Background
- Cardiac arrhythmias are relatively common presentations to ED.
- There are many causes, some more sinister than others.
- If your patient is not acutely unwell then expert advice may be required.
Category: Learning
Bradycardia
Causes
- Cardiac: Heart Block, Myocardial infarction, Myocarditis
- Metabolic: Hypothermia, Hyperkalaemia, Hypokalaemia, Hypothyroid, Hypoxia
- Toxin: digoxin, B-blocker
Treatment
For ALL conditions leading to bradycardia treating the underlying condition is the most appropriate treatment and for some the only thing that will work (i.e. severe hypothermia) Read more
Bronchiolitis
Quick Ref Guide
Actions
- Green – Send Home: Provide appropriate and clear guidance to the parent / carer and refer them to the patient advice sheet.
- Amber – Advice from Paediatrician should be sought and/or a clear management plan agreed with parents.
- Red – Move to Resus IMMEDIATE Senior/Paediatiric assessment
Proximal Myopathy/Muscle Weakness
The Case
An elderly patient attends the ED with difficulty mobilising, Nursing staff tell you that the patient needs a CT head for STROKE? – “They are really unsteady if they try to stand and they can’t lift their arms up”. Read more
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
DKA in Kids
Diabetic Ketoacidosis – remember in paediatrics this may be the 1st presentation of diabetes.
- Fluid – are more considered that adults due to the risk of cerebral oedema
- Insulin – WAIT – need 1hr of fluid first
- Paeds – involve them early
DKA Management Calculator (recommended by paediatrics)- HERE
Mental Capacity Act (2005)
Applies to all over 16’s
Principles
- Everyone is presumed to have capacity – until a lack of capacity has been established
- All practical efforts have been made to help patient make a decision
- Explain decision and options as clearly and concisely as possible (be flexible)
- Make every effort to help the person understand (language line, writing, etc.)
- Are there others who might help them understand? (nursing, medical, family, freinds)
- People are free to make an unwise decision
- Anything done under the act MUST be in the patients best interest
- Carefully consider what is the least restrictive option
Cervical (Carotid OR Vertebral) Artery Dissection
Cervical artery dissection is a rare but significant cause of stroke and headache/neckache, which is easy to overlook. Leading to a typically delay in diagnosis of 7 days. Unfortunately imaging the cervical arteries is not simple, with MRA being the method of choice. Hence these patients must be referred to the “Stroke Consultant”.
Major Incident/MAJAX Guide
NHS England have published this fantastic resource [Click here] covering Major Incidents including; gunshot, crush, nerve agents and much more.
This is not to replace our trusts “Major Incident Plan”, however its a great learning resource and worth going through Read more
LA – Toxicity
We are regularly doing femoral blocks next to major vessels. So warn the patient of the symptoms, & keep them monitored(at least 15 min).
Symptoms of local anaesthetic toxicity
- Circumoral and/or tongue numbness
- Metallic taste
- Lightheadedness/Dizziness
- Visual/Auditory disturbances (blurred vision/tinnitus)
- Confused/Drowsiness/Fitting
- Arrhythmia
- Cardio-Resp Arrest
Remember – Do basics WELL
Intralipid – in antidote cupboard (Green Majors treatment room)
-
- Bolus – 1.5ml/kg 20% lipid solution over 1min
- Then start Infusion – 15ml/kg/hr 20% lipid solution
- 5 mins reassess if Cardiac instability/deterioration
- Rpt Bolus 1.5ml/kg over 1min (max 3 boluses inc. initial)
- Increase infusion rate – up to 30ml/kg/hr
- Total Max dose 12ml/kg
Propofol is not a suitable substitute for lipid emulsion
Without Cardio-Resp Arrest
Use conventional therapies to treat:
- Seizures
- Hypotension
- Bradycardia
- Tachyarrhythmia (Lidocaine should not be used as an anti-arrhythmic therapy)
In Cardio-Resp Arrest
- CPR – using standard protocols (Continue CPR throughout treatment with lipid emulsion)
- Manage arrhythmias – using standard protocols
- Consider the use of cardiopulmonary bypass if available
- Recovery from LA-induced cardiac arrest may take >1 h
- Lidocaine should not be used as an anti-arrhythmic therapy
PDF:la_tox
