This is a relatively common presentation within the ED that has a myriad of possible diagnoses ranging from sprain to malignancy. One thing to remember is that patients and relatives will look for a traumatic reason for limb pain, and may link it to minor injuries that would not have caused it. Read more
Category: Learning
Hypercalcaemia
90% of hypercalcaemia is due to either malignancy or hyperparathyroid.
Severity: Adjusted Calcium (Ca)
- Severe: >3.5mmol/l – URGENT treatment (risk of dysrhythmia)
- Moderate: 3.0-3.5mmol/l – PROMPT treatment (maybe well tolerated if chromic)
- Mild: <3.0mmol/l – doesn’t require urgent treatment and often asymptomatic
Bell’s Palsy
Bell’s Plays is a lower motor neurone (LMN) lesion of the facial nerve (CN VII), which causes one side of the face to “droop” [1% of cases are bilateral], and patients are often concerned that it is a stroke.
However, unlike in stroke the whole face is affected, in stroke and other upper motor neurone (UMN) lesions the upper portion of the face is unaffected due to input from both sides of the brain. Read more
Hypoglycaemia – Adult
Hypoglycaemia (Blood glucose under 4.0 mmol/l) is potentially fatal and should be treated. it may be defined as “mild” self-treated, or “severe” treated by a third party i.e. you.
Hypoglycaemia is a common side-effect of insulin and sulfonylureas (they start with gli-) as they both work by lowering glucose concentration in the blood. Other diabetic medications work by preventing glucose rise, thus posing a lesser risk.
Signs & Symps
- Autonomic: Sweating, Palpitations, Shaking, Hunger
- Neuroglycopenic: Confusion, Drowsy, Odd behaviour, Incoordination, Speech difficulty
- General: Nausea, Headache
Risk Factors
- Medical:
- Diabetic: Strict control, Long term Insulin, Lipohypertrophy at injection sites,Impaired awareness of hypoglycaemia
- Organ dysfunction: Severe hepatic dysfunction, Renal impairment, Cognitive dysfunction/dementia, Endocrine (Addisons, hypothyroid, hypopituitary)
- GIT: Gastroenteritis, impaired absorption, Bariatric surgery
- Medication: Concurrent use of medicines with hypoglycaemic agents e.g. warfarin, quinine, salicylates, fibrates, sulphonamides (including cotrimoxazole), monoamine oxidase inhibitors, NSAIDs, probenecid, somatostatin analogues, SSRIs.
- Sepsis
- Terminal illness
- Lifestyle:
- Reduced/Irregular intake: Poor diet, Irregular lifestyle, Alcohol
- Increased use: Exercise (relative to usual), Early pregnancy, Breast feeding
- Poor control: Increasing age, No or inadequate blood glucose monitoring, Alcohol
Treatment
Conscious & Orientated
- 15-20g fast acting glucose
- 4-5 jelly babies
- 3-4 heaped teaspoons of sugar dissolved in water (milk delays absorption)
- 150-200ml fresh fruit juice
- Rpt Blood Glucose 10-15min
- if blood glucose remains <4.0mmol/l step one may be repeated up to 3 times in total
- Blood Glucose remains <4.0mmol/l
- 150-200ml 10% Glucose IV
- 1mg Glucogon IM (if starved or sulfonylureas may not work well)
- Blood Glucose >4.0mmol/l – Give long acting Carbs
- 2 Biscuits
- 1 Slice bread/toast
- 200-300ml milk (not soya)
- Meal
- Don’t omit insulin injections
- Diabetic review: most patients can be followed up by diabetic nurses but some may need admission.
- Patient Advice Sheet
Conscious but agitated, confused, unable to cooperate
- If patient CAN cooperate – follow guide above
- If patient CAN’T cooperate
- 1.5 -2 tubes 40% glucose gel (Glucogel) squeezed into the mouth between the teeth and gums (can be substituted for step 1 above)
- 1mg Glucogon IM (if starved or sulfonylureas may not work well)
- Follow subsequent steps as above
Unconscious, seizures, very aggressive
Start at step 3 above (while managing ABC), the choice of whether to use IV glucose or IM glycogen will be determined by practicality of achieving IV/IO access.
Although you will need to follow the remaining steps the patient will almost certainly require admission.
Reference
Hypokalaemia
Hypokalaemia (low potassium), is a common problem. It is found in 14% of outpatients and 20% of inpatients, however only 4-5% of those are of clinical significance.
Severity
- Severe: <2.5 mEq/l OR Symptomatic – Look for Hypomagnesaemia
- Moderate: 2.5-2.9 mEq/l (No or Minor symptoms)
- Mild: 3.0-3.4 mEq/l (Usually asymptomatic)
Sickle Cell Crisis
Painful Crisis
Severe pain is the most common reason that patients with sickle cell, will attend the ED. The pain can be agonising (and often underestimated by us), we need to act fast to help ease the symptoms Read more
Injuries in Non-Mobile Children
Unfortunately under 1 year olds are at a higher risk of NAI and this needs to be considered in ALL presentations. But remember if the child can’t Crawl/Stand/Cruise/Walk they shouldn’t injure themselves.
Rolling is NOT mobility!
iNFANT – user guide
the iNFANT is truly a design enigma, it is simple yet complicated, amazing yet frustrating, beautiful yet disgusting. And due to a unique production method, each iNFANT has its own variations and special features. Read more
Lateral Canthotomy
Like tension pneumothorax the biggest step is deciding to do it – Remember it it sight saving and they heal well
Retrobulbar Haematoma secondary to blunt eye injury is a a rare but potentially sight threatening injury.
- Blood collects in the retrobulbar space
- Pushing the eye forward to accommodate the extra volume.
- The Orbital Septum (made up of the eyelids and ligaments that attach them to the orbital rim) restricts this forward movement, creating a compartment syndrome for the eye. Thus threatening the patients sight if not treated quickly.
Recognition

- Severe pain
- Red/Congested conjunctiva
- Exophthalmos with proptosis – eye pushed forward
- Internal ophthalmoplegia – impairment or loss of the pupillary reflex.
- Visual flashes
- Loss of vision – initially colour vision (esp. red), progressing to local visual loss.
However, this may only be recognised on CT if there is significant facial injury and altered conscious level.
Treatment
Call Ophthalmology immediately to attend. If there is going to be any significant delay, it may be necessary for ED to preform a Lateral Canthotomy, to allow the eye to move forward, reduce the orbital pressure & preserve the patients sight.
Kit needed
- Lidocaine with adrenaline (needle & syringe)
- Clamp – ideally curved to crush the tissues
- Forceps
- Scissors
Resources
- Royal College of Ophthalmologists – Traumatic Orbital Emergencies
- Making a training model – Great article covering it HERE
- Tips not in the paper
- Creme Fraiche Pot – works (use 53mm paper tube to hold eye in place)
- Cut square hole 34x34mm
- Rubber band cut 40mm slit
- Reinforce the Eyelid corners with foam so the rubber band doesn’t stick (i.e. small square facing down
- When applying the foam eye lids ensure cants at the corners of the square
- Tips not in the paper
Hypocalcaemia
Hypocalcaemia can life threatening, due to arrhythmias and seizures.
Severity – Adjusted Calcium (Ca)
- Mild: >1.9mmol/l
- Severe: ≤1.9mmol/l OR Symptomatic