Category: Medical

COPD – exacerbations

COPD patients vary widely, due to their comorbidities, social circumstances, and wishes. So choosing the best treatment pathway for the patient can be complex. Involve senior decision makers.

Questions

  • Is hospital the best place for them?
  • Do they need NIV?
  • Are they dying? – would you want to die surrounded by strangers or with your family?

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Rash/Derm Guide

Guide Taken from the Primary Care Dermatology Society(PCDS) other good sourse is DermnetNZ.

A relatively easy way to find out what you’re looking at!

Rash – Apearance
Rash – Site
Lesions

Brown/Black/Blue

Red/Pink/Purple/Skin Colour

White

Yellow

Orange

Skin Conditions (DermnetNZ – a bit clunckier)

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. Sedation – if you’re restraining you will almost certainly need to sedate. IV is best but if access is too risky IM will have to do.
  4. Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC

Refusing treatment = Mental Capacity Assessment [LINK]


DrugRouteTypical Dose (mg)Onset (min)Duration (min)Warning
MidazolamIV2-51-530-60Respiratory depression, IM unpredictable onset
IM510-15120-360
LorazepamIV2-42-560-120
IM415-3060-120
HaloperidolIV5-1010180-360Arrhythmia Risk: Only if previously used OR ECG
IM10-2015-30180-360
KetamineIV1-2mg/kg120-30Theoretical risk of worsening cardiovascular instability
IM2-4mg/kg3-560-90

PDF:abd

Myocardial Infarction (MI) – PPCI/Thrombolysis

PPCI (Leeds PPCI Pathway)

  • Target: Door to balloon 90min
  • Criteria:
    • Time: Chest pain within 12hrs (or worsened within 12hrs)
    • ECG:  ST elevation MI (1mm Limb or 2mm Chest leads) OR New LBBB. (Posterior MI do posterior leads and discuss with LGI)
  • Actions:
    • Resuscitate
    • Contact PPCI team @ LGI (Mobile No. up in Resus)
    • Arrange blue light (P1) ambulance to LGI
    • Prasagrel 60mg if no previous CVA or Ticagrelor 180mg if previous CVA and Aspirin 300mg (if anti-coagulated Discuss with PCI team)
  • Problems: 
    • Intubated patient: Often LGI would accept but need to arrange Cardiac ICU. If no bed patient could go for PCI to return locally immediately after PCI to our ICU’S?
    • LGI Full: Occasionally the cath lab is full and can’t accept your patient
      • Calling Manchester and Sheffield: It’s worth a go but they don’t have agreements with us  so having your patient accepted can be difficult
      • Don’t Forget Thrombolyisis: We need to open up the patients artery, if there is no quick decision to go for PPCI – Consider Thrombolysis

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Alcohol Withdrawl

Generally we DON’T admit patients acutely solely for “Detox”

However the following groups should be admitted [taken from trust guide]

  • Patients requiring admission for another reason – refer to appropriate specialty (e.g.  Head injury going to CDU, or Upper GI bleed going to medicine)
  • ALL patients with symptoms / signs of Wernicke’s – medicine
  • ALL patients with Delirium Tremens – medicine
  • ALL alcohol withdrawal fits if patient to remain abstinent – medicine
  • ALL alcohol related seizures with possible other trigger – medicnie
  • ALL decompensated alcoholic liver disease – medicine

If admitted to CDU – complete the PAT tool

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Bell’s Palsy

Bell’s Plays is a lower motor neurone (LMN) lesion of the facial nerve (CN VII), which causes one side of the face to “droop” [1% of cases are bilateral], and patients are often concerned that it is a stroke.

However, unlike in stroke the whole face is affected, in stroke and other upper motor neurone (UMN) lesions the upper portion of the face is unaffected due to input from both sides of the brain. Read more

Hypokalaemia

Hypokalaemia (low potassium), is a common problem. It is found in 14% of outpatients and 20% of inpatients, however only 4-5% of those are of clinical significance.

Severity

  • Severe: <2.5 mEq/l OR Symptomatic – Look for Hypomagnesaemia
  • Moderate: 2.5-2.9 mEq/l (No or Minor symptoms)
  • Mild: 3.0-3.4 mEq/l  (Usually asymptomatic)

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