Getting some of the rarer antidotes has recently been clarified across Yorkshire (Accessing rarely used antidotes-SOP)
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Hyperemesis Gravidarum
Nausea and vomiting in pregnancy is common and at best an unpleasant experience for the patient, and at worst can be life threatening. It normal starts @ 4-7/40, peaks @ 9/40, and finishes @ 20/40.
We need to conduct a thorough history and examination looking for causes other than a high βHCG. these include:
- Abdominal pathology
- Urinary pathology
- Infections
- Drug History
- Chronic H.Pylori
Pulmonary Embolism in Pregnancy
Unfortunately the the normal pathway for investigation of PE performs poorly in pregnancy RCOG have the following pathway
1. Investigation – of suspected PE
- Clinical assessment – its all on the history and exam scoring doesn’t work
- Perform the following tests:
- CXR – sheilding can protect the baby and may avoid further radiation
- ECG
- Bloods: FBC, U&E, LFTs, Clotting
- Commence Tinzaparin (unless treatment is contraindicated – use booking weight to calculate dose) –[BNF]
Be #urosceptical
Ditch the Dipstick – for patients >65Yrs or Catheterised!
Approx. 50% of over 65’s and most of those with catheters have asymptomatic bacteriuria. The patient will not benefit from treatment and often gives us premature closure (i.e. we blame a fictitious UTI for the patients symptoms and stop thinking). Read more
Epistaxis – ACP/MG Teaching
Slide set – HERE
Main topics
- Anatomy
- Cautery
- Packing – Don’t force it call for ENT help (septal deviation or spurs)
- Remember – Elderly patients can have devastating posterior bleeds call ENT early
Kindly presented by Mr Habib
Paediatric Sepsis Podcast (RCPCH)
RCPCH have released a GREAT series of podcasts on paediatric sepsis. It is from a paediatric slant, but is applicable to the ED and well worth a listen [For Docs and Nurses]
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
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
Injuries in Non-Mobile Children
Unfortunately under 1 year olds are at a higher risk of NAI and this needs to be considered in ALL presentations. But remember if the child can’t Crawl/Stand/Cruise/Walk they shouldn’t injure themselves.
Rolling is NOT mobility!
iNFANT – user guide
the iNFANT is truly a design enigma, it is simple yet complicated, amazing yet frustrating, beautiful yet disgusting. And due to a unique production method, each iNFANT has its own variations and special features. Read more