Ep 134 - March 2019 Round Up

Highlights from March 2019: Key Insights and Updates Welcome to the St Emlyn's podcast. I'm Simon Carley and today; I'll be taking you through the highlights from our blog in March 2019. This was a busy month filled with exceptional content, insightful trips, and significant conferences. Let's dive into the details and explore some key topics, starting with adult congenital heart disease, top trauma papers, and the importance of responsible volunteering. Management of Adult Congenital Heart Disease March kicked off with an important post on the management of adult congenital heart disease (ACHD). This topic is particularly close to my heart as the hospital I work at is a level two centre for ACHD in the UK. Services have become centralized, and surgical components are now managed at a few specialized centres, with Liverpool being the hub for my region. Despite this centralization, we still encounter a large population of ACHD patients in our area. These patients often present complex medical histories and unique pathologies that can be challenging to manage in emergency settings. The guidance available typically focuses on chronic and surgical management, but emergency care for these patients requires a different approach. Common Issues in ACHD Patients ACHD patients commonly present with dysrhythmias, which can be particularly challenging to manage. Chest pain is also prevalent, although the incidence of ischemic heart disease isn’t significantly higher in ACHD patients, except for those who have undergone certain procedures like the switch operation. Other common issues include: Cyanotic patients: Those with single ventricle physiology and right-to-left shunts. Endocarditis: A rare but serious complication. Non-cardiac problems: Managing ACHD patients with conditions like appendicitis or pneumonia can be complex due to their unique circulatory dynamics. The bottom line is that these patients often require specialized management strategies. When ACHD patients present with cardiac complications, we consult our local cardiologist or the ACHD centre. However, non-cardiac issues in ACHD patients also warrant discussion with the ACHD centre to ensure comprehensive care. Key Takeaways for Emergency Physicians Emergency physicians should familiarize themselves with the unique aspects of Fontan circulation, which relies on venous return based on venous pressure. Aggressive interventions like CPAP, bagging, and diuretics can be detrimental. Understanding these nuances is crucial for providing optimal care. A Deeper Dive into Fontan Circulation The Fontan procedure, a surgical intervention for single ventricle defects, creates a unique circulatory system that can be difficult to manage in emergency settings. Unlike normal circulation, Fontan physiology depends heavily on passive blood flow from the veins to the lungs. This means that increasing intrathoracic pressure through methods like CPAP or bagging can reduce cardiac output and worsen the patient's condition. Fontan patients are particularly vulnerable to fluid shifts and pressures, making careful management of intravenous fluids and medications essential. Understanding these dynamics can be life-saving in the ED. For example, while diuretics might seem a reasonable choice for a patient with fluid overload, they can lead to dangerously low preload and cardiac output in a Fontan patient. Top Trauma Papers from the Trauma UK Conference Next up, we revisited some of the top trauma papers presented at the Trauma UK conference. These papers covered a range of topics, from the use of bougies in the ED to bag-mask ventilation during hypertensive resuscitation. Here are some key highlights: The PAMPer Trial The PAMPer trial examined the use of prehospital plasma in trauma patients and found significant survival benefits. This trial has important implications for trauma care protocols, emphasizing the potential of early plasma administration to improve outcomes. The trial showe