Category: Resus

NEW: Burns Referral Pathway

A new burns referral pathway has been developed with Mid Yorks to securely send images of the patients burn. Allowing the burns team to arrange the most appropriate follow-up for your patient.

This requires BOTH online referral & phone call

The Process

  1. GoTo –  Burns Homepage (NHS computers ONLY)
  2. Select – New Referral (NO login required)
  3. Complete – the following sections (* means required field)
    • Referrers Details – you will need an NHS email address
    • Patient Details
    • Injury Details – Answering “Yes” to airway burns or fluid resuscitation will open further boxes
    • Additional Details – Patient’s phone number and address (only appears if NO airway or resuscitation issues)
  4. Checklist – Ensure ALL completed and submit
  5. Sending an Image – After submission a QR code will appear to send an image you will need to us the SID App
    • Launch the SID App on mobile device – Yours or ED Co-Ordanator (apple/android)
    • Scan the QR code
    • Consent the patientPatient Information Leaflet
    • Take Photo of Injury  – this will not be saved on the device
  6. Phone Burns team – They can review the details and images and better advise you on management.

Resources

Lateral Canthotomy

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

From Royal College Ophthalmologists
  • 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, 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

Are You CO Aware?

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:

  • Gas
  • Coal
  • Wood/Paper/Card
  • 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.

Read more

Purple Glove Syndrome – Case

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)

Prevention

  • 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)

Stages

  1. Dark purple Pale blue discolouration occurs around or distal to injection site 2-12hrs after administration. (In our case approx 30 min)
  2. Discolouration and Oedema progresses around site and into fingers, hand and forearm over the next 12-16 hours
  3. 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

Treating

  • Stop giving phenytoin
  • Dry Warm Heat (moist heat my contribute to skin breakdown)
  • Elevate
  • Analgesia
  • 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

Learning Points

  • 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)

 

References