Wednesday, 24 October 2018
Tasers
A Taser
Two weighted barbs attached to long insulated wires
They fire at 180 feet / second
Deliver 50 000 volts of electricity, in pulses
Removal
Stretch surrounding skin, and tug sharply.
If difficult:
1. Anesthetize the area at the site of attachment. Possibly using an insulin syringe.
2. Insert an 18 gauge needle along the side of the barb with the bevel of the needle facing the barb.
3. Advance the needle about half a centimeter.
4. Pull out the needle and the barb together at the same time.
If this doesn’t work, use a scalpel.
http://epmonthly.com/blog/dont-taze-me-bro/
https://emj.bmj.com/content/21/2/136
http://epmonthly.com/article/they-tased-me-doc/
https://www.ncbi.nlm.nih.gov/pubmed/?term=Vilke+Bozeman+taser
Tuesday, 16 October 2018
Possible PE in pregnancy
Possible PE in pregnancy is a nightmare to investigate and to manage. There are several flowcharts...but lets look at the evidence.
1. Is this a PE?
Has someone just done a random d-dimer? If they have...think back to the symptoms. We know shortness of breath in pregnancy could have many causes, but we only worry about PE. Take a good history. Anecdotal evidence suggests PEs should be tachycardic.
2. Do a CXR
A whole load of investigating is prevented if they've got a pneumothorax or pneumonia.
3. Risk stratify
If they're high risk, they need imaging.
If they're low risk...continue.
4. In a low risk patient, a negative d-dimer is considered able to rule out VTE. Chances of it being negative are slim. The DiPep study recommends not using d-dimers, as does the RCOG greentop guideline.
5. Consider trimester adjusted d-dimers.
We know the d-dimer rises in pregnancy. These values will depend on your d-dimer assay.
1st 750 ng/dL, 2nd 1000 ng/dL, and 3rd 1250 ng/dL
D-dimer test with the new threshold for: the first of 286, the second of 457 and the third trimester of 644 ng/mL can be useful in diagnosis of pregnancy related VTE.
I can't find any strong evidence these are strongly evidence based - but Jeff Kline is amazingly knowledgable, so I'm sure he's right!
6. Imaging
Bilateral leg dopplers - if they're positive for DVT...start treatment
VQ scan - probably causes more radiation to the fetus
Other Summaries
https://emcrit.org/wp-content/uploads/2011/07/PE-DX-by-Jeff-Kline.pdf
https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/respiratory/pe/pe-pregnant
Thursday, 30 August 2018
Rashes - impetigo
Impetigo is a superficial infection of the epidermis caused by Staphylococcus aureus, group A beta-haemolytic streptococci or maybe even MRSA.
Children should stay away from school until lesions are crusted and healed, or 48 hours after commencing antibiotic treatment.
Several clinical forms of impetigo exist.
1. Non-bullous impetigo is the usual form. Red macules form initially, then golden crusts. It is itchy but not painful. Regional lymphadenopathy is common.
2. Bullous impetigo. Here there is sloughing of the epidermis due to toxin production. Vesicles/bullae may be on face, buttocks, nappy area or trunk. Inpatient care is required for infants with bullous impetigo and patients with widespread impetigenised dermatitis who may develop sepsis or dehydration.
Treatment: 1. use mupirocin nasal ointment to eradicate nasal carriage when treating impetigo on the face 2. Remove the scab, and then apply local treatment - fucidin and bactroban 3. Systemic if that fails 4. Remember not to go to school 5. Excellent hygieneWhat are the 3 types of impetigo? #RoshQuiz #FOAMed #FMRevolution #NursePractitioner #PANCE #PEM #PedsEM pic.twitter.com/94jnKr07ga— Rosh Review's Adam Rosh (@RoshReview) June 15, 2017
References https://wikem.org/wiki/Impetigo https://www.rcemlearning.co.uk/references/cellulitis/ http://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf https://www.summitmedicalgroup.com/library/pediatric_health/hhg_impetigo/ http://www.bad.org.uk/for-the-public/patient-information-leaflets/impetigo/?showmore=1&returnlink=http%3A%2F%2Fwww.bad.org.uk%2Ffor-the-public%2Fpatient-information-leaflets#.W4g8xehKjIUImpetigo. Local treatment first. Fucidin and bactroban. Not to school or nursery for 48 hours. #foamed
— South London EM FOAM (@slemfoam) October 16, 2014
Monday, 9 July 2018
Pelvic Binders
Most of our patients come in with their binders already on, but sometimes we do have to apply them.
