Opioid poisoning is a common occurrence in the Emergency Department. It can occur as a result of recreational drug use, such as heroin, or from prescribed opioids like morphine sulfate tablets or dihydrocodeine.

The symptoms of opioid overdose include a decreased level of consciousness or even coma, reduced respiratory rate, apnea, pinpoint pupils, low blood pressure, cyanosis, convulsions, and non-cardiogenic pulmonary edema (in cases of intravenous heroin usage). The most common cause of death from opioid overdose is respiratory depression, which typically happens within an hour of the overdose. Vomiting is also common, and there is a risk of aspiration.

Naloxone is the specific antidote for opioid overdose. It can reverse respiratory depression and coma if given in sufficient dosage. The initial intravenous dose is 400 micrograms, followed by 800 micrograms for up to two doses at one-minute intervals if there is no response to the preceding dose. If there is still no response, the dose may be increased to 2 mg for one dose (seriously poisoned patients may require a 4 mg dose). If the intravenous route is not feasible, naloxone can be given by intramuscular injection.

Since naloxone has a shorter duration of action than most opioids, close monitoring and repeated injections are necessary. The dosage should be adjusted based on the respiratory rate and depth of coma. Generally, the dose is repeated every 2-3 minutes, up to a maximum of 10 mg. In cases where repeated doses are needed, naloxone can be administered through a continuous infusion, with the infusion rate initially set at 60% of the initial resuscitative intravenous dose per hour.

In opioid addicts, the administration of naloxone may trigger a withdrawal syndrome, characterized by abdominal cramps, nausea, and diarrhea. However, these symptoms typically subside within 2 hours.

The tricuspid valve is the most commonly affected valve in cases of infective endocarditis among intravenous drug users. This means that when IV drug users develop infective endocarditis, it is most likely to affect the tricuspid valve. On the other hand, in cases of native valve endocarditis and prosthetic valve endocarditis, the mitral valve is the valve that is most commonly affected.

Further Reading:

Infective endocarditis (IE) is an infection that affects the innermost layer of the heart, known as the endocardium. It is most commonly caused by bacteria, although it can also be caused by fungi or viruses. IE can be classified as acute, subacute, or chronic depending on the duration of illness. Risk factors for IE include IV drug use, valvular heart disease, prosthetic valves, structural congenital heart disease, previous episodes of IE, hypertrophic cardiomyopathy, immune suppression, chronic inflammatory conditions, and poor dental hygiene.

The epidemiology of IE has changed in recent years, with Staphylococcus aureus now being the most common causative organism in most industrialized countries. Other common organisms include coagulase-negative staphylococci, streptococci, and enterococci. The distribution of causative organisms varies depending on whether the patient has a native valve, prosthetic valve, or is an IV drug user.

Clinical features of IE include fever, heart murmurs (most commonly aortic regurgitation), non-specific constitutional symptoms, petechiae, splinter hemorrhages, Osler’s nodes, Janeway’s lesions, Roth’s spots, arthritis, splenomegaly, meningism/meningitis, stroke symptoms, and pleuritic pain.

The diagnosis of IE is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Major criteria include positive blood cultures with typical microorganisms and positive echocardiogram findings. Minor criteria include fever, vascular phenomena, immunological phenomena, and microbiological phenomena. Blood culture and echocardiography are key tests for diagnosing IE.

In summary, infective endocarditis is an infection of the innermost layer of the heart that is most commonly caused by bacteria. It can be classified as acute, subacute, or chronic and can be caused by a variety of risk factors. Staphylococcus aureus is now the most common causative organism in most industrialized countries. Clinical features include fever, heart murmurs, and various other symptoms. The diagnosis is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Blood culture and echocardiography are important tests for diagnosing IE.

The Health Protection (Notification) Regulations currently require the reporting of certain diseases. These diseases include acute encephalitis, acute infectious hepatitis, acute meningitis, acute poliomyelitis, anthrax, botulism, brucellosis, cholera, COVID-19, diphtheria, enteric fever (typhoid or paratyphoid fever), food poisoning, haemolytic uraemic syndrome (HUS), infectious bloody diarrhoea, invasive group A streptococcal disease, Legionnaires’ Disease, leprosy, malaria, measles, meningococcal septicaemia, mumps, plague, rabies, rubella, SARS, scarlet fever, smallpox, tetanus, tuberculosis, typhus, viral haemorrhagic fever (VHF), whooping cough, and yellow fever.

