Management part 3 - Safety and Risk

Blog post retyped as somehow, it converted itself into Greek (ish).


Incident – an untoward or unexpected event including verbal abuse and threats.
Accident – an incident that results in loss or damage like violence.
Clinical Incident – an incident occurring to a patient during or because of treatment.
Clinical Accident – a clinical incident that results in actual harm to the patient
Serious Incidents - where there is potential for learning, or high consequences to patients, families, and staff as so significant that they warrant extra resources to investigate.
Never Event - must be reported. See below.

Should be declared internally as soon as possible. Reports should be completed within 60 days. A root cause analysis should be carried out - there are three levels of this.  
- Concise, comprehensive or independent (which may take 6 months).

 

Negligible
Minor
Moderate
Major
Catastrophic

- Open and transparent
- Preventative
- Objective
- Timely and responsive
- Symptoms based
- Proportionate
- Collaborative

Check patient, and then staff are safe. Obtain and secure all evidence. Offer support to any witnesses. Identify someone to do an initial incident review, and determine level of investigation required. Inform commissioners. Contact family, and support Log on incident management
Serious incidents must be reported to the commissioner within 2 days, sooner if media / public interest.

Retained foreign object post procedure.
Giving strong K+ instead of something else
Parentally administered oral meds OD of insulin due to abbreviations or incorrect device
OD of midazolam due to wrong strength administered
Chest or neck entrapment in bedrails
ABO mismatch transfusion
Misplaced NG or OG tube
Scalding of patients

If it's moderate - severe harm --> report externally to CCG
Never Events must be AId
 - Investigate and always do root cause analysis regardless of harm to patient
 - Reported externally
 - Should be process to stop these happening

https://www.england.nhs.uk/patientsafety/serious-incident/
http://www.npsa.nhs.uk/nrls/improvingpatientsafety/patient-safety-tools-and-guidance/risk-assessment-guides/risk-matrix-for-risk-managers/

Knee Aspiration

Contraindications
Joint replacement or prosthesis
Sepsis - local skin sepsis, bacteraemia, osteomyelitis
Cellulitis
Abnormal clotting eg haemophilia or anticoagulation
Immunocompromised or poorly controlled diabetes
Patient refusal.

Complications
Pain
Haemorrhage
Infection
Recurrence - of effusion or symptoms

Procedure
- Expose and position the knee in a relaxed semi-flexed position
- Palpate and identify the patella, patella tendon, and tibial tuberosity
- Mark a point approximately 1 cm medial and inferior to the lower pole of the patella, just medial to the patella tendon overlying the medial joint compartment
- Clean the skin
- Attach a 21G or 23G sterile needle to the syringe and insert the needle directly into the knee joint where previously marked
- Remove 10-20ml of fluid

References
http://bestbets.org/bets/bet.php?id=83
https://lifeinthefastlane.com/procedures/joint-aspiration/
http://learning.bmj.com/learning/modules/flow/JIT.html?execution=e2s1&moduleId=10033838&status=LIVE&action=start&_flowId=JIT&sessionTimeoutInMin=90&locale=en_GB&shouldStartAtQuestionSection=false

Ascites

Abdominal drains are part of our syllabus, but in practice they are normally not done in the ED.

Anatomy
The needle should not insert the rectus abdominus muscle, which is either side of the midline. This can cause epigastric bleeding. Aim for about 15cm lateral to the umbilicus.
Use the Z technique - pierce the skin, pull the skin tight, then aspirate.
The needle pierces:
    Skin
    Subcutaneous fat
    Superficial fascia
    External oblique muscle
    Internal oblique muscle
    Transversalis muscle
    Parietal peritoneum.

Contraindications
Patient refusal or distress
Pregnancy
Abdominal obstruction or distended bowel loops
Cellulitis overlying the puncture site
Severe coagulopathy

Complications
Abdominal Haematoma (1 in 100 patients)
Severe bleeding (haemoperitoneum)
Infection (secondary bacterial peritonitis)
Bowel perforation/organ damage
Persistent site leakage
Hypovolaemia or hypotension
Recurrence (highly likely unless followed up with diuretic therapy)

Causes of Ascites
High SAAG (“transudate”)
cirrhosis, hepatic failure, hepatic venous occlusion, constrictive percarditis, kwashiorkor, cardiac failure, alcoholic hepatitis, liver metastasis

Low SSAG (“exudate”)
malignancy, infection (bacterial, fungal, Tb), pancreatitis, nephrotic syndrome, bowel obstruction or infarction, bile leak

References
http://www.healthline.com/health/z-track-injection#what-are-z-track-injections1
https://lifeinthefastlane.com/ccc/ascitic-fluid/
https://lifeinthefastlane.com/procedures/paracentesis/
http://learning.bmj.com/learning/modules/end/JIT.html?moduleId=10033853&resType=&resTypeId=&locale=en_GB&presourceId=0&site=

Lumbar Puncture

None of the EDs I have worked in recently require us to perform lumbar punctures, but it is one of our competencies - so we should be able to do it...and could be tested on it! 

