Cardiomyopathy, Pericardial effusion, Departmental echo with cardiology assessing for valvular disease, chamber dilation, atrial and ventricular wall thickness and function, thrombus. Other radiological investigations to be guided by most likely underlying cause if any. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605715489564-J0PDPQ5LNO3EK7TANIZM/Screenshot+2020-11-18+at+16.04.41.png AFib Level A https://stjamesed.com/cardiology-lac-5 daily 0.75 2020-11-18 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605613251989-UJA8IU4PI1BBFXKHJM6J/Screenshot+2020-11-17+at+11.40.32.png Cardiology L.A.C 5 https://stjamesed.com/cardiology-lac-8 daily 0.75 2020-12-03 https://stjamesed.com/infective-endocarditis-level-a daily 0.75 2020-12-03 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605872573532-RFM4TOEW5L6JRX0YQ2CQ/Screenshot+2020-11-20+at+11.39.49.png Infective endocarditis Level A - Signs Signs of Sepsis Fever of unknown origin, tachycardia, hypotension, Tachypnoea, Hypoxia, altered conscious state Cardiac New or changed murmur, signs of CCF, Neurology From embolic events. Sign of meningitis, focal neuro deficits, stroke Abdominal signs Splenomegaly (30%), Hepatomegaly Peripheral Stigmata (extremely rare) Splinter haemorrhage, conjunctival petechial, Oslers Nodes, Janeway’s Lesion, Roth’s Spots on fundoscopy https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603120328533-PC2TRM2J6388ZZKQD2HQ/Bedside.jpg Infective endocarditis Level A - Bedside VBG ?evidence of sepsis, high lactate, low pH, low Hb, low Na Urinalysis often proteinuria + microscopic haematuria ECG Prolonged PR interval, TWI, Dysrhythmia, conduction disturbance https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603122032645-NLRCG12KPEHOREB33RFW/IMG_6847.jpg Infective endocarditis Level A - Laboratory Blood Cultures Very important. Multiple sets from multiple sites taken over at least a few hours. Ideally taken before antibiotic therapy FBC ? leucocytosis, ? anaemia U&E Renal Impairment is recognised complication Elevated CRP https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605701580118-6ZSM5UW3X1TAVZQQFL22/education%2Bpage.jpg Infective endocarditis Level A - Echocardiography Trans-thoracic echo 60% sensitive for vegetations Trans-oesophageal echo 90-99% sensitive, 90% specific. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605871223280-SGBHWOQ41R2ZJ56E8CO5/septic-pulmonary-emboli-and-chest-wall-abscess.jpg Infective endocarditis Level A - Radiology CXR may show cardiomegaly or signs of cardiac failure, cavitations in the lungs. CT TAP/CT Brain if concerned about septic emboli to brain, liver, spleen etc https://stjamesed.com/resus-septic-shock-lac-1-copy daily 0.75 2020-11-25 https://stjamesed.com/neuro-sepsis-lac5-copy daily 0.75 2020-11-25 https://stjamesed.com/resus-septic-shock-level-a daily 0.75 2022-04-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603119235663-J2WFXJQ9DJU8YCZD9111/Sepsis+Continuum.png Resus Septic Shock Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603122265522-TXCW59DRBI9JG1A3C2F9/IMG_5491.jpg Resus Septic Shock Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603122032645-NLRCG12KPEHOREB33RFW/IMG_6847.jpg Resus Septic Shock Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601566901919-JVB1XUX00DY7DLYTAK3Y/Multifocal+pneumonia.png Resus Septic Shock Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603124165620-ZZL82WODVTJRPABANU44/Screenshot+2020-10-19+at+17.15.56.png Resus Septic Shock Level A https://stjamesed.com/neuro-meningitis-level-a-copy daily 0.75 2020-11-25 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603115024790-A5GN0DYNU5V3WGG9WG6S/Bedside.jpg Neuro Meningitis Level A (Copy) - Bedside VBG ? high lactate, ? low pH in sepsis. ? Low BM accounting for GCS Urinalysis Seeking other causes for sepsis Urine Toxicology screen ECG https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603112616009-3V7CKQ5N6C9R5SRL7Y7N/LP%2Bequipment.jpg Neuro Meningitis Level A (Copy) - Laboratory General Investigations FBC, U&E, CRP, LFT, CoAg Assist in building the overall clinical picture e.g. presence of end organ dysfxn Blood Cultures Take prior to Empiric antibiotics especially if LP is delayed Lumbar Puncture – Antibiotics should not be delayed for LP CT before LP if decreased GCS, focal neurological abnormality, seizure, concern for SOL If evidence of high ICP on CT there is a risk of brain herniation during LP so it should be delayed CSF in bacterial meningitis = High opening pressure, High protein, Low glucose, High WCC mostly polymorphs, +ve Gram Stain CSF or Blood for viral and meningococcus PCR CSF or urine for rapid antigen tests for Strep, Listeria MSU - ? other cause of sepsis https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603114812943-3W5F5XOMI46JWF0YDHNP/CTB%2Bwork%2Bstation.jpg Neuro Meningitis Level A (Copy) - Radiology CT Brain occurs in most cases to out rule increased ICP/other causes of headache e.g. SOL, Haemorrhage etc CXR – as part of work up https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603116170662-6UB9K7O5H9ZMWAZMOLGT/IMG_7688.jpg Neuro Meningitis Level A (Copy) - Infection Control Patient should be managed in an isolation room with contact and droplet precautions and staff in full PPE https://stjamesed.com/haem-lac-2 daily 0.75 2020-11-27 https://stjamesed.com/dvt-level-a daily 0.75 2020-11-30 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606492803499-XT6PZNMVN6ARQ7712WEG/Wells+Score+for+DVT+.png DVT Level A - Well’s Score for DVT Calculates the risk of DVT based on a patient’s clinical criteria It is used in the ED and outpatient setting and is not reliable in hospitalised patients This scoring system divides patients into DVT likely and DVT unlikely and aids the decision to progress to further testing Score of 0 = low probability Score of 1-2 = intermediate probability Score of 3 or more = high probability https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603120328533-PC2TRM2J6388ZZKQD2HQ/Bedside.jpg DVT Level A - Bedside POCUS As a rule-in test only. An experienced operator may be able confirm the diagnosis Urinary Beta-hCG on all women of childbearing age ECG if concerned about PE https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606494152372-MWP2LAG6ZS1C7G5WMT3M/Picture1.png DVT Level A - Laboratory FBC assess Hb and platelets prior to anticoagulation elevated WCC more likely in cellulitis D Dimer Highly sensitive but not specific A negative D Dimer is useful for ruling out DVT in those in whom you have low or moderate suspicion for DVT (as per Wells Score) CRP more likely to be elevated if infectious or inflammatory cause for leg swelling Coagulation profile and LFTs prior to commencing anticoagulation U&E prior to commencing anticoagulation. Impaired renal function influences choice and dose of anticoagulant. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1597934301906-G2YD0KIRKYE6AYP1HPHO/VTE.png DVT Level A - Radiology Vascular Ultrasound of the venous system first line imaging modality for proximal DVT CT Venography and MR venography may also be used but are not common due to cost and availability CT Pulmonary Angiogram if concerned about concurrent PE https://stjamesed.com/haem-pe-level-a-copy daily 0.75 2021-10-15 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601826464327-W0M3F4O7070VFL273R9K/PERC.png Haem PE Level A (Copy) - PERC Rule Used when the diagnosis pf PE is being considered but the risk is considered low. If a patient is negative in all components of the PERC rule then they can be considered low risk and it may be reasonable to carry out no further work-up for PE If any component of the PERC rule is positive, the patient requires further investigation to assess for PE. The PERC rule is NOT for use in pregnancy https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601842373636-MSI9EFHOZW1YQR1BCG57/Wells+score.png Haem PE Level A (Copy) - Well’s Score A useful clinical decision rule to help assess the probability of a patient having a PE and guiding further investigation in patients where there is a suspicion of PE A low Well’s Score with a negative D Dimer result is considered safe in ruling out PE. Not validated in