ED Rounds – February 2015

An enjoyable and informative set of presentations by Dr Ramrattan, Dr Talbot and Dr Greer
The presentations can be downloaded and reviewed from the CPD File Store (Rounds)

Dr Brian Ramrattan – Alphabet Soup

TREKK –  Translating Emergency Knowledge for Kids
To create a national network that is a trusted source for easy access to the latest evidence, best practices, user-friendly resources and discussions in pediatric emergency care. It will be created and used by health professionals and the families they care for and its work will drive the highest quality of health care for children and families seeking emergency care in Canada.
Their mission is to deliver the highest standard of care to every child, whether they choose to seek treatment in a pediatric or general emergency department
More topics on their website
The following were presented:
Bronchiolitis, Croup, Gastroenteritis
  • Routine CXR not supported by evidence however need to take each case on its merits. If suspect pneumonia – CXR
  • NPA or CBC does not alter management
  • High risk groups – Prems, <3/12
  • Most can be discharged
  • Steroids do not reduce LOS
  • Epinephrine may reduce admissions on day 1 but there is no long term benefit
  • Bronchodilators are not effective in bronchiolitis
  • Steroids plus Epinephrine may reduce admission rates for up to 7 days, but not recommended routinely
  • Recommended- Oxygen and Hydration
  • Admission criteria – include unable to maintain sats > 90% without O2, Not feeding, increase WOB, Resp rate > 70
  • Worse at night
  • Usually improve on way to hospital
  • Clinical diagnosis
  • Febrile, bark, tachypnea
  • Westley Croup Score – may be useful for RT to do while observing child pending discharge
  • Lateral Neck X-ray may be helpful for retropharyngeal abscess, epiglotitis
  • Recommended – Steroids +/- Epinephrine (if need rapid Rx)
  • ORT as good as IV Rehydration
  • Anti emetics lower need for admission and IVRT
  • Not enough evidence for probiotics
  • Consider weight in kg as ORT mL per 5 mins e.g. 10kg = 10mls per 5 mins
  • Ondansetron 8-15kg – 2mg 15-30kg – 4mg
Alberta – Vomiting and Diarrhoea Pathway


Dr Jo-Ann Talbot – Do We Choose CPD Wisely?

We are not very good at deciding what to focus on?
Continuum from competence to expertise
Scope of Practice will impact on how we choose our CPD
Why should we have-  Practice Assessment
  • Role in Feedback in identifying areas where our competency can be improved
  • Flaws in self assessment
  • Increasing expectation of the profession
Revalidation is comming…
  • Association of Canadian Regional Colleges have guidelines
  • ACEP – Exam, PAR, Lifelong learning, Patient Feedback etc
  • UK GMC –  system
How can we Improve – Where is the Gap?
  • Perhaps chart reviews
  • Review M&Ms and complaints
  • Are there common things that we do that say if we are a safe doctor?
Needs Assessment Triangulation
  • Synthesis and integration of data from multiple sources
  • Narrow down to the most important problems
  • Assessment
    • Knowledge – e.g self assessment
    • Performance assessments – Sim, Audit, 360, Teaching
  • “How do we know if we are providing excellent care?” – Group discussion – suggested ways below
    • Informal follow up
    • CQI chart audits
    • Bounce backs
    • Procedural audits
    • External chart review
    • M&M’s
    • Trauma Charts
    • Should we get the discharge summary
    • Letters from clinics
    • But what is excellence?
      • Combination of knowledge, skill, implementation, communication
      • We are the experts in Emergency Care – we should set the standards.


Download (PDF, 5.91MB)

Dr Matt Greer – Turn it up to 11. LP in the Diagnosis of SAH

  • 1% Headaches = SAH
  • 14% of ED Headaches get CT (US Stats)
  • Unenhanced CT is 100% sensitive < 6hrs
  • Xantho is only useful >12hrs  but < 2weeks (this is now debated – see presentation for details)
  • Type and Location of pain has no predictability for cause
  • Do we still need to LP after CT – ( answered in the presentation)
  • No Gold standard
  • But CT plus LP had been considered standard for early studies
  • LP’s are hard to interpret
  • Unenhanced CT performed < 6hrs – 100% sensitivity
  • Need 3rd generation CT Scanner
  • Need Radiologist – who is routinely reading Head CTs
  • LP – most sensitive >12hrs  and < 2 weeks
  • Xanthochromia determined the positive result
  • But Xanthochromia may not be such a good gold standard?
  • Why  not just do CTA
  • But 2-5% have aneurysm in population
  • So which ones do you treat?
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