1.  Palpate the iliac crests and draw an imaginary line between the two. Mark this space (L3/L4) or the one below (L4/5) with a gentle indentation. Ask the patient if it feels like this is in the dead centre. 

Remember the spinal cord ends at L1/2 in adults. 

2. Surgically scrub. 

3. Clean the skin with antiseptic. If you're using a gallipot, remove the chlorhexidine after washing so there is no chance of accidentally injecting it. We should be using 0.5% chlorhexidine - it is better at preventing infection than iodine, and is less neurotoxic than 2%. 

4. Infiltrate local anaesthesia into the space

5. Insert a 20 or 22 gauge spinal needle into the space, with the stylet. 

You will pierce the skin, supraspinous ligament, the interspinous ligament, and then feel a slight resistance as you go through the ligamentum flavum. The needle then goes through the dura with a pop, and through the arachnoid into the sub arachoid space. 

6. Angle the needle slightly caudally, with the bevel parallel to the flanks so it pushes, rather than tears the dura. 

7. Check opening pressure if needed.

8. Collect CSF - get the patient to extend legs to speed up flow if needed. 

9. Replace the stylet before removing the needle to reduce pressure. 

10. Encourage ambulation. 

Complications

Post-LP headache

Infection

Bleeding

Cerebral herniation

Minor neurologic symptoms such as radicular pain or numbness

Late onset of epidermoid tumors of the thecal sac

Back pain

Contraindications

Possible raised intracranial pressure (headache, blurred vision, reduced GCS, vomiting, papilloedema)

Thrombocytopenia or other bleeding diathesis (including ongoing anticoagulant therapy)

Suspected spinal epidural abscess, cellulitis overlying the area

References

http://learning.bmj.com/learning/modules/end/ELU.html?moduleId=10033835

https://lifeinthefastlane.com/procedures/lumbar-puncture/ 

https://www.uptodate.com/contents/lumbar-puncture-technique-indications-contraindications-and-complications-in-adults 

http://rebelem.com/post-lumbar-puncture-headaches/

Vision Loss

Retinal Haemorrhage
This presents with sudden onset of floaters. Signs are reduced red reflex, with visible clots of blood. They must be seen by ophthalmology as retinal detachment presents very similarly, and can cause haemorrhage, and ophthalmoscopy can be normal.

There are lots of things that cause retinal haemorrhage, including:
diabetes mellitus                                      hypertension
raised intracranial pressure                      trauma and retinal detachment
retinal vein thrombosis                            subarachnoid haemorrhage
arteritis (giant cell arteritis, PAN etc.)     severe anaemia, especially pernicious anaemia
bleeding diathesis - defects in platelets (particularly leukaemia), coagulation factors, vessels.

Retinal Artery Occlusion
Sudden, painless visual loss. Central vision may be preserved if a cilioretinal artery is present. If suspected, patients should have ocular massage, and IV acetazolamide (500mg) to help. Make sure you exclude a temporal arteritis.

Central Retinal Vein Occlusion
Pizza pie on fundoscopy - flame haemorrhages with cotton wool spots. The artery has a cherry red spot with a pale macula.  Treat the cause (HT, DM,chronic glaucoma, hyperviscosity) and give antiplatelet.


Glaucoma
IV acetazolamide 500mg IV followed by 500mg PO (1g max in 24hours), topical antihypertensives (such as timolol drops) and miotics such as pilocarpine (1 drop in the affected eye), will reduce corneal oedema and lower intraocular pressure.

Subacute attacks
Subacute attacks with blurred vision, headache and pain around the eye, nausea and vomiting, and halos seen around lights, most commonly in the evening. They resolve spontaneously.

