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
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 – treat as per Toxbase
Toxicology screens (urinary/blood) should not be used to guide management or discharge decisions (Level 5 evidence).
Body Stuffers & Pushers should be observed for signs of toxicity for a minimum 8 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.
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
All patients transferred to police custody should receive a discharge letter, including
Suspected Internal Drug Traffickers.
Remember: is it a haemolysed blood sample? (you can do an iSTAT)
Severity
And either
Or
Onset is usually after 20 weeks of gestation, but it can also occur up to a few weeks postpartum.
Eclampsia- This is pre-eclampsia that has progressed to seizures
Clinical features of pre-eclampsia:
HELLP syndrome is a variant of severe pre-eclampsia characterised by haemolysis, elevated liver enzymes and low platelets.4
Symptoms and signs are similar to those of pre-eclampsia but also include jaundice and bleeding.
Management of Pre-eclampsia:
Definitive management:
Definitive management of pre-eclampsia is ultimately delivery of the fetus. Timing of delivery will be decided by senior members of the obstetric team according to the severity of pre-eclampsia, the current gestation and in consultation with the patient. Following diagnosis of pre-eclampsia, the majority of women are managed as inpatients until delivery.
ED Management of Eclampsia:
Full NICE guidance is available here
Opioid Toxicity causes:
Other Symptoms may include (but are not diagnostic or opioid toxicity):
Naloxone is the antidote to Opioids however as these are commonly co-ingested with other depressants. full reversal of symptoms may not occur with treatment.
In acute opioid toxicity, the aim of naloxone administration should be reversal of respiratory depression and maintenance of airway protective reflexes, not full reversal of unconsciousness.
Naloxone infusion if required is based on the total dose given to obtain Respiratory rate of 10
Link to the full guidance is here
Neurological Observations MUST include the following:
Head injury is witnessed, reported, suspected, or cannot be excluded.
Post fall Neurological Observations must be completed for at least 12 hours and at the above intervals as a minimum:
During this time If there is any deterioration in the patient’s condition including level of consciousness, pupil reaction, limb power, cardiovascular observation you must revert to ½ hourly neurological observation and seek URGENT medical review.
Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.
Under no circumstances should Neurological observations be omitted because the patient is asleep
Admitted with Head Injury
During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must revert to ½ hourly neurological observations and seek URGENT medical review. Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.
Under no circumstances should Neurological observations be omitted because the patient is asleep.
During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must seek URGENT medical review and revert to ½ hourly neurological observations as a minimum, or ¼ hourly, if still within the first 2 hours post thrombolysis.
Under no circumstances should Neurological observations be omitted because the patient is asleep.
If Yes to ANY proceed to 2.
If NO to ALL consider other diagnosis and possibility of GP follow-up
Adrenal crisis or insufficiency is a life threatening emergency due to the lack of glucocorticoid. Adrenal crisis can be primary due to destruction of the adrenal cortex (Addison’s), or secondary due to down regulation (chronic steroid use) Read more
