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1. HAZMAT – First Contact

REMOVE – REMOVE – REMOVE

Remove Them..

At reception ask them to go outside to designated area and staff will be with them shortly. Inform Nurse in Charge!

Remove Clothes..

Use the disrobing card to get the patient to safely remove and bag up clothes. Do your best to maintain privacy. CARD HERE

Remove Substance..

If we have ample warning or the number of patients will be significant, it may be worth deploying the decontamination tent but remember setting this up is time consuming.

Pulmonary Embolism in Pregnancy

Unfortunately the the normal pathway for investigation of PE performs poorly in pregnancy RCOG have the following pathway

1. Investigation – of suspected PE

  • Clinical assessment – its all on the history and exam scoring doesn’t work
  • Perform the following tests:
    • CXR – sheilding can protect the baby and may avoid further radiation
    • ECG
    • Bloods: FBC, U&E, LFTs, Clotting
  • Commence Tinzaparin (unless treatment is contraindicated – use booking weight to calculate dose) –[BNF]

 

VTE prophylaxis in lower limb Immobilisation (ED – 2023)

In the Emergency Department (ED) lower leg immobilisation after injury is a necessary treatment but is also a known risk factor for the development of venous thromboembolism (VTE). This accounts for approximately 2% of all VTE cases which are potentially preventable with early pharmacological thromboprophylaxis.

Read more

Bell’s Palsy

Bell’s Plays is a lower motor neurone (LMN) lesion of the facial nerve (CN VII), which causes one side of the face to “droop” [1% of cases are bilateral], and patients are often concerned that it is a stroke.

However, unlike in stroke the whole face is affected, in stroke and other upper motor neurone (UMN) lesions the upper portion of the face is unaffected due to input from both sides of the brain. Read more

Hypoglycaemia – Adult

Hypoglycaemia (Blood glucose under 4.0 mmol/l) is potentially fatal and should be treated. it may be defined as “mild” self-treated, or “severe” treated by a third party i.e. you.

Hypoglycaemia is a common side-effect of insulin and sulfonylureas (they start with gli-) as they both work by lowering glucose concentration in the blood. Other diabetic medications work by preventing glucose rise, thus posing a lesser risk.

 

Signs & Symps

  • Autonomic: Sweating, Palpitations, Shaking, Hunger
  • Neuroglycopenic: Confusion, Drowsy, Odd behaviour, Incoordination, Speech difficulty
  • General: Nausea, Headache

Risk Factors

  • Medical: 
    • Diabetic: Strict control, Long term Insulin, Lipohypertrophy at injection sites,Impaired awareness of hypoglycaemia
    • Organ dysfunction: Severe hepatic dysfunction, Renal impairment, Cognitive dysfunction/dementia, Endocrine (Addisons, hypothyroid, hypopituitary)
    • GIT: Gastroenteritis, impaired absorption, Bariatric surgery
    • Medication: Concurrent use of medicines with hypoglycaemic agents e.g. warfarin, quinine, salicylates, fibrates, sulphonamides (including cotrimoxazole), monoamine oxidase inhibitors, NSAIDs, probenecid, somatostatin analogues, SSRIs.
    • Sepsis
    • Terminal illness
  • Lifestyle:
    • Reduced/Irregular intake: Poor diet, Irregular lifestyle, Alcohol
    • Increased use: Exercise (relative to usual), Early pregnancy, Breast feeding
    • Poor control: Increasing age, No or inadequate blood glucose monitoring, Alcohol

Treatment

Conscious & Orientated

  1. 15-20g fast acting glucose
    • 4-5 jelly babies
    • 3-4 heaped teaspoons of sugar dissolved in water (milk delays absorption)
    • 150-200ml fresh fruit juice
  2. Rpt Blood Glucose 10-15min
    • if blood glucose remains <4.0mmol/l step one may be repeated up to 3 times in total
  3. Blood Glucose remains <4.0mmol/l
    • 150-200ml 10% Glucose IV
    • 1mg Glucogon IM (if starved or sulfonylureas may not work well)
  4. Blood Glucose >4.0mmol/l – Give long acting Carbs
    • 2 Biscuits
    • 1 Slice bread/toast
    • 200-300ml milk (not soya)
    • Meal
  5. Don’t omit insulin injections
  6. Diabetic review: most patients can be followed up by diabetic nurses but some may need admission.
  7. Patient Advice Sheet

Conscious but agitated, confused, unable to cooperate

  • If patient CAN cooperate – follow guide above
  • If patient CAN’T cooperate
    • 1.5 -2 tubes 40% glucose gel (Glucogel) squeezed into the mouth between the teeth and gums (can be substituted for step 1 above)
    • 1mg Glucogon IM (if starved or sulfonylureas may not work well)
    • Follow subsequent steps as above

Unconscious, seizures, very aggressive

Start at step 3 above (while managing ABC), the choice of whether to use IV glucose or IM glycogen will be determined by practicality of achieving IV/IO access.

Although you will need to follow the remaining steps the patient will almost certainly require admission.

 

Reference

Patient Advice Sheet – Hypo’s

Joint British Diabetic Society – The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus 3rd edition

 

 

Hypokalaemia

Hypokalaemia (low potassium), is a common problem. It is found in 14% of outpatients and 20% of inpatients, however only 4-5% of those are of clinical significance.

Severity

  • Severe: <2.5 mEq/l OR Symptomatic – Look for Hypomagnesaemia
  • Moderate: 2.5-2.9 mEq/l (No or Minor symptoms)
  • Mild: 3.0-3.4 mEq/l  (Usually asymptomatic)

Read more

Emergency Tracheostomy/Laryngectomy Management

Occasionally patients with Tracheostomy or Laryngectomy present with difficulty breathing due to problem. As this is rare for us in ED, this situation can be very difficult for all of us. However the protocols below can help.

 

Tracheostomy

Tracheostomy is simply a passage from the neck into the trachea. In most cases the trachea will still be connected to the nose and mouth (so can breath though their mouth too).

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Lateral Canthotomy

Like tension pneumothorax the biggest step is deciding to do it – Remember it it sight saving and they heal well

Retrobulbar Haematoma secondary to blunt eye injury is a a rare but potentially sight threatening injury.

  • Blood collects in the retrobulbar space
  • Pushing the eye forward to accommodate the extra volume.
  • The Orbital Septum (made up of the eyelids and ligaments that attach them to the orbital rim) restricts this forward movement, creating a compartment syndrome for the eye. Thus threatening the patients sight if not treated quickly.

Recognition

From Royal College Ophthalmologists

  • Severe pain
  • Red/Congested conjunctiva
  • Exophthalmos with proptosis – eye pushed forward
  • Internal ophthalmoplegia – impairment or loss of the pupillary reflex.
  • Visual flashes
  • Loss of vision – initially colour vision (esp. red), progressing to local visual loss.

However, this may only be recognised on CT if there is significant facial injury and altered conscious level.

Treatment

Call Ophthalmology immediately to attend. If there is going to be any significant delay, it may be necessary for ED to preform a Lateral Canthotomy, to allow the eye to move forward, reduce the orbital pressure & preserve the patients sight.

Kit needed

  • Lidocaine with adrenaline (needle & syringe)
  • Clamp – ideally curved to crush the tissues
  • Forceps
  • Scissors

Resources