Non-traumatic Subconjunctival Haemorrhage
Exclude systemic causes - check BP, and coag if on anticoagulants.
Reassure patients - takes 2-3 weeks to heal

Episcleritis
You get localised conjunctival injection. It is normally benign, but may be associated with rheumatological diseases like RA, sarcoidosis, and IBD. Patients complain of irritation. It is self-limiting, but normally gets ophthalmology review to ensure it is not uveitis. The redness disappears 5 minutes after phenylephrine instillation.

Scleritis is also an inflammatory condition, frequently associated with an underlying rheumatological disorder. Patients complain of a deep dull aching pain in the eye, that is often worse at night, and ocular movement. The engorgement persists even after phenylephrine drop instillation.

Uveitis
The majority of cases have the HLA B27 serotype (so associated with sarcoidosis, ankylosing spondylitis, and IBD) but can also occur with herpetic keratitis, and after surgery.

Patients present with a deep, boring pain worse on accommodation. There is perilimbal injecition, and the pupil may be irregular.

Acute ischaemic optic neuropathy
Acute ischaemic optic neuropathy is most commonly caused by giant cell arteritis. Vascular wall inflammation leads to eventual occlusion, causing infarction of the optic nerve. This should be recognised, and oral prednisolone started. 1mg/kg/day for four weeks seems pragmatic. As giant cell arteritis is the most common cause, temporal artery biopsies should be performed.

A non ischaemic neuropathy usually affects young women. Pain is worse on eye movement, and visual acuity is normally reduced. There may be a central scotoma. Make sure you exclude a space occupying lesion, and refer urgently to ophthalmology.

Corneal Abrasion
Eye pads do not speed up recovery, and may worsen things.
Dilating drops are no long recommended.
Topical corticosteroids have been shown to slow corneal epithelial and stromal healing, increase the risk of infection, and cause serious scarring and visual loss if a dendritic ulcer has been missed.

Topical antibiotics may reduce the risk of infective complications in patients with a corneal abrasion. In contact lens wearers an anti-pseudomonal antibiotic must be used.

Infective Conjunctivitis 
Role of antibiotics is controversial.
Always prescribe topical antibiotics:
  Purulent / mucopurulent secretion and patient discomfort and ocular redness
  Patients and staff in nursing homes, neonatal units, critical care units etc
  Children going to nursery
  Contact lens wearers

Ultraviolet Burns

Topical and oral analgesics may be used
A mydriatic (cyclopentolate) may be helpful for photophobia due to ciliary muscle spasm

CS Spray
Dispersed as a fine dust. Irrigation can worsen the symptoms as it's highly soluble in water. Place the patient in a room, and blow a fan across, making sure no cross contamination occurs.

History and Working out what happens
- Rapid is generally vascular or retinal detachment. Slower may be a space occupying lesion.
- Partial loss of vision must be differentiated between;
    a loss of part of the visual field e.g. quadrantopia, hemianopia or central scotoma
    a curtain coming down across the vision a typical description of a retinal detachment
    flashes usually due to retinal ischaemia
    floaters due to opacities in the vitreous after retinal detachment

Examination
Local anaesthetic may be needed. Cyclopentolate takes 15-30min to work, Tropicamide - takes 15-30min to work, Tetracaine = really stings

Distance from patient to the chart / lowest line patient can be seen
Finger counting, then hand motion, then light perception

Look for aniscoria (unequal pupils) - normal in 19%. Pathologically, may occur due to release of prostaglandins on the sphincter pupillae. No reaction to light may be due to an occulomotor nerve palsy. Asides from trauma and eye drops, causes are:
Oculomotor nerve palsy (dilated pupil)
Holmes-Adie syndrome (dilated pupil)
Horners syndrome (constricted pupil)
Argyll Robertson pupil (constricted pupil)

To do fundoscopy you  may need dilating drops. Tropicamide is good - very tiny risk of precipitating acute glaucoma.

