Category: Resus
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
Head Injury
Background
- Defined as any traumatic injury to the head other than superficial facial injuries.
- The commonest cause of death and disability in people age 1-40 in the UK.
- Account for 1.4 million ED attendances each year, 95% of these are minor head injuries that can be managed in the ED.
C-Spine Injury
C-spine injury ranges from the obvious fracture-dislocation to the less obvious ligamentous injury, affecting about 2.5% of blunt trauma patients. However, ALL of them are serious and can lead to life changing injuries, that we obviously don’t want to miss. Unfortunately reported miss rates range from 4-30%. [IJO 2007]
Malignant/Accelerated Hypertension
There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)
Patient has both:
- Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
- End-Organ Damage: Retinal Changes, Encephalopathy, Heart Failure, Acute Kidney Injury, etc.
Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.
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.
- High risk of Cardiovascular Collapse/Death – likely due to adrenaline surge, heat exhaustion and injury. It can happen very suddenly.
- Keep physical restraint to a minimum – Don’t allow patient to forced face down, it’s the most likely way of killing them.
- Sedation – if you’re restraining you will almost certainly need to sedate. IV is best but if access is too risky IM will have to do.
- Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC
Refusing treatment = Mental Capacity Assessment [LINK]
| Order | Drug | Route | Typical Dose (mg) | Onset (min) | Duration (hr) | Warning |
|---|---|---|---|---|---|---|
| First Line | Lorazepam - Adult | IV | 1mg IM/IV (max dose 4mg/24hrs) | 2-5 | 1-2 | Respiratory depression, IM unpredictable onset |
| IM | 15-30 | |||||
| Lorazepam-Elderly | IV | 0.5mg IM/IV (max dose 2mg/24hrs) | 2-5 | |||
| IM | 15-30 | |||||
| Second Line - Adult | Olanzapine (not within 1hr of IM Lorazepam) | IM | 5mg (max dose 20mg/24hr) | 15-45 | >10 | Arrhythmia Risk: Only if previously used OR ECG |
| Second Line - Elderly | Promethazine | IM | 10mg | 15-30 | >10 | |
| Sedation ST4+ involvement required | Ketamine | IV | 1-2mg/kg | 1 | 20-30 | Theoretical risk of worsening cardiovascular instability |
| IM | 2-4mg/kg | 3-5 | 60-90 |
Ingested Magnets
Ingestion of Strong Magnets is a TIME CRITICAL EMERGENCY
(Multiple Magnets OR a single Magnet and Metallic Objects)
Strong magnets (such as Neodymium)
- Now common place around the house
- From; fridge magnets to toys and peicings
Ingested:
- Intestinal injury can occur within 8-24 hours
- However, symptoms may take weeks to develop
- Symptomatic patients are a SURGICAL emergency
Detection:
- 2 views – to determine number of magnets (if in doubt assume multiple)
RCEM recommendation (best practice)
Aortic Dissection
Aortic Dissection (AD), is uncommon (1 AD:200 ACS) but is…Rapidly FATAL! Unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%. Read more
Anaphylaxis 2021
Not all Allergies are Anaphylaxis!
Anaphylaxis is defined as:
- Severe life-threatening systemic hypersensitivity reaction
- Where BOTH of the following criteria are met:
- Sudden onset & rapid progression
- Life-threatening compromise of ONE or MORE of: Airway/Breathing/Circulation
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
