ED Registrar Teaching Summary 23.09.2026

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ED Registrar Teaching Summary 23.09.2026

VBG of the Week  |  Sim: Refractory VF  |  Vestibular Assessment  |  Lung POCUS

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1. VBG of the Week

Gas: pH 7.475 | pCO₂ 24 | HCO₃⁻ 17.6 | Na 124 | K 3.7 | Cl 91 | Glu 8.8 | Lactate 7.6 | Cr 75 | Hb 139

  • Alkalaemia with primary respiratory alkalosis (arterial pCO₂ likely ~19–20)
  • Compensation: expected HCO₃⁻ 20.8 (acute) / 16 (chronic); Winter’s expected pCO₂ 34 ± 2 → mixed picture
  • AG 15.4 – smaller than lactate 7.6 predicts: check albumin; consider a third process (metabolic alkalosis)
  • Na 124: hypotonic hyponatraemia; Na-corrected Cl ≈ 103, so low Cl is dilutional
  • Summary: mixed respiratory alkalosis + lactic HAGMA with alkalaemic pH, plus hyponatraemia
  • Think: sepsis (pneumonia + low Na → Legionella), salicylates (send level), liver failure, PE

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2. Sim: Refractory VF – Learning Objectives

Medical objectives

  • Recognise refractory VF (≥3 shocks); ALS algorithm, 4Hs and 4Ts; adrenaline after shock 2, amiodarone 300 mg after shock 3.
  • Pads check – Ensure good contact, connected, working, no chest hair, sweat and correct position.
  • Escalate defibrillation: vector change to A-P pads.
  • Consider mechanical CPR, cath lab and ECPR pathway; initiate post-ROSC care

Performance objectives

  • Hands-off team leader: shared mental model, verbalised plan every loop. Early call for help/advice.
  • Team – encourage to voice opinions and escalate concerns where important.
  • Avoid task fixation – pause, summarise, “what haven’t we tried?”
  • Role allocation for second defib; closed-loop communication; ISBAR handover to cardiology/ICU

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3. Vestibular Assessment in ED: Central vs Peripheral

  • Timing & triggers: continuous → HINTS; positional → Dix-Hallpike; episodic → migraine, Ménière’s, TIA

Acute vestibular syndrome (AVS)

  • Acute-onset dizziness, nausea/vomiting, head-motion intolerance, nystagmus and unsteadiness, lasting ≥24 hours
  • HINTS is validated in AVS only – not required if the vertigo is not acute-onset and continuous
  • 3 tests: Head impulse   Nystagmus (spontaneous and gaze-evoked)  •  Test of skew

Performing HINTS – order: Nystagmus → Skew → Head impulse

  1. Nystagmus: follow finger, only slightly outwards (gaze-evoked); remove fixation – shine a light if no Frenzel goggles. Nystagmus present → proceed.
  2. Test of skew: complete alternate cover test; any vertical refixation = central.
  3. Head impulse (tests the peripheral system): catch-up saccade = peripheral cause. No saccade = normal person or stroke → image.
  4. HINTS plus: all else “reassuring” but new hearing loss → consider AICA stroke (less common) → image.
  • INFARCT = central: Impulse Normal, Fast-phase Alternating, Refixation on Cover Test
  • Always test gait: unable to sit/stand unaided = central, whatever HINTS shows

BPPV positional testing

  • Modified Dix-Hallpike: the lower ear is the ear being tested; bed in Trendelenburg; hold ≥30 s each side
  • Dix-Hallpike tests posterior and anterior canals: torsional upbeat = posterior (→ Epley); torsional downbeat = anterior
  • Supine roll test: lateral (horizontal) canal BPPV → horizontal nystagmus

Imaging & red flags

  • Imaging: CT misses most early posterior circulation strokes; early MRI DWI can be falsely negative
  • Red flags: sudden persistent vertigo, occipital headache, neck pain, 5 Ds, vertical nystagmus, skew
  • Red flags: normal HIT in AVS, hearing loss, truncal ataxia, anticoagulation/trauma, syncope

Bárány Society diagnostic criteria

Vestibular neuritis Probable acute prolonged vascular vertigo BPPV
•    Unidirectional nystagmus

