Category: Learning

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 may need help! Speak to pharmacy if support required.

CHFT Guideline

Calculate patch dose using trust guideline (hyperlinked above). Combine doses for patient on frequency not available. For example on five times day dosing combine BD an TDS dosing. If you need any assistance calculating the dose, please speak to pharmacy for advice.

NOTE: Most Parkinson’s medications now stocked in ED

LA – Toxicity

We are regularly doing 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

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: Quick Reference Handbook – Guidelines for crises in anaesthesia

 

Acute Behavioural Disturbance / Excited Delirium

Most of us will have seen patients like this – agitated, aggressive and often with police or security pinning them down.

  1. High risk of Cardiovascular Collapse/Death – likely due to adrenaline surge, heat exhaustion and injury. It can happen very suddenly.
  2. Keep physical restraint to a minimum – Don’t allow patient to forced face down, it’s the most likely way of killing them.
  3. Tranquilisation vs Sedation – Obviously oral tranquillisation is our first step, however, this is not always practical and needs to have a senior review and dynamic risk assessment .
  4. Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC

Refusing treatment = Mental Capacity Assessment [LINK]


The Trust Guide: Rapid Tranquillisation give a full in-depth guidance on tranquillisation and steps leading up to this. It also outlines alternative oral and IM medications.

RCEM -abd  Provides more in-depth guidance on those patients heading toward sedation

 

 

Acute Heart Failure (AHF) – ESC

Patients presenting with AHF have a high mortality 4-10% in-hospital and 25-30% at 1yr, and 45% if re-admitted. So rapid diagnosis a treat is essential.

AHF Triggers

there are many triggers for AHF, which if recognized and treated with help improve outcomes

  • Cardiac: ACS, Arrhythmia, Aortic Dissection, Acute Valve Incompetence, VSD, Malignant Hypertension
  • Respiratory: PE, COPD
  • Infection: Pneumonia, Sepsis, Infective endocarditis
  • Toxins/Drugs: Alcohol, Recreational drugs, NSAIDs, Steroids, Cardiotoxic meds
  • Increased Sympathetic Drive: Stress
  • Metabolic: DKA, Thyroid dysfunction, Pregnancy, Adrenal Dysfunction
  • Cerebrovascular Insult

ESC Guide – 2021 Heart Failure

Presentations

Decompensated Heart Failure

Isolated Right Vent-Failure

Pulmonary Oedema

Cardiogenic Shock

Managment

Treatment – Time Matters!!!

  • Mortality increased by 1%/hour IV treatment not started

Treat The Cause!: If you can identify the trigger treat it it will in turn improve the AHF. (e.g. AMI, Arrythmia(Tachy/Brady), Massive PE)

Oxygen
  • Not all patients should be given Oxygen ESC suggest maintain SaO2 >90%
  • Early NIV is suggested if any of:
    • RR >25bpm or SaO2 <90% despit oxygen
    • Signs type 2 respiratory failure

Metanalysis suggests early NIV may reduce need for intubation and improve mortality

NIV Guide-HERE

Diuretic

Vasodilator

Inotropes

Mental Capacity Act (2005)

Applies to all over 16’s

Principles

  1. Everyone is presumed to have capacity – until a lack of capacity has been established
  2. 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)
  3. People are free to make an unwise decision
  4. Anything done under the act MUST be in the patients best interest
  5. Carefully consider what is the least restrictive option

Read more

Hyperosmolar Hyperglycaemic State (HHS)

HHS (A.K.A. HONK) is a diabetic emergency, but unlike DKA we don’t always think about it.

Patients with HHS are often elderly with multiple co-morbidities, and they are always very sick.

Definition

  • Hypovolaemia
  • Hyperglycaemia – generally ≥30mmol/l
  • High Osmolality – generally ≥320mosmol/kg (Osmolality Calculation= 2[Na] + [Glucose] + [Urea])
  • & NOT:
    • Acidotic – pH >7.3, HCO3 >15mmol/l
    • Ketotic – blood <3mmol/l, Urine <2+

Read more

Hyponatraemia

Hyponatraema is a common finding, especially within our elderly population. However, its significance is is not a simple numbers game, and needs senior input. Prior to treatment the following need to be considered and balanced.

  1. Symptoms Severity – these are not exclusive to hyponatraemia and may be due to other disease processes (esp. if the low sodium is long-term)
  2. Sodium Level – the sodium concentration doesn’t always correlate to the clinical picture, and is dependant on speed of change, and co-morbidities
  3. Rate of Drop – the faster sodium levels drop the more symptomatic the patient often is (i.e. with long term hyponatraema the patient may be profoundly hyponatraemic but asymptomatic)
  4. Co-morbidities – Increasing sodium too quickly risks osmotic demyelination. How well will the patient cope with treatment?

Emergency treatment (hypertonic saline) is generally indicated in those with Severe/Moderately Severe Symptoms ONLY

Read more

#NoF – Fractured Neck of Femur

BOAST Guidance

  • #NoF patients (or other fragility fracture) who requiring CT Head (for head injury) also be performed a CT Neck
    • Fragility fractures indicate the patient is at high risk of also sustain C-Spine injury.
    • Also the pain is likely distracting and the patient is often over 65yrs old so Canadian C-Spine rules will not apply.

Hx/Exam

  • Why did They Fall? – was this a collapse?
  • Are they sick? – Co-morbidity/illness is common in this group and must be recognised
  • Anticoagulants? – This affects treatment
    • On Warfarin – If INR >1.5 (or unavailable) Vit-K 5mg
  • Other injuries? – >65’s the most common mechanism of TARN major trauma is fall <2m
  • Typically – Pain hip/buttock, shortened, externally rotated
  • Atypical – Few signs (can they lift their leg & is rotation at the hip painful)

Read more