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Are You CO Aware?

With the onset of colder weather, many households in the UK are turning on their heating for the first time in months. Heating appliances need chimneys and flues to work safely – and these can block up over the summer months. So autumn is traditionally the period when people get poisoned by carbon monoxide (although it can happen any time of the year!)

Carbon monoxide (CO) is produced when anything containing carbon burns or smoulders. For practical purposes, this means the burning of any kind of fuel, commonly:

  • Gas
  • Coal
  • Wood/Paper/Card
  • Oil/Petrol/Diesel – (All UK cars have a ‘catalytic converter’ in the exhaust system, which converts carbon monoxide (CO) to carbon Dioxide (CO2), which is less poisonous. However, these converters need to warmed up – a cold car produces fatal amounts of CO in the exhaust)

CO is very poisonous. Exposure to as little as 300 parts per million (that’s just 0.03%) can prove fatal.

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Purple Glove Syndrome – Case

Is a rare complication of I.V. Phenytoin, which presents with a triad of: Pain, Oedema & Discolouration, typically in the hand.

In our case a child presented in status epilepticus, having received rectal diazepam from the ambulance crew, then 0.1mg/kg lorazepam in the ED, followed by 20mg/kg I.V. Phenytoin over 30 min, via a 24g cannula in back of the hand.

After intubation the patients thumb, index and middle fingers were all noted to be purple. Radial pulse was weak however, we saw good flow on ultrasound doppler in the ED. The patient had no cardiovascular Hx or FHx.

 

What the literature says

Mechanism (poorly understood)

  • Phenytoin is highly Alkaline and may induce vasoconstriction and thrombus, resulting in  leakage into the extravascular tissue.
  • Phenytoin may precipitated when it mixes with acidic blood (More common in status patients rather than prophylaxis)
  • I.V. Canulation may cause small tears promoting extravasation (In our case the cannula required repositioning on insertion)

Prevention

  • Phenytoin infusion rate should be the lesser of 1-3mg/kg/min OR under 50mg/min (In our case the infusion rate was 22mg/min, less than 1mg/kg/min)
  • Smaller hand veins should be avoided (As in our case, most reports in literature involve the use of hand veins)
  • Use 20G cannula or larger (This is ideal for adults and older children)
  • Ensure filter used with phenytoin infusions

Stages

  1. Dark purple – Pale blue discolouration occurs around or distal to injection site 2-12hrs after administration. (In our case approx 30 min)
  2. Discolouration and Oedema progresses around site and into fingers, hand and forearm over the next 12-16 hours
  3. Healing, starts at the periphery  moving towards the injection site – most patients have a full recovery over 72hrs (few cases of necrosis requiring amputation have been reported

Treating

  • Stop giving phenytoin
  • Dry Warm Heat (moist heat my contribute to skin breakdown)
  • Elevate
  • Analgesia
  • Regular neuromuscular assessments
  • Avoid Cold (this will worsen the vasoconstriction)
  • GTN patches have also been used in several of the cases but efficacy is unknown

Learning Points

  • Avoid Hand veins for I.V. Phenytoin (this seems to be a contributing factor form the evidence, be it due to small size or more frequent injury of the vein though need to reposition?)
  • Avoid Cannulas that required repositioning (increase chance of leaking)
  • Use a big cannula (easier said than done in a fitting child)

 

References

#EuSEM2018 – Day 1

For those of you working hard on the shop-floor a quick summary of whats going on in Glasgow @ #Eusem2018

 

Sepsis

3 interesting talks from dual Emergency Med and Infectious disease specialists, from Denmark and Germany, which highlighted that we are all in the same boat, and again doing the basics right is what maters.

Antibiotic Stewardship (What we do in ED, dictates inpatient care)

  • Viral v.s. Septic – clinical differentiation is not reliable, and POCT for flu may be useful in the high prevalence of an outbreak but performs poorly the rest of the time.
  • Choosing well – we can reduce the use of broad-spectrum antibiotic usage dramatically by using our site specific antibiotics [68-85% of the time we can correctly establish site clinically i.e. without tests – if it sounds like a chest infection it is]
  • Blood cultures – really important for guiding the care of our inpatient colleges, esp. to help deescalation, [2 sets are better than 1]

Antibiotics within an hour

  • 33% mortality reduction –  more and more studies demonstrate the benefits of early antibiotic treatment

  • Delay of 2nd dose kills – with longer boarding times in ED waiting for wards we need to remember that second dose it matters.

 

Sedation

Is TCI (Target-Controlled Infusion) the way forward? Basically using an anaesthetic pump to smooth sedation instead of bolusing. Its already be used by non-anaesthetics in several areas and demonstrates lower complication rate than the RCEM sedation audit 0.05% vs approx 4%, when you look across studies.

PROTEDs group are currently doing a feasibility study into its application into the ED, early results show set up is quick, but the sedation time is slow. However, they admit that so far they have been very cautious with their dosing and are looking for optimal dosing regime.

 

Doing the basics well

There were a few pearls to take away.

  • ECG moment artefact – if you get the patient to hold their arms out forward until they are too tired to move the artefact goes away!!
  • Radiology in pregnancy
    • Doses under 50mSV are not harmful to baby
    • CXR is 0.1mSV (10 days background radiation)
    • CT abdo pelvis 20mSV
    • Once again doing the best for Mum is best for the baby
      • Use Ultrasound/MRI where we can but if X-Ray/CT is warranted use it
      • However, when multiple test are required (i.e. trauma) we need to actively monitor how that dose is increasing.

 

Viral Induced Wheeze

Quick Ref Guide

Background

  • Viral respiratory infections are the most common cause of wheezing in infants and young children
  • Risk factors include exposure to tobacco smoke and reduced lung function
  • Although treatment is broadly like treatment for asthma there are some differences

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ED essentials – for newbies

Departmental things

  • Daily huddle happens at 8am, 5pm and 10pm please ensure you are there to present your patients
  • Senior Reviews (ensure the review is documented):
    • Child under 1yr
    • Atraumatic Chest Pain >30yrs
    • Abdo Pain >70yrs
    • Return under 72 hrs (with the same condition)
  • Nursing Roles (unique to ED)
    • Nurse in Charge: They keep our department flowing, and need to know what is happening to your patients. Keep them updated with plans and referrals Or they will pester you.
    • Triage Nurses: They make a triage assessments, set priority and stream the patients to the most appropriate area. (they have <5min/patient). The information they document is really important – read it! But remember its a quick initial assessment and wont be perfect.
    • Multitalented HCA’s: They perform many roles in ED, bloods, cannulas, dressings, PoP’s and much more

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