pregnancy or people who inject drugs Score 0-1 – Low Risk (1.3% prevalence of PE) Score 2-6 – Moderate Risk (16.2% prevalence of PE) Score >6 – High Risk (37.5% prevalence of PE) https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601586838104-VLHXBGY2XSY05ZMOO379/LITFL+ecg.png Haem PE Level A (Copy) - Bedside 12 Lead ECG Assess for myocardial ischaemia to rule out ACS Sinus tachycardia is the most common ecg finding in PE S1Q3T3 pattern is rarely seen but if present suggests massive PE as it is a sign of right heart strain Deep S wave in lead I, Q wave in lead III and T wave inversion in lead III RBBB (right bundle branch block) may also be present which also suggests the presence of right heart strain ABG may show Hypoxaemia Respiratory alkalosis May be normal https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600701494853-PT5FHD5BBRP01OW09E14/blood+bottles.jpg Haem PE Level A (Copy) - Laboratory FBC, U&E, CRP, Coag screen, Troponin Helpful in ruling out other causes D Dimer Degredation product of fibrin and is raised as a result of fibrinolysis when clotting is taking place Can be raised for a number of other reasons including inflammation, trauma, recent surgery, pregnancy (has not been validated in pregnant patients and therefore should not be used). Sensitive but not specific Sensitivity 96.4%, specificity 52% for PE in the emergency department (3) A negative result is reliable for ruling out VTE in low to intermediate risk patients, but a positive result is not reliable for ruling in VTE https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601911339030-44H3FBPIA6FBMINQLTIN/Saddle+embolus.png Haem PE Level A (Copy) - Radiology Chest x-ray Useful for ruling out other causes (pneumothorax, infection) but is neither sensitive nor specific for diagnosing PE Rarely wedge shaped infarcts may be seen CT Pulmonary Angiogram (CTPA) is the most common diagnostic radiologic test to diagnose PE (4) A V/Q scan is performed less commonly as an alternative to CTPA The safety of CTPA vs V/Q scan in pregnancy has been extensively debated however, 2015 RCOG Guidance preferentially recommends CTPA for diagnosis of PE (5) https://stjamesed.com/haem-lac1-copy daily 0.75 2020-11-30 https://stjamesed.com/resus-haem-shock-lac-3 daily 0.75 2020-11-30 https://stjamesed.com/haemorrhagic-shock-level-a daily 0.75 2022-04-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606737953320-QXRS6AVPW156GDG2N392/Screenshot+2020-11-30+at+12.05.41.png Haemorrhagic shock Level A - Bedside VBG Low pH, low base excess + high lactate are all indicators of haemorrhagic shock. Haemoglobin has no diagnostic value in the early phase of massive haemorrhage as haemodilution as not occurred. Monitor ionized calcium on VBG eFAST can identify source of bleeding (chest/abdomen). Can out rule other causes of shock e.g. tension pneumothorax, tamponade ECG - ? ST elevation https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600701494853-PT5FHD5BBRP01OW09E14/blood+bottles.jpg Haemorrhagic shock Level A - Laboratory FBC – Monitor Hb trend. Platelets very important for clotting Group and Cross Match at least 6 units Coag – Assess for & monitor development of coagulopathy U&E, LFT, Amylase - baseline trauma bloods https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606743241945-IZSOWMVZSCIEIAFN0NEE/IMG_2311.jpg Haemorrhagic shock Level A - Radiology Portable CXR and Pelvic XR in resus post primary survey in the unstable patient If patient stable CT as clinically indicated to identify injuries and guide further management Plain films as clinically indicated in stable patient https://stjamesed.com/resus-anaphylaxis-lac-4 daily 0.75 2020-12-01 https://stjamesed.com/anaphylaxis-level-a daily 0.75 2022-04-14 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606820327626-BD8Z3B5U0EW2UJTGA31T/Screenshot+2020-12-01+at+10.58.20.png Anaphylaxis Level A - Second Line Treatment Little evidence but may have some role in controlling symptoms e.g. itch and preventing recurrence (Biphasic reaction) IV Anti-histamine – rash, itch IV Hydrocortisone – rash, itch, prevent biphasic reaction Salbutamol Nebuliser – SOB, Wheeze https://stjamesed.com/cardiogenic-shock-level-a daily 0.75 2022-04-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606999992483-3FCRDOGEUW5ZWXPAQ4FQ/IMG_5800.jpg Cardiogenic Shock Level A - Bedside ECG assessing for presence of ST elevation + territory, presence of heart block VBG Low pH and high lactate indicating end organ hypoperfusion POCUS Echo – assessing for LV dilatation, LV Dysfunction. Dilated IVC Lung US – presence of bilateral B lines consistent with pulmonary oedema, pleural effusions https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605534265404-QKILKFPEOK4GFU00A5QD/bloods%252B%25252B%252Bpod.jpg Cardiogenic Shock Level A - Laboratory FBC, U&E, LFT, CRP baseline bloods and seeking other causes Troponin Baseline Coag https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607000398500-WU62OJNC3O6O8ZJKKFJA/Picture1.png Cardiogenic Shock Level A - Radiology CXR – cardiomegaly and findings consistent with pulm oedema. (ABCDE) Alveolar Oedema Kerley B Lines Cardiomegaly Dilated upper lobe vessels Pleural Effusion Formal Echocardiography quantitative assessment of LV, RV and all valves Coronary Angiogram to seek and treat coronary artery disease causing myocardial ischaemia https://stjamesed.com/resus-cardio-shock-lac-2 daily 0.75 2020-12-01 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1606834816438-IR20GWP2UM6O7S5TB6R8/IMG_5792.jpeg Resus Cardio Shock L.A.C. 2 https://stjamesed.com/neuro-lac-4 daily 0.75 2020-12-03 https://stjamesed.com/status-epilepticus-level-a daily 0.75 2020-12-07 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607336186916-SQFYSEAP4J9R6RAHK9XR/IMG_5824.jpg Status Epilepticus level A - Bedside Rapid finger stick glucose should always be checked and hypoglycaemia treated if necessary Venous blood gas – Low pH, High Lactate characteristic in status. Also gives rapid Na, K, ionised Ca + BM ECG – In all patients following a seizure. Check QT Interval in particular. Urine BhCG on all women of child bearing age (BHCG can be undetectable in late pregnancy so always look at a seizing woman’s abdomen to check for gravid uterus) Urine toxicology – if concerned for possible OD e.g. cocaine, amphetamine NB negative urine tox does not out rule toxin ingestion https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607336602105-3J85QXN56WWS6BZ5E7HB/IMG_6847.jpg Status Epilepticus level A - Laboratory Routine bloods – FBC, U&E, LFT, CoAg, Mg, Ca look for underlying medical or metabolic cause for seizure Blood cultures if signs of sepsis Anti Epileptic Drug Levels may have role in some cases. Not done routinely https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607336781953-BS0BWQDCKDTUK1OYXZ4B/CTB%252Bwork%252Bstation.jpg Status Epilepticus level A - Radiology CT Brain – if first seizure to exclude any structural abnormality. All patients who have status should have CTBrain due to change in pattern of seizures CXR if concerned about sepsis or aspiration MRI brain if first seizure to further interrogate for structural abnormality. Not part of acute work up. Can happen as outpatient EEG can be useful in diagnosing underlying cause of status epilepticus once seizures have resolved or can be used to diagnose more subtle forms of status https://stjamesed.com/neuro-lac-1 daily 0.75 2020-12-07 https://stjamesed.com/stroke-level-a daily 0.75 2020-12-22 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607353710733-EUS2U169N2P42NL9WX65/JPEG%2Bimage-6D46997638AF-1.jpg Stroke Level A - Bedside Rapid finger stick blood sugar Hypoglycaemia is a common stroke mimic VBG pH, lactate, blood glucose, an estimate of Hb, and electrolytes. ECG Looking for Atrial Fibrillation Urine Toxicology if concerned drugs of abuse such as cocaine could be implicated https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607354216341-D68JGQQCLU76GU9BTFAW/bloods%252B%25252B%252Bpod.jpg Stroke Level A - Laboratory FBC signs of infection, haemoglobin, platelets Biochemistry Urea and electrolytes, CRP (Infection), LFTs (clotting) Coagulation Bleeding tendency, INR if on warfarin Group and Hold if thrombolysis is a possibility. