Q: Why are Smurf’s Blue?
A: Methaemoglobin (MetHb) of course!
– MetHb is produced by oxidisation of the Iron in Haemoglobin (Hb) from Fe2+ to Fe3+
– Fe3+ prevents Hb carrying oxygen (thus produces symptoms of hypoxia)
– Often due to chemical ingestion, but may also be genetic
– Treated with Methyl Blue & supportive measures
In the UK approximately 100 people are envenomated by a snake each year.
So what do you need to do if your patient has received a venomous bite from a snake? (not the classic UK cocktail).
Those suspected of concealing illicit drugs often present near ports and borders however they can present to any ED or be brought in by the police.
Body Packers – Swallow large quantities of well packaged drugs to smuggle them into countries or institutions. These are often well manufactured with a low risk of rupture but the potential for serious toxicity if rupture occurs.
Body Stuffers – Swallow small quantities of poorly packaged illicit substances often at the point of arrest to conceal them. These have a much high risk of package rupture but involve smaller quantities of substances.
Authorisation for an intimate search or radiological investigation must come from an inspector or higher with written consent from the patient.
Intimate searches must be carried out by a police surgeon but require immediately available resuscitation facilities therefore may be conducted in the ED. ED physicians should not handle the drugs at any time.
AXR or low dose CT scanning can be used to detect concealed packages in Body Packers.
Try to obtain a history of what and how much has been concealed
Look for toxidromes suggestive of package leak –
ECG
Body Stuffers should be observed for signs of toxicity for a minimum 6 hours, consider activated Charcoal
Body Packers with positive imaging who are asymptomatic can be discharged back to police custody for monitoring. Bowel preparation such as Cleanprep or movicol can be used.
Toxidromes should be treated as per toxbase guidelines Toxbase
Body Packers with signs of cocaine or amphetamine toxicity or signs of obstruction/ileus require urgent surgical intervention.
Body packers with signs of Heroin toxicity should be treated with Naloxone infusion as per toxbase guidelines
Getting some of the rarer antidotes has recently been clarified across Yorkshire (Accessing rarely used antidotes-SOP)
So a patient comes to ED after white powder thrown is at them what do you do? Your initial response can help them and everyone in the department!
If you haven’t seen the Initial Operational Response (IOR) training video please watch it.
The patient can then be thoroughly assesses, to identify the substance involved (this may involve witnesses, police info and symptomatology), and treated appropriately.
Police should be informed of the incident for several reasons: 1. Public safety, 2. To collect the evidence and possible find out what it was for you. (if this is not a criminal act Public health England can advise on return/disposal of personal effects)
Inform Manager On-Call of incident as it may disrupt the functioning of ED and can provide support.
In our recent case Public Health England advised
If anybody is symptomatic after button battery ingestion they need referral to the Surgical team for urgent endoscopic removal Read more
Generally we DON’T admit patients acutely solely for “Detox”
However the following groups should be admitted [taken from trust guide]
If admitted to CDU – complete the PAT tool
Scombroid poisoning (AKA – Histamine fish poisoning) is apparently more common than we think and accounts for 40% of seafood related illness in the USA according to the CDC. But Scombriod poisoning is missed as its put down to allergy. Read more
We are regularly doing femoral blocks next to major vessels. So warn the patient of the symptoms, & keep them monitored(at least 15 min).
Symptoms of local anaesthetic toxicity
PDF:la_tox
