The Crashing Asthmatic

May 17, 2013 by Andy Neill · 5 Comments

I had prepared this before the 3MG trial came out and hat tip to simon carley and his post for alerting me to it.

UPDATE: have since read the 3MG trial and here’s my thoughts on that

In my current dept, there’s a monthly joint ICU/ED meeting. I recently presented on some of the evidence base and strategies for managing life-threatening asthma. The 15 people there seemed to enjoy it so now i’m sharing it with the rest of the #FOAMed community.

I’ve included some references below from some of the papers cited in the talk.

Two talks in particular deserve mention.

One on EM:RAP by Mel Herbert himself back in 2007 [subscription needed] and the other from EMCrit.

Lim, Wei Jie, Redhuan Mohammed Akram, Kristin V Carson, Satya Mysore, Nadina A Labiszewski, Jadwiga A Wedzicha, Brian H Rowe, and Brian J Smith. “Non-Invasive Positive Pressure Ventilation for Treatment of Respiratory Failure Due to Severe Acute Exacerbations of Asthma..” Cochrane Database of Systematic Reviews (Online) 12 (2012): CD004360. doi:10.1002/14651858.CD004360.pub4.

Mohammed, S, and S Goodacre. “Intravenous and Nebulised Magnesium Sulphate for Acute Asthma: Systematic Review and Meta-Analysis..” Emergency Medicine Journal 24, no. 12 (December 2007): 823–830. doi:10.1136/emj.2007.052050.

Nair, Parameswaran, Stephen J Milan, and Brian H Rowe. “Addition of Intravenous Aminophylline to Inhaled Beta(2)-Agonists in Adults with Acute Asthma..” Cochrane Database of Systematic Reviews (Online) 12 (2012): CD002742. doi:10.1002/14651858.CD002742.pub2.

Rowe, B H, J A Bretzlaff, C Bourdon, G W Bota, and C A Camargo. “Magnesium Sulfate for Treating Exacerbations of Acute Asthma in the Emergency Department..” Cochrane Database of Systematic Reviews (Online) no. 2 (2000): CD001490. doi:10.1002/14651858.CD001490.

Tobin, A. “Intravenous Salbutamol: Too Much of a Good Thing?.” Critical Care and Resuscitation : Journal of the Australasian Academy of Critical Care Medicine 7, no. 2 (June 2005): 119–127.

“British Guideline on the Management of Asthma” (February 2, 2012): 1–151.

Filed Under: FOAM ·

Workshop for EMS Gathering

May 17, 2013 by Andy Neill · 1 Comment

This is the post I created for the guys who attended the “Social Media and EMS” workshop at the Irish EMS Gathering in May 2013. Hopefully something from the 2.5 hrs stuck in your brains so that you’re not seeing all this as entirely new material.

Twitter

Firstly we got everyone to join Twitter. You can do this via the website or via an app on your computer or phone. For interest sake I use TweetDeck through Chrome on my computer and use Twittelator Pro on my iPhone.

I suggested that when you join twitter you should put a little of biographical information about yourself. People are more likely to interact with you if they know something about you. There are a lot of fake, spam Twitter accounts and having some info on someone helps people to trust you.

I suggest having a profile picture as well rather than the default, anonymous egg.

For example here’s mine:

Follow People

When you get started I suggest you follow a few key people to start with. Here’s 5 to get you started:

The more interact, post and reply to people, the better your twitter experience will be. We don’t bite honestly, we loved being asked questions on Twitter.

Follow Lists

You can also follow lists, either other peoples or your own that you create. This is a good way to ensure that you’re spending your time well on Twitter. If you make a list of people who consistently tweet high value info then you’ll not be bored by dross about people’s dinner…

Here’s a list I have of “medical tweeters”

Follow Hashtags

Hashtags [words beginning with the '#' symbol] are good ways to join conversations together. My favourite hashtag is #FOAMed, this is a consistent conversation about FOAM resources. You can type #FOAMed into the twitter website or onto your twitter app to find it.

NB, on a mac the # symbol is produced by pressing the ‘option/alt’ key and ’3′ together.

If you want more twitter basics then check out momthisishowtwitterworks.com

Podcasts

I think the key is to get your podcasts on your smartphone. That way wherever you are yo can listen to them. It’s much more important to have them on your phone your computer in that sense.

The basic ‘podcasts‘ app from apple on the iphone is a reasonable place to start.

Once downloaded, start the app and click the ‘store’ button.

Once you’re in the store, search for whatever it is you’re interested in.

Once you find a podcast you want to subscribe too, just click on the subscribe button. Every time a new podcast is released it should download automatically to your phone.

LITFL have a great list of podcasts and a searchable database too, if you need to find more.

Feed Reader

Most of the FOAM websites produce new material on a regular basis. To save you having to visit the site to check if new amterial has been released, you can use something called a feed reader that will collect all the new material from all your favourite websites in one place. I used to recommend Google Reader but it’s shutting down in July 2013 and I’m now suggesting feedly as a good alternative.

