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Think -TB

The prevalence of Tuberculosis in our region is increasing and has significant issues for both the patient and public health if we miss it.

Symptoms

  • Cough
  • Fever
  • Night Sweats
  • Lymphadenopathy
  • Weight loss

High-Risk factors to consider

Characteristics

  • Previous/Latent TB
  • TB Contact
  • Immunocompromised
  • Substance Misuse
  • Homeless/Prision
  • Pubs – esp. Vulcan Hudds

Travel/Ethnicity

  • Eastern Europe
  • India/Pakistan
  • East Asia
  • Africa

CXR Changes

  • Upper Lobe Consolidation
  • Hilar Lymphadenopathy
  • Cavities

Actions

  • Provide 3 AFB samples – Ideally performed in ED/Ward (but if patient fit for discharge and unable provide samples in ED give patient pots and request which they return to their GP.
  • Don’t Commence TB treatment – unless instructed by respiratory team
  • If admitted isolation requested
  • If discharged Patient told to isolate and if must go into public wear face mask
  • Contact TB team:
    • Huddersfield/Halifax – Based on GP postcode
    • In-Hours: either through Switch board or as EPR referral
    • Out of Hours: Though EPR referral
    • They will ensure appropriate notification of Public Health

Huddersfield

  • Dr Anneka Biswas
  • Chantelle Lashington
  • Deborah Howgate

Halifax

  • Dr Nicholas Scriven
  • Mary Hardcastle
  • Manjinder Kaur

LA – Toxicity

We are regularly doing blocks next to major vessels. So warn the patient of the symptoms, & keep them monitored(at least 15 min).

Symptoms of local anaesthetic toxicity

  • Circumoral and/or tongue numbness
  • Metallic taste
  • Lightheadedness/Dizziness
  • Visual/Auditory disturbances (blurred vision/tinnitus)
  • Confused/Drowsiness/Fitting
  • Arrhythmia
  • Cardio-Resp Arrest

Remember – Do basics WELL

Without Cardio-Resp Arrest

Use conventional therapies to treat:

  • Seizures
  • Hypotension
  • Bradycardia
  • Tachyarrhythmia (Lidocaine should not be used as an anti-arrhythmic therapy)

In Cardio-Resp Arrest

  • CPR – using standard protocols (Continue CPR throughout treatment with lipid emulsion)
  • Manage arrhythmias – using standard protocols
  • Consider the use of cardiopulmonary bypass if available
  • Recovery from LA-induced cardiac arrest may take >1 h
  • Lidocaine should not be used as an anti-arrhythmic therapy

PDF: Quick Reference Handbook – Guidelines for crises in anaesthesia

 

Malignant/Accelerated Hypertension

There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)

Patient has both:

  1. Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
  2. End-Organ Damage: Retinal Changes, Encephalopathy, Heart Failure, Acute Kidney Injury, etc.

Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.

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Acute Behavioural Disturbance / Excited Delirium

Most of us will have seen patients like this – agitated, aggressive and often with police or security pinning them down.

  1. High risk of Cardiovascular Collapse/Death – likely due to adrenaline surge, heat exhaustion and injury. It can happen very suddenly.
  2. Keep physical restraint to a minimum – Don’t allow patient to forced face down, it’s the most likely way of killing them.
  3. Tranquilisation vs Sedation – Obviously oral tranquillisation is our first step, however, this is not always practical and needs to have a senior review and dynamic risk assessment .
  4. Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC

Refusing treatment = Mental Capacity Assessment [LINK]


The Trust Guide: Rapid Tranquilisation give a full in-depth guidance on tranquillisation and steps leading up to this. It also outlines altenitive oral and IM medications.

RCEM -abd  Provides more in-depth guidance on those patients heading toward sedation

 

 

Acute Heart Failure (AHF) – ESC

Patients presenting with AHF have a high mortality 4-10% in-hospital and 25-30% at 1yr, and 45% if re-admitted. So rapid diagnosis a treat is essential.

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

ESC Guide – 2021 Heart Failure

Presentations

Decompensated Heart Failure

Isolated Right Vent-Failure

Pulmonary Oedema

Cardiogenic Shock

Managment

Treatment – Time Matters!!!

  • Mortality increased by 1%/hour IV treatment not started

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)

Oxygen
  • Not all patients should be given Oxygen ESC suggest maintain SaO2 >90%
  • Early NIV is suggested if any of:
    • RR >25bpm or SaO2 <90% despit oxygen
    • Signs type 2 respiratory failure

Metanalysis suggests early NIV may reduce need for intubation and improve mortality

NIV Guide-HERE

Diuretic

Vasodilator

Inotropes

Hypomagnesaemia

Classification

  • Normal: 1.1-0.7
  • Mild: 0.69-0.5 – No symptoms or non-specific symptoms, such as lethargy, muscle cramps, or muscle weakness
  • Severe: <0.5 – Severe neurologic symptoms such as nystagmus, tetany, seizures, and cardiac arrhythmias

Signs/Symps (normally <0.5)

  • MSK: Muscle Twitch, Tremor, Tetany, Cramps
  • CNS: Apathy, Depression, Hallucination, Agitation, Confusion, Seizure
  • CVS: Tachycardia, Hypertension, Arrhythmia, Digoxin Toxicity
  • BioChem: Hypokalaemia, Hypocalcaemia, Hypophosphataemia, Hyponatraemia

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Mental Capacity Act (2005)

Applies to all over 16’s

Principles

  1. Everyone is presumed to have capacity – until a lack of capacity has been established
  2. All practical efforts have been made to help patient make a decision
    • Explain decision and options as clearly and concisely as possible (be flexible)
    • Make every effort to help the person understand (language line, writing, etc.)
    • Are there others who might help them understand? (nursing, medical, family, freinds)
  3. People are free to make an unwise decision
  4. Anything done under the act MUST be in the patients best interest
  5. Carefully consider what is the least restrictive option

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Ingested Magnets

Ingestion of Strong Magnets is a TIME CRITICAL EMERGENCY

(Multiple Magnets OR a single Magnet and Metallic Objects)

If unsure if magnet classes as a strong magnet ask to see others from parents. If clearly not a strong magnet from the rest of the alphabet letters parents have provided please manage as per Ingestion of Foreign Body and avoid unnecessary radiation. If there is any uncertainty follow the policy below!

Strong magnets  (such as Neodymium)

  • Now common place around the house
  • From; fridge magnets to toys and peicings

Ingested:

  • Intestinal injury can occur within 8-24 hours
  • However, symptoms may take weeks to develop
  • Symptomatic patients are a SURGICAL emergency

Detection:

  • 2 views – to determine number of magnets (if in doubt assume multiple)

RCEM recommendation (best practice)

Swallowed Foreign Body – Metal Detector

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