Discitis is an infection that affects the space between the intervertebral discs in the spine. This condition can have serious consequences, including the formation of abscesses and sepsis. The most common cause of discitis is usually Staphylococcus aureus, but other organisms like Streptococcus viridans and Pseudomonas aeruginosa may be responsible in intravenous drug users and those with weakened immune systems. Gram-negative organisms such as Escherichia coli and Mycobacterium tuberculosis can also cause discitis.

There are several risk factors that increase the likelihood of developing discitis. These include having undergone spinal surgery (which occurs in 1-2% of cases post-operatively), having an immunodeficiency, being an intravenous drug user, being under the age of eight, having diabetes mellitus, or having a malignancy.

The typical symptoms of discitis include back or neck pain (which occurs in over 90% of cases), pain that often wakes the patient from sleep, fever (present in 60-70% of cases), and neurological deficits (which can occur in up to 50% of cases). In children, refusal to walk may also be a symptom.

When diagnosing discitis, MRI is the preferred imaging modality due to its high sensitivity and specificity. It is important to image the entire spine, as discitis often affects multiple levels. Plain radiographs are not very sensitive to the early changes of discitis and may appear normal for 2-4 weeks. CT scanning is also not very sensitive in detecting discitis.

Treatment for discitis involves admission to the hospital for intravenous antibiotics. Before starting the antibiotics, it is important to send three sets of blood cultures and a full set of blood tests, including a CRP, to the lab. The choice of antibiotics depends on the specific situation. A typical antibiotic regimen for discitis may include IV flucloxacillin as the first-line treatment if there is no penicillin allergy, IV vancomycin if the infection was acquired in the hospital or there is a high risk of MRSA, and possibly IV gentamicin if there is a possibility of a Gram-negative infection. In cases where there is acute kidney injury and Gram-negative cover is required, IV piperacillin-tazobactam alone may be used.

Patients who have a STEMI caused by a blockage in the left circumflex artery (LCX) will usually show ST elevation in leads I and AVL. These leads correspond to the high lateral area of the heart, which is supplied by the LCX artery.

Further Reading:

Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

Carpal tunnel syndrome is a condition where the median nerve becomes trapped, resulting in nerve damage. This can lead to weakness and abnormal sensations in the areas supplied by the median nerve. To remember the muscles that are innervated by the median nerve, you can use the acronym ‘LOAF’: L for the lateral two lumbricals, O for the Opponens pollicis, A for the Abductor pollicis, and F for the Flexor pollicis brevis. It’s important to note that the abductor digiti minimi is not affected by carpal tunnel syndrome as it is innervated by the deep branch of the ulnar nerve.

Hypercalcaemia, which is an elevated level of calcium in the blood, is most commonly caused by primary hyperparathyroidism and malignancy in the UK. However, there are other factors that can contribute to hypercalcaemia as well. These include an increase in dietary intake of calcium, excessive intake of vitamin D, tertiary hyperparathyroidism, overactive thyroid gland (hyperthyroidism), Addison’s disease, sarcoidosis, Paget’s disease, multiple myeloma, phaeochromocytoma, and milk-alkali syndrome. Additionally, certain medications such as lithium, thiazide diuretics, and theophyllines can also lead to hypercalcaemia. It is important to be aware of these various causes in order to properly diagnose and treat this condition.

The use of a laryngeal mask airway (LMA) carries a higher risk of inducing laryngospasm compared to endotracheal intubation. However, LMAs are still considered excellent alternatives to bag masks as they reduce the risk of gastric inflation and aspiration. While they do decrease the risk of aspiration, they are not as protective as endotracheal tubes. Complications associated with LMA use include laryngospasm, nausea and vomiting, and a low risk of aspiration. LMAs have advantages over bag-mask ventilation, such as more effective ventilation, less gastric inflation, and a lower risk of aspiration. However, they also have disadvantages, including the risk of hypoventilation due to air leak around the cuff, greater gastric inflation compared to endotracheal intubation, and a very low risk of aspiration.