Once you’ve added feedly to your internet browser or downloaded the app to your phone or tablet then you can add the websites you’re interested by either clicking on the RSS symbol on the website

or copying and pasting the website URL into the search box

The mobile app is kept in sync with your computer and is set out in a similar easy to use way.

If you’re looking for one place to look for all the best in FOAM then check out Kane Guthrie’s LITFL review.

Blogs

So say you’re keen to start putting out your own FOAM material, then starting a blog is a good way to start. Here’s the website we set up at the workshop in 15 minutes.

This is what the ‘dashboard’; the construction site of the website looks like.

This is all free and easy to do via wordpress.

Google Plus

We only mentioned this briefly but I said I thought it was a brilliant platform for FOAMed but unfortunately under utilised. Its best features are probable communities [check out ECG+ and the EMCrit community] and the google hangouts. Here’s a nice example of google hangouts being used to stream a conference live.

Or here as a conversation between experts discussing some medical papers. Saves all the hassle (but not quite as much fun) of actually meeting up.

Screencasts

Due to technical issues we couldn’t quite pull this off live at the workshop but a screencast is typically a recording of what’s on your screen with a voice over. It’s a great way to share a lecture you’ve prepared with lots of other people. Once the video file is made you can upload it to YouTube, Vimeo or even better GMEP for other people to see.

Screenr.com let you record screencasts without having to download a separate app but I do a fair bit of this so I use one called screenflow.

As an example here’s a screencast of the talk I gave at the conference.

Lastly the app I used for displaying my iPhone screen was one called Reflector which is $12 but a really, really well put together app that lots of people recommended but I first found via Haney Mallemat and my brother the software developer.

UPDATE: Michelle Lin has just published a nice piece here outlining some social media basics. There’s a video to go with it too

UPDATE 2:

For those interested in EMS specific FOAM then here’s some useful sites [H/T to @amboFOAM for some of these]

Filed Under: FOAM · Tagged: EMS Gathering, FOAMed, social media, twitter

Anatomy for Emergency Medicine 027: Basic Anatomy of Abdomen and Pelvic Trauma

April 15, 2013 by Andy Neill · 6 Comments

This is the second part of a recent lecture I gave to some first year med students to get across how important their anatomy is to understanding trauma.

First part lives here

You may have to click through to the GMEP site to see the full HD version

PDF of slides

Filed Under: Anatomy in EM, FOAM · Tagged: anatomy, emergency medicine, FOAMed, trauma

Cranial Nerve Palsies -III, IV and VI

April 12, 2013 by Andy Neill · 1 Comment

This isn’t so much an AFEM post but more of a brief review of a paper and a video.

Everyone finds neuroanatomy tough, you’re not alone. Most of it doesn’t really concern us in the ED that much. However we will have people attend or be referred with isolated III, IV and VI palsies.

If you understand the basics you can know when to get worried and scan and admit and to relax and explain to the patient that this will likely improve with time.

First I suggest watching this video from the single best eye teaching source I’ve found [Chris Nickson found it for me of course ]

I also found this paper [via the only neuro blog I read] which covers the anatomy but also some advice on when to image and when not to. This is my basic summary.

In general

a lot of isolated palsies can be observed as most are vasculopathic and will resolve
isolated palsies in young people should cause consideration for mass. Non-vasculopathic sixth palsies are relatively high risk here
the key point is identifying isolated. If they have headache or other signs then it’s not isolated
temporal arteritis can be involved in all of them, as can myasthenia but there should be other signs/symptoms

III

if motor only can usually be observed as most will be vasculopathic if the risk factors exist
if mixed motor and pupil should be imaged
if pupil only then think about compression

even traumatic IVs don’t need imaging for ICH (though maybe for fracture)
head tilt is common along with pupils not at the same level
some are congenital that have decompensated
again the vasculopathic ones do quite well
sub-arach space rarely involved
isolated non-vasculopathic ones may (with caveats) be observed (unlike VI and III)

traumatic VI needs a scan
vasculopathic can be observed
non-vasculopathic should get scanned (they quote a 25% malignancy rate which seems awful high)
they oddly don’t mention benign raised ICP as a cause

In the ED it’s not always as straightforward as this as the key is follow up. Depending on your access to neurology/ophthalmology will dictate how you manage them.

Filed Under: Anatomy in EM, FOAM, neuro · Tagged: anatomy, emergency medicine, neuor, ophtho

Anatomy for Emergency Medicine 026: Basic Anatomy of Chest Trauma

April 9, 2013 by Andy Neill · 6 Comments

This is a screencast of a recent lecture I gave to some first year med students. It’s mainly to give the students some clinical info to keep their regular anatomy teaching relevant. It’s not designed to be a comprehensive intro to trauma in any way.

It’s longer than the usual podcasts so I’ve split into two parts.

Feedback, is as always, welcome.

You may have to click through to the GMEP site to see the full HD version

PDF of slides.

Filed Under: Anatomy in EM, FOAM · Tagged: anatomy, emergency medicine, FOAMed, trauma