Author: embeds

Hypothermic Arrest [Adult]

True Hypothermic Arrest is thankfully rare in the UK. However, when it does happen it is resource intense and prolonged. The ERC 2021 guidance has introduced a new decision step HOPE score to the algorithm, once the Initial phase of resuscitation has been completed without ROSC.

If the is HOPE score is <0.1  the team may which to consider terminating CPR [Warning: Adults ONLY Children have better survival] Read more

Nitrous Oxide Induced Neurotoxicity

Nitrous Oxide  has been used clinically and recreationally since its discovery in 1772. Since then Nitrous Oxide induced neurotoxicity have been reported, and has been shown to be dose depaendant. With infrequent users unlikely to be at risk of neurotoxicity, while heavier and habitual used at risk of serious neurological conserquences.

With the increase in recreation use of “Whippits” we need to remember to take a detailed recreation drug history when seeing patients presenting to ED with neurological symptoms. As Nitrous Oxide induced neurotoxicity is treatable.

Presentations

Nitrous Oxide induced neurotoxicity can present as either spinal cord demyelination , peripheral neuropathy or a a combination of the two.

  • Demyelination of the dorsal columns of spinal cord 
    • Typically onset is subacute  (i.e. weeks), but acute onset has been reported in the literature
    • Typically symmetrical but can be unilateral
    • Signs
      • Pyramidal weakness – weak upper limb extensors, and lower limb flexors
      • Dorsal Column Sensory loss – Vibration, Proprioception, Fine touch
      • Sensory Ataxia – Incoordination due to loss of proprioception and weakness
    • Level – Most frequently cervical 4-6 levels, but can affect any.
  • Peripheral Neuropathy
    • Typically Symmetrical (but not always)
    • Sensory loss (often painful)
    • Distal Weakness
  • Optic Neuropathy  – has been reported and may present with visual disturbance.

Pathophysiology

Nitrous Oxide usage can render vitamin B12 inactive, which in-turn disrupts myelination, causing the demyelination of nerves.

Differentials

  • Deficiencies: B12, Folate, copper, zinc
  • Inflammatory: Guillian-Barre syndrome, MS, Neurosarcoidosis
  • Infection: HIV, Syphilis
  • Cancer
  • Vascular: Spinal cord ischaemia, vasculitis

Tests

  • Vitamin B12 level (often in normal range)
  • Homocysteine and Methylmalonic Acid Level (not available in ED)
  • MRI – contrast enhanced

Treatment

Start before Tests are back (i.e. on clinical suspicion)

  • IM Vitamine B12 1mg OD
  • PO Folic Acid 5mg OD

Follow-up

  • Discuss admission with Medical team as potential for SDEC management
  • Treat until clinical improvement(King’s Team noted the following)
    • Sometimes treat for 5-7days only
    • Often switch to alternate days IM Bit B12
    • Can teach to self administer
  • Further Testing
    • Homocysteine and Methylmalonic Acid levels – often improve quickly
    • MRI often lags clinical improvement endnote necessary to repeat
  • Majority Improve clinically – but futureabstinence is often challenging

 

References

Humeral Brace – Application

Inclusion Criteria – All closed neurovascular intact adult humeral shaft fractures

Exclusion Criteria – Intra-articular fractures of either the proximal or distal humerus, and surgical neck of humerus.

Please note that the supplier/manufacturer of these braces can change from time to time. Please always consult the information provided with the brace, especially for sizing advice.

Read more

Haematoma Block – Colles’

Haematoma blocks can be a safe and effect method of pain relief to facilitate reducing Colles’ fractures.

It is also worth considering Penthrox as an alternative.

What to give?

  • 1% Lidocaine
    • Onset 10-15min
    • Offset up to 2hr
  • 3mg/kg (maximum dose)
    • 70kg patient could have up to 210mg
  • Volume 1% Lidocaine = 10mg/ml 
    • 70kg = 210mg / 10 = 21ml
  • Signs of TOXICITY 
    • Sensory Disturbance: Facial tingling,  Numbness, Metallic taste, Tinnitus, Vertigo
    • Functional Disturbance: Slurred speech, Seizures, Reduced GCS
    • Cardiovascular: Hypotension, Palpitations
    • Treatment – ABCD, see LA-Toxicity [HERE]

Asepsis

Remember you are putting a needle into a sterile fracture and bone infection never ends well.

  • Chloro prep or Betadine – ensure it has time to dry
  • Sterile field
  • Sterile Gloves (particularly when learning)
  • No-Touch technique (Only if proficient)

Method

a. Insertion

  • Find fracture site – move approx. 1cm proximally
  • Insert needle – bevel down & at approx. 30°, towards the fracture
  • Hit bone & slide – forward into the fracture
  • Aspirate – you should be able to aspirate some blood, but not always (however, its should not flow too easily, if it does are you in a vessel?)
  • Inject –  this often needs a bit of pressure, infiltrate approx. 1/4 of the volume.

b. Fanning (this is not always necessary but seems to improve outcome)

  • Withdrawal needle a little – keeping it under the skin.
  • Change angle & advance – into the fracture
  • Aspirate and Infiltrate – more lidocaine
  • Repeat – do this several times so you have walked needle across the fracture (Use approx. 1/2 the lidocaine)

c. Ulna styloid (Only needed if fracture or tender)

  • Find Ulna styloid
  • Insert needle – straight onto the styloid
  • Aspirate
  • Inject – you are not normally going into the fracture but leaving a bolus approx.1/4

Give the patient 10-15min while you set up for reduction for it to achieve peak effect –  then check how its working. (getting the patine to move their wrist is a good test)

 

ENP’s – DOP’s forms can be found here

Parkinson’s Disease & can’t swallow

We all recognise the importance of ensuring patients with Parkinson’s disease (PD) get their medication, but..

What do you do if the patient can’t swallow?

We will need to work out what alternative routes we could use, for example dispensable via NG or patches, and what dose. For an ED clinical it is most likely beyond us and we need help! However, that may be extremely difficult to get especially Out of Hours

https://www.parkinsonscalculator.com/calculator2-withoutNG.htmlpdmedcalc

Excellent website that can give you options – select the patients normal regime (initially just one line but you can add as many as needed) and press calculate.  It gives you a dispensable and patch dose, which can help the discussion with pharmacy about where we can get it

Syncope – ESC 2018

  • Defintion:Transient Loss of Consciousness (TLOC) due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery.
  • Common ED Complaint: 1.7% of all attendances
  • Difficult Diagnosis: less than 50% get a diagnosis in ED
  • Mortality & Serious Outcome: 0.8% mortality & 10.3% serious outcome @ 30 days

Ask 3 Questions!

  1. Is this Syncope?
  2. What is the underlying cause?
  3. What is the best Follow-Up for this patient?

Read more

Self-Discharge

Still in the ED

Left ED

  • Assess the risk, do we need to:
  • Inform Nurse-in-Charge
  • Add to handover board if actions are required by the in-hours team
Searchs: abscond, absconded, did not wait, didnt wait, didn’t wait

VFC/Orthopedic – Trust Treatment & Follow-Up

Select the appropriate body area for guidance table

No Spinal injuries, back pain, Cauda Equina, foot drop etc to be referred to VFC
 

Patients that will not be suitable & need a “face-to-face” as below

  • Homeless patients
  • Prisoners
  • Non English Speaking Patients
  • Inpatients
  • Patients with Hearing Difficulties
  • Phoneless Patients
  • Injuries Associated with Domestic or Child Abuse
  • Children under 2 Years of Age
Upper Limb

Lower Limb

5th MT zones