Tasty Morsels of EM 057 – Ketamine induced uropathy

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Wei YB, Yang JR, Yin Z, Guo Q, Liang BL, Zhou KQ. Genitourinary toxicity of ketamine. Hong Kong Med J. 2013;19:(4)341-8. [pubmed] Free PDF

I suspect most of us are aware that chronic ketamine abuse can cause this but I also suspect that we miss this fairly commonly by simply not asking and diagnosing young men with UTI or urethritis and sending them off into the night (and inevitably their cultures are negative)

I’ve seen/suspected this twice in the last few years and no doubt missed it in lots of others.

The paper is a nice summary of theories and potential treatments. There is a lovely free case report in WestJEM of bilateral hydro associated with this (presumably related to ureteric obstruction from bladder thickening) so yet one more excuse to channel your inner sono. 

  • young people
  • chronic ketamine use is a huge issue in south east asia
  • typically chronic abusers (they suggest more than 3 times in a week)
  • mechanisms:
    • unclear (what a surprise)
    • possible toxic effects of metabolites
    • possible damage to microvasculature
    • change in neuromuscular control due to the ketamine
  • typical manifestations are lower urinary tract symptoms including severe dysuria, painful haematuria, urinary urgency, urge incontinence and frequency
  • on imaging you might see an irregular thick walled bladder with small volumes. Hydro is quite common (up to 50%)
  • stopping the ketamine is the most important thing however there are significant numbers for whom this won’t work. the paper suggests resolution in only a third.
  • various treatments suggested
    • oral anti cholinergics
    • intra vesical hyaluronic acid or even botulinum
    • surgery is an option with all kinds of complicated procedures I don’t understand
  • there is genuine bad outcomes here – renal function decline from chronic hydro and irreversible LUTS and quality of life issues. This isn’t a STEMI by any means but it’s important we think of this and refere

Take home message – that young lad with “UTI” for no apparent reason probably doesn’t have a UTI…

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Tasty Morsels of EM 056 – Dystonic reactions

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

[Video via Larry Mellick’s excellent youtube channel]

Anyone working in any ED for any length of timee will have seen this – either from someone using an illicit substance and appearing at triage or in a poor young woman, 30 mins after your treatment for her migraine.

  • common with anti-emetics (metoclopramide/prochlorperazine) and anti-psychotics though the full list of potentials is huge.
  • pathophysiolgy is to do with dopamine in the basal ganglia (blockade of central dopaminergic receptors and some other mechanisms I struggle to follow)
  • Harwood-Nuss has a nice table of associated agents
    • drugs that might be used illicitly: cocaine/ketamine/bupropion/dextromethorphan
    • bizzarely both diphenhydramine and diazepam, (agents that are often used to treat dystonia) are on the list. Even propofol gets a mention
  • Tardive dyskinesia is more severe and usually with long term use of anti psychotics
  • drug or alcohol abuse is thought to be a predisposing factor
  • Look at the mandible the neck and the eyes – these are the commonest areas affected. Can affect the whole body
  • reactions can be delayed up to 5 days if starting a new drug
  • give an antimuscarinic to fix it
    • where I’ve worked this has always been procyclidine
    • elsewhere diphenhydramine and benztropine are commonly suggested agents
  • IV route seems to be significantly quicker in action than IM.
  • Harwood-Nuss suggests oral meds for a few days to prevent recurrence

Reference:

Harwood-Nuss 5th Edition, pg 1501

[featured image CC license, Wikimedia Commons, James Heilman, MD]

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Ireland and the NICE trauma guidelines

NICE in the UK has just published some draft guidance for trauma care. The 200 page document makes for some interesting reading. It’s available freely online so it’s worth going over and having a read.

There are some prominent trauma folk on there – perhaps best known to the twitter world would be Karim Brohi.

Natalie over at St Emlyns have already done a nice review of the NICE guidelines (!) and I’d recommend reading that before you get started here.

