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]
Category: Resus
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
Hyponatraemia
Hyponatraema is a common finding, especially within our elderly population. However, its significance is is not a simple numbers game, and needs senior input. Prior to treatment the following need to be considered and balanced.
- Symptoms Severity – these are not exclusive to hyponatraemia and may be due to other disease processes (esp. if the low sodium is long-term)
- Sodium Level – the sodium concentration doesn’t always correlate to the clinical picture, and is dependant on speed of change, and co-morbidities
- Rate of Drop – the faster sodium levels drop the more symptomatic the patient often is (i.e. with long term hyponatraema the patient may be profoundly hyponatraemic but asymptomatic)
- Co-morbidities – Increasing sodium too quickly risks osmotic demyelination. How well will the patient cope with treatment?
Emergency treatment (hypertonic saline) is generally indicated in those with Severe/Moderately Severe Symptoms ONLY
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
Consenting for Blood Transfusion
We frequently consent for Blood Transfusion, but what risks do we tell the patients about and how common are those risks?
Necrotising Fasciitis
Necrotising fasciitis (NF) is a rare but serious bacterial infection that affects the soft tissue and fascia (Fournier gangrene, is NF affecting the perineum). In many cases NF progresses rapidly and early recognition and treatment is vital to halt progress. The mainstay of treatment is IV antibiotics and aggressive surgical debridement. Any delay increased the amount of tissue loss as well as the mortality. Read more
