Sunday, 20 December 2020

Major Incident

 These guidelines from NHS England are excellent and cover triage, METHANE, blast injury and more. They say everything you need to know in one document - read them. 

End of Post

Monday, 30 November 2020

Portal Vein Thrombosis

 Portal vein problems might be caused by portal hypertension - cirrhosis, malignancy or hypercoagulable - prothrombotic conditions, malignancy, oral contraceptive pill, pregnancy, trauma. 

Portal vein thrombosis may present with many things including abdominal pain, nausea and fever, variceal bleeding, and encephalopathy - or be completely asymptomatic.  

Treatment includes observation, anticoagulation, thrombectomy and shunts. Need to prevent thrombus extension and mesenteric ischaemia. May present as an acute ischaemic bowel. 


References
https://www.gpnotebook.com/simplepage.cfm?ID=-1214644198&linkID=27047&cook=no
https://radiopaedia.org/articles/portal-vein-thrombosis?lang=gb
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353656/
https://wikem.org/wiki/Portal_vein_thrombosis
https://journals.sagepub.com/doi/pdf/10.1177/1358863X15611224

Renal Vein Thrombosis

 

Renal vein thrombosis in adults is normally triggered by infection (glomerulonephritis, renal sepsis), amyloidosis, SLE, diabetes, urinary obstruction, tumour thrombus. 

The passive congestion causes the kidney to swell and become engorged and nephrons degenerate causing flank pain, haematuria and decreased urine output. 

Treat by treating cause, and anticoagulation therapy. 

References
https://radiopaedia.org/articles/renal-vein-thrombosis
https://pubmed.ncbi.nlm.nih.gov/30725656/

Friday, 27 November 2020

Brucellosis

 

Mostly from non UK sources, with incubation 5-30 days, but maybe up to 6 months. Comes from unpasteurised dairy products - eating or inhaling airborne components. Take a thorough travel history. 
Previously called Maltese fever. 

Presentation
May be asymptomatic. 
Fever (74%)  may wax and wane
Constitutional  (26%) - fever, malaise, weakness, fatigue, headache, dizziness, myalgia, arthralgia and night sweats. 
Hepatomegaly and splenomegaly (33%)
Maloderous perspiration - almost pathognomic
Peripheral neuropathy, pleural effusions, pneumonia and endocarditis can also be present.

Rarely prostatitis or sacroillitis, epididymo-orchitis, pneumonia, hepatitis, endocarditis, uveitis, dermatitis and meningitis. 

Diagnosis
Blood culture in 20-80%
Serology, PCR testing
Leucocytopenia, lymphocytosis, thrombocytopenia or anaemia 

Treatment
Gentamycin for 7 days + doxycycline
Rifampin + doxy
Cipro + doxy


References
https://webarchive.nationalarchives.gov.uk/20140714100821/http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733811188  
http://southlondonem.blogspot.com/2014/07/fever-in-returning-traveller.html 

http://klossandbruce.com/graphic-guide-to-infectious-disease/ 
https://www.who.int/news-room/fact-sheets/detail/brucellosis 
https://en.wikipedia.org/wiki/Brucellosis 

Wednesday, 27 November 2019

Pain

Pain management is something we're really bad at doing, and even worse at documenting!

Assessment
Use a pain scale, or a pain ruler

Remember that pain has an emotional as well as physical component. When you catch your thumb in a door you shake it and look at it. If it does not bleed too much but still wiggles and the pain goes quickly, then that is mostly "red" - physical. However the longer a pain lasts the more the emotional component becomes part of the problem.
The emotional component is made up of three aspects. There is anxiety and worry and typically we worry about two things. We worry about the "meaning" of the pain, why is it there, what is causing it, what is going on. Then we worry about the future and how the pain will affect us and our lives and our work and relationships.
Pain also makes us unhappy, although not necessarily depressed. This typically occurs in three ways. It affects us directly to make us miserable. It commands our attention, both consciously and subconsciously so we are listening for the pain thus hearing it louder and more often. Finally it isolates us socially.
The final aspect of the emotional component is the frustration that accompanies it. We become frustrated that it does not go away, that promised cures do not work, and that that life gets worse.
Thus, the physical component can be viewed as the transmission of the message up to the brain and the emotional component can be viewed as the unpleasantness experienced. Of course the degree of disability and the behavioural changes are subsequent phenomena.

Physiology
Pain is felt, and travels up the spinothalamic tract to the thalamus.