Why
- tamponade blood
(yet pelvis has space for a baby and a beer filled bladder)
- oppose bone ends and stop bleeding
Why not
There is no evidence that pelvic binders are harmful when applied to patients with proximal femur or acetabular fracture.
They can cause pressure necrosis
Depending on the mechanism, they may make the injury worse.
How
Strip patient - should be to skin
Analgesia
Roll patient to 15 degrees
Put folded binder underneath buttocks
Apply over the greater trochanter or symphysis pubis
Minimise patient movement - ideally they should be scooped on.
SAM Splint:
Feed black strap through the buckle
Pull black and orange in opposite directions
Tighten
Fasten
Pregnancy - should be OK if applied correctly
https://phemcast.co.uk/2015/11/05/podcast-episode-2-the-pelvic-binder/
https://www.rcemlearning.co.uk/references/abdominal-trauma/
https://www.rcemlearning.co.uk/foamed/pelvic-fractures-a-guide-to-treatment-within-a-trauma-unit/
https://www.rcemlearning.co.uk/foamed/june-2017/#1496133043616-a1f3a145-a4a3
https://www.rcemlearning.co.uk/modules/blunt-trauma-to-the-abdomen-don’t-forget-the-kidneys/
http://emergencymedicineireland.com/2013/04/anatomy-for-emergency-medicine-027-basic-anatomy-of-abdomen-and-pelvic-trauma/
https://www.resus.com.au/2015/07/31/unstable-pelvic-fractures/
https://emj.bmj.com/content/30/12/1070
Why
- tamponade blood
(yet pelvis has space for a baby and a beer filled bladder)
- oppose bone ends and stop bleeding
Why not
There is no evidence that pelvic binders are harmful when applied to patients with proximal femur or acetabular fracture.
They can cause pressure necrosis
Depending on the mechanism, they may make the injury worse.
How
Strip patient - should be to skin
Analgesia
Roll patient to 15 degrees
Put folded binder underneath buttocks
Minimise patient movement - ideally they should be scooped on.
SAM Splint:
Feed black strap through the buckle
Pull black and orange in opposite directions
Tighten
Fasten
Pregnancy - should be OK if applied correctly
Good ResourcesPelvic binders. Do we slide up from knees to GTs, or tilt onto a folded binder? Can't find a consensus! #foamed @JGoulding444 @mattdoc1979
— Charlotte Davies (@OneLongPlait) November 3, 2015
https://phemcast.co.uk/2015/11/05/podcast-episode-2-the-pelvic-binder/
https://www.rcemlearning.co.uk/references/abdominal-trauma/
https://www.rcemlearning.co.uk/foamed/pelvic-fractures-a-guide-to-treatment-within-a-trauma-unit/
https://www.rcemlearning.co.uk/foamed/june-2017/#1496133043616-a1f3a145-a4a3
https://www.rcemlearning.co.uk/modules/blunt-trauma-to-the-abdomen-don’t-forget-the-kidneys/
http://emergencymedicineireland.com/2013/04/anatomy-for-emergency-medicine-027-basic-anatomy-of-abdomen-and-pelvic-trauma/
https://www.resus.com.au/2015/07/31/unstable-pelvic-fractures/
https://emj.bmj.com/content/30/12/1070
Wednesday, 22 November 2017
Meningitis
Causes
Viral or aseptic meningitis is the most common form and may be caused by enteroviruses.
Meningococcal disease is the most common (Neisseria meningitides) - infancy and adolescence and over the Winter months.