Ireland is in a very different position when it comes to trauma management than the UK. The UK has now established a trauma network with Major Trauma Centres and Trauma Units, and while I have no doubt there are still lots of issues, trauma is now a hot topic with lots of interest from those who hold the purse strings.

Back when I was an even more junior doctor than I am now, I worked in Northern Ireland and remember the NCEPOD report – Trauma Who Cares was published suggesting that trauma patients were getting a bit of a raw deal. I feel like the Republic Ireland is stuck some time around 2007 (or earlier!) and have seriously lagged behind as the UK has taken off with its restructuring of trauma care.

That being said there has been a little bit of a recent groundswell in Ireland as we have joined TARN (we can’t improve till know how bad we are at it), there are some national moves to develop a major trauma network (though I haven’t seen much published yet) and of course our own national EM organisation has published a position paper on it.

So the NICE guidelines make fascinating reading for a nation that may be on the cusp of delving seriously into trauma. If this is what our mature neighbours should be doing next door then what stands in the way of us keeping up with the Jones so to speak.

Please remember this is my very personal reflection and contains mainly anecdotes on where I have observed on what seems poor practice (by myself and others) it does not intend to tar everyone or the whole country with the same brush and certainly does not want to start a “those idiots in *insert specialty here* can’t manage trauma”. EM is no doubt as guilty as anyone else here. The first thing we need to overcome is specialty bias, tribes and silos if we’re going to fix this.

Airway management

Ensure that drug-assisted rapid sequence induction of anaesthesia and intubation is available for patients with major trauma who cannot maintain their airway and/or ventilation as soon as possible and within 30 minutes of the initial call to the emergency services. As far as possible this should be provided at the scene of the incident and not by diverting to a trauma unit

 

Ireland has a lot of hospitals receiving trauma – somewhere in the mid twenties (for a population of 4.5 million or so). If you are involve in a serious accident you will be brought (in general) to the nearest hospital that is likely not equipped or experienced with major trauma. Note some of the bigger hospitals have the facilities and specialists to deal with major trauma but this does not mean they have the expertise or frequency with it – a hospital full of specialists does not make the trauma centre.

So you have your accident, you’re brought to the nearest ED, they facilitate RSI, fight over trying to get imaging and then spend an hour on the phone trying to get you to a bigger hospital with a specialist service to accept secondary transfer. This is not ideal by any means.

Even with this current model of bringing the patient to the nearest trauma centre, way out west the transport times are too long to get someone to hospital for their RSI within 30 mins. It seems that the only way to achieve this kind of recommendation is with a HEMS system. Ireland does have a helicopter service but at present it is staffed by paramedics without credentialing to perform RSI. So, either we train our paramedics to do RSI (something not within their scope of practice at present) or provide a doctor-paramedic model (my personally preferred  choice). A helicopter is not a magic flying box that fixes patients. What we do with that helicopter and how we task it to the right people really matters if we’re in any way going to achieve RSI within 30 mins.

There is of course no large RCT suggesting that HEMS saves lives (there is no large RCT for a lot of what we do in trauma) however the UK is making recommendations here that could be seen as a compelling argument for HEMS.

Fluid Resuscitation

In hospital settings do not use crystalloids for patients with active bleeding

This is certainly not common or daily practice from what I’ve seen in Ireland. People still seem to love giving colloids (at least no starch…) and in lieu of that will happily give crystalloid to bleeding patients. People will sometimes look at you like you have two heads when you decline the kind suggestion to give them a “bag of gelo” when you know your O-ve is only 5 mins away.

For adults use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.

I am well aware that the evidence for this is not amazing by any means but in terms of Irish practice (or at least anecdote) it seems that we are depending on the INR and fibrinogen to guide our products. Plasma is often a bit of an afterthought after the 2nd INR comes back or the 4th unit..

Chest drainage

with regards to the pre hospital setting:

Use open thoracostomy instead of needle decompression if the expertise is available.