Treatment
Use WHO analgesic ladder
Combining two weak opioids isn't considered good practice.

References
https://www.frca.co.uk/article.aspx?articleid=100118
https://www.frca.co.uk/SectionContents.aspx?sectionid=148
https://www.paintoolkit.org/
https://www.change-pain.co.uk/
https://www.bscah.com/

Treatment
Use the WHO analgesic ladder


Tuesday, 26 November 2019

Hypothermia

Awake and Conscious Patient 
Assess symptoms:
Investigations:
Put the temperature on the gas machine
Look for J waves (osborn). The upward deflection of the terminal S wave (at the junction of the QRS and the ST segment) occurs at or near 32 C. It is first seen in leads II and V6.

Treatment:
Rewarming - consider bypass in cardiac arrest, haemodynamic instability and a core temperature below 32°C, frozen extremities and rhabdomyolysis with hyperkalaemia.
Treat electrolyte disturbances - being careful of hypokalaemia as potassium will increase with re-warming
Remember coagulopathy is common
Haemocrit will rise.

Frostnip
Frostbite
Treat with 40 degrees water, aspirin

In cardiac arrest 
Don't give up too soon. Watch this great youtube video. It's true!




Further Reading 
https://www.rcemlearning.co.uk/reference/hypothermia/
https://www.rcemlearning.co.uk/modules/severe-hypothermia/
https://www.rcemlearning.co.uk/modules/hypothermia-and-frostbite/
https://www.rcemlearning.co.uk/modules/a-systematic-review-of-therapeutic-hypothermia-for-non-shockable-cardiac-arrest/
https://www.rcemlearning.co.uk/foamed/emergency-casebook-its-cold-outside/
https://theresusroom.co.uk/hypothermia-2/
https://theresusroom.co.uk/hypothermia/

Wednesday, 20 November 2019

BNP

BNP is produced by cardiac myocytes in response to stretch which occurs in impaired diastolic or systolic function. BNP may play an important role in acute cardiac failure. BNP assays can supplement clinical judgment when the cause of a patients dyspnoea is uncertain. Results should be interpreted in the context of all available clinical data. The role of BNP in chronic heart failure is, however, well established for diagnosing, staging and risk stratifying patients.

BNP has reasonable sensitivity and therefore can be used to rule out heart failure as a cause of a patients breathlessness (in a primary care setting for example) but it is not very specific and therefore not useful for ruling the diagnosis in. BNP rises due to sepsis, renal or liver failure, hypoxia, myocardial ischaemia, tachycardia as well as many other reasons. In hyperacute or flash pulmonary oedema or acute mitral regurgitation the BNP level may not be elevated initially.
NT-proBNP is useful in differentiating between respiratory and cardiac disease in infants. It may be a good cardiac marker. May be useful for pneumonia prognostication. Can help risk assess PEs, although troponin is probably more sensitive so it's generally not considered useful.  It is a marker of secondary myocardial injury.

Interestingly: *Low risk patients do not need specific right ventricular (RV) functional assessment but where RV dilatation has been identified on CT or Echo in patients otherwise suitable for outpatient management, consider measuring BNP, NT-proBNP and hsTnI or hsTnT. Elevated biomarkers should prompt inpatient admission for observation. Incidental elevated troponin requires senior review and consideration of an alternative cause to the elevated troponin.


Probably adding noise to an already uncertain baseline. Sensitive but not specific.

https://bostoncityem.com/2017/04/11/night-school-bnp/
https://bostoncityem.com/2017/04/11/night-school-bnp/
https://first10em.com/bnp/
https://journals.lww.com/em-news/Fulltext/2016/04000/Myths_in_Emergency_Medicine__Natriuretic_Peptides.3.aspx
https://www.rcemlearning.co.uk/reference/chest-pain-low-risk-rule-out-pathways/#1568646432127-2dba9437-c8a1
https://twitter.com/RCEMLearning/status/581027630171836416
https://www.rcemlearning.co.uk/foamed/rcem-belfast-day-3/
https://www.rcemlearning.co.uk/foamed/my-patient-has-a-pulmonary-embolism-pe-can-i-still-send-them-home/#1538476808262-0c227bea-56b4
https://www.rcemlearning.co.uk/reference/cardiogenic-pulmonary-oedema/
https://bestbets.org/bets/bet.php?id=1136
https://bestbets.org/bets/bet.php?id=3032
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https://www.rcemlearning.co.uk/foamed/october-2018/#1538341979127-68faa802-c841