ALS changes

The 2015 AHA and ERC guidelines have been released.  The Australian Resuscitation Council has released a statement indicating their final guidelines will be released in December.  In the interim, the AHA Highlights document, albeit long, does give a good update on the changes that have occured since the 2010 guidelines with simple explanations for these reasons behind these changes.

“He doesn’t look good”

A 50 year old male presents to your ED by ambulance with a 3 hour history of progressively severe central pain which is pleuritic and radiating through to his back.  He has had a history of a provoked PE over 2 years ago.  He is brought to your resus area after the nurse-in-charge has noted that “he doesn’t look good”.

His vitals are normal however he is diaphoretic and clearly in pain.  His cardiac, respiratory, and gastrointestinal exams are normal.

His initial ECG is:

ECG 1

Repeat ECGs over the next 20 minutes remain unchanged from the above.  CXR is also normal.

What is your differential at this juncture and what are your next steps?

His story continues here.

Bedside ultrasound is commonplace in the ED having started with the FAST scan (first used in the 70s in Europe) and now encompassing a range clinical conditions that can be assessed at the bedside with the ultrasound machine becoming an extension of the physical exam.

This post from Academic Life in Emergency Medicine highlights the utility of occular ultrasound in the ED.  Like fundoscopy it is an acquired skill that needs practice, however compared to fundoscopy it can help us arrive at a diagnosis more quickly and confidently.