Ep 244 - July 2024 Monthly Update - Chest Pain, REBOA, Lidocaine patches and lots of paediatric emergency medicine

The St.Emlyn’s Podcast

Welcome back to the St. Emlyn’s podcast. This episode covers some of the most important developments in emergency medicine and critical care from July 2024. Whether you're practicing on the frontlines or keeping up with the latest research, this episode has something for you. From coronary risk scoring tools to cutting-edge AI in ECG interpretation, and the management of non-fatal strangulation, it’s packed with insightful updates. Here's a breakdown of the key topics:

The Manchester Acute Coronary Score (MACS Rule) is a valuable tool for risk-stratifying patients presenting with chest pain in the emergency department (ED). MACS uses both clinical characteristics and biomarkers like troponin to assess a patient's likelihood of experiencing an acute coronary event. A recent systematic review found that the T-MACS model (which uses troponin) has a sensitivity of 96%, making it highly effective at ruling out serious coronary events.

Though the specificity is lower, MACS’s real strength lies in its ability to drive clinical decisions and patient referrals. This tool is already integrated into the Electronic Patient Record (EPR) in Manchester, where it helps streamline the decision-making process for patients with chest pain. If you’re looking for a reliable method to quickly and accurately stratify risk, MACS could be the answer.

Artificial intelligence (AI) is revolutionizing healthcare, and its application in ECG interpretation is particularly exciting for emergency medicine. In this episode, Steve Smith joins us to talk about how AI can enhance the detection of occlusive myocardial infarction (OMI)—a concept that might one day replace the traditional ST-elevation and non-ST-elevation classifications.

By integrating AI into rapid assessment areas (like pit-stop zones in the ED), clinicians can benefit from real-time ECG analysis. This reduces the burden of interruptions and helps detect subtle abnormalities that might be missed in high-pressure environments. AI-driven ECG tools could dramatically improve patient outcomes, particularly in cases of high-risk cardiac events.

Non-fatal strangulation (NFS) is an often underdiagnosed condition in emergency medicine, but it carries significant risks, including carotid artery dissection. A new guideline from the Faculty of Forensic and Legal Medicine emphasizes the importance of detecting these cases and suggests that clinicians use contrast angiography to rule out vascular injuries.

Beyond the medical consequences, non-fatal strangulation is also a major indicator of future violence, including homicide. The guideline highlights the ethical challenges clinicians face when deciding whether to involve law enforcement, especially when patient consent is lacking. Safeguarding and appropriate referrals are essential for these high-risk patients.

REBOA has been evolving in recent years, and now it’s moving from the emergency department into the pre-hospital setting. In the latest advancements, partial REBOA—which allows for some blood flow below the balloon—is being used to resuscitate patients in traumatic cardiac arrest.

This partial occlusion technique may be more effective in maintaining coronary perfusion, essentially resuscitating the heart in cases of extreme hemorrhage. Early data from a feasibility study shows promise, with an 18% survival rate in patients who otherwise would have had little chance of survival. REBOA could become a life-saving pre-hospital intervention for trauma patients in the near future.

Paediatric eating disorders, particularly anorexia and diabulimia, remain under-recognized in emergency medicine. In this episode, we explore some of the red flags—such as rapid weight loss, bradycardia, and postural hypotension—and why emergency clinicians need to be more attuned to the signs of eating disorders.

Of all mental health disorders, anorexia has the highest mortality rate, and in cases of diabulimia, patients intentionally stop taking insulin to induce ketosis and lose weight. Given the severity of these conditions, it's crucial that we recognize them early and respond appropriately, especially when young diabetic patients present with unusual symptoms.

The advent of hybrid closed-loop insulin pumps is transforming the care of type 1 diabetes. These pumps act as an artificial pancreas, continuously monitoring blood glucose levels and adjusting insulin delivery automatically. The latest guidelines from NICE recommend these devices for all patients with type 1 diabetes in the UK.

However, these pumps come with their own set of challenges, especially in the emergency department, where clinicians need to know how to troubleshoot common problems, such as cannula blockages or starvation ketosis. In this episode, Nicola Trevelyan walks us through the essential steps for managing patients who use these devices.

Lidocaine patches have long been used as a low-risk intervention for managing pain in elderly patients with rib fractures, particularly when nerve blocks or NSAIDs aren’t viable options. But how effective are they? A recent feasibility study compared lidocaine patches with standard care and found that while the pulmonary complication rate remains high, the patches may offer some benefit for pain relief.

While more research is needed, lidocaine patches continue to be a low-harm option that might provide relief in certain patient populations, particularly where other pain management strategies are contraindicated.

Button battery ingestion remains one of the most dangerous emergencies in pediatric medicine. Francesca Stedman, a pediatric surgeon, explains the dangers of battery-induced burns, which can occur within hours of ingestion. Time is of the essence in these cases, and quick identification through radiographic imaging followed by rapid removal is critical to prevent long-term damage.

Even when batteries are lodged in places like the nose, they can cause significant tissue damage in a short time, making early intervention absolutely vital.

That’s a wrap for our July 2024 podcast update! From life-saving interventions like REBOA and AI in ECG analysis to the everyday challenges of managing pediatric emergencies and coronary risk, this month’s highlights offer a wealth of knowledge for clinicians. Be sure to check out the full blog posts and podcasts for more in-depth discussions on each of these topics. Thanks for listening and stay tuned for more cutting-edge insights from St. Emlyn’s!