Ongoing Referral
Post op Patients:-
Less than 2 weeks post op
         Moderate or severe pain / visual loss IMMEDIATE
         Mild pain, no visual loss WITHIN 24 HOURS, in clinic if possible
More than 2 weeks post op
         Moderate or severe pain/visual loss WITHIN 24 HOURS
         Mild pain, no visual loss NEXT AVAILABLE CONSULTANT CLINIC

Flashing lights/floaters:-
Less than 6 weeks history
         Loss of vision/ field defect IMMEDIATE
         No loss of vision WITHIN 24 HOURS
More than 6 weeks history
         Loss of vision/field defect WITHIN 24 HOURS
         No loss of vision/field defect CONSULTANT CLINIC

Trauma:-(including foreign body/abrasion,chemical)
WASH OUT ALL CHEMICAL INJURIES IMMEDIATELY
Severe pain/risk of penetrating injury IMMEDIATE
Mild pain, including suspected foreign body WITHIN 24 HOURS

Sight loss or distortion
Sudden, less than 24 hours IMMEDIATE
              More than 24hours WITHIN 24 HOURS
Gradual, less than 2 weeks WITHIN 24 HOURS
              More than 2 weeks CONSULTANT CLINIC

Pain/photophobia
Assess if FB or abrasion first, if so assess for trauma
If associated visual loss use to increase priority if indicated
Severe or moderate IMMEDIATE
Associated general malaise/jaw claudication IMMEDIATE
Mild, less than 2 weeks WITHIN 24 HOURS
More than 2 weeks CONSULTANT CLINIC

Redness or swelling
Assess any associated symptoms eg pain ,photophobia, sight loss first to increase priority if necessary. Associated general malaise or pyrexia IMMEDIATE
Less than 2 weeks WITHIN 24 HOURS
More than 2 weeks CONSULTANT CLINIC

Double vision:-ALWAYS REFER TO ORTHOPTIST FIRST
Onset less than 2 weeks, pain and/or ptosis IMMEDIATE
                                        No pain/ptosis WITHIN 24 HOURS
Onset more than 2 weeks, ptosis and pain IMMEDIATE
                                          Ptosis/no pain WITHIN 24 HOURS

                                          No pain or ptosis CONSULTANT CLINIC

https://www.rcemlearning.co.uk/modules/sudden-visual-loss/
https://first10em.com/2015/06/16/ebmlecturehandout2topicalanaestheticsfocornealabrasions
https://www.rcemlearning.co.uk/references/eye-initial-assessment/
https://www.rcemlearning.co.uk/references/corneal-injuries/
https://www.rcemlearning.co.uk/references/atraumatic-red-eye/
https://www.rcemlearning.co.uk/modules/more-than-meets-the-eye/
https://www.rcemlearning.co.uk/references/eye-infections/
https://www.rcemlearning.co.uk/modules/the-blind-side/
https://www.rcemlearning.co.uk/curriculum/hst-acute/hap32/
https://www.rcemlearning.co.uk/foamed/ophthalmology-clinical-2/
https://www.rcemlearning.co.uk/modules/more-than-meets-the-eye/
http://learning.bmj.com/learning/module-intro/qt-red-eye.html?moduleId=10051483&searchTerm=%E2%80%9Ceyes%E2%80%9D&page=1&locale=en_GB

http://learning.bmj.com/learning/module-intro/glaucoma-diagnosis-and-management-in-primary-care.html?moduleId=10056345&searchTerm=%E2%80%9Ceyes%E2%80%9D&page=1&locale=en_GB

https://www.wikijournalclub.org/wiki/Optic_Neuritis_Treatment_Trial

http://learning.bmj.com/learning/module-intro/sticky-eye-diagnostic-picture-tests.html?moduleId=6056483&searchTerm=%E2%80%9Ceyes%E2%80%9D&page=1&locale=en_GB

http://learning.bmj.com/learning/module-intro/sticky-eye-diagnostic-picture-tests.html?moduleId=10007412&searchTerm=%E2%80%9Ceyes%E2%80%9D&page=1&locale=en_GB

http://learning.bmj.com/learning/module-intro/.html?moduleId=10053762&searchTerm=%E2%80%9Ceyes%E2%80%9D&page=1&locale=en_GB

http://emj.bmj.com/content/17/5/324

http://learning.bmj.com/learning/module-intro/red-eye-diagnostic-picture-tests.html?moduleId=5004450&searchTerm=%E2%80%9Ceyes%E2%80%9D&page=1&locale=en_GB

https://www.rcem.ac.uk/docs/Local%20Guidelines_Audit%20Guidelines%20Protocols/12ri.%20Red%20Eye%20Algorithm.pdf
https://www.rcemlearning.co.uk/modules/in-your-face/

https://lifeinthefastlane.com/resources/retinal-haemorrhage-ddx/

Genital Ulcers

Genital Ulcers are specifically mentioned on our syllabus. They are more likely to be non sexually tramsitted than sexually transmitted (surprisingly!).