I am aware of colleagues who have done this in pre hopsital setting and been met with incredulity, confusion and even some degree of hostility by in hospital colleagues. I suspect this is simply due to unfamiliarity with the procedure. They also make the very important caveat that you’re only supposed to be doing thoracostomies on the sickies (ie tubed, suspected tension with significant compromise) not everyone who’s simply dropped a lung. Here’s a nice London HEMS paper [free full text] that goes through the procedure and indications.

This was one of the more controversial suggestions judging by twitter reaction.

Interventional radiology

Ensure that interventional radiology and definitive open surgery are equally and immediately available for haemorrhage control in all patients with active bleeding

IR is a precious and scarce resource. Maintaining  24/7 availability with the skills to so this well is very hard. Quite simply, Ireland will not be able to do this without major reconfiguration. At present it is likely that people with complex pelvic fractures and bleeding are expiring prior to their secondary transfer for IR.

Trauma teams

Ensure that multispecialty trauma teams are activated immediately in trauma units to receive patients with major trauma.

While a lot of hospitals in Ireland have some form of nominal trauma team my experience of these has been less than stellar. Remember most EDs in Ireland have 2 or 3 ED consultants with the busiest (>60000/yr) perhaps achieving the lofty heights of 5 or 6. There is very limited EM consultant leadership (and this is perfectly understandable) out of hours.  People were hoping that inventing a trauma team with certain specialty members required to attend will magically improve care. Without senior leadership and multi discipline simulation we are not going to get better at this.

Advanced imaging

Use whole-body CT (consisting of a vertex-to-toes scanogram followed by a CT from vertex to midthigh) in adults with blunt major trauma and suspected multiple injuries.

This is a tricky one. I’m all for the pan scan for the sickie or the intubed patient. I’m very wary of the pan scan the way it seems to be practiced in the US trauma systems where it seems everyone gets one regardless. It’s phrased nicely so it’s for those with “suspected multiple injuries” so there’s a bit of leeway there.

Ireland has lots of difficulties providing this service especially in more peripheral units where there are perhaps 4 or 5 consultant radiologists with no junior cover. They are understandably reluctant to perform CT at a low threshold and some places have implemented consultant to consultant referrals in this context which further complicates things as the EM consultant is likely not on site. Once again this is a fairly compelling argument for reconfiguration and a primary retrieval service that gets the right patients to the right centre.

X-ray and FAST

Limit diagnostic imaging (such as chest and pelvis X-rays or FAST [focused assessment with sonography for trauma]) to the minimum needed to direct intervention in patients with suspected haemorrhage and haemodynamic instability who are not responding to volume resuscitation.

I first picked up on this through Simon Carley a while back and as much as I love US I have to agree that if CT is immediately available why are we bothering with the plain films or US (excepting the lungs maybe). This is probably less of an issue in Ireland where there don’t seem to be that many of us USS junkies anyhow and in the absence of an efficient trauma system a +ve FAST can be a useful nudge for the radiologist to do the scan. As an aside my last two positive fasts were in ectopic pregnancies and one unexpected splenic rupture with unknown trauma.The FAST seems more use to me as part of a RUSH type exam in the undifferentiated hypotensive patient than the major trauma pt with CT immediately available

However I continue to hear various suggestions for trauma series films (CXR/pelvis and even a C-spine X-ray once) prior to obtaining a CT which seems a bit needless. If we’re not going to do the CT then fair enough get some plain films if you feel they still need imaging but if we’re going to CT no matter what then surely just get on with things.

Final thoughts

There are lots of other recommendations in here, some of less clinical and focussed on the arrangement of services. These are really important and worth the time as it’s likely the systems approach to trauma is where the real money is rather than isolated clinical interventions like RSI and TXA etc…

NICE guidelines are UK based of course and hold no authority in Ireland but they are produced in a historically somewhat similar health care system and they do form a useful “stick” to gently cajole those with the authority to change things.

These are also draft recommendations and there may be significant changes coming. Ireland has the chance to do this properly given enough political will and the right leadership. Potentially exciting times ahead. Until then your trauma care is a bit of a lottery.

Trauma is going to be a major focus at the IAEM scientific assembly in Cork in October. Be sure to book your place!

