Emergency Medicine
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Spontaneous retropharyngeal haematoma with direct oral anticoagulant medication.A 79-year-old man presented to the emergency department following a 1-week history of dyspnoea, dysphonia, dysphagia and a nonproductive cough. Previous medical history included atrial fibrillation, for which he was taking rivaroxaban, hypertension and obstructive sleep apnoea. On assessment, there was a mild stridor, swelling of the anterior aspect of the neck and submandibular bruising. CT of the neck demonstrated prevertebral soft tissue swelling extending from C1 to C6 levels, approximately 88 mm in length with a maximum depth of 25 mm. A diagnosis of spontaneous retropharyngeal haematoma was made: the airway was secured with fibreoptic nasal intubation and the patient admitted to the intensive care unit. Direct and fibreoptic assessment of the airway on day 3 confirmed that the haematoma had significantly reduced in size. The patient was extubated on day 4 and made a good recovery.
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Atraumatic trismus induced by duloxetine: an uncommon presentation of acute dystonia.Atraumatic trismus can be one of the presentations of medication-induced acute dystonia, particularly by antipsychotics and less commonly antidepressants. A case of an unusual emergency presentation of atraumatic trismus on initiation of duloxetine is reported. The patient was a 40-year-old woman experiencing sudden difficulty in mouth opening and speaking due to a stiffened jaw after taking 5 days of duloxetine prescribed for her fibromyalgia-related chest pain. Assessment of vital signs is prudent to ensure there is no laryngeal involvement. Other physical examinations and her recent investigations were unremarkable. She was treated for acute dystonia and intravenous procyclidine was given together with oral diazepam. Her symptoms improved immediately and her duloxetine was suggested to be stopped. To our knowledge, this is the first case of isolated trismus induced by duloxetine. Clinicians should be aware of this risk, especially considering the limitation of important physiological functions (such as swallowing, eating, etc) associated with this condition.
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Doctor's prescription : disarmament for climate justice and health at COP28No abstract available
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Popliteal venous access for renal replacement therapy in a critically ill patient with central access failureA woman in her 80s was admitted to the emergency department with an acute infective exacerbation of chronic obstructive pulmonary disease and type 2 respiratory failure, culminating in cardiac arrest for 2 min. She was successfully resuscitated, connected to a mechanical ventilator and subsequently transferred to the intensive care unit. Later in her hospital stay, the patient underwent a tracheostomy following prolonged intubation.During this period, she developed septic shock with complications, including acute kidney injury, metabolic acidosis and volume overload. As a result, the nephrologist recommended emergency haemodialysis. Initially, a left femoral haemodialysis catheter was established but had to be withdrawn a few days later due to the development of deep vein thrombosis (DVT). A left internal jugular catheter was then inserted but was removed after 5 days due to another DVT. It was subsequently replaced with a central line for vasopressor support.A Doppler scan revealed a large thrombus in the right internal jugular vein, extending to the area just above the superior vena cava. A similar thrombus was detected in the left internal jugular vein, with weak blood flow observed in both the right and left subclavian veins. Although the subclavian vein flows were deemed adequate, there was unsatisfactory blood flow through the catheter after insertion, rendering it unsuitable for haemodialysis.Due to an earlier central line-related infection, the right femoral site exhibited signs of infection and the presence of a pus pocket, making it unsuitable for haemodialysis access. To address this, the right popliteal vein was chosen for catheterisation using a 20-cm, 12 French catheter, the longest available catheter in the country at the time. The patient was placed in a prone position, and the catheter was smoothly inserted with ultrasound guidance, resulting in good flow. Subsequent haemodialysis sessions were carried out regularly.
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Project to improve the management of the head injury patients presenting to the emergency departmentIntroduction: At Sandwell General Hospital, there was no risk stratification tool or pathway for head injury (HI) patients presenting to the emergency department (ED). This resulted in significant delays in the assessment of HI patients, compromising patient safety and quality of care. Aims: To employ quality improvement methodology to design an effective adult HI pathway that: ensured >90% of high-risk HI patients being assessed by ED clinicians within 15 min of arrival, reduce CT turnaround times, and aiming to keep the final decision making <4 hours. Methods: SWOT analysis was performed; driver diagrams were used to set out the aims and objectives. Plan-Do-Study-Act cycle was used to facilitate the change and monitor the outcomes. Process map was designed to identify the areas for improvement. A new HI pathway was introduced, imaging and transporting the patients was modified, and early decisions were made to meet the standards. Results: Data were collected and monitored following the interventions. The new pathway improved the proportion of patients assessed by the ED doctors within 15 min from 31% to 63%. The average time to CT head scan was decreased from 69 min to 53 min. Average CT scan reporting time also improved from 98 min to 71 min. Overall, the average time to decision for admission or discharge decreased from 6 hours 48 min to 4 hours 24 min. Conclusions: Following implementation of the new HI pathway, an improvement in the patient safety and quality of care was noted. High-risk HI patients were picked up earlier, assessed quicker and had CT head scans performed sooner. Decision time for admission/discharge was improved. The HI pathway continues to be used and will be reviewed and re-audited between 3 and 6 months to ensure the sustained improvement.
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Disarmament is vital for climate justice and healthNo abstract available
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Impact of full personal protective equipment on alertness of healthcare workers: a prospective study.The COVID-19 pandemic has resulted in healthcare workers (HCWs) having to wear full personal protective equipment (FPPE) even for routine patient care. When worn for prolonged periods, FPPE has the potential to adversely affect the ability of HCW to carry out their tasks. This study aimed to assess the impact of FPPE on the alertness levels of HCWs in the intensive care unit. Fifty HCWs were tested using psychomotor vigilance test (PVT) and serial sevens test (SST) on two occasions during their shift-once without FPPE and once after they had been in FPPE for at least 2 hours. The median time in FPPE was 2.5 hours. FPPE induced a significant increase in the average reaction time and the number of false responses in PVT. Subjects took longer to complete SST in FPPE compared with without it. This study demonstrates that being in FPPE for as little as 2.5 hours can adversely affect HCW alertness. The findings of this study are relevant in terms of workforce environment considerations as the use of FPPE in certain settings is likely to become a regular feature.