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607355485954-BBM246ZWPKOKBV7PE3C0/left-mca-infarction-1.jpg Stroke Level A - Radiology Immediate, emergency, non-contrast CT Brain in the following patients with focal neurology patient presents within 4 hours of onset and symptoms are ongoing, patient is on an anticoagulant, known bleeding disorder, GCS < 13, Unexplained progressive or fluctuating symptoms, papilloedema, neck stiffness, fever, or severe headache at time of onset. CT Angiogram + CT Perfusion may be indicated depending on patient factors and non-contrast CT Brain findings MRI Brain posterior circulation and small lacunar infarcts may only be visible on MRI https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607358119847-YM8Q3ERT21RGHQ23UZ9P/Screenshot+2020-12-07+at+16.21.36.png Stroke Level A - Specific Treatment Assess for presence of any contraindications to tPA/thrombectomy (opposite) Different treatment options will be determined by patient factors, time of onset, NIHSS, and imaging. NB: There should be involvement of senior decision maker i.e. ED or stroke consultant Within 4.5 hrs of onset, and haemorrhage has been excluded, thrombolysis can be administered by specially trained staff. Within 6 hours of onset, thrombectomy is offered along with thrombolysis, to people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation on CT angiogram Between 6 – 24 hours thrombectomy can be offered in patients who have acute ischaemic stroke and there is potentially salvageable brain tissue as shown by CT perfusion. Aspirin 300mg PO/NG/PR If patient is not being thrombolysed give asap Do not give until > 24 hours post thrombolysis. https://stjamesed.com/metabolic-lac-1 daily 0.75 2020-12-08 https://stjamesed.com/hyperkalaemia-level-a daily 0.75 2020-12-11 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607681441382-X47SU8S85Q05OHZDBMI2/Picture2.png Hyperkalaemia Level A - Bedside VBG Elevated Potassium level. Concurrent low pH could indicate possible renal failure causing metabolic acidosis, sepsis, hypoperfusion. Low threshold to repeat VBG if difficult sample to obtain as haemolysis may cause pseudo hyperkalaemia ECG Changes are characteristic and indicate severity 6-7 mmol = Tall Peake T waves (>5mm) 7-8mmol = Widening QRS, Small P waves 8-9mmol = Fusion of QRS with T wave = Sine Wave (opposite) o > 9 mmol = AV dissociation, VT, V Fib, Asystole https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1600701494853-PT5FHD5BBRP01OW09E14/blood+bottles.jpg Hyperkalaemia Level A - Laboratory U&E Assess renal function. Confirm Hyper K on VBG FBC, CRP, LFTs, blood culture if ? Sepsis MSU https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607681725098-AMQSRYL32NENKS29CCLV/Picture1.jpg Hyperkalaemia Level A - Radiology CXR if concerned about fluid overload or chest sepsis Renal US if first presentation renal failure to assess for cause https://stjamesed.com/hypoglycaemia-level-a daily 0.75 2020-12-08 https://stjamesed.com/metabolic-lac-3 daily 0.75 2020-12-11 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607680800178-A7NJTLGKKX2OA1E9NSDW/Picture1.png Metabolic L.A.C. 3 https://stjamesed.com/metabolic-lac-2 daily 0.75 2020-12-08 https://stjamesed.com/dka-level-a daily 0.75 2020-12-30 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607353710733-EUS2U169N2P42NL9WX65/JPEG%2Bimage-6D46997638AF-1.jpg DKA Level A - Bedside Capillary BM + Ketones helps make diagnosis and track response to treatment VBG low pH + bicarbonate. Confirms diagnosis. Low PCO2 due to respiratory compensation. High K. Low Na. Patient will need hourly VBGs while being treated for DKA Urine BHCG in all women of child bearing age Urine dipstick ketonuria. May be evidence of concurrent UTI ECG Changes due to High/Low Potassium. Evidence of Myocardial infarction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607354216341-D68JGQQCLU76GU9BTFAW/bloods%252B%25252B%252Bpod.jpg DKA Level A - Laboratory FBC – often a leucocytosis U&E AKI. Potassium usually high initially due to acidosis and lack of insulin driving it into the cells. Drops quickly once treatment is started and patient will need K replacement LFT, CRP & Blood cultures if ? sepsis as underlying source MSU if ? urosepsis https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1601567331440-RVRT6PLTRSW83BJ0Z9ME/normal+cxr.jpg DKA Level A - Radiology CXR if ? Chest sepsis Other imaging as indicated by clinical condition https://stjamesed.com/vtvf-level-a daily 0.75 2021-01-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607700215350-VKO15OZ5WIGXH1XRYFSJ/Picture1.png VT/VF Level A Ventricular tachycardia - broad complex regular tachycardia. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607700320885-F6N8D3DYIVWMO4I252JL/Picture2.jpg VT/VF Level A Ventricular Fibrillation - rapid chaotic disorganised electrical activity https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610376035392-NCKYY77KVLD47QSQAFAY/Picture1.jpg VT/VF Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610376064927-G4UGWJSGDT6LFXJ0TVHF/blood%252Bbottles.jpg VT/VF Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610376088239-P3JMPNHOLFID8XGRDX9C/Screenshot%2B2020-11-03%2Bat%2B11.10.33.jpg VT/VF Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610381937207-C72YE37Z78FTL77JZJJQ/Screenshot+2021-01-11+at+16.18.00.png VT/VF Level A - Pulseless VT/VF Call for help Commence CPR Task someone to manage the airway. Apply O2 Attach defib/AED as soon as possible VT + VF are shockable rhythms if patient is on the defib and VT/VF arrest is witnessed shock them immediately otherwise analyse the rhythm and shock if inidcated as soon as the defib is available Early defibrillation is recognised as a priority in the chain of survival. The likelihood of success decreases with time until initiation Follow the shockable rhythm ACLS cardiac arrest algorithm opposite. (courtesy of https://www.aclsmedicaltraining.com/adult-cardiac-arrest-vtach-and-vfib/) https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604582492740-XDHL24CJ5QW0H52BPNON/Attachment-1%255B2%255D.jpg VT/VF Level A - Unstable VT Should be managed in resus with full non invasive monitoring Instability is implied if the patient is hypotensive, has a decreased level of consciousness, has signs of heart failure or chest pain. Call for help Task someone to manage the airway. Apply O2 Establish IV access Synchronised DC cardioversion with 100J in the first instance. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610384178871-HDVPEWC2R0MP7VWUPWEY/Screenshot%2B2021-01-11%2Bat%2B16.55.09.jpg VT/VF Level A - Stable VT Should be managed in resus with full non invasive monitoring. Stability is implied if the patient is awake and alert with a perfusing blood pressure. The stable patient with VT is at high risk of becoming unstable and suffering a cardiac arrest. Initial treatment involves loading with antiarrhythmic IV amiodarone 150mg over 10 mins. Can be repeated x 1. Then commence amiodarone infusion IV lignocaine or Sotalol are alternatives Replace electrolytes if Torsades de Pointes/Polymorphic VT IV MgSO4, IV KCl, IV Calcium as indicated If patient becomes unstable at any time proceed to urgent synchronised DC cardioversion https://stjamesed.com/cardiology-lac-4 daily 0.75 2021-01-11 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607683856213-FXBF39BNXS8M8XQWE6JP/Picture1.png Cardiology L.A.C 4 https://stjamesed.com/tox-lac1 daily 0.75 2022-04-13 https://stjamesed.com/alcohol-level-a daily 0.75 2022-04-13 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607353710733-EUS2U169N2P42NL9WX65/JPEG%2Bimage-6D46997638AF-1.jpg Alcohol Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603122032645-NLRCG12KPEHOREB33RFW/IMG_6847.jpg Alcohol Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/02f248c2-e0f0-4fa8-bb31-0614063321fb/CTB%252Bwork%252Bstation.jpg Alcohol Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607428164947-649DJNNNCDQWH1C4CZRY/IMG_5852.JPG Alcohol Level A - Initial Resuscitation Approach every patient with assessment of their: Airway - vomit is commonly found, in rare cases where the airway is threatened, endotracheal intubation might be required. Breathing - rarely alcohol causes respiratory depression; patients more commonly aspirate. Circulation – hypotension and tachycardia are common and usually respond to IV fluids. Disability- GCS is commonly low, it will require serial assessment to ensure that it is improving. Do not assume that a low GCS is due to alcohol intoxication alone, and assess your patient from the point of view of injury. Exposure - check temperature as patients who have collapsed outside may be profoundly hypothermic and require rewarming measures. Full screen for injuries. Glucose – should always be checked in patient with reduced GCS. