Category: Haem/Onc

2 Week Wait – from ED

Non-Site-Specific Service

The non-site-specific service is an excellent service for the investigation of suspected cancer within 2 weeks.

  1. Primarily NSS accept referrals for Cancer of Unknown Primary – if imaging suggests a cancer and the primary site is not clear clinically or radiologically.
  2. NEW: To improve cancer diagnosis from ED – they will also facilitate referrals to the site specific teams if we in ED identify the primary.

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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.

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Lower Limb DVT

Signs and Symps

No single feature is diagnostic:

  • Single limb oedema – Most specific
  • Leg pain – 50% but is nonspecific
  • Calf pain on dorsiflexion of the foot (Homan’s sign)
  • Tenderness of deep veins – 75% of patients
  • Warmth AND/OR erythema (although blanching is possible)
  • A palpable, indurated, cordlike, tender subcutaneous venous segment

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Massive Transfusion Pathway

In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MTP

Remember:

  • Do the Basics – don’t forget ABCD
  • Inform Transfusion and get someone to run a G&S sample down
  • FFP can take up to 45min and platelets come from Leeds
  • If you no longer need the MTP – inform transfusion and return products ASAP
major haemorrage

PDF:MTP

 

COVID-19 Vaccine Induced Thrombosis/Thrombocytopenia (VITT)

Inclusion Criteria [Both of]:

  1. Received AstraZeneca (AZ) COVID 19 vaccination within 42 days (typically 5-42 days from immunisation)
  2. New Onset thrombocytopenia (PLTs <150×109/L) – with or without Thrombosis
    • 5% of cases have had a “Normal” Platelet count at presentation
      • High index of suspicion repeat bloods next day
      • ‘High index of suspicion’ in this context is day 5- 28 post AZ vaccine with new onset headache or abdominal pain which is atypical and severe in nature.

Initial Investigations:

  • FBC– specifically to confirm thrombocytopenia <150x 109/L
  • Coagulation screen and D Dimers
  • Blood film to confirm true thrombocytopenia and identify alternative causes

PROBABLE CASE: (ALL 3 criteria)

  1. Received AZ COVID 19 vaccination within 42 days
  2. New Onset thrombocytopenia (PLTs <150×109/L)
  3. D Dimers > 2000 mcg/L

URGENT Scan to confirm the suspected clot.

[If patient doesn’t fit “PROBABLE CASE” proceed to usual treatment]

Condition specific advice:

Central clot:

  • inc. Cerebral Venous Sinus Thrombosis (CVST), Pulmonary Embolis (PE), Splenic, Proximal DVT
  • Discuss with Haematologist
  • Admit Medicine

Suspected DVT (scan unavailable):

  • Treat with Rivaroxaban (Do Not use Tinzaparin/LMWH)
  • Request Ultrasound
  • Return AAU Next Day
  • Safety-net Advice

Confirmed Distal DVT (Not above inguinal ligament)

  • Platelets  <100×109/L – Discus with Haematology
  • Platelets ≥100×109/L – Treat as normal

Thrombocytopenia only

  • Platelets  <100×109/L – Discus with Haematology
  • Platelets ≥100×109/L – Treat as normal

Treatment (will be directed by Haematology & Specialist teams):

Avoid:

  • Heparin Based anticoagulants
  • Antiplatelets
  • Platelet Transfusion

May Require:

  • IV immunoglobulin
  • Steroid
  • Anticoagulation with: DOAC, Fondaparinux, Argatroban

Further reading

 

Methaemoglobinaemia

Q: Why are Smurf’s Blue? 

A: Methaemoglobin (MetHb) of course!

– MetHb is produced by oxidisation of the Iron in Haemoglobin (Hb) from Fe2+ to Fe3+

– Fe3+ prevents Hb carrying oxygen (thus produces symptoms of hypoxia)

– Often due to chemical ingestion, but may also be genetic

– Treated with Methyl Blue & supportive measures

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