Herpes
HSV1 is now the most common cause of genital herpes. HSV2 is more likely to result in recurrent episodes. The majority of infections are subclinical and symptomatic viral shedding, or symptomatic lesions can occur.

Get painful ulceration, dysuria, urethral or vaginal discharge. May get fever and myalgia. On examination, you get blistering and ulceration with painful lymphadenopathy.

Treat with a full sexual health screen, and oral aciclovir. Condoms won't reliably prevent transmission - abstain for a week after symptoms resolve.

Syphillis
Syphillis should be treated in specialist GUM clinics. It is more common in MSM. It normally presents with a painless ulcer, with a clean base. Secondary infection has multisystem involvement.


Bechets
A systemic vasculitis of unknown aetiology (not considered to be auto-immune), that typically starts in young adults. You get recurrent oral and genital ulceration, uveitis, skin changes, arthritis, neuro involvement and tendency to thrombosis. It is prevalent in Japan, the middle East, and some Mediterranean countries. Treatment depends on which organ is involved.
Genital ulcers are less common than oral ulcers.

Reactive
EBV, CMV and parathyphoid can cause post infective or reactive genital ulcers (lipschutz ulcers). They can be very painful, and associated with lymphadenopathy. They normally resolve within a few weeks. The ulcers normally have a yellowish centre, that may become black due to tissue necrosis, with a surrounding red rim. They may be associated with swelling.
Take viral and bacterial swabs. Look for underlying illness, and test for EBV. Treat according to the cause.

Crohn's
Cancer
Pemphigus
Pemphigoid
Steven-Johnson syndrome
Erythema multiforme

References 
http://www.dermnetnz.org/topics/non-sexually-acquired-genital-ulceration/
http://www.aafp.org/afp/2012/0201/p254.html
http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1167392705
http://pmj.bmj.com/content/76/900/629
http://learning.bmj.com/learning/module-intro/genital-ulceration-diagnosis-management.html?moduleId=10058483&searchTerm=%E2%80%9Culcers%E2%80%9D&page=1&locale=en_GB

Penile Problems

Most penile problems are better evaluated if you have a nerve block in place.

Dorsal Penile Nerve Block
The two dorsal nerves are at 10 and 2 o'clock positions at the root of the penis.
Ramifications of these nerves usually commence 1 cm distal to the penile root, and a nerve block should be just proximal to those.
The depth of the needle need not be more than 0.25 to 0.5 cm.
Aim to hit the pubic symphysis, and then go below.

Phimosis
Check for diabetic control
Palpate the glans - and if there is a lump, refer urgently to urology
Consider a steroid cream - like betnovate

Paraphimosis
Remove a catheter or any piercings first
Start with analgesia - a nerve block might be helpful!

Manual Reduction - put pressure or a compression bandage on the distal penis
Ice 
Sugar on glans and penis
Puncture oedematous band
After reduction, urology follow up as is likely to happen again!

Fracture of the Penis
Differential is rupture of the deep dorsal vein of the penis
- You don't hear a crack or popping sound
- Detumescence doesn't occur
- Needs to be surgically explored
- Can get urethral injury

Priapism
Most of the time, this is primary (idiopathic) 40%

Secondary causes:
  Haematological   (sickle cell, leukaemia, myeloma)
  Neurologic    (spinal cord injury - leave these alone, time heals)
  Traumatic   (genital, perineal) 10%
  Neoplastic   (bladder, prostate)
  Medication   (antipsychotic like chlorpromazine and haloperidol   antidepressants like fluxetine, anticoagulation, recreational drugs like cocaine, intracavernosal injections)

  - analgesia
  - hydration
  - exercise (run up and down the stairs)
  - cold bath, or maybe a warm bath
  - therapeutic masturbation can help
  - involve urology team for drainage. This needs written consent - there is a high risk of associated impotence. It involves consent, cleaning, inserting a needing into the side of the penis to a depth of 1cm, take blood gas, then aspirate up to 100ml thick dark blood.

References 
http://bestpractice.bmj.com/best-practice/monograph/765/treatment/step-by-step.html
https://wikem.org/wiki/Priapism 
http://www.foamem.com/2015/04/17/priapism/
http://pedemmorsels.com/phimosis/
http://learning.bmj.com/learning/module-intro/.html?moduleId=10057996&searchTerm=%E2%80%9Cphimosis%E2%80%9D&page=1&locale=en_GB