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1608284480917-VE2KZCC7J8C70PEC5MBF/Pabrinex.jpeg Alcohol Level A - Symptomatic Treatment Symptomatic treatment will depend on your primary assessment: Hypotension and tachycardia – NaCl 0.9% Hypothermia – warming blanket, assess for cardiac arrythmias Nausea and vomiting – antiemetics Administer high dose thiamine – in Ireland most commonly used agent is Pabrinex I&II Treat hypoglycaemia with IV dextrose If aspiration is suspected, treat with antibiotics https://stjamesed.com/tox-lac2 daily 0.75 2021-01-12 https://stjamesed.com/opiate-level-a daily 0.75 2020-12-21 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607353710733-EUS2U169N2P42NL9WX65/JPEG%2Bimage-6D46997638AF-1.jpg Opiate Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607354216341-D68JGQQCLU76GU9BTFAW/bloods%252B%25252B%252Bpod.jpg Opiate Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607093814425-5MGGVQ0QBN2QXG55ZZWV/SAH.png Opiate Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1608284480917-VE2KZCC7J8C70PEC5MBF/Pabrinex.jpeg Opiate Level A - Naloxone Naloxone – is the antidote to opiates. It has a short half-life and the therapeutic effect lasts around 20 to 40 min. There is therefore a risk of repeated respiratory and CNS depression with longer acting opiates (ie; methadone) or larger doses of heroin. Rapid and over-reversal of opiates is also dangerous because; Patients may become agitated, leave and take a second dose of opiate. The Naloxone then wears off and they have the effect of both doses which may be fatal Over reversal can lead to nausea, vomiting, severe hypertension, tachyarrhythmias and ventricular fibrillation As such Naloxone dosing should follow the principles of start low and go slow. Naloxone infusions are generally safer than stat dosing, especially for overdose of long acting opiates. If IV access is unavailable there are many other routes of administration - intramuscular, subcutaneous and intranasal (rememeber wont work in respiratory arrest) Always follow your local hospitals prescribing guidelines for opiate reversal Patient may require respiratory support until the naloxone takes effect, depending on your breathing and airway assessment patients might need respiratory support with bag-valve-mask or C-circuit, they can also benefit from oropharyngeal or nasopharyngeal airway adjuncts. Once patients respiratory effort improves patient should be nursed on high observation bed with non-invasive capnography https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607428164947-649DJNNNCDQWH1C4CZRY/IMG_5852.JPG Opiate Level A - Other Measures Hypotension – might require IV fluids Hypothermia – some patients require active rewarming Hypoglycaemia – should be corrected with PO intake if awake patient and IV dextrose in patient with reduced GCS Seizures – IV or buccal benzodiazepines https://stjamesed.com/cardiology-lac-7 daily 0.75 2021-01-12 https://stjamesed.com/syncope-level-a daily 0.75 2021-01-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610450417783-75T53W5658RJQ71GC5H4/IMG_3018.jpg Syncope Level A - Bedside ECG ischaemia, arrhythmia, heart block, Brugada, QT prolongation, bradycardia VBG Hypoglycaemia, evidence of shock (low pH, high lactate), electrolytes, immediate Hb BHCG in all child bearing age females who present with syncope/presyncope POCUS severe cardiomyopathy, tamponade, tension pneumo, AAA, intra-peritoneal haemorrhage https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1605534265404-QKILKFPEOK4GFU00A5QD/bloods%252B%25252B%252Bpod.jpg Syncope Level A - Laboratory FBC anaemia, elevated WCC, low plts U&E assess hydration, renal function, deranged electrolytes LFTs liver disease increases risk of bleeding Troponin Only if acute ischaemia is suspected. Not a routine test https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610450667176-6OD5D69KO2BA6KU2IRRP/education%252Bpage.jpg Syncope Level A - Radiology CXR if concerned about chest sepsis or cardiac cause CT/MRI Brain if history/exam suggest neurological cause CTPA, CT Aortogram if suspicious for PE or Aortic emergency Echo where structural heart disease is suspected OPD Investigations GP or OPD specialist may consider referring for OPD holter, 24 hr BP monitor, Tilt table testing, loop recorder etc https://stjamesed.com/cocaine-od-level-a daily 0.75 2021-01-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610464380297-DR9WLWE9RIPCA83QYCPG/Bedside.jpg Cocaine OD Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610464491522-UFVAIZL85QNRF44U3A1V/IMG_6847.jpg Cocaine OD Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610464554780-46SME1UDP5M3DMA1NTI5/Pneumo%252B27mmsmaller.jpg Cocaine OD Level A https://stjamesed.com/psych-lac-2 daily 0.75 2021-01-13 https://stjamesed.com/toxicology-lac-4 daily 0.75 2021-01-12 https://stjamesed.com/mania-level-a daily 0.75 2021-01-13 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610551439756-4QSFQJQGIHMRS3J2OG2Q/IMG_6059.jpg Mania Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610551580341-D46WFLT5HYAP83D4UN8F/image.jpg Mania Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610551635026-EMUNJJ8ZAFBDGRS99S49/CTB%25252Bwork%25252Bstation.jpg Mania Level A https://stjamesed.com/abnormal-behaviour-level-a daily 0.75 2021-01-25 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611057736519-WKIY3IAGOY0QQGK6F8ZN/MSE.png Abnormal Behaviour Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611056313764-A38E6E6LBD1OMJXACDNU/Sedation.png Abnormal Behaviour Level A Adapted from RCEM Best Practice Guidance on the Management of Excited Delirium/Acute Behavioural Disturbance https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610464380297-DR9WLWE9RIPCA83QYCPG/Bedside.jpg Abnormal Behaviour Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607354216341-D68JGQQCLU76GU9BTFAW/bloods%252B%25252B%252Bpod.jpg Abnormal Behaviour Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610551635026-EMUNJJ8ZAFBDGRS99S49/CTB%25252Bwork%25252Bstation.jpg Abnormal Behaviour Level A https://stjamesed.com/psych-lac1 daily 0.75 2021-01-19 https://stjamesed.com/haem-lac-3 daily 0.75 2021-01-21 https://stjamesed.com/haemophilia-level-a daily 0.75 2021-02-08 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611229978214-PZ8ZE5V3PN5NKK4NVRAG/Screenshot+2021-01-21+at+11.52.49.png Haemophilia Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612794722158-I9BIZP0N5D1G2ZW4K9KP/IMG_5479.jpg Haemophilia Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612794825585-70EIPGEVFIGYXK33OWKD/image.jpg Haemophilia Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612795170858-65G9W3B5CDM7WDJHYMEA/IMG_1173.jpg Haemophilia Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612796800882-1E73CWPU25TPX1J7BG2C/Screenshot+2021-02-08+at+15.03.15.png Haemophilia Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612796976167-AYLF4B2QYVL20AKTLRR5/Screenshot%252B2021-02-08%252Bat%252B15.03.00.jpg Haemophilia Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612797344087-Q9R4K4HMFHVO2BD0195D/Screenshot+2021-02-08+at+15.15.33.png Haemophilia Level A https://stjamesed.com/procedures daily 0.75 2021-01-25 https://stjamesed.com/careers/workwithus/vacancies/fellowships daily 0.75 2022-11-30 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1596206927084-N720CVOBJGOXQ5A6ROWA/Resusbay.jpeg Careers, Vacancies ,Work With Us, Fellowships - Our Department We have over more than 50000 annual attendances to our ED. We serve a densely populated catchment area with double the national average of patients >65 years old and a high deprivation index. Our patient cohort is among the most diverse, high acuity and challenging in the country. Exceptional collaboration with Intensive Care Medicine, Radiology and our other specialty colleagues is a key characteristic of the department. Our department is accredited by the Irish Committee for Emergency Medicine Training (ICEMT) for core specialist and advanced specialist training in Emergency Medicine. We are also accredited by the Australasian College of Emergency Medicine for 6 months of emergency medicine training (discretionary time). https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611592065904-PIV917L2943UZQJPUZ6S/our+team+2.jpg Careers, Vacancies ,Work With Us, Fellowships - Our Team The multidisciplinary Emergency Medicine team consists of consultants, NCHD’s, nurses, advanced nurse practitioners, social workers, occupational therapists, physiotherapists and clinical nurse specialists along with dedicated administrative support. There is great consultant support and presence on the department floor to guide clinical decision making, facilitate clinical teaching and foster an environment of excellence. