Category: Medical

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

 

Rabies [notifiable disease]

Recent Incident: Bat contact was not recognized (effectively touching a bat without gloves means treatment is recommended)

Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in  “Rabies-Free” counties the bat population posse a risk.

In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.

Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.

Risk Assessment

To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]

Exposure Category

Combined Country/Animal & Exposure Risk

Treatment

Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.

If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)

 

You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]

Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400

 

 

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Pulmonary Embolism – PE

PE is somehow both the most over and under diagnosed condition. with severity ranging from the questionable sub-segmental PE to the Massive PE (an indication for thrombolysis). So think:

  • Does this presentation sound like a PE? – If not STOP here
  • Pregnant?  – Click Here
  • Do you think this is likely a PE? (if so you can’t use PERC)
  • Does D-Dimer answer  your question? (whats the Wells)
  • Massive PE  – think Thrombolysis
  • Sub-Massive PE – there is lots of debate (involve seniors), locally needs 2 consultant sign off and not considered time critical.

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Malignant/Accelerated Hypertension

There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)

Patient has both:

  1. Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
  2. End-Organ Damage: Retinal Changes, Encephalopathy, Heart Failure, Acute Kidney Injury, etc.

Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.

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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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Hypernatraemia

Hypernatraemia is a not a common presentation in ED, as intense thirst often prevents significant hypernatraemia in neurologically intact individuals. So… Mortality rates are high (20-70%) and the severity of hypernatraemia has been shown be an independent predictor of mortality.

However, there is little good data on hypernatremia to base guidance on, and definitions vary within the literature

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