Please see the updated SOP for Middle East respiratory syndrome coronavirus. Make sure you are familiar with this protocol and for anymore information please contact the Infection Control Team.
Category: Medical
Rare Antidotes – how to get
Getting some of the rarer antidotes has recently been clarified across Yorkshire (Accessing rarely used antidotes-SOP)
Pulmonary Embolism in Pregnancy
Unfortunately the the normal pathway for investigation of PE performs poorly in pregnancy RCOG have the following pathway
1. Investigation – of suspected PE
- Clinical assessment – its all on the history and exam scoring doesn’t work
- Perform the following tests:
- CXR – sheilding can protect the baby and may avoid further radiation
- ECG
- Bloods: FBC, U&E, LFTs, Clotting
- Commence Tinzaparin (unless treatment is contraindicated – use booking weight to calculate dose) –[BNF]
Be #urosceptical
Ditch the Dipstick – for patients >65Yrs or Catheterised!
Approx. 50% of over 65’s and most of those with catheters have asymptomatic bacteriuria. The patient will not benefit from treatment and often gives us premature closure (i.e. we blame a fictitious UTI for the patients symptoms and stop thinking). Read more
Hypoglycaemia – Adult
Hypoglycaemia (Blood glucose under 4.0 mmol/l) is potentially fatal and should be treated. it may be defined as “mild” self-treated, or “severe” treated by a third party i.e. you.
Hypoglycaemia is a common side-effect of insulin and sulfonylureas (they start with gli-) as they both work by lowering glucose concentration in the blood. Other diabetic medications work by preventing glucose rise, thus posing a lesser risk.
Signs & Symps
- Autonomic: Sweating, Palpitations, Shaking, Hunger
- Neuroglycopenic: Confusion, Drowsy, Odd behaviour, Incoordination, Speech difficulty
- General: Nausea, Headache
Risk Factors
- Medical:
- Diabetic: Strict control, Long term Insulin, Lipohypertrophy at injection sites,Impaired awareness of hypoglycaemia
- Organ dysfunction: Severe hepatic dysfunction, Renal impairment, Cognitive dysfunction/dementia, Endocrine (Addisons, hypothyroid, hypopituitary)
- GIT: Gastroenteritis, impaired absorption, Bariatric surgery
- Medication: Concurrent use of medicines with hypoglycaemic agents e.g. warfarin, quinine, salicylates, fibrates, sulphonamides (including cotrimoxazole), monoamine oxidase inhibitors, NSAIDs, probenecid, somatostatin analogues, SSRIs.
- Sepsis
- Terminal illness
- Lifestyle:
- Reduced/Irregular intake: Poor diet, Irregular lifestyle, Alcohol
- Increased use: Exercise (relative to usual), Early pregnancy, Breast feeding
- Poor control: Increasing age, No or inadequate blood glucose monitoring, Alcohol
Treatment
Conscious & Orientated
- 15-20g fast acting glucose
- 4-5 jelly babies
- 3-4 heaped teaspoons of sugar dissolved in water (milk delays absorption)
- 150-200ml fresh fruit juice
- Rpt Blood Glucose 10-15min
- if blood glucose remains <4.0mmol/l step one may be repeated up to 3 times in total
- Blood Glucose remains <4.0mmol/l
- 150-200ml 10% Glucose IV
- 1mg Glucogon IM (if starved or sulfonylureas may not work well)
- Blood Glucose >4.0mmol/l – Give long acting Carbs
- 2 Biscuits
- 1 Slice bread/toast
- 200-300ml milk (not soya)
- Meal
- Don’t omit insulin injections
- Diabetic review: most patients can be followed up by diabetic nurses but some may need admission.
- Patient Advice Sheet
Conscious but agitated, confused, unable to cooperate
- If patient CAN cooperate – follow guide above
- If patient CAN’T cooperate
- 1.5 -2 tubes 40% glucose gel (Glucogel) squeezed into the mouth between the teeth and gums (can be substituted for step 1 above)
- 1mg Glucogon IM (if starved or sulfonylureas may not work well)
- Follow subsequent steps as above
Unconscious, seizures, very aggressive
Start at step 3 above (while managing ABC), the choice of whether to use IV glucose or IM glycogen will be determined by practicality of achieving IV/IO access.
Although you will need to follow the remaining steps the patient will almost certainly require admission.
Reference
Sickle Cell Crisis
Painful Crisis
Severe pain is the most common reason that patients with sickle cell, will attend the ED. The pain can be agonising (and often underestimated by us), we need to act fast to help ease the symptoms Read more
Notifiable Diseases
Registered Medical Practitioners in England and Wales have a statutory duty to notify Public Health about the following diseases. To facilitate rapid treatment and control of outbreaks. (Links to Wikipedia for illustrative purposes) Read more
Pre-Arrival Blood (O-ve)
On rare occasions you may receive a pre-alert, where you want blood available for the patient when they arrive (for example in major haemorrhage). This process has been agreed with transfusion so this can be done safely and responsibly. Read more
1. Why we get things wrong – “A tale of two systems”
Very few of us come to work intent on doing harm. However, despite that we all keep making mistakes. Most of them pass unnoticed and do little harm, although we are all aware the times they don’t, and it is not only the patient that suffers. Read more
Are You CO Aware?
With the onset of colder weather, many households in the UK are turning on their heating for the first time in months. Heating appliances need chimneys and flues to work safely – and these can block up over the summer months. So autumn is traditionally the period when people get poisoned by carbon monoxide (although it can happen any time of the year!)
Carbon monoxide (CO) is produced when anything containing carbon burns or smoulders. For practical purposes, this means the burning of any kind of fuel, commonly:
- Gas
- Coal
- Wood/Paper/Card
- Oil/Petrol/Diesel – (All UK cars have a ‘catalytic converter’ in the exhaust system, which converts carbon monoxide (CO) to carbon Dioxide (CO2), which is less poisonous. However, these converters need to warmed up – a cold car produces fatal amounts of CO in the exhaust)
CO is very poisonous. Exposure to as little as 300 parts per million (that’s just 0.03%) can prove fatal.