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1608561915351-7WIYXUOM7NZP0XL0ZJX2/Intubation.png Careers, Vacancies ,Work With Us, Fellowships - Our Teaching We have well-established Registrar and SHO teaching programmes and provide a tailored approach to education of our NCHD’s with focus on exam preparation and individual career progression. We have very high success rates for our EM trainees in primary and fellowship examinations. We run a mentorship programme for our Core and Advanced Trainees, as well as doctors not on formal training schemes. We encourage our doctors to be involved in our audit, quality improvement and research programs. https://stjamesed.com/equipment daily 0.75 2021-01-26 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611587345976-PF3CI0OQPKR8I1STKNUO/IMG_6141.jpg Equipment - Belmont Rapid Infuser For use in haemorrhaging patients e.g. trauma, GI bleed, post partum haemorrhage and any situation where rapid replacement and warming of blood or replacement fluid is required. An instructional video demonstrating its setup and use can be found here. Written instructions can be found here. https://stjamesed.com/airway daily 0.75 2021-02-02 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1608561915351-7WIYXUOM7NZP0XL0ZJX2/Intubation.png Airway - Covid-19 Intubation This is a link to a video demonstrating a safe technique for Covid-19 intubations. Be aware that this isn’t the only safe way but is A safe way to conduct the procedure https://stjamesed.com/examinations daily 0.75 2021-01-25 https://stjamesed.com/emergency-nursing-education daily 0.75 2023-08-01 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1625559041018-CYFR1HHAMGUL5IIICCZI/Screenshot+2021-07-06+at+09.10.11.png Emergency Nursing Education https://stjamesed.com/emergency-nurse-foundation-course daily 0.75 2023-08-01 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612266177616-MTZP0MK7E13CPTLELB7I/Screenshot+2021-02-02+at+11.42.17.png Emergency Nurse Foundation Course - Foundation Programme in Emergency Nursing (Level 8) https://stjamesed.com/lcc1 daily 0.75 2021-02-09 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612864171070-W21WJ9HTHVAF00HJKE5E/image-asset.jpeg L.C.C.1 - A This patients airway was patent and protected with no noisy breathing B He had equal air entry and no abnormal breath sounds His Sats were 97% on RA and RR was 17 C This patients Hr was 84, BP was 169/82 and cap refil was normal Ecg was normal sinus with a normal Qtc https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612864433361-7M0JBWRMPAJI6ZJMNJ5M/image-asset.jpeg L.C.C.1 - D This patient describes feeling disorientated and is responding intermittently to questions but when he does respond he is responding appropriately. He is moving his limbs symmetrically but is too unsteady to walk independently He has no cerebellar signs on exam and his plantars are normal E His temp is 36.7, cardiovascular / resp / abdo and limbs examinations are normal His VBG shows a lactate of 3.0 and glucose of 10.7 https://stjamesed.com/neuro-lac-2 daily 0.75 2021-02-10 https://stjamesed.com/tia-level-a daily 0.75 2021-02-15 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612968968162-X736B6VHE0HIM2MHJK8D/a+fib.jpg TIA Level A - Bedside ECG - To look for arrhythmias particularly atrial fibrillation which is the most common embolic arrhythmia. Blood sugar - Hypoglycemia is one of the most common stroke / TIA mimics VBG – Gives a rapid assessment of electrolyte abnormalities and haemoglobin. Disturbance in either can mimic a TIA. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612969255632-NRKKSJ9LHC8MN2EXHNUZ/image-asset.jpeg TIA Level A - Laboratory FBC – to look for anaemia, thrombocytosis, raised WBCs. Urea & Electrolytes – to look for hyponatremia, hypokalemia and other electrolyte abnormalities. CRP - elevated inflammatory markers could raise suspicion for infection which can mimic TIA/stroke Fasting lipids, Fasting sugars and HbA1c will need to be done by the medical service that are following up the patient as part of their TIA work up. Younger patients may require work up for clotting disorders. These are not routine ED tests. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612969825044-4DPDO74XKKI0J8QC2UKC/Screenshot+2021-02-10+at+15.10.07.png TIA Level A - Radiology All patients who present with TIA should have neuroimaging (CT / MRI Brain) done within 24 hours of presentation to the emergency department. The aim of imaging is to look for any areas of infarction and to rule out other pathology e.g. bleeds, space occupying lesion. NICE recommend MRI Brain with diffusion weighted images as first line and advocate against CT brain (unless an alternate pathology is more likely than TIA). As part of their TIA work up they should have early in patient or outpatient Carotid Dopplers Transthoracic echo https://stjamesed.com/lbc2 daily 0.75 2021-02-15 https://stjamesed.com/gca daily 0.75 2021-08-31 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607354216341-D68JGQQCLU76GU9BTFAW/bloods%252B%25252B%252Bpod.jpg GCA https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1613419551305-BRAJU1MCEZEU80OD3IUO/LP%25252Bequipment.jpg GCA https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612969825044-4DPDO74XKKI0J8QC2UKC/Screenshot+2021-02-10+at+15.10.07.png GCA https://stjamesed.com/heart-block-level-a daily 0.75 2021-02-15 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1613399308587-ZJUOZNYJGK3ASJT3J1PF/UNADJUSTEDNONRAW_thumb_f.jpg Heart Block Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1613399407163-KB1ZEGRMVYUHJ22Y150Y/YiIPTjqHRwek3GEUnL3eag_thumb_10.jpg Heart Block Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1613399535161-83VCMGZB3KHAF0C22TKW/oAx31q4fQoenB2fuiOCUVg_thumb_11.jpg Heart Block Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1613399705617-6MCJ4RM3Y0LVXEH6BBDF/0KF%252BzbjISyWbV66cb%2525bmIg_thumb_12.jpg Heart Block Level A https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604582048376-1WW0OA78UZ22T8F0NFN9/Attachment-1%255B1%255D.jpg Heart Block Level A - Bedside ECG Assessing intervals, relationship between P wave and QRS complex, Number of P waves relative to QRS complexes Signs of underlying causes e.g. ischaemia VBG acid base balance, K, Na, Ionized Ca. POCUS in shocked patient can be useful in narrowing down cause e.g. cardiomyopathy, regional wall motion abnormality, pericardial effusion https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612794825585-70EIPGEVFIGYXK33OWKD/image.jpg Heart Block Level A - Laboratory FBC & CRP elevated acute phase reactants could indicate infection/inflammation Urea & Electrolytes Hyperkalemia, Hypokalaemia, Hypomagnesiemia, Hypocalcemia Troponin ? Acute myocardial infarction https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610450667176-6OD5D69KO2BA6KU2IRRP/education%252Bpage.jpg Heart Block Level A - Radiology/Other CXR ? signs of cardiac failure, ? infection Echocardiography pericardial effusion, Cardiomyopathy, RWMA, Valvular