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Running insitu SIM at CHT means we to learn and share our learning
@cazandal, @chftedsim
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:
Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.
Q: Why are Smurf’s Blue?
A: Methaemoglobin (MetHb) of course!
– MetHb is produced by oxidisation of the Iron in Haemoglobin (Hb) from Fe2+ to Fe3+
– Fe3+ prevents Hb carrying oxygen (thus produces symptoms of hypoxia)
– Often due to chemical ingestion, but may also be genetic
– Treated with Methyl Blue & supportive measures
Hypernatraemia is a not a common presentation in ED, as intense thirst often prevents significant hypernatraemia in neurologically intact individuals. So… Mortality rates are high (20-70%) and the severity of hypernatraemia has been shown be an independent predictor of mortality.
However, there is little good data on hypernatremia to base guidance on, and definitions vary within the literature
In the UK approximately 100 people are envenomated by a snake each year.
So what do you need to do if your patient has received a venomous bite from a snake? (not the classic UK cocktail).
We often worry about patients developing rhabdomyolysis and consequently developing AKI. However, there is much debate and little consistency in the published data, over how to diagnose and who needs admission to treat. So its important to consider both clinical context along with laboratory values
Those suspected of concealing illicit drugs often present near ports and borders however they can present to any ED or be brought in by the police.
Body Packers – Swallow large quantities of well packaged drugs to smuggle them into countries or institutions. These are often well manufactured with a low risk of rupture but the potential for serious toxicity if rupture occurs.
Body Stuffers – Swallow small quantities of poorly packaged illicit substances often at the point of arrest to conceal them. These have a much high risk of package rupture but involve smaller quantities of substances.
Authorisation for an intimate search or radiological investigation must come from an inspector or higher with written consent from the patient.
Intimate searches must be carried out by a police surgeon but require immediately available resuscitation facilities therefore may be conducted in the ED. ED physicians should not handle the drugs at any time.
AXR or low dose CT scanning can be used to detect concealed packages in Body Packers.
Try to obtain a history of what and how much has been concealed
Look for toxidromes suggestive of package leak –
ECG
Body Stuffers should be observed for signs of toxicity for a minimum 6 hours, consider activated Charcoal
Body Packers with positive imaging who are asymptomatic can be discharged back to police custody for monitoring. Bowel preparation such as Cleanprep or movicol can be used.
Toxidromes should be treated as per toxbase guidelines Toxbase
Body Packers with signs of cocaine or amphetamine toxicity or signs of obstruction/ileus require urgent surgical intervention.
Body packers with signs of Heroin toxicity should be treated with Naloxone infusion as per toxbase guidelines
Remember: is it a haemolysed blood sample? (you can do an iSTAT)
Severity