Pneumococcal - commonest cause in elderly people. Often have a distant focus of pneumococcal infection like pneumonia, otitis media, mastoiditis, sinusitis or endocarditis. Has a 30% mortality rate.
TB meningitis - often develop gradually over days or even weeks and is more common in the immunocompromised, especially with HIV.
Listeria meningitis remains uncommon. Neonates, the elderly, and immunocompromised people are at greatest risk.
Recurrent lymphocytic meningitis, also known as Mollaret’s meningitis, is a rare disease that is estimated to have a prevalence of 2.7 per 100 000 population. HSV-2 is the most common cause of recurrent lymphocytic meningitis, being responsible for 84% of recurrent meningitis in one study.
A suddenly worsening headache, followed by emerging signs of meningism, is often associated with rupture of the abscess. Rupture of a brain abscess is associated with a high mortality: up to 80%. Emergency surgery is indicated.
Clinical Presentation When a patient recovers from bacterial meningitis, headache, fatigue, and difficulty with coordination, concentration, and memory may persist for several months.
Rash - may be petechial, or in its early stages may be erythematous. The rash occurs in at least 60% of adults.
Triad of fever, headache, and neck stiffness(70% sensitivity) in less than 50% of patients. Changes in mental state are relatively sensitive and tend to occur more often in bacterial than viral meningitis.
Kernig's test is positive if there is pain or resistance in the lower back or posterior thigh when the knee is extended while the hip is flexed to 90°. Kernig's sign can be a useful test if positive, but a negative test does not exclude meningitis.
Brudzinski’s sign is not specific for meningococcal meningitis. You can elicit the sign by passive flexion of the neck, resulting in flexion of the hips and knees if positive.
Encephalitis has a similar presentation to meningitis, but confusion and drowsiness tend to be more prominent.
Management of Suspected Meningitis in the Emergency Department
http://www.journalofinfection.com/article/S0163-4453(16)00024-4/abstract http://www.journalofinfection.com/cms/attachment/2048213088/2058279234/mmc1.pdf
https://www.uptodate.com/contents/viral-encephalitis-in-adults?source=search_result&search=meningitis%20aciclovir&selectedTitle=3~150 http://lgnet/download.cfm?ver=10662
https://www.rcemlearning.co.uk/modules/intracranial-infections/
http://learning.bmj.com/learning/modules/flow/ICH.html?execution=e1s1&moduleId=5003335&status=LIVE&action=start&_flowId=ICH&sessionTimeoutInMin=90&locale=en_GB&shouldStartAtQuestionSection=false
http://learning.bmj.com/learning/modules/flow/ICH.html?execution=e2s1&moduleId=10041919&status=LIVE&action=start&_flowId=ICH&sessionTimeoutInMin=90&locale=en_GB&shouldStartAtQuestionSection=false
Viral or aseptic meningitis is the most common form and may be caused by enteroviruses.
Meningococcal disease is the most common (Neisseria meningitides) - infancy and adolescence and over the Winter months.
Pneumococcal - commonest cause in elderly people. Often have a distant focus of pneumococcal infection like pneumonia, otitis media, mastoiditis, sinusitis or endocarditis. Has a 30% mortality rate.
TB meningitis - often develop gradually over days or even weeks and is more common in the immunocompromised, especially with HIV.
Listeria meningitis remains uncommon. Neonates, the elderly, and immunocompromised people are at greatest risk.
Recurrent lymphocytic meningitis, also known as Mollaret’s meningitis, is a rare disease that is estimated to have a prevalence of 2.7 per 100 000 population. HSV-2 is the most common cause of recurrent lymphocytic meningitis, being responsible for 84% of recurrent meningitis in one study.
A suddenly worsening headache, followed by emerging signs of meningism, is often associated with rupture of the abscess. Rupture of a brain abscess is associated with a high mortality: up to 80%. Emergency surgery is indicated.
Clinical Presentation When a patient recovers from bacterial meningitis, headache, fatigue, and difficulty with coordination, concentration, and memory may persist for several months.