disease CT Coronary Angiogram/Cardiac MRI might be indicated depending on underlying cause and at the discretion of cardiology but are not indicated in the emergency department. https://stjamesed.com/cardiology-lac-6 daily 0.75 2021-02-15 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1613389135363-OC32086PA1W19F30DG6E/Complete+HB.png Cardiology L.A.C. 6 https://stjamesed.com/seretonin-syndrome-level-b daily 0.75 2021-02-19 https://stjamesed.com/serotonin-sx-level-b-case daily 0.75 2021-05-04 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1613747557700-BBBYH5302IP8VARGI682/Screenshot+2021-02-19+at+15.12.08.png Serotonin Sx Level B Case https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610464380297-DR9WLWE9RIPCA83QYCPG/Bedside.jpg Serotonin Sx Level B Case https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612794825585-70EIPGEVFIGYXK33OWKD/image.jpg Serotonin Sx Level B Case https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1613748084402-7UTIK2IKRMQOBWQ2M8ZE/CTB%2525252525252Bwork%2525252525252Bstation.jpg Serotonin Sx Level B Case https://stjamesed.com/respiratory-lbc-1 daily 0.75 2021-02-23 https://stjamesed.com/haemoptysis-level-b daily 0.75 2021-02-24 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1603747479493-74JIRG3U0WJ2Y4RN7G2Z/Bedside.jpg Haemoptysis Level B - Bedside Arterial Blood Gas (if Hypoxic) ?Respiratory Failure. Hb, Lactate, BM, Electrolytes ECG Cardiac cause for symptoms https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1607354216341-D68JGQQCLU76GU9BTFAW/bloods%252B%25252B%252Bpod.jpg Haemoptysis Level B - Laboratory FBC, CRP, blood culture if ?sepsis or infectious cause Group and Hold/Crossmatch in severe cases Coagulation screen U&E, Bone profile + LFTs may show abnormalities in some malignancies Sputum culture (If concerns regarding infection including TB) + Urinary antigens if ? pneumonia not routinely done in ED but may be organised by admitting team. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1614181299171-3H88O4JBT5QLVHF3G49S/Screenshot+2021-02-24+at+15.41.16.png Haemoptysis Level B - Radiology CXR May identify an underlying cause. 20-30% will have normal CXR CT CT Thorax with contrast screening test of choice for ? malignancy, ? AVM, ? abscess. Further investigations may be needed to confirm diagnosis e.g. biopsy. IV contrast can demonstrate is there is active bleeding CTPA if ? PE. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1614177839278-MO3T6RIAFRAPDLQG1Q7G/image-asset.jpeg Haemoptysis Level B - Bronchoscopy Investigation of choice in cases where an abnormality of the bronchial tree is suspected Direct visualisation and biopsy In cases of massive haemoptysis therapeutic interventions can be done under direct vision via bronchoscopy as outline below. https://stjamesed.com/sickle-cell-crisis-level-a daily 0.75 2021-04-09 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1617963122993-URI3PKOA59IZZS83AK93/Bedside.jpg Sickle Cell Crisis Level A - Bedside ECG - if complaining of chest pain Urinary BHCG all - women of child bearing age VBG - if concerned about sepsis or shock. Assess lactate and acid base balance ABG - if concerned about respiratory failure https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610464491522-UFVAIZL85QNRF44U3A1V/IMG_6847.jpg Sickle Cell Crisis Level A - Laboratory FBC- compare baseline and current Hb Blood film – assess for target cells and schistocytes U + E, LFT, CRP, LDH- assess for infection and evidence of end organ failure Consider Group and hold/cross match Appropriate microbiology samples as clinically indicated eg blood cultures, sputum https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1617963573199-75IHQWV9ZRE5OTTYXOHO/unsplash-image-59pGROkKJPE.jpg Sickle Cell Crisis Level A - Radiology CXR - If patient has chest pain or if concerned about resp failure. CT Abdo - If concerend about intra- abdominal pathology or severe splenic sequestration https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1617965926111-DPJLTJWY1MHSQG7ZZOGG/Screenshot+2021-04-09+at+11.58.11.png Sickle Cell Crisis Level A Figure 1: Saint James Hospital Emergency Department Protocol for management of Acute Sickle Cell Crisis https://stjamesed.com/haem-lac-4 daily 0.75 2021-04-08 https://stjamesed.com/psych-lac3 daily 0.75 2021-04-20 https://stjamesed.com/depression-level-a daily 0.75 2021-04-20 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1618912348606-J77UU7UN5P8YK6EBH5ED/SADPERSONS.png Depression Level A - Scoring Systems Scoring systems have been developed in order to stratify risk in patients presenting with suicidal ideation, though the objective assessment of the patient and their perceived risk is much more important than their score on an assessment tool. One such scoring system is the modified SADPERSONS score and is a component of the Royal College of Emergency Medicine 2015 curriculum. Components of the SADPERSONS score is opposite. A score of 0-5 is indicative of low risk and may be considered safe to discharge, 6-8 indicates necessity for psychiatric input and >8 may warrant admission. https://stjamesed.com/tox-lbc-2 daily 0.75 2022-04-13 https://stjamesed.com/neuroleptic-malignant-sx-level-b daily 0.75 2022-04-13 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1610464380297-DR9WLWE9RIPCA83QYCPG/Bedside.jpg Neuroleptic Malignant Sx Level B https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611585270922-CUH5QY6MUV4UCFNWUPC5/LP%2Bprocedure.jpg Neuroleptic Malignant Sx Level B https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1613748084402-7UTIK2IKRMQOBWQ2M8ZE/CTB%2525252525252Bwork%2525252525252Bstation.jpg Neuroleptic Malignant Sx Level B https://stjamesed.com/psych-lbc-2 daily 0.75 2021-05-10 https://stjamesed.com/deleriumdemential-level-b daily 0.75 2021-05-18 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1620658995507-WCKN0VPD3PUTU7NIVJHB/Screenshot+2021-05-10+at+16.03.04.png Delerium/Demential Level B https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1621332421610-Q96S6T2HN362Q6XF6RZA/IMG_6639+%281%29.jpg Delerium/Demential Level B - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1621332949680-AWU8F74G2IGO0CA9QGJ2/IMG_5491.jpg Delerium/Demential Level B - Bedside Urinalysis UTI’s are frequently but not always the precipitant of delirium. Leucocytes on dipstick do not out rule other causes. ECG - ? Myocardial ischaemia, ? conduction disturbance VBG - ? Acid base disturbance, hypoglycaemia, electrolyte abn POCUS - ? urinary retention https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1621333350287-J6T05PDDLO96MOMA3BQ6/bloods%252B%25252B%252Bpod.jpg Delerium/Demential Level B - Laboratory FBC + CRP - Leucocytosis, elevated inflam markers ?possible infection U&E - ? uraemia, hypo/hypernatraemia, ? hypo/hyperkalaemia LFT - ? hepatic encephalopathy Microbiology culture blood, sputum, urine or CSF as clinically indicated Other e.g. TFTs, drug levels https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1621333809048-QVLFD6GI5448DM697GEK/CTB%252Bwork%252Bstation.jpg Delerium/Demential Level B - Radiology CXR Routine in all delirious patients. ? Respiratory or cardiac cause underlying CT Brian If any suspicion of intracranial cause or history of trauma including simple falls. If underlying cause for delirium is not clear there should be a low threshold for CT brain https://stjamesed.com/metabolic-lbc-1 daily 0.75 2021-05-28 https://stjamesed.com/addisonian-crisis-level-b daily 0.75 2021-05-28 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1622204102965-H03019LLBT097F48FLYJ/IMG_5479.jpg Addisonian Crisis Level B - Bedside VBG Typical findings in adrenal crisis = NAGMA + Hyperkalaemia + Hyponatraemia Hypoglycaemia + Hypercalcaemia often also occur ECG ? changes consistent with hyperkalaemia, ? AMI Urine dipstick ? evidence of UTI as underlying cause https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1622204877547-OLVA3M19B5JBSAWHJQZZ/unsplash-image-Zp7ebyti3MU.jpg Addisonian Crisis Level B - Laboratory U&E, Bone profile Assess renal function and confirm electrolyte disturbance FBC, CRP, LFTs, ? raised inflamm markers, acute liver injury Blood, urine +/- sputum/CSF cultures if ? sepsis Urine