Category: Learning

Silver Trauma

The population is ageing and thus our ‘typical’ trauma patient is also changing. In 2017 the TARN report “Major injury in older people” highlighted the following issues:

  • The typical major trauma patient: has changed from a young and male to being an older patient.
  • Older Major Trauma Patients (ISS>15): A fall of <2m is the commonest mechanism of injury
  • Triage/Recognition of ‘Silver Trauma’ is POOR
    • Pre-hospital: Not identified hence taken to TU’s (Here) not MTC’s (Leeds).
    • The ED: Often seen by Junior Staff and endure significant treatment delays.
    • Hospital: Much less likely to be transferred to specialist care.
    • Outcomes: More likely to die, but those who survive have similar levels of disability to younger people.

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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

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?

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Tetanus – Wounds

Tetanus prone and High Risk definitions

Immunisation schedule

  • Primary: 2, 3 & 4 months old
  • Boosters: 3½ – 5yrs and 13-15yrs

Warning:

  • Immunisation only started nationwide in the UK in 1961 (people born before 1961 are unlikely to have completed a primary course)
  • Immunocompromised patients are unlikely to produce adequate antibodies
  • Immediate reinforcing dose of vaccine – these patients are expected to have a rapid response to vaccine dose conferring protection

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Mpox (Formerly: Monkeypox)

Wear Gloves & Wash Your Hands!!!

There have been >100 patients identified as having Mpox in the UK during the current outbreak. Most of these cases have been amongst men who have sex with men.

Reports have suggested that although lesions occur any where including palms and soles. Genital lessons and lymphadenopathy are very common

March 2024 – UKHSA warn there is increasing cases in DRC (Democratic Republic of Congo), so stay vigilant in travellers from central Africa.

 

Trust SOP -HERE

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