•    ≥24 h; can take weeks for nystagmus to compensate

•    Reduced VOR → positive head impulse

•    No hearing loss or other neurology

•    No skew deviation

 •    Acute vertigo or unsteadiness ≥24 h, AND ≥1 of:

•    Focal central neurological symptoms/signs

•    A central HINTS component, e.g. direction-changing or vertical nystagmus

•    Other ocular-motor abnormality

 •    Recurrent attacks

•    Provoked by lying down or turning over

•    Last < 1 minute

•    Positional nystagmus after a brief latency, or with no latency on the supine roll test

 

Resources: Geeky Medics HINTS Dizzy History Taking Geeky Medics

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4. Lung POCUS

  • Setup: curvilinear probe with lung settings; 8 zones (anterior & lateral, superior & inferior, each side)
  • Normal: bat sign, lung sliding (seashore on M-mode), A-lines, ≤2 B-lines per rib space, lung pulse
  • M-mode: only needed if lung sliding cannot be identified on 2D
  • B-lines: must extend to the bottom of the screen. >2 in >2 rib spaces = interstitial syndrome (bilateral → APO; focal → pneumonia / contusion)
  • Lung point: the only sign that completely confirms pneumothorax.
  • Effusion: anechoic above diaphragm, spine sign (spine visible above diaphragm – normally hidden by aerated lung), sinusoid sign on M-mode
  • Consolidation: hepatisation, shred sign, dynamic air bronchograms
  • Document: views adequate; pleura (sliding, lung point); lung fields (B-lines, effusion, consolidation)

 

Pneumothorax Pneumonia
•    No lung sliding / barcode sign

•    Lung point

•    A-lines, no B-lines

 •    Effusion

•    Unilateral (focal) B-lines

 

BLUE protocol

LITFL Lung POCUS
Geeky Medics Lung USS

 

New Education Registrars

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Please welcome Vanessa Vasconcelos and Rob Walker, both SRs completing their Emergency Medicine training here in WA.

Vanessa is a PGY9 registrar originally from Portugal by way of Wimbledon. She trained at UCL in London before completing her Acute Care Common Stem (EM) and MRCEM in the South West of England, followed by a year as a retrieval registrar in the NT. Outside of work, she’s an avid 4-wheel driver who loves exploring remote locations — and she’s a devoted Friends fan. She is a self-proclaimed Monica wishing she was Rachel.

Rob is a PGY11 registrar hailing from “bonny” Scotland. He began his ED career in Edinburgh and Glasgow before heading to the South West of England to complete his ACCS(EM). Rob also served as a British Army officer, starting out in an infantry regiment before transitioning into a medical role. He finished his military service in the British Army’s specialist retrieval regiment. Under duress Rob has identified as Phoebe.

Having both since seen the light, Vanessa and Rob made their way to WA to complete their Emergency Medicine training.

ECG of the Week 28/5/25

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Today’s ECG is from a 75yr old male patient. You have been handed over an EAU chest pain patient, the nurse hands you the following ECG and asks you if you are happy to discharge the patient given he is now pain free and has negative troponins.

Of course, as part of your assessment you compare to his initial ECG 3hrs ago when he had 5/10 central chest pain

What are you going to do?

VBG of the week 14 May 25

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The following patient was found collapsed outside a warehouse. What is his diagnosis and management?

ph            7.26
pCo2            49
pO2             22
HCO3            22
Base Xs         -5
Sample type: Venous

Na             146
K              4.1
Cl             112
IonCa          1.1
Creatinine      88
Hb             137

Glucose        5.9
Lactate        3.8

Carboxy Hb     0.7
Met Hb         42.2

ECG of the week 30/4/25 “Doc is my pacemaker pacing properly?

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This week we have a series of 3 ECGs from separate patients. These patients all had the same question. “Doc is my pacemaker pacing properly?”

Patient 1 78yr female presents following a mechanical fall. Her CXR shows likely left side nondisplaced rib fractures. The patient is worried that the fall may have dislodged the pacing leads. What will you tell her?

Patient 2 is a 65yr female who presents with chest pain. What is on her ECG?

Patient 3 75yr female presents with renal colic and complains of chest palpitations during periods of pain. Her ECG is below:

They say things come in 3s, I hope you enjoy todays trifecta of ECGs!