Rash - may be petechial, or in its early stages may be erythematous. The rash occurs in at least 60% of adults.
Triad of fever, headache, and neck stiffness(70% sensitivity) in less than 50% of patients. Changes in mental state are relatively sensitive and tend to occur more often in bacterial than viral meningitis.
Kernig's test is positive if there is pain or resistance in the lower back or posterior thigh when the knee is extended while the hip is flexed to 90°. Kernig's sign can be a useful test if positive, but a negative test does not exclude meningitis.
Brudzinski’s sign is not specific for meningococcal meningitis. You can elicit the sign by passive flexion of the neck, resulting in flexion of the hips and knees if positive.
Encephalitis has a similar presentation to meningitis, but confusion and drowsiness tend to be more prominent.
Management of Suspected Meningitis in the Emergency Department
- Recognise
- Investigate – Take extra two EDTA (purple) tubes for meningococcal or pneumococcal DNA using PCR. Do not wait for the results before commencing treatment. It is difficult to differentiate viral meningitis from bacterial meningitis on clinical grounds alone so we need to do a LP.
- Treat –
a. Sepsis 6 with antibiotics as per trust antimicrobial guidelines
(Ceftriaxone 2g + amoxicillin 2g if >50years or immunocompromised)
b. Dexamethasone 10mg IV
c. Aciclovir if features of encephalitis (fluctuating consciousness, motor or sensory deficits, altered behaviour and personality changes, and speech or movement disorders).
There are currently no treatments with a proven benefit for the common causes of viral meningitis, although acyclovir is often used, despite it being nephrotoxic and lowering seizure threshold. It does reduce the mortality of encephalitis from 70% to less than 30%. Treatment should be supportive. - CT would be indicated if there are focal neurological signs, papilloedema, controlled or uncontrolled seizures, GCS <12 or diagnostic uncertainty. The medical team may ask the ED team to arrange the CT, but this should not delay their review of the patient.
- For continuity of care, it is expected that the medical team will report “acute meningitis” to Health Protection Team (SLHPT) .
- Isolate – as per trust policy
A patient with known or suspected meningococcal meningitis should be isolated in a single room with droplet precautions for 24 hours from the time that effective antibiotic treatment has been started.
Staff caring for the patient should observe the standard infection control precautions and wear FFP3 masks, gloves and aprons.
Staff performing procedures that may generate aerosols, for example suctioning, intubation or inserting an airway, should wear properly fitted FFP3 masks and eye protection. - Antibiotic Prophylaxis for close contacts should be coordinated by SLHPT. OH Assist will coordinate antibiotic prophylaxis for healthcare workers
Antibiotic prophylaxis is offered to the following groups of people: - Those who have had prolonged close contact with the patient during the seven day incubation period. This includes people who live or sleep in the same household, dormitory or halls of residence.
- Intimate (kissing) contacts.
- Those exposed transiently to large droplets from the upper respiratory tract of the patient during their admission to hospital. For example, a healthcare-worker inserting an airway or suctioning the upper respiratory tract without wearing appropriate personal protective equipment may be at risk.
http://www.journalofinfection.com/article/S0163-4453(16)00024-4/abstract http://www.journalofinfection.com/cms/attachment/2048213088/2058279234/mmc1.pdf
https://www.uptodate.com/contents/viral-encephalitis-in-adults?source=search_result&search=meningitis%20aciclovir&selectedTitle=3~150 http://lgnet/download.cfm?ver=10662
https://www.rcemlearning.co.uk/modules/intracranial-infections/
http://learning.bmj.com/learning/modules/flow/ICH.html?execution=e1s1&moduleId=5003335&status=LIVE&action=start&_flowId=ICH&sessionTimeoutInMin=90&locale=en_GB&shouldStartAtQuestionSection=false
http://learning.bmj.com/learning/modules/flow/ICH.html?execution=e2s1&moduleId=10041919&status=LIVE&action=start&_flowId=ICH&sessionTimeoutInMin=90&locale=en_GB&shouldStartAtQuestionSection=false
Monday, 20 November 2017
Phenytoin Toxicity
An 80 year old attends your emergency department "not right". He is known epileptic, but you are unable to get a collateral history to know what form his seizures normally take. He is on phenytoin, and as far as you know is compliant. He looks well, but has a strange rhythmic movement of his mouth, and upper limbs. You wonder what is causing this...luckily the medics take a phenytoin level...