Electrolytes & Osmolality if significant hyponatraemia Serum Cortisol & ACTH before rx if possible Synacthen test - to confirm dx of adrenal insufficiency Not an ED test https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1622205261454-5GIF0JA5N4EPWQLM0PIV/unsplash-image-NMZdj2Zu36M.jpg Addisonian Crisis Level B - Radiology CXR Initial evaluation for source of sepsis CT Brain May be required depending on initial presentation and current mental status Other imaging as clinically indicated https://stjamesed.com/eclampsia daily 0.75 2021-05-21 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1621332949680-AWU8F74G2IGO0CA9QGJ2/IMG_5491.jpg Eclampsia https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612794825585-70EIPGEVFIGYXK33OWKD/image.jpg Eclampsia https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612969825044-4DPDO74XKKI0J8QC2UKC/Screenshot+2021-02-10+at+15.10.07.png Eclampsia https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1604074189511-SG7RWE48XG8ZTYLPOUE2/IMG_5567.jpg Eclampsia - Immediate As with any seizing patient Nurse on their side – left side in pregnant patients ABCDE approach Suction airway as required Apply high flow O2 via face mask Apply monitors Check blood glucose (hypoglycaemia also causes tonic clonic seizures) Gain IV access Call for help – anaesthesia and obstetric as urgent delivery will be required (or gynaecology on call if no obstetrics on site) https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612266177616-MTZP0MK7E13CPTLELB7I/Screenshot+2021-02-02+at+11.42.17.png Eclampsia - Specific treatment Magnesium sulphate 4g over 5-10mins iv Commence Magnesium sulphate infusion at a rate of 1g/hour Further 2g boluses of Magnesium Sulphate can be given if further seizures occur after initial loading dose In patients not responding to magnesium consider traditional status epilepticus management and alternative diagnosis If inadequate ventilation consider early RSI - experienced physician as difficult intubation is likely https://stjamesed.com/resuslbc2 daily 0.75 2021-08-31 https://stjamesed.com/psych-lbc-1 daily 0.75 2021-07-30 https://stjamesed.com/new-page daily 0.75 2021-08-31 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1628004135634-D8WJ8P7VFQBIOPFA4DXN/Screenshot+2021-08-03+at+16.20.31.png Capacity, Consent, MHA Level B Capacity A persons capacity may vary over time or a lack of capacity may be temporary. For example a person may lack capacity while they are intoxicated or suffering a physical or mental condition that cause confusion, drowsiness or a loss of consciousness. An adult has capacity to make a decision (including a decision to refuse treatment) if he/she can: Understand and believe the information relevant to the decision Retain the information long enough to be able to make a decision Is able weigh that information as part of the process of making a decision Is able communicate their decision Always seek senior advice if you are unsure if your patient has capacity. https://stjamesed.com/audit-archive daily 0.75 2022-12-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1627994238865-PVCYXPCUYEYA0L9Z0KB9/Screenshot+2021-08-03+at+13.30.43.png Audit Archive SJH ED Audit Archive https://stjamesed.com/qip-archive daily 0.75 2022-12-05 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1627984936059-6BP39HGDQP8AD2C14L2L/Screenshot%2B2021-08-03%2Bat%2B11.00.03.jpg QIP Archive https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1627985374940-OTGUFBZ8P6YN7H03P7T6/Screenshot+2021-08-03+at+11.09.08.png QIP Archive https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1627986224666-YGB7VKORW3MRMMCW2L0G/Screenshot+2021-08-03+at+11.23.15.png QIP Archive https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1627986849576-RV8YILI4CU8BRQDVC516/Screenshot+2021-08-03+at+11.33.10.png QIP Archive https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1627996599304-X79KTULQV1PVELIA9KLN/Screenshot+2021-08-03+at+14.06.01.png QIP Archive https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1628696409257-WV83ZOGXYPBO85DA0QAD/Screenshot+2021-08-11+at+16.21.44.png QIP Archive https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1659964345162-81MVS67TOBQIAOYED70V/DVT+QIP.png QIP Archive https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1659965467512-QYCZUHEYYL51A4QJ6IGF/Mental+health+QIP.png QIP Archive https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1660038959223-LGU057I8MODYI13G6NNL/Cardiac+arrest+proforma+copy.png QIP Archive https://stjamesed.com/qip-resources daily 0.75 2021-08-03 https://stjamesed.com/abdolbc2-1 daily 0.75 2021-08-20 https://stjamesed.com/ovarian-torsion-level-b daily 0.75 2021-08-24 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1621332949680-AWU8F74G2IGO0CA9QGJ2/IMG_5491.jpg Ovarian torsion level B - Bedside Urinary HCG - rule in alternative diagnosis - ectopic pregnancy Urinalysis - exclude urinary tract infection Lactate - may be elevated but usually is not https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1621333350287-J6T05PDDLO96MOMA3BQ6/bloods%25252B%2525252B%25252Bpod.jpg Ovarian torsion level B - Laboratory FBC - leucocytosis may be present CRP - may be elevated U&E, LFT, Amylase - aid in excluding alternative diagnosis https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/17222245-0429-4400-9e29-af5220102107/RIF2.JPG Ovarian torsion level B - Radiology Ultrasound pelvis May demonstrate large cyst or mass Ovary may appear abnormal in appearance, position or demonstrate reduced flow Doppler flow on ultrasound does not exclude the diagnosis as torsion can be intermittent or there may be incomplete occlusion of the blood supply Other CT & MRI are not indicated in the work up of ovarian torsion. If performed they would show similar findings https://stjamesed.com/helpful-resources daily 0.75 2023-01-31 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1629890574863-MF44W1SSKWY94RD0WT67/Domestic+Violence+1.jpg Helpful Resources https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1629890979460-TOI31RKNJCN9HFGEI7BU/unsplash-image-eAkjzXCU0p0.jpg Helpful Resources https://stjamesed.com/domestic-violence daily 0.75 2023-01-31 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1629893842937-OKERZEMJQ5SYUZ49H9SA/unsplash-image-Yui5vfKHuzs.jpg Domestic Violence What is domestic violence? An incident or pattern of incidents of controlling, coercive, threatening, degrading and violent behaviour, including sexual violence, in most cases by a partner or ex-partner, but also by a family member or care giver. Why are we concerned in emergency department? Domestic violence is common, more common that you can imagine. Domestic violence does not imply physical injuries only. It is a vicious cycle of emotional, financial, sexual, psychological, and physical violence leading to coercion where the abnormal becomes normal. This leads of a myriad of mental and physical illnesses with which these people present to emergency department. Why should we screen people for domestic violence / abuse in emergency department? It takes on an average 35 events of physical violence before a person reports domestic abuse. The time spent in the emergency department may be the only time these people might have away from their abusive environment and to seek help. Rather than waiting for the 35th presentation, asking a screening question might change a person’s life in a positive manner. