- A VBG is adequate for the diagnosis and ongoing management of patients with DKA. ABGs offer no added benefit and are associated with increased pain and complications.
- Patients with DKA may present with a weak or absent nitroprusside assay reaction on urinalysis for ketones as this test only checks for acetoacetate (the minor ketone body produced in DKA). Serum beta-hydroxybutyrate testing may be helpful in certain cases in making the diagnosis.
- There is no established role for administration of sodium bicarbonate to patients with DKA regardless of their pH. Sodium bicarbonate administration is associated with more complications including hypokalaemia and cerebral oedema.
- Insulin should not be started in patients with DKA until the serum potassium level is confirmed to be > 3.5 mEq/L. The use of an insulin bolus prior to infusion has not been shown to improve any patient centred outcomes or surrogate markers and is associated with an increased rate of hypoglycaemic episodes.
- HHS is defined by hyperglycemia and hyperosmolarity due to volume depletion with resultant altered mental status
- Profound hypokalemia is common as a result of osmotic diuresis. Replete aggressively
- Hypokalemia = hypomagnesemia. Replete both of these electrolytes simultaneously
- Fluid repletion is the key point in management but careful repletion is vital as patients may not tolerate aggressive administration
- All patients should have an exhaustive investigation of the cause of their decompensation. Look for signs of infection, ischemia, trauma etc.
- Too Slow or Too Fast Chest Compressions
- Too Shallow or Too Deep Chest Compressions
- Too Many or Too Slow Breaths
- Leaning on the Chest
- Too Many Interruptions
- Giving Up Too Soon
- Too Slow Adaptation
Humidified oxygen is widely administered in hospitals and EMS vehicles and this is presumed to alleviate nasal and oral discomfort in the non-intubated patient. Humidification of supplemental oxygen is commonly delivered by bubbling oxygen through either cold or warm sterile water before it reaches the patient. However, the effect on patient comfort is negligible. Bubble humidifiers may, however, represent an infection hazard and should not be used.
A modular e-learning course that can easily be accessed by medical providers in an effort to improve emergency trauma care. Give it a try.
Treatment of Helicobacter pylori Infection
The Health Act 2017 – Emergency Care
Thank you for all the support in 2017. We look forward to providing you with even greater emergency care content in 2018. From all of us at the Emergency Medicine Kenya Foundation, HAPPY NEW YEAR!
And don’t’ forget…
The Health Act 2017 – Emergency Care
10. All Shock Explained
|Non-ischemic (high-flow)||Ischemic (low-flow)|
|Physical Exam||Typically painless, not fully tumescent||Painful, fully tumescent with corpus cavernosa rigidity without involvement of corpus spongiosum and glans penis|
|Aetiology||High-flow priapism is extremely rare and most commonly associated with antecedent trauma including blunt trauma, or resulting from needle injury of the cavernosal artery.||Low-flow priapism is caused by impaired relaxation and/or paralysis of cavernosal smooth muscle and in sickle-cell disease|
8. 2016 Guidelines
7. Sepsis Six in 60 Minutes: World Sepsis Day – September 13th
NEW SEPSIS PATHWAY
…for every hour you delay, the patient has a 33% increased risk of death!
6. Did you know about the RULE OF TENS for Fluid Resuscitation in Burns?
Burns Rule of TENS:
1. Estimate burn size (TBSA) to the nearest 10%.
2. Multiply %TBSA x 10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg).
3. For every 10 kg above 80 kg add 100 mL/hr to the rate.
5. New 2015 Resuscitation Guidelines Compedium
4. LFTs explained
- LFTs = ‘hepatocellular’ or ‘cholestatic’ arrangement based on the pattern of elevation.
- Hepatocellular pattern = transaminases > ALK
- ALT is generally considered to be more specific to liver damage
- Magnitude of aminotransferase elevation => guide initial diagnosis: mild (<5x), moderate (5-10x), or marked elevation (>10x)
- Mild = NAFLD, Drug Induced Liver Injury, Alcohol-Induced Liver Injury
- Moderate = Alcoholic Hepatitis, Biliary Tract Disease
- Severe = Acute Viral Hepatitis, Ischemic Injury, Acetaminophen Toxicity
3. The GCS is out-of-stock
Contrary to common belief, The Glasgow Coma Scale (GCS) is NEVER out-of-stock and the lowest score possible is 3.
- An intubated patient still gets 1 point for verbal meaning they score 3T…there is nothing like a 2T score (at least not in human beings)
- The phrase ‘GCS of 11’ is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11.
- The Scale was described in 1974 by Graham Teasdale and Bryan Jennett (Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2:81-4.) and is the most reference paper in medical literature
2. Nairobi Accident Hotspots
The most dangerous time to walk on Nairobi’s streets is on a Friday, around 7am, particularly along Mombasa Road.
1. Salter-Harris Fracture (remember the mnemonic SALTR)
- Slipped (i.e., through growth plate and not involving bone) / Type I
- Above growth plate (i.e., through metaphysis) / Type II (most common)
- Lower growth plate (i.e., through epiphysis) / Type III
- Through (i.e., through metaphysis growth plate and epiphysis) / Type IV
- Rammed (i.e., Crush injury) / Type V (worst prognosis)
The World Day of Remembrance for Road Traffic Victims (WDR) is commemorated on the third Sunday of November each year – to remember the many millions killed and injured on the world’s roads, together with their families, friends and many others who are also affected. It is also a Day on which we thank the emergency services and reflect on the tremendous burden and cost of this daily continuing disaster to families, communities and countries, and on ways to halt it.
- Guidelines recommend checking an ABG or VBG in all patients with DKA. This practice is not evidence-based and should be abandoned.
- ABG or VBG provides little information about whether or not the patient has DKA (beyond what is already known from the serum chemistries).
- Rather than pH, serum bicarbonate may be used to gauge the severity of acidosis.
- There is no evidence that detecting or reacting to a very low pH is helpful.
- Decisions about the level of ventilatory support that a patient needs can almost always be made on a clinical basis. When in doubt, close attention to the patient with serial examination is often a sound approach. Focus on the patient, not the blood gas.
- VBG might be helpful in cases where it is unclear whether the patient requires intubation, or if there is a significant underlying respiratory disease (e.g. COPD or obesity hypoventilation syndrome).