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
Author: embeds
Adrenal Crisis
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
COVID-19 Vaccine Induced Thrombosis/Thrombocytopenia (VITT)
Inclusion Criteria [Both of]:
- Received AstraZeneca (AZ) COVID 19 vaccination within 42 days (typically 5-42 days from immunisation)
- New Onset thrombocytopenia (PLTs <150×109/L) – with or without Thrombosis
- 5% of cases have had a “Normal” Platelet count at presentation
- High index of suspicion repeat bloods next day
- ‘High index of suspicion’ in this context is day 5- 28 post AZ vaccine with new onset headache or abdominal pain which is atypical and severe in nature.
- 5% of cases have had a “Normal” Platelet count at presentation
Initial Investigations:
- FBC– specifically to confirm thrombocytopenia <150x 109/L
- Coagulation screen and D Dimers
- Blood film to confirm true thrombocytopenia and identify alternative causes
PROBABLE CASE: (ALL 3 criteria)
- Received AZ COVID 19 vaccination within 42 days
- New Onset thrombocytopenia (PLTs <150×109/L)
- D Dimers > 2000 mcg/L
URGENT Scan to confirm the suspected clot.
[If patient doesn’t fit “PROBABLE CASE” proceed to usual treatment]
Condition specific advice:
Central clot:
- inc. Cerebral Venous Sinus Thrombosis (CVST), Pulmonary Embolis (PE), Splenic, Proximal DVT
- Discuss with Haematologist
- Admit Medicine
Suspected DVT (scan unavailable):
- Treat with Rivaroxaban (Do Not use Tinzaparin/LMWH)
- Request Ultrasound
- Return AAU Next Day
- Safety-net Advice
Confirmed Distal DVT (Not above inguinal ligament)
- Platelets <100×109/L – Discus with Haematology
- Platelets ≥100×109/L – Treat as normal
Thrombocytopenia only
- Platelets <100×109/L – Discus with Haematology
- Platelets ≥100×109/L – Treat as normal
Treatment (will be directed by Haematology & Specialist teams):
Avoid:
- Heparin Based anticoagulants
- Antiplatelets
- Platelet Transfusion
May Require:
- IV immunoglobulin
- Steroid
- Anticoagulation with: DOAC, Fondaparinux, Argatroban
Further reading
Rabies [notifiable disease]
Recent Incident: Bat contact was not recognized (effectively touching a bat without gloves means treatment is recommended)
Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in “Rabies-Free” counties the bat population posse a risk.
In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.
Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.
Risk Assessment
To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]
Exposure Category
Combined Country/Animal & Exposure Risk
Treatment
Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.
If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)
You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]
Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400
Octaplex – work fast its an EMERGENCY!
- Activate EARLY in head injury patients on warfarin.
- Order on EPR & Paper [see below]
- Infuse over no more than 30 min
- Recheck INR at 30 min after finished infusion
Indications
- EMERGENCY reversal of Warfain
- Factor II or X deficiency
Read more
Vertigo in ED
Vertigo is not always labyrinthitis!! There are some potentially serious conditions to think about. Your main question should be is it peripheral [good] or central [bad]?
C-Spine Injury
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]
Anti-D immunoglobulin
Rhesus (Rh)-D negative women, pregnant with Rh-D positive foetus are at risk of developing antibodies against future pregnancies if/when they suffer a sensitising event. (Remember, this should be considered a standard treatment for all Rh-D negative women, as we are never certain of the fathers Rh-D status) Read more
Teaching – Palliative Care
As we know everybody dies, but recognition and palliation of the dying patient can be difficult. One of our palliative care consultants Mary Keily has produced a video on “End of life care medicines”.
- We also have the Palliative care bundles in our quick orders on EPR, to make prescribing easier.
Pulmonary Embolism – PE
PE is somehow both the most over and under diagnosed condition. with severity ranging from the questionable sub-segmental PE to the Massive PE (an indication for thrombolysis). So think:
- Does this presentation sound like a PE? – If not STOP here
- Pregnant? – Click Here
- Do you think this is likely a PE? (if so you can’t use PERC)
- Does D-Dimer answer your question? (whats the Wells)
- Massive PE – think Thrombolysis
- Sub-Massive PE – there is lots of debate (involve seniors), locally needs 2 consultant sign off and not considered time critical.