Past teaching sessions and blog posts
Provocative Testing in ACS
No risk
No test.
Even an exercise ECG is dangerous in these people because a false positive will lead to an Angiogram which may lead to a stroke, dissection, renal failure, cancer. Whilst these complications are unlikely if they just don't have the disease clinically then no test is indicated.Low risk
Male with exercise ability
Exercise ECG generally the appropriate test.
Recurrent presentations depsite negative EST or unable to exercise
Cardiac CT gives lower rates of people coming back with undifferentiated chest pain.. Once you have seen the arteries are normal you can feel more confident. Here this is only available as an outpatient (medicare) test. Radiology will provide same day or next business day test. Order must include consultant provider number and signature.
Remember, while it has a high sensitivity for significant stenoses ot has a much lower specificity so false positives are a problem in this group. Really it is better as an intermediate risk patient test but it might help with the repeat visitors.
Low risk female
Stress ECHO test of choice.
Too many false positives with exercise ECG and too much breast radiation with cardiac CT .
Intermediate risk
Young patient
Stress ECHO.
Older patient
Cardiac CT and/or thallium. The combination of CTCA, followed by thallium if positive, helps to sort out who has lesions that are meaningful although there is some uncertainty about whether you should just get on to the definitive procedure if you get a positive on either test rather than mucking around more.
Save the stress ECHO spots for those at more risk from radiation.High Risk
You shouldn't even be here! If the patient has a positive Troponin or ECG changes or the whole thing just screams crescendo angina then they should be getting admitted for an angiogram.
Subarachnoid Haemorrhage
Here is the powerpoint presentation for the talk on SAH from 29/10/2011.
And here is a link to the BMJ article about CT in the first 6 hours.
Head Injury Presentation June 30
Head Injury
Head Injury Presentation - Ben McKenzie. Some physiology, overview of the spectrum of injury, when to CT people, how to care for people with raised ICP.
Post Traumatic Amnesia - Abbreviated Westmead Scale is probably more sensitive to diagnose this instead of GCS but uses more resources to administer - likely best reserved for mild head injury patients who need hours of observation in short stay.
Post Concussion Syndrome - Don't forget patients do better when you give them information (like this booklet) about what to expect.
Canadian CT Head Rules Original Research Article
Inflicted Injury and the Child at Risk
Bruising patterns
These charts outline the typical bruising patterns of accidental and non-accidental injury in small children and are a useful adjunt to the information after the jump. I am indebted to Dr Nicola Cunningham FACEM from the Victorian Institute of Forensic Medicine and St Vincent's Emergency Department for sending me these slides from her talk at the St Vincent's and Bendigo Regional Teaching Day on Dec 14th 2011. They come originally from the following excellent article on the topic.
Which injuries may indicate child abuse? S Maguire, Arch Dis Child Educ Pract Ed 2010 95: 170-177 originally published online October 6, 2010 doi: 10.1136/adc.2009.170431.
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