Further Reading:

Techniques to keep the airway open:

1. Suction: Used to remove obstructing material such as blood, vomit, secretions, and food debris from the oral cavity.

2. Chin lift manoeuvres: Involves lifting the head off the floor and lifting the chin to extend the head in relation to the neck. Improves alignment of the pharyngeal, laryngeal, and oral axes.

3. Jaw thrust: Used in trauma patients with cervical spine injury concerns. Fingers are placed under the mandible and gently pushed upward.

Airway adjuncts:

1. Oropharyngeal airway (OPA): Prevents the tongue from occluding the airway. Sized according to the patient by measuring from the incisor teeth to the angle of the mandible. Inserted with the tip facing backwards and rotated 180 degrees once it touches the back of the palate or oropharynx.

2. Nasopharyngeal airway (NPA): Useful when it is difficult to open the mouth or in semi-conscious patients. Sized by length (distance between nostril and tragus of the ear) and diameter (roughly that of the patient’s little finger). Contraindicated in basal skull and midface fractures.

Laryngeal mask airway (LMA):

– Supraglottic airway device used as a first line or rescue airway.
– Easy to insert, sized according to patient’s bodyweight.
– Advantages: Easy insertion, effective ventilation, some protection from aspiration.
– Disadvantages: Risk of hypoventilation, greater gastric inflation than endotracheal tube (ETT), risk of aspiration and laryngospasm.

Note: Proper training and assessment of the patient’s condition are essential for airway management.

Cellulitis is a common cause of swelling in one leg. It is characterized by red, hot, tender, and swollen skin, usually affecting the shin on one side. Other symptoms may include fever, fatigue, and chills. It is important to consider deep vein thrombosis (DVT) as a possible alternative diagnosis, as it can be associated with cellulitis or vice versa. Unlike cellulitis, DVT does not typically cause fever and affects the entire limb below the blood clot, resulting in swelling in the calf, ankle, and foot. Necrotizing fasciitis is a rare condition. Gout primarily affects the joints of the foot, particularly the first metatarsophalangeal joint. Erythema migrans usually produces a distinct target-shaped rash.

Further Reading:

Cellulitis is an inflammation of the skin and subcutaneous tissues caused by an infection, usually by Streptococcus pyogenes or Staphylococcus aureus. It commonly occurs on the shins and is characterized by symptoms such as erythema, pain, swelling, and heat. In some cases, there may also be systemic symptoms like fever and malaise.

The NICE Clinical Knowledge Summaries recommend using the Eron classification to determine the appropriate management of cellulitis. Class I cellulitis refers to cases without signs of systemic toxicity or uncontrolled comorbidities. Class II cellulitis involves either systemic illness or the presence of a co-morbidity that may complicate or delay the resolution of the infection. Class III cellulitis is characterized by significant systemic upset or limb-threatening infection due to vascular compromise. Class IV cellulitis involves sepsis syndrome or a severe life-threatening infection like necrotizing fasciitis.

According to the guidelines, patients with Eron Class III or Class IV cellulitis should be admitted for intravenous antibiotics. This also applies to patients with severe or rapidly deteriorating cellulitis, very young or frail individuals, immunocompromised patients, those with significant lymphedema, and those with facial or periorbital cellulitis (unless very mild). Patients with Eron Class II cellulitis may not require admission if the necessary facilities and expertise are available in the community to administer intravenous antibiotics and monitor the patient.

The recommended first-line treatment for mild to moderate cellulitis is flucloxacillin. For patients allergic to penicillin, clarithromycin or clindamycin is recommended. In cases where patients have failed to respond to flucloxacillin, local protocols may suggest the use of oral clindamycin. Severe cellulitis should be treated with intravenous benzylpenicillin and flucloxacillin.

Overall, the management of cellulitis depends on the severity of the infection and the presence of any systemic symptoms or complications. Prompt treatment with appropriate antibiotics is crucial to prevent further complications and promote healing.

Common side effects of bendroflumethiazide include postural hypotension, electrolyte disturbance (such as hypokalaemia, hyponatraemia, and hypercalcaemia), impaired glucose tolerance, gout, impotence, and fatigue. Rare side effects of bendroflumethiazide include thrombocytopenia, agranulocytosis, photosensitive rash, pancreatitis, and renal failure.