Vertigo is not always labyrinthitis!! There are some potentially serious conditions to think about. Your main question should be is it peripheral [good] or central [bad]?
Category: speciality
Giant Cell Arteritis – GCA
GCA is a is a vasculitis generally seen in the over 50’s and associated with polymyalgia rheumatic (PMR). However, unlike a lot of rheumatology, GCA is far from a benign condition that can be passed back to the GP’s, it can lead to some significant problems
- Sudden irreversible visual loss
- Development of thoracic aortic aneurysm
Methaemoglobinaemia
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
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
Retrobulbar haemorrhage
What is retrobulbar haemorrhage?
- Rapidly progressing haemorrhage into the retrobulbar space which is rare but potentially sight threatening.
- Retrobulbar haemorrhage causes a rapid rise in intraorbital volume and pressure.
- If not treated it can quickly lead to retinal ischaemia and infarction resulting in permanent visual impairment or complete visual loss.
Measles
Suspected/Confirmed patients should be ISOLATED & wear PPE
Treating Staff – (should not be; non-immunised, pregnant or immunocompromised)
- single-use, disposable gloves
- single-use, disposable apron (or gown if extensive splashing or spraying, or performing an aerosol generating procedure (AGP))
- FFP3 – respiratory protective equipment (RPE)
- eye/face protection (goggles or visor)
Patient
- Surgical face mask
Background
- Measles is highly infectious – (4 day prior to and after rash appears) suspected patients should be isolated within the ED
- Measles Immunisation – 1 dose 90% effective, 2 doses 95% effective
- Measles is a notifiable disease
PEARS
Rhabdomyolysis
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
Hypocalcaemia
Hypocalcaemia can life threatening, due to arrhythmias and seizures.
Severity – Adjusted Calcium (Ca)
- Mild: >1.9mmol/l
- Severe: ≤1.9mmol/l OR Symptomatic
Primary Intracerebral Haemorrhage
In anybody who there is suspicion of a non-traumatic haemorrhage arrange an urgent CT Head.
All patients need IV access and U&E, FBC, Coag
If CT confirms PICH (not traumatic, not SAH): –
Anticoagulation
If anticoagulated with warfarin or NOAC discuss with stroke consultant and Haematologist regarding reversal
If not anticoagulated give Tranexamic acid – 1g in 100mls Saline/Glucose over 10 mins followed by 1g in 250mls Saline over 6 hours.
Blood Pressure
BP needs to be <150/80 – use labetalol (max 400mg – until BP <160 or HR <50) and GTN infusion
Neurosurgical Referral
Not all patients with intracerebral bleeds need referral to neurosurgery – you could save yourself and your patient a lot of time and effort!
Those to refer:
- GCS 9-12/15 with lobar haemorrhage
- Isolated intraventricual haemorrhage
- Hydrocephalus on presentation
- Rapid deterioration following arrival (gcs drop by 2 points or more in the motor component)
- Cerebellar bleed
Admit those not going to Neurosurgery to HASU at CRH after discussion with Stroke team
