Author: embeds

Emergency Tracheostomy/Laryngectomy Management

Occasionally patients with Tracheostomy or Laryngectomy present with difficulty breathing due to problem. As this is rare for us in ED, this situation can be very difficult for all of us. However the protocols below can help.

 

Tracheostomy

Tracheostomy is simply a passage from the neck into the trachea. In most cases the trachea will still be connected to the nose and mouth (so can breath though their mouth too).

Read more

COVID-19 (Paediatric multisystem inflammatory syndrome)

AKA: Paediatric Inflammatory Multi-system Syndrome – Temporally associated with SARS-CoV 2 

Although COVID-19 seems a benign disease in almost all children there are increasing evidence (however rare) of a “Paediatric multisystem inflammatory syndrome”. This is a RARE and newly emerging condition and there are many questions still e.g. It is currently unclear if it is directly related to the COVID-19 pandemic.

Read more

COVID-19 (DKA/HHS)

Experience is showing that those with diabetic patients with COVID-19 are more likely to develop DKA/HSS. However, treating them with the traditional large amount of fluid is detrimental to their chest, if they have Covid-19

Hence the following has been developed from the Guy & Thomas’ guidance – CLICK HERE

High Clinical Suspicion of Covid-19

  • Clinical: Fever ≥37.8°C plus any of; cough, short of breath, myalgia, headache, sore throat
  • CXR: consistent with Covid-19

Read more

COVID-19 (40 Step Desaturation Test)

NHS England has introduced the use of a “40 step desaturation test” into discharge planning from the ED. You will have heard Covid -19 patients complaining of increasing SOB on exercise, and it’s important that we test this prior to discharge.

Method:

  • Is this appropriate? – Could the patient walk 40 steps before they were ill?
  • Patient remains in cubical – with mask on
  • Attach Sats probe – ensure good trace
  • Walk on spot 40 steps 
  • Monitor SaO2

 

 

COVID-19 (Awake Self-Proning)

There is increasing evidence that Awake Self-Proning of our Covid-19 patients can improve oxygenation. Proning the patient can has several effects which can dramatically improve their SaO2

  • Improves Ventilation to back of the lung (the back of the lung contains more alveoli than the anterior lung)
  • Improves Perfusion – as blood supply to the back of the lung is always better than the front
  • Improves Clearance of secretions
  • Be patient can take 15-20min

Contraindications (all seem obvious)

Absolute contraindications:

  • Respiratory distress (RR ≥ 35, PaCO2 ≥ 6.5, accessory muscle use) 
  • Immediate need for intubation 
  • Haemodynamic instability (SBP < 90mmHg) or arrhythmia 
  • Agitation or altered mental status 
  • Unstable spine/thoracic injury/recent abdominal surgery 

Relative Contraindications: 

  • Facial injury 
  • Neurological issues (e.g. frequent seizures) 
  • Morbid obesity 
  • Pregnancy (2/3rd trimesters) 
  • Pressure sores / ulcers 

 

COVID-19 (X-Ray learning resource)

British Society of Thoracic Imaging (BSTI) have released a free learning resource containing CXR and CT of confirmed Covid-19 cases, will short history including time image was taken from onset of symptoms.

From the China experience CXR/CT doesn’t seem to be a rule out strategy in ED at the moment – However, its a useful resource to help recognition of Covid-19 CXR’s

BSTI Covid-19 image bank

 

Acute Heart Failure (AHF) – ESC 2016

 

AHF Triggers

there are many triggers for AHF, which if recognized and treated with help improve outcomes

  • Cardiac: ACS, Arrhythmia, Aortic Dissection, Acute Valve Incompetence, VSD, Malignant Hypertension
  • Respiratory: PE, COPD
  • Infection: Pneumonia, Sepsis, Infective endocarditis
  • Toxins/Drugs: Alcohol, Recreational drugs, NSAIDs, Steroids, Cardiotoxic meds
  • Increased Sympathetic Drive: Stress
  • Metabolic: DKA, Thyroid dysfunction, Pregnancy, Adrenal Dysfunction
  • Cerebrovascular Insult

Presentation & Clinical Classification

The presentation of AHF can vary but tends to fall in to the following 4 categories, which can be determined clinically and can help guide your approach to treatment; warm-dry, warm-wet, cold-dry, cold-wet.

It is worth noting that the vast majority of patients will be norm-hypertensive. However, 5-8% are Hypertensive this confers a very poor prognosis.

Investigations

  • ECG: Rarely normal (High NPV), and may identify underlying cause
  • CXR: Pulmonary congestion, Effusion, Cardiomegaly (20% will have an almost “Normal” CXR)
  • BNP: Can be helpful (we have it)
    • >845 show increased mortality
    • <100 AHF is unlikely
    • BNP is not a specific test and will elevate for many reasons
  • POCUS: This can be very useful in identifying cases but training is required [Bilat B lines in 2 zones each side]
  • Condition specific tests: Try to identify the underlying trigger dependent on history and exam (e.g. ABG, Trop, U&E, TFT, LFT, CTPA)
  • ECHO: this is important but not necessary in the ED phase (unless the patient has haemodynamic instability i.e. cardiogenic shock)

Treatment – Time Matters!!!

  • Mortality increased by 1%/hour IV treatment not started
  • Treatment after 12hrs from onset makes little difference

Treat The Cause!: If you can identify the trigger treat it it will in turn improve the AHF. (e.g. AMI, Arrythmia(Tachy/Brady), Massive PE)

  • Vasodilator: has 2 effects reducing vascular resistance and thus increasing stroke volume [NOT to be used if sBP<90mmHg] 
  • Diuretic: commonly we use frurosemide 20-40mg IV, however, depending on the patient higher doses can be used. [Doses over 160mg has been shown to increase mortality!]
  • Oxygen: maintain SaO2 of 95% OR 88-92% if at risk of hypercapnic coma [Avoid hyperoxia]
  • NIV: recommended in respiratory distress (RR >25bpm, SpO2 <90%) & start ASAP, this can reduce intubations and make the patient feel more comfortable. However, doesn’t increase survival NIV Guide-HERE
  • SHOCK!!!: there is no agreement on the best treatment, ICU & Medical/Cardiology input is vital, as inotropes & vasporessors (Noradrenaline recommended) will need to be considered.

ESC Guide – 2016 Heart Failure