Phenytoin
Phenytoin is a sodium channel blocker with slow and erratic oral absorption.
Peak levels are delayed by 24 – 48 hours
It is 90% protein bound, so dialysis is ineffective.
It is metabolised in the liver, importantly this metabolism is saturable and plasma levels can rise dramatically with only a slight increase in daily dosing.
Elimination half-lives in a poisoned patient can vary between 24 to 230 hours.
Problems
Acute overdose has cardiovascular side effects as the biggest problem. Because of the poor oral absorption, these are only really likely with IV - bradycardia, hypotension, vf, asystole, wide QRS.
Neurological signs are the most common with nystagmus (initially on forced lateral gaze only, later becomes spontaneous), ataxia, decreased consciousness.
Can also cause Nausea and vomiting
"Purple glove syndrome" and Stevens Johnson can also occur
Anticonvulsant hypersensitivity syndrome
Toxicity symptoms by phenytoin level^
Level Sypmtoms
>10 Usually no symptoms
10-20 Occasional mild nystagmus
20-30 Nystagmus
30-40 Ataxia, slurred speech, Nausea/vomiting
40-50 Lethargy, confusion
>50 Coma, seizure (rare)
Correct the phenytoin level for albumin = Observed phenytoin (mg/L) (O.2 x albumin [g/dL]) + 0.1. If possible, take a trough level (ie just before next dose), but if you suspect toxicity or need to treat status, just take a level - treat the patient not the numbers.
Other laboratory testing
LFTs, hepatic dysfunction increases risk of phenytoin toxicity
CBC, frequently show eosinophilia or marked leukocytosis
Total CK
ECG, may see arrhythmias, AV block, or sinus arrest with junctional or ventricular escape
POC glucose, rule out hypoglycemia as cause of AMS
Acetaminophen and salicylate levels, rule out common coingestion
Urine pregnancy test
Management
Supportive care
avoid lidocaine (same antidysrhythmic properties as phenytoin)
Activated charcoal PO
Falls risk
References
https://www.rcemlearning.co.uk/references/dystonia/
https://wikem.org/wiki/Phenytoin_toxicity
http://www.emdocs.net/em3am-phenytoin-toxicity/
https://lifeinthefastlane.com/tox-library/toxicant/anticonvulsants/phenytoin/
http://journals.sagepub.com/doi/pdf/10.1177/201010581302200307
<blockquote class="twitter-tweet" data-lang="en"><p lang="en" dir="ltr">Phenytoin effects at therapeutic and toxic levels<a href="https://twitter.com/hashtag/InsidersGuideITE?src=hash&ref_src=twsrc%5Etfw">#InsidersGuideITE</a> <a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> <a href="https://twitter.com/hashtag/EMBoardReview?src=hash&ref_src=twsrc%5Etfw">#EMBoardReview</a> <a href="https://twitter.com/hashtag/MedEd?src=hash&ref_src=twsrc%5Etfw">#MedEd</a> <a href="https://t.co/4AVsCWXmlF">pic.twitter.com/4AVsCWXmlF</a></p>— Adam Rosh (@RoshReview) <a href="https://twitter.com/RoshReview/status/671166731914711040?ref_src=twsrc%5Etfw">November 30, 2015</a></blockquote>
<script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
Phenytoin
Phenytoin is a sodium channel blocker with slow and erratic oral absorption.
Peak levels are delayed by 24 – 48 hours
It is 90% protein bound, so dialysis is ineffective.
It is metabolised in the liver, importantly this metabolism is saturable and plasma levels can rise dramatically with only a slight increase in daily dosing.
