Aortic Syndrome Part Two: Abdominal Aortic Aneurysm

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You place your hands on the patient's abdomen...you think you can feel it...thud...thud...thud...

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In the second part of our aortic syndromes series Dr Craig Douglas once again joined us to go through Abdominal Aortic Aneurysm (AAA)

In this episode we discuss:

  • Definition of an aneurysm and pseudoaneurysm
  • The screening process for AAA
  • When to suspect AAA
  • Diagnosing and managing ruptured AAA
  • Craig and Jamie's mutual bugbear that a FAST scan does not look for the abdominal aorta! 

For more information on the sensitivity and specificity of palpating a pulsatile-expansile mass here is our #OHMNHS blog on the subject

Here is our #TakeVisually for this episode 

Arrhythmias Part One: Palpitations

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In this episode Dr Bill Jamieson kick starts a series of podcasts on Arrhythmias by looking at the well patient presenting with palpitations.

We cover:

  • Red flags in the presentation of a patient with palpitations
  • The approach to assessing the ECG with 'WOBBLER' 
  • The key parts of the history not to miss
  • Examination and investigations
  • Arranging follow-up (and deciding if it is needed) for our patient  

Here is the RCEM Learning page on 'Palpitations'

Here is our Take Visually for this episode

Our second Arrhythmia episode on Bradyarrhythmia can be found here

Aortic Syndrome Part One: Aortic Dissection

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Dr Craig Douglas came down to take us through aortic dissection, a rare but potentially fatal diagnosis.  We discuss who gets it, why they get it, how it presents and what we can do about it.  

  • The presentation of aortic dissection including 'Chest Pain Plus One' - Abdominal pain, Collapse, Neurological Symptoms, Syncope and Vascular Symptoms
  • The risk factors for aortic dissection and the Stanford Classification
  • What investigations might make us suspicious for aortic dissection including the chest radiograph features and the role of synchronous blood pressures in both arms
  • The management of aortic dissection
  • Potential future risk stratification  

Also check out the RCEM Learning Aortic Dissection page

For a slightly franker take on aortic dissection here is David Carr's talk on 'The Aorta will %$#@!& You Up' from SMACCDUB 2016. 

Here is our Take Visually for this episode: 

Neurosurgery

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This special episode is a live recording of Dr Andrew Dapaah, ST2 in Neurosurgery presenting at the QMC Emergency Department Academic Meeting.  It is designed as a useful guide to Neurosurgery in the Emergency Department.

Andrew covered several topics:

  • The approach to interpreting CT Head scans, both Blood Can Be Very Bad and the 'spaces' approach (Foramen Magnum, Basal Cisterns, Uncal herniation. Midline shift and Sulcal effacement (stroke/oedema)
  • Trauma including acute vs chronic subdural haematomas, the role of Burr holes and acute craniotomy and extradural bleeds
  • Here is the Bullock criteria for acute subdural haematoma
  • He discussed neurovascular conditions including the WFNS Grade of Subarachnoid Haemorrhage and the Glasgow Outcome Score 
  • He finished talking us through hydrocephalus and shunt emergencies

This podcast is best listened to with his slides which are here.  Just press on the slide or use the direction arrows to move between them:

Here is our Take Visually for this episode:

Vertigo

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Dizzy! My head is spinning; Like a whirlpool it never ends; And it's you girl making it spin...or is it Benign Paroxysmal Positional Vertigo?  Or Labyrinthitis?  Or a posterior stroke?  Luckily this podcast with Emergency Medicine consultant and PHEM enthusiast Dr Chris Gough will help us through the dizzying world of vertigo.

As mentioned by Chris here is the HINTS exam:

Here is the Dix-Hallpike Manoeuvre from BMJ Learning:

And here is the Epley Manoeuvre also from BMJ Learning: 

The NICE Clinical Knowledge Summary for Vertigo can be found here

Here is the RCEM Learning Package for Vertigo

Here is our Take Visually for this episode:

Paracetamol Overdose

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In this podcast Dr Chris Gough, consultant in Emergency Medicine and pre-hospital doctor talks us through the very latest guidance on the management of Paracetamol overdose.

These guidelines can be found at Toxbase who we always recommend for the management of all overdoses (you'll need your institution's log in details)

More information on the SNAP Protocol that Chris talked about can be found here.

Here is the Take Visually for this episode:

Chronic Obstructive Pulmonary Disease

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The amazing Medicine SpR Dr Charley Peal talks us through Chronic Obstructive Pulmonary Disease (COPD).

Guidelines used are the NICE Guidelines CG101 and BTS 2016 Guidelines.

Inclusion and Exclusion Criteria for Non-Invasive Ventilation (NIV) (from BTS):

You can also check out our podcast on the management of stable COPD here.

And here is the Take Visually for this episode:

Upper Gastrointestinal Bleed

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In this episode the always excellent Dr Charlotte Peal guided us through the often dramatic world of Upper GI bleeds.

NICE guidelines? Yes, here they are.

Pre-Endoscopy risk assessment is with the Glasgow Blatchford Score.

Post is based on what you find on endoscopy and is through the Rockall Score (mortality and re-bleeding risk).

And here is the Take Visually for this episode:

Community Acquired Pneumonia

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Don't CURB your enthusiasm (get it?) for more #FOAMed brilliance as our favourite Respiratory SpR Dr Harry Pick came down to the pod to talk about Community Acquired Pneumonia.

Harry kindly gave us his Powerpoint on Community Acquired Pneumonia.  Click either side of the images to scroll through them.

And here is our Take Visually for this podcast:

As mentioned by Harry here is the Pneumonia Trust website.

BTS Pneumonia guidelines are here and here are the NICE guidelines.  

Here is the CURB 65 severity score for Pneumonia.

For information on Sepsis check out the podcasts for Sepsis and the NICE guidelines.

Pulmonary Embolism

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In this bumper podcast Dr Harry Pick, Respiratory Registrar and Research Fellow extraordinaire came down to talk us through pulmonary embolism (PE).  

He discusses the personal and setting based risk factors for pulmonary embolus including the risk scores used in diagnosis: Well's, PERC and the simplified PESI.

There is a talk through of when (and more importantly when NOT) to use D Dimer as a blood test and the key question of radiation exposure - CTPA vs V/Q scan.  

For more information on the Radiological findings related to PE here is the Radiopaedia page.

Here is the Take Visually for pulmonary embolism: 

Acute Abdomen

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Mr Riad Hosein came down to discuss the Acute Abdomen and how to approach a patient with abdominal pain.  Red flags are discussed as well as how to differentiate the patient with a life threatening acute abdomen.

Some key points from the podcast:

  • 40% will have a final diagnosis of non-specific abdominal pain
  • 20% appendicitis
  • 20% gallstone disease
  • 20% other causes

(Patterson-Brown, S., The acute abdomen, in Principles and Practice of Surgery, e.a. OJ Garden, Editor. 2007, Churchill Livingstone: Edinburgh. p. 332-340, King KE, W.J., Abdominal Pain, in Rosens Emergency Medicine: Concepts and Clinical Practice, H.R. Marx JA, Walls RM, Editor. 2006, Mosby: Alibani. p. 1343-54).

Cochrane review stated that there is no evidence that opiates mask the signs of peritonism or lead to a delay in diagnosis (Lameris, W., et al., Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ, 2009. 338(jun26_2): p. b2431-).

Here's the RCEM page on Abdominal Pain without shock