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Tasty Morsels of EM 055 – Paeds Cardiology: Murmurs

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Today we have some notes from a lecture by a paeds cardiologist at a recent national EM training day.

Murmurs in babies

  • mostly VSD and ASD
  • mostly picked up antenatally these days
  • TGA is the one often missed antenatally
  • poor feeding is the hallmark sign (as it seems to be of all bad things in neonates). If feeding alright then the murmur is unlikely to be a big problem
  • 92% of those with coarctation will have lost femoral pulses at 5 days (afraid I don’t have a reference for this). Which means some femoral pulses will be normal at discharge
  • less than a 20 mmhg difference between the upper and lower limbs is reassuring that there is no coarct
  • in his cardiology clinic they are trying to move away from echo for everyone (see the 2014 appropriate use guidelines for this)
  • recommended murmurlab.com and the pediatric ECG stat app

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Tasty Morsels of EM 054 – Paeds Cardiology: Long QT

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Today we have some notes from a lecture by a paeds cardiologist at a recent national EM training day.

The first is on long QT

  • the Schwartz score can be useful for diagnosis of long QT syndrome. Now a bit old and superseded by genetics but important to know that it is not all about the QT on the ECG – it’s a syndrome with various factors.
  • T wave alternans is a marker of ventricular instability
  • 3 main provocations of arrhythmia
    • swimming
    • arguing
    • alarm clocks
  • long QT in the first 2 weeks of life will usually be normal
  • like many folk he emphasised the importance of manual measurement of QT
  • beta blockers really good for this disease. Only if you have an event on a beta blocker do you get an ICD implanted
  • there are the Bethseda guidelines on exercise which tend to be very conservative. There are some recent moves to relax this
  • if you find someone with syncope and a long QT then they probably don’t need admitted but this totally depends on the paeds cardiology service you have – they need to have a planned follow up and in my opinion if you’re in a system where you can’t get that then maybe admitting them is the way to go

 

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Tasty Morsels of EM 053 – Use of Naloxone

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Today it comes from a paper I found via the Poison Review from two well known names in Toxicology, Hong Kim [here him speak on MarylandCC Project] and Lewis Nelson.

For those that work with me naloxone is a bit of a personal hobby horse of mine. I think it gets overused and poorly used and we seem to take perverse pleasure and moral superiority in acutely and totally reversing someone’s “high”.

Below are some of the pearls and learning points I got from it..

  • despite popular opinion, if you can’t reverse a clearly opioid toxicity then it may well be buprenorphine you’re dealing with. (due to the complex chemical bit that I don’t really follow…)
  • 0.04mg (a tenth of the dose found in most amps in the UK/Ireland) is probably the starting dose of choice (probably, not great science behind this but it’s what all the smart people say) in the opioid dependant person and titrate up. You can titrate up to 10mg or maybe even more.
  • However if they have respiratory depression from opiates you have given the patient then feel free to give the whole  amp (in our case 0.4mg)
  • naloxone is short acting as it is very lipophilic and redistributes very quickly (possibly quicker than the opiate you were reversing) therefore patients can rebound into opiate toxicity (possibly after absconding from your ED…)
  • if the patient is profoundly bradypneoic or apnoeic then it might be better to bag them first prior to reversal. The theory is that if they have a high pCO2 when you reverse them it may cause an increased catecholamine response with the reversal (this is animal data but it’s a nice pearl)
  • therefore they suggest against use of o2 for patients with respiratory depression without CO2 monitoring. This is probably the right thing to do despite the routine practice of people slumped in wheelchairs with a face mask on and sats of 100% and a CO2 of dear knows what…
  • they recommend the widely known infusion of 2/3 of the reversal dose over an hour
  • they warn of the dangers of acute reversal (something many people seem quite satisfied with)

Check out the paper [if you can get access] and remember to watch my favourite scene of naloxone in popular culture.

Kim HK, Nelson LS. Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. Expert Opinion on Drug Safety. Informa UK, Ltd; 2015;14 (07 ):000–0.

 

Featured image via “M” on flickr CC license

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