Mind the Gap is a handbook of clinical signs in black and brown skins
Category: speciality
Metastatic Spinal Cord Compression (MSCC)
You need to be a bit more suspicious and have a lower threshold for investigation than in patients without Known, Suspected OR Previous Malignancy Read more
Tick-Bourne Diseases
The prevalence of diseases transmitted by tick bite have increased in recent years, within the UK. And it is now recognised that there are 3 main infections
- Lyme Disease
- Tick-Bourne Encephalitis
- Babesia
Hypercalcaemia
90% of hypercalcaemia is due to either malignancy or hyperparathyroid.
Severity: Adjusted Calcium (Ca)
- Severe: >3.5mmol/l – URGENT treatment (risk of dysrhythmia)
- Moderate: 3.0-3.5mmol/l – PROMPT treatment (maybe well tolerated if chromic)
- Mild: <3.0mmol/l – doesn’t require urgent treatment and often asymptomatic
Hypoglycaemia – Adult
Hypoglycaemia (Blood glucose under 4.0 mmol/l) is potentially fatal and should be treated. it may be defined as “mild” self-treated, or “severe” treated by a third party i.e. you.
Hypoglycaemia is a common side-effect of insulin and sulfonylureas (they start with gli-) as they both work by lowering glucose concentration in the blood. Other diabetic medications work by preventing glucose rise, thus posing a lesser risk.
Signs & Symps
- Autonomic: Sweating, Palpitations, Shaking, Hunger
- Neuroglycopenic: Confusion, Drowsy, Odd behaviour, Incoordination, Speech difficulty
- General: Nausea, Headache
Risk Factors
- Medical:
- Diabetic: Strict control, Long term Insulin, Lipohypertrophy at injection sites,Impaired awareness of hypoglycaemia
- Organ dysfunction: Severe hepatic dysfunction, Renal impairment, Cognitive dysfunction/dementia, Endocrine (Addisons, hypothyroid, hypopituitary)
- GIT: Gastroenteritis, impaired absorption, Bariatric surgery
- Medication: Concurrent use of medicines with hypoglycaemic agents e.g. warfarin, quinine, salicylates, fibrates, sulphonamides (including cotrimoxazole), monoamine oxidase inhibitors, NSAIDs, probenecid, somatostatin analogues, SSRIs.
- Sepsis
- Terminal illness
- Lifestyle:
- Reduced/Irregular intake: Poor diet, Irregular lifestyle, Alcohol
- Increased use: Exercise (relative to usual), Early pregnancy, Breast feeding
- Poor control: Increasing age, No or inadequate blood glucose monitoring, Alcohol
Treatment
Conscious & Orientated
- 15-20g fast acting glucose
- 4-5 jelly babies
- 3-4 heaped teaspoons of sugar dissolved in water (milk delays absorption)
- 150-200ml fresh fruit juice
- Rpt Blood Glucose 10-15min
- if blood glucose remains <4.0mmol/l step one may be repeated up to 3 times in total
- Blood Glucose remains <4.0mmol/l
- 150-200ml 10% Glucose IV
- 1mg Glucogon IM (if starved or sulfonylureas may not work well)
- Blood Glucose >4.0mmol/l – Give long acting Carbs
- 2 Biscuits
- 1 Slice bread/toast
- 200-300ml milk (not soya)
- Meal
- Don’t omit insulin injections
- Diabetic review: most patients can be followed up by diabetic nurses but some may need admission.
- Patient Advice Sheet
Conscious but agitated, confused, unable to cooperate
- If patient CAN cooperate – follow guide above
- If patient CAN’T cooperate
- 1.5 -2 tubes 40% glucose gel (Glucogel) squeezed into the mouth between the teeth and gums (can be substituted for step 1 above)
- 1mg Glucogon IM (if starved or sulfonylureas may not work well)
- Follow subsequent steps as above
Unconscious, seizures, very aggressive
Start at step 3 above (while managing ABC), the choice of whether to use IV glucose or IM glycogen will be determined by practicality of achieving IV/IO access.
Although you will need to follow the remaining steps the patient will almost certainly require admission.
Reference
Hypokalaemia
Hypokalaemia (low potassium), is a common problem. It is found in 14% of outpatients and 20% of inpatients, however only 4-5% of those are of clinical significance.
Severity
- Severe: <2.5 mEq/l OR Symptomatic – Look for Hypomagnesaemia
- Moderate: 2.5-2.9 mEq/l (No or Minor symptoms)
- Mild: 3.0-3.4 mEq/l (Usually asymptomatic)
Sickle Cell Crisis
Painful Crisis
Severe pain is the most common reason that patients with sickle cell, will attend the ED. The pain can be agonising (and often underestimated by us), we need to act fast to help ease the symptoms Read more
Hypocalcaemia
Hypocalcaemia can life threatening, due to arrhythmias and seizures.
Severity – Adjusted Calcium (Ca)
- Mild: >1.9mmol/l
- Severe: ≤1.9mmol/l OR Symptomatic
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 Symptoms ONLY
Ophthalmology Referral Pathway
The following pathway will continue post-pandemic
InHours: Direct dial from HRI 152539, From CRH 2539.
Out of Hours: On Call Ophthalmology
We should no-longer be completing Email referrals to ophthalmology – if ophthalmology are insisting please contact Ruth Lush via switch who will fed back to staff.
ED to Opthalmology COVID-19 Referral Pathway v2