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1629893794215-33WDFUVLS6U738OI39RV/Coercive+Controle.JPG Domestic Violence What should I do if someone discloses domestic abuse? Believe them (even if the history makes no sense). Maintain a non-emotional body language. Be reassuring ‘You are not alone & it is not your fault’. Listen with out interruption. Get senior help (ED Registrar / Consultant / CNM) early. Follow Emergency Department Domestic Violence Pathway. What should I do if there are children involved? Firstly ascertain if there is an immediate risk to the welfare of the child / children or if they are somewhere safe. If you are uncertain if there is an immediate risk to a child escalate to a senior colleague and the CNM2 in charge immediately. Follow the child protection algorithm. https://stjamesed.com/haem-lac-5 daily 0.75 2021-10-15 https://stjamesed.com/symptomatic-anaemia-level-a daily 0.75 2022-04-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1622204102965-H03019LLBT097F48FLYJ/IMG_5479.jpg Symptomatic Anaemia Level A - Bedside VBG Immediate approximation of Hb result. Allows you to start looking for source of anaemia, planning for transfusion etc. Signs of hypovolaemic shock —> acidosis, high lactate, low HCO3 + Base excess POCUS Guide resuscitation/identify sites of heamorrhage in shocked patients ECG Patients with pre-existing IHD may present with chest pain + acute coronary syndrome in setting of tissue hypoxia secondary to anaemia Faecal Occult Blood Rule in test only. Not used to rule out GI losses in someone with anaemia. May guide disposition planning in ED https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1612794825585-70EIPGEVFIGYXK33OWKD/image.jpg Symptomatic Anaemia Level A - Laboratory FBC Hb, WCC + Diff, Platelets, MCV, MCHC, Hct, Blood Film U&E + LFTs + TFTs ? CKD, ↑ Bilirubin in haemolysis, Thyroid dysfunction as a cause. Coagulation Studies ? coagulopathy as a cause of bleeding, ? bone marrow failure Other specialist tests are not routinely ordered by EM but include; Iron Studies (Serum Iron, Transferrin Sats, TIBC), B12, Folate, Ferritin Reticulocyte count, EPO levels, Bone marrow aspirate https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1614181299171-3H88O4JBT5QLVHF3G49S/Screenshot+2021-02-24+at+15.41.16.png Symptomatic Anaemia Level A - Radiology Choice of radiological investigation, if any, should be dictated by what the underlying cause of anaemia is thought to be. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/7126fd05-43c6-4aac-8f5e-8d56f2554d33/unsplash-image-XbkpzLGuj2g.jpg Symptomatic Anaemia Level A - Other OGD + Colonoscopy Chronic GI losses are a common cause of Fe Deficiency anaemia. The diagnosis is made by direct visualisation https://stjamesed.com/vtac-injury-leaflets daily 0.75 2024-06-06 https://stjamesed.com/physio-patient-information-leaflets daily 0.75 2021-12-21 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1611585968317-FZAVNBA0ERYLHA54RBTZ/examinations.jpg Physio Patient Information Leaflets ED Physiotherapy Referral Information Muscular Neck Injury Advice Lower Back Pain Advice Shoulder Injury Advice Rib Fracture Advice Knee Injury Advice Ankle Injury Advice https://stjamesed.com/sepsis-lbc-1 daily 0.75 2022-04-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/64f85245-0318-4274-a57f-ca3a90c7291a/Nec+Fasc.jpg Sepsis L.B.C. 1 - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://stjamesed.com/nec-fasciitis-lbc-1 daily 0.75 2022-04-12 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/6103ec16-0079-4aaa-9dbb-c5fc482c8b13/Bedside.jpg Nec Fasciitis L.B.C 1 - Bedside Venous Blood Gas Assess lactate and pH balance as part of Sepsis 6 Electrolytes, Blood Sugar ECG Sinus Tachycardia POCUS Assess cardiac function and IVC collapsibility in shocked patient https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/73cea584-39fa-460d-bbaf-8417ff8c6179/Blood+Cultures.jpg Nec Fasciitis L.B.C 1 - Laboratory Blood Cultures Bacteraemia is present in 25-30% of cases and is a strong predictor of mortality FBC Leucocytosis, Neutrophilia, Thrombocytopaenia, Anaemia U&E + CK Acute kidney injury, Hyponatraemia, Myoglobinaemia are common LFTs + CoAg ? Acute Liver injury and coagulopathy https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/2041ea48-7daf-48b6-94ee-77441d8010af/necrotising-fasciitis-1.jpg Nec Fasciitis L.B.C 1 - Radiology The diagnosis of necrotizing soft tissue infection is primarily a clinical one. Definitive treatment is time critical and should not be delayed for radiology. Plain x-ray May reveal subcutaneous gas but it is not a sensitive test CT more sensitive (80%) and can demonstrate facial thickening, oedema, deep tissue collections and subcutaneous gas. IV contrast is not necessary. MRI more sensitive again but introduces significant delays into treatment. https://stjamesed.com/tox-lbc-3 daily 0.75 2022-04-13 https://stjamesed.com/anticholinergic-sx-level-b daily 0.75 2022-04-13 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/d7684e78-4f67-4604-bcca-f82fa415c6f5/Kloss-and-Bruce-Anticholinergic.jpeg Anticholinergic Sx Level B - Symptoms Hot, thirsty, confusion, blurred vision Signs Central – Agitated delirium (may last days), Tremor, Hyperthermia, Coma, Seizures (rare) Peripheral = Dry skin, Dry mouth, Mydriasis, Facial Flushing, Tachycardic, Decreased bowel sounds, Urinary retention NB actively look for evidence of urinary retention in these patients. Their confusion may limit their ability to communicate. Urinary retention may further exacerbate their delirium. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/fab5d8bb-1bd7-45e8-b89d-f5842ba754e0/Attachment-1%255B1%255D.jpg Anticholinergic Sx Level B - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/a89d6123-73e9-48ef-a049-3e1fa1ab04e6/image.jpg Anticholinergic Sx Level B - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/3de333ec-192b-40d9-892c-cd4bfe784b9a/CTB%252Bwork%252Bstation.jpg Anticholinergic Sx Level B - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://stjamesed.com/neuro-lbc4 daily 0.75 2022-06-22 https://stjamesed.com/idiopathic-intracranial-htn daily 0.75 2022-06-23 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/f98e786d-02df-400b-a740-a3468a03dd7e/ICP+ECG.jpg Idiopathic Intracranial Htn - Bedside ECG ECG changes due to raised ICP most commonly seen in massive ICH Most common changes are widespread TWI and QT prolongation. BHCG in women of child bearing age VBG - Assess for metabolic, electrolyte, glucose disturbances https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/b7781c0b-dc63-430f-a63c-8b24d52efb29/LP+procedure.jpg Idiopathic Intracranial Htn - Laboratory FBC - exclude anaemia as a contributory cause U&E - if concerned for hypertension as cause of sx assess for evidence of hypertensive nephropathy LFT - ? hepatic encephalopathy TFTs - exclude hypothyroidism as contributory cause Lumbar Puncture Elevated opening pressure > 25cm H20 is an essential element of diagnosis. Otherwise CSF analysis is normal https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/07df05e5-8648-4bdb-8b68-0734bf05e532/idiopathic-intracranial-hypertension-17.jpg Idiopathic Intracranial Htn - Radiology CT/MRI Brain Neuroimaging is primarily used to out-rule central cause of secondary intracranial hypertension Brain and ventricles appear normal in patient with IIH but there may be some nonspecific signs on CT or MRI that can favour the diagnosis Visual Field testing Formal visual testing should be arranged to assess the severity of optic disc involvement https://stjamesed.com/itresources daily 0.75 2023-05-22 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1667483f-62c5-44f1-a9e8-95188906ccaf/Blurred+Ger.jpeg https://stjamesed.com/anp-resources daily 0.75 2023-08-01 https://stjamesed.com/resus-trauma-pps daily 0.75 2024-03-25 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1711379996154-B5OC01QBALYYG65MSNV5/image-asset.jpeg https://stjamesed.com/sedation-procedures-pp daily 0.75 2024-03-25 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/b7781c0b-dc63-430f-a63c-8b24d52efb29/LP+procedure.jpg https://stjamesed.com/respiratory-pps daily 0.75 2024-03-25 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1711380858793-4NS8XY4WPR42KUF46IVU/image-asset.jpeg https://stjamesed.com/stroke-neuro-pps daily 0.75 2024-03-25 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1711381007510-EH5Z32YTXT4X41M0OFUX/image-asset.jpeg https://stjamesed.com/orthopaedics-pps daily 0.75 2026-04-01 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1627985374940-OTGUFBZ8P6YN7H03P7T6/Screenshot+2021-08-03+at+11.09.08.png https://stjamesed.com/dvt-haematology-pps daily 0.75 2024-03-25 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/1711381620617-X5GBFYKOYJ1SMVV2VU35/image-asset.jpeg https://stjamesed.com/urology-pps daily 0.75 2024-03-25 https://images.squarespace-cdn.com/content/v1/5eeb603f3577e2315b147b8b/f84f4c24-fec5-4665-9156-0820cc4cb84a/Urology.PNG