Elimination half-lives in a poisoned patient can vary between 24 to 230 hours.
Problems
Acute overdose has cardiovascular side effects as the biggest problem. Because of the poor oral absorption, these are only really likely with IV - bradycardia, hypotension, vf, asystole, wide QRS.
Neurological signs are the most common with nystagmus (initially on forced lateral gaze only, later becomes spontaneous), ataxia, decreased consciousness.
Can also cause Nausea and vomiting
"Purple glove syndrome" and Stevens Johnson can also occur
Anticonvulsant hypersensitivity syndrome
Toxicity symptoms by phenytoin level^
Level Sypmtoms
>10 Usually no symptoms
10-20 Occasional mild nystagmus
20-30 Nystagmus
30-40 Ataxia, slurred speech, Nausea/vomiting
40-50 Lethargy, confusion
>50 Coma, seizure (rare)
Correct the phenytoin level for albumin = Observed phenytoin (mg/L) (O.2 x albumin [g/dL]) + 0.1. If possible, take a trough level (ie just before next dose), but if you suspect toxicity or need to treat status, just take a level - treat the patient not the numbers.
Other laboratory testing
LFTs, hepatic dysfunction increases risk of phenytoin toxicity
CBC, frequently show eosinophilia or marked leukocytosis
Total CK
ECG, may see arrhythmias, AV block, or sinus arrest with junctional or ventricular escape
POC glucose, rule out hypoglycemia as cause of AMS
Acetaminophen and salicylate levels, rule out common coingestion
Urine pregnancy test
Management
Supportive care
avoid lidocaine (same antidysrhythmic properties as phenytoin)
Activated charcoal PO
Falls risk
References
https://www.rcemlearning.co.uk/references/dystonia/
https://wikem.org/wiki/Phenytoin_toxicity
http://www.emdocs.net/em3am-phenytoin-toxicity/
https://lifeinthefastlane.com/tox-library/toxicant/anticonvulsants/phenytoin/
http://journals.sagepub.com/doi/pdf/10.1177/201010581302200307
<blockquote class="twitter-tweet" data-lang="en"><p lang="en" dir="ltr">Phenytoin effects at therapeutic and toxic levels<a href="https://twitter.com/hashtag/InsidersGuideITE?src=hash&ref_src=twsrc%5Etfw">#InsidersGuideITE</a> <a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> <a href="https://twitter.com/hashtag/EMBoardReview?src=hash&ref_src=twsrc%5Etfw">#EMBoardReview</a> <a href="https://twitter.com/hashtag/MedEd?src=hash&ref_src=twsrc%5Etfw">#MedEd</a> <a href="https://t.co/4AVsCWXmlF">pic.twitter.com/4AVsCWXmlF</a></p>— Adam Rosh (@RoshReview) <a href="https://twitter.com/RoshReview/status/671166731914711040?ref_src=twsrc%5Etfw">November 30, 2015</a></blockquote>
<script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
<blockquote class="twitter-tweet" data-lang="en"><p lang="en" dir="ltr"><a href="https://twitter.com/RCollEM?ref_src=twsrc%5Etfw">@RCollEM</a> be careful when drawing up phenytoin and always administer with cardiac monitoring <a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> <a href="https://twitter.com/hashtag/FOAMcc?src=hash&ref_src=twsrc%5Etfw">#FOAMcc</a> <a href="https://twitter.com/hashtag/FOAMped?src=hash&ref_src=twsrc%5Etfw">#FOAMped</a> <a href="https://t.co/LLatwq4hJA">pic.twitter.com/LLatwq4hJA</a></p>— Hasan Qayyum (@hasqay) <a href="https://twitter.com/hasqay/status/796446929693605888?ref_src=twsrc%5Etfw">November 9, 2016</a></blockquote>
<script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
Saturday, 4 November 2017
Adult C-Spine Immobilisation
I think the RCEM guidelines say everything we need to know about adult c-spine immobilisation.
They're summarised beautifully by ALIEM here together with a good discussion on distracting injuries.
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