Category: Medical

Medical SDEC

Note: If the referrer feels the presentation of a patient is not within the inclusion/exclusion criteria they can still contact the SDEC co-ordinator and check for acceptance into SDEC.

  • ED referrals ONLY 08-18:00
  • Check Capacity prior to sending
  • Investigations: FBC/U&E/Clotting/ECG

Read more

LVAD – Resus & Troubleshooting

ctsurgerypatients.org

LVADs (Left Ventricular Assist Device) are becoming more common and there are patients in our region with them as a bridge to transplant or recovery and in some cases a destination therapy.

The patient and their family will likely know more about this device than you and should have brought spare parts. Our local LVAD centre is Wythenshaw however, there are other units around the country the patient may direct you to.

The patient may not have a palpable pulse, the blood pressure will be low and the heart pump sounds like a buzz when you listen.

If patient is unresponsive or has a history of collapse its important to troubleshoot the device and resusitation may be required

Read more

Asthma – Adult

  • Severity – Severe or Life threatening – think RESUS
  • Treatment within 30 min – bronchodilators and steroids should bee given within 30min
  • 1hrs Observation after Neb – better after a neb don’t just send home they may deteriorate when it wears off.
  • PEFR – must be >75% expected prior to discharge (at least 1hr after treatment finished)
  • Discharge advice sheet – can print off from this guide, remember to check inhaler technique and consider a spacer

Read more

Atrial Fibrillation/Flutter (AF)

Before you start 

  • Whats the cause? – treating the precipitant often sorts the AF (adding B-Blockers to Sepsis can make things worse)
  • Stable or Unstable?  – Electricity vs. Drugs
  • CHADS-VASC vs. ORBIT– Anticoagulation (previously HAS-BLED)
  • Rhythm vs. Rate control??
  • NEW Symptomatic Arrhythmia Clinic [6-8weeks] – referral form attached tho the PDF

Read more

Nitrous Oxide Induced Neurotoxicity

Nitrous Oxide  has been used clinically and recreationally since its discovery in 1772. Since then Nitrous Oxide induced neurotoxicity have been reported, and has been shown to be dose depaendant. With infrequent users unlikely to be at risk of neurotoxicity, while heavier and habitual used at risk of serious neurological conserquences.

With the increase in recreation use of “Whippits” we need to remember to take a detailed recreation drug history when seeing patients presenting to ED with neurological symptoms. As Nitrous Oxide induced neurotoxicity is treatable.

Presentations

Nitrous Oxide induced neurotoxicity can present as either spinal cord demyelination , peripheral neuropathy or a a combination of the two.

  • Demyelination of the dorsal columns of spinal cord 
    • Typically onset is subacute  (i.e. weeks), but acute onset has been reported in the literature
    • Typically symmetrical but can be unilateral
    • Signs
      • Pyramidal weakness – weak upper limb extensors, and lower limb flexors
      • Dorsal Column Sensory loss – Vibration, Proprioception, Fine touch
      • Sensory Ataxia – Incoordination due to loss of proprioception and weakness
    • Level – Most frequently cervical 4-6 levels, but can affect any.
  • Peripheral Neuropathy
    • Typically Symmetrical (but not always)
    • Sensory loss (often painful)
    • Distal Weakness
  • Optic Neuropathy  – has been reported and may present with visual disturbance.

Pathophysiology

Nitrous Oxide usage can render vitamin B12 inactive, which in-turn disrupts myelination, causing the demyelination of nerves.

Differentials

  • Deficiencies: B12, Folate, copper, zinc
  • Inflammatory: Guillian-Barre syndrome, MS, Neurosarcoidosis
  • Infection: HIV, Syphilis
  • Cancer
  • Vascular: Spinal cord ischaemia, vasculitis

Tests

  • Vitamin B12 level (often in normal range)
  • Homocysteine and Methylmalonic Acid Level (not available in ED)
  • MRI – contrast enhanced

Treatment

Start before Tests are back (i.e. on clinical suspicion)

  • IM Vitamine B12 1mg OD
  • PO Folic Acid 5mg OD

Follow-up

  • Discuss admission with Medical team as potential for SDEC management
  • Treat until clinical improvement(King’s Team noted the following)
    • Sometimes treat for 5-7days only
    • Often switch to alternate days IM Bit B12
    • Can teach to self administer
  • Further Testing
    • Homocysteine and Methylmalonic Acid levels – often improve quickly
    • MRI often lags clinical improvement endnote necessary to repeat
  • Majority Improve clinically – but futureabstinence is often challenging

 

References