In Aug 2021 the treatment of paracetamol toxicity within the trust is due to change, for both adults and children. We will start using the SNAP N-acetyl cysteine (NAC) regime 12hrs, and 2 bags, (instead of the traditional 21hr & 3 bag regime)
Category: Medical
Lower Limb DVT
Signs and Symps
No single feature is diagnostic:
- Single limb oedema – Most specific
- Leg pain – 50% but is nonspecific
- Calf pain on dorsiflexion of the foot (Homan’s sign)
- Tenderness of deep veins – 75% of patients
- Warmth AND/OR erythema (although blanching is possible)
- A palpable, indurated, cordlike, tender subcutaneous venous segment
Read more
NIV (Non Invasive Ventilation)
NIV should be considered for use in patients with a persisting Acute Hypercapnic Respiratory Failures after a maximum of one hour of standard medical therapy.
- Complete the Ad-hoc form
- Increase pressures from Initial 12/5 cmH2O to 20/5cmH2O – as tolerated over 1st hour
However, ICU should be contacted early if the patient has one of the following:
- Asthma – Intubation the option of choice in Life threatening
- Pneumonia – NIV should only be considered as a bridge to intubation
- No pre-exisiting respiratory issue – NIV not likely helpful
- pH <7.25 (low threshold for ICU input)
- pCO2 >6.5kPa (low threshold for ICU input)
- Type 1 Respiratory Failure (low threshold for ICU input)
Proximal Myopathy/Muscle Weakness
The Case
An elderly patient attends the ED with difficulty mobilising, Nursing staff tell you that the patient needs a CT head for STROKE? – “They are really unsteady if they try to stand and they can’t lift their arms up”. Read more
Massive Transfusion Pathway
In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MTP
Remember:
- Do the Basics – don’t forget ABCD
- Inform Transfusion and get someone to run a G&S sample down
- FFP can take up to 45min and platelets come from Leeds
- If you no longer need the MTP – inform transfusion and return products ASAP
High INR
Patients sometimes present to ED or are send to ED due to over anticoagulation with warfarin
1. Is there Major/Significant bleeding?
Yes
- Resuscitate (ABCD)
- Give 5mg Vitamin K IV
- Octaplex Guide
- Treat bleeding and admit to appropriate speciality
Cervical (Carotid OR Vertebral) Artery Dissection
Cervical artery dissection is a rare but significant cause of stroke and headache/neckache, which is easy to overlook. Leading to a typically delay in diagnosis of 7 days. Unfortunately imaging the cervical arteries is not simple, with MRA being the method of choice. Hence these patients must be referred to the “Stroke Consultant”.
LA – Toxicity
We are regularly doing femoral 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
Intralipid – in antidote cupboard (Green Majors treatment room)
-
- Bolus – 1.5ml/kg 20% lipid solution over 1min
- Then start Infusion – 15ml/kg/hr 20% lipid solution
- 5 mins reassess if Cardiac instability/deterioration
- Rpt Bolus 1.5ml/kg over 1min (max 3 boluses inc. initial)
- Increase infusion rate – up to 30ml/kg/hr
- Total Max dose 12ml/kg
Propofol is not a suitable substitute for lipid emulsion
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:la_tox
Scombroid Poisoning- NOT another fishy allergy
Scombroid poisoning (AKA – Histamine fish poisoning) is apparently more common than we think and accounts for 40% of seafood related illness in the USA according to the CDC. But Scombriod poisoning is missed as its put down to allergy. Read more
Aortic Dissection
Aortic Dissection (AD), is uncommon (1 AD:200 ACS) but is…Rapidly FATAL! Unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%. Read more