Author: rebecca isles

Concealed Illicit Drugs

Background

Those suspected of concealing illicit drugs often present near ports and borders however they can present to any ED or be brought in by the police.

Body Packers – Swallow large quantities of well packaged drugs to smuggle them into countries or institutions.  These are often well manufactured with a low risk of rupture but the potential for serious toxicity if rupture occurs.

Body Stuffers – Swallow small quantities of poorly packaged illicit substances often at the point of arrest to conceal them. These have a much high risk of package rupture but involve smaller quantities of substances.

 

Investigations

Authorisation for an intimate search or radiological investigation must come from an inspector or higher with written consent from the patient.

Intimate searches must be carried out by a police surgeon but require immediately available resuscitation facilities therefore may be conducted in the ED. ED physicians should not handle the drugs at any time.

AXR or low dose CT scanning can be used to detect concealed packages in Body Packers.

 

General Management

Try to obtain a history of what and how much has been concealed

Look for toxidromes suggestive of package leak –

  • Cocaine: Tachycardia, hypertension, agitation, diaphoresis, dilated pupils, hyperpyrexia, seizures, chest pain, arrhythmias and paranoia.
  • Heroin: pinpoint pupils, respiratory depression, decreased mental state, decreased bowel sounds
  • Amphetamines : – Nausea, Vomiting, Dilated Pupils, Tachycardia, Hypertensions, Sweating, Convulsions and the development of non-cardiogenic pulmonary oedema

ECG

Body Stuffers should be observed for signs of toxicity for a minimum 6 hours, consider activated Charcoal

Body Packers with positive imaging who are asymptomatic can be discharged back to police custody for monitoring. Bowel preparation such as Cleanprep or movicol can be used.

Toxidromes should be treated as per toxbase guidelines Toxbase

Body Packers with signs of cocaine or amphetamine toxicity or signs of obstruction/ileus require urgent surgical intervention.

Body packers with signs of Heroin toxicity should be treated with Naloxone infusion as per toxbase guidelines

 

Algorithms

 

 

Full RCEM Guide

Primary Intracerebral Haemorrhage

In anybody who there is suspicion of a non-traumatic haemorrhage arrange an urgent CT Head.

All patients need IV access and  U&E, FBC, Coag

If CT confirms PICH (not traumatic, not SAH): –

Anticoagulation

If anticoagulated with warfarin or NOAC discuss with stroke consultant and Haematologist regarding reversal

If not anticoagulated give Tranexamic acid – 1g in 100mls Saline/Glucose over 10 mins followed by 1g in 250mls Saline over 6 hours.

Blood Pressure

BP needs to be <150/80 – use labetalol (max 400mg – until BP <160 or HR <50) and GTN infusion

Neurosurgical Referral

Not all patients with intracerebral bleeds need referral to neurosurgery – you could save yourself and your patient a lot of time and effort!

Those to refer:

  • GCS 9-12/15 with lobar haemorrhage
  • Isolated intraventricual haemorrhage
  • Hydrocephalus on presentation
  • Rapid deterioration following arrival (gcs drop by 2 points or more in the motor component)
  • Cerebellar bleed

Admit those not going to Neurosurgery to HASU at CRH after discussion with Stroke team

Sore Throat

Background

Acute sore throats are often caused by a virus, last about a week and get better without antibiotics. withholding antibiotics rarely causes complications. Antibiotic stewardship is everyone’s responsibility to prevent resistance developing.

Assessment

Are there any concerns regarding airway compromise?  – If yes – transfer to resus, give high flow Oxygen, IV steroids, IV antibiotics, Nebulised adrenaline 1:1000, IV fluids, take bloods and refer to both anaesthetics and ENT registrar.

Otherwise:

Assess all under 5s  with a temperature as per the NICE fever guidelines

Assess the patient for signs of severe sepsis – if present use the severe sepsis guidelines

If no signs of sepsis assess patient, exclude Quinsey (unilateral swelling, paina nd trismus) and calculate the FeverPAIN score and Centor score

FeverPAIN = 1 point for each of –

  • Fever
  • Purulent tonsillar exudate
  • Attendance within 3 days of onset
  • severely Inflamed tonsils
  • No cough/coryza

Centor = 1 point for each of –

  • Tonsillar exudate
  • Tender anterior cervical lymphadenopathy or lymphadenititis
  • History of fever >38
  • No cough

Treatment

Can the aptient swallow fluids and medication – if not give a stat dose of IV Dexametasone, IV antibiotics, IV fluids and analgesia – review in 2 hours. If they can swallow at this time then you can consider discharge with a patient information leaflet.

FeverPAIN = 0 or 1/ Centor = 0,1 or 2 – no antibiotics, self care advice

FeverPAIN = 2 or3 – no antibiotics or a script for 3-5 days time if no better, self care advice

FeverPAIN = 4 or 5 / Centor 3 or 4 = give Antibiotics immediately, self care advice

Patients to seek medical advice if become more unwell or not improving after 1 week

Self care advice – Paracetamol, Ibuporfen, Adequate fluids, Medicated lozenges

 

 

Antibiotics –

Phenoxymethylpenicillin 5-10 days

If Penicillin allergy – Clarithromycin or Erythromycin 5 days

Tonsillitis Patient Information Leaflet

Full NICE Guidance

 

Search: tonsillitis

Paediatric Mental Health

The provision of out of hours mental health services for Children and young people (under the age of 18) is changing: –

Between 8pm and 9am the onsite Mental Health Liason team (RAID) will see these patients initally and help with the mental health aspects of their care. Between 9am and 8pm contact CAMHS via switchboard as normal.

COVID-19 (Palliative Care)

Some patients who present with COVID-19 infection will be not suitable for escalation and actively dying when they attend the ED, for these patients the best management may be palliative care. The primary symptom that causes distress is breathlessness.

Palliative Care of COVID-19 patients will ideally be provided with a syringe driver and their symptoms well controlled using the standard guidance available via the Kirkwood Hospice Palliative Care Toolkit available HERE – Latest

However if there is no syringe driver available an alternative pathway has been produced

Injectable

Non-Injectable