Vascular Ischaemia

Physical Exam
Cardiac - murmur, AD
Extremity - look for signs of chronic peripheral vascular disease
Neurological - sensory and motor loss
Vascular - grade peripheral pulses
ABPI

Amputations are more common with thrombotic occlusions.
Emboli are different - and most often from the heart and comprised of platelets. They can also come from aneurysms - and will be made of atheroma.
Vasculitis, iatrogenic, compartment syndrome, aortic dissection are also risk factors.

Upper arm emboli are less common. Thoracic outlset syndrome may masquerade - pressure on the subclavian artery from a cervical rib or abnormal soft tissue band may lead to a dilatation lined with thrombus, predisposing to occlusion or embolisatoin.  Popliteal aneurysms are very likely to be dislodged.

PAIN - worse on movement, and relieved by hanging your legs over the edge. Tenderness on examination is often due to muscle death.
PALLOR - limbs are often white. Chronically ischaemic limbs may turn sunset pink due to compensatory response. Dry gangrene is black, and a sign of chronic ischaemia for more than two weeks.
PARAESTHESIA-
PERISHINGLY COLD - compare
PULSELESSNESS - use dopplers

Check bloods including a creatinine kinase.

Treatment: Analgesia, Oxygen, 5000 units IV heparin, heparin infusion, IV fluids
   Unless bleeding, pregnant, CVA/TIA, tumour, previous GI bleed, trauma

References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117769/
https://www.rcemlearning.co.uk/references/acute-limb-ischaemia/
https://learning.bmj.com/learning/module-intro/aae-arterial-disease.html?moduleId=10057018&searchTerm=%E2%80%9Cvascular%E2%80%9D&page=1&locale=en_GB

Sexual Assault and STIs

As a presentation to ED, I don't think sexual assault is that common, and the brief mention in the curriculum probably supports that. Sexual assault is maybe underrepresented and more common than we think.

Treatment of sexual assault in ED. #EMConf #FOAMed pic.twitter.com/r0J740Nb7T

— David Lewandowski (@DaveLewMD) November 29, 2017

Sexual Assault
- Examine carefully including in the mouth and treat any injuries - consider liasing with SARC for forensic samples to be taken before irrigating wounds if appropriate.
- Advise patient not to wash or bathe, eat or drink - as it will affect samples
- Refer to SARC if patient wishes to attend. The investigations may take three hours. DNA can be gathered for up to seven days after vaginal penetration, up to two days in oral penetration and for up to three days in anal/penile penetration irrespective of washing or bathing
- Offer emergency contraception
- Safeguarding referrals
-Accelerated Hep B - one now, one month, two month
  If high risk Hep B immunoglobulin
- Bloods 3 months after exposure
- Consider PEPSE
- STI prophylaxis -  Cefixime 400mg + Azithromycin 1g + Metronidazole 2g as single oral stat
 (pregnant or breastfeeding women Cefixime 400mg + Azithromycin 1g).


Domestic Violence
SAFE Questions
S tress/Safety Do you feel safe in your relationship?
A fraid/Abused Have you ever been in a relationship where you were threatened, hurt, or afraid?
F riend/Family Are your friends aware you have been hurt?
E mergency Plan Do you have a safe place to go and the resources you need in an emergency?

Sexually Transmitted Infections
Reactive Arthritis aka Wegener's aka Reiter Syndrome 
2-6 weeks following infection (Chlamydia, salmonella, shigella, yersinia, campylobcater)
Symmetrical arthritis, knees, ankles, feet and heels
Triad - can't see, can't pee, can't climb a tree.
 Conjunctivitis or uveitis
 Dactylitis
 NSAIDs

Gonococcal Arthritis often causes septic arthritis

Other STIs
Our curriculum says we need to know the main types. I think that seems sensible...although actually, all we really need to know I think is test test test.

And secondary syphilis is making a come back.   

Herpes Zoster
Significant exposure
- infected people with exposed or disseminated lesions, or those with compromised immunity are more likely to shed the virus. Low risk of contracting the virus from the zozster rash under clothing.
- Infectious 48hrs before until crusts.
- Closeness and duration of the contact - face to face or contact in the same room for >15minutes.

Gonorrhoea
The clap. Causes urethritis and cervicitis. Can get extragenital infection in the rectum, pharynx, and conjunctiva. It can disseminate to cause polyarthritis, tenosynovitis and detrmatitis or septic arthritis. Disseminated gonococcal meningitis and endocarditis can occur but are rare. Treat!

Anogenital warts- condylomata acuminata
90% caused by HPV6 and 11. Most are asymptomatic, and warts are mostly painless. Can confirm with biopsies.

Syphilis
10- 90 days incubation.
Primary infection - chancre
Secondary - 4 - 10 weeks later with a symmetric, non-pruritic, reddish pink rash. Condylomata latum may appear. Resolve over 3-6 weeks and disease becomes latent.
Tertiary Syphilis - 3 - 15 years later. Neuro, cardiovascular, or gummas - growths in skin, liver or bone. May get argyl robertson pupil. May cause anerysms. May get snuffles. Test for it - and treat with ben pen.

Chlamydia
Often silent. Can infect the eye causing trachoma.

Herpes Simpex
Incubation 2- 12days. Lifelong infection. Acyclovir can help. Can get skin to skin or skin to mat transmittion. Causing whitlow, eye problems and mouth and gums.

Trichomoniasis
Women more than men. Give metronidazole. Get frothy green smelly discharge.

References
https://www.rcemlearning.co.uk/modules/sexual-assault-victims-in-the-ed/
https://www.rcemlearning.co.uk/foamed/emergency-contraception/
https://www.rcem.ac.uk/docs/College%20Guidelines/5s.%20Management%20of%20Adult%20Patients%20who%20attend%20Emergency%20Departments%20after%20Sexual%20Assault%20and%20or%20Rape%20(revised%20Oct%202015).pdf

https://www.rcem.ac.uk/docs/College%20Guidelines/5t.%20Management%20of%20Domestic%20Abuse%20(March%202015).pdf

http://southlondonem.blogspot.com/2014/07/sexual-assault.html
https://learning.bmj.com/learning/search.html?locale=en_GB&collection=The+BMJ&collection=BMJ+Learning&searchTerms=sexual
https://www.rcemlearning.co.uk/foamed/rcem-guideline-domestic-violence/
https://learning.bmj.com/learning/module-intro/-women-domestic-abuse.html?moduleId=5003147&searchTerm=%E2%80%9Cdomestic%20violance%E2%80%9D&page=1&locale=en_GB
https://www.nice.org.uk/guidance/PH50
https://emj.bmj.com/content/21/1/9
https://www.aliem.com/2013/07/pv-intimate-partner-violence/
https://emergencymedicinecases.com/intimate-partner-violence/
https://learning.bmj.com/learning/module-intro/-women-domestic-abuse.html?moduleId=5003147&searchTerm=%E2%80%9Cdomestic%20violance%E2%80%9D&page=1&locale=en_GB
https://www.bmj.com/content/334/7585/143