In our trust we don’t have paediatric critical care beds. However, in our region we use EMBRACE (a paediatric critical care transport team), who can transfer critically ill children to specialist centers (in or out of region).
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.
Exophthalmos with proptosis – eye pushed forward
Internal ophthalmoplegia – impairment or loss of the pupillary reflex.
Loss of vision – initially colour vision, progressing to local visual loss.
However, this may only be recognised on CT if there is significant facial injury and altered conscious level.
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.
On rare occasions you may receive a pre-alert, where you want blood available for the patient when they arrive (for example in major haemorrhage). This process has been agreed with transfusion so this can be done safely and responsibly. Read more
We often worry about patients developing rhabdomyolysis and consequently developing AKI. However, there is much debate and little consistency in the published data, over how to diagnose and who needs admission to treat. So its important to consider both clinical context along with laboratory values
With the onset of colder weather, many households in the UK are turning on their heating for the first time in months. Heating appliances need chimneys and flues to work safely – and these can block up over the summer months. So autumn is traditionally the period when people get poisoned by carbon monoxide (although it can happen any time of the year!)
Carbon monoxide (CO) is produced when anything containing carbon burns or smoulders. For practical purposes, this means the burning of any kind of fuel, commonly:
Oil/Petrol/Diesel – (All UK cars have a ‘catalytic converter’ in the exhaust system, which converts carbon monoxide (CO) to carbon Dioxide (CO2), which is less poisonous. However, these converters need to warmed up – a cold car produces fatal amounts of CO in the exhaust)
CO is very poisonous. Exposure to as little as 300 parts per million (that’s just 0.03%) can prove fatal.
Is a rare complication of I.V. Phenytoin, which presents with a triad of: Pain, Oedema & Discolouration, typically in the hand.
In our case a child presented in status epilepticus, having received rectal diazepam from the ambulance crew, then 0.1mg/kg lorazepam in the ED, followed by 20mg/kg I.V. Phenytoin over 30 min, via a 24g cannula in back of the hand.
After intubation the patients thumb, index and middle fingers were all noted to be purple. Radial pulse was weak however, we saw good flow on ultrasound doppler in the ED. The patient had no cardiovascular Hx or FHx.
What the literature says
Mechanism (poorly understood)
Phenytoin is highly Alkaline and may induce vasoconstriction and thrombus, resulting in leakage into the extravascular tissue.
Phenytoin may precipitated when it mixes with acidic blood (More common in status patients rather than prophylaxis)
I.V. Canulation may cause small tears promoting extravasation (In our case the cannula required repositioning on insertion)
Phenytoin infusion rate should be the lesser of 1-3mg/kg/min OR under 50mg/min (In our case the infusion rate was 22mg/min, less than 1mg/kg/min)
Smaller hand veins should be avoided (As in our case, most reports in literature involve the use of hand veins)
Use 20G cannula or larger (This is ideal for adults and older children)
Dark purple– Pale blue discolouration occurs around or distal to injection site 2-12hrs after administration. (In our case approx 30 min)
Discolouration and Oedema progresses around site and into fingers, hand and forearm over the next 12-16 hours
Healing, starts at the periphery moving towards the injection site – most patients have a full recovery over 72hrs (few cases of necrosis requiring amputation have been reported
Stop giving phenytoin
Dry Warm Heat (moist heat my contribute to skin breakdown)
Regular neuromuscular assessments
Avoid Cold (this will worsen the vasoconstriction)
GTN patches have also been used in several of the cases but efficacy is unknown
Avoid Hand veins for I.V. Phenytoin (this seems to be a contributing factor form the evidence, be it due to small size or more frequent injury of the vein though need to reposition?)
Avoid Cannulas that required repositioning (increase chance of leaking)
Use a big cannula (easier said than done in a fitting child)