Category: Medical

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”.

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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)

    1. Bolus – 1.5ml/kg 20% lipid solution over 1min
    2. Then start Infusion – 15ml/kg/hr 20% lipid solution
    3. 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

 

Rabies [notifiable disease]

Recent Incident: Bat contact was not recognized (effectively touching a bat without gloves means treatment is recommended)

Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in  “Rabies-Free” counties the bat population posse a risk.

In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.

Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.

Risk Assessment

To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]

Exposure Category

Combined Country/Animal & Exposure Risk

Treatment

Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.

If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)

 

You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]

Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400

 

 

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Pulmonary Embolism – PE

PE is somehow both the most over and under diagnosed condition. with severity ranging from the questionable sub-segmental PE to the Massive PE (an indication for thrombolysis). So think:

  • Does this presentation sound like a PE? – If not STOP here
  • Pregnant?  – Click Here
  • Do you think this is likely a PE? (if so you can’t use PERC)
  • Does D-Dimer answer  your question? (whats the Wells)
  • Massive PE  – think Thrombolysis
  • Sub-Massive PE – there is lots of debate (involve seniors), locally needs 2 consultant sign off and not considered time critical.

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