Category: Medical

2WW – Suspected Cancer

Some patients present to ED with symptoms or investigations suspicious an undiagnosed cancer, but don’t require emergency admission. To reduce the barriers to care the trust has implemented a referral route for ED.

Emergency Department MDT referral request – HERE

Once completed the PPC team will review the request and feed them into either “Fast-Track Clinics” if further workup required or MDT’s if fits those pathways.

This should allow our patients quick access to appropriate clinics, without the inherent delays and wasted clinical time of asking the patient to attend their GP. BMA/NHSe

Lower Back Pain: Red & Yellow Flags

Each year 1:15 of the adult population will seek medical help for Lower Back Pain, that is 2.6 million patients in the UK. Most Lower Back Pain is not serious and will revolve within 8 weeks, with analgesia and self physio.

However, this is not the case for some. This may be due to serious underlying pathology ‘RED Flags‘, or psychological factors that indicate chronicity ‘Yellow Flags‘.

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Hyperkalaemia

Remember: is it a haemolysed blood sample? (you can do an iSTAT)

Severity

  • Mild: 5.5-5.9mmol/l – No urgent action required (Dietary & Medication modification & GP F/U)
  • Moderate: 6.0-6.4mmol/l – Follow treatment guide (maybe suitable for discharge)
  • Severe: ≥6.5mmol/l OR ECG changes – Follow treatment guide, must admit

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Nitrous Oxide Induced Neurotoxicity

Nitrous Oxide  has been used clinically and recreationally since its discovery in 1772. Since then Nitrous Oxide induced neurotoxicity have been reported, and has been shown to be dose depaendant. With infrequent users unlikely to be at risk of neurotoxicity, while heavier and habitual used at risk of serious neurological conserquences.

With the increase in recreation use of “Whippits” we need to remember to take a detailed recreation drug history when seeing patients presenting to ED with neurological symptoms. As Nitrous Oxide induced neurotoxicity is treatable.

Presentations

Nitrous Oxide induced neurotoxicity can present as either spinal cord demyelination , peripheral neuropathy or a a combination of the two.

  • Demyelination of the dorsal columns of spinal cord 
    • Typically onset is subacute  (i.e. weeks), but acute onset has been reported in the literature
    • Typically symmetrical but can be unilateral
    • Signs
      • Pyramidal weakness – weak upper limb extensors, and lower limb flexors
      • Dorsal Column Sensory loss – Vibration, Proprioception, Fine touch
      • Sensory Ataxia – Incoordination due to loss of proprioception and weakness
    • Level – Most frequently cervical 4-6 levels, but can affect any.
  • Peripheral Neuropathy
    • Typically Symmetrical (but not always)
    • Sensory loss (often painful)
    • Distal Weakness
  • Optic Neuropathy  – has been reported and may present with visual disturbance.

Pathophysiology

Nitrous Oxide usage can render vitamin B12 inactive, which in-turn disrupts myelination, causing the demyelination of nerves.

Differentials

  • Deficiencies: B12, Folate, copper, zinc
  • Inflammatory: Guillian-Barre syndrome, MS, Neurosarcoidosis
  • Infection: HIV, Syphilis
  • Cancer
  • Vascular: Spinal cord ischaemia, vasculitis

Tests

  • Vitamin B12 level (often in normal range)
  • Homocysteine and Methylmalonic Acid Level (not available in ED)
  • MRI – contrast enhanced

Treatment

Start before Tests are back (i.e. on clinical suspicion)

  • IM Vitamine B12 1mg OD
  • PO Folic Acid 5mg OD

Follow-up

  • Discuss admission with Medical team as potential for SDEC management
  • Treat until clinical improvement(King’s Team noted the following)
    • Sometimes treat for 5-7days only
    • Often switch to alternate days IM Bit B12
    • Can teach to self administer
  • Further Testing
    • Homocysteine and Methylmalonic Acid levels – often improve quickly
    • MRI often lags clinical improvement endnote necessary to repeat
  • Majority Improve clinically – but futureabstinence is often challenging

 

References

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 need help! However, that may be extremely difficult to get especially Out of Hours

https://www.parkinsonscalculator.com/calculator2-withoutNG.htmlpdmedcalc

Excellent website that can give you options – select the patients normal regime (initially just one line but you can add as many as needed) and press calculate.  It gives you a dispensable and patch dose, which can help the discussion with pharmacy about where we can get it

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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