There has been a resent increase in cases of Legionnaires Disease in the North West. So remember to request Urine Legionella Antigen test, if you have suspicions.
Category: Respiratory
Acute Flaccid Paralysis (AFP)/ Acute flaccid myelitis (AFM)
AFP/AFM is rare rare but serious neurological condition, which is associated with POLIO infection but has also been linked with other infections (and in the USA they have spikes every 2 yrs last 2020). AFP leads to weakness and paralysis affecting face and limbs but also the respiratory muscles and may lead to respiratory failure.
Scombroid Poisoning- NOT another fishy allergy
Scombroid poisoning (AKA – Histamine fish poisoning) is apparently more common than we think and accounts for 40% of seafood related illness in the USA according to the CDC. But Scombriod poisoning is missed as its put down to allergy. Read more
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)
- High-Risk (Wells >4) – Treat before CT
- 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.
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
Chest Trauma – WYMTN
Chest injury as part of major trauma, can range from painful to life threatening so prompt treatment and recognition is vital. Esp. in ‘Silver Trauma’ when ‘minor’ injuries may have devastating consequences – the full guidance can be found @WYMTN – HERE
Emergency Tracheostomy/Laryngectomy Management
Occasionally patients with Tracheostomy or Laryngectomy present with difficulty breathing due to problem. As this is rare for us in ED, this situation can be very difficult for all of us. However the protocols below can help.
Tracheostomy
Tracheostomy is simply a passage from the neck into the trachea. In most cases the trachea will still be connected to the nose and mouth (so can breath though their mouth too).
NIV (Non Invasive Ventilation)
NIV should be considered for use in patients with a persisting Acute Hypercapnic Respiratory Failures after a maximum of one hour of standard medical therapy.
- Complete the Ad-hoc form
- Increase pressures from Initial 12/5 cmH2O to 20/5cmH2O – as tolerated over 1st hour
However, ICU should be contacted early if the patient has one of the following:
- Asthma – Intubation the option of choice in Life threatening
- Pneumonia – NIV should only be considered as a bridge to intubation
- No pre-exisiting respiratory issue – NIV not likely helpful
- pH <7.25 (low threshold for ICU input)
- pCO2 >6.5kPa (low threshold for ICU input)
- Type 1 Respiratory Failure (low threshold for ICU input)
CPAP Set-Up
NIPPV 3 machines are used throughout the trust to deliver NIV and CPAP – and should be commenced in ED if transfer to ward/ICU is adding significant delay
- NIV/CPAP is NOT an Aerosol Generating Proceedure (AGP) [as of Sept 2022]
- CPAP/EPAP levels of 8-15cmH2O
This video demonstrates how to set up CPAP on the NIPPV 3
Acidosis & VBG’s
We are frequently asked to check the lactate on Venous Blood Gases (VBG’s), by the nursing staff. However, remember to look at the first result (pH) it is the most important.
Acidosis: Unless you have a good reason (e.g. you know its due to DKA) you should be investigating and performing an Arterial Blood Gas (ABG)
